Hair cortisol concentration (HCC), as a novel promising method to retrospectively measure hypothalamic-pituitary-adrenal (HPA) axis activation, is being increasingly studied. We tested the relationships between HCC and a range of possible confounding variables in a Spanish sample of healthy adults and pregnant women.The number of healthy adults who participated in the study was 529, being 270 males and 259 females, with a combined mean age of 37.88 years (SD = 15.66). Additionally, a separate sample of 62 pregnant women was also recruited with a mean age of 32.95 (SD = 3.67), and in the first trimester of pregnancy. Each participant was interviewed before the study to obtain sociodemographic and lifestyle variables, and a hair sample was taken from the posterior vertex of the head, cut as close to the scalp as possible. Assuming the average growth rate of head hair is 1 cm per month, a 3-cm segment was analysed, in order to measure the cortisol concentrations from a three-month period. For the pregnant women, hair samples for each trimester of pregnancy were analysed.The mean hair cortisol concentration was 127.91 (111.52) pg/mg for the general sample. The variables of age, education, employment status, use of hair dyes, use of oral contraceptives, and physical exercise had a significant relation to HCC. When adjusted for further variables, only education and physical exercise remained statistically significant. When including the use of oral contraceptives and only with respect to females, only physical exercise remains statistically significant. For the subsample of pregnant woman, the mean hair cortisol concentration was 334.51 (409.77) pg/mg for the first trimester, 302.18 (270.24) pg/mg for the second trimester, and 331.31 (295.46) pg/mg for the third trimester of pregnancy. None of the assessed confounding variables , except education level, was related to HCC.In this sample of healthy Spaniards, results suggested an association between HCC and physical exercise and educational level. In pregnant women, the prevalence of HCC was higher than in non-pregnant woman, and was related to educational level. This study emphasises the need to determine the relationship between HCC and confounders such as sociodemographic and lifestyle variables in the general population and specific groups formed by individuals such as pregnant women. Cortisol is a steroid hormone, or more specifically, a glucocorticoid that is secreted by the adrenal glands. Cortisol affects many bodily systems and plays an important role in bone growth, arterial pressure regulation, immune and nervous system functions, fat, carbohydrate and protein metabolism and, more specifically, in the response to stress . In partTwo mechanisms activate the stress response: the sympathetic adrenomedullary system, which secretes catecholamines to induce a rapid response of the cardiovascular system; and the hypothalamic-pituitary-adrenal (HPA) axis. The HPA axis is activated through the secretion of corticotropin-releasing hormone (CRH) by the hypothalamus, which stimulates the pituitary to secrete adrenocorticotropic hormone (ACTH). The ACTH is then transported in the blood to the adrenal cortex, which triggers the secretion of glucocorticoids . One of Due to these limitations, researchers have been seeking alternatives that allow for a non-invasive and retrospective assessment of cortisol. In recent years, a new method has been developed for measuring cortisol in humans and animals by extracting cortisol from hair. For years, hair has been used as a substrate for measuring environmental agents, drugs or toxins and even for retrospectively measuring steroid hormones , 10, incMacaca mulatta) [To date, many studies have applied this method as a biomarker for chronic stress. Since the development and validation of the technique in rhesus macaques (mulatta) , hair comulatta) , 16 thatmulatta) ; studiesmulatta) , 17, stumulatta) , 19, andmulatta) , and othmulatta)  and Addimulatta) . Moreovemulatta) . In partmulatta) . In pregmulatta) . Furthermulatta) . The mosTo clarify the effect of possible confounders is relevant for the validity of the HCC methodology. Studies on some of the confounders of HCC are reviewed by Wosu  who findThere is a need for research on possible confounders of HCC levels, as well as the possible relation of HCC with a wide range of psychological, sociodemographic and lifestyle variables. Furthermore, it is not clear whether HCC and its relationship with these variables vary along different populations or cultures. To our knowledge, there are no previous studies on HCC using a broad sample from the Spanish population. Therefore, the objective of this research was to study HCC in a sample of healthy Spaniards, to investigate possible confounders of HCC, as well as to study HCC in a sample of pregnant woman.A sample of healthy Spanish adults, 537 in number, who were primarily from Granada, Jaen, Almeria and Alicante (Spain), participated in this study. The invitation to take part in the study was sent by e-mail and advertisements posted on the notice boards at different public centers. In Granada, participants were recruited at the University (15.3%), employment offices (8.5%), civic centres (9.8%), and day care centres (4%). In Jaen, participants were recruited at the University (10.4%) and civic centres (12.1%). In Almeria, participants were recruited at the University (7%), civic centres (7.8%), and day care centres (2.3%). In Alicante, participants were recruited at the University (15.1%) and civic centres (7.8%). Additionally, a sample of 62 pregnant woman were also recruited when attending at prenatal appointments in 3 public health centres in Granada and Almeria, and in a general hospital in Almeria. Having any physical or physiological illness, using of glucocorticoids or medication known to alter glucocorticoids metabolism and psychiatric disease and being pregnant for women in the general sample were used as exclusion criteria.After having removed outliers in the cortisol levels, the general sample consisted of 270 males 51%) and 259 females (49%), making a total of 529 participants with a mean age of 37.98 years (SD = 15.66). The separate sample of pregnant women consisted of 62 participants with a mean age of 32.95 (SD = 3.67). The sociodemographic and lifestyle variables are shown in Tables % and 259The Human Studies Ethics Committee at the University of Granada (Spain) gave approval for this study, which was in accordance with the American Psychological Association’s (APA) Ethical Principles of Psychologists and Code of Conduct , 29. TheAge and sex were recorded. Relationship status was categorised as “partner” vs. “single”. The former category included “in a relationship”, “married”, “separated or divorced”, and “widowed” people. The variable dependent children was asked as having one or more children cohabiting and depending economically on the person. Indicators of socioeconomic status included educational attainment and employment status. Educational attainment was divided into “primary school or less”, “secondary school”, “vocational education” and “higher education”. Employment status was divided into “student”, “employed”, “unemployed” and “retired”. In relation to lifestyle measures, physical exercise was framed as “regular physical exercise” vs. “non-regular physical exercise”, as well as consumption of drugs and use of hormonal contraceptives (but not in the pregnant women group). Additionally, the use of hair dyes was registered. Pregnant women were also asked about previous miscarriages, type of conception, and body mass index (BMI).The hair samples consisted of locks of approximately 150 strands of hair taken from the posterior vertex, cut as closely to the scalp as possible. Each sample was then wrapped in aluminium foil to protect it from light and humidity, and stored in an envelope at room temperature. Later, the samples were analysed in the Department of Pharmacology at the University of Granada, Spain.°C for later analysis [In our study, we collected 3-cm long hair samples to measure HCC from a 3-month period (assuming an average growth rate of 1 cm per month). After collection, the samples were first washed twice in isopropanol, to remove any cortisol from the outside of the hair shaft that had been deposited from sweat or sebum. After drying, the samples were weighed and ground to a fine powder using a ball mill  to break up the hair's protein matrix and to increase the surface area for extraction. Cortisol from the interior of the hair shaft was extracted into HPLC-grade methanol by incubation of the sample for 72 hours at room temperature in the dark, with constant inversion using a rotator. After incubation, the samples were centrifuged and the supernatant was evaporated until completely dry using a vacuum evaporator . This extract was then reconstituted in 150 uL of phosphate buffered saline (PBS) at pH 8.0. The reconstituted sample was immediately frozen at -20 analysis , 31, 32.The intra-assay variation precision was analysed on three hair samples, which were assayed eight times on the same calibrator curve. The intra-assay coefficients of variance were 5.3% at 2.6 ug/dl, 5.4% at 3.3 ug/dl, and 12.4% at 4.4 ug/dl, respectively. For inter-assay precision three hair samples were analysed on eight separate runs and the coefficients of variance were 13.7% at 2.2 ug/dl, 1% at 3.3 ug/dl, and 10.2% at 4.2 ug/dl, respectively.The study was organised into two phases. First, all the participants were informed of the study’s objective and the procedure to be followed, before signing the informed consent form. Then, the participants completed the semi-structured interview questionnaire and provided their personal information.In the second phase, a hair sample was cut from the posterior vertex of the participant’s head. For the general sample, hair was collected in one action, while for the pregnant women, subsample hair was collected in three separate actions over time: at the first trimester , the second trimester , and the third trimester . On average, the entire procedure took approximately twenty minutes in the first collection and five minutes in the second and third collection for pregnant women.t-test and univariate ANOVAs with a Bonferroni post-hoc test. For the subsample of pregnant women mixed 2 × 3 analysis of ANOVAs were conducted to check for statistically significant differences between groups, in accordance with each sociodemographic variable. The first factor includes two levels between the independent groups for each sociodemographic variable . The second factor involved repeated-measures within-subjects factors during three trimesters: 1st trimester HCC; 2nd trimester HCC; 3rd trimester HCC. The Greenhouse-Geisser correction was applied in the repeated-measures analyses. When a significant Group x Sampling Time interaction was found, Bonferroni analysis was conducted to determine the trimesters where there were differences between trimesters. Additionally, for all of the confounders with significant effect, effect size was calculated: r2 for normally distributed variables, Cohen’s d and eta-squared for categorical variables. Effect sizes of 0.20 were considered as small, around 0.50 were considered as medium and around 0.80 were considered as large for Cohen’s d. For r2 and eta-squared values of 0.02, 0.13 and 0.25 were considered as small, medium and large respectively [All data were explored and HCC outliers of more than three standard deviations (SD) were excluded   of HCC entered simultaneously. This allowed for mutual adjustment and, as such, enabled us to identify the most relevant confounders of HCC. The statistical significance level was set at alpha = .05. Additionally, percentiles were calculated for the general sample HCC by using the Weighted Average method. Statistical analyses were performed using SPSS 23.0 .Finally, a multiple linear regression was run, with all relevant confounders (defined as SD = 15.66), with a broad age range from 18 to 93 years, and the same proportion of males and females , range: 25–41 years see . Most ofr2 = .03), see t-test show statistically significant differences for the use of contraceptives, hair dyes and regular physical exercise; with higher levels of HCC for participants with natural hair, females using contraceptives, and participants who practiced regular physical exercise. Cohen’s d showed a low effect size for hair dyes (d = .25) and physical exercise (d = .11) and a medium effect size for the use of contraceptives (d = .45).For the general sample, as can be seen in p = .01) with an effect size of .68 (Cohen’s d), but not in the second (p = .08) and third trimesters (p = .37). Pregnant women with a secondary level of education showed higher levels of HCC than pregnant women with university studies. Means and standard deviations are presented in For the subsample of pregnant women, bivariate Pearson correlations showed no significant relation between HCC during the three trimesters and age and BMI. The mixed 2 × 3 ANOVA analysis with repeated measures shows interaction only between groups of participants with a secondary education level, and participants with a university level education. Bonferroni analysis showed significant differences in the first trimester of pregnancy (r2). For females, when introducing the use of contraceptives along with the other variables, only regular physical exercise remains a predictor of HCC. The regression analysis for regular physical exercise resulted in an explained variance of the regression model of .01 (adjusted r2).All previously identified confounders with a significant effect on HCC  were entered simultaneously into one regression model. Use of contraceptives, valid only for females, was included in a regression analysis, along with the rest of the variables and run only for female participants. Bivariate Pearson correlation and Spearman correlation below .80 indicated no collinearity between variables . Only edConsidering the large sample from the Spanish population of the present study, we have elaborate percentiles in order to show the data distribution of HCC. Results did not show strong relations between HCC and any of the sociodemographic or lifestyle variables, hence percentiles were elaborated with no grouping. Percentiles were calculated using the Weighted Average method and are shown in In recent years, the measurement of HCC has been on the rise, because of its significance in evaluating chronic stress and other associated disorders, such as depression or post-traumatic stress. Furthermore, HCC is useful for evaluating disorders that entail inadequate HPA response, such as Cushing’s disease, Addison’s disease, or various autoimmune diseases. As this method becomes increasingly more prevalent, a deeper understanding about its relationship with other confounder variables is needed, as well as, information about HCC in different groups and populations. Therefore, the objective of this research was to study HCC in a sample of healthy Spaniards, to research on possible confounders of HCC, as well as to study HCC in a sample of pregnant woman. Results have shown a significant relation between HCC and age, education, employment status, physical exercise, and use of hair dyes and contraceptives. However, in the adjusted model, only education and physical exercised remained as predictors. Pregnant women showed higher levels of HCC than non-pregnant women during the three trimesters of pregnancy, and their HCC was related to education level in the first trimester.The effect of age has been studied in several studies, finding different relations with varying hair cortisol levels. According to the meta-analysis of Stalder , age wasIn relation to the sex of the participants, our results show no statistical differences between women and men. In accordance with this, previous investigations reveal no sex differences in hair cortisol levels , 37, whiIn the review by Wosu , vigorouHPA activation during pregnancy has a relevant effect in perinatal outcomes, furthermore, pregnancy is related to a natural increase of HCC levels. Previous works have shown an increase of HCC during pregnancy , 45, whiSome limitations of the present study are noted here. First, young participants with a high educational level are over-represented. Consideration of having any illness as an exclusion criteria, permitted us to exclude the confounder effect of many health problems, but also to reduce the number of possible participants in older ages. Moreover, while there are controversial results related to the gender of the sample and its relation with HCC, to our knowledge, there are no investigations setting differences in HCC across different levels of education or employment status by using a sample with a wide range of ages. In relation to education, only Boesch  finds siDespite the limitations, to our knowledge, this is the first instance of a research with a large sample and a wide age range from the general population of Spain, in studying HPA activation via HCC means and its relation with sociodemographic variables, as well as using a sample of pregnant women. Considering hair cortisol as an important factor that is associated with endocrine functioning, as well as with a health risk for the general population, and specially during pregnancy, such a biomarker would also potentially help facilitate the earlier detection of individuals who are most at risk for deleterious health outcomes, and help to develop preventive methods to mitigate stress. Additionally, normative scores will help to better understand conditions associated with HPA functioning, such as Cushing syndrome, depression, or Post-traumatic stress disorder (PTSD) , 50.Research using the HCC methodology is still in its early stages. Therefore, the body of evidence is still little or non-existent and also it is inconclusive. In our sample of healthy Spaniards, HCC decreases with age. We also find an interaction with educational level, employment status, use of contraceptives, use of hair dyes, and physical exercise. In our sample of pregnant women, we find higher levels of HCC than in non-pregnant women during the three trimesters of pregnancy. Only during the first trimester did we find a relation with education level. This study emphasises the need to determine the relationship between HCC and confounders such as sociodemographic and lifestyle variables in the general population and specific groups formed by individuals such as pregnant women. HCC has the potential of becoming a valuable tool in diagnosing and controlling the progression of HPA diseases and conditions which have an effect on HPA functioning. Further research is needed to clarify the value of HPA in clinical practice and research, and also in order to improve the methodology, its application and the interpretation the research results.


The work aimed at studying the serological and clinical factors, as well as the risk factors of the Newcastle disease (ND) on broilers herds in Algeria.A sample of 1248 birds was randomly selected from 52 broiler flocks. We took blood samples from each bird at the level of the wing vein area where an indirect enzyme-linked immunosorbent assay technique was carried out through the use of an IDvet kit.The flocks showed 82.69% of seroprevalence. Clinically speaking, the most common symptoms were sneezing, rale, greenish diarrhea, torticollis, and motor discords. Most commonly observed postmortem lesions were the proventriculitis, tracheitis, and enteritis. Especially, the caeca are hemorrhagic. The scores show the effect of risk factors. There was a significant effect on the mortality, the hygiene and vaccination groups on antibody titers in time 2. The antibody titers were elevated in the herd that recorded a high mortality (more than 10%) compared with those which recorded a low mortality (<10%) (p=0.002). Therefore, the antibody titers were elevated in herds with bad hygiene, compared with the ones with good hygiene (p=0.04). At last, when broiler chicken were not boosted by ND vaccine, flocks appeared to be more seropositive (p=0.02).The serological survey conducted in this study provided an important scope for ND as a dominant viral disease in broilers. Many factors are responsible for the onset of these diseases; correct biosecurity measures are needed to reduce the impact of this pathology in poultry farms. The Newcastle disease (ND) is the most economically important disease in poultry, due to the high rate of morbidity, mortality, slaughter, and associated sanitary measures in poultry farms, particularly in developing countries . ND is cVarious diagnostic methods, as the enzyme-linked immunosorbent assay (ELISA), have frequently been used all over the world to detect viruses from the field samples ,6. CliniTherefore, the present study was undertaken to find out a relationship between the disease diagnostic parameters. Clinical signs, postmortem lesions, and serological tests for the diagnosis of the ND in broilers flocks, to assess the risk factors, were associated with the disease in the affected farms.Experimental procedures were approved by the Institutional Committee for the Protection of Animals of the National Administration of Higher Education and Scientific Research of Algeria .The experiment was carried out at commercial farms in the central-east and west of Northern Algeria (longitude 36° and latitude 3°). From July 2016 to December 2017, on 52 broiler flocks with different strains  aged between 4 and 7 weeks and contained 5000-10,000 birds/farm. The studied flocks were initially vaccinated for ND with live vaccines through different protocols .For both protocol 1 and 3, the primo-vaccination and booster ; the vaccine was bivalent against the Newcastle and infectious bronchitis (IB) diseases. The strains were MA5+ Clone 30. For Infectious Bursal disease, vaccines in the protocol (1), the strain was E228 Intermediate+. In the protocol (3), the strains D78 intermediate was used for primo-vaccination, and for the recall, the strain was E228 Intermediate+.Concerning protocol 2, the primo-vaccination was bivalent against the Newcastle and the IB diseases. The strains were MA5+ Clone 30; for the booster , it was the strain Villegas–Glisson/University of Georgia (VG/GA) for ND and variant strain IB 4-91 for IB. For infectious bursal disease vaccine strain was E228 Intermediate+. The two strains used against the ND in this study, Clone30 and VG/GA strains were classified as lentogenic.The analyzed flocks were suspected of acquiring a viral disease (ND) after showing the characteristic, clinical, and necropsy signs.st day after the appearance of the first clinical signs. The second one was done 2-3 weeks time interval, to put in fact the antibodies kinetics in the sera.A sample of 1,248 birds were randomly selected from 52 broiler flocks (10-15 samples/flock). According to our protocol, two samples were taken from each farm. The first was performed the 1Blood samples were collected from the wing vein, in dry tubes and centrifuged (5000 rpm for 10 min) at the same day to recover the sera that were stored in test tubes “Eppendorf,” and frozen at −20°C until analysis.The clinical diagnosis was based on a clinical history from the responsible persons of the farms, including veterinarians in charge of monitoring, recording clinical signs, and gross lesions, which were pathognomonic of the ND on affected chickens through autopsy.® NDV Indirect. The sera were diluted to 1/500th and then loaded to ELISA plates to start an immunosorbent reaction as guided by the manufacturer’s manuals. ELx800 spectrophotometer  equipped with the 450-nm filter where the measured optical density was transformed into titrated antibody read ELISA plates. The averages of the titers and the coefficient of variation (CV) were automatically calculated by the band and by series of samples, with the software provided by the laboratory .An indirect ELISA technique was carried out through the use of IDvet Innovative Diagnostics kits : ID ScreenTo interpret the ELISA results, the following parameters were taken: The presence of clinical signs and postmortem lesion during the autopsy, the antibodies kinetics; titers between the first and the second sampling. Moreover, mainly according to the Interpreting Poultry Baselines provided by the manufacturer of IDvet ELISA kits: According to the baselines of IDvet, the expected average antibodies titers after the use of one live vaccine, vary from 1000 to 3000 after 3-5 weeks after vaccination. The expected average antibodies titers after the use of two live vaccines, varied from 1000 to 4000 after 3-5 weeks after vaccination. Below the threshold of 1000, it means that there is a poor or no vaccination intake or an immunodepressive disease, and above 3000 for a single live vaccine and 4000 for two live vaccines with a tight CV means that there is a viral passage.A standardized survey was used to assess the risk factors associated with the mortality previously observed. The survey covered the following parameters: Flock characteristics, strain, hygiene, vaccination programs, mortality and morbidity rates, age of occurrence, clinical and necropsy lesions, stocking density, season, area, and climate.ijkY = µ+iG+kT+ikGT+ijkɛ. Where, ijkY=Antibody titer, μ=overall mean, iG=effect of group, kT=effect of time of sampling (k=1 and 2), ikGT=effect of group × time, and ijkɛ=random residual error. Stacked line plots of antibody titer changes were generated using Prism 5.01 .First, descriptive statistics were used to characterize the flocks according to the different factors. Thus, statistical analysis was performed with SAS . Before fitting statistical analysis, the examination of the distributions of the antibody titers indicated that using  could not be considered normally distributed. Through time, the antibody titers of the disease were analyzed by fitting the fixed effects of the day. The group and the interaction of the day*group in a repeated measure variance analysis using PROC MIXED models with the random effect of the herd (SAS Inst. Inc. 9.1). Covariance structure used (compound symmetry or autoregressive [AR1]) was chosen and was based on the Akaike information criterion. The layout of our model was as follows: In some flocks, we had observed vaccine failure, the titers of the antibodies after the vaccination do not even reach the minimum expected protective threshold. For the remaining 17.31% of the cases, the average titers of the antibodies were in the expected norms of the baselines provided by IDvet; there were no clinical signs or lesions that evoke the ND.Clinically speaking, the most common signs and lesions of the ND  were resThus, using the necropsy and clinical signs to detect the disease, we observed a very high specificity (85%). In other words, all the birds suspected of having ND had specific antibodies. However, the sensitivities were 75.0%, so for this disease, necropsy, and clinical diagnosis were particularly reliable .Therefore, the antibody titers were elevated in the herds with bad hygiene compared with the ones with good hygiene (p=0.04) . At lastet al. [Our serological scores showed that the farms chosen as samples had a seropositivity rate of 82.7% for ND. For this mentioned disease, a low CV (CV= 31%-44%) has been shown as well as a difference (p<0.0001) in antibody titer between the first and the second samples . For that reason, an immune status in response to the viral diseases was estimated by measuring the serological response objectified by detection of specific antibodies, previously produced either in response to an infection or following vaccination, on the one hand [et al. . Our samClinical and necropsic manifestations of affected birds can help to diagnose a disease, but laboratory diagnosis is needed to confirm it . Howeveret al. [et al. [et al. [et al. [et al. [Clinically speaking, the most common signs in our farms were respiratory , digestive (greenish diarrhea), nervous signs (torticollis and motor discords), and death. Clinical signs seen on affected farms are similar to the observations of Yune and Abdela , Banerjeet al. , and Broet al. . The moset al. , De Oliv [et al. , Brown a [et al. , Brar et [et al. , Crespo  [et al. , and Tal [et al. .et al. [et al. [et al. [As far as factors affecting ND are concerned, there was a significant effect of mortality, hygiene, and protocol of vaccination groups on antibody titers in time 2. The antibody titers were elevated in the flock that recorded high mortality (>10%) compared with those which recorded a low mortality (<10%) (p=0.002). Therefore, the antibody titers were elevated in the flocks with bad hygiene compared with those with good hygiene (p=0.04). At last, when broiler chicken was not boosted by ND vaccine, flocks appeared to be more seropositive (p=0.02). Regarding mortality, ND has been a very serious problem for poultry production in many countries. The disease causes high economic losses due to the high rate of morbidity and mortality . The ND et al. , Mayers  [et al. , and Ora [et al.  had repoet al. [Incidence of ND in vaccinated flocks may be due to inadequate vaccination practices or biosecurity flaws, as signaled by Dortmans et al. . In our et al. [et al. [Alsahami et al.  and Bulb [et al.  reported [et al.  reported [et al.  had repoThis serological study conducted in this assay had provided an important scope about ND as a dominant viral disease on the broiler chickens and had found that the majority of the broiler flocks were seropositive. Clinical manifestations and postmortem findings of the affected birds may assist in diagnosing a disease. However, a laboratory diagnosis is necessary for the confirmation of the disease. However, the findings also suggest that the risk factors related to poor biosecurity measures, inadequate vaccination program, and farm practices appear to have a significant role in the severity of the disease already observed in the affected farms. If those factors were alleviated, the severity of the ND problems in farms would greatly reduce. Further investigations are recommended to identify the circulating virus genotypes and models of transmission for a better understanding of ND epidemiology in the broilers flocks in Algeria.CRM, OS, DK, AL, AM, RK, and KA designed the study. CRM and OS wrote the manuscript and collected data. OS and AL diagnosed the disease and collected the samples. CRM, OS, and AM carried out the laboratory work. OS performed statistical analysis. CRM, OS, DK, and AL analyzed the data. CRM, OS, and AL reviewed the manuscript. All authors read and approved the final manuscript.


Around 90% of all fatal and non-fatal unintentional injuries occur in low- and middle-income countries (LMICs). The magnitude of unintentional injuries is unclear due to limited research and data. This paper describes the burden of lesser-known injuries  in rural Bangladesh, using data from the Saving of Lives from Drowning (SoLiD) project in Bangladesh. Descriptive statistics were used to report counts and rates of injuries by socio-demographic factors, injury characteristics, and circumstantial details. The annual morbidity rate of LKIs was 6878 injuries per 100,000 persons, involving 3.4%  of the population. Cut injury  and injury by blunt objects  attributed in large numbers to the overall burden of LKIs. Males (66.1%) suffered more injuries than females. More than half (52.9%) occurred among people aged 25 to 64 years. Those involved in agriculture suffered the most injuries, mainly cut injuries  and machine-related injuries . Most injuries occurred in the home setting. Increased awareness about packaging, storage, and the proper handling of appliances can help lower the frequency of LKIs. Safe architecture and awareness about home injuries is required to reduce injuries occurring in the home environment. There has been a rise in the rate of unintentional injuries globally, claiming more than 25.62 lives per 100,000 people in 2017 alone . AdditioLesser-known injuries impose a heavy burden. Industrialization and lack of awareness towards easily accessible household supplies contributed to about 86,400 deaths globally in 2015 in the form of unintentional poisoning .Bangladesh is no exception to the shifting paradigm of urbanization and rapid development. In 2017 alone, lesser-known unintentional injuries, namely poisoning, suffocation, cut injuries, and electrocution, led to a vast number of deaths and morbidities in Bangladesh ,9.The aim of this paper is to describe the socio-demographic characteristics and injury characteristics of non-fatal cut injuries, unintentional poisoning, machine injuries, electrocution, injury by blunt objects, and suffocation, using data from a census covering approximately 1.18 million people in seven rural sub-districts of Bangladesh. The data used for this analysis was collected as part of the Saving of Lives from Drowning (SoLiD) project in Bangladesh across 51 unions from seven sub-districts of the country in 2013. The SoLiD project was rolled out with the main objective of evaluating the large-scale effectiveness and cost effectiveness of two drowning prevention interventions in reducing drowning deaths in children under five years of age . The SoLA baseline census with a total population of approximately 1.18 million respondents from all households in 51 unions was conducted in 2013. The data included information on the socio-demographic and injury-related characteristics of all included individuals. Fatal and non-fatal injury events were recorded with a recall period of one year and six months, respectively. For the purposes of this study, an injury event was defined when a person sought treatment or had to miss one work or school day due to the injury [The data collection included two rounds of interviews—the first round collected socio-demographic information as well as the occurrence of an injury, the second round focused only on those households that reported an injury event within the follow-up period. The second round of interviews involved the use of injury modules , disaggregated by socio-demographic characteristics such as sex, age, education, occupation, marital status, and sub-district. Since non-fatal events were recorded over a period of six months, the rates of non-fatal events were annualized by doubling the rates for six months with the assumption that the injury rates were constant throughout the year. Sex was coded as a binary variable and age was categorized into eight groups. Education, occupation, and marital status were categorized as nominal categorical variables with seven, nine, and six categories, respectively. The circumstances of each injury type were described in detail. Stata 15.1 I/C package was used for all statistical analyses . ApprovaOur study population was comprised of 51.5% females . Around A total of 26,311 (22.1%) people suffered from cut injuries in the study population with a morbidity rate of 4466.1/100,000/year. The morbidity rate of cut injuries was significantly higher for males ) than for females ) . People The object that caused the most cut injuries was a “boti/da” (37.9%). A boti is a sharp cutting instrument with a long blade that cuts on a platform held down by the foot. A boti/da is used for cutting fruits, vegetables, meat, etc. in rural households and is regularly used during cooking. Other objects such as a sickle, broken glass, scissors, and a knife were also associated with cut injuries. In 65.3% of cases, the injured person was working with the sharp instrument when the injury occurred . n = 45; 51.7%) had a slightly higher number of occurrences of unintentional poisoning than males  (n = 2), rodenticides (n = 8), sleeping pills (n = 3), and soap and detergent (n = 10). More than 80% of poisonings occurred in the home environment  . People ironment . A bottln = 374; 29.0%) compared to people in other occupations. The highest number of machine injuries occurred in people who had primary level education . Married people had the highest occurrences of machine injuries   and 50.9/100,000/year (95% CI: 43.5–59.6) for males and females, respectively. Skilled professionals had more non-fatal machine injuries  . Machinen = 259; 30.3%), those with primary level education , and among those who were married   than in females . High numbers of electrocutions were seen in retired and unemployed people  . The soun = 4398; 37.3%) followed by construction sites . As seen with other injuries, injuries by blunt objects were also more common in males  than in females . Unskilled and domestic workers , people with no formal education , and married people  had more injuries by blunt objects than others . Fixed bn = 70; 36.5%), retired/unemployed , and married people  had more suffocation injuries than others. Retired/unemployed persons suffered more from suffocation injuries  than in males . Individuals with primary education  occurred in the home environment and surrounding areas.In this study, men suffered more unintentional injuries than women. A study that used the Global Burden of Disease data, along with reports from World Health Organization, United Nations Children’s Fund, and the World Bank, also found similar differences of the burden of injuries shared by men and women . In ruraUnintentional poisoning was highest in children under five years of age, as has been seen in other LMIC contexts . PreviouAgricultural machines were shown to contribute more to machine-related injuries in our study as well as in studies from India ,22. StudIn this study, electrocution, like other injuries, occurred more commonly among men compared to women, and mostly at home. Males are more likely to get involved in fixing broken or interrupted electric cables and other appliances that put them at a higher risk of electrocution . ChildreReviewing the gap in the literature about consistent and evidence-based interventions for managing such injuries, it would be safe to at least suggest awareness and education programs for communities to improve their literacy about these less common injuries and methods to reduce and manage injuries. To raise awareness and promote safety for the prevention of injuries, a study in China, via government funding, introduced the concept of “Safe Communities”—a platform for high-risk and vulnerable groups as well as others across age and gender in the community to engage and promote injury safety literacy . Local gExisting literature gives information about the prevention of road traffic injuries, drowning, falls, burns, etc. and about several policies established to prevent such injuries, such as swimming pool fencing, seatbelt use, window bars to prevent falls, and the use of smoke-detectors, respectively, for example . HoweverThere are some limitations to the study. As a six-month recall period was used for collecting data on non-fatal injuries, recall bias may be present in our data. As the prevalence of deaths from the six injuries was very low, we focused only on non-fatal injury events, thereby underreporting the true burden of unintentional injuries in rural Bangladesh. Additionally, data were collected only from rural Bangladesh, thus results may not be generalizable to urban Bangladesh as risk factors and lifestyles vary. Additionally, the specific injuries need to be studied in more detail to understand their implications and develop targeted interventions to reduce their respective burden. The purpose of this study was to provide urgently needed insights into the burden of lesser-known injuries, which attribute to a significant number of morbidities. It is evident that these injuries are a common occurrence in the households of rural Bangladesh. Education and awareness programs to make safer homes can tackle the burden of these injuries. Further studies are needed to investigate the short-term and long-term implications of such injuries on lives and livelihoods in rural Bangladesh. Based on the study results and identified gaps in data, we propose developing a multidisciplinary intervention package to raise awareness and improve safety measures to confront the burden of lesser-known injuries, and integrating injury prevention programs in existing national surveillance platforms.


Prostate cancer is a male malignant tumor disease with high prevalence in recent years. Patients with advanced prostate cancer are more likely to have bone metastasis and have strong bone pain, and even lead to pathological fracture, which has a serious impact on the quality of life of patients. Traditional Chinese medicine has good clinical efficacy in treating pain caused by prostate cancer .This review hopes to adopt meta-analysis to evaluate the efficacy and safety of TCM in the treatment of pain caused by prostate cancer and provide evidence for its application in clinical practice.We will search for PubMed, Cochrane Library, AMED, EMbase, WorldSciNet; Nature, Science online and China Journal Full-text Database (CNKI), China Biomedical Literature CD-ROM Database (CBM), and related randomized controlled trials included in the China Resources Database. The time is limited from the construction of the library to June 2019.We will use the criteria provided by Cochrane 5.1.0 for quality assessment and risk assessment of the included studies, and use the Revman 5.3 and Stata13.0 software for meta-analysis of the effectiveness, recurrence rate, and symptom scores of pain caused by prostate cancer.This systematic review will evaluate the efficacy and safety of TCM for pain caused by prostate cancer. Because all of the data used in this systematic review and meta-analysis has been published, this review does not require ethical approval. Furthermore, all data will be analyzed anonymously during the review process Trial.PROSPERO CRD42019131544 The secretion of prostaglandin could accelerate the bone resorption around the tumor. Due to the intense sensibility of the nerve endings, sharp pain hence generate. According to vast research, it has proved that traditional Chinese medicine could be efficient in analgesic therapy.,5 Recent years have witnessed great promotion of the living standard, which also accompanied with the increasing morbidity of prostate cancer, and this has caused great impact on people's life and quality of life. Meanwhile, with the increasing progress of modern medicine, we could not only focus on prolonging lifespan of the cancerous person, but also on the impact to the quality of life.,7 Enormous clinical literatures have indicated that TCM has positive effect on ameliorating pain and improve the quality of life in patients who suffer from advanced prostate cancer.,9Prostate cancer is a male malignant tumor disease which has a high prevalence in recent years. Meanwhile, the morbidity also has significant difference across the world, which we found that the highest incidence, comparing with the lowest incidence, is about 25 times. In the United States, the morbidity of the disease ranks first in all male malignancies, which accounting for about 29%. During 2004 to 2008, the morbidity of this cancer had been turned to 152.9 per 100,000, which was counted after the rise of age.,12Prostate cancer is the most common malignant tumor of the male genitourinary system, accounting for the fifth place in the global cancer rate. According to the WHO Global Cancer Epidemiology Statistics (GLOBOCAN 2008), the global morbidity of prostate cancer ranks second in males who suffer from malignancy in 2008 (ranking only second to lung cancer), which accounting for 14%.,14 The morbidity of the symptom is about 70% to 90%. According to the statistics which announced by WHO in 2003, there are about 10 million new cancer patients in the world every year, and 300 to 1000 million cancer patients fail to receive timely and effective treatment.Cancer pain is one of the most important symptoms in patients who suffer from advanced cancer, and it greatly deteriorate the physical and psychological health, meanwhile, the quality of life of patients. Meanwhile, studies in the United States have found that using large doses of anesthetics for a long period of time is vulnerable to promoting tumor angiogenesis, accelerating tumor growth and increasing the spread of cancer cells. Besides, patients who accept the treatment always accompanied with constipation, nausea and vomiting, dizziness, drowsiness, rash, high blood pressure, coma and other adverse reactions, so far as to further aggravating the pain.,18At present, aiming at the symptom, the medical community mainly adopts the “3-step” analgesic drug therapy recommended by WHO, which means that the patients need long-term high-dose anesthetics in order to release the pain. It can relieve pain caused by prostate cancer to some extent. On the basis of TCM theory, Chinese herbal compound can regulate the balance of qi and blood, which aims at improving physiological function. Meanwhile, vast studies have shown that some ingredients in traditional Chinese medicine can adjust the production of neurotransmitter, mainly 5-HT, and reduce nerve sensitivity. By preliminary database searching, we found that the randomized controlled trials about TCM for curing pain caused by prostate cancer have been increasing. However, most clinical trials confront with the inferior quality of the studies with small sample size and the insufficiency of evidence-based exploration because of the limitation of the size and number of clinical centers. Therefore, we expect to adopt meta-analysis to evaluate the efficacy and safety of TCM in the treatment of prostate cancer, which in order to provide evidence for its clinical application.TCM has been widely used in clinical trials of pain caused by prostate cancer in recent years. The process of analgesia by TCM is complicated. Vast studies have proved that Chinese herb extracts can accelerate the secretion of various mediators and opioid peptides from peripheral nerve to central nervous system, such as spinal cord, low brainstem, diencephalon, limbic system and cerebral cortex, which together form the “anti-pain system” of the human body and produceTCM has its unique advantages in the treatment of cancer pain. The operation is convenient, it could dredge the meridians, regulate the balance of qi and blood, which achieve the goal of relieving pain caused by qi stagnation and blood stasis and meridians impassability. With the deepening of the research and animal experiment on the mechanism of TCM and analgesia in recent years, there have been increasing reports on the application of TCM to various acute and chronic pain treatments.Chinese herbal medicine analgesic effects.2This systematic review protocol has been registered on PROSPERO as CRD42019131544. The protocol follows the Cochrane Handbook for Systematic Reviews of Interventions and the Preferred Reporting Items for Systematic Reviews and Meta-Analysis Protocol (PRISMA-P) statement guidelines. We will describe the changes in our full review if needed.2.12.1.1The selected literature will include the TCM-related randomized controlled trials which aim at treating pain caused by prostate cancer. The language is limited to Chinese and English. Non-randomized controlled trials, quasi-randomized controlled trials, case series, case reports, crossover studies will be excluded.2.1.2Male patients who were diagnosed with prostate cancer will be included, the type of the disease includes adenocarcinoma (adenocarcinoma), ductal adenocarcinoma, urothelial carcinoma, squamous cell carcinoma, and adenosquamous carcinoma. Meanwhile, the patients who were recruited should have the symptom of pain caused by prostate cancer, including bone pain caused by bone metastasis. However, the patients who suffer from pain caused by other factors would be excluded. Patients who suffer from cognition impairment and other severe mental illness will also be excluded. In addition, the inclusion criteria will not be restricted by region, country, nation, and origin.2.1.32.1.3.1The drug composition, the dose-specific Chinese medicine preparation or the combined western medicine are used as experimental interventions. Both prescription and Chinese patent medicines will be included. Other traditional Chinese medicine treatments such as intravenous medication, acupuncture, and massage will be limited.2.1.3.2As for the control interventions, who accepted simple western medicine can be used as a control intervention or didn‘t get any treatment as a blank control would be adopted. However, once they had accepted the therapy of TCM, the trials will be rejected.2.1.42.1.4.1Adopting NRS  of pain criteria as the main evaluation, the specific division: Painless 0 points; mild pain 1 to 3 points; moderate pain 4 to 6 points; severe pain 7 to 9 points; severe pain 10 points, 0 to 10 points representing the patient's pain level. Significantly effective: the patient's pain level is reduced by at least 2 or 3 levels, or the patient is painless; Effective: The patient's pain level is reduced by one grade or the patient presents moderate and mild pain; Invalid: The patient's pain does not have any relief, and there is even a tendency to aggravate.2.1.4.2(1)International prostate symptom score (IPSS), the patient self-evaluation form;(2)Quality of life scores for patients with prostate cancer before and after treatment (PRSSQOL): A scale, designed by the University of California, USA, to evaluate the condition and living quality of patients who suffer from advanced, hormone-insensitive prostate cancer. It specifically includes nine aspects: Physical strength, pain, fatigue, appetite, family/marriage, constipation, mood, defecation, and overall feelings. Each item is calculated with 100 points, and the lower the score, the worse the situation.2.22.2.1Database search: Searching PubMed, Cochrane Library, AMED, EMbase, WorldSciNet; Nature, Science online and China National Knowledge Infrastructure (CNKI), China Biology Medicine disc (CBM), China Resources Database. The temporal interval is limited from the time that the databases created to June 2019, and the combination of keyword and free word retrieval is adopted. The search terms include “Chinese medicine”, “traditional Chinese medicine”, “proprietary Chinese medicine”, “Chinese herbal medicine”, “prostate cancer”, “prostate cancer”, “pain”. “Random Control”. The complete PubMed search strategy is summarized in Table 2.2.2We will search ongoing experimental studies related to the disease through the WHO International Clinical Trial Registration Platform (ICTRP), ClinicalTrials.gov, and Chinese clinical trial studies. As for these ongoing experiments, we will try to contact the trial author to help provide the most up-to-date clinical data. Besides, we also tempt to adopt the manual searching which mainly aims at relevant literatures, earlier than the database above-mentioned, such as “China Rehabilitation Medicine Journal” “Chinese Journal of Physical Medicine and Rehabilitation” and “Chinese Journal of Urology”.2.32.3.1Initial evaluations were performed independently by 2 investigators through filtrating the titles and abstracts of each documents in the Endnote database, eliminating duplicates and documents that were clearly inconsistent with the study. After the preliminary assessment, in order to screen out eligible trials, the full text of the selected literature would be evaluated, which mainly aims at whether there were problems just like uncontrolled studies, no randomization, inconsistent assessment criteria, and similar data. When the two researchers could not reach a consensus, the third judge would make the final judgment.2.3.2There will be 2 investigators independently extract information from the included literature, mainly contents: Author (year), sample size, disease stage, patient age, intervention factors, control factors, intervention time, observation index, NRS score, symptoms Ratings, quality of life scores, etc. The extracted literature data is filled in a unified data statistics table.2.3.3Cochrane Intervention System Evaluation Manual, it is divided into low risk, high risk and unclear.Two investigators independently assess the quality of the included literature by using the Cochrane Collaboration's bias risk assessment tool. The assessment includes: random sequence generation, allocation concealment, blinding, incomplete outcome data, selective outcome reporting, and other possible biases. According to the relevant standards in the 2.3.4In the event of data loss during the screening and extraction of literature data, primarily, we would actively look for the cause of the loss, and then we would contact the experimental research author by telephone, mail, etc. to retrieve the lost data. If the loss could not be retrieved, we will only extract and analyze the useful data, and the situation would be indicated.2.3.5P < .05. Heterogeneity test would be analyzed by using chi-square test. When P ≥ .1, the difference was considered to be not statistically significant. When P < .1, I2 > 50%, the random effect model would be used, as for the other situation, the fixed effect model would be adopted. For studies that provide baseline and post-treatment data, we will estimate the change values by the method recommended by Cochrane. The details of selection process will be shown in the PRISMA flow chart  or odds ratio (OR) and 95% CI. As for the continuous variables, we select weighted mean difference (WMD) or standard mean difference (SMD) and 95% CI, the difference would be statistically significant when 2.3.6If there is significant heterogeneity between a group of studies, we will explore the reasons for the existence of heterogeneity from various aspects, such as the characteristics of the subjects and the degree of variation of the interventions. Necessarily, sensitivity analysis or subgroup analysis would be adopted to explain the heterogeneity.2.3.7The forest map and funnel plot would be drawn and analyzed by Rev Man5.3 software, and the funnel plot would be used to analyze the potential publication bias.2.3.8The quality of evidence for the main outcomes will also be assessed with the GRADE approach. The evaluation included bias risk; heterogeneity; indirectness; imprecision; publication bias. And each level of evidence will be made “very low,” “low,” rate,” or “high” judgment.Patient and public involvementNo patients will be involved in this study.3 Recent years have witnessed an increase on the study of treating cancer pain, vast researches have indicated that analgesics have great efficiency in ameliorating pain, but the pesticide effects are short, and there are kinds of adverse reaction, such as kidney damage, liver damage, cardiovascular and cerebrovascular damage, digestive disease, etc.,24 Generally speaking, numerous patients who suffer from cancer could not gain satisfied control effect. Moreover, these patients need long-term use of analgesic drugs to ameliorate pain, which also directly increase the cost of therapy for patients.At present, pain has been the fifth vital sign, which together with respiration, blood pressure, pulse and body temperature. In 1996, the American Pain Association (APA) first proposed the concept of pain and its control, which indicated that an effective pain relief program for patients is a basic requirement for clinical medical work. It has been a difficulty problem to the treatment of pain caused by prostate cancer and its bone metastasis in the middle and advantaged stage, which has belonged to refractory cancer pain. In recent years, TCM therapy has been widely used in clinical trials of pain caused by prostate, and the recent studies have shown that the therapy could ameliorate the pain cause by prostate cancer to some extent and improve the quality of the life.Traditional Chinese medicine, possessing thousands of years history in China, has been proved that it is a safe, feasible and effective treatment. The clinical operation and theory of TCM have been inherited and carried forward by the majority of clinicians, especially in the treatment of pain. This therapy could ameliorate vast kinds of pain efficiently, and there are not adverse reaction which could insure the security.As far as we know, there has not made any comparison of the effectiveness of TCM in the treatment of prostate cancer pain. Therefore, we will use systematic review and meta-analysis to evaluate the efficacy and safety of TCM for the treatment of pain caused by prostate cancer. We expect that the review could provide a basis for TCM treatment of pain caused by prostate cancer and offer more and better options for the treatment to patients. In addition, the literature on TCM therapy on pain caused by prostate cancer is relatively inadequate and the overall quality is a little low, which may affect the authenticity of this study.Ethics and disseminationThis systematic review will evaluate the efficacy and safety of TCM for pain caused by prostate cancer. Because all of the data used in this systematic review and meta-analysis has been published, this review does not require ethical approval. Furthermore, all data will be analyzed anonymously during the review process Trial.Conceptualization: Ning Wang.Data curation: Ning Wang.Investigation: Li Xu, Ji-Sheng Wang.Methodology: Ji-Sheng Wang.Project administration: Ji-Sheng Wang, Sheng Deng, Fu-Xing Ge.Resources: Xu-Dong Yu, Li-Yuan Chu, Sheng Deng, Fu-Xing Ge.Software: Xu-Dong Yu.Validation: Li-Yuan Chu.


Background: According to dynamical systems theory, an increase in movement variability leads to greater adaptability, which may be related to the number of feedforward and feedback mechanisms associated with movement and postural control. Using Higuchi dimension (HDf) to measure complexity of the signal and Singular Value Decomposition Entropy (SvdEn) to measure the number of attributes required to describe the biosignal, the purpose of this study was to determine the effect of kinesiology and strapping tape on center of pressure dynamics, myoelectric muscle activity, and joint angle during the Y balance test.Method: Forty-one participants between 18 and 34 years of age completed five trials of the Y balance test without tape, with strapping tape (ST), and with kinesiology tape (KT) in a cross-sectional study. The mean and standard errors were calculated for the center of pressure, joint angles, and muscle activities with no tape, ST, and KT. The results were analyzed with a repeated measures ANOVA model (PA < 0.05) fit and followed by Tukey post hoc analysis from the R package with probability set at P < 0.05.Results: SvdEn indicated significantly decreased complexity in the anterior-posterior (p < 0.05) and internal-external rotation (p < 0.001) direction of the ankle, whilst HDf for both ST and KT identified a significant increase in ankle dynamics when compared to no tape (p < 0.0001) in the mediolateral direction. Taping also resulted in a significant difference in gastrocnemius muscle myoelectric muscle activity between ST and KT (p = 0.047).Conclusion: Complexity of ankle joint dynamics increased in the sagittal plane of movement with no significant changes in the possible number of physiological attributes. In contrast, the number of possible physiological attributes contributing to ankle movement was significantly lower in the frontal and transverse planes. Simply adhering tape to the skin is sufficient to influence neurological control and adaptability of movement. In addition, adaptation of ankle joint dynamics to retain postural stability during a Y Balance test is achieved differently depending on the direction of movement. Postural control and balance involve coordination between proprioceptive input, individual muscle output, joints, and limbs to provide stability. Whole body biomechanical and sensory-motor feedforward and feedback mechanisms play a role in retaining postural stability. Postural stability has been investigated using both static and dynamic balance tests  is commonly used to stabilize the ankle joint and improve balance by limiting range of motion at selected joints. It is also a means to prevent lateral ankle sprains, especially when performing sporting activities  is a common linear analysis method applied for characterizing sEMG activity or amplitude changes. However, it has inherent limitations since sEMG signals are irregular, complex and non-stationary  quantifies the complexity of the scaling variability associated with biosignals, such as CoP, muscle contraction and muscle bundle recruitment dynamics Higuchi, . It has Entropy is also a characteristic of non-linear, complex systems, and indicates the extent of regularity in a system, that is, a certain signal characteristic is likely to occur again  and female (n = 20) participants  aged 18–34 years completed this study. Based on a power analysis with Power set at 0.8, large effect size and p ≤ 0.05 (G*Power 3.1.9.4 for Windows), the sample size required is 34 participants (17 in each group)  requires the participant to balance on their dominant leg, and reach with their non-dominant leg as far as possible in the anterior, posterolateral, and posteromedial directions , where joint angle and ground reaction force data underwent fourth-order Butterworth low-pass filter with cut-off frequencies at 18 and 50 Hz, respectively. A Cartesian local coordinate system defined the y-axis as lateromedial, x-axis as posterior-anterior, and z-axis as external-internal rotation . Intersehttps://pypi.org/project/neurokit/) for purposes of the current analysis. sEMG signals were filtered with a script downloaded from Scientifically Sound  prior to determining HDf and SvdEn.All complexity measures were calculated using a Python script based on the complexity.py script available through the Neurokit package  quantifies the degree of fluctuation of the time series. The HDf is defined as:k is the discrete time interval between points, m represents the initial time value, and L(k) is the length of the curve for the time interval k. The maximal k was set at eight  was applied followed by the Tukey post hoc method from the R package for comparing a family of three estimates , to allow for P-value adjustment.The mean and standard error (SE) were calculated for the CoP, joint angles and muscle activities with no tape, ST and KT. To determine the relevance of the results, a repeated measures ANOVA model  and Tukey post hoc analysis in the anterior-posterior (PA = 0.40) and mediolateral directions (PA = 0.28) (No significant effects of taping were observed for the CoP using a repeated measures ANOVA ( = 0.28) , despitePA = 0.95), mediolateral (PA = 0.25), and internal-external rotation (PA = 0.61) directions during the YBT  = 7.12; PA = 0.0015) as well as the internal-external rotation  = 70.56, PA = 0.0001) in association with taping. The anterior-posterior direction joint angle dynamics were significantly lower for ST as compared to NT (P = 0.006), and KT as compared to NT (P = 0.004). SvdEn for the internal-external rotation of the ankle joint movement was also significantly lower when comparing taped (KT & ST) and non-taped conditions (P = 0.0001) shown in However, the ANOVA and F = 2.96, PA = 0.057). KT led to a reduction, whereas ST led to a slight increase in SvdEn as compared to NT. However, a significant difference was seen between ST and KT (P = 0.047)  .Kinesiology taping also led to lower SvdEn for the rectus femoris and the fibularis longus muscles as compared to ST but were not significant .PA = 0.64) and mediolateral directions (PA = 0.78)  .PA = 0.6), mediolateral (PA = 0.13), and internal-external rotation (PA = 0.32) directions during the YBT were also not significant  = 18.5, PA = 0.0001) with a significantly higher HDf for both KT and ST vs. NT with P < 0.0001 in the mediolateral direction only  compared to no tape, similar to the findings with SvdEn .HDf analysis of muscle myoelectric activity during the YBT showed a strong trend for the gastrocnemius muscle when using KT or ST when applying the repeated ANOVA (th SvdEn , but wasPostural control is a complex continuous process regardless of whether static stance or dynamic movement is taking place. Many physiological signals exhibit complex non-linear fractal scaling and indicating possible common feedforward and feedback control mechanism on different time scales (Ivanov et al., According to previous studies on postural sway whilst standing, a loss of CoP complexity, measured with detrended fluctuation analysis, is due to the reduction in postural control system functionality (Zhou et al., According to our results, the CoP did not change with taping when analyzed with SvdEn or HDf. This agrees with previous work, showing no influence of elastic taping on the CoP during static or dynamic balance tasks, although decreased postural control was reported with strapping tape (Abián-Vicén et al., Similarly, there was no significant difference between no tape and taping conditions, for knee angle dynamics during the YBT. Gribble et al. reported that participant fatigue created kinematic pattern changes that led to changes in knee angle during the SEBT but that taping in normal control participants made no difference in maximum reach distance during the SEBT (Gribble et al., Proprioception at the ankle joint is one of the most important elements contributing to the control of balance. Taping is often used to support joints, but also decreases freedom of movements. According to manufacturers, KT adhesive taping is able to provide improved dynamic support and potentially enhance afferent sensory stimulation when compared to conventional strapping techniques, which improves proprioception as part of the sensorimotor neural response system and better postural control (Capobianco and Van Den Dries, A reduction in SvdEn identified a decrease in the number of physiological attributes, contributing to ankle movement for both KT and ST conditions in the anterior-posterior and internal-external rotation directions. Whereas, HDf, which is measure of the complexity of ankle dynamics, was shown to increase significantly for both KT and ST in the mediolateral direction. Interestingly, having not observed an increase in HDf in the anterior-posterior and internal-external rotation directions, this may imply that the changes to SvdEn were not related to movement complexity, but instead to the reduction in physiological attributes associated with the movement. This is possibly a reflection of a change in the neurological processing, or increased stability of the ankle in the anterior-posterior and internal-external rotation directions in the presence of tape.If viewing the reduction in SvdEn from a purely anatomical perspective, the ankle strapping is applied with a view to inverting the foot. When moving into an inverted subtalar joint position, the midtarsal joint is believed to become “locked,” therefore limiting overall flexibility of the foot (Blackwood et al., The significant changes observed in the ankle joint dynamics can be related to muscle myoelectric activity during the balance test, as limitations of gastrocnemius extensibility can contribute to a more everted foot position in the frontal plane. There were, however, no significant changes in the electromyographic muscle activity noted at the fibularis longus and rectus femoris, and SvdEn changes to gastrocnemius were only found to be trending. Minimal changes to muscle myoelectric activity may challenge the suggestion that KT application increases afferent activity, and that resulting joint changes reflect an effect isolated to joint motion but not the supporting structures. Alternatively, gross and intentional movements may override the potential sensory effects of facilitative taping.Similar findings were noted at the rectus femoris, with no significant changes observed. While no previous studies that we are aware of have investigated the role of the rectus femoris in dynamic postural control during the YBT, overriding of facilitative tape effects may also exist in this case. Although the rectus femoris as knee extensor, acts concentrically, it also controls knee flexion eccentrically, and is considered the main muscle controlling weight during single leg stance. Signal regularity and complexity for the sEMG activity of the rectus femoris and fibularis longus muscles did not change due to taping in our study. This observation agrees with previous work, which reported no significant effect on response latency of the fibularis longus whilst strapping the ankle (Correia et al., Increased gastrocnemius muscle myoelectric activity and greater ankle motion were associated with lower SvdEn and HDf using KT and slightly elevated SvdEn and HDf with ST, as compared to no tape. Significantly higher ST, as compared to KT, using SvdEn may be indicative of increased gastrocnemius muscle myoelectric activity and greater contribution of the proprioceptive and somatosensory systems in the muscle response. Decreased regularity is a likely indicator of increased torque requirement to oppose the decreased ankle flexibility, following strapping taping application, which predominates muscle regularity due to sensorimotor feedback associated with kinesiology taping (Di Giulio et al., kmax, is also important and should be set at ~40, which corresponds to 0.08 s and is equivalent to about twice the minimal reaction time recording in human subjects (Zhou et al., A number of limitations need to be mentioned here relating to the use of HDf and SvdEn. When applying the Higuchi dimension to calculate fractal or non-linear properties of time signals the number of data points should be at least 15,000. Although during the SEBT more data points have been observed, it is more difficult to obtain this number with the YBT as it is a shorter test. The number of data points in related to the sampling frequency, which should not exceed 500 Hz as any faster sampling frequency would not be consistent with the physiology measured. The choice of the scaling parameter Sensorimotor integration and the associated movement variability depend on feedforward and feedback information pathways along the neuroaxis. Movement variability, as reflected by the biosignal complexity measured using HDf, provides a global measure of movement output. SvdEn provides insight into the possible regulatory mechanisms associated with movement complexity and measures the possible number of factors contributing to the complexity of the signal. Such complexity typically increases from a simple reflex controlled at the spinal cord level only to movement controlled at level to brainstem, subcortical, and cortical levels.Utilizing HDf and SvdEn measures in this work provided a novel perspective on ankle stabilization using different types of tape and differences in the possible mechanisms and attributes contributing to ankle joint dynamics and movement variability, in lieu of traditional single parameter measures, such as the range of motion, typically used to quantify the effectiveness of taping. A significant decrease in SvdEn was observed in the anterior-posterior direction of joint motion as well as the internal-external rotation in association with taping. However, HDf for both KT and ST vs. NT was significantly higher in the ankle joint mediolateral direction only. These results suggest different sensorimotor feedforward and feedback mechanisms associated with retaining postural control.The datasets generated for this study are available on request to the corresponding author.All necessary information has been provided. The Charles Sturt University Human Ethics Committee approved the study, and all participants provided written consent having been informed about the research process and aims in accordance with the Declaration of Helsinki.LH, LD, and JP collected the data. HJ, LD, LH, and JP performed the data analysis. HJ, KK, JP, AK, LH, and LD contributed equally to the interpretation of results and writing the paper, conceived and contributed substantially to the research design.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.


Regular physical activity (PA), adequate gestational weight gain (GWG), and healthy eating are important for the long-term health of both mother and baby. Hence, it is important that women receive current and updated advice on these topics and are encouraged to adopt a healthy lifestyle during pregnancy.The aim of this study was to investigate the main information sources among pregnant women regarding PA, GWG, and nutrition as well as to evaluate how these information sources may affect their health behaviors.P<.05).A cross-sectional study design, comprising an electronic questionnaire, was distributed to 2 antenatal clinics, as well as pregnancy-related online chat forums and social media. The inclusion criteria were ≥18 years, ≥20 weeks gestation, and able to read and write Norwegian. In total, 150 pregnant women answered the questionnaire, which was a mix of 11-point Likert scales, close-ended questions, and semi–close-ended questions with the option to elaborate. The relationship between information sources and selected variables, including health behaviors and descriptive variables, were assessed by logistic regression, linear regression, or chi-square as appropriate (2) were 31.1 (SD 4.3), 30.6 (SD 5.9), and 24.2 (SD 4.2), respectively. More than eight out of 10 had received or retrieved information about nutrition  and PA , whereas 54.0% (81/150) reported information on GWG. When combining all 3 lifestyle factors, 38.5% had retrieved information from blogs and online forums and 26.6%, from their midwife or family physician. Women who reportedthe internet and media as their primary source of information on weight gain had increased odds of gaining weight below the Institute of Medicine (IOM) guidelines compared with gaining within the guidelines . Higher compliance with nutritional guidelines was seen among those who cited the internet and media as their main source of information on nutrition . On the other side, receiving advice from friends and family on weight gain was significantly associated with gaining weight above the IOM guidelines compared with gaining within the guidelines . No other associations were found between information sources and health behaviors.Mean age (years), gestation week, and prepregnancy body mass index (kg/mThe small number of health professionals giving information and the extensive use of internet- and media-based sources emphasize the need to address the quality of internet advice and guide women toward trustworthy sources of information during pregnancy. The association between information sources and PA, GWG, and nutrition requires further research. Regular physical activity (PA), adequate gestational weight gain (GWG), and healthy eating may lower the incidence and severity of serious conditions associated with pregnancy, including gestational diabetes mellitus -3, pregnResearch show that pregnant women retrieve health information from a variety of sources, including the internet, books, family and friends, parenting magazines, blogs, online forums and health professionals -10. Of tIn previous studies investigating pregnant women’s information sources on PA, GWG, and/or nutrition ,19,21-27The present project was a cross-sectional study conducted in Oslo, Norway, from February to August 2016. Pregnant women were asked to fill an electronic questionnaire investigating their health behaviors, as well as information sources with regard to PA, GWG, and nutrition. The study was reviewed by the Regional Committee for Medical and Health Research Ethics (REK 2015/1941 A), who concluded that, according to the act on medical and health research , the study did not require full review by REK. The study was approved by the Norwegian Social Science Data Service (NSD 45111).Enrolment was limited to women living in Oslo, ≥18 years, ≥20 weeks gestation, and being able to read and write Norwegian.To ensure a representative sample with regard to different ethnicities, age groups, and socioeconomic backgrounds, all antenatal clinics in Oslo (n=18), both urban and rural, were invited to participate. However, due to ongoing research projects only 2 agreed to distribute questionnaires to their pregnant patients. Hence, we needed to recruit participants from other arenas. We chose to spread the link to the online survey through advertisements on Facebook and Instagram, as well as through various pregnancy-related online chat forums and the university website. The advertisement on Facebook and Instagram was not limited to pregnant women but targeted women living in Oslo. The internet-based questionnaire was active between June 1 and August 15, 2016.The survey items used to answer our research questions were derived from a multidimensional survey that assessed pregnant women’s information sources, PA level, nutritional habits, and GWG. The survey also investigated social support, motives, and barriers for being physically active, as well as pregnancy complaints and quality of life. The multidimensional electronic survey contained 101 questions and was developed using existing and validated questions -30, as wAll statistical analyses were performed using IBM SPSS Statistical Software version 21.0 for Windows. Background variables and information sources are presented as frequencies, percentages, or means with standard deviation.For the purpose of analysis, we divided the participants into 3 groups based on the information source perceived to mostly impact maternal health behavior:Internet and media .Health professionals (including midwives and family physicians).Friends and family.P<.05.Whether a woman had gained weight below, within, or above the GWG guidelines was calculated using mean recommended weight gain in the first trimester (1.5 kg), adding the mean recommended number of grams per week multiplied by the number of weeks the woman was pregnant above the first trimester . Good nu2. The mean number of antenatal consultations was 5.2 .Participant characteristics are shown in Almost 90% of women reported that they were physically active for a minimum of 150 min of moderate intensity each week before pregnancy. This number decreased to less than 50% in the current gestation week .As shown in Perceived good nutritional habits and compliance with the nutritional guidelines was reported by 65.3% (98/150) of the women.Most women reported multiple information sources on PA, GWG, and nutrition . More thP<.001; GWG: chi-square=38.13; P<.001; nutrition: chi-square=67.11; P<.001; P=.007), but there was no difference between family and friends and health professionals with regard to GWG  and nutrition .When examining sources of information across sociodemographic groups, including age, education level, employment status, parity, number of children, marital status, and country of birth, the only significant association was between high education and friends and family as the main information source on nutrition. The odds of reporting friends and family as the most important source of information with regard to nutrition during pregnancy was 67% lower among women with ≥4 years of college or university education compared with women with <4 years of college or university education . Choosing friends and family as the most important source on GWG information increased the odds of gaining above the guidelines compared with gaining within . Otherwise, no significant relationships or interaction effects were observed.Binary logistic regressions on the impact of information sources on GWG revealed that choosing internet and media or health professionals as the most important source on GWG information increased the odds of gaining below the guidelines compared with gaining within the guidelines . This association remained significant when controlling for self-reported diet before pregnancy (P=.03). No significant associations were found between the categories, family and friends or health professionals and compliance with nutritional guidelines.Linear regressions revealed that choosing the internet and media as the most important information source on nutrition was associated with an increase of 0.7 on the 11-item scale representing compliance with nutritional recommendations (n=133; 95% CI 0.07-1.3; To our knowledge, this was the first study investigating the relationship between pregnant women’s information sources and their health behaviors. Consistent with previous research, the most common sources of information were the internet and media ,33. AbouOur recruitment method may be an important reason for the large proportion of women choosing the internet and media as preferred information sources and may have skewed the results. On the contrary, our results correspond with other studies, recruiting women in the first hospital antenatal visit ,27. A quAccording to the Norwegian guidelines for antenatal care, all prenatal patients should receive lifestyle counselling, including advice on PA, GWG, and nutrition on the first prenatal visit . ConsistStating the internet and media as the most important sources on GWG information significantly increased the odds of gaining below the GWG guidelines. Hicks and Brown  found thReporting friends and family as the main information source on GWG was associated with gaining above the GWG guidelines. Public health guidelines on GWG have been revised several times over the past decades ,37 and fThe most frequently reported information source on nutrition was books and information pamphlets, highlighting the importance of this media for dietary information. The Norwegian Directorate of Health  distribuThis is one of the largest studies investigating pregnant women’s information sources and the first to explore how different information sources may impact 3 distinct but importantly related health topics: PA, GWG, and nutrition. In addition, the questionnaire used covered a broad range of factors that could possibly explain women’s health behaviors and was based on previously validated questions and questions used in similar studies -30,38. FThe small number of health professionals giving information and the extensive use of internet- and media-based sources highlight the need to address the quality of internet advice and guide women toward trustworthy sources of information during pregnancy. Even though internet and media sources seemed to have a positive impact on nutritional behavior, it was also associated with gaining below the GWG guidelines. Further research investigating how different information sources influence PA, GWG, and nutritional behaviors is needed.


Researchers in educational psychology have researched Teacher Self-Concept (TSC) and Teacher Efficacy (TE) as two main predictors predicting burnout. Guided by a model developed by Zhu, Liu, Fu, Yang, Zhang & Shi (2018), the researchers aimed at building a model involving TSC, TE, and three components of burnout; Emotional Exhaustion (EE), Depersonalization (DP), and Reduced Personal Accomplishment (RPA) through Structural Equation Modeling (SEM). The researchers investigated predicting factors of burnout by reporting TSC and TE that might directly affect the components and examine the probability of TE to become a mediator of the correlation between TSC and burnout. This research also examined whether the difference emerges constantly among demographic information (gender and teaching experience) regarding all involved variables. A sample of 876 teachers across three Indonesian provinces completed a printed form of questionnaires. Some statistical procedures namely Content Validity Index (CVI), Exploratory Factor Analysis (EFA), Confirmatory Factor Analysis (CFA), Covariance-Based Structural Equation Modeling (CB-SEM), and t-test were conducted. Findings informed that the model is valid and reliable. TSC could directly affect EE, DE, and RPA, as well as indirectly influence them mediated by TE. Besides, TE is also reported to have significant relationships with EE, DE, and RPA. No significant differences in terms of age and teaching experiences emerge, except for EE. Teachers, TSC, TE, Burnout, Gender, Teaching experience, Education; Educational psychology; Health education; Pedagogy; Teaching research, Psychology. Work-reTheoretically, there are three components of burnout that have been introduced and conceptualized called “Maslach Burnout Inventory” (MBI) . The par22.12.2Many researchers have explored TE e.g. . In the The correlational studies between TE and burnout have been investigated by many researchers e.g. . For exa2.3TSC was defined as teachers’ perception of the evaluation of the effectiveness of instructional activities . TeacherIn this research, TSC is defined as teaching competence beliefs that is different from SE in several terms used in previous studies . Specifi2.4The researchers further investigated if the mediation emerges continually among demographic information of gender and teaching experience. Gender has been reported to have a significant difference in predicting TSC, TE and burnout. Some studies  informed2.5H1There will be a significant relationship between TSC and TEH2There will be a significant relationship between TSC and EEH3There will be a significant relationship between TE and EEH4There will be a significant relationship between TSC and DEH5There will be a significant relationship between TE and DEH6There will be a significant relationship between TSC and RPAH7There will be a significant relationship between TE and RPASix hypotheses were included to help guide the readers of this study. 3Some procedures were conducted to achieve the purpose of this research, namely; Content Validity Index (CVI), EFA, CFA, CB-SEM, and t-test. Universitas Negeri Yogyakarta that funds this research did not require any ethical approval for the study. Informed consent was obtained from all individual participants involved in the study. The researchers ensured the anonymity of the participants.3.1Five items of TSC were constructed from the TSC Evaluation Scale by 3.2A CVI procedure  involvin3.3After the CVI process, a pilot study was done with 50 Indonesian teachers from one province. The researchers permitted the teachers to write comments about how they comprehended each item and confusing items were revised. In addition, a reliability test was conducted at this stage by assessing Cronbach's alpha values. No values were found to be less than .700  as the c3.4As the reliability assessment of the pilot study was done, we distributed the instruments to the participants. Through, simple random sampling, the researchers distributed printed instrument to 1000 Indonesian high school teachers from 3 cities, Jambi, Bandung, and Yogyakarta. Eight hundred and seventy-six data were fully completed and measurable after the data screening process . There w4Before the main procedures of data analysis  were conducted, the normality assessment was done by measuring the Skewness, Kurtosis, and Histogram. Hair at al. (2010) recommended the threshold value from -1 to +1 for the Skewness and -2 to +2 for the Kurtosis. Multicollinearity issue happens if the correlation matrix with correlations was more than 0.90 .4.1The findings of the Skewness and Kurtosis values of each construct were reported to be satisfactory . The Ske4.2The main examination of the data was conducted through Cronbach's alpha to see the reliability, EFA, CFA for the factor analysis assessment, and CB-SEM for deciding the fit model . Since tp < .001). Using Varimax rotation, five factors were achieved with eigenvalues from 1.014 to 8.975. No issue emerged for the Communality. One item (EE5) was eliminated due to highly detected cross-loading. The Cronbach's alpha (α) values ranged from .754 to 875.The complete explanation of reliability and EFA procedures can be seen in 4.3Following the EFA procedure, CFA was examined using three indices to confirm the EFA: the Chi-Square Test (χ2), the Root Mean Square Error of Approximation (RMSEA), and the Standardized Root Mean Square of Residual (SRMR) were all measurements of this procedure. The relative goodness-of-fit indices recommended for this study are; Comperative Fit Index (CFI) and Tucker-Lewis Index (TLI). To achieve a fit model, the cut-off points were implemented for each measurement; RMSEA = ≤ .080 , SRMR = Using different samples, CFA was conducted in order to verify the EFA result or test measurement model. CFA can facilitate further evaluation regarding the fitness of the model in line with the structure of the factors . The ini4.4r value guideline , TE and EE is significant and strong , TE and DE is significant and moderate , TE and RPA is significant and moderate , TSC and EE is significant and strong , TSC and DE is significant and moderate , TSC and RPA is significant and moderate , EE and DE is significant and weak , EE and RPA is significant and moderate , DE and RPA is significant and weak .To support the path analysis of CB-SEM, the correlational analysis was conducted through Pearson correlation coefficient. This study implemented general uideline ; 00-.19 uideline  indicateSimilar to the testing measurement model, some threshold points were also implemented for each measurement to assess the final model; RMSEA = ≤ .080, SRMR = ≤ .08, TLI = ≥ .900, and the CFI = ≥ .900. The findings of the SEM report the structural model of χ2 = 881.682, χ2/df = 5.4090, RMSEA = 0.071, TLI = .910 and CFI = .923. All loading values were in the range from .62 to .90, exceeding the desirable standard of .50 . The hypp < .001) than DE  and RPA (β = .29 p < .001). TE was correlated to all three burnout components. The TE effect of mediation could be essential. Through the mediation of TE, TSC had a greater indirect effect on DE  and RPA  than that of EE  indicating a partial mediation effect. Additionally, the final result of the SEM process is depicted in TSC was included as an independent variable that predicted EE, DE, and RPA as burnout components, and TE was included as variable mediating TSC for burnout in the modeling process for this research. TSC had the stronger effect to EE  Complete information and comparison of the values across the demographic can be seen in The study also investigated whether the demographic information (gender and teaching experience) differs regarding all constructs . The t-test results reported that there is no statistical difference between male and female teachers concerning all constructs. Similarly, no significant differences emerge for teaching experience but one construct, DE , the model that involves TSC, TE, and burnout components  is informed to be valid and reliable for . ThroughThe researchers examined TSC and TE as the exploring factors to predict teachers' burnout. The study includes a large sample of Asian culture and tested whether teachers’ burnout varies based on their demographic information. The findings are hoped to facilitate a current understanding of the systematic function of TSC and TE in predicting EE, DE, and TRA as the burnout components in a different context and circumstance. Based on CB-SEM analysis, the findings informed that TSC directly affects burnout, as well as indirectly influences burnout via TE. The findings of the research facilitate our hypotheses that have been assumed based on the study reported by TSC has been described as a general belief of competence in instruction. This general belief can directly affect all components of burnout, TE, DE, and RPA and indirectly impact the other two syndromes of burnout through TE. Compared to TSC, TE had less impact on burnout. A possible elaboration for this might be that TE reflects a more specific perception of competence; thus, low TE could cause the increasing of burnout. Even though this study was carried out with teachers from a non-western psychosocial circumstance, teachers' professional appreciation has also been conducted based on individual achievement, similar to teaching appreciation in many western countries. Therefore, a social comparison should always be conducted in research about teachers’ burnout in the future with different cultures of the samples .The findings of the also informed that most demographic information (gender and teaching experience) do not significantly differ regarding all constructs . Only one construct in the burnout component (DE) is found to be different regarding teaching experience. The results of current study argue what 6All predictors (TSC and TE) have been reported to be significant in predicting teachers' burnout. The findings of the research advocate the proposed model. The model can be a guidance for future Asian researchers to predict teachers’ burnout. On the other hand, the study informed that gender and teaching experience are not significantly different for all variables; one construct is reported to be different regarding teaching experience for DE. Based on the results of this study, the needs of building TSC and TE to prevent burnout is recommended for the Asian context. Educational stakeholders should ensure that schools can be institutions that teachers will be successful in promoting learning activities. As a result, TSC and TE are fostered and burnout can be eliminated. The simplest and most practical way for school is to facilitate teachers multiple opportunities experiencing beneficial teaching such an open course with some motivated students. Through this way, they can be motivated to keep developing their own style and influence other teachers for learning to teach. Working with peers would also be useful while making lesson plans. With this kind of self-learning and peer learning, they can accumulate experience and verbal encouragement and appreciation from expert teachers that will improve TSC and TE .st-century education make research about teachers' burnout, to be a priority since students’ academic performance is now less valued causing the students to have more problems with behaviors or discipline problems. Therefore, this research considered future research motivating students to both attain achievement and decrease student discipline problems. A limitation that should be considered is that the adopted TE items focused on promoting students attain good achievements, not their discipline problems. Since there have been many reports with students in the context of Indonesia, a more measurement to deal with students discipline problems must be considered. Another lack of this research is the method of this study; in-depth and enriched information through qualitative inquiry is recommended for future researchers, especially in developing countries.Some advantages of the concept and measure of this study can be detected. TSE was a concept of a general belief of teaching competence. The sample represented an appropriate size. The shifting condition in Indonesia from achievement attainment to process-based instruction in the 21Lantip Diat Prasojo: Conceived and designed the experiments; Performed the experiments; Wrote the paper.Akhmad Habibi: Conceived and designed the experiments; Analyzed and interpreted the data; Contributed reagents, materials, analysis tools or data; Wrote the paper.Mohd Faiz Mohd Yaakob, Mat Rahimi Yusof, Amirul Mukminin, Suyanto: Contributed reagents, materials, analysis tools or data; Wrote the paper.Robin Pratama: Performed the experiments; Analyzed and interpreted the data; Contributed reagents, materials, analysis tools or data.Farida Hanum: Analyzed and interpreted the data; Wrote the paper.Universitas Negeri Yogyakarta No. 4868AA/UN34/SPK/2019 done from January to June 2019.This research was fully funded by The authors declare no conflict of interest.No additional information is available for this paper.