Alternatively, it could be that proficiency varies across semantic categories of the bilingual’s two languages. Here, we investigated lexical access in color terms in Tsimane’–Spanish bilinguals. Given that color terms are generally more frequent in Spanish than Tsimane’, participants may have better lexical access for color words in Spanish despite being overall more proficient in Tsimane’. Twenty-two Tsimane’–Spanish bilinguals took part in a picture naming task where participants labeled colors and animals. Participants were equally fast and accurate at naming animals in Tsimane’ and Spanish. However, participants were faster and more accurate at naming colors in Spanish than Tsimane’ except for the three color words that are most frequent  in Tsimane’, for which they were equally fast in both Tsimane’ and Spanish. These results suggest that category-specific proficiency is a better predictor for lexical access than overall proficiency.A standard assumption in the bilingual language processing literature is that the ease of access of a word in a language is determined by the speaker’s  While bilingualism is a heterogeneous phenomenon10, in general, bilingual speakers report being better at naming words in the language they acquired earlier and consider themselves to be more proficient in13. The idea seems deceptively simple: the better you are overall in a language, the better you are at naming individual words in that language. However, it is possible that overall proficiency in a language is not similar across all categories of that language. For instance, a non-native English speaker that attends an English-based university might be more proficient for those academic terms in English than their native language, despite being overall more proficient in their native language14. Yet, most research in bilingualism tends to assess and report overall proficiency, assuming it to be similar across different categories in the language.Humans express their thoughts and ideas one word a time. How do speakers choose which word to produce next? This question is rendered more complex for the majority of the world’s population, who speak more than one language15. However, this model is not supported by experimental evidence showing that words in both languages are activated even when only one is intended to be produced16.Do models of bilingual lexical access distinguish between overall proficiency  and category-specific proficiency ? According to the earliest proposed model of bilingual lexical access, lexical selection occurs only within the target language, thus predicting that words in the non-target language will never be activated regardless of frequency and proficiency of the speaker17. Green proposed a third model, the inhibitory control model, under which there is activation of concepts in both languages, but with one language being suppressed via an inhibitory mechanism18. This model explains a further empirical observation: there is a larger cost associated with switching from a non-dominant language back to a dominant language than the other way around. Under the inhibitory control model, when producing your non-dominant language, more inhibition of the dominant language is required, thus leading to slower responses when returning to the dominant language19. The language-specific selection model and inhibitory control model differ on the existence of a competitive selection process in selecting the correct target word: the inhibitory control model assumes competition among words in the non-target language that need to be suppressed via inhibition, while no such process is assumed in the language-specific selection model.Thus Costa et al. proposed a second model, the language-specific selection model, according to which, lexical candidates in both languages are activated during production, and the target language restricts selection to words in that language. This model accounts for the activation of both languages even when only one is intended to be produced as follows: an independent semantic system is shared between the two languages, and relevant semantic information is activated regardless of the language spoken, but only the lexical nodes in the target language are selected, with easier activation for the most dominant language21, although there are instances where they are disentangled, with speakers unable to speak a language acquired early22, and speakers becoming fluent in a language acquired later23. In these models, lexical selection is proposed to be easier in the more proficient language, and similar for equally proficient languages7. Critically, proficiency seems to be assumed to be consistent across the two languages for all categories.Critically, in both models, the notion of proficiency is not well-defined. Participants in studies that test these models define proficiency either by self-reported expertise or age of acquisition, where earlier acquisition equates with higher proficiency. These two measures are typically highly correlated26. Second, this difference is exacerbated for lower frequency words27. And third, the difference disappears with words with equal frequencies, such as proper nouns28, or where words between the two languages are cognate words29.Differences in lexical access have not only been observed between the two languages of a bilingual speaker, but several studies also report differences in bilingual and monolingual lexical access. First, bilinguals take longer than monolinguals in naming pictures and producing noun phrases25, such that bilinguals tend to be exposed to words in each of their languages less than a monolingual (in one language), thus leading to slower access by the bilingual to the lexemes of their two languages. Blanco-Elorrieta and Caramazza incorporate this notion into their model, where frequency of a word is used to explain lexical access effects, but not an independent notion of proficiency (as in the previous models)30. This proposal thus dispenses with the notion of overall proficiency as an explanatory factor, in favor of exposure frequency alone. Exposure frequency, in turn, does not assume uniformity across categories of a language: one can be more exposed for some words in one language, and for other words in another language.Consequently, Gollan et al. proposed the frequency-lag hypothesis31.A strong prediction of the category-specific proficiency hypothesis is that it should be possible to find conceptual domains where words are more frequent in the globally less proficient language. Such examples have not been investigated thus far because the languages that have been investigated so far come from similar cultures, and hence the frequencies of related words were highly correlated32. Specifically, we look at the domain of color concepts, which are labeled more frequently in industrialized cultures than non-industrialized cultures33. One such example is Tsimane’–Spanish bilinguals. Tsimane’ speakers are farmer–foragers living in the Bolivian Amazon rainforest34; in contrast to industrialized cultures, the Tsimane’ do not talk about color very much and consequently have a limited shared color vocabulary33. Whereas all Tsimane’ speakers know words corresponding to black (tsincus), white (jaibes) and red (jaines), monolingual Tsimane’ speakers use less consistent labels for other colors. However, due to globalization, some Tsimane’ leave their communities temporarily to visit nearby Spanish-speaking villages and thus end up learning Spanish as well. In Bolivian Spanish, there are 12 commonly used color words: blanco (white), negro (black), rojo (red), verde (green), amarillo (yellow), celeste (light blue), azul (dark blue), rosado (pink), anaranjado (orange), violeta (purple), and gris (grey). Spanish speakers show greater consistency of labeling for most colors, compared to Tsimane’. Furthermore, Spanish-Tsimane’ bilinguals show greater consistency in labeling most colors in Tsimane’ than Tsimane’ monolinguals . Thus, although Tsimane’ monolinguals have a few consistent color labels, Tsimane’–Spanish bilinguals have existing Tsimane’ labels for the color words tsincus (black), jaibes (white), jaines (red), shandyes (green), chames (yellow), nyushnus (blue), chocolateyeisi or cafeyeisi (brown), itsiyeisi (purple), chimdyes (grey). The consistency of labeling is plausibly an indirect measure of frequency of use across individuals33.In the current study, we rely on the vast cultural differences between industrialized cultures and non-industrialized cultures to investigate this prediction, leveraging the benefits of studying non-Western, Educated, Industrialized, Rich and Democratic  societiesOur critical task is lexical access via picture-description, where a Tsimane’–Spanish bilingual participant is asked to name a color or animal as fast as possible, in the target language (Tsimane’ or Spanish). For the control set of materials—animals—both theories, i.e., the overall-proficiency and category-specific proficiency theories, predict faster and more accurate naming in Tsimane’ than Spanish for these Tsimane’–Spanish bilinguals, because these are common local animals, which the Tsimane’ know and have talked about in Tsimane’. For both the overall proficiency and category-specific proficiency-based theories, this follows because the speakers are more proficient in Tsimane’ and hence they should access words in Tsimane’ more easily.The theories make differing predictions for the color-labeling task. The overall-proficiency-based theories make the same prediction as for the animals: faster and more accurate naming in Tsimane’ than Spanish, because the participants are more proficient in Tsimane’. On the other hand, the category-specific proficiency-based theory relies only on word frequency to explain lexical access, and hence predicts faster and more accurate labeling in Spanish than Tsimane’ overall, because color words are more frequent in Spanish than Tsimane’, and hence the Tsimane’–Spanish bilinguals will probably have been exposed to the Spanish words more overall than the Tsimane’ versions. In other words, the category-specific proficiency-based theory predicts an interaction between language and word-type , while the overall proficiency-based theory predicts only a main effect of language.jaibes (white), tsincus (black) and jaines (red). It is plausible that the frequency of these words is larger than their Spanish counterparts, in the experience of the Tsimane’–Spanish bilinguals. Thus, it is possible that the Spanish dominance may apply only to the other color words that we tested—yushnus/azul (blue), chocolateyeisi/marrón (brown), shandyes/verde (green), chimdyes/gris (grey), chames/amarillo (yellow)– where the Spanish words are likely much more frequent than the Tsimane’ counterparts.Furthermore, if frequency is the main driver in proficiency, the ease of access should depend on the particular color words. The only Tsimane’ color terms that all speakers share are 33, and tend to use one term for all of green and blue (‘grue’)35, we first sought to ensure that the conceptual representation for each of the tested color words was similar for the two languages.Given that Tsimane’ monolingual speakers have idiosyncratic responses for less frequent color words2 = 13.51, df = 16, p = 0.63), green , red , white  and yellow . The distributions for the remaining two colors that we tested differed .First, we examined whether the distribution of the chips selected in the Munsell chips labeling task for each of the color terms was similar. As can be observed in Fig. 36. which was created by the Inter-Society Color Council, a group of vision scientists37. The hue of a color is the attribute that distinguishes one color from another. In the Munsell space, hues are placed in a circle, with red, yellow, green, blue, and purple placed at approximately equal intervals around the circle. We obtained the hue values for each of the chips in our array with the R package ‘munsellinterpol v.2.6-1’ from Gama et al.36. In the Munsell array used in the present experiment, hue is represented across columns, with the hue in column 1 being 5, the hue value of column 10 is 50, and the hue value of column 20 being 100. According to the ISCC-NBS System, the range of hue values from 55 (green–blue) to 75 (purple–blue) is “blue”; from 10 (red–brown) to 25 (yellow–brown) is “brown”; from 35 (green–yellow) to 55 (green–blue) is “green”; from 5 (red) to 95 (purple–red) is “red”; and from 15 (yellow–red) to 35 (green–yellow) is “yellow”. The mean hues of the chips chosen by speakers to represent the terms nyushnyes/azul , chocolateyeisi/café , shandyes/verde , jainas/rojo  and chames/amarillo  fell within the established range, thus indicating that all these terms fall within conventional boundaries for each of the color terms. The colors black, white, and grey do not have hue values, and participants were not asked about the color grey.Second, we asked whether the mean hue values of chips chosen for each of the color words fell within the canonical ranges established by the ISCC-NBS SystemTaken together, these results suggest that there are similar color concepts underlying the Tsimane’ and Spanish color terms that we investigated.word-type , as animal words are similarly frequent in Spanish and Tsimane’, while color words are more frequent in Spanish than Tsimane’. On the other hand, overall proficiency was captured by the variable language, as all participants rated themselves to be more proficient in Tsimane’ than Spanish; this was established by asking participants to rate themselves on various dimensions  and run (from 1 to 8) as main effects. Following Meuter and Allport19, trials where participants switch between languages were expected to be slower and less accurate than trials where participants continue naming in the same language . Furthermore, participants were expected to become faster and more accurate as they progress through the runs. Finally, subjects (n = 22) and items  were entered as random effects. The maximal models we started with included Word-Type × Language main effect and interactions for both subjects and items. We removed interactions and then main effects from item first and then subjects until the model converged. We report the maximal model that converged for each of the analyses below.To disentangle whether overall proficiency in a language or frequency of exposure to individualized words predict better behavioral results (accuracy in naming or reaction time data), we used linear-mixed effect models for reaction time data and generalized mixed effects models for accuracy data with the R package ‘lme4’; p-value approximations was done using R package ‘rstatix’Results from the generalized linear mixed effect model that predicted naming accuracy Table  indicateWhat was the nature of the errors? Most of the errors came from intra-language interference  for both animals (86% of errors) and colors (64% of errors), although interlanguage interference  occurred more for colors (34% of errors) than for animals  in Spanish when naming color words despite it being the less proficient language. These results suggest that exposure to a word’s frequency drives lexical access, not overall proficiency within a language.Are participants aware that they are faster at naming color words in Spanish than Tsimane’? After they completed the experiment, a subset of participants (n = 16) were asked whether they spoke about color words more in Tsimane’ or in Spanish. Most participants (9/16) claimed they spoke about colors more in Tsimane’, while some claimed they mainly used Spanish words (5/16) and a minority claimed they used both languages (2/16). We analyzed the data of the subjects who claimed to speak about colors primarily in Tsimane’ . To test this, a new linear mixed effect model was created to fit data for color words. We don’t have word-based frequency estimates in Tsimane’ because there are no Tsimane’ corpora yet. We therefore divide the color words into two groups: jaibes (white), tsincus (black) and jaines (red) trials were coded as high frequency color words and the other color words were coded as low frequency color words. The language, the frequent  and their interaction were entered in the regression, along with run (1–8) and trial-type (switch or non-switch). Finally, participants (n = 22) and trials (n = 8) were entered as random effects.If the word-type × language interaction is driven by the fact that color words are used less often in Tsimane’ than Spanish, we would expect to find less of a difference in color naming for the color words that are most widely used in Tsimane’ . These results seem to indicate that category-specific proficiency is a more important factor than overall proficiency in accessing words. In other words, lexical access depends on exposure to words, irrespective of the overall proficiency in the language.We sought to understand whether overall proficiency in a language (as defined by self-report) or category-proficiency (as measured by frequency of exposure to words) is more important in bilingual lexical access by probing Tsimane’–Spanish bilinguals in a naming task. While frequency of a word and overall proficiency of a language are usually confounded, Tsimane’–Spanish bilinguals encounter color terms more frequently in their less proficient Spanish than in their native Tsimane’, therefore allowing for the disentangling of the two factors. First, we observed that the bilingual speakers’ understanding of color was not conceptually different between their two languages. Critically, results in a picture-naming task indicated that, despite reporting to be overall more proficient in Tsimane’, Tsimane’–Spanish bilinguals were better at naming colors in Spanish, except for the three color terms that are of higher frequency in Tsimane’ , word exposure plays a larger role in lexical access; future research may be able to explore whether overall proficiency in a language also plays a significant role in lexical access as well, or if it’s entirely driven by word exposure.14. It so happens that in the Tsimane’, this effect occurs at the population level, while in the other case discussed above, the effect is idiosyncratic to speakers and their experiences. In other language pairs, unlike in Tsimane’, which does not have a corpus, larger corpora can be used to detect differences between the frequencies of translation word pairs. An interesting scenario may be languages where new terminology and translations are being introduced, as is the case for scientific terminology44.While the present study is an example of why the study of under-represented, non-WEIRD communities can benefit our understanding of language processing in particular and cognitive processing in general, our results are not necessarily restricted to these populations. Specifically, the dissociation between frequency and proficiency is not confined to cases of farmer–forager tribes becoming more industrialized but might be more common in bilingual settings of industrialized societies too. For instance, a non-native English speaker attending an English-based university will encounter academic terminology in their non-dominant language45 prior to the study, received compensation for their time, gave an informed consent as required by the Committee on the Use of Humans as Experimental Subjects (COUHES) from MIT and were paid for their participation. The sample size was determined by convenience, given the limited number of participants available for testing.Twenty-two Tsimane’–Spanish bilinguals took part in the experiment. All bilinguals first learned Tsimane’ and then Spanish, and all participants rated themselves to be more proficient in Tsimane’ than Spanish . Participants were asked to label the chips in Tsimane’ first, and then in Spanish, or vice versa  and 8 animals  in Tsimane’ and in Spanish. Given the heterogeneity across monolingual Tsimane’ speakers in naming colors33, participants were first shown individual pictures of the colors and the animals, and their labels for each were annotated in order to allow for corrections. Then, participants were presented with a series of cued trials, consisting of a fixation cross at the center of the screen presented for 700 ms, followed by a cue presented for 300 ms, followed by the target for a total of 3000 ms. Participants were asked to name the target in either Tsimane’  or Spanish (cued by a Spanish flag); once the target was named, the target disappeared, and a fixation cross would appear until the 3000 ms elapsed. Participants labeled both colors and animals for a total of 400 trials, alternating between Spanish and Tsimane’ trials at random intervals for 150 of the 400 trials. Due to the length of the experiment, participants were asked to name 50 trials at a time, with each set of 50 trials forming a run, for a total of 8 runs. A break was provided between runs, with the participant deciding on the duration of the break; they continued to the next run by pressing the space key on the keyboard. All stimuli were presented using Psychtoolbox48. Methods were carried out in accordance with relevant guidelines and regulations by the Committee on the Use of Humans as Experimental Subjects (COUHES) from MIT. All experimental protocols were approved by the Tsimane' Council in San Borja and the Centro Boliviano de Desarrollo Socio Integral (CBIDSI).In the Supplementary Information.


Data were analyzed using descriptive statistics and thematic analysis, respectively, and integrated to provide holistic findings. Our results confirm overwhelmingly positive attitudes and a high degree of interest in education, implementation, and taking on more corresponding responsibility, but a lack of substantial knowledge of the subject matter, and only tentative implementation of practices. Identified barriers include a lack of knowledge, resources, and policies. Further research, education, and policy development on overcoming these barriers is required. This will facilitate harnessing the extant enthusiasm and advance environmental sustainability in South Africa’s healthcare practice. Climate change, biodiversity loss and large-scale environmental degradation are widely recognized as the biggest health threats of the 21st century, with the African continent already amongst the most severely affected and vulnerable to their further progression. The healthcare system’s contribution to climate change and environmental degradation requires healthcare professionals to address environmental issues urgently. However, the foundation for context-relevant interventions across research, practice, and education is not readily available. Therefore, we conducted a convergent mixed-methods study to investigate South African healthcare professionals’ knowledge, attitudes, practices, and barriers to environmental sustainability. Healthcare professionals participated in a cross-sectional questionnaire ( Climate change, biodiversity loss and large-scale environmental degradation are widely recognized as the biggest threats to 21st century health and civilizations . The AfrWith Sub-Saharan Africa remaining the poorest region in the world, these environmental changes have grave implications for its people and a large proportion of low-income communities ,10. ThouIn addition to these health impacts, the urgency for healthcare professionals to address environmental issues, directly and indirectly, is further exacerbated by the fact that healthcare systems and services contribute to climate change and environmental degradation. Healthcare-related carbon emissions, waste production, plastic pollution, toxic waste, and other undesirable outputs are also threatening good health, or even contributing to poor health in a Sisyphean process of improving the health of people ,19,20. NThe World Health Organization (WHO) recently highlighted four urgent actions for the health community: (1) the training of the health workforce to respond to climate change, (2) taking climate action in the healthcare sector, 3) enabling health professional advocacy on climate change and health, and (4) protecting the health of future generations  enabling,24,25,26In the context of Sub-Saharan and Southern Africa, improvements in the sustainability of healthcare systems have been primarily focused on social and economic aspects, as necessitated by considerable socioeconomic and political challenges ,34,35. HIn this article, we present findings from a convergent mixed-methods study, combining a cross-sectional questionnaire and semi-structured focus group discussions (FGDs) to identify South African healthcare professionals’ KAP and barriers to environmental sustainability. Our findings point to a pressing need and desire for: (1) healthcare professional education in environmental sustainability, (2) factoring environmental sustainability into clinical practice guidelines while ensuring availability of matching equipment and infrastructure, and (3) corresponding policy development. Timely research, development, and implementation across these three arenas will be essential to advance the implementation of environmental sustainability into South African healthcare systems and daily professional practice.To determine the KAP of the selected healthcare professionals, a convergent mixed-methods design was executed, consisting of two parallel phases of data collection. One phase was quantitative, and the other was qualitative . During We completed separate data analyses and brought the findings together to present a comprehensive view. We discuss each phase’s methodology and the results’ convergence below.We conducted a cross-sectional questionnaire in this phase. The following healthcare professionals were invited to participate: audiologists, human nutritionists, occupational therapists, physiotherapists and speech-language pathologists. The professional had to be a South African citizen registered with the Health Professions Council of South Africa (HPCSA). The target population included clinicians and academics with at least six months of working experience since completing a year of compulsory community service in the public sector. The final analysis included a convenience sample of 100 healthcare professionals spanning several professions, regions and universities attended. The authors identified participants in their networks, who shared it again with their communities of practice.Data were collected after we received ethical clearance from the Ethics Committee, Faculty of Health Sciences, the University of Pretoria (reference number 798/2020). The questionnaire was developed based on a literature review about environmental sustainability in healthcare and consisted of five sections: (1) demographics; (2) participants’ knowledge about local and global environmental issues and their health impacts; (3) attitudes towards environmental sustainability in general and concerning healthcare practice within their respective fields; (4) current practices in their respective professional contexts to maintain a healthy environment; and (5) barriers in implementing environmental sustainability and healthcare practice See .In A senior research consultant and statistical analyst at the University of Pretoria, as well as two occupational therapists and three physiotherapists with a particular interest in environmental sustainability, gave feedback on the questionnaire to ensure face validity. We uploaded the questionnaire to the electronic platform Qualtrics. Finally, we distributed the questionnaire as an anonymous link via emails and using social media.Two hundred and three participants started the questionnaire; however, only 100 completed it. The participants’ results with 100% questionnaire completion were considered and analyzed. We used descriptive statistics to describe the demographics of the participants. The summary statistics are given in the form of frequency tables for categorical variables and descriptive statistics such as mean, range, standard deviation for numeric answers.We used an exploratory, descriptive study design to qualitatively investigate healthcare professionals’ perceptions and practices regarding environmental sustainability . The popData were collected after we received ethical clearance from the Ethics Committee, Faculty of Health Sciences, the University of Pretoria (reference number 559/2020). Participants were contacted via email. The FGDs were conducted on the informed consent brochures, and the demographic section of the questionnaire was emailed to participants to complete and return. The demographic questionnaire collected information about participant’s date of birth, sex, profession, work sector, work setting, year of qualification, type of qualification, and university at which they graduated. The guest link to the online session on the Blackboard Collaborate Ultra (BCU) platform was distributed to participants via email. Five FGDs were conducted with the number of participants per session ranging from three to five . A semi-The transcripts were analyzed in six steps common to thematic analysis ,44: (1) After the data from the quantitative and qualitative phases were analyzed separately, the results were compared, and congruences and differences were determined. These are presented as descriptive statistics in tables and narrative passages in the following section.The participants of the quantitative phase were mainly from the OT profession (69%), whereas in the qualitative phase, the majority belonged to the PT profession (11/18 participants). Age ranges for participants in both phases were very similar, with a mean of 33.6 and 39.9 for the quantitative and qualitative phase, respectively. Please see In the quantitative phase, most (31%) of the participants’ primary area of work was within the private practice sector. The area with the second most participants was the education sector, comprising 15% of the population. The other main work areas include mental health services, community, and acute or secondary care. In the qualitative phase, the number of participants was evenly distributed between private and public sectors, with a few from non-governmental organizations. Participants were mainly clinicians and educators compared to academics/researchers and managers. A number of the participants in the qualitative phase were also junior physiotherapists in the public sector who rotated between settings. Work settings were evenly distributed between private practices, public hospitals, and local authorities.In the quantitative phase, most participants (83–87%) correctly defined essential terms such as sustainable healthcare, environmental sustainability, and environmental degradation. When asked whether they consider environmental sustainability in practice, 51% of the participants reported that they did not. They also indicated that they would describe their current knowledge regarding environmental sustainability as limited. They described their knowledge specific to environmental degradation, sustainability, and sustainable healthcare as limited. Of the participants, 77% reported that they believed that environmental degradation affects disease patterns and human health. The remainder indicated that they did not know if they believed that environmental degradation directly influences healthcare .“the basic needs for human life are reliant on the environment being able to sustain and produce itself” ; and that “environmental sustainability is highly related to human wellness because we rely on the environment for daily living” .In the qualitative phase, the central theme regarding the participant’s knowledge of environmental sustainability revolved around the insight that human well-being is dependent on a healthy environment. Participants emphasized that “let’s say a bird singing and good oxygen and the wind in the willows, that is good for the human, that’s something we would like to sustain that is good for future generations” .Beyond mere necessity for survival, participants also noted that the natural world can have positive effects on human well-being that need to be safeguarded for future generations, as “If we just look into the respiratory kind of a shift that [climate change] can have on a patient… If there [is] dust, for instance,… and dust levels that’s been controlled without having an effect on your patients’ [clients’] health, …the physical, as well as the psychological health of the patient” ; “…but let’s say the [degraded] environment [can influence] cancers and sinusitis and problems with new-born babies. We don’t want… that” .Negatively speaking, both deleterious physical and mental health effects were discussed by our participants, alongside the need to avoid these: “One big area that really influences health everywhere, and all our patients [clients] [is that] in [informal settlements they] are living in conditions, that’s not conducive to good health. So, it always impacts on their health. And again, psychological as well. If you don’t have a clean environment, a nice place to live, and clean air to breathe, of course, you will get sick” .Living in informal settlements that remain highly common in Southern Africa, that is, urban areas where inhabitants have small self-made dwellings often made of iron sheets, cardboard, or wood, was also highlighted as being detrimental to healthcare due to poor environmental conditions: “anything that we can do to use our resources sparingly, making sure that we leave something full for the future”.Building on the insight that human health and well-being depend on conducive environmental conditions, which, therefore, warrant protection, environmental sustainability was principally discussed as a question of managing resource consumption to, quite in-line with common definitions, ensure their availability to present and future generations alike. As noted by participant 6, PT, female, it is In the quantitative phase, 91% participants agreed that the current state of environmental degradation is concerning, with 5% disagreeing and 4% being neutral on the matter. Similarly, 91% percent of the participants also agreed that environmental sustainability should be incorporated into healthcare, as opposed to 4% who disagreed and 5% who neither agreed nor disagreed. That “the lack of environmental sustainability in the healthcare sector has an impact on our environment” was also agreed on by 88% of the participants, while 5% disagreed and 7% were impartial. Additionally, equally, 91% of the participants supported the statement that “environmental degradation has an impact on the health of individuals throughout their lifetime” (50% strongly agree and 41% agree) while only 4% of the participants disagreed.Most of the participants felt that healthcare professionals should take a leading role in advocating and implementing environmental sustainability in the healthcare sector (57% agree and 27% strongly agree), while only 7% disagreed with this. This finding differed slightly to questions of responsibility for environmental sustainability in the healthcare sector. Here, the highest percentage of participants felt that the government  should take responsibility (92%), followed by healthcare professionals (89%), leadership in communities  (84%) and individuals (clients) (80%). Yet, the absence of significant difference between these percentages, indicated a relatively even share of responsibility in the eyes of our participants.Although the participants reported a relative lack of knowledge and information regarding environmental sustainability in healthcare practice, an overwhelming 97% indicated that they would be interested in implementing relevant strategies and 93% were interested in corresponding educational input, with only 2% opposed and 5% impartial. “…reduce the impact on the environment [which] is at this stage about education and informing people” ; “you have to educate them on what is environmental sustainability, how can the environment be preserved and what are the benefits of as well as making them understand” ; “…obviously as a professional creating more awareness, like using less paper in our practices and like the more practical things so I know like with nowadays like of the more telehealth is you know a thing coming up” ; “we have to start working on creating more awareness and making people aware how to use things, and reuse things” .The high degree of interest in implementation and education was also matched in the FGDs, but was additionally linked to passing on awareness, knowledge and practice to patients [clients], as to “Basically, being more friendly to the environment so that future generations can also have time on earth experiencing the environment as it is today, and still experiencing nature, as it is.”Matching general knowledge of human health depending on environmental integrity, concerns for future generations and the benefits of looking after the environment were also expressed clearly by participant 4, PT, female: In the quantitative phase, more than half of the participants (58%) disagreed with the statement that “the healthcare sector is currently taking environmental sustainability into consideration in healthcare practices”, while only 8% of the participants agreed and 19% remained impartial. The same number of participants (58%) also reported that they had considered implementing environmental sustainability in practice. More specifically, 44% reported that they were implementing environmental sustainability in some form, while 51% claimed not considering it yet when using or purchasing equipment, resources, consumables, or other devices.In the qualitative phase, three main practice themes emerged from the analysis, covering: intervention and practice environments; practices related to waste, recycling, reusing, and reducing the use of resources; and opportunities for advancing environmental sustainability.“Let’s say it’s after a stroke and rehabilitation will be lifelong in an ageing population. My feeling is [that] if you can combine nature with the rehabilitation, that is better” ; “…encourage people to grow plants, or if you cycle, that is, encouraging patients [clients] to grow their own tree and doing a vegetable garden… and reducing our carbon dioxide footprint” ; “at an old age home we gave palliative care… but we were still be able to take them outside and they used to really enjoy going to the sun” ; “working in public health having group classes outside benefits the patient [clients] a lot more; they seem to be a lot more cheerful. Even if we look at psychological and mental aspects of rehab [rehabilitation] … outdoors they definitely have more of a positive attitude” .In the FGDs, it became clear that some participants were in favor of clients spending time outdoors during treatment sessions and when relaxing: “The department where I used to work was not very neat and there were old walking frames standing around that needed to be repaired” .The benefits of outdoors practice were further supported by the observation that practice environments can also be less than favorable: There was a matching focus on waste and practices related to recycling, reusing, or reducing the use of wasteful materials across the quantitative and qualitative phase of our study. In the quantitative phase, 24% of the participant that chose to elaborate on the open-ended questions stated that they were currently recycling in their practice, and 7% mentioned using biodegradable materials in practice. Additionally, 73% indicated that they consider reusing and recycling when buying/using equipment and resources, 9% indicated considering biodegradable materials, and another 9% consider the use of less equipment. Participants also indicated that they thought that equipment such as PPE, thermoplastic and plastic packaging, paper, and plastic equipment contribute to climate change and environmental degradation. “we use our recyclable materials to do activities, especially in hospitals on areas or community areas where there is not a lot of resources” ; “…there are active recycling projects happening at the hospitals. However, I find that most of the hospital’s important waste, like paper that could be recycled, is just thrown into normal dustbins” . “…with COVID-19 at this stage we are just throwing away so much plastic and gloves and aprons and stuff it actually breaks your heart” .In the qualitative phase, participants reported on recycling in hospitals, departments, practices, and in their capacity, but also noted inconsistencies in implementation: “I try to implement it into both my professional and personal life, but unfortunately you can’t really be equally environmentally sustainable or environmentally conscious in your personal and professional life if you are a healthcare worker” .To some extent, these inconsistencies or tentativeness were also mirrored in more personal attempts and reflections on implementing environmentally sustainable practice. This was clearly expressed by participant 6, PT, female who stated: “I must say going from paperless to the cloud... I prefer my accounts online. But my clinical data is on paper”; “we have got solar heating on the premises where the practice is”; “I think the load shedding made a lot of physios think about using machines. If a patient expects a certain method of treatment and it’s not possible to give it; that they might cancel appointments or feel that they are not properly attended to. The way that I work, I never touch a machine, although I have an electrically adjustable plinth that I absolutely love” .Giving a few more specific examples, participant 7, PT, shared her efforts in moving to paperless work, using fewer electronic apparatuses, solar heating, and saving electricity: “So I think there’s like so many opportunities and potential in South Africa that we can use to make use of, like, recycling to benefit the community as well” ; “and the thing about Africans, we have so many opportunities like putting solar panels for hospitals to save on the energy they need” .The discussions also made evident that participants saw considerable potential for advancing environmental sustainability within the South African context: “Physios especially in private practice who have a lot of people they interact with, and people always see healthcare professionals as sort of role models, you, if they see people are doing it then it’s not that much of an effort, and it is the right thing to do, then they will be more eager to try it themselves. So, I think we have to be an example, you know just to make the difference, where you are in your own practice, and then be like a role model or a champion for environmental sustainability” .A significant opportunity noted was also the potential to act as role models in environmental sustainability: n = 64, 37%), a lack of finances , the effort required , a lack of time  and a lack of resources . Only two persons (1%) indicated that they were not interested in having an environmentally sustainable practice. Additional information provided included the poor accessibility of environmentally sustainable materials and equipment, and the costs associated with purchasing these; as well as the influence of team dynamics such as a lack of collective insight, common goals and buy-in from all the members.In the quantitative questionnaire, participants were able to choose more than one barrier from a pre-determined list; as well as indicate other barriers not listed with a description. From this, the main barriers for the implementation of environmental sustainability included a lack of knowledge . Closely related to that the absence of recycling depots and collections by the local authority, even in urban areas, hindered good intentions, especially as it could be at the person’s own cost: “You really have to drive from facility to facility with bags in the back of your boot during office hours to recycle. So as much as we would like to do it is a difficult thing” ; “So, if it’s made easier, then people will probably do it more and will be more positive about it” .In the qualitative phase, the barriers discussed all related to either the lack of relevant policies or infrastructure. As argued by participant 2, OT, female, The findings from our study of South African health professionals’ KAP regarding environmental sustainability in healthcare strongly resonate with findings from similar studies from other regions of the world ,23,26. MWhat is encouraging though, is that most participant health professionals considered environmental sustainability and its further implementation as being of critical importance for the health of present and future generations alike. While many expressed that responsibility for its advancement in the health sector should be shared among governments, health professions, communities, and clients the vast majority of study participants also shared the sense that healthcare professionals should show much more involvement and leadership in this area and act as role models to clients and communities, based on a growing understanding of the relationships between health and environment. This largely positive trend can be observed clearly everywhere now, as relatively new fields such as sustainable healthcare and planetary health are growing at a rate that is making it near impossible to track the waves of new publications, research projects, organizations, activist efforts, education initiatives, etc., that are emerging everywhere around the world.That our study asserts lack of knowledge as one of the main barriers to advancing environmental sustainability in healthcare  simultanWhile lack of finances was identified as the other main barrier next to lack of knowledge, the fact that this was associated particularly related to equipment accessibility and costs potentially also points to an issue that might nonetheless be remedied by way of education (and related research and innovation). That is, if the high cost of more environmentally sustainable equipment is perceived as a barrier, it begs to question whether more education about the reduce-reuse-recycle triad  might not be critical to overcome the perception that equipment itself might be the solution, rather than its reduction, reuse, and recycling . This isAs highlighted by our study participants, and equally in-line with other studies, however, it should be clear that education is far from a silver bullet since a range of systemic barriers are significantly impeding the implementation of environmental sustainability in South African healthcare practice across education, individual practitioner, and systems scale ,52,53. BOur study was not free from limitations. The professions were not equally represented in both phases of our study. Most of the respondents to the questionnaire were occupational therapists and worked in two of the seven provinces of South Africa, specifically, KwaZulu Natal and Gauteng. As the FGDs were conducted virtually, occasional poor network connectivity led to sections in the recordings that were not sufficiently audible for transcription. Self-reported knowledge is limiting, especially as explanations of some key concepts in the questionnaire items were not given. Additionally, completion of the questionnaire may have seemed too arduous, considering only 100 of the 203 participants (51%) did not complete beyond the demographics section. The first question required a matching of terms and definitions, and in its formulation, this question may have been confusing or rendered participants unsure of how to proceed. It is also possible that our study only included participants that had a pre-existing interest in environmental sustainability and so a disposition to have some basic knowledge and positive attitudes to the subject matter.We recommend that future research build on the findings of this study while considering its limitations. For a better completion rate of the questionnaire, further instrument validation needs to be performed prior to its roll out in other contexts. Considering the vulnerability of Sub-Saharan Africa we recommend continued research especially in this region, where corresponding knowledge is equally lacking and urgent. Most importantly, we need concerted efforts in education; research that generates reliable and evidence-based suggestions for practice; and the policies and infrastructures that will make environmental sustainability a staple foundation of Sub-Saharan Africa’s healthcare systems and services.To lay the foundation for context-relevant interventions to advance environmental sustainability in South Africa’s healthcare system and services, the aim of this study was to identify South Africa’s healthcare professionals’ KAP, and barriers regarding environmental sustainability in healthcare. This was achieved through a convergent mixed-methods study design. Results indicated overwhelmingly positive attitudes and a high degree of interest in education, implementation, and taking on more corresponding responsibility. There is, however, a lack of substantial knowledge on the subject matter, and only tentative implementation of practices relevant to recycling, reusing, and reducing waste and resource consumption. This highlights the need for urgent integration of sustainable healthcare and planetary health education in South Africa’s healthcare professionals’ curricula. Additionally, systemic barriers to implementation—lacking resources , policies and infrastructures—must be addressed to harness the extant enthusiasm and advance environmental sustainability in healthcare practice on the African continent.


The aim of this study was to evaluate the acceptability and feasibility of a theory-derived sedentary workplace intervention for police office staff. Twenty-four staff participated in an 8-week intervention  incorporating an education session, team competition with quick response (QR) codes, team trophy, weekly leaderboard newsletters, a self-monitoring phone app, and electronic prompt tools. The intervention supported participants to reduce and break up their sitting time with three minutes of incidental movement every 30 min at work. Feasibility and acceptability were assessed using mixed methods via the RE-AIM QuEST and PRECIS-2 frameworks. The intervention was highly pragmatic in terms of eligibility, organisation, adherence, outcome, and analysis. It was slightly less pragmatic on recruitment and setting. Delivery and follow-up were more explanatory. Reach and adoption indicators demonstrated feasibility among police staff, across a range of departments, who were demographically similar to participants in previous office-based multi-component interventions. The intervention was delivered mostly as planned with minor deviations from protocol (implementation fidelity). Participants perceived the intervention components as highly acceptable. Results showed improvements in workplace sitting and standing, as well as small improvements in weight and positive affect. Evaluation of the intervention in a fully powered randomised controlled trial to assess behaviour and health outcomes is recommended. Just because of what I’ve said earlier I was mostly more focused on the health bit and making sure the organisation are taking part rather than myself”.“(P17)Participants who did not attend an education session most likely did not complete the booklet. Managers stated that they participated in the study to demonstrate solidarity with employees:Electronic promptsI think having several people in the office did, it really helped because as I said, especially those that are more regimented and sat at their desk, they would have an alarm set. They would get up every, so, literally one person would get up and all of us would go, ‘It’s time!’ and follow each other up”.“(P14)To begin with, implementation of some intervention components had to be adapted due to security permissions. For example, because free computer prompt software options were open source, it was not possible to use these in a high security setting, and there was neither the time nor the resources to procure closed source software. The intervention was adapted by instructing individuals to choose from a selection of electronic prompts available on their phone or computer . It was hypothesised that if the participant chose their preferred mode of prompting, they would be more likely to engage with it. Engagement with the prompts varied based on the individual but according to the interviews, the majority of participants used a prompt tool or were prompted to break up their sitting by their colleague’s prompt tool or behaviour:As time went on, I kind of got used to it and then I was looking for it, even before it pinged, if you know what I mean. But, and I think the QR code really helped in like giving you a reason to get up”.“(P8)Over time, participants began to anticipate the prompt showing improved awareness of time spent sitting:QR codesJust it [the office QR code] was the closest by. I did use the one in the canteen a few times. And I used the one that I had on the card as well for like the meetings”.“(P9)Participants indicated that the most frequently used QR codes were those located within their respective offices:Yeah, I’ll have a meeting and, well, we said this before about maybe standing up, but yeah in practice it doesn’t work so much”.“(P4)Evidence of behaviour patterns emerged; for example, a couple of participants regularly walked during their breaks and would scan the same QR codes in the order that they passed them. Participants still found it challenging to take breaks and/or stand during meetings:CompetitionI like that camaraderie that, ‘Let’s do it together. Let’s motivate each other”.“(P15)The competition helped make the taking of breaks acceptable because of the team-based nature of it:They cheated!”.“(P9)A complaint of cheating made in a joking manner over email was explored by the research team in the second week:Sometimes mine didn’t register. Because I was going to scan it and I thought I couldn’t connect, particularly downstairs. Or sometimes, my phone’s not brilliant, it wasn’t connecting to wherever it should connect, so it’d scan but then it gets stuck”.“(P4)QR code break logs checked by the researcher (MLB) confirmed that two participants were repeatedly logging breaks less than 30 min apart. Once the pattern was detected, the decision was made to cap the number of breaks a participant could claim based on their working hours that day . The competition also had to be altered due to the very high and very low engagement of certain teams. It was felt that large discrepancies in points between these teams would lead to amotivation among low engagers and therefore the decision was made to average the team points based on participating individuals within the team each week. Interviews revealed that there were occasional issues around internet connectivity and specific devices that affected their ability to log their sitting breaks:EmailsYeah I liked that. I think that was good and everybody was like, ‘Oh, [colleague’s name] you’ve won again on that team. ((laughs)) Something like that that’s fine, you know, a little bit of fun isn’t it? And a little trophy. ‘Oh yes, we’ve got the trophy’. Yeah so that was good”.“(P18)Participants reported looking forward to the emails each week in large part due to finding out the leaderboard standings:I think it’s always good to see little messages and things. That little extra inspiration or something”.“(P18)No adaptations were made to the intervention apart from the research liaison adding a personalised message in weeks one and five. Participants did not feel the presence or absence of management’s involvement with the emails impacted how they perceived the message, nor did it affect their engagement with the rest of the intervention. It was generally remarked that they felt supported by the organisation:® appRise and rechargeI quite like the way it laid out like the colours and the circles and things. Quite visual it was easy to see how you’ve done in the day”.“(P13)Most participants reported downloading and engaging with this sitting break tracking smartphone app:I did wonder whether it was that accurate because there were some times where I swear I’d got up and it hadn’t registered. And I think in that sense, the biggest problem that I had, ‘cos I don’t really have pockets in my trousers, so I’ll just have my phone on my desk so if I do just nip to the toilet or something, I’d often forget to take the phone with me”.“(P13)Importantly, the app only gave feedback on break behaviour. The optional prompting function was not operational throughout the entirety of the study and thus was not used by participants. An issue that was sometimes reported was accuracy, but it was unclear if this was due to app performance or participants taking breaks without their phone:Study measurementsn = 13). A couple of participants remarked on receiving the letters, stating that they impacted their other health behaviours such as nutrition and health seeking behaviour:My cholesterol was better [at the end] which I was a little bit worried about. And so I did make some dietary changes as well. […] probably, after I received my letter about my cholesterol. So then I decided to just make a few changes”.“(P10)Referral letters were provided after baseline measures to participants with cardiometabolic risk marker readings outside of NICE health guidelines Implementation Maintenance No follow-up was planned after the intervention had ended. In post-intervention interviews, participants discussed their plans for maintenance which included continuing to take frequent breaks from sitting, although sometimes at a lesser frequency, but also attempting/continuing with other healthy behaviours such as making use of sit-stand hot desks, improving their diet, and discussions around forming a walking group:I don’t think I will do half an hour. I would definitely try and do it in within an hour to be able to get up and go do something. Yeah, I think that would work better for me”.“(P12)That’s something I’ve been doing with the up and down-y desks. A lot more is standing up and doing the shift”.“(P1)New sitting break habits were established in just eight weeks to the point that one person earned a nickname for getting up often to make hot drinks for colleagues:Generally, I’ll make sure, as I say, I’m making coffee every hour and a half, at least. I’ll be up doing that and obviously taking breaks in between then, so yeah, that is definitely more of a habit”.“(P1)Others were regretful that they had not done more initially to form new habits:I mean I would like to [continue] however, in reality, I probably should have bought into the kind of psychological techniques that you suggested early on… largely because of the kinda the extra strain that I was under”.“(P12)Maintenance (by the organisation)Long-term follow-up was not assessed in this feasibility trial; however, feedback following a presentation by AMC and MLB to the police Health and Wellbeing Board in February 2020 indicated that the police force would like to consider continuing with the QR code competition as routine practice.During work time, there were significant differences from baseline to end of intervention . This included decreased sitting time −17.65 min per workday or −3.68% of the workday) and increased standing time (15.49 min) with medium effect sizes see . PercentThere were no significant changes in any daily sitting, standing or stepping variables  from baseline to end of intervention see .The data for these variables are presented in Positive affect significantly improved from baseline to post-interventions with a large effect size see . No otheThe A-REST intervention was feasible to implement and demonstrated good acceptability among police staff. In terms of feasibility, the study was assessed as highly pragmatic, had a 12% reach among the targeted population, was adopted across a variety of departments, and was largely implemented as intended, though there was potential for unintended BCTs and spill-over effects. In terms of acceptability, the intervention had 80% participant retention, produced positive changes in sitting behaviour at work and positive affect, and received favourable and constructive interview feedback.PragmatismMost aspects of the study, according to the PRECIS-2 assessment, were pragmatic as it was deployed under usual conditions at the participating organisation with participants who may be representative of typical police staff ,82. ThisThis is the first multi-component intervention aiming to reduce and break up sitting by implementing a team-based QR code competition. Interventions where entire worksites, offices or floors of a building participate together has been found to encourage social support  and beneReach and adoptionA reach of 12% in the police setting was comparable to other sedentary workplace interventions ,87,88,89Adoption rates showed that the intervention was feasible across a range of police staff and departments, although uptake was low in some departments. This could be due to eligibility criteria limiting the participation of part-time workers, those with active/mobile duties, and those who work across different office sites during the week. Increasing adoption in police staff may require a more inclusive set of eligibility criteria when scaling up.ImplementationQualitative perceptions around engagement with the intervention found that frequent short breaks in sitting were feasible to implement and acceptable to participants. This is important because productivity concerns can be a barrier for police staff in reducing and breaking up sitting . In addiParticipants expressed appreciation for the organisational support demonstrated by personalised weekly emails sent out by management. However, management did not realistically have the time to write and send personalised messages every week. A pragmatic solution would be to ask management to brainstorm a range of short, personalised messages at the outset of the intervention (perhaps as part of the education session), which could be transferred onto the email template and scheduled for automated delivery each week. This pragmatic approach should be considered when scaling up interventions that utilise organisational support in this way.Unintended effectsData collection was identified as providing unintended BCTs for some participants, such as Monitoring of behaviour by others without feedback, Monitoring without feedback, and Biofeedback. Repeated measurements may influence participants’ motivation . Doctor MaintenanceMaintenance was not evaluated in this feasibility trial. However, management feedback to the research team revealed that the QR codes were still present in the organisation two months after the trial and that there were plans to investigate how the organisation could make the competition routine practice. Participants talked about continuing with their new sitting habits and starting up a walking group. Long-term follow-up of individual and organisational maintenance behaviours should be evaluated in a full-scale trial.® activity monitor and ‘Bupa Boost’ smartphone app to deliver individual components , as well as social components . However, the intervention did not lead to changes in sitting  [In the present study, sitting time at work significantly reduced from baseline to end of the intervention. Sitting appeared to be replaced predominantly with standing. According to interviews, the most frequently accessed QR codes were those in participants’ offices, thus, they did not have to walk far and may have spent most of their break time standing. Interventions targeting (and reporting on) sitting outcomes are understudied in the police and it is therefore difficult to make comparisons. The PAW-Force trial , a 12-wenal use) . Other snal use) ,74,84,95nal use) ,87,96. Inal use) ,97,98. ADespite there being reductions in sitting at work, the lack of change in total daily sitting may suggest a compensation effect outside of work hours whereby participants sat more during non-work hours ,100. FutThere were limited effects of the intervention on cardiometabolic risk markers, although body weight decreased by 0.86 kg on average. The timeframe of eight weeks in the present study may not have been sufficient to achieve improvements in other cardiometabolic risk markers. Sedentary workplace interventions have shown promise for improving cardiometabolic risk markers, but studies suffer from small samples sizes, low quality, and inconsistencies across risk markers assessed and outcomes achieved . Short-tLimitations of the study involved threats to internal validity. The single-arm, repeated measures design meant there was no control group for comparison of potential behavioural and health effects. A further limitation is that the study was not powered for detecting differences in secondary outcomes. Thus, caution should be exercised when interpreting the results regarding intervention effects. A further limitation was that participants self-selected for the intervention leading to possible bias in the results . InformaData collection was identified by nearly all participants as providing unintended BCTs, the effects of which may be considered a threat to internal validity. The ‘mere measurement’ effect of repeat testing has been shown to influence sedentary behaviour due to greater awareness of the study purpose . Other lAs feasibility and acceptability of the intervention were the primary outcomes of this study, the limitations of this study design were balanced by the greater amount of quantitative and qualitative data provided on the intervention experience . The useThe cohort was predominantly white British (87%) and female (79%), which may limit the generalisability of the findings. Recruitment methods may have an impact on participation levels. The research liaison and the study lead (MLB) were white female, which might have influenced recruitment. The online recruitment methods occurred via emails disseminated by departmental line managers (whose demographic characteristics were not captured) and via e-poster  on the organisation’s intranet. Potential participants were encouraged to sign up with officemates/colleagues/friends at work because office team clusters of three people were needed. Also of note, 12.5% of participants in this study were people from ethnic minority backgrounds which was similar to figures (15.7–22%) reported in prior sedentary workplace interventions ,73,74. TThe main strength of this study is the comprehensive, mixed-methods assessment of feasibility and acceptability using the standardised PRECIS-2 and RE-AIM QuEST frameworks. The present study also adds to the greater understanding of how and if data collection, as perceived by participants, delivers unintended BCTs. A strength of the study was that all outcome measurements were deemed as feasible and acceptable, though the short-term nature of the intervention remains a limitation. Longer-term studies are needed to evaluate primary and secondary outcomes over time. This is the first study, to the authors’ knowledge, that has used both frameworks simultaneously to comprehensively assess a sedentary workplace intervention trial. The mixed-methods approach also provides a richer understanding of RE-AIM components to better inform the scaling up of A-REST and other interventions in fully powered RCTs.The findings from this study suggest that it is feasible to implement and evaluate a theory-based, multi-component sedentary workplace intervention in a police staff setting. The study was highly pragmatic in terms of eligibility, organisation, flexibility for adherence, primary outcome, and primary analysis. Reach and adoption indicators showed that the intervention was feasible with a range of police staff and departments; and had employees who were demographically similar to those in other multi-component interventions. Reach, adoption and implementation were somewhat affected by security procedures at the participating organisation. With regards to implementation, the intervention was delivered mostly as planned with minor deviations from the protocol. There were potential improvements in sitting and standing in response to the intervention. Overall, the findings from this study suggest that a full RCT powered to detect changes in sitting and health outcomes should be conducted to establish the effectiveness of the intervention and its adoption into routine practice in the police setting.


I have read the interesting and informative paper recently published by Alghnam and colleagues that examined associations between obesity and diabetes (DM) and hypertension (HTN) . This crSecondly, patients with type 1 diabetes (T1DM) who depend on insulin from the onset of the disease were less likely to have been included in the study; this is because insulin, despite its near-exclusive indication for DM, was not considered when identifying diabetic patients. The system captures the discharge diagnosis only, and hence, such patients who have T1DM as a secondary diagnosis would not have been identified. Furthermore, insulin can be used to augment or even replace oral glycemic medications in patients with type 2 diabetes mellitus, which, if not addressed, may have resulted in those patients also being overlooked.Thirdly, cancer was among the diagnoses extracted from the system; however, it is unclear why it was included as it was neither discussed in the results section nor represented in the tables/graphs.p < 0.01), the potentially confounding influence of DM was not controlled for. Similarly, a significant association between BMI and DM (p < 0.01) was found, without controlling for the potentially confounding influence of HTN. Hence, it is conceivable that the significant associations found between BMI and HTN and between BMI and DM may be due, at least in part, to patients with both HTN and DM as the “diabetic/non-diabetic” groups did not filter out patients with HTN and DM was not excluded in the “hypertensive/non-hypertensive” groups.Finally, the investigators classified patients into diabetic and non-diabetic groups, and hypertensive and non-hypertensive groups, but did not account for patients who may have had both conditions. While the study reported a significant association between BMI and HTN (While the study provides important information regarding the prevalence of obesity and its association with DM and HTN, I encourage the authors to further clarify the points raised in this letter, as such clarification would be a valuable addition to the existing literature.


The electronic MEdical Records and GEnomics (eMERGE) consortium will return risk reports pertaining to specific diseases, a key component of which will be polygenic risk scores (PRS), to 25,000 participants, including 5000 children. Understanding comprehension and the perceived value of these PRS-based reports among parents will be critical for effective return of results in children. To address this issue, we conducted semi-structured interviews with 40 African American and Hispanic parents at The Children’s Hospital of Philadelphia and Boston Children’s Hospital. Each participant received a hypothetical risk report identifying their child as high risk for either type 2 diabetes or asthma. Participants were assessed on their comprehension of absolute versus relative risk framing, likelihood of following risk-reduction recommendations, perceived value of the information, psychosocial impact, education/support needed, and suggestions to improve the PRS-based report to make it more accessible. Results demonstrated high perceived value in receiving PRS-based reports but also draws attention to important shortfalls in comprehension due to factors including the health of the child, family history, and how the risk was framed. This study provides an insight into implementing the return of genomic risk scores in a pediatric setting. The last several years have seen a surge of interest in the use of polygenic risk scores (PRS) to assess an individual’s disease susceptibility. PRS, which use genotype data to assess risk, have the potential to outperform clinical predictors for several diseases, including but not limited to breast cancer, type 1 diabetes, asthma, and prostate cancer ,3,4.Several studies have shown that simply providing people with their genetic risk information does not lead to improved health behavior ,6. LittlBarriers to acting on PRS information may also affect adoption of improved health behaviors and may include income inequality and health disparities. The ethical, legal, and social implications of reporting PRS, particularly when individuals do not have the means to change lifestyle, are important to consider . AdditioTo further understand how PRS could be integrated into clinical care, the electronic MEdical Records and GEnomics Network Phase 4 (eMERGE 4) was funded by the NHGRI/NIH to conduct a large-scale study to develop and validate PRS for common adult and pediatric diseases and study the medical outcomes and impact on providers and participants. The Network will target enrollment of racially and ethnically diverse and underserved populations, who have yielded comparatively less benefit from genomics research to date . A majorTo inform the development of return of results materials and processes in the pediatric setting, we examined the perceived value of returning genomic risk estimates in children to their parents and investigated factors influencing that perception. We conducted semi-structured interviews with parents who received hypothetical risk reports on their child to assess their (1) understanding of PRS-based hypothetical reports, (2) overall risk perception, (3) barriers to following report recommendations, and (4) education/support needed. We aimed to explore whether factors such as risk framing, overall comprehension of the PRS and report, and the ease of implementation of risk-reducing recommendations influenced parental perceptions of genetic risk estimates. The goal was to obtain data to develop best practice recommendations for the return of genomic risk estimates in children. Ultimately, these findings will be used to inform the development of reports returning PRS-based risk to parents.Participants were parents/legal guardians of children enrolled in the Center for Applied Genomics at The Children’s Hospital of Philadelphia (CHOP) or the Precision Link Biobank at Boston Children’s Hospital (BCH). Patients at each institution were offered voluntary enrollment to the biobanks for research study purposes from trained study staff who approached patients during hospital stays or routine-care visits in accordance with site-specific IRB protocols. Those who were enrolled in the biobank had the option to indicate that interest in hearing about future research studies, if eligible, by being re-contacted. Those who had enrolled in the biobank within the previous two years, and who had given permission for re-contact, were contacted by the recruitment team(s) and given information about this study. Because of the eMERGE 4 Network’s focus on enrollment of traditionally underrepresented individuals, parents of Black/African American or Hispanic ancestry were contacted. To avoid bias in the interviews, those individuals with known diagnoses of type 2 diabetes and/or asthma were excluded. We were otherwise naïve to the medical history of participants’ children. The study was approved by the Institutional Review Boards (IRBs) at CHOP and BCH.To control for order effects, participants were randomized to receive a hypothetical risk report called “GIRA” or “Genome Informed Risk Assessment” based on the GIRA planned to be returned in the eMERGE 4 study . The repWithin each condition, participants additionally were randomized to receive the hypothetical risk estimates presented as either (1) absolute risk  or (2) relative risk . Half of the participants were shown the absolute risk reports first, and half were shown the relative risk report first. They were then presented with the alternate report (absolute or relative), allowing them to compare the two methods of displaying risk .https://www.dedoose.com, accessed on 22 July 2022). Codes were used to identify participants in this study and then shortened for readability. The first letter indicates what site the participant was from . The second letter indicates what condition the participant was high risk for . The third letter indicates which risk framing method the participant saw first . The following numbers are unique study identification codes to differentiate participants during coding.Two interview guides were developed, one for a hypothetical risk report for T2D and one for asthma see  During tQualitative coding was used to systematically categorize themes and patterns based on content analysis of the interviews. The analysis team  used a deductive coding approach, which leverages codes developed a priori by the team . The codebook was refined via preliminary coding of the first four interviews by two study team members (M.C.D. and S.T.). Discrepancies between the coded interviews were reviewed and adjustments to the codebook were made throughout the process. Once the final codebook was developed, coding was completed separately by the two coders (M.C.D. and S.T.). Each coder coded half of the remaining interviews, from both sites. After initial coding was completed, each coder reviewed the other coder’s interviews for reliability. Coders then worked together to review and identify discrepancies between datasets, which were ultimately merged.Each site conducted 20 interviews for a total of 40 interviews . There wn = 40), and relatively small effect sizes, we were not sufficiently powered to attempt quantitative analyses of the six Likert-based questions listed in the codebook. As such, the results below are based on qualitative analyses of the study interviews. With a small sample size . Additionally, knowing exactly where their child stands in their risk to develop the condition was something that was very important to the participant, and this was something perceived as more easily accessible using absolute risk, “It’s more helpful with the number of the actual percentage, because as a parent, I feel that knowing the exact amount would probably be better to obtain the information” (BAA06).When given risk displayed in two different formats, 50% of participants preferred absolute risk, while 37% of participants indicated a preference for relative risk see  . Thus, there was often a lack of concordance in risk perception between participants in this study and the eMERGE Network. Other participants interpreted the high risk result as low/average. One participant commented on the risk inherent in the (reported high) T2D result by saying, “I would say, average. Because sometimes just because he has genetic predisposition doesn’t mean that your child will actually get the disease” (BDA19). Due to the common nature of these conditions, there was some confusion as to whether the absolute risk was even higher compared to the general population, “I guess if I were reading this I would say, wouldn’t everybody be 2%?” (CDA23). It is important to note that baseline risks were not included on the hypothetical reports, causing participants to rely on various other factors and experiences that play into risk perception.Although most participants preferred absolute risk framing, the percentages were often perceived as indicative of low risk. For T2D and asthma, respectively, the framing of “2% risk” and “9.1% risk”, which the eMERGE Network defined as “high risk,” often was perceived differently by participants, “I don’t have it, but my sister and aunts have it, and my husband has it, so I figure she has it on both sides. It would be high” (CAA30). Having close family members with the condition lead participants to state that their children were automatically at a higher risk.Family History: Participants with a strong family history of the condition expressed that the high risk report was warranted based on their family history, “I trust her judgement, which is great. So as long as I trust her, I don’t have to worry about what she has to tell me” (CDA22).Trust in primary care providers (PCP)/pediatrician and hospital: Seeing that the report was from a health care system and/or doctor that they trusted led some participants to accept the report at face value. One participant stated, “My background of having a kid with medical conditions—we have very pressing medical conditions, and then we have medical conditions that I would go crazy if I had to constantly worry about. If I got this result about asthma, I’d be like ecch, I’m not going to worry about that” (BAA05).Children with multiple medical conditions: Although we did not ask participants about their child’s medical conditions, some participants mentioned that they have a child with extensive health concerns and some stated that those existing health concerns supersede concerns about the risk report, “I mean it’s a lot of variables that they can or cannot get it, so it’s not definitive…it all depends on their genetics, and their surroundings, and just being around certain things” (CAR32).Role of environment: Many participants noted the multifactorial nature of the conditions (asthma and T2D) and that the risk for developing the condition was not dependent only on genetic risk, “All participants reported willingness to take at least one risk-reduction step, which was consistent across phenotypes and reports. However, respondents highlighted barriers and needed resources.I know it’s hard to get my child to eat more and trying to get him to—physically try to get them to eat more or to participate in certain activities”. (CAR27). Several participants noted that having a child with a behavior disorder, such as ADHD or autism, could magnify these barriers, “She’s autistic, so the behavioral issues of her, and the lack of motivation and cooperation with her” (CDA29). Participants also noted that pressure from their child’s peers and stigmatization could diminish compliance with recommendations , “… having a child feel different from their peers and stuff… I know that that can be a toll on kids, too. You know, like if they have to take an inhaler and stuff and the age group”. (BAR06).Some participants expected a lack of motivation/cooperation in their child, including a reluctance to change diet or exercise habits (T2D), monitor blood sugar (T2D), or participate in certain activities (asthma/T2D). One participant said, “I hate my copays. I hate the $30.00 copay…that’s a barrier for many people. I know people who don’t go to the doctor because they don’t have the copay”. (CDA23). Another participant summarized a phenomenon thought to affect many families saying, “It’s sad that healthy food is more expensive than everything we shouldn’t eat. So, when you don’t qualify, like so many others, for food stamps, it digs a very, very deep hole in the pocket” (CDR36). Lack of time was identified as a barrier, for example, to attend clinic, exercise, and cook healthy meals: “Time is a resource, and you know, a resource that many of us do not have, especially if you have a child where you’re not able to get off. Your job doesn’t offer, you know, like medical leave or anything” (CAA25). Not having a detailed plan with the PCP was also identified, which speaks to a desire for shared decision-making and more education with someone they trust, “It would be good if, you know, the doctor would put a plan together, like Monday through Sunday” (CDR34). Additional barriers/lack of resources include a perceived lack of control over what occurs in the care of others , having other children (thereby straining resources/time), and problems applying too many changes at once .When discussing risk-reduction steps, participants highlighted difficulties in having the proper resources when it came to (1) affordable healthy food, (2) educational materials, (3) insurance, (4) in-home behavior services, and (5) physical activity/recreation. Barriers related to affordability/cost were expressed, where even relatively minor costs can be prohibitive. One participant stated, “When I look at diabetes, people who I know who have had it…that’s just because of my experiences. So, I would say a little anxious”. (CDA23). Additionally, having no experience with this type of result and report made individuals feel overwhelmed by the amount of information and the impact associated with it, “I can see feeling a bit of like overwhelmed and confused at first. Especially if you don’t take the time to stop and read through…I would definitely be anxious or worried”. (CAA25).The three most reported negative responses expressed by participants were anxiety (40%), worry (33%), and confusion (23%).  Past experiences with the condition or having been previously told their child was high risk made participants concerned with the results on the report, “It gives you a sense of relief, as well. I think that you have a report that is going to help you alleviate more risk”. (BAR14). Specifically, the report section on “ways to reduce risk” made participants confident they had the proper resources to lower the risk and receive care, “I like the fact that I’m confident in the things I can do to change…I’m confident I can fulfill it”. (CAA35).The top three reported positive responses were curiosity (38%), relieved (28%), and confident (25%). Many participants felt this report was a way to reduce the chances of their child developing the condition and provided them with information to act in their child’s best interest, saying, “, “When I first looked at it, the first thing that jumped out was the red section…which freaks me out. But then when you read more into it, it is not as scary as you think it is” (BDR20). Seeing the words “high risk” and the colors associated with the report, made participants feel there was a high level of concern for their child. However, once participants were able to read through the report, several stated it made them feel at ease and empowered to help their child, “It gave me hope because that way…it doesn’t have to be a sad situation where the illness defines her…it makes me think, okay, well now that I read this report, I can help my child make sure she’s healthy” (CDA23).Although most participants had some sort of response to the report, many felt negative feelings at first, but after processing, felt more positively overallIf once it does come up, you start doing research on it and you can prepare yourself for what’s ahead”. (BAR06). Additionally, they considered genetic risk testing and receiving risk reports to be beneficial for understanding not only the potential risk for immediate family members, but also their own risk in the context of family history, “If I got this report for my son I would then be concerned or already preparing for my daughter to possibly have the same genetic disposition” (BDR04).While anxiety, worry, and confusion were common reactions, many participants expressed that seeing these kinds of reports would help them feel prepared to take actions to reduce their child’s risk for getting a disease, “A lot of time when you have questions and you need information… you count on them to be able to refer you to a specialist… to give you the information you need so that you can understand”. (CAR27). Additionally, most participants stated that their child’s PCP would be able to clearly explain the results of the testing, monitor for signs of the disease, and they would trust their PCP’s recommendations to reduce risk. As one participant noted, having their child’s PCP review the results helped them feel confident moving forward with care, “It’s very important because I don’t know what to look for, so with the primary doctor… they see different signs of multiple different things where they know to have it looked at, stuff that I may look at as something small and not important but to them, it’s something that may mean a whole lot in her development”. (CDR36).Recognizing participants may not understand everything on the report themselves, the majority (88%) stated that having their PCP explain the results of their genetic risk testing was highly valuable. Participants emphasized the value in having someone who is intimately acquainted with their child’s health, such as their child’s PCP, review the results of risk testing, “As eMERGE 4 prepares to provide 25,000 individuals with genomic risk scores, and in particular 5000 children, it is imperative that we begin to develop best practice recommendations for the return of genomic risk estimates. In the context of return of results to children, making sure we understand parent perspectives, especially those from populations traditionally underrepresented in biomedical research, will contribute to a more well-rounded and equitable development of risk return practices for children.The most common difference in understanding related to the interpretation of “high risk”. The eMERGE Network reported the results as “high risk” as the increased risk associated with the results is deemed by the Network to be clinically actionable, recommending lifestyle, medication, or surveillance changes. On the other hand, just under half of all participants did not interpret the risk of the condition, based on the result, to be “high” . Although the report with absolute risk framing was (moderately) more preferred by participants, reflecting a similar pattern in the literature ,13, for Although the level of understanding of the report varied amongst participants, the expressed willingness to follow through on risk-reduction steps was consistent. When presented with ways to reduce the risk in their child, many parents stated they were certain they would follow through. This is similar to what has been seen in the past with the intention of changing behavior noted in many studies where risk information is shared with participants ,17. HoweSystemic issues such as lack of access to affordable healthy food, safe places for physical activities, and health care were expected responses from participants as common barriers. These issues are not new, as they have been discussed previously in the literature as prevalent limitations for minority and underrepresented communities ,21. PerhParticipants interviewed in this study generally agreed the reports were highly valuable and would be helpful not only for informing their child’s care, but also to the rest of their immediate family. Participants felt being able to review the risk report with their child’s PCP would make them feel the most comfortable and confident in their understanding. When receiving these results and report, participants emphasized what mattered most was having a resource they could trust to review the report with and ask questions. Additionally, participants were concerned about making sure their child’s PCP has knowledge of the report to watch for signs of disease throughout their child’s development. Knowing this is essential for planning for the return of polygenic results in the greater eMERGE 4 study. It will be critical that providers build trust with parents so they may address the questions and concerns appropriately. Looking at past research, there may be some burdens and barriers to PCPs to provide this extra care ,25. Our There are limitations to this study. One limitation is our sample population, as our findings were limited to forty parent/guardian interviews. We sampled participants from two East Coast children’s hospitals in metropolitan areas which could reflect a sampling bias in the opinions and thoughts of our participant group. Participants were parents/legal guardians of children already enrolled in biobanks at CHOP or BCH and did not necessarily constitute a representative sample. In addition, a relatively high proportion (37.5%) had prior experience with genetic testing see . AlthougIn conclusion, while participants saw great value in receiving risk score reports such as this, the reports did not come without some confusion. Absolute risk scores were preferred, and factors such as health of the child, family history, and the low statistical value contributed to participants not fully understanding the high risk associated with the report. When trying to create best practices to return these results to the pediatric population, we will need to utilize PCPs to aid in the return of results process, create educational materials to aid in understanding, and strategize ways to overcome systemic barriers found in the lives and neighborhoods of these individuals. Overall, this study provides an improved insight into implementing the return of genomic risk scores to pediatric patients in a clear, understandable, and fair way.