Multiple system atrophy (MSA) is a progressive neurodegenerative disease. However, little is known about the regional cerebral blood flow (rCBF) and functional connectivity changes in the disease. In this study, the magnetic resonance imaging (MRI) data including 24MSA-c-type patients and 20 healthy controls were collected by using voxel wise arterial spin labeling (ASL) perfusion analysis, several regions of the altered rCBF were identified in the MSA c-type patients. And then, the changes of the functional connectivities of identified rCBF regions were analyzed by using functional MRI (fMRI). Finally, rCBF value of cerebellum was extracted to differentiate the MSA c-type patients and controls. Compared with the controls, the MSA c-type patients showed distinct disruption of rCBF in the cerebellum. The disconnection of the identified cerebellar regions was revealed in several regions in the MSAc-type patients, including right middle frontal gyrus (MFG), right precuneus, left superior temporal gyrus (STG), right lingual gyrus, left postcentral gyrus (PoCG), right cerebellum 7b, right cerebellum 8, and left cerebellum 4,5. These regions were involved in the default mode network (DMN), sensorimotor network, visual associated cortices, and cerebellum. Using the rCBF value of vermis as biomarker, the two groups can be differentiated and reached a sensitivity of 95.8% and specificity of 100%. This is the first study to demonstrate the MSA-specific rCBF abnormalities using the ASL method, which are closely associated with several functional networks on resting state fMRI. The rCBF of vermis might be used as the potential imaging biomarker for the early diagnosis of MSA c-type. Multiple system atrophy (MSA) is a progressive neurodegenerative disease characterized by parkinsonism with low dopamine response, cerebellar ataxia, and dysautonomic . The mosStructurally, most MSA neuroimaging researches have been focused on the gray matter atrophy detected by the structural magnetic resonance imaging (MRI) . As the Functionally, resting-state functional MRI (rs-fMRI) has attracted increasing attention to be used to explore intrinsic brain activity and connectivity . SeveralBased on the previous study, underlying physiological mechanism of brain function was closely coupled with the cerebral perfusion, which can be detected by arterial spin labeling (ASL) analysis. As a non-invasive technique, ASL can provide quantitative information of regional cerebral blood flow (rCBF). In a previous study of healthy normal people, by combining ASL and fMRI analysis, the researchers found that functional brain hubs showed striking spatial correlation with rCBF . Recent In this study, we focused on the MSA-c type. By combining the voxel wise ASL and resting state fMRI methods, we hypothesized that there might be decreased rCBF in some specific regions in MSA, which were closely associated with the functional changes. Furthermore, rCBF changes might be affected early in the disease course, we expected that ASL of specific regions can accurately describe and track disease progression, which can be applied as a valuable imaging biomarker for early diagnosis of MSA-c type.Twenty-four MSA patients and 20 controls were recruited at the clinic of Dongfang Hospital of Beijing University of Chinese Medicine. The two groups matched for age and gender. The diagnosis of MSA was according to the established international diagnostic criteria of probable MSA defined by the American Academy of Neurology and American Autonomic Society . All subThe inclusion criteria for controls were as follows: (1) there were no neurological or psychiatric disorders including obsessive disorder, anxiety disorder, schizophrenia, depression, epilepsy, and so on; (2) there were lack of significant cognitive decline (MMSE score > 24); (3) there were no neurological deficiencies including visual or hearing loss; (4) there were no treatment with deep brain stimulation or operation; (5) there were no evidence of movement disorder, vascular brain lesions, brain tumor, and/or marked cortical and/or subcortical atrophy on MRI scan.The exclusion criteria for the subjects were as follows: The subjects of hemorrhage, infarction, tumors, trauma, or severe white matter hyperintensity were excluded from the study. Clinical and demographic information of the subjects were shown in All subjects gave written informed consent in accordance with the Declaration of Helsinki. The protocol was approved by the Medical Research Ethical Committee of Dongfang Hospital of Beijing University of Chinese Medicine.2, resolution = 64 × 64 matrix, slices = 36, thickness = 3 mm, gap = 1 mm, voxel size = 3.75 × 3.75 × 3 mm3, and bandwidth = 2232 Hz/pixel. For volume calculation, high-resolution anatomical images were collected using a 3D brain volume (BRAVO) T1-weighted sequence with the following parameters: TR/TE/inversion time (TI)/FA = 8150 ms/3.17 ms/450 ms/12°, resolution = 256 × 256 matrix, slices = 188, thickness = 1 mm, voxel size = 1 × 1 × 1 mm3. 3D ASL data were acquired using the following parameters: TR/TE = 2.0 s/14 ms, Post label delay (PLD) = 2.0 s, FOV = 256 × 256 mm2, matrix size = 64 × 64, in plane resolution = 3 × 3 mm2, bandwidth = 2,232 Hz/px, phase partial Fourier = 6/8, EPI factor = 64. Twelve slices of 6 mm-thickness were acquired. All the participants were instructed to keep their eyes closed, move as little as possible, think of nothing in particular, and stay awake during the scans.Magnetic resonance imaging data acquisition was performed on a GE 3.0T Discovery 750 scanner. Foam padding and headphones were used to control head motion and scanner noise. The resting-state fMRI data was acquired by using the following parameters: repetition time (TR)/echo time (TE)/flip angle (FA) = 2,000 ms/30 ms/90°, field of view (FOV) = 24 × 24 cmThe images with differences in 3D-ASL were averaged, and the rCBF map was calculated with the weighted reference image of proton density . Image p1. The first 10 volumes for each participant were discarded to allow the signal to reach equilibrium and the participants to adapt to the scanning noise. The remaining volumes were corrected for the acquisition time delay between slices. Then, realignment was performed to correct the motion between time points. In resting state fMRI, a common finding is that many long-distance correlations are decreased by subject motion, whereas many short-distance correlations are increased. Therefore, we estimated subject head motion immediately after the fMRI scans to ensure that all participants’ data were within the defined motion thresholds . To spatially normalize the fMRI data, the realigned volumes were spatially standardized into the MNI space using the EPI template. The functional images were resampled into a voxel size of 3 mm× 3 mm× 3 mm. Then, the functional images were smoothed with a Gaussian kernel of 4 mm FWHM. Finally, several nuisance covariates  were regressed out from the data. After preprocessing, time band-pass filtering (0.01–0.08 Hz) of the fMRI data reduced the effects of a low-frequency drift and high-frequency physiological noise, such as respiratory and cardiac rhythms.Data Processing Assistant for Resting-State fMRI DPARSF, 1. The fiz is obtained using Fisher’s r-to-z transformation to improve the Gaussianity of its distribution.To investigate change in network level function in MSA patients, we conducted a seed-based inter-regional correlation analysis. According to the rCBF result, there might be several regions identified as significant abnormalities in patients with MSA. We selected the regions presenting most significant difference between the two groups as cluster masks, and defined them as regions of interest for functional connectivity analysis. Correlation analysis between the time series of seed and the time series of the entire brain in a voxel-wise way was performed. The value of To eliminate the influences of brain atrophy on the resting state functional connectivity, we took voxel wise gray matter (GM) and white matter (WM) volumes as covariates during the rCBF analysis. First, each subject’s GM and WM volume map was estimated from the normalized T1WI images by VBM method (VBM8 toolbox). Then, a two-sample was performed between the MSA and controlgroup, which showed brain atrophy in the MSA patients.p < 0.05) to conduct the multiple comparison corrections, with age, gender, education levels, GM and WM volumes as covariates using Statistical Parametric Mapping software package (SPM12)2.For between-group comparisons (rCBF differences between the MSA patients and the controls), we use voxel-wise Family-wise error (FWE) rate correction .Then, the regions that were significantly changed in terms of the rCBF were selected as areas of interest (ROIs). The whole brain functional connectivity of the ROIs was computed and independent-samples P < 0.05).To explore the associations of the clinical variables with the rCBF and connectivity in the MSA patients, a partial correlation analysis was performed with age, gender and education levels being used as nuisance covariates  analysis with SPSS 20.0 to obtain a sensitivity and specificity imaging biomarker for MSA diagnosis.Demographic and clinical characteristics were described in Compared to the healthy controls, the patients with MSA-c type showed significantly decreased rCBF in the left cerebellum 6, right cerebellum crus 1 and vermis 4,5. The peak voxels within those significantly different clusters were shown in To investigate functional connectivity alterations in the MSA-c type patients, seed-based interregional correlation analysis was performed. We selected the three regions of bilateral cerebellum, which were significantly changed in rCBF as seeds. In the In the MSA-c type group, we didn’t find significant correlations between the UMSARS scores and rCBF as well as functional connectivity changes.As shown above, the vermis was the region with the most significant rCBF differences between the two groups, which raised a possibility that the rCBF values for the vermis might serve as markers to differentiate the MSA patients from healthy controls. To explore the possibility, we calculated the rCBF value of each subject within vermis 4, 5 and performed ROC analysis to differentiate the MSA patients and the healthy controls. By performing ASL analysis, we observed significant decreased rCBF values of several cerebellum regions in MSA-c type patients. By using the altered rCBF regions as seeds, we found functional disconnectivities between the selected cerebellum regions and several other regions including the right MFG, right precuneus, left STG, right lingual, left PoCG, right cerebellum 7b, right cerebellum 8, and left cerebellum 4,5. Importantly, these regions were involved in several specific networks including default mode network, sensorimotor network, visual associated cortices and cerebellum. Finally, we found the rCBF value of vermis could be used as a sensitive biomarker to differentiate MSA and controls. These findings might be helpful for us to understand the neural pathophysiology mechanisms of MSA.Decreased rCBF values were revealed in several cerebellum regions in MSA-c type patients, suggesting the impaired cerebral perfusion in the disease. Typical histopathological findings of MSA-c type have been observed predominantly in cerebellum. Structurally, recent study found the disrupted structural atrophy in the cerebellum of the MSA-c type, presenting gray matter loss and white matter degeneration . FunctioBased on the altered rCBF regions, we revealed the disrupted functional connectivity pattern in MSA-c type, which exhibited functional disconnection between the cerebellums and several brain regions, involving the DMN, sensorimotor network (SMN), and cerebellar network.We found the disrupted connectivity between the cerebellum and the several DMN regions  in the MSA-c type patients. As we known, these regions were functionally connected with each other and constituted the primary hub of the DMN during resting state . The DMNBesides, we noticed decreased connectivity between the cerebellum and the region of PoCG, which was involved in the SMN. This network was constituted by primary sensory and motor cortices, indicating the important role of the related function . By explWe found decreased connectivity between the cerebellum and the right lingual gyrus in MSA c-type patients. The lingual gyrus is a structure in the visual cortex that plays an important role in processing vision. In a previous study, impaired visual memory was associated with the gyrus or disconnections between the gyrus and other brain structures . Recent Finally, we also detected the decreased connectivity among the several different cerebellum regions including right cerebellum 7b, right cerebellum 8, and left cerebellum 4,5. To our knowledge of cerebello-cortical circuit: The afferent fibers of cerebellum mainly come from the opposite cerebellopontine nucleus and the inferior olivary nucleus, passing through the middle and lower cerebellar peduncles to the new cerebellum, and then, the cerebellar cortex sends the efferent fibers to dentate nuclei and forms the main body of the superior cerebellar peduncles, which project into the contralateral thalamus and cerebral cortex. From the view of the process of the cerebello-cortical circuit, many cerebellum regions played an important role in the network, which was responsible for the balance, planning, and coordination of motor functions. In this study, the disconnection within the several cerebellum regions was consistent with the pathology of the MSA-c type, which emphasized on the cerebellum atrophy and dysfunction . In addiIn the current study, by using the rCBF of the vermis as the biomarker, we could differentiate the two groups at the cut-off value of 0.958 yielding a sensitivity of 95.8%, specificity of 100%, and the AUC value of 0.960. It was an interesting result which could be used as valuable imaging biomarkers for the early diagnosis of MSA-c type.In the previous study, most researchers used structure changes as biomarker to differentiate the MSA-c type and controls. For example, a previous study used the “hot cross bun” sign as biomarker to diagnose MSA-c type, yielding a high specificity of 97%, but its sensitivity was only 50% . While aThere are still some issues to be addressed. First, in the current study, we mainly focused on the cerebral perfusion and functional connectivity. Further studies using multi-mode methods including resting state and task related fMRI, diffusion, perfusion, and spectroscopy analysis would be more helpful for deep understanding the mechanism of MSA. Second, recent studies have paid more attention to MSA p-type. In the future, exploring MSA different subtype (parkinsonian and cerebellar variants) would provide valuable biomarkers for the early differential diagnosis of the disease. Finally, we didn’t detect the correlation between the parameter changes and the clinical performances; in the future, a large sample of fMRI data needs to be performed to test the current findings and a longitudinal design would be useful to elucidate the progressive functional changes of the MSA patients and its relationship with clinical performances.In conclusion, we identified the regions of significantly decreased rCBF in the MSA patients, which were mainly located in cerebellum. In addition, we found the disrupted functional connectivity of the selected cerebellum regions in the MSA patients, which were involved in different functional brain networks such as DMN, SMN, visual associate cortices and cerebellar network. These findings added the new evidence for the disrupted rCBF and disconnection syndrome of MSA, which might provide the potential biomarker for detecting early MSA in the future.The datasets analyzed in this manuscript are not publicly available. Requests to access the datasets should be directed to wangzhiqun@126.com.The studies involving human participants were reviewed and approved by Medical Research Ethical Committee of Dongfang Hospital of Beijing University of Chinese Medicine. The patients/participants provided their written informed consent to participate in this study.ZC and ZW carried out the research project and conceived the study. ML organized the study. HZ and QZ executed the results. WZ carried out the statistical analysis and designed the study. HZ executed the results. ZW reviewed and critiqued the manuscript. WZ and SR wrote the first draft of the manuscript.The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.


Urban green space is believed as a beneficial landscape for mental restoration in the urban settings. This study aims to examine the restorative quality of the urban green space from a multi-sensory perspective, focusing on both direct and indirect connections between visual, auditory, and tactile sensations and mental restoration. Two hundred and fifty park users of Tianhe Park in Guangzhou, China, were surveyed. Data were collected regarding their three types of sensations, i.e., the perceived mental restoration, health-related behavioral activities and emotional responses in the urban park. As a result, visual and auditory sensation were found to be linked with mental restoration directly and indirectly, while the tactile sensation was only associated with mental restoration indirectly; and health-related behaviors and emotional response mediated the relations between the three sensations and mental restoration significantly. It is concluded that the greater effects of auditory sensation and the under-studied potential effects of tactile sensation on mental restoration should be more emphasized in the future design of urban park. This is expected to contribute to the high restorative quality of the urban green space and promote public health.  Increasing attention has been paid to the restorative landscape associated with public health during the past decade, acknowledging the contribution of an appealing landscape to health and wellbeing . The wayThe paper is organized as follows. Restorative environment refers to an environment beneficial to psychological and physical health through reducing stress and various negative emotions, decreasing mental fatigue, improving attention, facilitating disease recovery, etc. ,11. StemBased on these fundamental theories, a bunch of studies make efforts on the exploration of the restorative effect of natural experience, the key influential factors of mental restoration, as well as their underlying mechanisms within different local contexts . NumerouAn expanding body of research focus on the links between landscape and health  paying pEnvironmental perception is multi-sensory, including the five senses or more, which could be categorized into distance sense  and nearness senses (tactile and touch)  (p. 41).The multi-sensory theory was originally developed to design sensory parks for specific people, enhancing multi-sensory perception and stimulation ,35. In pTo provide evidence for plan and design of urban park with restorative qualities, this study aims to examine the relationship between users’ multi-sensory perception and the perceived mental restoration of urban parks in China through investigating the restorative effects of urban parks from the lens of perceived multi-sensory perspective. The hypothesis is set as that: The multi-sensory perception in urban parks could influence user’s perceived mental restoration both directly and indirectly. Emotional responses and behavioral activities occurred in the park  could mediate between multi-sensory perception and people’s perceived mental restoration in urban parks. A theoretical-indicated framework is thus developed: individual’s visual, auditory and tactile sensation in urban parks affect the restorative effects of urban parks directly and through the mediation of emotional response and behavioral activities . The detHypothesis 1 (H1).The multi-sensory dimensions of urban parks have significant positive impacts on the restorative effects.Hypothesis 1a (H1a).The visual sensation of urban parks has significant positive impacts on the restorative effects.Hypothesis 1b (H1b).The auditory sensation of urban parks has significant positive impacts on the restorative effects.Hypothesis 1c (H1c).The tactile sensation of urban parks has significant positive impacts on the restorative effects.Hypothesis 2 (H2).The multi-sensory dimensions of urban parks have significant positive impacts on residents’ behavioral activities.Hypothesis 2a (H2a).The visual sensation has significant positive impacts on residents’ behavioral activities.Hypothesis 2b (H2b).The auditory sensation has significant positive impacts on residents’ behavioral activities.Hypothesis 2c (H2c).The tactile sensation has significant positive impacts on residents’ behavioral activities.Hypothesis 3 (H3).The multi-sensory dimensions of urban parks have significant positive impacts on residents’ emotional responses.Hypothesis 3a (H3a).The visual sensation has significant positive impacts on the emotional responses of residents.Hypothesis 3b (H3b).The auditory sensation has significant positive impacts on the emotional responses of residents.Hypothesis 3c (H3c).The tactile sensation has significant positive impacts on the emotional responses of residents.Hypothesis 4 (H4).The residents’ behavioral activities have significant positive impacts on the emotional responses of residents.Hypothesis 5 (H5).The residents’ behavioral activities have significant positive impacts on the restorative effects.Hypothesis 6 (H6).The emotional responses of residents have significant positive impacts on the restorative effects.2, including water area (10 hm2) and land area (60.7 hm2). In terms of the landscape element, Tianhe Park is comprised by various natural elements such as trees, shrub, lawn, lakes, and hills, resulting in a green coverage ratio as high as 90%. Functionally, it is designed into five zones: Flowers garden zone, entertainment and leisure zone, activity area for the elderly, forest rest zone, and logistics management zone. Tianhe Park in Guangzhou is selected as the typical case for this study. Located in the center of Tianhe district, Tianhe Park serves as a central park on urban level, attracting urban residents from the whole city . It enjoWe carried out questionnaire surveys during 11 March 2019 and 16th March 2019 to gain the information on the perceived multi-sensory dimensions of Tianhe Park and users’ perceived mental restoration. Two modes of survey were conducted to improve the representativeness of our samples: On-site face-to-face survey and online survey. The on-site survey was conducted on both weekdays and weekend from 7 a.m. to 7 p.m., using a random sampling method at five different spots in the five zones, respectively. The online questionnaire was supplement used to enlarge the range of target population, including those who have been to the Tianhe Park from time to time but didn’t come to the park during the on-site survey period. Finally, 174 on-site questionnaires and 85 online ones were collected. Excluding the invalided respondents such as the same responses for each single item and incomplete responses, there were 250 valid respondents left in this study.I feel relieved from physical pain and discomfort; (2) I feel relieved from anxiety, depression and stress; (3) My attention is enhanced; (4) My health is good and my level of activity is improving; (5) I feel loneliness is reduced; and (6) I feel my quality of sleep is improved. Respondents were asked to rate 1–5 to indicate the level of agreement with above statements. Based on the ART and referring to existing measurements of restorativeness, a five-point Likert scale comprised of six items was developed to measure the perceived mental restoration: (1) Perceived multi-sensory dimensions of the urban park were investigated by a five-point Likert scale (from strongly disagree to strongly agree), focusing on users’ visual sensation, auditory sensation and tactile sensation particularly. Visual perception was measured by six items: Variety of plants (V1), richness of plants’ color (V2), plant light and shadow mottle V3), nice road texture (V4), rich terrain and wide view (V5), the water is highly ornamental (V6). Auditory perception was measured by five items: Natural sounds (A1), sweet background music (A2), happy people sounds (singing or playing instruments) (A3), quiet space (background city) (A4), and no traffic noise (A5). Tactile perception was investigated by four items: the road material is comfortable and the foot feels good (T1), strong hydrophilic (T2), the seat is comfortable for sitting (T3), and there is comfortable grass for flat lay (T4) [, nice roTwo mediators between multi-sensory perception and mental restoration, emotional responses and behavioral activities, were investigated by five-point Likert scales, respectively. First, four types of emotional responses were evaluated: comfort, happiness, sense of belonging, and attraction. The intensity of these feelings was measured by five degrees, ranging from very strong, strong, neutral, weak, to very weak. Second, six types of behavioral activities that often occur in the park was investigated, including the activities of relaxation and thinking, social interaction, fitness exercise, walking, art activity, and family activities. The frequency of these activities was evaluated by five levels, ranging from always, often, sometimes, occasionally, and never. Socio-demographic characteristics and visiting habits were investigated as the individual correlates since they are regarded as the potential confounders between environmental perception and mental restoration. These individual correlates include: gender, age, general health status, companion, duration of stay, and attitude on the importance of urban park for stress releasing. p value was (0.000) less than 0.001. The extracted value (AVE) of each latent variable was almost above 0.45, which was close to or greater than the critical criterion (0.5), indicating that the selected observed variable had a certain correlation. Reliability and validity of above variables are reported in To examine the theoretical-indicated hypotheses proposed in Descriptive statistics of the samples are presented in For the restorative effect, the average scores of R1, R2, and R5 ranged from neutral to agree (3.76–3.96) in the five-point scale, and the average scores of R3, R4, and R6 ranged from agree to strongly agree (4.04–4.12), indicating positive restorative effects of the park, especially in terms of the promotion of attention recovery and mental wellbeing, physical health and activity level, and sleep quality. For visual sensation, mean scores of V1, V2, V3, V4, V5, and V6 ranged from agree to strongly agree (4.00–4.24), with V6 was lower than 4 in the five-point scale, indicating good visual sensation of the park except for the ornamental value of water. Similarly, among the five indicators of auditory sensation, only one item’s (A2) average score was lower than 4 in the 5-point scale, suggesting good auditory sensation except for the background music. For tactile sensation, the mean scores of hydrophilic (T2) and comfortability of the grass (T4) were lower than 4, indicating that the relatively poorer perception on these two aspects than on the road material (T1) and seat quality (T3). For behavioral activities, the frequency of literary activities (B4) was the lowest, between occasionally and sometimes (mean = 2.68), to contrast, the frequency of other activities was all between sometimes and often (mean scores ranged from 3.06 to 3.84) in the five-point scale ranging from always to never. For the emotional response, respondents tended to report strong to very strong perceptions of comfort, pleasant, and attraction (4.20–4.27), while the average score of sense of belonging was between neutral and strong (3.98), indicating less intensity of the feel of belonging. Normality test on all observed variables indicate the normal distribution of the data set, and the structural equation model produced acceptable fit indices as shown in The factor loading of the latent variables on all indicators were relatively high, ranging from 0.41 to 0.81. For visual sensation, the loading of rich in plant species, the standardized path coefficients of plant colors, plant light and mottled, road texture, terrain, and water body were respectively 0.68, 0.68, 0.60, 0.65, 0.59, and 0.60. For auditory sensation, the standardized path coefficients of the natural sound, background music, singing and dancing, quiet space, and traffic noise were 0.73, 0.52, 0.48, 0.63, and 0.63, respectively. For tactile sensation, the standardized path coefficients of the material of the road, the foot feeling, the hydrophilicity, the seat, and the grass were 0.63, 0.73, 0.73, and 0.68, respectively. Standardized coefficients and their statistical significance obtained from the structural equation model were presented in For the mediation effects of behavioral activities and emotional response, results were presented Based on the primary data from the place-based survey of Tianhe Park in Guangzhou, this study examined the link between multi-sensory perception and the restorative effect of the urban green space. Urban park users’ multi-sensory perception plays a significant role in their behavioral activities occurred in the urban park, emotional responses generated in the urban park, and the mentally restorative experiences of the urban park. For the underlying pathways, specifically, the visual sensation and the auditory sensation had both direct and indirect links with mental restoration, while the tactile sensation only affected mental restoration indirectly. In addition, mediations of the frequency of behavioral activities and the intensity of emotional response between multi-sensory perception and mental restoration were also confirmed. This study thus could enrich the evidence of the health implication of the landscape perception in a multisensory manner to some extent , particuRegarding the visual perception of the urban park, this study consistently ascertains the positive effects of viewing the natural elements  of the park on the level of restorative effects directly and through the mediating process. This supports the established knowledge that viewing vegetation, water, and other naturel elements could ameliorate stress, promote more positive moods and feelings, induce behavioral changes that could improve mental and physical health, and be beneficial for recovery from illness ,44. For Focusing on the perception of sounds in the park, we confirmed the significant role of urban park users’ auditory sensation in their restorative experience of the urban park. First, the comfort auditory sensation generated in the urban park could increase park users’ mental restoration directly. We propose that natural sounds, ‘happy people’ sounds such as singing and music, quiet background city, and less traffic noise could contribute to a pleasant soundscape environment that nurtures better mental restoration. This finding echoes the established knowledge that accessing to green areas could lower the noise annoyance and stress-related psychosocial symptoms and improve relaxation and sleeps to some extent . Second,For the association between tactile sensation and mental restoration, this study argues that the perception of touching may determine the restorative quality of the urban park through influencing the health-related activities and the resultant emotions. Few existing evidences could be found in previous studies, which may be due to the absence of the direct link between tactile sensation and mental restoration as suggested by this study. However, the tactile sensation formulated by the contact with natural elements  and the use of facilities  could determine the health-beneficial activities that occurred in the urban park and evocate emotional responses, affecting the restorative effects accordingly. This study thus particularly highlights the potential role of tactile sensation of the urban park on the restorative effects.Therefore, based on the restorative effect of multi-sensory perception, health-related behaviors and emotional responses of the urban park found in this study, we provide more local evidences supporting the argument that “the experience generated in a place is just as important as the presence of certain physical aspects in making a place restorative to the individual” ,49. For The study identified the mental restorative effects of multi-sensory perceptions of the urban park, and examined the mediating effects of health-related behaviors carried out in the park and the resultant emotional responses. We ascertained the direct association between the visual and auditory sensations and mental restoration, the indirect association between tactile sensation and mental restoration, as well as the mediation of behavioral activities and emotional responses between the three multi-sensory perceptions and mental restoration. In comparison, it is particularly found that auditory sensation has relatively greater contribution to mental restoration than the other two sensations—calling for further explanations in future studies. Operationally, the multi-sensory perception perspective should be considered seriously when designing urban green space, particularly in terms of the direct restorative effects of auditory and visual sensations, and the requirements of users’ health-related behaviors and emotions.There have been advances in our understanding of the associations between multi-sensory perception and mental restoration. Nevertheless, limitations of this study should be admitted: Due to the numerus variables included in the research design, only the main effects of the three sensations on mental restoration were focused on, that is, the potential interactions across the sensations and their potential effects on mental restoration have not been observed. Identifying the effects of mutual interactions of multi-sensory perceptions on the restorative quality of urban green space is one of the major necessity research of the future.


Type 2 diabetes mellitus (T2DM) patients are involved closely with cancer. This work aims to conduct a systematic review and network meta-analysis (NMA) to examine the effect of different types of statins on cancer incidence in patients with T2DM.  We systematically searched the Cochrane Library, PubMed, Embase, and Wanfang databases from January 1999 to March 2017. We performed a pairwise meta-analysis to estimate the pooled ratios (ORs) and 95% confidence intervals (CIs). A NMA was performed to compare different types of statins.  Seven publications were included. In pairwise meta-analysis, the incidence of cancer in T2DM patients was reduced when simvastatin, atorvastatin, pravastatin, fluvastatin, lovastatin, rosuvastatin, and pitavastatin were used. In the result of NMA, the usage of simvastatin (RR 0.30 and 95% CI 0.16–0.56), atorvastatin (RR 0.29 and 95% CI 0.09–0.88), pravastatin (RR 0.34 and 95% CI 0.12–0.93), fluvastatin (RR 0.27 and 95% CI 0.09–0.83), rosuvastatin (RR 0.22 and 95% CI 0.10–0.49), and pitavastatin (RR 0.33 and 95% CI 0.20–0.57) was superior to the nonstatin groups. When compared with six other statins, rosuvastatin appeared to be the best one.  Different statins can reduce the risk of cancer in patients with T2DM. Our analyses suggest that rosuvastatin may be more effective than others. Diabetes mellitus (DM), mainly type 2 diabetes mellitus (T2DM), and cancer are two critical diseases which have a high incidence . As repoBy inhibiting 3-hydroxy-3-methylglutaryl coenzyme A (HMG-CoA) reductase, statins could reduce the levels of cholesterol. For decades, statins have been commonly used to treat the hypercholesterolemia –11. Currin vitro have suggested the effect of statins on growth, migration, apoptosis, and autophagy of cancer cells [in vivo studies, statins may act as a preventive drug for hepatocellular carcinoma, bladder cancer, and malignant glioma [A growing number of studies have suggested statin-related potential for reducing the risk of cancer –18. A loer cells –25. Accot glioma –28. HoweGiven the high incidence of cancer in patients with T2DM and the widespread use of statins, it is necessary to understand the relationship between statins and cancer. For this purpose, we performed this meta-analysis to evaluate the impact of different types of statins on the risk of cancers with T2DM. Network meta-analysis (NMA) can provide strong evidence to support potential strategies for T2DM-related cancers for different statin subtypes.To identify the studies, we search the Cochrane Library, PubMed, Embase, Wanfang, and Chinese National Knowledge Infrastructure databases from January 1999 to March 2017 without any language restrictions. Search key terms included “statin(s),” “cancer,” and “diabetes mellitus.” The search was limited to human subjects. The references of published articles were manually reviewed to complement the search. The titles and abstracts were scanned to exclude the irrelevant studies, and the full texts of the remaining articles were carefully read to assess whether they had enough information. Unpublished articles were also excluded. The protocol for meta-analysis was conducted in accordance with preferred reporting items for systematic reviews and meta-analyses (PRISMA) .The studies which were included in this meta-analysis should meet the following criteria: (1) the design of studies should be controlled strictly, including case-control studies, cohort studies, and RCTs; (2) no prior diagnosis of any cancer prior to the date of cancer diagnosis; (3) studies should specific one or more types of statins, including rosuvastatin, atorvastatin, simvastatin, pravastatin, fluvastatin, cerivastatin, and lovastatin; (4) studies should be designed to evaluate the impact of statins on the risk of cancers with T2DM; (5) studies should have provided sufficient information to calculate odds ratios (ORs) and 95% confidence intervals (CIs). If publications were duplicated or overlapped, only the most recent one was included. All the studies should be peer review papers in full length.Two investigators independently screened the titles and abstracts and reviewed the full paper. If there was any disagreement regarding data extraction, it would be resolved with a third review. When some information or data was needed but unclear, the original authors would be asked by email. The following characteristics were collected from each study: publication data , study design, population characteristics, type of statins, number of total sample size, and number of cancer cases. The quality of case-control studies was assessed using the Newcastle-Ottawa Quality Assessment Scales (NOS), and the quality of RCTs was evaluated by the Jadad scale , 31.To compare the risk of cancer in diabetic patients when they were exposed to different statins, two methods were used.First, a traditional pairwise meta-analysis was performed to directly compare the same interventions. The pooled OR and 95% CI were calculated basing on the clear data described in the included articles. Considering the between-study heterogeneity, a quantity I  statistiThen, by using the NMA package of STATA 14.0, a NMA was presented. To compare the effect of different statins on diabetic patients for the risk of cancers directly and indirectly, ORs were calculated by employing frequentist techniques, which were performed in the form of graph. A network plot, inconsistency plot, predictive interval plot, comparison-adjusted funnel plot, and rank diagram of respective statin types were applied using NMA tool as described in published article .The quality of the two RCTs was assessed using the Jadad scale. According to the scores, both of them were high. The methodological quality of the remaining 5 studies was evaluated according to the NOS. If the scores of studies were 6 or more, they would be regarded as high quality. The scores of included studies are displayed in As shown in p were bigger than 0.05, there were no statistically significant and it needed further studies to analyze their consistencies. Thus, the consistency of lovastatin-rosuvastatin-nonstatin for direct evidence and indirect evidence was the highest and the conclusions between their comparisons were more reliable.As shown in The horizontal axis presents direct comparison, as the vertical axis presents the result of the indirect comparison. The matrix was formed by different comparison in horizontal axis contribution to merged comparison results in vertical axis. From p > 0.05).From Y) of the total effect of the comparison groups on the funnel pattern of the scatter of the total effect (X). 68 scattered points represented 32 studies; 28 different colors represented different comparisons. Most of the scattered points were symmetrically distributed around the vertical line of X = 0  . Among aNevertheless, there are several limitations which should be mentioned. First, the populations in this study were not the same. Most of them were from the United States. Second, unpublished studies were not included, which may have a difference to the results. Third, because of cancer latency, the incidence of cancer may be underestimated, which may have an effect on the validity of the outcomes. Fourth, several confounders, such as therapies of glycemic control and treatment of cancers, were not analyzed.In conclusion, our network meta-analysis clearly presents the advantage of statin usage in cancer prevention of patients with T2DM. Rosuvastatin may be the best of all for reducing cancer risk of T2DM patients compared with others. Our current work could provide new insights into the role of statins on cancer prevention. Given the different population using statins, latency for cancer of T2DM patients, and long-term usage of statins, it is necessary to design RCTs well and continue monitoring the safety of statins.


Non-small cell lung cancer (NSCLC) is a main cause of cancer-related mortality worldwide. The relationships of the phospholipase C beta (PLCB) enzymes, which are encoded by the genes PLCB1, PLCB2, PLCB3, and PLCB4, with NSCLC have not been investigated. Therefore, the aim of the present study was to identify any correlations between NSCLC prognosis and the expression patterns of PLCB family members. The prognostic values of the PLCB gene family members in NSCLC patients were evaluated using the “Kaplan–Meier plotter” database, which includes updated gene expression data and survival information of a total of 1,926 NSCLC patients. The GeneMANIA plugin of Cytoscape software was used to evaluate the relationships of the four PLCB family members at the gene and protein levels. Gene ontology enrichment analysis and KEGG pathway analysis were performed using the Database for Annotation, Visualization, and Integrated Discovery. High mRNA expression levels of PLCB1, PLCB2, and PLCB3 were significantly associated with poor overall survival (OS) of all NSCLC patients and significantly associated with poor prognosis of adenocarcinoma. In contrast, high mRNA expression of PLCB4 was associated with better OS of adenocarcinoma patients. In addition, the expression levels of the PLCB family members were correlated to smoking status, clinical stage, and patient sex but not radiotherapy and chemotherapy outcomes. PLCB1, PLCB2, PLCB3, and PLCB4 appear to be potential biomarkers for the prognosis of patients with NSCLC. The prognostic values of the PLCB genes require further investigations. Lung cancer (LC) is the most frequently diagnosed cancer in both males and females  and the primary cause of cancer-related mortality worldwide . In addition, LC is the leading cause of cancer-associated mortality in men and the third most common in women , with thThe phospholipase C beta (PLCB) class of phospholipases comprises four isozymes (b1–b4) which are encoded by varied genes . PLCB3 iThe KM-plotter is an online survival analysis instrument designed to immediately assess the impact of genes on the prognosis of cancers of the breast, lung, ovary, liver, and stomach, with the use of genome-wide microarrays. Accordingly, the KM-plotter instrument was used in the present study to assess the prognostic values of PLCB genes in patients with NSCLC.https://david.ncifcrf.gov/home.jsp; accessed on August 8, 2018) [https://www.genemania.org/; accessed on August 14, 2018. STRING: https://string-db.org/) [Analyses of Gene Ontology (GO) and Kyoto Encyclopedia of Genes and Genomes (KEGG) enrichment of PLCB genes were conducted using the Database for Annotation, Visualization, and Integrated Discovery  . Gene-gedb.org/) , 17.https://www.ncbi.nlm.nih.gov/geo/; accessed on August 5, 2018).In total, 1,926 patient samples were classified in accordance with the median and overall survival (OS) rates. Medical data, which included the patient's sex, smoking history, histological grade, American Joint Committee on Cancer stage, and success of surgery, radiotherapy, and applied chemotherapy for NSCLC, were collected from the Gene Expression Omnibus database  to identify correlations between PLCB family members at the mRNA level and the prognosis and OS of NSCLC patients [A database was created with the use of the KM-plotter . In lung AC, PLCB3 was significantly associated with PLCB2 . Detailed results are presented in Pearson's correlation analysis was carried out with the use of the expression data of PLCB family members gathered from the Metabolic gEne RApid Visualizer (MERAV) gene expression database , while PLCB1, PLCB2, and PLCB3 were significantly associated with both smoking and nonsmoking status   .p = 0.0032, 6.6e−05, 6.4e−06 and 0.00059, resp.), while grade II disease was significantly correlated with PLCB2 (p = 0.0072) but not PLCB1, PLCB3, or PLCB4 . There was no correlation between grade III disease and PLCB1, PLCB2, PLCB3, and PLCB4 , while being male was significantly associated with PLCB1 (p = 0.0072) but not PLCB2, PLCB3, or PLCB4  = 1.32, 95% confidence interval (CI) = 1.17–1.5; Assessment of the prognostic values of PLCB family members was performed using the KM-plotter online website. The Affymetrix ID of PLCB1 is 215687_x_at. There were statistically significant correlations between the tissue type and AC, as well as the SCC type [Next, the prognostic value of PLCB2 mRNA expression was investigated using the KM-plotter. The Affymetrix ID of PLCB2 is 210388_x_at. High mRNA expression of PLCB2 was associated with a poor OS of every NSCLC patient , and data from 14 different platforms were collected. The characteristics of the samples collected in different data platforms were different. Among the sample characteristics, it did not collect them in detail in which nonsmoking LC patients should be divided into never smoking and ex-smoking patients. Also the information on the different chemotherapy methods and chemotherapy cycles in the sample characteristics was not collected. Therefore, we regret that we could not further explore the relationship between PLCB gene family members and patients who never smoked or ex-smoked and we have not been able to further analyze the relationship between PLCB gene family members and different chemotherapy and also failed to analyze the relationship between PLCB gene family members and the chemotherapy cycle relationship. In spite of these limitations, to the best of our knowledge, the current study is the first to explore the correlations between the mRNA expression patterns of PLCB family members to predict the OS of patients with NSCLC. Besides, these findings bring an understanding of the role of PLCB genes in the clinical outcomes of cancer and further illustrate the application for patient prognosis as well as decision-making in NSCLC management.There were some limitations to the current research which should be addressed. First, the study cohort was relatively small; thus future studies with larger cohorts involving multiple centers with patients of various races are required to verify these findings. To address these issues, we are planning well-designed functional verification studies, which include bothIn conclusion, the aim of the present study was to explore the associations between NSCLC prognosis and the expression patterns of PLCB gene family members. The results showed that high mRNA expression levels of PLCB1, PLCB2, and PLCB3 were linked to a poor OS of every NSCLC patient and were significantly associated with poor prognosis of AC. In contrast, elevated mRNA expression of PLCB4 was associated with better OS of AC patients. Additionally, the expression levels of the PLCB family members were correlated to smoking status, as well as clinical stage and patient sex, but not radiotherapy and chemotherapy outcomes. Accordingly, the PLCB family is likely to have prognostic value in NSCLC patients, but additional investigations are needed.


The chicken egg is the most consumedworldwide, being a food of affordable price, and, above all, of practical cookingand good nutritional profile.3Among the types of cooking, the fried chicken egg, stir-fried, cooked, pochê,roast, in the form of omelet and soufflés, besides being an ingredient ofvarious preparations, stands out. The nutritional aspects of the chicken egg areextensive. It is a source rich in proteins of high biological value, unsaturatedfats, liposoluble vitamins (mainly vitamin A and E), vitamin B12 and antioxidantcomponents.6I carried out studies of great sample character, exhibiting interesting adjustmentsthrough the ingestion of chicken eggs. Data from observational methodology and humanintervention support new research.Hence, we sought to analyze the impact of the intake of whole chicken eggs on thelipid profile from older and recent studies.7 through areview encompassing a survey of 167 studies, whereof cholesterol intake in morethan 4000 individuals was analyzed, shows that every 100 mg of dietarycholesterol intake the total plasma cholesterol increased only 2.2 mg/dL. Awhole chicken egg unit (~ 50 g) contains a cholesterol content equivalent to theamount analyzed in the McNamara study,7 presenting approximately 100-150 mg ofcholesterol,8therefore, being one of the main foods that provided the increase of thecholesterol intake.8In 2000, McNamara7 population increased the LDL levels by 1.9mg/dL and HDLlevels by 0.4 mg/dL. Nevertheless, the mean change in the proportion of LDL: HDLper 100mg of dietary daily cholesterol in the patients was 2.60 to 2.61, thatis, both values were literally negligible for the outcome of cardiovascularproblems, such as plaque atheroma and stroke.7Regarding the LDL and HDL lipoproteins, the addition of 100 mg of cholesterol perday from the diet in the general McNamara7 also shows therelationship of dietary cholesterol response to heterogeneity, whose people aredivided into hypersensitive and hypersensitive. According to the author, 15% to25% of the population is sensitive to dietary cholesterol, in which there is agenetic increase in the production of apolipoprotein E4 and apolipoprotein B.However, the impact of daily dietary cholesterol intake per 100mg increased byonly 1.4 mg/dL of total cholesterol levels in hypo-responsive individuals and3.9 mg/dL in hyperresponsive individuals.7McNamara7 does notemphasize whether the main food responsible for dietary cholesterol was chickenegg. A subject to analyze is the response of the lipid profile of patients withdyslipidemia to the eggs ingestion. In 1997, Knopp et al.9 already had data for thisissue.However, McNamara9 conducted a verywell controlled study involving 130 patients with hypercholesterolemia andcombined hyperlipidemia. For six weeks was used a diet based on traditionalrecommendations, and from that period randomized patients to receive two wholechicken eggs per week or at most one whole chicken egg per week, lasting 12weeks. They analyzed the lipid profile before and after the intervention andobserved that patients with hypercholesterolemia who consumed two eggs dailyincreased their HDL levels by an average of 48 to 52 ng/dL (p = 0.003), whilethey did not change other markers such as LDL, total cholesterol, VLDL andapolipoprotein B. On the other hand, patients with combined hyperlipidaemia whoconsumed two eggs per day increased mean total cholesterol from 238 to 250 ng/dL(p = 0.001), LDL from 150 to 162 ng/dL (p = 0.001), HDL from 42 to 45 ng/dL (p =0.02), and apolipoprotein B (p = 0.05). A decrease in VLDL from 103 to 95 mg/dL(p = 0.007) was observed in this study, which was probably notexpected.9Knopp et al.5A recently published study showed that consumption between two to four (n = 4493)and greater than four whole chicken eggs (n = 214) per week did not increase theincidence of cardiovascular disease compared to individuals with a consumptionhabit of less than two eggs per week (n = 2509). It is noteworthy that thisstudy is of the renowned group PREDIMED (PREvención con DIetaMEDiterránea), in which the individuals followed a Mediterranean foodstyle, therefore, with habitual consumption of olive oil and oilseeds. In thisway, the increase in egg consumption was accompanied by a good dietary style,which was confirmed by the control of macronutrients and type of ingestedlipids, as a relevant percentage of monounsaturated fats  and moderate in saturated fats .5 in a study with a considerable sample (n = 1231) it isstated that the higher the consumption of whole chicken eggs, the greater thearea of the atheroma plaque in the carotid .However, in the study lack physical exercise control, waist circumference andmainly, dietary habits. Nevertheless, the increase in plaque area was related toan older age and history of smoking.10Despite the study by the PREDIMED group,6Another recent study showed that the daily intake of two to three whole chickeneggs increased the functionality of HDL and plasma carotenoids, which areanti-inflammatory and antioxidant factors. Thirty-eight healthy participantsparticipated in a study in which initially they stayed a period of 2 weekswithout eating egg, and later consumed an entire egg of chicken for 4 weeks, andprogressively two and three whole eggs daily every 4 weeks; the interventionlasted 14 weeks. Compared with the time of deprivation of egg ingestion,consumption of one to three eggs/day resulted in increased concentrations oflarge LDL (21-37%), large HDL (6-13%) and apolipoprotein AI (9-15%) whereasingestion of two to three eggs/day promoted an increase in apolipoprotein AII by11% and lutein and plasma zeaxanthin by 20-31%, whereas the ingestion of threeeggs/day resulted in an increase of 9-16% in serum paraoxonase-1 activitycompared to the intake of one to two eggs/day. Intake of one egg/day wassufficient to increase HDL function and particle concentration of large LDL. Ingeneral, the daily intake of less than three eggs/day favored a better LDLparticle profile, improved the function of HDL and increased plasma antioxidantsin healthy young adults.6 The increase of paraoxonase-1 and apolipoprotein AIlevels as a function of egg ingestion are beneficial, since they are precursorsof HDL formation, providing greater functionality.12 In reference to the increase of large LDL, itdoes not mean a bad factor, but a beneficial modulation of the molecule, becausethe higher the volume, the lower is the propensity for endothelial penetrationin the arteries, unlike LDL of lower volume .13This recent intervention adds to the literature a more biologically detailedimpact as a function of the consumption of whole chicken eggs, since it goesbeyond classic lipid profile markers in clinical practice, analyzing lipoproteinprecursors and antioxidant character.14 In agreement with the most recentrecommendations in the medical literature, a new consensus from the AmericanHeart Association,15 basedmainly on the dietary guidelines of the Dietary Guidelines forAmericans,16 in theperiod from 2015 to 2020, cholesterol consumption is still limited to thatadvocated by the V Brazilian Guideline on Dyslipidemias and Prevention ofAtherosclerosis.14However, such recommendations do not specify where dietary cholesterol comesfrom, for example, whether it is primarily from a Western-style diet rich infritters as a whole, or from a type of nutrient-rich diet rich in functionalsubstances. The American Heart Association's recent positioning encouragesMediterranean feeding, citing the PREDIMED group, which, in parallel, can bebased on a considerable weekly frequency of intakes of whole eggs.16The V Brazilian Guideline on Dyslipidemias and Prevention of Atherosclerosisencourages the ingestion of cholesterol < 300 mg/d for patients in general,and for dyslipidemics the incentive is < 200 mg/d.Analyzing a food in isolation requires detailed adjustments, and the egg is a foodthat undoubtedly remains controversial. There are two strands, one more cautious andanother one that overestimates the potential of the egg as food. Following thetraditional recommendations of cholesterol intake is of some importance; however,one should consider the whole lifestyle.17Probably, in individuals who exercise and have good dietary control, the routineintake of whole eggs will not cause harm to the lipid profile, since, presumably,the body is in a good redox balance, being a protective factor for cardiovascularoutcomes.18 In a cross-over study of 33 elderly (mean age 79years), the daily consumption of a whole chicken egg for five weeks did not changeany traditional lipid profile marker compared to the same period without theingestion of eggs, and serum antioxidant markers (+26% lutein and + 38%zeaxanthin).19Even in elderly individuals, the daily consumption of eggs, at least non-abusively,may be insignificant in altering the lipid profile.19 Thus, like the PREDIMED study, if the individualhas good eating habits as a whole, the intake of whole eggs with considerable weeklyfrequency seems to be safe. Above all, the prescription of eggs in clinical practiceis a very individual factor, mainly depending on lipid and protein adjustments.Given the importance of redox balance as a protector to the cardiovascular side,perhaps the consumption of whole eggs is also not of concern for patients withdyslipidemias, because as was quoted, its consumption exhibits beneficialantioxidant modulation to lipoproteins. The PREDIMED study is a good baseline,encompassing middle-aged and large sample patients. Regarding whole eggs intake inthe style of Mediterranean food, two to four eggs per week are consumed on average,whereas less than two servings of sweetmeats and red meat and less than a portion ofprocessed meat are consumed. The white meat intake is two servings and the portionsof vegetables, fish or shellfish are two or more per week.Taken together, dietary cholesterol mainly by using the egg as a source can alter thelipid profile by increasing the markers in general. However, in assessing the actualbiological impact this appears to be practically insignificant. Genetic factors canincrease the cholesterol, LDL and triglycerides levels of individuals because ofhigher cholesterol intake, but nonetheless not quite alarming.


Environmental contamination with heavy metals and metalloids due to industrial, smelting and mining activities have become common in large and growing cities. Kumasi is one of the most industrialized cities in Ghana and experiences metal pollution due to recent and past activities. Although metals are naturally abundant in the area, their accumulation in soils could potentially lead to adverse effects on local ecosystems.The aims of this study were to determine the distribution, enrichment, geoaccumulation and sources of metals in Kumasi soils and to estimate the contamination factor (CF) and pollution load index (PLI) of these metals in soils.Concentrations of eight heavy metals and a metalloid were determined in 112 soil samples randomly collected from 31 sampling sites in the area. In addition, 5 soil samples were collected from a pristine site  for data comparison, to determine the local background values for metal concentrations and to evaluate the extent of metal pollution in the study area.Heavy metals such as zinc (Zn), lead (Pb), cadmium (Cd) and chromium (Cr) were enriched in 65, 32, 58 and 93% of the sampling sites, respectively, and geo-accumulation indexes for Cr, Zn, Cd, mercury (Hg) and Pb showed moderate to extreme contamination in 100, 97, 77, 65 and 45% of the sampling sites, respectively. Principal component and cluster analyses revealed that industrial activities including mining were the major sources of metals in Kumasi soils with high metal input in the community of Suame. Distribution maps revealed hotspots of Cd, nickel (Ni), arsenic (As), cobalt (Co), copper (Cu) and Pb in Suame. The highest CFs for Cu, Cd, Ni, As, Co and Pb highlighted anthropogenic inputs in Suame, while Hg was highest in Mbrom, Zn in Suntreso, and Cr in Aboabo.The PLI of metals revealed Suame as the most polluted study site, while Anomangye and Bomso were the least polluted. Contamination of soil with heavy metal and metalloids results mainly from anthropogenic activities including mining, smelting, tanning, draining of sewage and dumping of wastes. Although metals occur naturally in the environment, chemical and metallurgical industries are the most important sources of metal contamination.32 (98 sq miles). It is the second largest city in Ghana with over 2.5 million inhabitants. The land is dominated by middle Precambrian rocks and the major soil type is forest Ochrosols.5Kumasi (6° 40′00″ N 1° 37′00″ W) is the capital city of the Ashanti Region and covers a land area of 254 kmThere have been a limited number of studies assessing the enrichment/pollution levels and sources of heavy metals and metalloids in the Kumasi metropolis. The objectives of the present study were to determine the concentrations of heavy metals and a metalloid in Kumasi soils, determine the levels of metal accumulation compared to a pristine site using enrichment factor and geo-accumulation index, develop distribution maps of heavy metals/metalloid throughout the sample site using geographic information system (GIS), identify the possible sources of metals by multivariate analysis, and evaluate the extent of metal pollution in Kumasi soils using contamination factor and pollution load index.CFContamination factorEFEnrichment factorGMGeometric meangeoIGeoaccumulation indexKNUSTKwame Nkrumah University of Science and TechnologyPCPrincipal componentPLIPollution load indexUSEPAUnited States Environmental Protection AgencySoil samples were randomly collected from 31 communities (sample sites) in the Kumasi metropolis. A map showing the sampling sites is presented in 7–9All samples were stored at −20°C in the Department of Chemistry, KNUST, Ghana and later transported to the Laboratory of Toxicology, Graduate School of Veterinary Medicine, Hokkaido University, Japan, where they were stored at −30°C until analysis.Prior to chemical analysis, soil samples were air-dried at room temperature and passed through a 2 mm sieve to remove the coarse soil fraction. Briefly, 1 g of dried soil was weighed into pre-washed digestion vessels and digested  using 10.0 mL of 60% nitric acid, . The microwave unit was calibrated to a temperature of 200°C and digestion was allowed for 45 minutes at 180 psi. After digestion, the solutions were allowed to cool, filtered using ashless filter paper 5B  into Corning tubes . Lanthanum chloride  was added to prevent ionization/interference during metal analysis. Samples were diluted to 50 mL with 2% nitric acid prepared with Milli-Q water. Concentrations of heavy metals and metalloids were determined by atomic absorption spectrophotometry (AAS)  after preparation of calibration standards. Cadmium (Cd), chromium (Cr), nickel (Ni), lead (Pb) and arsenic (As) were analyzed by graphite furnace AAS (argon gas) with Zeeman background correction. Copper and zinc (Zn) were analyzed by flame AAS (acetylene flame) with deuterium background correction.In addition, total mercury (Hg) was measured by thermal decomposition, gold amalgamation and atomic absorption spectrophotometry , after preparation of calibration standards. Blanks were prepared using the same procedure.The water content (WC) of each sample was measured after 12 h of oven drying at 105°C. Organic matter (OM) content was determined by loss of weight on ignition at an oven temperature of 600°C for 5 hours. Then pH was measured in a soil deionized water suspension  with a calibrated pH meter.For quality control, blanks were analyzed after every 10 samples. The instrument was calibrated using standard solutions of the respective metals . The detection limits (mg/kg) were 0.5 for Cr, 0.5 for cobalt (Co), 1.0 for copper (Cu), 0.1 for Zn, 0.2 for Cd, 1.0 for Pb, 0.5 for Ni and 2.0 for As. Reference materials, Standard Reference Material 1944 (New York/New Jersey Waterway Sediment) and BCR–320  were used for method validation. Replicate analyses of these reference materials showed good accuracy and recovery rates ranged from 80% to 115%. Recovery rates (%) of Hg for these certified reference materials  ranged from 92–103. The detection limit of Hg in soil samples was 2.0 pg total Hg.sample is the geometric mean (GM) concentration of metal in soil, Coref is the GM of Co in the reference sample , Mref is the GM of metal in reference sample and Cosample is the GM of Co in the sample. Classification of EF by Chen et al. was adopted in this study and has been provided in Supplemental Material 1.A common approach to estimating the anthropogenic impact on soil is to calculate the enrichment factor (EF) for metal concentrations above uncontaminated background levels. The EF method normalizes the measured metal content with respect to a reference metal.geo) is calculated using n is the GM concentration of the element in the enriched samples, and Bn is the background or pristine value of the element . A factor of 1.5 was introduced to minimize the effect of possible variations in the background values which may be attributed to lithologic variations.geo by Muller was used .This method assesses the degree of metal pollution in terms of seven enrichment classes based on the increasing numerical values of the index. Geoaccumulation index , respectively.Contamination factor (CF) reflects the anthropogenic input in elemental pollution and is widely used as a measure of overall contamination of soil. CF was calculated using The pollution load index (PLI) for a set of “n” polluting elements is defined as a value calculated from the GM of the contamination factors of those elements. PLI was calculated by the following expression given by Tomlinson et al: p value was less than 0.05. Statistical analyses were carried out after data were log transformed . Spatial distributions were performed using Arc-GIS 9.3 . Kriging was adopted for the interpolation of geographical data. Geographic Information System coordinates and concentrations of metals obtained in soil were used to create the distribution maps. In order to identify the important parameters that affect the chemistry of soil, Pearson's correlation matrix was used (at a significance level (p) less than 0.05). Principal component analysis and cluster analysis were carried out to describe the degree of association/possible sources of metals in Kumasi soils. The principal components based on log transformed data were extracted with eigenvalues > 1 through a varimax rotation. Cluster analysis was also performed based on Euclidean distance using Ward's clustering method.Statistical analyses were performed using SPSS 20.0 . Kolmogorov–Smirnov and Shapiro–Wilk's tests were used to determine the normality of data and data were considered statistically significant if the p < 0.01) in metal distribution in Kumasi soils (Table 1). As shown in Concentrations of eight heavy metals and a metalloid (As) were measured in Kumasi soils and results are shown in si soils . As showSupplemental Material 2), suggesting anthropogenic inputs. As shown in Igeo; Supplemental Material 3) in these areas. The Igeo values for Cr, Zn, Cd, Hg and Pb indicated moderate to extreme contamination (Igeo classes 3 to 6) in 100, 97, 77, 65 and 45% of the sample sites, respectively,  when compared the reference site. In Suame, all the studied metals showed moderate to extreme contamination with Igeo ranging from 2.92 (Co) to 5.62 (Cd) .The results of EF revealed that 65, 32, 58 and 93% of soils from the sample sites were moderately to extremely high enriched with Zn, Pb, Cd and Cr, respectively  and was dominated by high loadings of Ni, Co, and Cr, while PC3 (Hg) explained 12.7% of the total variance.Principal component (PC) analysis was used to characterize sources of metals in Kumasi soils. From the results, three principal components  were extracted and accounted for 66.9% of the total variance. As shown in Figure 3). The dendrogram revealed five classes with Suame and KNUST Botanical Gardens in different clusters . Kejetia, Asawase, Mbrom, Ashtown, Racecourse, Yennyawoso, Romanhill, Tafo, Adum, Central market and Asafo were in class 1 of the dendrogram , indicating a strong association between metal levels, sources or distribution in soils at these sites.Hierarchical cluster analysis was used in this study to identify the degree of association and/or accumulation pattern of heavy metals from the sample sites (Table 1). pH influences the rate of adsorption, retention and the transfer/migration of heavy metals in soil.Table 1). In the present study, concentrations of metals did not correlate with either pH or organic matter , similar to the results of a previous study.20The physico-chemical parameters determined in Kumasi soils were soil pH, organic matter and water content. Mean pH values ranged from 7.88 ± 0.49 (Kejetia) to 9.11 ± 0.5 (Romanhill)  as hotspot zone, indicating high metal concentrations (4). The hotspots identified from the geochemical map for Zn, Cr and Hg indicated high concentrations of these metals in Suntreso, Aboabo/Yennyawoso and Mbrom/Kejetia/New Suame, respectively.The distribution maps of Cd, Ni, As, Co, Cu and Pb highlighted Suame  as the sample site most polluted with metals, followed by Kejetia (10.3) ≥ Yennyawoso (10.1) > Racecourse (9.47) > Mbrom (8.93) > Aboabo (7.84) ≥ Asafo (7.79) ≥ Adum (7.60) ≥ Central market (7.46) > …, Afunkwanta (3.90) ≥ Bomso (3.77) = Anomangye (3.77). The study showed that all study sites  were polluted with metals when compared to KNUST Botanical Gardens (Table 2).geo of heavy metals and a metalloid from some sample sites within the Kumasi metropolis were higher and this could be due to the fact that the sampling sites in Kumasi were located within an area with heavy vehicular movement/traffic and industrialization. In addition, the high soil metal enrichment could be attributed to differences in the magnitude of input for each metal and/or differences in the removal rate from soil.The concentrations, EF and I2+ ions into water bodies.22As shown in Processing ore after blasting gold bearing rock involves roasting, and this results in the production of arsenic trioxide gas which is distributed throughout the study area by air currents. Arsenic is toxic and could accumulate in surface soils because of its non-biodegradable nature.24Large amounts of vehicular/industrial emissions and improper disposal of wastes could have contributed to the Cu, Pb, and Zn levels in Kumasi. Although no longer in use, previous use of leaded fuel could have accounted for the levels of Pb in soils. Lead is considered immobile in sub-surface soil and generally gets accumulated and remains strongly bound to soil mineral or organic components when deposited.25geo from the sample sites, especially for Cr, suggest an anthropogenic input from industrial sources.27Ni, Co and Cr were grouped in the same principal component. The high EF and IArtisanal and small-scale gold mining, production of cement and non-ferrous metals  and disposal of Hg wastes are some of the main sources of environmental Hg contamination.32Figure 3) and this trend could be attributed to the low metal concentrations compared to other sites and the world range for unpolluted soils.Table 1) which was in class 4 of the dendrogram  and, EF and Igeo indicated moderate to extreme contamination at this site . Differences in metal sources or the higher level of soil metal contamination could have contributed significantly to the present results.KNUST Botanical Gardens (reference site) was grouped in a different cluster of the dendrogram , implying a similar/single source of metal pollution at these sites. Sources of metals in Mbrom and Central market, and Adum and Asafo were closely related and showed a strong association with metals levels in Racecourse, Kejetia and Yennyawoso . As shown in Sampling sites such as Kejetia, Asawase, Mbrom, Ashtown, Racecourse, Yennyawoso, Romanhill, Tafo, Adum, Central market and Asafo were grouped in class 1 of the dendrogram , the high metal concentrations in Suame could also be due to heavy vehicle traffic and the large amount of metal scrap in the area. The “Suame Magazine” is one of Africa's largest light-industrial clusters. It is a 200 hectare area filled with polluted industrial waste, auto-mechanic workshops and saw mills, with frequent burning of tires generating a significant amount of waste.As shown in the distribution maps (geo values, Cr, Zn, Cd, Hg and Pb showed moderate to extreme contamination in 100, 97, 77, 65 and 45% of the sample sites, respectively. Distribution maps and pollution load index values highlighted Suame as the most significantly polluted site, followed by Kejetia ≥ Yennyawoso > Racecourse > Mbrom > Aboabo ≥ Asafo ≥ Adum ≥ Central market > …, Afunkwanta ≥ Bomso = Anomangye. Finally, the present study indicates that industrial activities, including mining, are the major sources of metals in Kumasi soils, as observed at the most contaminated site of Suame.Concentrations of heavy metals and a metalloid were studied in Kumasi soils and Zn, Pb, Cd and Cr were found to be enriched in some of the sample sites, suggesting anthropogenic inputs. Based on the obtained IClick here for additional data file.


Bosmina, Ceriodaphnia and Daphnia, the NNDs were significantly correlated with the biomass, pond morphology (volume and depth), total phosphorous (TP) and fish presence. For copepod species, including Eodiaptomus and cyclopoids, NNDs were significantly correlated with pond morphology, TP and fish presence, but not with biomass. In GLMs of SDNND, significant correlated factors were less than those for NND, and for some species, pond morphology and TP were significantly correlated with SDNND. Here, we found that the NND and SDNND of zooplankton species were related to various factors, including their biomass, predator presence, pond size and water quality. For cladocerans, biomass may be supported by trophic niche breadth, probably because of the consequences of resource competition. Also, predation and ecosystem size may influence trophic niche breadth due to changes in zooplankton behaviours.Zooplankton species have different feeding habits, but the diversity of their food resources and the factors governing them are still largely unknown. We here estimated the differences in the trophic niche breadths of dominant zooplankton species in ponds, using stable isotopes. To understand the differences in trophic niches of different zooplankton species, we measured the carbon and nitrogen stable isotope ratios and calculated the nearest-neighbour distance (NND), and standard deviation of NND (SDNND) of the bi-plot space of stable carbon and nitrogen isotopes in pond zooplankton. We tested the relationship between the NND/SDNND and environmental factors, as well as the zooplankton biomass, using generalized linear models (GLMs). For cladocerans, including  It is13C and δ15N) reflect food sources and trophic positions of consumers, respectively, and the ratios between these isotopes have been widely used to analyse food webs in natural systems [Stable carbon and nitrogen isotopes ratios , total phosphorus, pond morphology (volume and depth) and the presence of zooplanktivorous fish and their biomass in the study ponds, to investigate the driving factors of zooplankton trophic niche breadths in these ponds.In this study, we estimated the differences in the trophic niche breadths of dominant zooplankton species in ponds, using isotope niche space derived from stable isotope bi-plot space. We also tested the relationships between isotope niche indices, the nearest-neighbour distance (NND) and standard deviation of NND (SDNND), of zooplankton species and environmental factors, including phytoplankton biomass . The region is temperate and has distinct seasonal temperatures. Pond volumes ranged from 850 to 54 400 mto 7.1 m . These p2.2.Zooplankton were collected by vertical net towing (200-μm mesh net) from near the bottom to the surface in each pond. For identification and enumeration, the collected zooplankton were preserved in approximately 5% formalin. The body lengths of individuals were measured, and their biomass was calculated using length–weight regression . For sta2.3.Daphnia spp. , Eodiaptomus copepods , Bosmina spp. , Ceriodaphnia spp. (10 sites) and cyclopoids . Zooplankton individuals were sorted and placed in a tip cup , and examined under a stereomicroscope. All zooplankton samples were dried at 60°C for 48 h and stored in desiccators until the isotope ratios were analysed. The carbon and nitrogen isotope ratios of the samples (n = 3) were measured using a continuous-flow isotope mass spectrometer . All isotopic data are reported using the conventional δ notation, where δ13C or δ15N = (Rsample/Rstandard − 1) (/‰). R is the 13C/12C or 15N/14N ratio for δ13C or δ15N, respectively. Vienna Pee Dee Belemnite and N2 in air were used as international standards for δ13C and δ15N, respectively. The overall analytical error values were within ±0.2 (/‰) for both δ13C and δ15N.We collected the following dominant zooplankton: 2.4.13C and δ15N values . To compare niche differences among the 14 ponds, we considered the potential isotope space of the zooplankton competitors and standardized NND, according to the method described by Layman et al. [et al. [13C and δ15N bi-plots. First, we calculated the Euclidean distance (ED) between the isotope values of zooplankton species in δ13C and δ15N bi-plot spaces using the datasets in electronic supplementary material, appendix S1 and the following equation:i and j indicate species i and j, respectively.We analysed the distance between trophic niches using the NND of the zooplankton species on the basis of their mean δn et al.  and Jack [et al. . Thus, wn = 5):Second, we calculated the isotopic ellipses of each pond using the following equation with 95% confidential interval , becausei as the smallest EDi among combinations of species i and other zooplankton species per PNS of each pond:Finally, we calculated NNDi indicates the distance of the trophic niche of species i from the other species in the zooplankton community; smaller NND values suggest higher trophic redundancy for the species. The carbon isotope ratios of the zooplankton varied within the individual ponds . Thus, the NND primarily showed the carbon isotope differences between species. Layman et al. [NNDn et al.  suggesten et al. ,24). Thun et al. ) to esti2.5.a concentration, we collected 2 l of surface water  with a column sampler. A 250-ml aliquot of each water sample was filtered through a 0.2-µm Nuclepore filter  to retain the seston. Each filter was placed in a glass test tube, and N,N-dimethylformamide was added to extract chlorophyll a. Chlorophyll a concentration was determined using a fluorometer . We measured the pH of the surface water using Twin-pH portable meters . Total phosphorus (TP) concentration of the surface water was determined by colorimetric analysis with a continuous-flow system . The presence and the absence of plankton-feeding fish, including Carassius spp., bluegill sunfish and small carp, were estimated based on observations from the shore and angling. We used the presence–absence data for plankton-feeding fish to define the presence or the absence of fish predators of zooplankton.To determine chlorophyll 2.6.a of surface water, mean water depth of the pond, total pond volume, TP of surface water and zooplanktivorous predator presence (as categorized data) as the explanatory variables in the model. Preliminary Shapiro–Wilk tests for normality showed that TP and chlorophyll a were not normally distributed; thus, we transformed these variables using a log10 (x + 1) transformation. We also selected the best model of GLMs using a backward stepwise procedure based on Akaike Information Criterion (AIC). The environmental factors and the biomass of zooplankton used in the GLM are shown in electronic supplementary material, tables S2 and S3. In all statistical analysis, we set α = 0.05. We performed all statistical analysis using the R software v. 3.3.2 [To determine the differences in isotopic niche indices (NND and SDNND) among the zooplankton species in the ponds, we performed one-way analysis of variance (ANOVA). To analyse the relationships between biomass and other parameters, including the NND of the species, we used a generalized linear model (GLM). We used zooplankton biomass, chlorophyll v. 3.3.2 .3.3.1.F = 2.01, p = 0.090 for NND, F = 0.720, p = 0.581 for SDNND). Higher variations in NND and SDNND among the ponds were observed in all species; for example, NNDs of Daphnia and Eodiaptomus varied fivefold among ponds.The NND and SDNND calculated by the isotope bi-plot space in each pond ecosystem are shown in 3.2.Bosmina, Ceriodaphnia and Daphnia were significantly related to NND . For Daphnia and cyclopoids, lake morphology, pond volume and water depth were significantly related to the SDNNDs. For Eodiaptomus, the SDNND was significantly related to TP.For SDNND, the relationships with the factors assessed were almost not significant b. For Da4.Bosmina, Ceriodaphnia and Daphnia, species biomass in the ponds was one of the potential drivers of isotopic niche breadth, indicating that biomass may be related to the differences in trophic niches in populations sharing limited food resources, such as different algal species. However, these cladocerans are filter feeders that feed on phytoplankton, bacteria and fungi [Daphnia, Ceriodaphnia and Bosmina have different body size, and their feeding efficiencies can differ according to their feeding ranges and filtering rates as well as by size, motility and morphology of available prey items [Our results showed that there was high variation in the NNDs, and SDNNDs of zooplankton species among ponds. From the generalized linear models, we identified some factors that potentially drive the variation in NND and SDNND. For the cladocerans, including nd fungi ,12,26. Dey items . Thus, tEodiaptomus and cyclopoids, NNDs were not significantly related to biomass, probably because competition for their food resources was lower than that in the cladocerans. The feeding mode of copepod species is more predacious, and they feed mainly on larger algae and microzooplankton such as small protozoan, rotifers and cladocerans often with feeding selectivity [By contrast, for copepod species, including ectivity ,28,29. TDaphnia significantly correlated with the pond volume. Pond volume may be indirectly related to NND, due to ecosystem-size effects on population dynamics, food-chain length and increased species diversity [For most zooplankton species, NNDs were significantly correlated with fish presence, but that of iversity . The preiversity . Zooplaniversity , and coniversity ,34. ThusEodiaptomus and cyclopoids, their NNDs and SDNND were significantly correlated with TP. Total phosphorous is classically an index of pond primary productivity [For copepod species, including uctivity , so the In the SDNNDs, the significantly related factors were less than those for NND, and for some species, pond morphology and TP were significantly related to SDNND. These relations for SDNNDs may also be related to factors discussed above, for NND, such as ecosystem-size effect and pond primary productivity. However, for SDNND, plankton biomass and fish presence were not significant factors for all species. The differences in NND and SDNND results may be caused by the different meanings of the indices. The NND showed more variation in primary food resources than SDNND because the NNDs of the species were primarily determined by carbon isotope variations in isotope bi-plot space, whereas SDNND showed more variation in the total area of niche space. The different behaviours in the isotopic niche positions may allow us to estimate trophic niche space based on different aspects.Although the trophic breadth and the plasticity in the zooplankton species may also be evolutionarily driven , the preOur study had a few limitations. We only estimated the dominant zooplankton competitors. We could not consider interactions between rare species and different trophic guilds, such as rotifers and ciliates, because it is difficult to measure their isotopic signatures. Previous studies have suggested strong competition among mesozooplankton because their food ranges often overlap  while miIn conclusion, we showed the trophic niche breadths of zooplankton species in the habitats even within narrow areas. We also found that factors related to the trophic niche breadth were variable, including their biomass, ecosystem size, predator presence, as well as total phosphorus. Our study data limits us from making conclusions about general trends in these dynamics, but this is an initial step towards the evaluation of trophic niche breadth of primary and secondary consumers in natural habitats, using stable isotope techniques.


College students are exposed to an environment that places their health at risk. As a result, they are vulnerable to health-related problems. In order to improve health promotion behaviors, it is necessary to identify the variables affecting these behaviors. However, few studies have comprehensively examined health consciousness, health perception, and self-esteem as variables in health promotion behaviors among college students.The purpose of this study is to identify the factors influencing health promotion behaviors in college students.Data were collected from 331 students, using a structured questionnaire based on the Health Promoting Lifestyle Profile , Dutta-Bergman’s Health Consciousness Scale , the Health Perception Questionnaire , Rosenberg’s Self-Esteem Scale (self-esteem), and sociodemographic data. To assess the factors that influence health promotion behaviors, a multiple regression analysis was performed.p<.001), health perception was higher , and self-esteem was higher . The constructed model for health promotion behaviors showed that the statistically significant explanatory variables were health cognition, health perception, and self-esteem. The model explained 34.9% of the variance in health promotion behaviors.Health promotion behaviors were higher when health cognition was higher (r=.421, It will be necessary to develop an intervention program targeting health cognition, health perception, and self-esteem in order to increase health promotion behaviors in college students. NeverthHealth promotion is an educational, social, and environmental approach intended to improve health through the introduction of beneficial lifestyles and habits. It is designed to help people reach optimal levels of physical, mental, social, and spiritual well-being . In othei.e., subjective understanding of one’s health), as well as self-esteem . Accordingly, this study investigates the levels of health consciousness, health perception, self-esteem, and the promotion of health behaviors among college students. In doing so, this research identifies the variables affecting health promotion and behavior, and provides baseline data for the development of interventions in health promotion activities for college students.According to previous studies, variables influencing health promotion and behavior include sex, religion, type of residence , and uni1.2The purpose of this study is to examine the levels of health consciousness in college students; it examines their health perception, self-esteem, and health promotion behaviors, in order to identify differences based on general characteristics. In doing so, this study will identify the variables that influence health promotion behaviors. The specific purposes of this research are summarized as follows:First, this research aims to identify the degree of health consciousness in college students, as well as their health perception, self-esteem, and health promotion behaviors.Second, this research aims to identify differences in health consciousness, health perception, self-esteem, and health promotion behaviors depending on general characteristics.Third, this research aims to identify possible correlations between health consciousness, health perception, self-esteem, and health promotion behaviors.Fourth, this research aims to identify variables that predict the promotion of health behavior among college students.22.1This is a quantitative cross-sectional descriptive survey intended to identify the level of health promotion behaviors among college students and the related variables.2.2The participants of this research were students from two universities in Korea. The required sample size was calculated using G*Power 3.1  with an 2.32.3.1Health consciousness is a concept indicating how integrated one’s interest in health is with one’s daily activities . This re2.3.2Health perception refers to self-evaluation of an individual’s physical and mental well-being . This re2.3.3Self-esteem was measured using Rosenberg’s Self-Esteem Scale . This sc2.3.4Health promotion behaviors are a proactive response to the environment that enables to achieve a higher level of health. Pender  has note2.4Data was collected from college students attending two universities in Korea between November 20 and December 16, 2016. The researcher explained the study’s objectives and the questionnaire items to students enrolled in chapel class after obtaining approval from the minister in charge of the chapel class. Chapel classes were chosen because they comprised all liberal arts classes, regardless of participant major. Questionnaires were disseminated to participants who agreed to participate by providing their consent in writing. It took participants an average of 15 minutes to complete the questionnaire. The questionnaires were then submitted in a collection box.2.5Appropriate measures were taken to protect participants against coercion or unjust influence during the recruitment or consent process. Only those who voluntarily agreed to participate could fill out the questionnaire; an explanation of the research purposes and the questionnaire was provided. It was made clear to the students that they had the freedom to not participate in this research, that there were no advantages or disadvantages resulting from their participation in this research, and that they could quit at any time even if they had agreed to participate. The participation agreement included a statement about protecting the participants’ anonymity and confidentiality, and explained that participating in this research would have no impact on their grades etcetera.2.6The collected data were analyzed using the IBM SPSS 20.0 program. The general characteristics of the participants—as well as their health consciousness, health perception, self-esteem, and health promotion behaviors—were indicated in counts, percentages, means, and standard deviations. The level of health promotion behaviors, depending on participants’ general characteristics, was measured using a t-test and one-way ANOVA. The Pearson’s correlation coefficient was calculated to analyze correlations between variables. In addition, to identify their effect on health promotion behaviors, variables that correlated significantly with health promotion behaviors were entered as independent variables in a multiple regression analysis. Statistical significance was adopted at the level of p<.05.33.1nd grade of university accounted for 204 (61.6%) of the participants; and 202 (61.0%) indicated that they followed no religion. Of the total respondents, 33 (10%) claimed to have experienced a relatively serious disease, while 154 (46.5%) reported that family members, close relatives, or significant others had experienced a serious disease (Table 1).With the exception of four questionnaires, in which responses were invalid, this research analyzed a total of 331 respondents’ questionnaire. The general characteristics of the participants were as follows: the average age was 20.48 years, with 228 participants (68.9%) in their 20s or older; 210 (63.4%) of the participants were women; 21).Those aged 20 or older had significantly more health promotion behaviors than others . An examination of university level as a variable indicated that health promotion behaviors among juniors were significantly higher than those of freshmen . There were no significant differences in health promotion behaviors according to sex, religion, university level, or whether college students or their significant others had experienced a relatively serious disease (Table 3.22).On average, the health consciousness score of respondents was 4.15 points, and their health perception score was 2.12 points (both ranging from 1 to 5). On average, the self-esteem score was 3.48 points (range of 1 to 5), and the health promotion behaviors score was 2.57 points (range of 1 to 4). An examination of other categories of health promotion behaviors revealed the following average scores: self-actualization, 3.01 points; health responsibility, 2.20 points; exercise and nutrition, 2.02 points; interpersonal relationship, 3.04 points; and stress management, 2.74 points , health perception , and self-esteem  (Table 3).Table 3.44).Multiple regression analysis was used to analyze the effects of health promotion behaviors. Health consciousness, health perception, and self-esteem were used as explanatory variables, and age was set as a control variable. A review of the assumptions of the regression analysis showed that the residuals were normally distributed, and in terms of multicollinearity, tolerances were .81 to .85 and the variation information factor was 1.18 to 1.23. Therefore, multicollinearity was not present. An analysis of the explanatory variables showed that health consciousness, health perception, and self-esteem were statistically significant. A model including these variables showed an explanatory power of 34.9%  on the health promotion behaviors of the participants  or stressors related to self-actualization . This suggests that the stress of interpersonal relationships or self-actualization can have a negative effect on physical well-being and the promotion of health behaviors. Accordingly, it is necessary to manage mental and physical health in a balanced way, including the use of coping strategies to maintain mental health. Another means of achieving this is through the introduction of intervention measures, such as a change of environment and support systems to accomplish physical health goals, including exercise and good nutrition.The purpose of this research was to identify the extent of college students’ health consciousness, health perception, self-esteem, and health promotion behaviors, and to identify the variables affecting these health promotion behaviors. According to this study’s findings, health promotion behaviors of college students were scored 2.57 points on average. In similar studies, health promotion behaviors in college students were scored 2.31  and 2.67Analysis of the general characteristics of the participants in this study showed that those aged 20 years or older had the highest level of health promotion behaviors, and that juniors displayed a greater degree of these behaviors than freshmen. This is consistent with the results of previous studies, which reported differences in health promotion behaviors depending on the age  and univThis study found no difference in health promotion behaviors depending on whether college students themselves or their family members, relatives or significant others, had experienced a serious disease. This supports the findings of a previous study, which reported no significant difference in health promotion behaviors if respondents had a family member suffering from a chronic disease . This meA model established based the variables influencing health promotion behaviors found that health consciousness, health perception, and self-esteem were significant. Health consciousness is a concept showing how integrated health interests are in an individual’s daily activities . An indiThe findings of this research confirm that physical health promotion behaviors among college students may be particularly vulnerable. As college students are in a new and relatively free environment, it is easy for them to neglect their health promotion behaviors in their regular daily activities. Therefore, college students can be particularly vulnerable to health promotion. Given the variables influencing health promotion behaviors in college students-health consciousness, health perception, and self-esteem-this research suggests that it is necessary to perceptions of the importance of health and health management among students, and to develop intervention strategies for the promotion of self-esteem.This research sought to identify levels of health consciousness, health perception, self-esteem, and health promotion behaviors among college students. To do so, this study examined the variables affecting the promotion of health behaviors. A health promotion behaviors model was established using data from 331 college students, and it demonstrated that health consciousness, health perception, and self-esteem were significant explanatory variables. This model explained 34.9% of variance in health promotion behaviors. Throughout the college period, which is typically during early adulthood, students are exposed to an environment that places their health at risk. Health promotion behaviors are necessary for this age group because they improve health consciousness, health perception, and self-esteem, which in turn enable the maintenance of physical, mental, and social well-being. To achieve this, the development and implementation of a training program are required, so that individuals can integrate healthy behaviors into their daily lives with the understanding that they can protect their own health.