Female genital mutilation/cutting (FGM/C) is a harmful traditional practice that violates the human rights of girls and women. It is widely practiced mainly in Africa including Ethiopia. There are a number of studies on the prevalence of FGM/C in Ethiopia. However, little has been devoted to its spatial epidemiology and associated factors. Hence, this study aimed to explore the spatial pattern and factors affecting FGM/C among girls in Ethiopia.A further analysis of the 2016 Ethiopia Demographic and Health Survey data was conducted, and a total of 6985 girls nested in 603 enumeration areas were included in this analysis. Global Moran’s I statistic was employed to test the spatial autocorrelation, and Getis-Ord Gi* as well as Kulldorff’s spatial scan statistics were used to detect spatial clusters of FGM/C. Multilevel logistic regression models were fitted to identify individual and community level factors affecting FGM/C.p-value < 0.01), and eight significant clusters of FGM/C (hotspots) were detected. The most likely primary SaTScan cluster was detected in the neighborhood areas of Amhara, Afar, Tigray and Oromia regions , the secondary cluster in Tigray region , and the third cluster in Somali region . In the final best fit model, about 83% variation in the odds of FGM/C was attributed to both individual and community level factors. At individual level, older maternal age, higher number of living children, maternal circumcision, perceived beliefs as FGM/C are required by religion, and supporting the continuation of FGM/C practice were factors to increase the odds of FGM/C, whereas, secondary or higher maternal education, better household wealth, and regular media exposure were factors decreasing the odds of FGM/C. Place of residency, Region and Ethnicity were also among the community level factors associated with FGM/C.Spatial clustering of FGM/C was observed (Moran’s I = 0.31, In this study, spatial clustering of FGM/C among girls was observed in Ethiopia, and FGM/C hotspots were detected in Afar, Amhara, Tigray, Benishangul Gumuz, Oromia, SNNPR and Somali regions including Dire Dawa Town. Both individual and community level factors play a significant role in the practice of FGM/C. Hence, FGM/C hotspots require priority interventions, and it is also better if the targeted interventions consider both individual and community level factors. Female genital mutilation/Cutting (FGM/C), also known as “female circumcision”, refers to “all procedures involving partial or total removal of the external female genitalia or other injury to the female genital organs for non-medical reasons” . It is aFGM/C is associated with adverse health consequences in women over both the short and long terms , 4. ImmeGlobal estimates indicated that more than 200 million women and girls have experienced FGM/C , 7. In ADespite international and national efforts to eliminate the practice of FGM/C, it has been widely practiced mainly in Africa for various reasons , 11. ReaThe government of Ethiopia has committed to eliminating the practice of FGM/C by 2025 . HoweverStudy findings on FGM/C in Ethiopia have focused solely on prevalence, characteristics of individuals affected and individual level factors associated with FGM/C –19. The In this study, Kulldorff’s spatial scan statistic was used since it is widely suggested in detecting appropriate local clusters compared to other spatial analysis techniques –22, mainIn addition, previous studies identified individual level factors associated with FGM/C using a basic ordinary logistic regression model that has less statistical power, and could not control the nesting effect of clusters at different levels , 19, 24.This study was conducted using the data from the 2016 Ethiopia demographic and health survey (EDHS). In Ethiopia, this national and subnational representative household survey is conducted every five years. Being the most populous country in the region, Ethiopia is located in the horn of Africa between 3 and 15 degrees north latitude and 33 and 48 degrees east longitude . EthiopiA cross-sectional data analysis was conducted using the secondary data from the 2016 EDHS, which was collected from January 18 to June 27, 2016.The study population of this study were all girls aged 0–14 years in the randomly selected enumeration areas (EAs) of Ethiopia. Girls from the EAs with no geographical coordinates were excluded from this study.In the 2016 EDHS, data were collected through a stratified, two-stage cluster sampling technique using the complete list EAs for the 2007 PHC as a sampling frame. The primary and secondary sampling units were EAs and households, respectively.The 2007 PHC had a complete list of 84,915 EAs, and from this sampling frame a total of 645 EAs  were selected with probability proportional to EAs size (PPS). In the second stage, 28 households per cluster were selected with an equal probability systematic selection. Overall, 16,650 households were interviewed successfully in this survey, yielding 98% household response rate. From those interviewed households, 16,583 women in the reproductive age were identified for individual interviews, and 15,683 women were interviewed successfully, yielding a response rate of 95%. Among the household in which the 15,683 women interviewed, 7795 households were selected for FGM/C interviews. By excluding 321 girls from the EAs with no geographic coordinates, 6985 girls aged 0–14 years were included for this study. The detailed methodology has been published in the 2016 EDHS final report .https://www.dhsprogram.com/data/dataset_admin) to all registered users, downloaded with permission. After reviewing and understanding the details of the EDHS data structure and dataset types, we selected the recommended dataset type for girls’ circumcision. Data on FGM/C, and its potential explanatory variables  were extracted.The datasets used for this study are publicly available in the DHS Program repository  . The detailed ethical issue is found in the final report of the 2016 EDHS  with the ICC of 49%. As compared to the variance in model 2, incorporating community-level characteristics to the null model decreased the variance in FGM/C among the communities , and also the ICC lowered to 32.4%.As the multilevel logistic regression analysis results depicted in Table The final best fit model (model 4) which incorporated both the individual and community level characteristics revealed statistically significant variability in the odds of FGM/C among the communities  with the ICC of 23%. The PCV comparing the null model (Model 1) with the model containing both individual and community characteristics (Model 4) was 0.831, and it indicated that about 83% of the variance in the odds of FGM/C was attributed to both individual and community-level characteristics.In this study, the MOR was 9.98 in the null model (model 1), 5.45 in model 2, 3.30 in model 3, and 2.57 in model 4. Hence, MOR of 9.98 in the null model indicated the presence of heterogeneity across communities, and incorporating both individual and community level factors to the null model could reduce the unexplained heterogeneity to the MOR of 2.57 Table .In this study, the overall prevalence of FGM/C among girls was found to be 18.6%, which indicates declining as compared to the national prevalence (24%) reported in the 2005 EDHS . The finp-value< 0.01). This could indicate that the practice of FGM/C is clustered across the communities in the country, and suggested an extended local test, a focused test which used to detect local clusters of areas with high rate of FGM/C. The results of other studies in and outside Ethiopia also supported this finding of spatial clustering in FGM/C practice [The global test for spatial autocorrelation indicated the presence of clustering in FGM/C across the study areas without specifying the spatial location (Moran’s I = 0.31, practice , 38.The Kulldorff’s spatial scan statistic detected FGM/C ‘hotspots’ among girls in Ethiopia. Moreover, the results of the Getis-Ord Gi* statistic supported and confirmed the results of the findings of the Kulldorff’s purely spatial analysis.In this study, northeastern parts of the country, particularly in Afar, Amhara, Tigray and Oromia regions, were detected as FGM/C hotspots. This may be due to the fact that the neighborhood areas of the regions may share common characteristics in relation to traditional practices. In addition, FGM/C hotspots were detected Somali, Benishangul Gumuz, and SNNPR regions including Dire Dawa Town. This finding can indicate that the communities located in the Northern, Northeastern and Eastern parts of the country are FGM/C ‘hotspots’ and are areas in need of urgent attention. This local clustering of FGM/C can also indicate that daughters who lived in the FGM/C hotspot areas had a high probability of experiencing circumcision compared with those who lived outside the identified clusters. This may be due to differences in community background characteristics such as Ethnicity, religion, community perception to FGM/C, and this identification of clusters with high FGM/C practice can lead to targeted interventions.The multilevel regression analysis confirmed that the variation in daughters’ FGM/C in Ethiopia was attributed to both individual and community level factors which accounted for 83% of the variation.Like other studies , 39, thiIn this study, older maternal age was found to be a factor to increase the risk of FGM/C among their daughters. This could be justified by lower awareness of FGM/C impacts in older age women, and older women may be more likely to conform to traditional practices, including FGM/C.The results of this study showed that the daughters of women with secondary or higher educational status had lower odds of experiencing FGM/C compared to the those who had no education, and it is supported by other studies conducted in and out of Ethiopia , 39. ThiCompared to the daughters of uncircumcised women, the daughters of circumcised women are at higher risk of FGM/C, and this finding is consistent with another study finding in Kenya . This maLike what has been documented elsewhere , 40–42, In many communities, the practice of FGM/C is believed to be a deeply rooted traditional practice, which is attributed to the cultures and religion , 39, 45.Among the community level characteristics incorporated in this study, place of residence, geographical region, ethnicity and proportion of community with regular media exposure were identified as factors affecting the practice of FGM/C. In contrast to a study findings in Kenya , this stAs evidences revealed, the practice of FGM/C is associated with ethnic identity , 7, 39. This study also identified that higher proportion of the community with regular media exposure lowers the risk of FGM/C in daughters by 30% as compared to the lower proportion of the community with regular media exposure. This may be due to the fact that media exposure has an important role in disseminating health information; and communities who have media exposure are more likely to have information on the risks of FGM/C practice.In this study, the results should be interpreted cautiously since it requires an understanding that not all girls have reached their final cutting status; some of the girls who are not cut yet may still be cut in the future. Applying both spatial and non-spatial statistical methods for a more comprehensive and sound analysis was the strength of this study. However, girls from the EAs with no the geographical coordinates were not included in in this analysis and this may affect the results of the study including the generalizability. Hence, it could be mentioned as the limitation of the study.In conclusion, the spatial distribution of FGM/C among girls in Ethiopia exhibits a clustered pattern. FGM/C hotspots were detected in Afar, Amhara, Tigray, Benishangul Gumuz, Oromia, SNNPR and Somali regions including Dire Dawa Town. Both individual and community level factors play a significant role in the practice of FGM/C among girls, which accounted for 83% variation across the communities. Older maternal age, lack of maternal education, maternal circumcision, better wealth index, higher number of living children, regular media exposure, perceived religious believes to FGM/C, women’s opinion towards the practice of FGM/C were statistical significant individual-level factors associated with the daughters’ FGM/C. Whereas, place of residence, geographical region, ethnicity, and community media exposure were the community level factors associated with the practice of FGM/C among daughters. Hence, it is good if the federal ministry of health of Ethiopia and other concerned reproductive health programmers give priority for the FGM/C hotspots identified in this study. Furthermore, elimination of FGM/C requires integrated interventions both at individual and community levels: improving women’s education, promoting media utilization, education of women on religious believes to FGM/C, and changing their attitudes towards the practice of FGM/C, and improving the households’ wealth status.


The scientific literature on women’s basketball is still limited, mainly in performance parameters. The purpose of this study was to analyse the state of art on the internal and external loads supported by female basketball players during sports practice. The design of this research is theoretical. The most relevant databases were searched for pertinent published studies according to the following keywords: “basketball”, “female” or “woman”, “training” or “competition”, “load” or “demand”. Of the 644 studies initially identified, 26 were selected for a complete review. These investigations were characterised by having as an objective an individualization of training for this type of population. Of the selected studies, it was evaluated: (i) goal ; (ii) category ; (iii) type of load ; (iv) instruments used and (v) variables analysed. The most studied goal was competition, mainly in senior national level, carrying out an analysis of the external and internal load together. Depending on the instruments and the variables used, the subjective load analysis was recurrent and important in the publication of articles in this topic. The quality of the studies was good, but for a better description of women’s basketball, there is a need to jointly investigate sports training and competition, to study the training categories and to use micro technology that guarantees obtaining objective and reliable data. Team sports, such as basketball, are difficult to analyse due to their unpredictable and intermittent nature . BasketbCurrently, given the number of participants, basketball can be considered one of the most popular sports in the world. The increase in the number of high-level female athletes, amateurs and those in training stages has been gradually consolidated in recent years in Spain , in addiThus, the scientific community is beginning to show a special interest in studies that regard factors of performance and load involved in this sport. Load control in basketball requires scientific information to establish analytical assessment protocols. The most common demand analysis in basketball has been (i) analysis of internal load through heart rate and subjective scales; and (ii) external load analysis by time motion analysis ,10. PrevAs for women’s basketball, the first women’s basketball game was played in 1893, when Senda Berenson adapted James Naismith’s basketball rules for women. The professional Women’s National Basketball Association (WNBA) was founded in 1996, attracting a great deal of interest worldwide. Conversely, the scientific literature on women’s basketball is still limited, particularly regarding performance parameters . The most researched object of study in women basketball players is injury. In addition to this, the female gender has been studied through hormonal, biological and anatomical factors, defining the characteristics of the athletes, but not how to work with them. Boles and Ferguson  present Therefore, although there are large numbers of high-level women athletes, amateurs or players in the training stages, no research is specifically focused on their characteristics. That is why better description of women’s basketball is, thus, warranted. There are different methods to facilitate the description and analysis of the athletes’ load during training and competition. Consequently, an updated systematic analysis of the literature is necessary for the following reasons: (i) the previous reviews ,15 did nTo the best our knowledge, no previous research has systematically verified the literature to identify the demands of female basketball players during training and competition. Men’s basketball is the most investigated; thus, there is an important gap in the available research that does not allow us to conclude whether women’s basketball has the same needs. For example, in the last review published, one of the exclusion criteria was that the sample be women . In thisThe study is a systematic literature review. The design of the research is theoretical , compiliThe Web of Science electronic database (WOS), Scopus and PubMed were searched on 11 November, 2019, using keywords. For its search, the following terms and Booleans were used: Basketball AND  AND (Training OR Competition) AND (Load OR Demand). The key words were used next to the logical operator “AND” and “OR”. The initial search was conducted by a researcher and 644 articles were obtained. Then, the duplicates were eliminated and an intensive review of all the titles and abstracts obtained was carried out. For the final selection process, the full version of the remaining articles was read and studies not related to the subject of review were excluded. Finally, a qualitative analysis of the studies included in the review was performed.This review included original articles that considered female basketball players. The study participants were classified into four groups: U15, U16, U18 and senior. In addition, they were classified in three competitive levels: state, national and international. In the analysis of load demands, a distinction was made between training and competition, or both. The type of load analysed  and the type of measures and variables analysed were differentiated. This demand analysis had to be completely ecological, excluding those studies where tests or field tests, training programs, etc., were performed.Therefore, the studies included in this review met the following criteria: (i) the study was published in English or Spanish; (ii) the study included internal, external or both load variables during training and/or competition in basketball; and (iii) the participants were women of all categories and levels. Studies were excluded if (i) the study participants were men; (ii) the study participants were wheelchair basketball players; (iii) The participants were referees; (iv) the data collected did not describe the training or competition demands; and (v) the study consisted of a review or field tests.To evaluate the quality of the studies, quality criteria were used to analyse the quantitative publications  and compThe protocol carried out for the definition of the characteristics of the articles included the following: year, goal, category, level, type of load, instruments and variables analysed.Year: date of article publication.Goal (G): three types of objectives were established: (i) competition analysis (C). The load supported by the players during official matches; (ii) training analysis (T). The load supported by the players during the tasks carried out in the training sessions, without a goal of specific improvement or modifications for the achievement of the same. (iii) Analysis, both competition and training (B).Category (C): the women’s basketball studies were classified in different formative stages: (i) U15 (14–15 years old); (ii) U16 (15–16 years old); (iii) U18 (17–18 years old) and senior (>18 years old).Level (L): the competitive level is classified in: (i) State (S): competing in regional leagues; (ii) national (N): high level competing nationally or (iii) international (I): high level competing internationally.Type of Load (TL): the work load that the athletes support, either in training or during the competition is, according to González-Badillo and Serna , “The seInstruments (I): the following instruments were used by the researchers to collect the data; (i) internal load measurements: heart rate bands (HRB), blood markers (BM), subjective scales (SS), etc.; (ii) external load measurements: time motion analysis (TMA) and microtechnology-like inertial devices (ID), Global Positioning System (GPS) devices, accelerometers (AC), etc.(i)Internal load variables: (a) heart rate (HR): measured in beats per minute. The values have been expressed as average heart rate (HRavg), maximum heart rate (HRmax), percentage (%) maximum heart rate (% HRmax) and work zones. (b) Blood lactate concentration (LAC): obtained from blood samples taken from athletes by subcutaneous puncture and analysed automatically in a portable instrument that interprets lactate values. (c) Subjective load (SL): scales, interview, fatigue, questionnaires, etc.(ii)−1. (d) Accelerometry (ACC): acceleration data, interpreted as external load, are obtained from a tri-axial accelerometer. The straight addition of the instantaneous change of rates of resultant accelerations  over time represent the acceleration load for a drill or activity. (e) PlayerLoad™: accumulative triaxial  g-force alterations produced by an athlete. (f) Subjective load (SL): the training load is evaluated from surveys or subjective scales of effort. (g) Movement (MOV): extracted match activity outcome measures were defined and classified into the following categories: standing/walking, jogging or low speed running, running or moderate speed running, striding or high-speed running and sprinting or maximal speed running; technical actions, such as changing direction, dribbling, upper body movements, passes and static exertion. Finally, rest has also been analysed.External load variables: (a) distance (D): meters or steps travelled by the athletes throughout the activity analysed. (b) Jumps (J): movement that consists of elevating oneself from the court with an impulse that implies more than 400 ms of flight, in order to land in the same place or another. The time from the start of the jumping action to the completion of landing; any movement or activity whereby a player initiates a jumping action and feet break contact with the playing surface; players spring into the air using a one- or two-leg take-off. (c) Speed profile (SP): forward movement at a high intensity characterised by effort and purpose at close to maximum, multidirectional movement performed at velocities of >7 msVariables (V): the variables analysed in the computation of studies ,15 and wn = 26) given by the value of Cohen’s kappa [A descriptive analysis was made of all the variables recorded in the research (frequency and percentage). A multiple response analysis was carried out on the following variables: goal, level, load, instruments and variables. These variables were coded as different if more than one record was identified. The analysis was completed with contingency tables and figures to identify the relationships between the research variables . Regardi’s kappa .n = 33). Other reasons for exclusion were (i) data were included from other types of formats, such as reviews, conferences, abstracts, etc., (ii) from other types of team sports and (iii) from other populations  (n = 7).The main reason for exclusion was that a published study did not concern match or training analysis . In terms of level, the national category is the most studied (n = 14). Increasingly, research implements analyses of both internal and external loads together (n = 15), especially in competition (n = 12).Depending on the category, most of the studies included senior players (2 = 0.7476), in the period analysed , while at national levels they focus on the study of the competition. Regarding the type of load, 50% of studies analysed internal and external load during training, while 54.5% of studies analysed both loads during competition. The most relevant outcomes were found in the studies that investigated, jointly, both contexts (training and competition) and both types of load  (66.7%).The most commonly used variables in the reviewed articles are heart rate and movement patterns . Therefore, the instruments most used by the authors are heart rate bands  and subjective scales  . The subThe main variables analysed during training were the heart rate (60%) from heart rate bands (60%) and subjective loads (50%) from scales and questionnaires (70%). However, during the competition, the analysis of movement patterns (63.6%) takes more presence from video analysis (36.4%).To analyse the quality of the selected studies, the classification designed by Law, Stewart, Pollock, Letts, Bosch and Westmorland  was utilRegarding the items, criteria 1, 3, 4, 8, 9, 10, 11 and 14 obtained a coefficient of kappa = 1. Discrepancy between observers was obtained in criteria 2, 5, 6, 7, 12, 13, 15 and 16. Still values above 50% were found. Five items were mainly related with methodological deficiencies in the selected studies. (i) Criterion 4, where 20.41% of studies did not describe the sample in detail. (ii) Criterion 5, where 36.73% of studies sizes sample were not classified. (iii) Criterion 12, where 20.41% of articles did not inform about practice. (iv) Criterion 13, where 57.14% of cases did not report about dropouts. (v) Criterion 16, where 59.18% of articles did not clearly acknowledge the limitations of the study.About Goal, the studies with the highest quality (85.42%) are those carried out on competition and training together. The category where the highest quality of studies was found was U18 (88.75%), finding lower levels in training categories. Depending on the level, the lowest quality levels were obtained in the state (81.81%) compared to national and international (87.5%). Regarding the type of load analysed in the investigations, those where the external load was exclusively analysed obtained higher quality values (88.75%); however, in articles where the internal load was analysed, mainly subjectively, the low quality (80%). Therefore, those studies that used objective instruments for load analyses were studies of higher quality (88.28%).The aim of this research, based on a systematic review, was to analyse the scientific production on women’s basketball. Studies where the load supported by the female players during practice and competition was investigated and evaluated. In this way, the intention was to identify the trends, samples, variables and instruments used, as well as the designs and research procedures used for this topic. The main results show that, in women’s basketball, competition has been mostly analysed, specifically by 48.15% of the studies evaluated. Only 14.81% of the studies have analysed training and competition together. This is a problem, since examining the demands imposed on the players, from both training and competition, provide a context to create an optimal training environment .Sports competition analysis is the most demanded. There are many hypotheses based on results, game statistics, quarters, playing position, etc. With regard to women’s basketball, the reviewed articles are responsible for characterizing sports competition in different levels . Competition in women’s basketball is defined to be able to replicate the demands during sports training. However, if the training is not analysed, it is impossible to know if the demands that generate are according to those in competition. The studies that have obtained a higher score regarding its quality have been those that jointly investigate training and competition, for which reason, it is considered of vital importance to increase the production of this type of research. Concerning demands, although the requirements of the competition in men’s basketball are greater than those of women’s basketball, Stojanović, Stojiljković, Scanlan, Dalbo, Berkelmans and Milanović [During training, load has been analysed according to the type of situations used in tasks, which in the reviewed articles are evaluated according to their characteristics and type of game situation employed . It is common to reduce the number of players in training tasks, as well as the size of the playing area or the track. These types of situations are known as small-sided games, and are arousing more interest in the scientific and sports communities . TherefoThe most analysed category has been senior, finding that research in training categories (U15 and U16) is very limited (7.4% each). The vast majority of studies are carried out on state and national level samples . In lower categories (U14–U18), analysis of training sessions is more common, while in senior categories (amateur and elite) the studies are more frequent on sports competition. It is important to highlight that, although the most carried out studies are at the state level, they are the lowest quality compared to national and international studies. A review of the literature found significant differences in relation to the level and category of the sample. In competition, the distance covered by the athletes is similar (5–6 km per game) but there are differences between categories related to the intensity of play. Higher-level players spend more time in more intense work areas and vary between them more intermittently (21). The same happens with the physiological responses to the different types of activity, when the activity is more intense the internal load increases. In turn, it is found that in U14 and U16 there are fewer studies and those that exist are less complete.The load has been analysed in female basketball during training and sports competitions. The most common is the analysis of the internal and external load together, even so, during the competition, the analysis of the external load has been more investigated (30.77%). Furthermore, studies that tried to provide information on external load have obtained a higher quality than the rest. Even so, it is considered interesting to increase the quality of the studies carried out with external and internal load together, since they provide a more global vision of the demands of the game in athletes ,15.Specifically, for the analysis of internal load during training in women’s basketball, the heart rate  and subjective variables, such as the RPE (Rating of Perceived Exertion) scale or questionnaires , have been mainly analysed. With respect to analysis of the internal load in women’s basketball, the authors have established in competition a HRavg of 162–173 ppm, a HRmax of 188–195 ppm for % HRMax 82.4%–92.5% . As for lactate measurements, values have been obtained between 3.7–5.2 mmoles .Inertial devices and TMA are the most commonly used tools for external load analysis. Information is extracted about the activity that is being carried out on frequency of actions, and their duration or intensity. In addition, data are obtained relating to distances travelled and changes in movement. In women’s basketball, Scanlan et al. (21) record that the players cover an average of 5214 ± 315 m per game. The intensity at which they work during the race is 30.2%–39.3% walking, 12.8%–24% jogging, 4.9%–11% running, and 0.6%–7.8% sprinting . An average of 576–652 changes of movements are made, producing one every 2.49–2.82 s ; however, Scalan et al. (21) collected 1752 movement changes per game in amateur Australian players. Regarding high-intensity actions between 19–71 jumps per game (1–1.77 jumps per minute) and between 44 and 49 sprints per game  have been reported, although, Scalan et al. (21) recorded an average of 108 sprints per game. These previous studies that have examined the load using time motion video analysis led to controversial conclusions. For this reason, in the most current studies, measurements derived from accelerometers, GPS and other devices are used as alternative, objective and reliable methods to evaluate the external training load.The evaluation of loads analysed by these devices have only been carried out in studies on training sessions due to the negative posture of federations as to their use during the sports competition. Load has been evaluated in sports training with the main objective of comparing the game situations used in the training tasks. Significant differences have been found between small-sided games  compared to the full game , the former causing more demands in full court tasks . These authors have established differences in the distance travelled, the average speed, PlayerLoad (PL), the speed ranges in accelerations, heart rate, sprints and jumps. Herran et al. (6) recorded 5-min games in situations of 3 vs. 3 and 5 vs. 5, obtaining differences in the total distance values (249.6 vs. 209.35 m respectively), average speed (49.9 vs. 41.8 m/min) and PlayerLoad (47.6 vs. 41.8). On the other hand, Kluseman et al., (7) studied tasks lasting 10 min in situations of 2 vs. 2 and 4 vs. 4, obtaining values of % RH (86.4% vs. 83.5%), number of jumps (26.1 vs. 16.6), in addition to observing activity of greater intensity in 2 vs. 2 situations. Reina et al.,  did not Some limitations should be addressed when considering this research on the training load and competition demands in women’s basketball. First, it should be noted that this review is not intended to accurately provide the demands performed during competition and training in women’s basketball. This review aims to establish where there are declines to encourage researchers to create scientific evidence in this poorly studied population. When differentiating between levels, it is found that the number of studies in training categories is lower, making it difficult to define them adequately in order to create specific training patterns. The same applies to the type of load analysed and the instrument used. Depending on the level and purchasing power, in some studies, the training load will be more precisely quantified. Being important, a great investment in training categories and women’s basketball. Finally, regarding the qualitative analysis, it was found that, mainly, the studies in training categories (U15 and U16) together with the studies carried out in level state were of a lower quality. This is an aspect to take into account since, on the one hand, it is important to individualize training according to age and, on the other hand, the largest number of existing studies is in level state.Currently, conditions for obtaining relevant scientific information that allows us to monitor and establish workloads in basketball players are optimal, and this systematic review establishes a profile of knowledge about the load supported by women’s basketball players. It has been possible to verify that the bibliography dedicated to this topic is scarce, being nourished from data coming from men’s basketball, but at the same time, proposals for the study of women’s basketball are being established.Studies are necessary that propose individualized training for this type of population, that not only characterize the hormonal profile of the women athletes or evaluate the etymology of their injuries, but also prescribe specific training to prevent injuries and, consequently, to increase their performance. It is important to highlight the use of inertial devices today. This type of device is booming, with tendency to be the most used instrument by researchers for the analysis of sports performances in the future. For a better description of women’s basketball, there is a need to jointly investigate sports training and competition, to study the training categories and to use micro technology that guarantees obtaining objective and reliable data. Finally, this review takes into consideration the evaluation of quality of the studies, a risk-of-bias form developed to the specific context.


Background: Nucleus accumbens (NAc) is a brain structure with a well-established role in the brain reward processing system. Altered function of the NAc is shown to have a role in the development of food addiction and obesity. However, less is known about sex differences in the role of NAc function as a predictor of children’s change in body mass index (BMI) over time. Aim: We used the Adolescent Brain Cognitive Development data (version 2.01) to investigate sex differences in the predictive role of the NAc functional connectivity with the frontoparietal network on children’s BMI change over a one-year follow-up period. Methods: This 1-year longitudinal study successfully followed 3784 9–10-year-old children. Regression models were used to analyze the data. The predictor variable was NAc functional connectivity with the frontoparietal network measured using resting-state functional magnetic resonance imaging (fMRI). The primary outcome was BMI at the end of the 1-year follow up. Covariates included race, ethnicity, age, socioeconomic factors, and baseline BMI. Sex was the effect modifier. Results: NAc functional connectivity with the frontoparietal network was predictive of BMI changes over time. This association remained significant above and beyond all covariates. The above association, however, was only significant in female, not male children. Conclusion: The epidemiological observation that NAc functional connectivity is associated with BMI changes in children is an extension of well-controlled laboratory studies that have established the role of the NAc in the brain reward processing. More research is needed on sex differences in the brain regions that contribute to childhood obesity. Nucleus accumbens (NAc), a central region in the basal ganglia, has a significant role in Pavlovian learning ,3,4,5,6.The NAc mediates cue-triggered reward-seeking behaviors ,22,23,24The NAc, however, does not perform its functions in a vacuum as it receives projections from a plethora of brain regions and networks. Among the various brain networks that work with the basal ganglia, striatum, and NAc is the frontoparietal network . Such a Although NAc function is a well-established predictor of food-seeking behaviors , less isA secondary analysis was performed with a cross-sectional design. We used data from the Adolescent Brain Cognitive Development (ABCD) study ,47,48,49In the ABCD, we only included children who were between the ages of 9 and 10 years. The ABCD children were enrolled from multiple cities across the United States. Overall, children were recruited to the ABCD study from 21 sites. The primary strategy for sampling in the ABCD study was the school systems . In the We used neuroimaging data which were already processed. The ABCD Magnetic Resonance Imaging (MRI) data include functional and structural MRI. Functional MRI (fMRI) includes resting-state and task-based fMRI. Resting-state fMRI was used for this analysis. Beta correlation between the frontoparietal network and the automatic subcortical segmentation (ASEG) region of interest (ROI) right-accumbens area was calculated. Tesla 1 (T1) and T2 weighted fMRI and sMRI images were taken using a 3 tesla (T) Siemens Prisma , General Electric 750 , and Phillips  multi-channel coiled scanners, all capable of multiband echo-planar imaging (EPI) acquisitions. A localizer was implemented at the beginning of each scan, followed by a T1 weighted fMRI image acquisition. Functional T2 weighted scans were then acquired at rest and then throughout three psychological tasks. A large-scale multimodal data acquisition allowed the ABCD study to collect an unprecedented set of images on a large number of adolescents that were selected and enrolled via 21 data acquisition sites across various U.S. states. As mentioned above, both ABCD structural and functional MRI data are processed and the tabulated regions of interest (ROI) data were downloaded from the National Institute of Health (NIH) Data Archive (NDA). ABCD imaging data were limited to resting-state fMRI. More information on the imaging protocols are available here ,53,54.Body Mass Index (BMI). The children’s BMI at baseline and at the end of the 1-year follow-up was calculated based on participants’ measured height and weight. Height was measured three times in inches. The weight of the child was measured up to three times in pounds. BMI was treated as a continuous measure. Although some research has used percentile BMI related to age and sex norms, we used raw BMI because the analyses broke the sample by sex and the age range of the participants was very narrow (only 9- and 10-year-old children). Other research has also used BMI rather than percentile BMI related to age and sex norm.NAc. Using resting-state fMRI, NAc was defined as the average correlation between the frontoparietal network and ASEG ROI right-accumbens area. This is functional connectivity between the frontoparietal network and the NAc. The resting-state fMRI was measured at baseline at the same time that socioeconomic status (SES) indicators and baseline BMI were measured.Race. Race, a self-identified variable, was two binary variables: Blacks, other races, and Whites (reference category).Ethnicity. Ethnicity, a self-identified variable, was 1 for Hispanics and 0 for non-Hispanics (reference category).Sex. A dichotomous variable, sex was coded as below: males = 1, females = 0.Age. Age (months), calculated as the difference between birth and the time of enrollment to the study, measured in months, was reported by parents.Parent education (y). Parents reported their years of schooling. This variable was operationalized as a continuous  variable ranging from 0 for no formal education to 21 for doctoral degrees.Parent employment. Parents reported their employment. This variable was operationalized as a categorical variable with 0 for non-employed and 1 for employed.Family income. Family income was a 1–10 interval measure where a higher score indicated higher income. The total combined family income in the past 12 months was asked. Responses were 1 = less than USD 5000; 2 = USD 5000; 3 = USD 12,000; 4 = USD 16,000; 5 = USD 25,000; 6 = USD 35,000; 7 = USD 50,000; 8 = USD 75,000; 9 = USD 100,000; 10 = USD 200,000.Model 1), and our 2nd model was with (Model 2) an interaction term between sex and NAc functional connectivity with the frontoparietal network. Our next models were run for females (Model 3) and males (Model 4). Models were identical for right and left NAc. All models were statistically significant at a 0.001 and explained more than 20% of the variance of the outcome, mainly because the outcome and independent variable (predictor) had a strong correlation (baseline and time 2 BMI). This information is added to the statistical analysis section of the paper. We did not adjust the BMIs based on the age and sex of the participants because the BMI values of each individual were being compared at two time points (baseline and follow up BMI). As every individual is compared to his/herself, there is no need to adjust based on the distribution of BMI in the population. There are several studies that have used the same approach and have not adjusted based on norms. Unstandardized coefficient (b), standard error (SE), 95% confidence interval (95% CI), and p-value were reported for our model. A p-value equal or less 0.05 was significant.The statistical package, SPSS 22.0 , was applied for data analysis. Mean  and frequency  was used to describe all the study variables. We also used the Pearson correlation test for bivariate analysis of the associations between the study variables. For multivariable modeling, we ran four regression models. To do so, first we tested the assumptions that are required for running a regression model. BMI time 1 and time 2 had a near to normal distribution. There is no collinearity between the study variables. In our model, the NAc functional connectivity with the frontoparietal network was used as the independent variable (predictor), baseline BMI and demographic and SES indicators as the covariates and follow-up BMI as the outcome. Our 1st two models were performed in the pooled sample. Our 1st model was without  approval from several institutions, including but not limited to the University of California, San Diego (UCSD). All participating children provided assent. All participating parents signed informed consent . As we oA total number of 3784, 9–10-year-old children were analyzed. Participants were 1953 male and 1831 female children. p = 0.012 for right and b = −32.31; p = 0.000 for left NAc functional connectivity with the frontoparietal network) but not males . Results were identical for right and left NAc. BMI baseline was also positively and significantly associated with time 2 BMI, which is reflective of autoregressive correlation .As the appendix shows, we ran a full series of sensitivity analyses to test if we could successfully replicate the results of our main analysis. As shown above, our main analysis shows that the effect of NAc functional connectivity with the frontoparietal network on BMI time 2, while covariates and BMI time 1 was controlled. We ran a mixed effects model with BMI time 1 as the outcome. The argument behind this approach is if the result of our main analysis with BMI time 2 is robust, then we should test the same interaction in our replication model, despite the sample size and the temporal aspects of the measures having changed. As our findings show, our sensitivity analysis replicated the same interaction between sex and NAc functional connectivity with the frontoparietal network on BMI  receptors (a receptor for the GABA hormone released by the brain to regulate dopamine levels in its reward pathways) in the NAc shell mediate hyperphagia, overeating, and associated weight gain [Our first main finding is supported by the lab-based observations that the basal ganglia (striatum and NAc) and frontoparietal network function together , and thaght gain . NAc conght gain . Motivatght gain . NAc medght gain . The NAcght gain . Recent ght gain . Chronicght gain . The NAcght gain .Our second main finding, the predictive role of the frontoparietal network and NAc functional connectivity on BMI time 2 of female but not male children is very novel. An extensive body of research has previously shown that sex alters predictors of obesity and BMI change over time ,68,69,70In our main analysis, we had follow-up BMI as the outcome and baseline BMI as a covariate. This is one of the two main approaches to analyze the repeated measure outcome only with two observations. Maria Glymour and others have discussed how controlling for baseline status of an outcome alters the interpretation of the results. We decided to control for baseline BMI when the outcome was time 2 BMI based on the causal diagram . Still, Function of the NAc is believed to be modifiable through neuro-modulation . NAc funAll studies, particularly those who are secondary analysis of some existing data, are limited in their design, methods, and measurements. NAc activity and high BMI may have bidirectional effects. However, we used a longitudinal design and established the longitudinal effect of baseline NAc function on children’s BMI change over time. We only had a few confounders, and we did not have data on diet, food cues, obesogenic environment, mental health, emotion regulation, and food addiction. Finally, we should emphasize that in this study, our outcome was not a dichotomous variable of obesity but the continuous measure of BMI. As such, the result should not be interpreted as NAc function predicts obesity, but BMI value at time 2 . That means, regardless of passing or not passing the threshold that we use to define obesity or overweight, NAc function predicts who develops a higher BMI over time.As the duration of follow up in our study was short, long-term longitudinal data are needed. Imaging studies on longitudinal association between the NAc, and behavioral development are needed. We only described a link between the NAc and BMI change. Future research should study the mechanism of the effects of the NAc on BMI change. Future work is needed on various social, behaviors, and brain mechanisms that can explain how baseline NAc function predicts future obesity, and how these paths may differ for various groups of American children. As the NAc is not only responsive to food but also other categories of rewards such as alcohol  and sex In this longitudinal epidemiological study, the NAc functional connectivity with the frontoparietal network was predictive of future BMI increase among female but not male American children. The NAc, the frontoparietal network, and their functional connectivity may be a part of the brain circuits involved in the development of obesity among female children.


To compare perioperative visual field (VF), balance functions (BF), and changes in the other ocular parameters in patients undergoing upper eyelid dermatochalasis (DC) surgery.  One hundred and fifty-eight eyes of 79 patients who underwent DC surgery were included in the study. The VF, BF, intraocular pressure (IOP), pachymetry (PM), macular, and optic nerve measurements were recorded. Measurements were repeated at postoperative month 1. The preoperative and postoperative ocular measurements and the balance data were compared. p < 0.05).  Nineteen of 79 (24.05%) patients were male and 60 of 79 (75.95%) were female, while the mean age of the patients was 58.65 ± 7.38 years. There were statistically significant differences in terms of VF and macular thickness between the preoperative and postoperative values. The improvements in mean defect, standard loss variance, and mean sensitivity values of global VF parameters in both eyes were statistically significant after surgery. Central macular thickness, mean macular thickness, and macular volume decreased significantly in all eyes after surgery ( Although a marked improvement was observed in VF and peripheral vision after surgery, no significant change was found in BF parameters including primarily falling risk. The significant change in the macular parameters was only remarkable, and we think that the decrease was due to subtle vasospasm. There is a need for further comprehensive studies including especially patients older than 65 with a view to understanding the effect of DC surgery on BF. Dermatochalasis (DC) is the most frequent cause of acquired pseudoptosis, which causes a decrease in superior visual field (VF) due to the loosening of the upper lid skin, which is folded by the atrophy of the elastic tissue with advanced age , 2. It lPosture control depends on the integration of information derived from proprioceptive, vestibular, and visual perceptive systems . Visual To the best of our knowledge, our study is the first to measure BF, macula, and optic nerve parameters as well in addition to perioperative VF, IOP, and PM measurements in patients with dermatochalasis. In particular, we think that BF evaluation will contribute to the literature as it can improve the quality of life in addition to its effect on visual quality after surgery., standard loss variance (sLV), and mean sensitivity (MS) values were assessed by perimetry . Central macular thickness (CMT), mean macular thickness (MMT), macular volume (MV), disc area, rim area, rim area/disc area ratio (RA/DA), ganglion cell layer (GCL), retinal nerve fiber layer (RNFL) thickness measurements, and also thickness measurements within four quadrants as superior, nasal, temporal, and inferior were assessed by optical coherence tomography . Intraocular pressure (IOP) and pachymetry (PM) values were measured with tonometry (Canon Noncontact TX-20).BF was measured by computer-based static posturography . Posturography is a diagnostic system which analyzes a subject's balance and the mechanisms employed to maintain balance. This method of posturography is based on the assessment of the vertical pressure fluctuations on four independent force plates, each placed beneath the two heels and toe parts of the subject while he/she stands in an upright position. The Tetrax plates  are equipped with a strain gauge, the output of which consists of fluctuations of voltage. This output is transformed by an A-D device into a digital signal, which is analyzed by Tetrax software. The weight of the examinee is automatically controlled by the software while height does not interfere with the Tetrax parameters, as shown by systemic examinations [STI is the numeric variable expression of a patient's postural defects and controls, which cannot be detected clinically. It evaluates changes in the center of gravity. The total amount of sway from the four footplates  is summed up and then divided by the subject's weight . That parameter was calculated as the square root of the sum of squared differences between adjacent pressure fluctuation signals, transmitted by the A-D device and sampled at a rate of 32 Hz for each of the four platforms. Limit values are considered as the standard deviations from 1.5 to 3. Higher values indicate higher imbalance , 15.The FHI is a regression analysis of postural sway intensity through the Fourier transform, which shows a different frequency for each lesion that causes instability. Transformations consisting of four independent wave signals are divided into eight different frequencies and recorded. The FHI evaluates the regression pattern of the eight Tetrax frequency bands. Tetrax program compares the Fourier power values of posturographic performance to a mathematically computed regression curve and evaluates the discrepancy between the graph obtained from the collected data and the theoretical “ideal” regression in the form of a coefficient. This spectral pattern is designated as Fourier Harmony and its coefficient as the Fourier Harmony Index. FHI is the assessment of normal posture performance. Values from 0.9 to 0.99 are the normal limits. If lower values are detected, they indicate problems in the visual, vestibular, and postural feedback mechanism .WDI shows discordant weight distribution in the foot platform and may be an indication of an orthopedic problem. WDI assesses the synchronization pressure patterns of feet and the pressure on the plates where the heel and the toe are placed, while the effectiveness of coordinated movements between the heel and the toes of each foot are also evaluated.Falling index is used to reevaluate the data. Its algorithm is based on the addition of standard deviation scores, which are obtained when calculating by how many standard deviations the performance of an examinee deviate from the mean of the normative database provided by IBS software. Adding the standard scores for stability, Fourier intensities of ∼0.3 and ∼1.00 Hz, and synchronizations, a fall index is graded as minimum falling risk (0–36), moderate level 37–58), high level (58–100), according to which precautions and supportive treatment can be planned , high le.t-test for paired samples. For the continuous variables that were not normally distributed, the Wilcoxon test was used to compare the preoperative and postoperative values. p values <0.05 were considered statistically significant.All data were analyzed with SPSS  software for Windows . Individual and aggregate data were summarized using descriptive statistics including mean, standard deviations, medians (min-max), frequency distributions, and percentages. Dependent variables with normal distribution were compared with Student's Out of 79 patients (158 eyes) who underwent upper DC surgery (blepharoplasty), 19 (24.05%) were male and 60 (75.95%) were female, while the mean age of the patients was 58.65 ± 7.38 years (Ranged: 36–84 years). In our study, no significant difference was found between the preoperative and postoperative visual acuity, IOP, and PM for both eyes .p < 0.05) (p < 0.05)  . Further < 0.05) .p < 0.05) decrease was observed in CMT, MMT, and MV values measured in all eyes (According to macular thickness and volume evaluation results; a statistically significant (all eyes . There wall eyes .While the balance functions in STI, FHI, and WDI dimensions were measured in various body, head, and eye positions , fallingThe VF test is applied for legitimizing the blepharoplasty. According to the international standard guidelines, upper margin-reflect distance should be more than 2.5 mm, and the VF has to improve by more than 30% after blepharoplasty . Kosmin Thirty percent of the population aged 65 and older die or become permanently disabled due to falling once a year or more . Every 1Retinal changes are observed mainly at early stages with the rise of retrobulbar hemorrhage after the blepharoplasty, followed by the application of local anesthetics containing epinephrine, vasospasm, inflammation, and systemic hypotension, respectively , 31. TheAtalay et al. assessed corneal hysteresis, corneal resistance factor, PM, and IOP and reported no significant difference in PM and IOP values after DC surgery . Bleyen In conclusion, BF, macula, and optic sinir parameters were evaluated for the first time in our study in addition to perioperative VF, IOP, and PM measurements in patients with dermatochalasis. Although a marked improvement was found in peripheral vision with VF, no significant change was observed in general in BF parameters including primarily fall risk. The significant change in the macular parameters was only remarkable, and we think that the decrease was due to subtle vasospasm. There is a need for further comprehensive studies including especially patients older than 65 with a view to better understanding the effect of blepharoplasty surgery on fall risk and balance functions.


Some studies have been conducted in order to assess the association between weight status (assessed by body mass index) and socio-demographic factors. Nevertheless, only a few of them have indicated these associations by other anthropometric parameters . The aim of this study was to determine, compare, and examine the influence of age, sex, type of the schooling, per capita income, area of residence, and immigrant status on obesity parameters in schoolchildren aged 6–13 from the Region of Murcia. A cross-sectional study was carried out in six different Primary schools of the Region of Murcia (Spain). A total sample of 370 children (166 girls) aged 6–13 (8.7 ± 1.8) were selected. In order to determine participants’ body composition, body mass index, waist circumference, waist-to-height ratio, and skinfold measurements were calculated. Higher associations of excess of weight  and abdominal obesity  were shown in the case of children from public schools. A greater association of high trunk fat mass was found in children from municipalities with high per capita income . Therefore, lower association of having an inadequate %BF was found in the participants aged 6–9 , and immigrant students . Our study suggested that overweight/obesity among schoolchildren in the Region of Murcia is higher than the overall prevalence of Spain. The results of the adjusted analyses showed that age, type of schooling, per capita income, and immigrant status were associated with obesity parameters. Globally, overweight and obesity have reached worryingly high levels , especiaRegarding obesity identification, body mass index (BMI) is the most applied anthropometric parameter in children; existing several reference cut-off points, both internationally ,7,8 and Following this line, some studies have been conducted in order to assess the association between weight status (assessed by BMI) and socio-demographic factors, such as sex , type ofIn addition to this, children and adolescents who have obesity are about five times as likely to be obese in adulthood than their counterparts who do not present obesity . Thus, bAccording to the worrying situation of childhood obesity in Spain, particularly in the Region of Murcia, as well as the lack of information about those sociodemographic factors that could be related to childhood obesity, the aim of this research was to determine, compare and examine the influence of age, sex, type of the schooling, area of residence, immigrant status, and per capita income on obesity parameters in schoolchildren aged 6–13 from the Region of Murcia.This study had a cross-sectional design. All nine primary schools from the Valley of Ricote  were invited to take part, with six schools agreeing to participate. Out of 972 possible participants, a total of 370 schoolchildren (166 girls and 204 boys) with ages between 6–13 years old (8.7 ± 1.8) participated, representing a response rate of 38.1%. For this study we used the non-probability sampling technique. In spite of this, all schoolchildren were likewise offered to join.All the children involved in the study had to provide a signed consent form by their parents/legal guardians. Before the performance of the study, both parents and children were informed about the purpose of the research and the type of tests that would be carried out. Data was obtained in the 2017/2018 academic year. All the measurements were performed during Physical Education classes. As an inclusion criterion, only schoolchildren aged 6–13 who had obtained positive informed consent from their parents or legal guardians were included.n = 71), 61.1% are of South American origin, 29.1% of Arab origin, 5.6% from other European countries, 2.8% born in Asia, and 1.4% of African origin.Regarding the origin of the immigrant students (The Bioethics Committee of the University of Murcia (ID 2218/2018) approved the present study. It has been executed respecting the human rights of the participants and following the Helsinki Declaration.2). Besides, weight status was determined using the age-specific and sex-specific thresholds provided by the WHO [Sex and age were self-reported. The type of schooling was dichotomised into two categories: (1) public and (2) private with public funds. Area of residence was divided into (1) urban (>5000 inhabitants) and (2) rural (≤5000 inhabitants) . Student the WHO . WC was  the WHO . Moreove the WHO . Skinfol the WHO . To calc the WHO . Siri fo the WHO , and fat the WHO .All the measurements were performed by the same trained researcher. Two measurements were taken and, if existed discrepancies exceeding 0.1 centimetres (cm) between measurements the procedure, was performed again. The relative technical error of measurement (TEM) was obtained by performing a number of repeated measurements on the same participant, taking the differences and inserting them into a correct equation. For intra-observer TEM of the two measurements taken the following equation was applied: √ΣD/2N, where “D” is the difference between measurements and “N” is the number of participants measures. Also, the absolute TEM was multiplied by 100 and divided by the variable average value in order to provide the relative TEM (%TEM). The %TEM were 0.3%, 0.2%, 0.5%, and 2.3%, for weight, height, WC, and skinfolds, respectively.n) and percentage (%). Likewise, the confidence intervals (95%) were calculated. To assess the differences between groups of age, sex, type of schooling (public/private), per capita income (high/low), area of residence , and immigrant status (native/immigrant), the Chi-squared test was used or, if expected values were lower than 5, Fisher’s Exact test was applied. Furthermore, binary logistic regression analyses were performed to determine the association between sociodemographic characteristics and the different obesity parameters. Finally, data analysis was performed using the software SPSS  for Windows (v.24.0). Statistical significance was maintained at p-value ≤ 0.050.For all continuous variables, data was shown as mean (M) and standard deviation (SD). Conversely, all categorical variables were expressed as number (Data of age and continuous variables of anthropometric characteristics are shown in p < 0.001). So, a greater number of children aged 10–13 with great levels of %BF (22.3% higher) was identified. Regarding the type of schooling, children from public school showed greater values in all variables of obesity. Likewise, statistically significant differences were shown in most of obesity parameters that were examined (except for %BF). Also, higher prevalence of excess weight, abdominal obesity, high trunk fat mass, and high adiposity was found in the case of high per capita income group . Finally, according to the area of residence, children from urban areas showed greater association with having higher obesity parameter (except for WC) without showing statistically significant differences for any obesity parameter. Data on absolute and relative frequencies is available in The aim of the present study was to determine, compare, and examine the influence of age, sex, type of the schooling, per capita income, area of residence, and immigrant status on obesity parameters in schoolchildren aged 6–13 from the Region of Murcia. In this line, this study revealed that a great number of schoolchildren are overweight/obese in the analysed sample. Our results are higher than those reported by the last Estudio ALADINO , which rIn addition, in relation to age, our adjusted model did not show statistical significance in order to have excess weight. Obesity prevalence rises as children grow older , and ageConcerning sex, the categorisation of BMI reported very close prevalence of excess weight between boys and girls. Thus, we observed that being a girl or boy did not predict the likelihood of having excess weight/obesity, a finding that is consistent with some previous studies conducted ,43. HoweRegarding the type of schooling, children from public school were more likely to have excess weight when compared to children of private schools. This fact matches with the findings of other studies which evaluated children and adolescent’s excess weight in different countries ,50 and iConversely, a higher prevalence of excess weight, abdominal obesity, and especially of high trunk fat mass were shown in children from high per capita income. Our findings match with those reported by Arruda et al. , who repConcerning the area of residence, the evidence available on this relationship is inconclusive . For exaIn the case of immigration, we observed that immigrant children had a higher prevalence of excess weight and high adiposity. This fact is consistent with others studies performed both in Europe  and SpaiIn this study, we found some strengths that characterise our study, we assessed several obesity-related parameters such as WC, WHtR, or %BF, apart from the most commonly used BMI. This choice is based on the intention to offer a better understanding of the childhood obesity problem since, according to previously recommendations, BMI should be complemented by other anthropometric parameters  to establish efficiently the risk in individuals ,15. FurtFinally, our study suggested that overweight/obesity among schoolchildren in the Region of Murcia is higher than the overall prevalence of Spain. The result of the adjusted analyses showed that age, type of schooling, per capita income, and immigrant status were associated with obesity parameters. The identification of socio-demographic variables related to paediatric obesity can be an appropriate tool for possible early prevention and intervention. Public health policies and interventions aimed at the prevention and treatment of childhood obesity should incorporate a sensitive and clear focus on social and economic inequalities; emphasising on the groups most at risk.


Adverse childhood experiences (ACEs) are known to have deleterious effects on individuals across the life span, but less is known about how they affect grit, a strong predictor of achievements and well-being. This study seeks to investigate the effect of ACEs on grit in a sample of Chinese college students during the COVID-19 pandemic. Data were collected from 1,871 students across 12 universities in China. Findings indicated a significant effect of ACEs on grit, particularly abuse and neglect dimensions of ACE. Since grit is particularly important for professional success, those who have experienced abuse and neglect victimization may struggle throughout their education, and subsequently, in their careers. This calls for interventions to buffer the effects of ACEs on grit. Studies have shown that, regardless of geographic location, almost two-thirds of youth have experienced a significant adverse event  specifically was found to significantly predict academic performance and subjective well-being, while consistency of interests did not (showing steady long-term interest)  developed by Duckworth and Quinn (perseverance of effort and consistency of interests (referred to as perseverance and consistency hereafter), each containing 4 items. Example items for Grit-S include “Setbacks don't discourage me. I don't give up easily;” and “I have been obsessed with a certain idea or project for a short time but later lost interest.” Answers for each item ranged from 1 (Very much like me) to 5 . We recoded the scores of each item so that higher scores indicated higher levels of grit. We calculate the average score of grit, as well as perseverance and consistency, by averaging the item scores. The range of the scores to each item ranged from 1 to 5. The Cronbach's alphas were 0.72, 0.83, and 0.69 for the full scale, the perseverance subscale, and the consistency subscale, respectively.nd Quinn . The 8 ind Quinn . There aadverse childhood experiences, was measured by the Adverse Childhood Experience scale (ACE) and assessed ACEs during the respondent's first 18 years of life [Center for Disease Control and Prevention (CDC), The key independent variable, Proximity to COVID-19 infection was measured by asking students whether their family members or friends had tested positive or died due to COVID-19.This study included socioeconomic characteristics of the respondents as covariates. We collected information about respondents' age, sex , ethnicity , and household registration . We also collected information about their parents' and family's background, including parents' marital status , parents' highest educational background , number of family members, annual family income in the last year, and welfare status  in the last year. In addition, since we sampled students from 12 colleges across China, we consider that different college characteristics may affect the grit of students. Thus, we took college into account by controlling for college as one of the covariates. Specifically, we used college-fixed dummies that were taken to be constant across individual colleges as covariates.Descriptive analysis was performed to examine the distribution of each main variable. We then conducted regression analysis to estimate the association between key independent variables and the dependent variable while controlling for students' socioeconomic characteristics. The framework underlying this study posits that the extent of grit in college students is determined by ACEs, COVID-19 infection in family and friends, socioeconomic characteristics of the students, and college-level characteristics. The specification of the analytic model is represented by the following equation:Yi is grit of the subject i; αi is the individual constant; χ is a vector of ACEs, COVID-19 infection in family and friends, and socioeconomic characteristics of subject i; Ci is the college for subject i, or college-fixed effect; β is a vector of regression coefficients; and εi is the cross-section error component. Note that with college-fixed effect, the model controls for differences across colleges. Ordinary least squares (OLS) regression was used for the analyses. All analyses were conducted using STATA software 16.0.where p < 0.001). Students who had family members or friends infected with COVID-19 did not have any statistically significant difference in grit scores compared to their counterparts. Overall, level of grit increased with age. The adjusted R-square of Model 1 was 0.03. The adjusted R-square kept stable at 0.03 in Model 2. Model 2 showed that the ACE score had a significant and negative association with grit. Like occurrence of ACE, a one standard deviation increase in the ACE score was associated with a 0.09 standard deviation reduction in grit (p < 0.001). The rest of the results of Model 2 were similar to those reported in Model 1. The small adjusted R-square values in both models suggest that a lot of variances in grit in Chinese college students were not explained in the models.B = −0.07, p < 0.01). Both the abuse and neglect subscales had a significant negative relation with grit. There was a greater association with abuse , followed by neglect . The household challenge subscale had no significant association with grit. Next, only three ACE items  were significantly associated with lower levels of grit. All had an effect size around −0.07 (p < 0.01). Physical abuse was marginally associated with grit, with an effect size of −0.04 (p < 0.10). All types of household challenges did not have any statistically significant association with grit overall.Last, we conducted robustness tests on the relationship between ACEs and grit. The same regression analyses in B = 0.10, p < 0.01). This was reflected by the results of regressing consistency onto individual ACE items: parental separation or divorce; mother treated violently; substance abuse in the household; and mental illness in the household all showed significant positive effects on consistency of interests. Overall, each 1-point increase in ACE score was associated with a 0.07 standard deviation increase in consistency of interests (p < 0.01).By contrast, household challenges appeared to have a significant positive association with the consistency of interests dimension of grit (p < 0.001), as opposed to a 0.09 standard deviation decrease in grit overall (p < 0.001). Students who had reported experiencing at least one ACE had 0.12 standard deviation less perseverance of effort than those who did not experience any ACEs (p < 0.001). Those who had experienced 3 or more ACEs had 0.10 standard deviations less perseverance than those who experienced <3 (p < 0.001). Meanwhile, each type of ACE—abuse , neglect , and household challenges —also had significant negative associations with perseverance. Finally, each individual ACE item appeared to have significant negative associations with perseverance. Emotional abuse and substance abuse in the household had the greatest negative association with perseverance , followed by sexual abuse, emotional neglect, and parental separation or divorce , physical neglect and mental illness in the household , physical abuse , incarcerated household member , and finally mother treated violently .Interestingly, ACEs had a greater negative association with the perseverance of effort dimension. Each point increase in ACE score was associated with a 0.16 standard deviation decrease in perseverance (p < 0.01), while the occurrence of at least one ACE and the occurrence of three or more ACEs did not have any significant association with consistency. The association between ACEs and consistency came from household challenges , while abuse and neglect had no statistically significant relation with consistency. Specifically, parental separation or divorce , mother treated violently , substance abuse in the household , and mental illness in the household  all had significant and positive associations with consistency.Finally, ACEs tend to have different relations with consistency. Each point increase in ACE score was associated with a 0.07 standard deviation increase in consistency (p < 0.001). Results also indicated that not all types of ACEs nor the number of ACEs experienced were equally negatively associated with grit. Effect sizes varied when grit was regressed onto different ACE specifications. Emotional and sexual abuse, as well as emotional neglect, were most strongly negatively associated with grit overall. Meanwhile, the association between physical abuse and grit was marginally significant.This study sought to examine ACEs as an antecedent of grit in Chinese college students. Guided by trauma theory Herman, , we hypoThe significant negative associations between emotional and sexual abuse and emotional neglect and grit may be a result of decreased sense of relatedness. Datu  found thAnother potential explanation for the effects of emotional and sexual abuse on grit can be formulated based on the relations between sexual abuse and mindfulness . This finding is interesting considering that Datu et al. (Interestingly, household challenges had no significant association with students' grit, but when we regressed grit on the ACE subscales, household challenges appeared to have a significant and positive association with the consistency of interests dimension (u et al.  previousu et al.  reportedu et al. ,b to maiu et al. , howeveru et al. , placingWhen the ACE specifications were regressed on perseverance of effort dimension, all specifications—that is, more than one ACE, more than three ACEs, each type of ACE, and each individual ACE scale item—had a significant negative association with perseverance of effort. It is possible that ACEs negatively affect perseverance of effort through their deleterious effects on psychological well-being Herman, , as thosOur findings reflected that COVID-19 had no significant association with grit, though this result may have been caused by measurement error and low COVID-19 prevalence in China at the time of data collection. The prevalence of COVID-19 had stabilized and remained low since April 2020, when the last city, Wuhan, lifted its lockdown (Zhong and Wang, This study has several limitations. First, our analyses were based on a cross-sectional dataset, which can only approximate an associative relationship, rather than a causal one, among ACEs, COVID-19 infection, and grit during the pandemic. Future studies may use a longitudinal design to examine the causal relationships of these variables. Second, there were other unobserved variables, such as academic stressors and peer support, that could affect grit but were not included in the study. The absence of these unobserved variables may have effects on the estimates reported in this study. Third, the findings of this study are based on data from students of social science departments in 12 colleges across China. Although the large sample size and geographic diversity of these colleges increase our confidence, the extent to which these findings can be generalizable to all Chinese college students is unknown and requires further research. Fourth, the lack of any significant effect of COVID-19 on grit may be the result of measurement error since this was dependent on students' recall of events. There had been low prevalence of COVID-19 in China since April 2020, 5 months prior to data collection. Future research using other countries, where the COVD-19 pandemic still continues to affect daily life, is warranted. Finally, data gathered for key variables such as grit and ACEs relied on students' self-reports. Self-reporting leaves our data subject to unintended and intended reporting errors, including social desirability bias, particularly for data related to ACEs. Considering that ACEs relate to the respondent's home and filial relations, it is possible that respondents may avoid answering questions that reveal intimate details of family's life to preserve their own image as well as their family's image (Eriksson et al., This study is one of the first to examine how childhood experiences, specifically ACEs, may differentially predict grit during emerging adulthood. The results indicate that sexual abuse, emotional abuse, and neglect had significant negative associations with grit. Given that grit is particularly important to predict academic and professional success, as well as psychological well-being, those individuals who have experienced sexual and emotional victimization may experience challenges related to their education, career, and health. Our results suggest that interventions to buffer the negative effects of ACEs on grit are necessary. Mindfulness interventions have been found to improve self-esteem (Randal et al., The raw data supporting the conclusions of this article will be made available by the authors, without undue reservation.The studies involving human participants were reviewed and approved by Review Committee, School of Public Administration, Guangdong University of Foreign Studies. Written informed consent for participation was not required for this study in accordance with the national legislation and the institutional requirements.SC, C-CH, and CZ: conceptualization, validation, formal analysis, and writing—original draft preparation. SC and C-CH: methodology and software. C-CH and CZ: resources and investigation and data curation. All authors contributed to the article and approved the submitted version.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.


COVID-19 lockdown has significantly disrupted the higher education environment within the Netherlands and led to changes in available study-related resources and study demands of students. These changes in study resources and study demands, the uncertainty and confusion about educational activities, the developing fear and anxiety about the disease, and the implementation of the COVID-19 lockdown measures may have a significant impact on the mental health of students. As such, this study aimed to investigate the trajectory patterns, rate of change, and longitudinal associations between study resources–demands and mental health of 141 university students from the Netherlands before and during the COVID-19 lockdown. The present study employed a longitudinal design and a piecewise latent growth modeling strategy to investigate the changes in study resources and mental health over a 3 month period. The results showed that moderate levels of student resources significantly decreased before, followed by a substantial rate of increase during, lockdown. In contrast, study demands and mental health were reported to be moderate and stable throughout the study. Finally, the growth trajectories of study resources–demands and mental health were only associated before the lockdown procedures were implemented. Despite growing concerns relating to the negative psychological impact of COVID-19 on students, our study shows that the mental health during the initial COVID-19 lockdown remained relatively unchanged.The  The COVID-19 pandemic has resulted in a global health crisis . OfficiaCOVID-19 lockdown led to a significant disruption in all business sectors, where organizations were forced to close or radically change their modus operandi (study resources (SR), the increased study demands (SD), the uncertainty and confusion about educational activities, development of fear caused by the ever-increasing COVID-19 infection/mortality rates, and the implementation of lockdown procedures may have a significant impact on their mental health (MH)  .Given the radical changes in SR and SD and the potential MH problems associated with the COVID-19 lockdown, it is imperative to understand how such develops over time. It is important to investigate how Dutch university students’ perceptions of SR/SD and MH changed before and during the COVID-19 lockdown.emotional , psychological , and social well-being , which refers to more than just the absence of psychopathology. Traditionally, MH was described as a single-lane continuum with psychopathology at the one end and well-being on the other end of the spectrum energizing or motivational process. However, during pandemics, the experiences of SD and SR may be significantly different from those during “normal times,” given the radical changes in both the external environment and the educational modus . It is ta priori hypotheses could be formulated, except that the COVID-19 lockdown procedures adversely affected the trajectories of SR/SD and MH.As such, the present study aimed to investigate the trajectory patterns, rate of change, and longitudinal associations between SR/SD and MH of Dutch students before and during the COVID-19 lockdown. Given the novelty of the situation, no 1 Participants were enrolled for a master’s level course on research methodology at a Dutch university. Data collection occurred over a 3 month period during the third quartile of the academic year (January to April 2020) and involved the completion of a battery of electronic psychometric assessments weekly for 7 weeks, with a follow-up assessment 1 month later. Questionnaires were distributed electronically through QualtricsTM. Four weekly self-report assessments were conducted before the COVID-19 lockdown procedures were introduced. A fifth assessment took place during the week of lockdown announcements and university closures, which was followed by two weekly assessments directly after. The final assessment occurred 1 month after the seventh assessment.A longitudinal survey-based research design was employed to investigate the longitudinal trajectories and associations of SR/SD and MH within a sample of Dutch university students.Before the first assessment, participants were invited to participate in the study via email. Potential participants were informed of the voluntary nature of the study, and the research procedure was explained. In this email, their rights and responsibilities were highlighted and their confidentiality guaranteed, and they were informed that they could withdraw at any time. Participants were also informed that they may request feedback on their data and that upon request, their individual responses would be removed. Further, to ensure anonymity, participants were requested to create a personal identification code which was to be used to link the different data collection processes to each other after completion. To further ensure anonymity, two research partners not associated with the current university managed the distribution of the questionnaires and ensured that any and all potentially identifiable information of participants were removed from the dataset . A separate email account was also set up where participants could direct any questions or queries about the study or discuss any problems they may have encountered throughout the process. All guidelines for Ethical Research Practices by the American Psychological Association as well as local legislation were strictly followed.attention checks based on the guidelines of post hoc analysis of the response consistency, pattern of responses, and effort was evaluated as a function of the time it took to complete the assessments  server in compliance with the research institution’s data management policy and the General Data Protection Regulation .A census-based sampling strategy was employed to gather data from 174 master students studying at a university in the Netherlands. Data were screened for response quality , which lcf. The final sample consisted of 141 participants cf. . The majIn each wave, the mean scores of the following instruments were used as indicators of overall SR/SD and MH.Study Demands and Resources Scale , lecturer support , growth opportunities , and information availability (“Are you kept adequately up-to-date about issues within the course?”) as well as overall SD (“Do you have too much work to do?”). Participants were requested to reflect upon the preceding week and rate items on a 5-point Likert scale ranging from 1 (“Never”) to 5 (“Always”). The scale showed to be a reliable instrument across all eight time points in this study with Cronbach’s alpha ranging from 0.84 to 0.96.The es Scale  was usedMental Health Continuum Short-Form , a series of unconditional latent growth models (LGMs) were estimated to determine the starting point (intercept) and growth trajectories (slopes) of students’ SR, SD, and MH. Mean scores of SR, SD, and MH were created at each time point based on their respective factor scores. These were used as indicators for the LGM. Separate growth models, representing linear, quadratic, and piecewise growth trajectories, were estimated to determine which fitted the data best. For the piecewise LGM, two separate linear growth factors were estimated representing the slopes before (Times 1–4) and after (Times 5–8) COVID-19 lockdown measures were implemented. Time 1 was set as point 0 within the analyses. Time 5 represented the breakpoint/knot and indicated as point 4 in the analyses  = 37.04, p = 0.09, Tucker–Lewis index (TLI)/comparative fit index (CFI) = 0.99, root-mean-square error of approximation (RMSEA) = 0.05, standardized root mean square residual (SRMR) = 0.08], SD . Two phases of development for both factors were identified: Phase 1, which is prior to the lockdown procedures (Times 0–4), and Phase 2, which is during lockdown (Times 5–7). The interior knot was set at Time 5.Next, intercept-only, linear, quadratic, and piecewise unconditional LGMs were separately estimated for SR, SD, and MH. ISr = 3.529, SE = 0.04, p < 0.05), SD , and MH . At the start of the semester, students therefore reported above average levels of SR and MH as well as average levels of SD. The variances for all intercepts were significant, indicating interindividual variability. Individual growth trajectories significantly differed from one another around the estimated mean for both factors.Sr = −0.022, p < 0.05). During lockdown, it significantly increased by 0.012 base points every week . In contrast, both latent growth factors for SD  and MH were non-significant . SD and MH, therefore, remained relatively stable before and during the lockdown. The average trajectories for all three factors are graphically presented in Both mean growth factors  for SR were significant. This implies that prior to the COVID-19 lockdown procedures, SR decreased in a linear fashion  = −0.256, p < 0.05] as well as intercept and Slope 1 of SD  indicates that the rate of change in SR/SD was significantly negatively related to its initial levels. Those who reported high levels at baseline had a slightly faster rate of decline prior to the lockdown measures. Further, a significant covariance between Slope 1 and Slope 2 of SD  was found. This implies that the rate of change in SD before the lockdown was negatively associated with the rate of change after the lockdown.The significant covariance between the intercept and slope 1 of SR . At baseline, the initial state of SR (ISr) was positively associated with mean intercept of MH (IMh) . Higher initial levels of SR therefore influenced initial levels of MH. Further, the rate of change in SR (S1Sr) prior to the COVID-19 lockdown procedures predicted the rate of change in MH (S1Mh) in the same phase . This implies that if the rate of change in SR increased before the lockdown procedures, it would positively affect the rate of change in MH.The first sequential piecewise multi-process LGM, presented in ISr, S1Sr) = −0.25, SE = 0.09].Further, the covariance between the intercept and pre-lockdown slope of SR indicates that the rate of change in SR is dependent upon its initial position. Higher reported levels in SR is associated with a faster decline before lockdown . At baseline, the initial state of SD (ISd) was not significantly associated with mean intercept of MH (IMh) . Initial levels of SD therefore did not influence initial levels of MH. Further, the rate of change in SD (S1Sd) prior to the COVID-19 lockdown procedures was negatively associated with the rate of change in MH (S1Mh)  during the same phase. This implies that if the rate of change in SD increased before the lockdown procedures, it would negatively affect the rate of change in MH.The second sequential piecewise multi-process LGM, presented in Sd, S1Sd) = −0.35, SE = 0.10].The covariance between the intercept and pre-lockdown slope of SD indicates that the rate of change in SD is dependent upon its initial position. Higher reported levels of SD is associated with a faster decline before lockdown [Cov, SD was reported to decrease significantly after lockdown .No association between the intercepts and rate of change in SD post-lockdown and between the intercepts and slopes of MH could be established. After lockdown, both SD and MH changed at different rates and in different directions. Where MH stayed relatively stable before and after lockdown (IThe study employed piecewise LGM to investigate the developmental trajectories and longitudinal association of students’ SR, SD, and MH before and during the COVID-19 lockdown at a Dutch university in the Netherlands. The results showed that moderate levels of SR significantly decreased before, followed by a substantial rate of increase during, the lockdown. In contrast, both SD and MH were reported to be moderate and stable throughout the study. Finally, the growth trajectories of SR and MH were associated only before the lockdown.study-related resources significantly decreased before and increased during the lockdown. Perceptions of available study-related resources are known to fluctuate throughout a semester/course (cf.The results showed that r/course . At the r/course . As SD (r/course . Furtherr/course . In turnr/course . This raurse cf.. The COVurse cf.. Howeverstudy-related demands were relatively stable both before and during the COVID-19 lockdown. No statistically significant changes in these perceptions were reported; however, a slight increase was observed before lockdown and a slight decrease after lockdown. This implies that students did not perceive a difference in study load, time pressure, or study volatility throughout the quartile. This contrasts with the findings of cf. Further, perceptions of Finally, the results showed that MH stayed relatively stable throughout the first weeks of the COVID-19 outbreak, which differs from other studies during pandemics. Where others found pandemics like SARS to have precipitated psychological distress , our resWithin this sample, the growth trajectories of study-related resources and MH were shown to be associated only before lockdown procedures. The average level of study-related resources at baseline was significantly related to the initial state of MH. When students perceive that they have adequate levels of study-related resources at the beginning of the course, it may positively affect the initial levels of their MH . SimilarFurther, only the growth trajectories of SD were associated with those of MH before lockdown procedures were implemented. No other direct associations could be established. This implies that when SD increased before the lockdown, it negatively affected MH changes . HoweverDespite the novelty of this study, it does present with several limitations. First, given that the COVID-19 lockdown was unexpected and occurred during the study, no pandemic-specific explanatory mechanisms which could have affected the growth trajectories could be measured/controlled. However, the study shows how perceptions of SD, SR, and MH changed from before to during the COVID-19 lockdown. Second, participants in this study originated from a single cohort of students from a university in the Netherlands that comprised mainly males. This limits the generalizability of the findings outside of the given context. Given that the assessments of this study occurred before and during the first COVID-19 lockdown, it would not be possible to collect additional data from other institutions to enhance generalizability. The results may look different for academic institutions in under-resourced institutions. Third, the direction of the effects from SR to MH is based on literature, and analyzing the reciprocal relationships was beyond the scope of this paper. Finally, the paper focused on modeling group-level changes and did not include specific inter-individual differences.The findings, design, and context of this study also provide a foundation for future research. First, it would be valuable to determine students’ experiences of the lockdown and its impact on MH through focus groups or individual interviews. Second, it is suggested that the “during the pandemic” component of the study be replicated in other European countries and that such be contrasted with more developing countries. Third, an evaluation of the usefulness or effectiveness of newly introduced teaching methods and approaches during the pandemic would be valuable. Finally, it is suggested that future research focus on developing and evaluating educational interventions to enhance students’ MH during the pandemic.Despite growing concerns relating to the negative psychological impact of COVID-19 on students, our study shows that no changes in MH were reported during the first lockdown. The university’s measures to manage the impact of the lockdown procedures increased perceptions as to the available study-related resources; but none of the measures or online education processes increased demands. Our study, albeit limited in scope, shows that society’s concern as to the adverse effects of COVID-19 on MH of students may be ill founded in some situations.The raw data supporting the conclusions of this article will be made available by the authors, without undue reservation.Ethical review and approval was not required for the study on human participants in accordance with the local legislation and institutional requirements. The patients/participants provided their written informed consent to participate in this study. All ethical guidelines proposed by the APA and the Helsinki Convention were strictly adhered to.All authors listed have made a substantial, direct and intellectual contribution to the work, and approved it for publication.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. The reviewer ES declared a shared affiliation with several of the authors, LZ, SR, to the handling Editor at time of review.