The widespread under-screening and under-treatment of alcohol use disorder (AUD) contributes to its health and socioeconomic burden. We conducted a mixed-methods  study in people with alcohol use disorder (PWAUD) to explore their expectations, as well as barriers and levers to AUD care.N = 179) were interviewed using computer-assisted interviews in several medical and non-medical sites  (quantitative substudy). We also conducted semi-structured face-to-face interviews with 36 PWAUD . Using logistic regression, we explored factors associated with having previously received/sought care for AUD. Three major themes were identified in the qualitative textual analysis using a descending hierarchical classification.Individuals with AUDIT > 15 , regular smoking (9.72[3.91–24.15]) and feeling discriminated against (2.35[1.10–5.05]) were independent levers to having sought/received care for AUD, while being aged < 50 and employment were independent barriers. The five predominant themes in PWAUD discourses emerging from the textual analysis were: drinking context, medical care, alcohol treatment, tobacco/addiction and family. When triangulating results from the logistic regression and the textual analysis, two barriers , and two levers (family influence and tobacco addiction), emerged.These results underline the need for interventions targeting families and the social network to increase awareness about AUD and related care. Simplified and novel comprehensive care trajectories are urgently needed to reduce the clinical and public health burden of AUD. All VIF values were ≤ 1.5.After multiple adjustment Table , the folAmong the 36 participants in the qualitative substudy, 15 (41.6%) were female. One (2.7%) participant was born between 1940 and 1949 (age 79–88), 4 (11.1%) between 1950 and 1959 (age 69–78), 16 (44.4%) between 1960 and 1969 (age 59–68), 7 (19.4%) between 1970 and 1979 (age 49–58), 6 (16.6%) between 1980 and 1989 (age 39–48), and 1 (2.7%) between 1990 and 1999 (age 29–38). Thirty (83.3%) participants were receiving AUD care at enrolment while 6 (16.6%) had not sought/received care for this specific disorder.Five lexical field classes were defined using Iramuteq’s descending hierarchical classification, and were categorized into themes separately by two researchers to ensure the reproducibility of results. They then discussed their respective findings together to choose the titles for these emerging themes. Table Triangulating data from the logistic regression and the textual analysis, two barriers , and two levers (family influence and tobacco addiction) emerged:In the multivariable analysis, PWAUD who did not socialized with heavy drinkers and those unemployed were, respectively, almost 4 times (3.84 [1.66–8.85]) and 2 times (2.40 [1.11–5.20]) more likely to have received or sought care to stop or reduce their alcohol consumption.The verbatim transcripts seemed to highlight that being surrounded by people who drink was itself an incentive to drink. Excerpts below illustrate this trend:"My husband always drinks a beer or two at noon, as an aperitif; in the evening, he always drinks one, two, or more glasses of vodka or rum ….""I went to hang out with my colleagues, I gambled a little, and there I was, with everyone drinking, and I said to myself I was going to have a shot, it doesn’t matter if I have one, two...""Actually I started drinking around twenty, with friends, in the evening, and it started with beer, without getting drunk, but we hung out in the garden and we started to drink."“For now, I get help from the addiction centre; then, if I notice that it gets worse, that instead of decreasing, my consumption increases, I’ll ask the doctor so I can go back to rehab.” (In care)“I had made an appointment with a nurse at the time and I explained to her, but I was still drinking, so she said to me: ‘Well, listen, if you want, we’ll send you to rehab ...’, but I never went back to her.” (In care)In the statistical analysis, the quality of the relationship with one’s general practitioner was not associated with AUD care. Furthermore, the qualitative study revealed that the process of accessing medical care was never linear: patients had to deal with several health professionals from different services and structures which referred them or re-referred them to other services, and this sometimes constituted an impediment to entering care.“It’s not that I don’t like the support group, it’s just that we always hear the same things, they’re always complaining over there.” (In care)In addition, some participants reported not feeling comfortable with certain dimensions of care, such as support groups.“No, I take Selincro, as well as drugs to cure alcohol abuse and antidepressants. First, I was given Aotal three times a day, and then I started Selincro.” (In care)Moreover, patients considered that using pharmacotherapy was a complex process: they had to try several drugs before finding the most appropriate therapy:“Concerning medications, there is the one I currently have; I take two anti-depressants in the morning. I don’t take anxiolytics because here, I’ve quit benzodiazepines.” (In care)“I already take so much medicine for HIV, thyroid, cholesterol ... so I was afraid to take another drug ... Too many side effects: I read the leaflet, and there are many of them.” (Not in care)Additionally, PWAUD with comorbidities often had to combine several pharmacological treatments, which in some cases hindered them from taking AUD pharmacotherapies:“I would agree to take pharmacological drugs, but warily, because I’ve never taken either anxiolytics or antidepressants ... And I think it would be stupid to quit one addiction for another.” (In care)Finally, the fear of developing another addictive behaviour was frequently cited as an impediment to agreeing to take AUD pharmacotherapies.In the multivariable analysis, tobacco smoking remained significantly associated with an increased likelihood of seeking/receiving care to reduce or stop alcohol consumption. Regular smokers were almost ten times (9.72 [3.91–24.15]) more likely to have received or sought such care.Our qualitative data shed light on the interaction between tobacco smoking and alcohol. First, some people who had already successfully stopped smoking felt they might be able to do the same with alcohol. Furthermore, they indicated that even if their attempt did not work, it would in any case give them more confidence to try to stop drinking alcohol:“There are improvements in certain periods I noticed something quite interesting. Last December I had lung problems, I was hospitalized, suddenly I quit smoking, I stayed at the hospital for five days, I didn’t drink a drop, I didn’t feel any craving ( …) That’s exactly it; when I was in the hospital, I quit smoking, I used a nicotine patch for four days. I didn’t miss tobacco a lot, even though I was a very heavy smoker. When I left the hospital, I realised that I hadn’t smoked for four days and I didn’t miss it. It would have been stupid to start again. It’s not the same for alcohol, I had spent four days without drinking too, but when I got to my place, I went to buy a good bottle of wine, for the pleasure of it (...).”  (In care)“It’s really on alcohol that I want to focus, because it’s difficult for me; it is the strongest dependence and the most harmful (...). Perhaps, if I kept smoking a little, it could help me to stop alcohol, I would feel that I’m not stopping everything all at once, I would be satisfied.” (In care)Second, the presence of both alcohol and tobacco consumption made some people feel they were poly-addicted, and this drove them to tackle their addiction issues. For those who were apprehensive about stopping both substances at once, participants indicated they would prefer to treat AUD first as they perceived it to be the more harmful of the two addictions.“That’s exactly it”, etc.) does not support our quantitative result (people who successfully quit smoking were categorized as “non-smokers”), but suggests that tobacco addiction consultation could be an entry point to address AUD: the satisfaction of successfully quitting tobacco could represent an incentive to stop or reduce alcohol consumption.The first excerpt “It was my family, my child, who made me consult health professionals, because they noticed that during family dinners, I lost control.” (In care)“The first time, no, it was the doctor who decided to send me to the psychiatric hospital, the other two times, yes, it was my wife who called the emergency service and who sent me to the psychiatric hospital …” (In care)The theme of ‘family’  was present in many interviews. Family, especially children, was often an important incentive to seek care for AUD.In the multivariable analysis, people who had already experienced discrimination because of their alcohol consumption were twice as likely (2.35 [1.10–5.05]) to have already sought or received AUD care. Importantly, discrimination mainly came from family members (data not shown).Although we did not use an implementation science model, we formulated different hypotheses which, if confirmed during our study, might provide useful indications for improving access to care for AUD. These hypotheses were based on the possible effect of various factors  on access to and engagement in AUD care.The qualitative study enabled us to provide greater detail about the specific barriers and levers not revealed by the quantitative study. An example of the former was the complexity of the care trajectory, as revealed by the numerous healthcare professionals required for AUD care. An example of the latter was the importance of tobacco cessation programs as an entry point for AUD care, as they are likely to be less stigmatising than programs offered for AUD.To our knowledge, this is the first study to use a mixed-methods approach to investigate barriers and levers to receiving and seeking AUD care among PWAUD in France. In contrast with our hypothesis, we did not find a positive association between “awareness that AUD care no longer necessitates abstinence” and the outcome. The convergence of the results from the two substudies  provided us with important information on PWAUD decision-making regarding care.In both substudies, a social drinking environment appeared to be a barrier to care. More specifically, our quantitative data showed that not socializing with heavy drinkers was associated with the outcome. In the qualitative substudy, “drinking context” was the second most discussed theme in the textual analysis. Furthermore, the qualitative data highlighted that living with a drinker made alcohol reduction or cessation more difficult.The cultural norm of drinking alcohol in France, especially wine, appears clearly in the textual analysis, as does the social function of alcohol. Together, they may constitute a barrier to seeking/receiving care. More specifically, as drinking is considered normal in the country, people are less likely to question their own consumption.Social environment is known to influence alcohol consumption , 37, 38.In the quantitative substudy, having already experienced discrimination because of AUD (which mainly came from family members) was a predictor of receiving/seeking care to stop or reduce one’s alcohol consumption. This is consistent with the fact that in the qualitative substudy, the theme ‘family’,  appeared to be a lever for the outcome. The desire to improve familial relationships is known to be an incentive to seek medical care for alcohol consumption , and greOur results highlighted that older age (> 50) was associated with an increased likelihood of seeking/receiving treatment. Consistent with some previous studies , 44, theThere are many possible explanations for the association between older age and seeking AUD treatment. Older people are more likely to have a longer alcohol history, and therefore are more likely to seek treatment . There aFor some of the study population, the unexpected association between unemployment and seeking care for AUD might be attributable to job loss or difficulties finding a job due to alcohol consumption. This contrasts however with previous studies which found a positive association between job loss, unemployment and AUD , 50, espThe absence of any association between the general practitioner-patient relationship and access to care contrasts with another study which reported the importance of this relationship in helping to address alcohol issues during routine medical consultation . HoweverWith regard to the complexity of accessing care, it worth remembering that healthcare expenses for all individuals living legally in French territory are covered by the universal public health insurance system . MoreoveOur quantitative results highlighted that being a regular smoker was associated with a greater likelihood of seeking/receiving care. This runs counter to previous studies’ findings which found a negative association between tobacco smoking and alcohol treatment participation , 56.programs offered for AUD [Furthermore, our qualitative data highlighted the double role of tobacco cessation initiatives and programs. First, they constitute an opportunity to start AUD . It is possible that smoking cessation as an entry point for AUD care may be less stigmatising than  for AUD . Second, for AUD . These r for AUD  but alsoOur qualitative findings revealed that PWAUD may be reluctant to add another medicine to their current daily medication schedule. This result is in line with previous studies showing that pharmacotherapy is not a preferred treatment for AUD .The theme of family was prominent in textual analysis and the verbatim transcripts showed that some participants decided to enter into care because of family pressure. It has been demonstrated elsewhere that people who are assigned to care by their family are more likely to aim at being abstinent . ConsequOur study has limitations. First, as recruitment was not only carried out in healthcare facilities (a decision to ensure that those excluded from care would be reached), we were unable to recover data on possible clinical diagnosed comorbidities (e.g. liver disease) which could be predictor of access to care for AUD.Moreover, some of the participants recruited in the two bars may have been under the influence of alcohol while they took the survey. However, we decided to include this specific population in the study, as it was the only possibility to reach PWAUD not receiving medical care for AUD.In our outcome, we combined those who sought care, but had not received it (which was a very limited group) with those that had both sought and received it. These two groups could conceptually be characterised as being different. Nevertheless, we preferred to combine them as we considered that seeking care is a necessary condition to engage in a process of reduction/cessation of alcohol consumption.Furthermore, with regard to logistical reasons, recruitment took place in healthcare structures and bars in order to obtain two groups which could be compared and contrasted . Consequently, external validity is not guaranteed.Another limitation is that all our data, including data on alcohol consumption, were based on self-reports which may be subject to social desirability bias. Nevertheless, previous research has already proven the validity of self-reports in alcohol-using populations . FinallyOne of the most important findings of this study is the difficulty in accessing medical care for AUD which can sometimes constitute an impediment to reducing or stopping one’s alcohol consumption. This highlights the urgent need for simplified and novel comprehensive care trajectories to reduce the clinical and public health burdens of AUD.Our results underline the need for interventions targeting families and the social drinking network to increase awareness about AUD and related care. Greater emphasis should be placed on non-pharmaceutical approaches to reduce alcohol consumption, and on the delivery of clearer and more complete information regarding reduced drinking as a real therapeutic goal.


The first 1000 days is a critical window of opportunity to promote healthy growth and associated behaviours. Health professionals can play an important role, in part due to the large number of routine contacts they have with parents. There is an absence of research on the views of parents towards obesity prevention and the range of associated behaviours during this time period. This study aimed to elicit parents’ views on early life interventions to promote healthy growth/prevent childhood obesity, particularly those delivered by health professionals. Semi-structured interviews were conducted with 29 parents  who were resident in Ireland and had at least one child aged under 30 months. Data were analysed using reflexive thematic analysis. Two central themes were generated: (1) navigating the uncertainty, stress, worries, and challenges of parenting whilst under scrutiny and (2) accessing support in the broader system. Parents would welcome support during this critical time period; particularly around feeding. Such support, however, needs to be practical, realistic, evidence-based, timely, accessible, multi-level, non-judgemental, and from trusted sources, including both health professionals and peers. Interventions to promote healthy growth and related behaviours need to be developed and implemented in a way that supports parents and their views and circumstances. The first 1000 days—the period from conception to a child’s second birthday—is a critical window of opportunity to promote the health of women and their children . Early lEarly life factors—such as high maternal pre-pregnancy weight, smoking during pregnancy, high infant birth weight and rapid weight gain, infant feeding mode, and the early introduction of solid foods—are associated with the development of childhood overweight/obesity ,13,14 anParents have regular contact with health professionals during pregnancy and the first two years of life as part of routine health visits . Early lTo date, research has examined parents’ views of interventions around discrete behaviours or topics, such as infant feeding and weight management during pregnancy ,24,25,26This study aims to address these current gaps in the literature by eliciting parents’ views of early life interventions to promote healthy growth and/or prevent obesity and those delivered by health professionals in particular. We defined intervention broadly as any advice, help, or support regarding a child’s weight and/or growth, and associated behaviours, from any source, whether solicited or unsolicited. Findings will aid the development and/or adaptation of early life interventions to promote healthy growth.This study formed part of a larger study, which also sought to explore parents’ perceptions of healthy growth and associated behaviours during the first 1000 days. The findings of the broader study will be reported elsewhere. Face-to-face, semi-structured interviews were conducted. This methodology was best suited to address the study aim. The philosophical underpinnings of this research combined constructivist ontology with interpretivist epistemology, with the aim of providing insight into participants’ constructions of reality and the ways in which such constructions are socially and culturally situated . EthicalA Parent Advisory Group , convened to advise the research team for the purposes of this study, reviewed and refined the study protocol and study materials (available on OSF ). They wThis study was conducted in Ireland, where over 60,000 babies are born annually . Women oWe included parents and/or primary caregivers of children aged under 30 months living in Ireland. Parents were purposively recruited, on a range of criteria, to ensure variety in the sample: mothers/fathers, socio-economic backgrounds, prima/multi-parous parents, parents whose babies were breast-/formula-fed, location–urban/rural, ethnic/cultural backgrounds, and body mass index (BMI). This information was captured in a brief demographic questionnaire administered to participants before each interview. Participants were asked to self-report their height and weight, and BMI was calculated.Participants were recruited through community groups  and social media. Gatekeepers in community groups provided a copy of the information sheet and consent form to potential participants. Parents were asked to make contact with the lead researcher if interested in participating or if they required more information. Upon agreeing to take part, participants completed a consent form, and a suitable time and location for the interview was agreed.Interviews were conducted by MH, a 38-year-old female, experienced in public health and health services research, who was neither a parent/ever pregnant. An interview guide  includedWe deemed that sufficient sampling occurred when the major categories showed depth and variation in terms of their development. We focused on achieving a high level of “information power”   rather tInterview audio recordings were transcribed verbatim, checked for accuracy and de-identified. Transcripts were imported into NVivo  and data analysed using reflexive thematic analysis ,38. MH rWe interviewed 24 mothers and 5 fathers, with infants/children ranging in age from 7 weeks to 25 months, with two of the interviewees also being pregnant at the time of interview. One mother and one father were co-habiting; the remainder were from separate families. Four of the participants were known, to varying extents, to individual members of the study team; however, the lead researcher did not have a relationship with any of them, beyond acquaintance. Participant characteristics are outlined in Two central themes, with several sub-themes, were generated from the data: (1) Navigating the uncertainty, stress, worries, and challenges of parenting under scrutiny and (2) Accessing support in the broader system .This theme describes the challenges parents experienced in navigating this stage of life. New parents felt vulnerable, full of uncertainty, and experienced stress and worry as a result. This was compounded by both felt and perceived judgement, stigma, and guilt in relation to their parenting. Most spoke about the challenges of parenting and trying to maintain balance between caring for their child(ren), work and other commitments. All of this influenced their need for support, and their ability to access information and support, but also to put the acquired knowledge and/or skills into practice. With growing experience, parents’ confidence increased.“…one of the best things in that group was the whole understanding and expectation that you may not find it easy or any way doable to breastfeed for the first two or three or four days” (D04). Others, however, felt that they did not know what to expect, one saying “it’s like you’re finding your way around in the dark” (D01).Almost all participants spoke about how parents experienced various stresses relating to their parenting role. Some highlighted how mothers are particularly vulnerable in the early postnatal period. Many mentioned their lack of knowledge as a first-time parent in general, but also particularly in relation to breastfeeding and introducing solids. Most felt it was important to know what to expect and be prepared when it came to breastfeeding, with some highlighting the importance of knowing what to expect and be prepared in relation to child weight and general parenting. Some stated that they had felt well prepared antenatally: While many felt that breastfeeding was often perceived as “easy”, the reality, initially at least, was quite different and stressful. Various challenges were experienced: getting breastfeeding established, physiological problems, and knowing that their baby was getting enough milk and gaining sufficient weight. Many described how they persevered with breastfeeding, or with other aspects of child feeding  to a lesser extent. For the majority, when they saw the outcomes of their efforts, it gave them confidence in their ability/decision. Many spoke of the pride they felt when their babies were doing well as a result of their efforts. For some, however, particularly in instances where a baby’s weight needed to increase, they had to let go of their desire to exclusively breastfeed.“…I was just making sure, trying to make sure that we were feeding her enough and that she would have enough. So I was a bit anxious about the midwives’ visit to weigh her” (M13). A few spoke about becoming unnecessarily “obsessed” about weighing their children. Other concerns centred on infant’s sleep, fear around giving birth, and generally “keeping them alive”.Most participants had concerns about their child’s weight/growth at one point or another, particularly insufficient weight gain. Some spoke about the stress associated with weight and/or developmental checks, especially if their child had an issue identified, and questioned their parenting ability: “If you can give them the support and information early on, in their pregnancy, and that you start building those layers of confidence…” (M04), with some noting that parents with less resources may require additional support.Most parents highlighted the importance of early intervention and parental support: Judgement, or fear of being judged by others, was experienced by almost all participants—especially in relation to infant feeding issues, and parenting more generally. This impacted on their views and experiences, particularly in terms of who they discussed issues with/sought advice and support from. Many negative encounters with health professionals, peers, and family members were relayed.Participants spoke about maternal feelings of guilt or shame around infant feeding/parenting. Discussions often centred on the breastfeeding versus formula-feeding “divide”, and feelings of guilt or shame if women could not meet their breastfeeding goals, with decisions to breastfeed for an extended period/follow baby-led weaning less frequently mentioned. Some spoke about negative relationships with, or support from, their own mothers or other women, particularly if these women had not breastfed/met their own breastfeeding goals. Many felt that:You breastfeed and you get like flack for it, or you’re defending yourself or you’re covering yourself up. Or… you don’t breastfeed, and you’re giving a bottle to your child… there’s just so much guilt and shame and judgement around so many different things with parenting.(M16).Participants also mentioned comments from others around child size/weight and felt that parents were often, or could be, judged by others if their child had a weight issue.“Some people were expressing and some people were doing half formula half breastfeeding. And that just led to much more, being able to talk about what’s hard about it. And that actually makes you breastfeed longer” (M12).Some participants spoke about judgement experienced—directly or indirectly—in online forums, particularly in relation to infant feeding. Some were cautious of online forums, and just “lurked”, and while the pros outweighed the cons for some, others stopped using them altogether. The importance of a supportive, open, and inclusive environment within in-person groups was also mentioned by some participants. This included breastfeeding support groups that permitted those who did not exclusively breastfeed to participate: “when you’re a first-time mum, you put a lot of pressure on yourself…You feel like you can’t ask for help because then everyone will think you’re useless” (M17). Many spoke about instances where they did not disclose or tell the truth about certain issues “for an easy life” (M01) or fear of judgement: “you think, they’re going to get me locked up. They’re going to take my baby away” (M04). This could be in relation to infant feeding  primarily, or infant sleep and activity during pregnancy, for example.Some parents felt that their parenting skills would be judged by others if they sought support because “…it’s great that there’s movement towards trying to encourage it, but (.) some people take that to the extreme” (M03). There was a general feeling that “they [haven’t] really cracked it yet, how to talk about breastfeeding” (M15). Participants noted that while “Breastfeeding is promoted…they’re not doing anything to support it” (M13), citing societal, cultural, and economic reasons that shaped attitudes and norms around infant feeding and child growth, and undermined women’s beliefs in their ability to feed their babies. The need for more support for breastfeeding was stressed by many—to make it “more normal” (M16) and to provide more practical supports to mothers/parents, including around enabling them to make informed infant feeding decisions. Participants viewed exposure to breastfeeding and positive support received as enablers.Some felt that how breastfeeding is promoted/discussed led to judgement, stigma, shame, or guilt. Some participants spoke of interactions with those who had strict or “militant” views about breastfeeding: “wider cultural shift [is needed]….I think we need to be much more supportive of parents in general” (M02). This was primarily in relation to breastfeeding , and from health professionals and peers/friends. They valued the confidence boost it provided, often by confirming that the issues they were experiencing were “normal” and/or that they were doing a good job.The majority stressed the importance of non-judgemental, positive, and reassuring information and support, and that a “We’re a lot more confident in everything we do with [Niall], you know what I mean, compare to poor little [Rosie] who was like our first and we stressed about everything” (M17). Many highlighted how learning what was “normal” for babies , while acknowledging that all babies are different (even within families), and finding or accepting their own normal, was important. Many spoke about the need for parents to trust their own judgement, and “go with their guts” or instincts, sometimes citing that they do not, but over time, they learn to trust them more. A few parents spoke about not asking questions, particularly as a first-time parent, and how they would ask if they were in similar situations again.Most parents relayed how their confidence grew with support and time/experience. Some spoke specifically about how their confidence increased as they grew into their parenting role: Some participants spoke about being “less wound up” on subsequent pregnancies—not worrying about things as much (or having the time to) and/or doing as much information seeking. Some highlighted that increased knowledge/confidence meant that they did not need or rely on such support on subsequent pregnancies, some mentioned that health professionals held less power, while others stated that people just “leave you at it”:…for first time mums there’s so much interfering and advice giving and shoving it down your throat. And it’s just such an anxious time already because you don’t know what to do… Whereas the second time people go oh yeah look she knows what she’s doing and they leave you at it, and EVERYTHING is easier.(M02)Theme 2 describes how parents navigated and accessed supports in the broader system. They had a range of sources, with health professionals , peers/family, online, partners/husbands, and “own research” most often mentioned. Health professionals encountered included general practitioners (GPs), midwives, public health nurses (PHNs), lactation consultants, and, to a lesser extent, obstetricians, pediatricians, and practice nurses. Parents primarily recalled discussions with health professionals around infant/child feeding, as well as child growth assessments, with tummy time also frequently mentioned; other topics received less attention and often only took place when parents brought them up. Further details are provided in Parents highlighted structural, inter-personal, and personal barriers and facilitators to accessing support. Health professional support was often perceived difficult to access. Parents appreciated the accessibility of online peer support. Levels of trust varied in information sources. Parents were often in receipt of lots of advice from different sources, which was often unhelpful if not clear and tailored to their needs. Relationships and relatability were highly valued. Resultantly, parents valued a combination of both professional and peer support.“one lactation consultant who does the whole of [Maternity Hospital 3], which is not enough” (M07). Difficulties accessing other breastfeeding supports, lack of choice in what health professionals  you get to see, and delays in between PHN checks or falling through the system were also highlighted. Many felt that services and health professionals  were “stretched”, which impacted on availability of health professionals, as well as time available to discuss issues and provide support, primarily around breastfeeding. Some women reported feeling “on the clock” during appointments and that interactions lacked meaningful engagement: “… at every appointment they have a little blurb that they have to say that they explained X Y and Z to you, like breastfeeding’s best for baby…… They tick their box and they hand you the leaflet…” (M01). Similar experiences were reported in relation to developmental checks, which were often merely seen as “a tick-box exercise to see is your child progressing against certain milestones”. (M08)Most participants spoke about the importance of being able to access and/or engage with services and supports, especially when you needed them. There were mixed reports about the difficulty (or ease) in getting appointments with health professionals. Lack of access to lactation consultants in hospital was a significant issue: Many participants spoke about having to access supports privately, particularly for lactation consultants, tongue tie releases, and/or, to a lesser extent, antenatal classes. The majority had accessed such private supports but noted the cost implications  and how this was not possible for everyone.Being able to contact PHNs, lactation consultants, and peer breastfeeding supports by phone  with any queries was mentioned positively by several participants. Some also spoke about the benefits of the internet for its 24/7 support, particularly in relation to breastfeeding. The ability to have opportunistic discussions with PHNs at peer support groups was valued by some.“…they’ll give you some [information] and then I feel like it was up to me to go off and find out more” (M17). Many also spoke about the importance of being able to ask questions, particularly in relation to being able to engage with a health professional, ask them questions, or challenge their advice. The need and ability to judge the quality of information received was also stressed.Many participants spoke about doing their own research to supplement (and sometimes check) information from other sources and/or to find alternatives that would work for them: “She [community midwife] knew me. She knew the history with me and the birth, everything. I wasn’t talking to another random stranger” (M09). A few participants spoke about the importance of contacts made during the antenatal period , which extended postnatally and “it meant that I had a contact for when I was postnatal and things weren’t going particularly well” (M11).Many highlighted the importance of continuity of care and support, primarily in relation to health professionals; this facilitated trust and relationship building, which was not the experience for many. Those on homebirth, DOMINO , or Early Transfer Home schemes . Some participants spoke about trusting peers and/or friends or family, sometimes more than health professionals: “they get where you’re coming from so then you tend to believe them more” (M18), or a perception that health professionals “can deal with the normal stuff, but they can’t deal with anything outside the realm of normal” (M02). Others reported trusting health professionals more than information received through online forums. The majority stressed the need for a mix of information sources.Participants had mixed levels of trust in health professionals, within and across disciplines. While some noted that as a first-time parent you have total faith in health professionals and “go with what they say”, this trust sometimes waned. This could be due to negative experiences such as feeling unsupported during encounters and/or receiving (perceived) incorrect or conflicting advice, including inaction or mis- or late diagnoses . This often left parents seeing that “…see how other people are getting on and how are you getting on… you’re all in the same boat” (M09). Peer support via WhatsApp, text or phone call was also mentioned and valued.Social support (or lack thereof), encompassing emotional, informational, and practical support from peers and/or family members, was discussed by all participants. Face-to-face peer support groups  were generally highly regarded, as you could “they treat you like you’re a bit thick you know. And you’re kind of, no I’m actually mad into this” (D02).Many participants (mothers and fathers) stressed the importance of dads as a source of practical and emotional support for mothers, particularly around breastfeeding. Some noted that fathers might not be as supportive when difficulties were encountered  or when babies were breastfed for an extended period. Some highlighted the need to and/or value of engaging dads and also the role they play in their children’s lives. Despite this, three of the participant fathers spoke about feeling undermined/patronised by health professionals: “they’ve had kids themselves, so they understand, you know, that not everything is going to happen by the book” (M03). Many spoke about reassurance received from health professionals, primarily around their child’s growth at checks but also in relation to gestational weight gain or child feeding. Some spoke about the importance of health professionals listening to, and being respectful of, parents. A few participants spoke about the need for health professionals to see the “bigger picture”  and also respect parents views and wishes, particularly in relation to developmental checks/growth assessment. Some felt that PHNs took a narrow view and needed to “come down a little bit to your level” (M16), whereas GPs took more account of context: “[GP] had no issue [with the child’s growth] because he knew more of the background I guess of the family”. (M22). Some also felt that midwives provided more holistic care to both mother and baby compared to other health professionals, and “… always really human and just asking well how are YOU doing” (M12).Most parents stressed the value of support from someone who understands, with experience, and who could empathise, as Almost all participants described instances where they were on the receiving end of unhelpful attitudes, advice, and support or pressure to engage in certain practices, from a wide range of sources and whether sought or not. Again, much of this centred around infant feeding and breastfeeding in particular. Participants highlighted the value of clear communication from health professionals and the importance of consistent messaging/advice between different health professionals and/or other information and support sources.“…they were trying to encourage her [sister-in-law] to get to six months [before introducing solids], but they were telling me it was okay from four months…” (M01). The internet was also a place where “you’d see conflicting things. Often it’s people’s opinions” (M03).Conflicting, unclear, or inconsistent advice from health professionals was often reported. This was primarily in relation to infant/child feeding, for example, Parents voiced concern that while health professionals promoted breastfeeding, they were quick to offer formula. Pressure to give a breastfed baby formula was frequently mentioned, especially in relation to the early postnatal period in hospital, with formula top-ups arising from concerns about weight loss, as well as perceived widespread availability and unprompted provision of formula:hospitals need to be less pushy with their formula……And I didn’t get any support on that either you know as in like there was no expressing equipment or anything like that, so it was just you know a case of do you want a bottle, do you want a bottle…And then even when we were leaving the hospital they gave us a box of bottles.(M10).Health professionals were seen to prioritise weight over breastfeeding:…one of the most stressful things is those four or five weeks after you give birth, where the first, Jesus like if your baby doesn’t make their weight back up in the first ten days, God help you…(M18)“… the hardest thing that I’ve found about being a parent, is everybody else” (M07).Lack of support from family members around breastfeeding was also raised, as was unsolicited advice from members of the public: “general information probably doesn’t work so well with me. It’s like people actually figuring out what’s YOUR specific issue and solving that” (M11). Many participants spoke about lack of knowledge or skills amongst all categories of health professionals, particularly concerning breastfeeding and child growth patterns. Many spoke about the need for health professionals, particularly GPs and PHNs, to be more pro-active in providing support and/or raising issues—even if it could be hard for parents to hear, particularly in relation to a mother’s weight and related behaviours, or a child’s weight/growth. Some, however, felt that if there was an issue, their health professional would raise it (particularly around weight). Some felt that health professionals required more education/training to be able to raise and/or discuss issues and keep up-to-date, particularly around infant feeding and especially baby led weaning.Some participants felt that they received no new, useful, or relevant information, during contacts with health professionals or via online/printed resources. More tailored approaches were suggested: Most parents stressed the need for information to be practical and realistic, with some mentioning that they did not follow advice “to the letter” if this was not the case. They also welcomed being shown how to do things. Practical support in relation to breastfeeding, particularly in hospital to get it established or from lactation consultants, was highly valued. Such demonstration of behaviours was also appreciated in relation to hands-on activities in antenatal classes and weaning workshops or during routine checks . Videos were also popular, especially amongst fathers. Participants also liked guidance to be clear, not too directive, and that they could adapt to their own situation. Some spoke about how some antenatal classes engaged fathers really well, with some also noting how they and/or their partners were highly engaged when information around the science of breastfeeding was presented.Most participants highlighted the value of timely information and support. They also expressed a preference for a staged approach to information provision, rather than receiving lots in one go: this involved receiving information specific to a child’s developmental stage/needs (at the right time). Some also highlighted that information only becomes relevant when going through a particular issue/stage, e.g., information provided at antenatal classes only becomes relevant when the baby arrives.Some participants also made explicit reference to the mode of delivery of information or support, with some preferring face-to-face as they could ask questions. As mentioned earlier, group support was valued by many (in-person and online), while a few preferred one-to-one support, as either they did not like being in groups and/or appreciated the tailoring to their individual circumstances.This study set out to elicit parents’ views on early life interventions to promote healthy growth/prevent childhood obesity, particularly those involving health professionals. Two central themes were generated from the data. The first relates to parents themselves “Navigating the uncertainty, stress, worries, and challenges of parenting whilst under scrutiny”. Parents, particularly first-time parents, felt vulnerable during this period, in which there is a lot of uncertainty, stress, and worry, often exacerbated by both felt and perceived judgement, stigma, and guilt in relation to their parenting/feeding practices, which were often under scrutiny. With the right support and time, however, their confidence increased, underscoring the importance of supporting and reassuring parents during this key life stage. The second theme “Accessing support in the broader system” demonstrates that while parents are receptive to, and would welcome, such support, particularly around feeding, several critical components need to be considered.The first theme reinforces much of what is known about the transition to parenthood, a challenging time for both mothers and fathers ,42,43,44Many participants in our study, however, noted how health professionals often prioritised weight gain over all else, with infant formula often provided in hospitals if infants were not gaining sufficient weight. This was also observed in a study involving women with a higher weight in Sweden . Women cParticipants, including those who exclusively breastfed and those who did not, highlighted how better approaches to breastfeeding promotion were needed, as some women could feel pressured to breastfeed ,65 and fThe second theme generated in the study focuses on what parents require in terms of information and support. Support around infant feeding, particularly breastfeeding, was highlighted in particular. This is perhaps unsurprising, given that most participants interviewed (or their partners) had breastfed their babies, coupled with the fact that Ireland has one of the lowest rates of breastfeeding globally , with inBarriers highlighted by parents in this study such as lack of time, knowledge, and resources may account for this and should be addressed within interventions. Indeed, health professionals themselves have identified lack of knowledge, confidence and/or relationships with women, time, continuity of care, and resources as barriers to them supporting women around a range of health behaviours ,78,79,80It is clear from our study that there is no one intervention and/or approach that will work for all parents. Parents wanted high quality information, in a variety of formats . Consistent with other research, particularly around infant feeding, parents felt that they were often in the receiving end of conflicting and confusing advice ,87,88 anThe strengths of this study include: the inclusion of both mothers and fathers, primiparous and multi-parous parents; the examination of a broad range of factors related to healthy growth in young children, not simply infant feeding; and the involvement of parents in the design and conduct of the study. Several limitations should be noted, however. Despite our best efforts to engage a diverse group of parents, our sample had a high number of parents with higher education levels and those who breastfed/were breastfeeding their children. Furthermore, many of the participants worked in health and social care roles so this may have influenced their views. In addition, while we used various strategies to engage fathers, including relationship development and targeted communications, we encountered challenges in recruitment. This is not uncommon within studies relating to the promotion of healthy growth, where fathers are often under-represented ,98. WhilThe first 1000 days of life is a critical window of opportunity to support the development of healthy growth and associated behaviours in children. Interventions involving health professionals in particular can be important, given the large number of routine contacts between parents and the health service during this period. This study elicited parents’ views and experiences of interventions, in general and specifically those delivered by health professionals. Parents reported a range of sources of information and support, and mixed experiences with each. They were receptive to, and would welcome, support during this critical time period, particularly around feeding. Support, however, needs to be practical, realistic, evidence-based, timely, accessible, non-judgemental, and from trusted sources, including both health professionals and peers. Various levels of support and intervention are required, at individual/intra-personal, inter-personal, organisational, community, and policy levels. Interventions to promote healthy growth and related behaviours need to be developed and implemented in a way that supports parents and their views and circumstances.


Overweight and obesity are a worldwide public health problem. Obesity prevalence has increased considerably, which indicates the need for more studies to better understand these diseases and related complications. Diet induced-obesity (DIO) animal models can reproduce human overweight and obesity, and there are many protocols used to lead to excess fat deposition. So, the purpose of this review was to identify the key points for the induction of obesity through diet, as well as identifying which are the necessary endpoints to be achieved when inducing fat gain. For this, we reviewed the literature in the last 6 years, looking for original articles that aimed to induce obesity through the diet. All articles evaluated should have a control group, in order to verify the results found, and had worked with Sprague–Dawley and Wistar rats, or with C57BL-/-6 mice strain. Articles that induced obesity by other methods, such as genetic manipulation, surgery, or drugs were excluded, since our main objective was to identify key points for the induction of obesity through diet. Articles in humans, in cell culture, in non-rodent animals, as well as review articles, articles that did not have obesity induction and book chapters were also excluded. Body weight and fat gain, as well as determinants related to inflammation, hormonal concentration, blood glycemia, lipid profile, and liver health, must be evaluated together to better determination of the development of obesity. In addition, to select the best model in each circumstance, it should be considered that each breed and sex respond differently to diet-induced obesity. The composition of the diet and calorie overconsumption are also relevant to the development of obesity. Finally, it is important that a non-obese control group is included in the experimental design. Obesity is a global public health issue with high prevalence in all age groups , 2. It gThe treatment and prevention of obesity involves the control of body weight and adiposity through a negative energy balance in which both, diet and physical activity, are important. But, due to changes in people's lifestyles, with less physical activity and shifts in eating behavior, the study of alternatives for the treatment of obesity, such as functional foods, and bioactive compounds, is gaining increasing relevance .Obesity rates are increasingly higher , 2, whicThis article aims to evaluate diets-induced obesity models in mouse and rat published in the last 6 years. It seeks to identify which are the main methodological strategies to induce obesity through diet, as well as identifying which are the main parameters to be taken into account to achieve a successful model.diet” + “obesity” and “high fat diet” + “obesity”.The search for articles was carried out manually on PubMed database by a single researcher in February 2020. The combination of the descriptors used was “In the PubMed database the following filters were selected: “species/other animals”, “case reports”, “clinical trial”, “clinical trial veterinary”, “comparative study”, “controlled clinical trial”, “evaluation study”, “newspaper article”, “observational study”, “observational study veterinary”, “periodical index”, “programmatic clinical trial”, “randomized controlled trial”, “twin study” e “validation study”. Duplicated articles were excluded and the rest were evaluated according to the inclusion and exclusion criteria Table . We wantdiet” + “obesity” and 19816 by the terms “high fat diet” + “obesity”. After using the filters on PubMed database, 1625 articles were found for the “diet” + “obesity” search and 819 articles for the “high fat diet” + “obesity” search, totaling 2444 articles. After the exclusion of 812 articles that were duplicated, 1632 articles were considered eligible for reading titles and abstracts. According to the inclusion and exclusion criteria  is relevant to the increase in food consumption, including compulsive behavior, and consequently weight gain , 15. DieCaloric excess is essential for the development of obesity . In thisThe diet-offering method directly affects consumption and the ability to induce obesity. Thus, it is likely that when the diet is offered according to the ad libitum or free access methods, food intake is stimulated . On the The intervention time required for the development of obesity varies widely, ranging from 8 days to 27 weeks  . In the present study, most of the analyzed studies used C57BL/6J mice Table . Those a©) , 46.Rats are used in DIO studies Table . SpragueThe age  and the Young male mice have bigger weight gain than females; however, when they are middle-aged the opposite occurs, and female mice have bigger weight gain than males. Inflammatory genes—upregulated in juvenile males—and hormonal parameters—estrogens can regulate inflammatory pathways in female—may justify the results found . Gene exMale animals are commonly used in the study of obesity; however, if the study aims to evaluate the brown adipose tissue, females should be used, since this tissue is more easily observed in this sex , 51. HowCalorie overconsumption leads to an increase in body weight gain and abdominal fat accumulation , 15, 19.The taste and texture of diets influence the amount of food consumed. Diets rich in processed foods, with high levels of sodium, sugar and saturated fatty acids, are more palatable, which can lead to a higher weight gain in comparison with purified diets even when saturated fatty acids are added to them . AdditioConsidering that a spontaneous caloric increase is difficult to achieve in rodents, even when flavored diets are offered , DIO musIn an attempt to induce a voluntary hyperphagia, Blancas-Velazquez et al.  providedBecause of the absence of a specific marker and a consensus, for both mice and rats, that defines the presence or absence of obesity, some studies have established their own parameters: the difference of 15%  or 20 g No article considered the distribution of body composition  as a parameter for detecting obesity. However, the majority of studies consider the differences in total body weight gain as the main parameter to assess the outcome of the development of obesity Table .Table 3CWhen there is no significant difference in body weight gain, other parameters can be considered , 56, 57.Visceral fat is the depot that surrounds the abdominal organs. It is more vascularized, innervated, inflammatory, metabolically active and sensitive to lipolysis, which results in greater release of cytokines, fatty acids and triglycerides. Therefore, in humans it is related to a higher mortality prediction when compared to subcutaneous adipose fat , 59. In Body fat accumulation depends on the connection between different metabolic pathways, as well as the interaction between genes and diet. Wistar rats, for example, have a differential expression of genes in the subcutaneous adipose tissue in comparison with Sprague–Dawley rats, which justifies the higher fat depots found in this breed . The conA low-grade inflammatory condition is often observed in obese animals , 35, 56.This inflammatory condition contributes to the development of metabolic disorders , 35, sucThe consumption of a high-fat diet can also reduce the brown adipose tissue, since it may inhibit the biosynthesis of fatty acids and increase oxidative stress and cell apoptosis ; therefoIn addition, the increase in brown adipose tissue may be a strategy to fight obesity, since higher levels of brown adipose tissue indicate greater energy expenditure, with consequent weight loss , 66. TheHigher values in blood glucose , 29, 51 Changes in the glycemic parameters occur because the insulin metabolism is unable to adapt to the damage caused by the chronic excess of calories offered by the obesogenic diet, which gradually deteriorates insulin activity, leading to insulin resistance and subsequent type 2 diabetes development . Also, tTriglycerides are the main component of adipose tissue; therefore, high serum concentrations of this lipid may indicate the presence of metabolic changes . LikewisIn this way, some of the evaluated studies noticed an increase in the serum concentration of triglycerides , 61, 63 Liver health, measured through hepatic triglycerides, can be impaired by the development of obesity. Hepatic steatosis happens because the excess of fat present in the body is stored in this organ causing intracytoplasmatic accumulation of triglycerides. This ectopic accumulation occurs as a consequence of the downregulation of AMPK , 61 and As the amount of stored fat increases, the liver starts to suffer oxidative damage  and, as In the present study, we included studies that used Sprague–Dawley and Wistar rats, as well as C57BL-/-6 mice, because these are the main models used for DIO. This strategy can be considered a limitation of the study, since other rodent models may also be prone to diet-induced obesity; however, they are not widely used. In fact, the biggest difficulty to find an effective model for DIO is the lack of standardization among obesity-inducing protocols. Different times of intervention, diets, types of fat and carbohydrates, animal strains, and sex, among others, are used in the studies, which makes it difficult to compare the results and to better evaluate and determine the best way to induce obesity in an animal model.Among the animal obesity models, those that develop a phenotype more similar to human physiopathology are those induced by dietary challenge; in this context, better results are obtained through high-fat diets with high concentrations of saturated fatty acids, since these diets directly affects the metabolism, are palatable and have a high caloric density, which stimulates weight and body fat gain.To choose an animal model for a study of diet-induced obesity, it should be considered that rats and mice respond differently to this type of diet; in addition, strain, sex and age, affect the response to the obesogenic diet, with young animals and males being more sensitive to obesity-related comorbidities.The markers used to assess the development of obesity include body weight and fat  gain, but other parameters related to inflammation, hormone concentration, blood glycemia, lipid profile, and liver health are often desired. It is suggested that these markers should be used together, since the presence of more than one of these markers reinforces the determination of obesity. Changes in the release of inflammatory cytokines are used to justify the symptoms found, not being a determining parameter for the induction of obesity. As there are no cutoff points for any of these parameters in animals, researchers should always conduct their studies with a non-obese control group so that the results can be compared.


This systematic review aimed to investigate the psychometric properties of the school health’s assessment tools in primary schools through COSMIN Risk of Bias checklist. We examined the studies that have addressed the measurement properties of school-health instruments to give a clear overview of the quality of all available tools measuring school health in primary schools. This systematic review was registered in PROPERO with the Registration ID: CRD42020158158.Databases of EBSCOhost, PubMed, ProQuest, Wily, PROSPERO, and OpenGrey were systematically searched without any time limitation to find all full-text English journal articles studied at least one of the COSMIN checklist measurement properties of a school-health assessment tool in primary schools. The instruments should be constructed based on a school health model. The eligible studies were assessed by COSMIN Risk of Bias checklist to report their quality of methodology for each measurement property and for the whole study by rating high, moderate or low quality.At the final screening just seven studies remained for review. Four studies were tool development, three of them were rated as “adequate” and the other study as “very good”; five studies examined the content validity, three of them were appraised as “very good”, and the two remaining as “inadequate”. All seven studies measured structural validity, three of them were evaluated as “very good”, three other were scored as “adequate”, and the last study as “inadequate”. All the seven studies investigated the internal consistency, five of them were assessed as “very good”, one was rated as “doubtful”, and the last one as “inadequate”. Just one study examined the cross-cultural validity and was rated as “adequate”. Finally, all seven studies measured reliability, two of them were rated as “very good” and the rest five studies were appraised as “doubtful”. All rating was based on COSMIN checklist criteria for quality of measurement properties assessment.The number of studies addressing school health assessment tools was very low and therefore not sufficient. Hence, there is a serious need to investigate the psychometric properties of the available instruments measuring school health at primary schools. Moreover, the studies included in the present systematic review did not fulfill all the criteria of the COSMIN checklist for assessing measurement properties. We suggest that future studies consider these criteria for measuring psychometric properties and developing school health assessment tools. That is why the impact of childhood health status on adulthood health has been widely investigated  identify existing instruments that measure the factors of school health at primary schools, and (2) evaluate these measures’ psychometric properties. All studies have been screened for the risk of bias and quality of measurement using the modified COnsensus-based Standards for the selection of health Measurement INstruments (COSMIN) checklist. This review will help to clarify whether the current instruments, tools, scales, and indexes measure the school health’s factors.The review protocol of the study used the Preferred Reporting Items for Systematic Review and Meta-Analyses (PRISMA) guidelines. This review was registered with the International Prospective Registry of Systematic Reviews (PROSPERO) (Registration ID: CRD42020158158) before starting the research according to the PRISMA guideline recommendation .The criteria for the selection of the studies included in this systematic review were that the studies: (1) developed or evaluated an instrument to measure school health; (2) the instruments should measure the school health factors; (3) evaluated at least one of the psychometric properties described in COSMIN Risk of Bias checklist for a school health instrument; (4) the population of the study should be primary school children; (5) were original research journal articles ; and (6) were in English. All articles that were not available online in full text were also excluded from the study.Two of the authors (Maryam Kazemitabar and Mojtaba Habibi) performed, independently from each other, a systematic search strategy to find articles with the specified criteria. The articles were divided into three groups of “completely related”, “somewhat related”, and “not related”. The authors selected the articles based on the relatedness of the title and abstract of the articles, then the full texts of those placed in the “completely related” and “somewhat related” groups were studied. In case of any disagreement, the second author (Ali Moghadamzadeh) intervened until consensus was reached.school health”, “health-promoting schools”, “coordinated school health”, “psychometric properties”, “reliability”, “validity”, “tool”, “scale”, “index”, “instrument”, “evaluation”, and “questionnaire”. We have also conducted hand search on the references lists of the selected studies. The studies were searched through the EBSCO(host), ProQuest, PubMed, and Wily databases, also a gray literature search was performed in PROSPERO, OpenGrey, and Google Scholar. No publication date was considered. Each database was queried from November 2019 using the Boolean operators (AND/OR). The terms searched were: “We have sent an Email to the corresponding author of one of the articles to access the full-text of it, but we have not received any reply so it has been excluded from this Systematic Review. The search for articles was finalized by December 2019. A total of 649 studies were identified for this review.From the 649 articles, we excluded all articles that did not report the psychometric properties of the instrument cf.  or that n = 7) were assessed by the modified COSMIN checklist, which was developed to assess the methodological quality of studies on measurement properties. The original COSMIN checklist contains 10 parameters. In the modified version of the COSMIN checklist used in this systematic review, however, the parameters “criterion validity” and “responsiveness” were omitted because none of the studies reported these parameters. Thus, eight parameters were used in the present systematic review: PROM development, content validity, structural validity, internal consistency, cross-cultural validity/measurement invariance, reliability, measurement errors, and hypotheses testing for construct validity.The selected studies . The overall quality of each psychometric property is operationalized as the lowest rating of any standard in the box is taken   . In thisA customized data extraction form was developed by the first reviewer (Maryam Kazemitabar), and then characteristics data of the studies and participants were extracted; the second reviewer (Mojtaba Habibi) also extracted the data independently, the results of the two extractions were compared and in case of any differences the third reviewer (Ali Moghadamzadeh) intervened to reach consensus. The data regarding characteristics of the selected studies included: first author name, year of publication, country, sample size, time to answer the items, number of items, response scale, participant age/grade, participant sex, and instrument factors.The instruments studied in this systematic review were: Scale for Health-Promoting Schools (SHPS), Quality of Life in School, School Health Policies and Program Study 2000 Questionnaire, Healthy School Indicator Tool (HSIT), and School Health Evaluation Instrument.The search strategy was conducted throughout 6 data bases: EBSCOhost, PubMed, ProQuest, Wily, PROSPERO, and OpenGrey. This resulted in 952 articles; and then in 649 after removing the duplicates. After the screening of titles and abstracts 515 articles were selected; then the full-text of the articles were studied for investigating the eligibility criteria including original journal articles, articles that studies at least one of the COSMIN Risk of Bias checklist measure properties of a school health assessment tool, study’s population should be primary schools, articles of English language and articles with full-text availability. After this procedure, seven articles remained for inclusion in this systematic review .The following descriptive characteristics of the articles included in this systematic review was extracted: first author name, publication year, country, sample size, time to answer the items/number of items, response scale , participant age/grade, participant sex, instrument’s factors .The articles were assessed by three raters who agreed that none of the seven articles scored “high quality”, three of the articles were assessed as “moderate quality”, and the remaining four articles as “low quality”.There are some requirements for developing an instrument. First of all the theory, framework or model used for developing the instrument should be clearly described, the target population should be specified. Context of use and qualitative data collection method should be clarified. The interviewer should be skilled and the data collected from qualitative study should be recorded and transcribed and coding section should be performed by at least two researchers independently. In addition a pilot study should be conducted to test the comprehensibility of the items, and the appropriate number of examinees for qualitative studies should be ≥7 and for quantitative studies ≥50 to score as “very good”.Four articles of the seven articles included in this review  were devAccording to the checklist the study should examine items both in an expert group and the target population to determine relevance and comprehensiveness by skilled interviewers. Other criteria are similar to the “tool development” parameter.Five of the seven studies examined content validity of the instrument at hand. Three of them have met these criteria and received “very good” . One of Measuring structural validity is only applicable for instruments that are based on a reflective model, something that all instruments included in this systematic review were. The studies that have conducted confirmatory factor analysis and had a sample size that was seven times the number of items and ≥100 get scored as “very good”, studies with exploratory factor analysis and a sample size at least five times the number of items and ≥100 or the sample size at least six times the number of items but <100 get scored as “adequate”.All of the seven articles have investigated the structural validity of the instrument at hand. Three articles have performed confirmatory factor analysis with a sufficient sample size (seven times the number of items) and were scored as “very good” , three sIn COSMIN Risk of Bias checklist any study that measures internal consistency for each of the subscales independently is considered to have a “very good” quality and any study presenting only the total internal consistency or not calculating the internal consistency at all, receives the score “inadequate”. Five studies have calculated Cronbach’s alpha for each subscale or unidimensional scale and were therefore evaluated as “very good” , one of Cross-cultural validity or measurement invariance is needed for a translated or culturally adapted instrument to compare performance of the items to the original version of the instrument. The samples should be similar for relevant characteristics except for the group variance; the sample size should be 200 subjects per group to be scored as “very good” and 150 subjects per group to be scored as “adequate”. Cross-cultural validity assesses if the instrument is Measurement Invariance and not Differential Item Functioning occurs; this indicates that examinees from different groups with the same latent trait level act invariant to an item. Appropriate methods for Classical Test Theory (CCT) studies are regression analyses or confirmatory factor analysis, while for Item-Response Theory (IRT), the appropriate method is Differential Item Functioning .Only two of the studies could be investigated for cross-cultural validity. One study was scored as “adequate”, because it did not report comparison between different groups clearly , and theAs the reliability value should be stable on the construct to be measured between repeated test administrations, the time interval should be appropriate, the test condition should be similar to original instrument .Moreover, the intraclass correlation coefficient should be calculated for continuous scores. For dichotomous/nominal/ordinal scores Cohen’s kappa should be calculated, for ordinal scored weighted kappa should also be calculated and it is recommended to describe weighting scheme for ordinal scores .Two of the studies received score “very good” because one of them has performed split-half reliability  and the Conditions for measurement error is similar to reliability, the same examinees, appropriate time interval, and similar conditions for measurements. Standard Error of Measurement, Small Detectable Change or Limits of Agreements should be calculated. Percentage (positive and negative) agreement should be calculated for dichotomous/nominal/ordinal scores. Calculation of Standard Error Measurement through Cronbach’s alpha is not appropriate, because it does not take the variance between time points into account and it should be calculated by a test-retest design . None ofHypothesis testing for construct validity requires comparisons of the instrument under development with other outcome measurement instruments  through Pearson correlation and describing distribution of scores or mean scores. Performing confirmatory factor analysis or structural equation modeling over scales are also proper methods to measure differences between similar constructs. Discrepancy in scores among ‘known groups’  should be also measured. In discriminative or known group validity study significant characteristics of the groups under study such as age, gender, language etc. should be reported.Only one of the studies  has calcThis systematic review assessed the measurement properties of school health assessment tools used in primary schools through the modified COSMIN methodology checklist. The selected instruments measure school health’s different factors. Despite the importance of existing valid and reliable tools to measure school health, there are only a few number of school health assessment tools. Moreover, for instruments like CDC’s School Health Index and CDC’s School Health Profile, our search strategy was not able to find any study measuring their psychometric properties. Nevertheless, we systematically found seven studies that were recognized as eligible for our criteria. As far as we know, this is the first systematic review that has methodologically studied the quality of school health assessment tools.The results showed that all of the seven selected studies have performed structural validity, internal consistency, and reliability. Most of the studies had satisfactory results in internal consistency, that is, they have conducted Cronbach’s alpha for each subscale or have tested the instruments’ unidimensionality.Concerning structural validity and content validity, more numbers of the studies were scored “very good” among the other measurement properties after the internal consistency, indicating a relatively strong level of evidence on these measurement properties compared to others. Conversely, none of the studies have calculated measurement error and just one study has considered the hypotheses testing for construct validity. If not specified otherwise, the random or biased errors of the scores are not obvious; which implies that we do not know the difference between the observed scores and the true scores . That isTwo instruments have been translated to other languages  and therReliability measurement requires a double test for the instrument with stable samples and proper time interval and calculating intraclass correlation coefficient or Kappa. Just two studies could be scored as “very good”  that shoEventually, none of the studies scored as “high quality” because they have not measured all the required measurement properties using the correct statistical methods; three studies were scored as “moderate quality” ; and theα = 0.97, RMSEA = 0.07, CFI = 0.98). The internal consistency between factors has ranged from 0.86 to 0.91. The Quality of Life at School Questionnaire (r < 0.69. The School Health Evaluation Instrument (The Scale for Health-Promoting School’ items  were devionnaire  has beenstrument  has beenOur findings suggest that measuring all aspects or factors of school health is not widespread. Most of the studies have measured just one, two or some factors related to school health. Measuring health at school is necessary, since it affects the policies and decisions of stakeholders of schools. Further investigations are required into measuring comprehensive and precise psychometric testing on existing tools, as well as advanced development of new tools considering appropriate statistical methods for measuring cross-cultural validity, reliability, measurement error, and construct validity. Nevertheless, among the existing tools, the Scale for Health-Promoting Schools  and the In sum, we found only a few instruments assessing school health. What is more, there are only a few studies measuring the psychometric properties of these instruments. Importantly, this small number of studies have not considered some of the measurement properties mentioned in the COSMIN checklist. Thus, there is not enough evidence on the quality of these instruments. This systematic review suggests that researchers need to conduct more studies on school health assessment tools in order to acquire better conclusions on these instrument’s measurement properties.The studies included in this systematic review show that their instruments had a relatively strong internal consistency, a moderate quality for both structural validity and content validity, and a poor quality for tool development, reliability, cross-cultural validity, measurement error, and hypotheses testing for construct validity. Due to the inconsistency of school health assessment tools, we recommend that future studies on measurement properties of school health assessment tools adhere to the measurement properties of the COSMIN Risk of Bias checklist as it can be used as a helpful detailed manual or guideline to report the psychometric properties of school health instruments.“Let no one ignorant of geometry enter”—Plato10.7717/peerj.9459/supp-1Supplemental Information 1Click here for additional data file.10.7717/peerj.9459/supp-2Supplemental Information 2Click here for additional data file.10.7717/peerj.9459/supp-3Supplemental Information 3Endnote format.Click here for additional data file.


The story of phenylketonuria (PKU) started in 1934 with Asbjørn Følling’s examination of two mentally retarded siblings from a Norwegian family. However, if their mother had not been so persistent in her search for somebody who could give her a reason why both her children were retarded, Asbjørn Følling’s name might never have been associated with PKU and surely the history of PKU would have started differently. In the short review below, the authors give a partly personal and therefore rare account of the early history of PKU, its treatment and the start of neonatal screening. Prof. Woolf is a pioneer of both the dietary treatment of PKU and neonatal screening; Mr. Adams is a long-time advocate for PKU patient interests. Asbjørn Følling, a resident in paediatrics in western Norway who had trained in chemistry before studying medicine, examined two mentally retarded siblings in 1934. To reassure the mother that he had examined them thoroughly, he tested their urine for “ketone bodies”, using ferric chloride, and obtained a green colour instead of the expected purple. He correctly identified the unknown chromogen as phenylpyruvic acid. This substance had never been found in nature before. Følling concluded that it was derived from dietary phenylalanine and named the condition oligophrenia phenylpyruvica ,3,4. HisArchives of Disease of Childhood. We disagreed with Penrose [In early 1948, Horst Bickel spent a couple of weeks in my (Dr. Woolf’s) laboratory at The Hospital for Sick Children, Great Ormond Street, London (GOS) before going to Birmingham, and from time to time we visited each other over the next few years. In 1949, David Vulliamy and I found a case of PKU at GOS and wrote it up for I (Dr. Woolf) thought an artificial diet consisting of a mixture of amino acids, without phenylalanine, to replace dietary protein, together with carbohydrates, fats, vitamins, minerals etc., might be efficacious. Individual amino acids were very expensive at that time, and I abandoned the idea. Then, I went to a meeting on the microbiological assay of amino acids in proteins using a protein hydrolysate from which phenylalanine had been removed by filtration through charcoal. Before going to GOS, I had worked at a drug company making protein hydrolysates for oral or intravenous (IV) nutrition, and I knew that they were safe and could be manufactured easily and cheaply. Things came together and I resurrected the idea of dietary treatment of PKU. At GOS the suggestion floated like a lead balloon; I was told, not unkindly, that I should be devising new diagnostic tests, not dreaming up crazy treatments for conditions that everybody knew were incurable.Bickel came to see me (Dr. Woolf) in 1952. He had a patient with PKU who was very badly deteriorated, and asked if I could suggest any treatment. I gave him full details of my proposed artificial diet , emphasising the need to add enough phenylalanine to permit normal growth, as well as tryptophan, tyrosine, methionine (as a source of sulphur), minerals, all known vitamins, trace elements and essential fatty acids. He prepared the diet, doing much of the manual work himself, fed it to the child, and reported a dramatic improvement in her behaviour . SeveralWhen the GOS people saw Bickel’s report, it was decided to treat PKU patients with the diet but to use objective cognitive tests of the result. Ruth Griffiths joined the team in about 1958, and found a steady improvement in I.Q. over time, particularly in those not too severely brain-damaged. We also found a sudden cessation of epileptic seizures as soon as the diet was started .l-tyrosine and synthetic tryptophan and methionine from a chemical manufacturer, and gluten-free wheat flour, peanut oil, sugars, calcium dihydrogen phosphate, a multi-vitamin mixture and trace elements as far as they were known at the time. Then, Allen and Hanbury’s started making the mixture for us and marketing it as “Cymogran”, leaving us to add the vitamins and minerals, and milk or cream as a source of phenylalanine. Other companies, namely, Trufood, Mead Johnson, and Scientific Hospital Supplies (Milner’s company), started manufacturing competing products  and yet others explored the subject. The diets were “prestige products” costing more than they could be sold for. Nevertheless, there was bitter rivalry between the companies, with one suggesting  that the other’s products lacked essential fatty acids. The protein used to make the hydrolysate was casein (Cymogran and Minafen), lactalbumin  or bovine serum albumin (Albumaid). One company claimed that its competitors had chosen proteins with less than ideal amino acid compositions  and that its own mixture mirrored the amino acid composition of the native “ideal” protein except for phenylalanine. They forgot that, since patients with PKU could not convert phenylalanine to tyrosine, they should have added tyrosine equivalent to the sum of tyrosine plus phenylalanine in the original protein. Later they corrected this error, though without fanfare. It is ironic that the company loudest in criticism of the amino acid and essential fatty acid composition of competing products should be the only one marketing a defective product for a time.The diet was prepared by our dietician, Frances Dillistone, using charcoal-treated casein hydrolysate purchased from Allen and Hanbury’s (a drug company and baby food manufacturer), Of course we made mistakes. At first we aimed at keeping the blood phenylalanine concentration at precisely the normal level, but it fluctuated. This meant that at times it was too low, causing the infant to go downhill. We could not at first believe how much phenylalanine  a six-month old with PKU needed. We later decided to aim at a blood phenylalanine level of 1.5 to 4 mg/100 mL, i.e., 1½ to 4 times normal but still low enough to prevent mental or neurological deterioration. Methionine is a good source of cystine/cysteine in older children, but we found that neonates do not convert it efficiently and we had to add cystine or cysteine. I (Dr. Woolf) was far too obsessive in avoiding any protein except for the carefully-measured milk or cream. In retrospect, addition of more relatively low-protein natural foods would have made the diet easier to take .Years later, in 1955, I found that Marvin Armstrong in Salt Lake City had reached the same conclusion about causation and treatment as myself and had treated a patient using a mixture of pure single amino acids which someone donated. This may have been before Bickel’s patient, but Armstrong did not publish until 1955 .At that time, patients for treatment could be found only by testing the urine of children who presented with mental retardation at ages ranging from 1 to 12 years, and who therefore already had more-or-less severe brain damage that was only partially reversible. Then, in about 1958, the ward sisters noticed that one of our in-patients being treated with the diet was being visited by her father but not her mother. On enquiry, we were told that her mother had just given birth in another hospital. We tested the baby’s urine at age 17 days and she became the first neonate to be treated . The res