We are reporting a case of a 30-year-old male with no past medical history who presented with new onset of renal failure, anemia, and splenomegaly and was diagnosed with multiple myeloma. Given the splenomegaly and the patient's Jewish heritage, blood tests were done and the patient was found to be a Gaucher disease carrier. The association of Gaucher disease and multiple myeloma has previously been reported; however, we want to describe the case of a young Gaucher disease carrier who developed multiple myeloma and provide a review of the literature. Multiple myeloma (MM) is a clonal disease of the plasma cell, resulting in renal failure, anemia, hypercalcemia, and bone lesions. MM accounts for 1% of all malignancies and up to 10% of hematologic malignancies. In 2015, the annual incidence of MM in the United States was 26,850, with 11,240 deaths [A 30-year-old male with no significant history who was recently treated with levofloxacin for a community-acquired pneumonia presented to the hospital with abnormal renal function and anemia. The patient presented with a normocytic anemia, hemoglobin of 9.3, creatinine of 3.10, and uric acid of 11.1. On CT imaging, the patient had splenomegaly up to 18 cm and innumerable osteolytic lesions, predominantly in the pelvis. The patient was subsequently found to have an IgG lambda M-spike of 6.5 gr/dl. Bone marrow biopsy was obtained and was consistent with plasma cell myeloma. Upon immunophenotypic analysis, monoclonal IgG lambda (CD38 bright) population was present at 15% of the bone marrow. Further evaluation on FISH and cytogenetics revealed a translocation t gene rearrangement and del17p. Patient subsequently underwent treatment at an outside institution. Given his renal dysfunction, he was started on induction therapy with CyBorD . Patient achieved partial response with improvement in organ dysfunction and was subsequently transitioned to D-RVD . Patient achieved a very good partial response and had an M-spike of 0.1 gr/dl prior to transplant. He successfully underwent an autologous stem cell transplant with melphalan-200 and was recently discharged with a hemoglobin of 12.2, a creatinine of 0.98, and plans to initiate maintenance therapy. For his bony lesions, he has been tolerating therapy with denosumab.Given the patient's Jewish heritage and presence of splenomegaly, testing for Gaucher disease was performed and the patient was found to be a carrier of Gaucher disease. Peripheral blood specimen was sent off revealing one copy of the c.1226A>G (p.Asn409Ser) mutation in GBA.Gaucher disease is an autosomal recessive metabolic disorder secondary to genetic deficiency of the lysosomal enzyme glucocerebrosidase, which allows for the accumulation of its natural substrate glucosylceramide and its deacylated product glucosylsphingosine in the lysosomes of macrophages. These macrophages are known as “Gaucher cells” . In addiStudies have noted an increased frequency in Gaucher disease with gammopathy and malignancy. The association with immunologic abnormalities and polyclonal hypergammaglobulinemia may occur at diagnosis in 14-41% of adults –9. In GaThe pathologic link between Gaucher disease and lymphoproliferative disorders may be related to enhancement in cytokine release . In a fuIn summary, the association between Gaucher disease and malignancy is well-documented in the literature. Multiple studies have shown pathologic links between Gaucher disease and increased risk of malignancy, specifically multiple myeloma. Interestingly, the association of malignancy with Gaucher disease carriers still has not clearly been defined. Fortunately, the patient presented was successfully treated for his myeloma and is in clinical remission.Given the paucity of literature on Gaucher disease carriers, this case report and the review of literature should serve to increase awareness of the potential for malignancy, especially hematologic malignancy, in patients who are Gaucher disease carriers.


The subjects were asked whether they knew each FODMAP food, eating habit, and cooking habit. Chi-squared tests were used for analyzing the characteristics of LGIP-related factors. Logistic regression models were utilized to select foods which predict LGIP. Results: Women cooking by themselves and who were younger indicated less LGIP (Chai-square for trend). More than 60% reported that they often ate rice, coffee, eggs, pork, chicken, breads, noodles, and onions, which are solely classified as high-FODMAP foods. LGIP was related to age and self-cooking habits in women. Soybeans had the least significant relationship with LGIP (odds ratio (OR) 0.48, 95% confidence interval (CI) 0.32–0.73), followed by seaweed, shellfish, wheat, cow’s milk, green beans, and cauliflower. In contrast, artificial sweeteners were most significantly related with LGIP , followed by margarine and tomato paste. Conclusions: The associations between FODMAP foods and LGPI appeared to be different from the Western results. Furthermore, some diets related to LGIP are suggested.Background: There has been an increasing interest in low fermentable oligosaccharides, disaccharides, monosaccharides, and polyols (FODMAP) diets for irritable bowel syndrome. The aims of the present study were (1) to survey knowledge and eating habits with respect to low- and high-FODMAP foods in a general population, and (2) to analyze the relationship between lower gastrointestinal problems  and habits/foods for prevention. Methods: The present study was carried out with medical examinees ( Irritable bowel syndrome (IBS) is a common gastrointestinal illness characterized by the presence of abdominal pain and altered bowel habits ,2. DietaBefore starting low-FODMAP diet therapy for IBS patients and non-IBS patients, it is important to understand diets related with lower gastrointestinal problems  when consulting in primary care . We inven = 1024). This research was approved by the ethical committee of Hoshigaoka Maternity Hospital in Nagoya, Japan.The present study was performed with medical examinees at a clinic in Nagoya, Japan between 2 and 19 December, 2015. Office staff of the clinic asked the 1110 examinees to participate in the current study. The staff handed the self-administered questionnaire to the examinees who consented to participate in the study. The participants completed the questionnaire while they were waiting for their medical checkup. All participants were literate and understood the Japanese language well. The enrollment rate was 91.4% (The questionnaire was printed on both sides of A4-sized paper (297 mm × 210 mm) for ease of answering. The questionnaire collected data on sex, age bracket, whether one cooked for oneself, LGIP, and food intake. Cooking habits were evaluated by the question “Do you cook for yourself?” and the answer options available were “Yes, always”, “Yes, almost all the time”, “Sometimes”, or “No”. LGIP was evaluated by the question, “Are you suffering from abdominal pain and disordered defecation (constipation or diarrhea)?” The answer options were the same as those for cooking habits. Name, address, ID, and date of test that could identify the individual were not obtained.Food selection was made by referring to the list of low and high FODMAP foods (186 foods) released from Stanford Hospital & Clinics , in whicp-value < 0.05 was considered to indicate statistical significance.Submitted questionnaire sheets without sex, or age-bracket were excluded for analysis. The Japanese version of the IBM SPSS Statistics 24  and SAS 9.3  were used to analyze data. A chi-squared test was used to analyze the associations between LGIP and age brackets, and between LGIP and cooking habits. To identify variables that predict LGIP, multiple logistic regression models were applied, where the LGIP  was used as a dependent variable and the independent variables were age strata (reference: ages 20–29), sex, and whether one cooked one’s own meals . Various multiplicity issues which can arise in data analysis were not corrected, with the exception of independent variables in regression models. A p < 0.05). Women suffered from LGIP significantly more frequently than men .Ten participants out of 1024 were excluded due to them not providing all of the answers in the questionnaire prior to analysis. Nineteen questionnaire sheets were also excluded because they lacked sex, or age-bracket. Consequently, 995 were analyzed. The compliance rate was 97.2%. The characteristics of participants are demonstrated in The supplementary table  displaysp < 0.05), whereas there were no differences in terms of generations in men (p < 0.05), whereas there were no differences in terms of cooking habits in men . This is the first report on the awareness of low and high FODMAP foods in the Japanese population in medical checkups. The high enrollment rate of 91.4% (1024 out of 1110 examinees), high compliance rate of 97.2% , and the high kappa vale of concordance of “blueberries” (0.72) suggested that the present results were highly reliable. As written in the method section, we added “Blueberries” into “Meat, non-dairy alternatives, fruits category” as a dummy in addition to the “Fruits” category to check the reliability of answers to the questionnaire.We investigated the knowledge and eating habits of low- and high-FODMAP foods in medical health check-up populations in Japan. We found that a positive LGIP was more prevalent in the younger generation of women and women without a habit of self-cooking . FurtherWomen were most likely to report confidence with foods, techniques, or dishes . One IntThe FODMAP diet varies markedly across geographical regions. The current database of food content specifically addressing FODMAPs is predominantly from Australia, North America, the United Kingdom, and Scandinavian countries ,8,9. EveIn order to analyze the relationship between low- and high FODMAP foods and IBS in future research, the independent variables to predict LGIP, which are among the characteristic signs and symptoms of IBS, were investigated in this study. Soybeans, seaweed (nori), shellfish, wheat, cow’s milk, green beans, and cauliflower were less related with LGIP . In contThe limitations of the present study are as follows: first, the questionnaire did not include the current drug usage, past history of abdominal surgery, and pain due to menstruation, which might affect the LGIP. Second, the relationship between a certain diet checked in the current study and LGIP does not indicate a causal relationship due to the cross-sectional study design. Third, this study only enrolled a health check-up population, prohibiting the generalization of the results.In spite of these limitations, the novel findings in terms of awareness and eating habits from the viewpoints of high- and low-FODMAP foods should provide some clues to clarify whether dietary therapy for low-FODMAP foods in Japan will be useful for IBS patients in the future. In summary, two-thirds of FODMAP foods were recognized by more than 90% of participants. LGIP was related to age and self-cooking habits in women. The relationship between a certain diet and LGIP was different from Western studies for some foods. Further investigation is warranted to clarify the causal relationship in Japan.


Background: Despite recent advances in acute stroke care, only 1–8% of patients can receive reperfusion therapies, mainly because of prehospital delay (PHD). Objective: This study aimed to identify factors associated with PHD from the onset of acute stroke symptoms until arrival at the hospital. Methods: A cross-sectional study was conducted including all patients consecutively admitted with stroke symptoms to Burgos University Hospital . Socio-demographic, clinical, behavioral, cognitive, and contextualized characteristics were recorded, and their possible associations with PHD were studied using univariate and multivariable regression analyses. Results: The median PHD of 322 patients was 138.50 min. The following factors decreased the PHD and time until reperfusion treatment where applicable: asking for help immediately after the onset of symptoms  4.47–23.99), onset of stroke during the daytime  and the weekend , occurrence of stroke outside the home , using a prenotification system , patient’s perception of being unable to control symptoms without assistance , previous knowledge of stroke as a medical emergency , call to emergency medical services as the first medical contact , speech/language difficulties experienced by the patient , and the identification of stroke symptoms by the patient . Conclusions: The interval between the onset of symptoms and arrival at the hospital depends on certain contextual, cognitive, and behavioral factors, all of which should be considered when planning future public awareness campaigns. Stroke is one of the most frequent causes of mortality, dependency, and disability among adults worldwide, leading to high economic costs for the patients, their families, and health services ,2,3.Despite recent advances in acute stroke care that can improve clinical outcomes ,5, only This study aimed to identify socio-demographic, clinical, behavioral, cognitive, and contextual factors that influence the early arrival of patients with acute stroke at the hospital.This one-year cross-sectional prospective study, part of a larger project on PHD, stroke awareness, and treatment, was conducted at the Neurological Department, Burgos University Hospital, a large-scale tertiary care center in north Spain, with a well-established intravenous thrombolysis program and stroke unit. Emergency medical service (EMS) was provided by the regional Emergency Medical Dispatch Centers, which responded to the European phone number (112) and used validated and standardized protocols for stroke screening . No publThe study included patients of both sexes, aged ≥18 years, who were consecutively admitted to the emergency department (ED) during the first year, within 12 h after the onset of acute stroke. The diagnosis of stroke was as per the definition of the World Health Organization, and cerebral infarction based on neuroimaging (computed tomography (CT) or magnetic resonance imaging) results was differentiated from intraparenchymal hemorrhage . ExclusiPatients were informed of the purpose of the study and invited to participate. In case of acceptance, they were asked to sign the informed consent. Patients answered a structured questionnaire for 15–20 min in a face-to-face interview within 72 h of admission to minimize in-hospital stroke education and information loss. The medical records were reviewed to obtain complete data, confirmed by participants. The study was approved by the Institutional Review Board (IRB 1479).The primary outcome was PHD, the time in minutes from the onset of symptoms to the arrival at the hospital. The time of stroke onset was the moment when the patient or a witness first noticed a neurological deficit. The time of arrival was the earliest time routinely documented in the electronic medical record of the ED. The PHD was divided into two subperiods: the initial part or decision delay (DD), i.e., the interval between the symptom onset and first contact to ask for help depending on the patient, and the final part or transport delay (TD), i.e., the interval from the request for assistance to arrival at the hospital. Five domains were evaluated: socio-demographic features, clinical characteristics, behavioral response to symptoms, cognitive response to symptoms, and the context in which the stroke occurred. Stroke severity was assessed during admission using the “National Institute of Health Stroke Scale” (NIHSS) , represep-value of <0.20 in the univariate analysis or those considered particularly relevant in the literature were included. The cutoff of 210 and 360 min was selected as per the time window for intravenous thrombolytic therapy, assuming an additional hour of intra-hospital delay, which would in no case exceed 270 min and for mechanical thrombectomy without CT perfusion, respectively [p-value of <0.05 was considered statistically significant. The statistical analysis was performed using the SPSS statistical software package Version 24.0 .PHD was not normally distributed; therefore, for descriptive statistics, the median values and interquartile range (IQR) were calculated. The association between PHD and possible explanatory variables was assessed using either the Mann–Whitney U-test or the Kruskal–Wallis test. A forward stepwise multivariable regression analysis and binary logistic regression analysis adjusted by sex and age were performed to identify possible predictive factors for PHD greater or lesser than 210 or 360 min, in which those variables with a n = 136), the stroke onset time was unknown (n = 53), no ischemic stroke on final diagnosis (n = 18), in-hospital stroke (n = 21), recurrent stroke (n = 19), no possibility of follow-up (n = 8), and inability to communicate data (n = 6). The characteristics of this group were similar to the 322 patients included in the study with respect to age and gender. Of the 583 eligible patients, 261 were excluded for the following reasons: arrived 12 h after stroke onset  min. The median PHD was even shorter when the patient was transported by EMS to the hospital . If the patients were classified by PHD, more than three-fifths of patients (62.42%) arrived at the hospital in the first 210 min after symptom onset, 15.53% within 210–360 min, and one-fifth (22.05%) took more than 360 min. The median DD and TD were 60.00 (IQR 10–240) min and 56.50 (IQR 35–91) min, respectively. The median TD among the 221 patients who used the EMS was 47.00 (IQR 33–74) min, which was divided into four consecutive intervals: EMS activation delay (median 5.00 (IQR 5–28) min), EMS arrival delay (median 10.00 (IQR 7–16) min), EMS delay on scene (median 15.00 (IQR 10–23) min), and patient transport delay from the scene to hospital by EMS (median 13.00 (IQR 9–38) min) . ConsideIn the multivariable regression analysis, the following factors were significantly associated with a PHD of ≤210 min: asking for help immediately after symptom onset by the patient  4.47–23.99), stroke onset during the daytime , using a prenotification system , patient’s perception of controlling symptoms without any assistance , stroke occurrence outside the home , calling EMS as the first medical contact , and patient experienced speech/language difficulties . When the repeated analysis was performed with early arrival defined as a PHD of ≤360 min, several results were consistent with those obtained for a PHD of ≤210 min. The previous knowledge of stroke as a medical emergency , stroke onset during the weekends , and identification of stroke symptoms by the patients  were all associated with an increased likelihood of arriving at the hospital with a PHD of ≤360 min . The obtained median PHD after the onset of symptoms was lesser than that obtained by other studies ,18,19,20Treating stroke early can reduce in-hospital delay and TD, which is not dependent on the patient, but on motivated professionals . MoreoveSocio-demographic and clinical factors are nonmodifiable and have been previously reported to be associated with PHD, although conflicting and inconclusive results have been obtained in some studies ,20,21,22Behavioral and cognitive factors are associated with the patients and therefore can prolong or reduce the PHD. These factors have not been studied previously in association with stroke delay and therefore require further examination. p < 0.001), maintaining a sense of normality (p < 0.001), and the presence and influence of another person (p < 0.001); these results are consistent with those of previous studies [p < 0.001). Moreover, 44.41% patients called EMS as the first medical contact, which is consistent with other studies [Three-fifths of patients asked for help on the onset of symptoms in the first hour. The time to seek medical attention represented 51.50% of the PHD, similar to other studies ,18. If t studies . In addi studies ,29, withp = 0.859). Patients who recognized initial symptoms as stroke arrived at the hospital on time for thrombectomy without advanced neuroimaging compared with those who attributed the symptoms to other pathologies . However, only 73.17% of patients recognized their symptoms as a stroke and went to the hospital or called the EMS. In line with several other studies, having had a stroke or similar symptoms was associated with better recognition of the acute event [p = 0.038) [Patients’ interpretation of symptoms was also crucial: when they thought the situation could not be self-managed, the PHD decreased to 253 min . The PHD of patients with a generally proactive attitude was not shorter because they believed they could control the situation without any assistance or the symptoms would spontaneously improve ,20,29,30te event ,22. Inte= 0.038) ,22,31. D= 0.038) . A histoOther factors influence the PHD depending on how and when the stroke occurred. In line with other studies, an association between stroke occurring outside the home and early arrival at the hospital was observed . When the stroke occurs in public places, symptom onset is more likely witnessed by family members, friends, or bystanders who often take a more active approach and request medical assistance quickly . PatientPublic awareness campaigns on stroke have shown little success to date . These cThis study had some limitations: It was performed at a third-level hospital, and additional analyses, including the indications of mechanical thrombectomy published in 2018, were not performed because the study had been completed prior to its publication. The strengths of this study were the consecutive, rather than retrospective, nature at the time of stroke and the detailed analysis of the PHD factors associated with the patients, some of which were not studied previously.This study identified different contextual, cognitive, and behavioral factors that decrease the PHD and the time until reperfusion treatment. It is necessary to develop public awareness campaigns, wherein asking for help should be the first response after the onset of stroke symptoms. Telestroke and new neuroimaging techniques for reperfusion have improved the diagnosis and treatment of stroke occurring at nighttime or in rural areas. The activation of the prenotification system (stroke code) can help patients arrive at the hospital sooner; therefore, all health professionals must know when and how to use it.


The transtheoretical model (TTM) is an integrative model of intentional change consisting of stages of change, processes of change, decisional balance and self-efficacy. This study aimed at validating the TTM questionnaires on physical activity for Malaysian children using confirmatory factor analysis.The participants were 381 Malay students , aged 10–12 years old, with a mean age of 10.94 (SD = 0.81). The original version of the TTM was translated into the Malay language using forward and backward translation. Certain phrases were adapted based on the local culture and vocabulary suitable for primary school students.The final measurement models and their fit indices were: processes of change ; decisional balance ; and self-efficacy .Care must be taken when using the TTM with children, as it has been prevalently validated with adults. The final version of the TTM questionnaire for Malay primary school children had 24 items for process of changes, 13 items for self-efficacy and 10 items for decisional balance. Physical activity is defined as any bodily movement that results in the expenditure of energy. It is well established that physical activity can reduce the risk of depression and non-communicable diseases, such as hypertension, obesity, cardiovascular diseases, diabetes and colon and breast cancer . AccordiDespite these numerous health benefits, Poh et al.  found thThe transtheoretical model (TTM) is an integrative model of intentional change of health behaviours developed based on numerous theories of the psychotherapy . The TTMThe central construct of this model is the stages of change, which has a temporal dimension as individuals progress cyclically through six stages when attempting to change their behaviour . The sixIn addition to the processes of change, the TTM construct includes decisional balance, or individuals’ weighing of the relative pros and cons of change . OriginaWe found no published Malay version instrument measuring the TTM constructs  specifically for younger children or primary school student in Malaysia. However, it is important to understand the TTM constructs that influence younger children’s participation in physical activity in Malaysia. Furthermore, the TTM questionnaires are commonly used in studies on adult populations, and research on the validity of the questionnaires with younger children is limited. This study, therefore, was aimed to translating the TTM questionnaire into the Malay language and examining its reliability and validity among children and students studying at Malay primary schools.This cross-sectional study was conducted in a local primary school in the district of Kelantan, Malaysia. The purpose of this study was to validate the Malay language version of the TTM on physical activity, including questionnaires on processes of change, decisional balance and self-efficacy, specifically for Malay primary school children. The study was intended to give insights into the use of TTM on physical activity in the Malaysian setting.N = 381) was adequate for the confirmatory study.A total of 381 students  10–12 years old (mean [SD] = 10.94 [0.81]) volunteered to participate. The students were all Malay and had engaged in at least one 30-minute session of physical and leisure activities in the past seven days. Confirmatory factor analysis (CFA) was performed as larger samples generally produce more stable solutions and are more likely to be replicable . A samplThe original English language version of the TTM was translated into the Malay language in the following steps. First, one author forward translated the English version into Malay, retaining the meanings and considering the children’s vocabulary level. Second, a local Malay lecturer bilingual in Malay and English back-translated the Malay version to English. Third, two experienced lecturers in sports sciences, sports psychology and physical activity reviewed the English translation from Malay and the Malay translation from English and compared each item to its corresponding item in the original English version. They also assessed whether the contents were compatible with Malaysian culture and noted any deviations in meaning. Fourth, a pre-test of the final version of the TTM was carried out with a class of thirty 12-year-old students at Sekolah Kebangsaan Seri Kota, Kota Bharu, Kelantan. They were asked to answer the questions and comment on the wording of the questionnaires. The pre-test results indicated a need for several changes in the wording and presentation to make it easier for the students to answer.The stages of physical activity adoption was developed by Marcus et al. . For sixThe processes of change construct was developed by Nigg et al. . In thisThe decisional balance construct was developed by Plotnikoff et al. . In thisThe self-efficacy in exercise construct was developed by Bandura . The revThe Leisure-time Exercise Questionnaire (LTEQ) was developed by Godin and Shepard , was useData collection was conducted in Sekolah Kebangsaan Seri Wakaf Bharu, Kelantan. Convenience sampling was used to recruit students from classes not taking major school or national exams. The study was approved by the Research Ethics Committee of Universiti Sains Malaysia (USM/JEPeM/18020104) and conducted in accordance with the Declaration of Helsinki. Approval was also obtained from the Malaysian Ministry of Education, Kelantan State Education Department and schools. The study followed a two-step validity process; content validity was checked by the translation process, and construct validity was checked via CFA.Students were given consent and assent forms for their parents to read, comprehend and sign to allow their children to participate in this study. The students were informed that their participation was voluntary and that they could withdraw from the study at any time without any loss of benefits to which they were entitled. The questionnaires were administered to the students during school hours, and was conducted in the school’s main hall. Before the students completed the questionnaires, each section was clearly explained to them. The students took approximately an hour to complete the questionnaires. Once they finished, the students were given an honorarium in the form of a certificate as a sign of gratitude for participating in the study. The study results were also shared with the school.Statistical analysis was carried out using Mplus version 8 and SPSS version 22. Data were screened for missing values before the analysis. Nineteen students had more than five missing values, so they were excluded from the study. Another 20 students did not have signed informed consent forms, leaving a total of 381 questionnaires for analysis. The numerical data was reported as means and standard deviations, and the categorical data as frequencies and percentages. Descriptive analysis and Cronbach’s alpha were conducted using SPSS. A CFA function is not available in the SPSS package, so CFA and composite reliability was conducted using Mplus. The following fit indices were used to assess the CFA model fit: comparative fit indices (CFI) and Tucker and Lewis index (TLI) with a desired value of more than 0.92; and root mean square error of approximation (RMSEA) and standardised root mean square (SRMR) with a desired value of less than 0.08 . FurtherP-value = 1.00. The initial model for decisional balance also fit the data well: SRMR = 0.045, RMSEA = 0.038 (90%CI = 0.014–0.057), RMSEA P-value = 0.844. Although CFI (0.897) and TLI (0.864) indicated that the model did not fit the data well, the model for decisional balance was not further modified as the items in decisional balance were found to be suitable and important for the study population. The initial model for self-efficacy showed very poor fit  and required modification. After adequate theoretical support was carried out, the error correlations of several items, including items 4 with 8, 12 with 13, and 8 with 15, were iteratively added to the model. Low-loading items 4, 5, 9, 12 and 16 were removed to acquire better fit. The final model for self-efficacy had good fit based on several fit indices: CFI = 0.934, TLI = 0.915, SRMR = 0.042, RMSEA = 0.032 (90%CI = 0.011–0.047), RMSEA P-value = 0.977.The measurement model in The study aim was to determine the validity and reliability of the TTM Malay version questionnaires for Malaysian children. This study combined three distinct questionnaires on processes of change, decisional balance and self-efficacy as it was important to measure these changes across the stages of change. However, due to the large scope of measuring the changes in the three constructs across the stages of change  and calculating the construct validity and internal reliability of each construct, the authors believed that it was sufficient to analyse the latter via CFA in the Malaysian setting. Moreover, to the authors’ knowledge, fewer validation studies have used CFA with younger populations than have measured these constructs across the stages of change . NonetheThe processes of change measured overt  and covert  changes to individuals’ health behaviour. For adults, most studies have replicated a good fit for the model –33. HoweThe environmental re-evaluation factor was also removed due to low factor loadings. Only two of its three items showed low factor loading, but it could not be represented by only one item, so it was removed. Item 7  was a straightforward question that students could easily understand and showed acceptable factor loading . Item 8 Decisional balance, another construct in the TTM, represented the pros and cons of adopting more physical activity for individuals’ lifestyles. In similar studies on adults, a two-factor, 10- item questionnaire showed good validity and reliability , 43. In The study results showed low factor loadings for items 3, 4, 6, 7 and 8 . Item 3  and item 4  represented the pro factor. Item 6 , item 7  and item 8  represented the cons factor. These factors may have been relevant to adult and college-age populations, but the children might not have had sufficient responsibility to make decisions based on the pros and cons of exercise. A revised model of decisional balance provided sufficient evidence among genders and ethnicities but not age groups . For exaP-value = 0.977. Previous studies showed a good-fit model for a three-factor, 18-item scale , followed by self-efficacy (18 items) and decisional balance 10 items), based on previous validation studies conducted with Asian adults and adolescent populations  items, b, 48. TheThe validity and reliability of the Malay version of the TTM questionnaires  for physical activity among Malay primary school children were tested using CFA. This study provided insights into the use of the TTM for physical activity in the Malaysian setting. Extensive modifications, particularly correlating the items’ residuals and removing problematic items, were needed to improve the model for younger children. The final version of the TTM questionnaires for Malay primary school children had 24 items for process of changes, 13 items for self-efficacy and 10 items for decisional balance. A total of 47 (81%) of 58 TTM items were retained. The shortened version of the Malay version of TTM questionnaires was considered to be valid, and the remaining items were found to be suitable for Malay primary school children.


The gradient relationship between mean corpuscular volume (MCV) and mortality due to ischemic vascular disease has not been researched using a large-scale population-based study. This study evaluated the association between MCV and death attributable to cerebrovascular disease (CVD) and cardiovascular disease (CAD) in a large population- and community-based Taiwanese cohort. A longitudinal study with a 9-year follow-up was conducted to evaluate individuals aged 20 years or older who had participated in the Keelung (the northernmost city in Taiwan) community-based integrated screening (abbreviated as KCIS) program since September 1999. The mortality rates associated with CVD and CAD were classified across a range of different MCV levels. Increased MCV levels were associated with an increased risk of CVD/CAD-related death . Marginally statistically significant associations were noted for specific deaths from ischemic heart disease  and cerebral ischemic stroke , respectively, but no significant gradient relationship was noted for death from cerebral hemorrhage stroke . A gradient relationship between baseline MCV level and CVD/CAD-related death was noted, but whether such gradient relationships existed for two specific deaths and how these relationships may be confounded by extraneous factors that were not considered here should be investigated in the future. Effective preventive strategies for ischemic disease and stroke in Asia are important for stopping the increasing trend, especially given that more than 60% of the world’s population is located in Asia2. Therefore, the importance of identifying the potential risk factors that are responsible for the occurrence of stroke cannot be overemphasized. Many major risk factors, such as hypertension, diabetes mellitus, hyperlipidemia, and heart disease, can lead to stroke5. However, some risk factors, particularly those related to hemorheology, have not been well defined. Platelets play an important role in stroke, and antiplatelet agents are one of the main interventions for the prevention of primary and secondary ischemic stroke (IS)7. Several studies have revealed the relationship between stroke and white blood cell (WBC) count and subtype, and the results have demonstrated that WBC count is an independent predictor of stroke severity and outcome after acute IS8. Another study found that an elevated WBC count was positively associated with poor clinical outcomes in patients with acute IS9.In light of the global burden of disease (GBD) based on the World Health Organization (WHO) database, ischemic heart disease  and stroke  are the second and third most common causes of death and disability. These diseases are independent of gender and the country’s economic status (developing or developed), which has led to a dramatically increased absolute number of patients on healthcare encumbrance10 and susceptibility to cardiovascular events11. Another study addressed the relationship between RDW and the incidence of cardiovascular events in people with coronary disease12. Other studies have examined RDW in relation to the risk of cardiovascular morbidity and mortality14. RDW is an indicator of variation in red blood cell (RBC) size within blood samples, not the actual width of individual RBCs. RDW-coefficient of variation (CV), a measure of RDW, is derived from the equation (1 unit of standard deviation [SD] of erythrocyte volumes divided by mean corpuscular volume [MCV]) × 100%15. Therefore, a relationship exists between RDW and MCV. MCV is the common item of the complete blood count (CBC) examination package without any transformation. However, few studies have investigated the association of cerebrovascular disease (CVD)/cardiovascular disease (CAD). One case-control study conducted in 2001 identified an association between MCV and peripheral arterial disease in male subjects16. MCV may also predict left atrial stasis in patients with nonvalvular atrial fibrillation17. Based on these findings, elevated MCV may play a significant role in ischemic vascular disease. However, no study has evaluated the temporal relationship between MCV and stroke in a large population- and community-based longitudinal study. In the present study, empirical data from the Keelung Community-based Integrated Screening (KCIS) program in Taiwan were evaluated. The KCIS program collected information on factors associated with metabolic syndrome and biological markers (including MCV). In this large longitudinal study, the relationship between MCV and mortality from various types of cardiovascular disease, in addition to other established factors, was evaluated during a long-term follow-up.Despite these findings, how red blood cells affect stroke risk has not been fully elucidated. A previous study explored the association between red blood cell distribution width (RDW)After a 9-year follow-up  period, CVD- and CAD-specific mortality rates were estimated based on demographics, biomarkers, and lifestyle factors  compared with the proportion of individuals who were still alive (7.3%). Of the 3642 total deaths, there were 663 deaths from CVD/CAD, and this group included a slightly increased proportion of participants with an elevated MCV level. A greater proportion of participants who had specific causes of death related to CVD/CAD, particularly cerebral IS and ischemic heart disease (IHD), demonstrated elevated MCV levels , outcomes were stratified by cause of death. Conventional risk factors, including components of metabolic syndrome, hypertension, hyperglycemia, and anemia, had significant effects on IS-related death. Additionally, an elevated MCV level was a significant risk factor compared to a low MCV level . After adjusting for other significant factors, an elevated MCV level showed a marginally significant association with IS-related death , and the trend was of borderline statistical significance .In addition to the above well-known factors, an elevated MCV level was also statistically significantly associated with an increased risk of CHS-related death ; however, an elevated MCV level showed a lack of a significant effect on CHS-related death  after adjusting for other factors. In the univariate analysis, the effect of MCV on specific mortality from IHD was statistically significant . After adjusting for potential confounding factors, an elevated MCV level remained significantly associated with the risk of death from IHD , but the gradient relationship between MCV level and IHD-related death was marginally statistically significant   was associated with a significant increase in CVD/CAD-related mortality. Participants with a level above the mean difference had 1.96 times the risk of CHS-related mortality compared with those with levels below the mean difference. However, there was a lack of significant findings among the causes of mortality after adjusting for age, gender, baseline MCV, and anemia. The influence of the rate of change in MCV on mortality was evaluated using the difference in MCV divided by the time between two MCV measurements. The results show that the change rate far above the mean value (−0.13) led to a 1.99-fold greater risk of CHD-related mortality compared to that below the mean value, but this relationship was not statistically significant in the multivariable analysis after adjustment for age, gender, baseline MCV, and anemia. The lack of significance may be due to the adjustment for baseline MCV in the multivariable analysis  was an independent risk factor for CVD- and CAD-related death, with a possible larger impact on death caused by IS and IHD but less influence on CHS. These findings may suggest that the mechanisms of IS and CHS differ. The results remained significant after adjusting for multiple CVD and CAD risk factors. Overall, an elevated MCV level (>99 fL) was associated with a 42% increase in the risk of death related to CVA/CAD and 66% and 44% increases in the risk of death related to IS and IHD, respectively, compared with a low MCV level (<95 fL). Importantly, these findings were further confirmed by the significance of the dose-response relationship between MCV level and risk of death. According to the annual hazard rate of mortality due to cerebral ischemia (CIS), shown in Supplemental Fig. The novel findings mentioned above are in contrast to the results of most previous studies in several aspects. First, the target populations in the majority of these previous studies were based on consecutive clinical series, whereas the present study was based on a community-based screening program representative of the general population.11. Another community cohort study examining RDW and the risk of cardiovascular events and mortality found that an elevated RDW was associated with an increased risk of mortality, but not the development of CAD, in the general population11. A large population-based cohort study from the healthcare maintenance organization in Israel reported that the risk of cardiovascular morbidity and all-cause mortality was significantly associated with an increase in the percentage of RDW13. A Swedish cohort conducted by Malmo revealed that the incidence of fatal coronary disease increased with increasing RDW, but this relationship was not observed for nonfatal disease14. Collectively, these studies reveal that elevated RDW is associated with increased cardiovascular events and deaths, but it should be noted that MCV was not evaluated. A previous case-control study found an association between MCV and peripheral arterial disease in males and concluded that an elevated MCV is a predictor of symptomatic peripheral arterial disease15; however, the influence of MCV on the arteries in the brain and heart was not assessed. A previous study using MCV and RDW to predict left atrial stasis in patients with non-valvular atrial fibrillation17 revealed that both parameters may be markers of left atrial stasis. However, no studies have focused on the relationship between MCV and CVD/CAD mortality, especially in IS and IHD. The third unique feature of this study is that the outcomes included not only all-cause mortality but also various causes of death. Finally, the temporal relationship between MCV and CVD/CAD mortality was further reinforced by a gradient relationship.Second, most studies have focused on RDW rather than MCV. A randomized trial examined the relationship between RDW and cardiovascular event rate in people with coronary disease and concluded that a greater RDW was a risk factor for death and cardiovascular events18. Factors that affect blood viscosity include hematocrit, erythrocyte aggregation, erythrocyte flexibility20, platelet aggregation and plasma viscosity19. Hematocrit is a major factor that influences blood viscosity, and there is a logarithmic relationship between viscosity and hematocrit19. Hematocrit plays an important role in blood viscosity, which may also contribute to cerebral and heart ischemia. However, as such information on hematocrit examination was not available in the present cohort, its independent role in the mortality of cerebral ischemic stroke and IHD could not be assessed. However, such an interesting subject is worthy further investigation.There are several reasons for the biological plausibility of MCV. First, the finding that elevated MCV increased the mortality associated with CVD and CAD can be explained by the pathophysiology of cardiovascular and cerebrovascular ischemia. According to the general role of cardio-cerebral blood rheology, cardio-cerebral blood flow is reduced by increased blood viscosity24. Previous studies have revealed the significant effect of hemoglobin on CVD and CAD. Undoubtedly, when investigating the risk factors for CVD and CAD, hemoglobin should be considered. Because the current study data were based on an integrated screening that included various biomarkers and general CBCs, these markers could be adjusted for in the multivariable analysis. The results showed that hemoglobin concentration has a significant effect on both CVD and CAD, similar to previous findings.Second, anemia and hemoglobin levels are strong predictors of the development of CVD- and CAD-related mortality in various populations25, and some studies have also revealed the significant impact of deficiencies in vitamin B12 and folate on IS26. The putative mechanism that drives an increase in MCV level might result from these deficiencies, which implies that MCV may be a risk marker rather than a risk factor for CVD/CAD-related death. Moreover, factors affecting MCV also include existing diseases 28 and lifestyle factors 29. The association between MCV level and CVD/CAD-related death may be partially explained by these factors. In the multivariable regression analysis, the statistically significant gradient relationship with an emphasis on IS- and CHD-related deaths was attenuated to borderline statistical significance when these additional variables, such as abnormal liver function, eGFR, exercise, and vegetable intake, were controlled in the model. Significant gradient relationships were shown after removing these variables possibly associated with MCV level, as noted in Supplementary Table Third, in addition to gender and age, MCV level is associated with nutritional deficiency, such as deficiency in vitamin B12, iron, or folic acid12. To identify the best marker, RDW should be evaluated in a future study. Second, no information on IS subtypes, such as large-vessel IS, small-vessel IS or cardiogenic stroke, was available, and therefore, the relationships between stroke subtype and MCV level could not be specifically assessed. Third, no detailed information on anemia subtypes  was available, which prevented further analysis of this variable despite the fact that different types of anemia cause different vascular injuries24. Several other factors affecting MCV were not considered in the current study, including other diseases 28 and drug use 30. Third, the sparsity of deaths may limit the statistically significant associations, particularly when two specific deaths were investigated. A larger study is therefore required to gain a better understanding of how these factors may affect MCV level in association with CVD and CAD deaths.This study has several potential limitations. First, because the screening procedure did not include RDW data, MCV could not be compared with RDW in this cohort study. According to other study results, RDW may also be a risk factor for CADIn conclusion, the results of this study demonstrated that elevated MCV dose-dependently increased the mortality rates attributed to CVD and CAD. This finding supports the use of MCV as a new biomarker for the prediction of risk of death due to CVD and CAD, but a larger study is required to elucidate the specific influences on IS and IHD.31. The KCIS program combined health evaluations for these diseases with a routine check of biomarkers and a physical examination. Residents aged 20 years and older based on a population-based household registry were invited to participate. This outreach program still exists and serves approximately 20,000 residents annually. The coverage rate of the KCIS program exceeds 65%.The study population was gathered from an outreach, integrated screening program in Keelung, known as the KCIS program, which was launched in September 1999 to evaluate characteristics related to five types of cancer  and three chronic diseases th and 75th percentiles was 4.31 and 7.51 years, respectively.The KCIS database was utilized to conduct a longitudinal study to investigate the effect of baseline MCV on mortality from CVD or CAD. To ensure adequate induction time for the occurrence of stroke or CAD, the study subjects (limited to enrollees aged 40 years or older) were analyzed between 2000 and 2009 and were followed until the end of 2010. The median follow-up time was 6.21 years with minimum and maximum follow-up times of 0.03 and 8.75 years, respectively. The distribution of time for the 2533. Both systolic blood pressure (SBP) and diastolic blood pressure (DBP) were measured twice with intervals of more than 20 minutes. The lower of the two values was used in this study. The procedure for measuring blood pressure was also described previously33. Exercise was defined as non-occupational physical activity and was also collected as a dichotomous variable (Yes/No) from the participants using the question, “Do you perform leisure-time exercise at least once regularly per week with a duration of at least 30 mins each time?” Those who answered “Yes” were defined as frequent exercisers, and the others were defined as infrequent exercises. Moreover, as the aim of this study was to evaluate the effect of changes in MCV, those who attended the program two or more times during the study period were focused on.Those who participated in the KCIS outreach screening program were given a structured questionnaire by well-trained public health nurses to collect demographic features, anthropometric measurements, lifestyle factors, biomarkers, and self-reported family histories of cancer and chronic diseases. Information on alcohol consumption and cigarette smoking was also obtained, including age at commencement, current status , duration of cessation, frequency and length of time. Further details are described elsewhereA whole blood examination, including WBC, RBC, hemoglobin, platelet, and MCV measurements, was performed. According to standard laboratory measurements of MCV, those who had MCV >99 fL and <80 fL were classified as high and low MCV levels, respectively. In addition to two extreme criteria, the middle values were categorized as 80–94.9 fL and 95–98.9 fL. The crude mortality rates of CVD/CAD were 1.44, 1.39, 1.92, and 3.99 per 1000 for <80, 80–94.9, 95–98.9, and >99 fL -9 was used for National Mortality Registry Database coding, but the ICD-10 has been used since 2009. Specific causes of death were identified with the following codes: cerebral IS: 433, 434, 436, 437; CHS: 430, 431, 432; hypertensive disease: 401, 402, 403, 404, 405; IHD: 410, 411, 412, 413, 414; heart failure: 428; pulmonary heart disease and pulmonary circulation disease: 415, 416, 417; disease of arteries, arterioles, and capillaries: 440, 441, 442 (other aneurysm), 443, 444; other venous embolism and thrombosis: 453; late effect of CVD: 438. The ICD-10 was also utilized in the same manner as the ICD-935, but central obesity was redefined as a waist circumference ≥90 cm in men and ≥80 cm in women based on the Asia-Pacific WHO conference. A TG level ≥150 mg/dL was classified as abnormal. Abnormal HDL was defined as lower than 40 mg/dL for males and as lower than 50 mg/dL for females. Those who had a history of hypertension, a SBP ≥ 130 mmHg or a DBP ≥ 85 mmHg were defined as having abnormal BP. A fasting plasma glucose level ≥ 100 mg/dL or a history of diabetes mellitus (DM) was classified as abnormal.The first screening results, defined as the baseline, included biochemical markers, lifestyle factors, previous disease history, and anthropometric data. Metabolic syndrome was defined according to the U.S. National Cholesterol Education Program Adult Treatment Panel III (NCEP-ATP III)The results obtained at the first screening, including biochemical and anthropometric data, were utilized as the baseline measurements in this study. Causes and dates of death were obtained from the Taiwan National Mortality Registry Database. Time-to-death analysis was conducted to calculate the individual follow-up person-year value from the first date of screening entry to the date of death. Those who were still alive at the end of 2010 or had died from other causes of death (whichever came first) were treated as censored cases. The cumulative mortality rate of specific causes of death at each half-year was estimated using an actual life-table method according to different MCV levels. To check the proportional hazards assumption, a graphical method was used to plot log) against log(time) to check whether subgroups paralleled each other; second, a time-dependent Cox model was applied to check whether the MCV level interacts with time. A Cox proportional hazards regression model was constructed to estimate the hazard ratios (HRs) for different MCV levels with regard to specific causes of death and to obtain the adjusted HR (aHR) after adjusting for potential confounding factors. The parsimony model for each Cox proportional hazards regression was used with a p-value entry level of less than 0.1. The significance level was set to 5% for all statistical tests. Statistical analysis was performed using SAS, version 9.4 .Informed consent was obtained from all subjects for inclusion in this study, which was governed by the Health Bureau. This study was reviewed by the Ethics Committee of Chang Gung Memorial Hospital and was approved by the Institutional Review Board with Issued Numbers 103-4784B and 104-0263C.All procedures followed were in accordance with the ethical standards of the responsible committee on human experimentation  and with the Helsinki Declaration of 1975, as revised in 2008.Supplemental file


Background: Overweight and obesity are increasing at an alarming rate in South Africa, while childhood undernutrition remains persistently high. This study determined the magnitude and predictors of stunting and underweight among schoolchildren in the Dikgale and Health Demographic Surveillance System Site, a rural site in South Africa. Methods: A cross sectional study using multistage sampling was conducted among 508 schoolchildren and their mothers. Anthropometric measurements were taken from children and their mothers, while sociodemographic information was obtained from mothers using a questionnaire. The World Health Organization Anthro Plus was used to generate height-for-age and weight-for-age z-scores to indicate stunting and underweight, respectively, among the children. Maternal overweight and obesity were assessed using body mass index. Bivariate and multivariate logistic regression analyses were used to evaluate the predictors of stunting and underweight among schoolchildren. Results: Twenty-two percent (22%) of children were stunted and 27% were underweight, while 27.4% of the mothers were overweight and 42.3% were obese. The odds of being stunted were lower in younger children, whereas having a mother who was overweight/obese and had a short stature increased the odds of stunting. Access to water, having a refrigerator, and having a young mother were protective against being underweight. Having a mother who was overweight/obese increased the odds of being underweight. Conclusions: The study showed a high prevalence of stunting and underweight among children, and overweight and obesity among mothers, indicating a household double burden of malnutrition. The age of the child and maternal overweight/obesity and short stature were predictors of stunting and underweight, while having a younger mother and access to water and a refrigerator were protective against being underweight. The need for an evidence-based and feasible nutrition program for schoolchildren, especially those in rural schools, cannot be over-emphasized. Childhood undernutrition remains a major public health problem in Sub-Saharan Africa, including South Africa ,2. UnderUnderweight  remains one of the most common causes of morbidity and mortality among children throughout the world and is a composite measure of stunting and thinness  ,13. UndeThe United Nation International Children’s Fund (UNICEF) has indicated that stunting is the most prevalent form of child undernutrition. Globally, more than 200 million school-aged children are stunted and underweight, and if no action is taken, the number will grow to nearly a billion by 2020 . StuntinThe World Health Organization (WHO) Framework on Childhood Stunting indicates that stunting results from a complex interaction of household, environmental, socioeconomic, and cultural influences . StewartSchool-aged children are amongst the most vulnerable groups within the population due to their susceptibility to undernutrition, which is attributable to the vicious cycle of poverty ,28,29. IIn South Africa, undernutrition remains persistent among schoolchildren, despite efforts to alleviate it through the National School Nutrition Program, which was introduced to provide primary schoolchildren with nutritious meals. Stunting, in particular, is identified as a major global health priority  because This paper is an extraction from a doctoral dissertation written by the first author, which determined the growth patterns of primary school children and the maternal factors influencing these growth patterns. The doctoral dissertation also explored the influence of the cultural beliefs and practices of mothers on the growth of children in the Dikgale Health and Demographic Surveillance System Site. The study used a convergent mixed method design with parallel phases of quantitative and qualitative enquiry. A cross-sectional quantitative survey was used to determine the growth patterns of schoolchildren using nutritional indicators for stunting, underweight, thinness, and overweight/obesity. In addition, data on the anthropometry, socio-demographics, obstetric history, knowledge of nutrition and child growth, the influence of societal cultural beliefs and practices on child nutrition and food security were collected from the mothers. In the qualitative phase of the enquiry, focus group discussions were conducted to explore the influence of socio-cultural beliefs and practices of the mothers on their children’s growth and nutrition. The study was conducted from August 2017 to December 2017. This paper reports on the prevalence and predictors of stunting and underweight among schoolchildren in the research population in a rural context.The study was conducted in the Dikgale Health and Demographic Surveillance System Site (DHDSSS). The DHDSSS is a well-researched rural site that was founded in 1995 and forms part of the International Network for the Demographic Evaluation of Populations and their Health (INDEPTH). INDEPTH is an umbrella organization for a group of independent health research centers operating 43 Health and Demographic Surveillance Sites in 20 LMICs . The DHDThere are 19 public primary schools in the villages forming part of the DHDSSS, with an estimated total enrolment number (EN) of learners of 7772 in 2016, ranging from an enrollment number of 112 children in the smallest school to 776 in the largest school . The priThis was a child–mother paired study. The study population comprised of primary school learners and their mothers.The sample size was calculated using Rao software . The sofA structured interviewer-administered questionnaire, translated from English to a local language (Sepedi), was used to collect data. The questionnaire took into consideration the determinants of nutritional status  and coveFor the children, anthropometric measurements were converted to height-for-age z scores (HAZ) and weight-for-age z scores (WAZ) and compared to reference data for 5–19 year olds. The children were classified as stunted if the HAZ was less than or equal to −2SD or underweight if the WAZ was less than or equal to −2SD. The Anthro-plus software was unable to generate weight-for-age (WAZ) values for 189 children because the indicator excludes children aged 11 years and above. Thus, a sample of 319 was analyzed for WAZ for children 10 years old and younger. According to the software, WAZ reference data are not available beyond 10 years of age because this indicator does not distinguish between height and body mass in the age period where many children experience pubertal growth spurts and may appear to have excess weight (by weight-for-age) when in fact they are just tall .2) = weight (kg)/height (m2)). Normal BMI is within 19 to 24 kg/m2. Underweight is defined as BMI < 18.5 kg/m2, overweight as BMI of 25 to 29.9 kg/m2, and obesity as BMI ≥ 30 kg/m2. The cut-off point for central obesity in females is a waist circumference ≥88 cm [For the mothers, body mass index (BMI) was calculated as the weight in kilograms divided by the height in meters squared  with a 95% confidence interval (CI) were generated and used to determine the independent strength of the associations. Significance was considered at p < 0.05.The data were analyzed using STATA version 14. Descriptive statistics for the age, body weight (W), height (H), and HAZ and WAZ of the children were computed for the mean, the standard deviation (SD), the median, and the interquartile range (IQR). Comparison of the means was done using a Mann–Whitney test, while the percentages of children with variables below, on, or above the cut-off points were compared using a chi-square test. Bivariate and multivariate logistic regression analysis was used to determine the association between the nutritional status indicators of children, their stunting and underweight, and independent variables. Bivariate analyses were used to identify the association between the dependent variables and each of the independent variables. Independent variables that had a This study was conducted according to the guidelines laid down in the Declaration of Helsinki and all procedures involving human subjects were approved by Sefako Makgatho Health Sciences University Research and Ethics Committee (SMUREC) (SMUREC/H/161/2016: PG). Furthermore, this study received permission from the Department of Education (DoE) in the Limpopo Province, South Africa. The nature of the study was explained to the mothers of the children prior to their participation. Informed consent was obtained from the mothers and verbal assent was obtained from the children.n = 225) and the intermediate phase as school grades 4 to 7 (n = 283). The children were further divided into two age groups; younger children aged 6–9 years old (n = 254) with a mean age of 8 years (SD = ±1) and older children aged 10–15 years old (n = 254) with a mean age of 11 years (SD = ±1). The anthropometric data from 508 schoolchildren were imported into Anthro-plus to generate HAZ and WAZ. From the sample of 508 children, the software used a weighted sample of 508 for HAZ  and 319 for WAZ . This meant that 189 children aged above 10 years and older were excluded by the software and, thus, had no WAZ values.A representative sample of 508 primary schoolchildren aged 6–15 years was achieved in this study, with a mean age of 10 ± 2.2 years. Of the 508 child participants, 209 (41%) were boys and 299 (59%) were girls. The children who participated in this study were in grades 1 to 7, and were categorized into two phases by school grade. The foundational phase was categorized as school grades 1 to 3 (p ≤ 0.0001), weight (p ≤ 0.0001), and height (p ≤ 0.0001) were observed between the foundation and intermediate phases. No significant differences in HAZ (p ≤ 0.25) or WAZ (p ≤ 0.26) were observed. Significant differences in age (p ≤ 0.0001), weight (p ≤ 0.0001), height (p ≤ 0.0001), HAZ (p ≤ 0.0001), and WAZ (p = 0.03) were observed between children aged 6–9 years and 10–15 years. The results showed no significant differences in age, weight, height, HAZ, or WAZ between boys and girls.In p = 0.01), and between younger children and older children . There was no significant difference observed between boys (25%) and girls . Severe stunting (HAZ < −3 z-scores) was observed in 5% of children with stunting. A few  children were very tall according to the HAZ cut off measures and were excluded from the analysis. The prevalence of underweight in the schoolchildren was 27%. There was no significant difference between the foundation and intermediate phases (27% vs. 28%), younger and older children (25% vs. 35%), or between boys and girls (28% vs. 27%). Of the underweight children, 6% were severely underweight (WAZ < −3 z-scores). A small proportion  of children had a growth problem as indicated by the WAZ cut off measures and were excluded from the analysis. Just less than half (43.4%) of the children suffered a combination of underweight and stunting (results not shown in tables).The comparison of the prevalence of stunting and underweight by the categorical independent variables are presented in p ≤ 0.0001). Mothers who were short were two times more likely to have stunted children  and mothers who were overweight/obese were almost two times more likely to have stunted children . On the other hand, underweight was significantly associated with maternal age, maternal BMI, water access, and having a refrigerator, after controlling for child age and gender, learning grade, maternal WHR, WC, height, marital status, employment, education, household income, and household size. Younger mothers were less likely to have underweight children . Mothers who were overweight/obese were almost two times more likely to have underweight children . Children with access to water were less likely to be underweight  when compared to children with no access to water . Children living in a household with a refrigerator were less likely to be underweight .The results of logistic regression analyses to determine the predictors of stunting and underweight are presented in This study determined the prevalence and predictors of stunting and underweight in primary schoolchildren in a rural context. Most of the mothers and their children lived within a depressed socio-economic status, as indicated by high rates of unemployment with no income (82.3%) and a dependency on social grants (86.8%). The majority lived in large households with 5–9 members, used pit toilets (95.5%), and had access to water (73.8%), with electricity being a common source of energy (78.5%). The South African National Health and Nutrition Examination Survey (SANHANES-1) reported unfavorable socio-economic conditions in most South African households . MothersIn the current study, the prevalence of undernutrition in the form of stunting (22%) and underweight 27%) was reported among the child participants. In contrast with the reports of studies in other rural South African settings, this study reports a higher prevalence of stunting compared to the previously estimated 6–9% % was rep and 7.4–The current study reported the age of the child, maternal height, and maternal BMI as predictors of stunting. A higher prevalence of stunting was observed among children aged 10–15 years (30%) than children aged 6–9 years (14%). The study reports reduced odds of younger children being stunted . The findings of this study are consistent with those reported in various parts of Ethiopia and in Indonesia; that stunting is significantly higher in children older than 10 years when compared to younger children ,56,57,58In the current study, mothers who were overweight/obese were more likely to have stunted children . Similar findings on the association between stunting and maternal BMI has been reported in India . The resThis study further showed a prevalence of 27% for underweight in schoolchildren. There were no significant differences in the prevalence of underweight for gender, age groups, and school phases. In contrast with the reports of studies in other rural South African settings, this study reported a higher prevalence of underweight (27%) compared to the 5–7%  reportedA significant association of underweight with maternal age, BMI, access to water, and having a refrigerator was observed in this study. Factors associated with underweight among children below five years of age have been well studied in various countries such as Ghana, Ethiopia, and Nepal ,71,72. HIn the current study, underweight predictors were maternal age, BMI, access to water, and having a refrigerator. In addition, overweight/obese mothers were more likely to have underweight children . The results further showed that not having a refrigerator was significantly associated with being underweight . The current study also revealed that access to water was protective against being underweight . In African countries such as Nigeria, the probability of a child being underweight was significantly lower for children drinking borehole or piped water. Researchers have reported that bad-quality water can predispose diarrhea, which is associated with underweight .The findings from this study should be considered in view of some limitations. Similar to other studies using a cross-sectional study design, we could only make inferences about the associations of stunting and underweight with child and maternal factors. We could not establish causality or temporality of events, which requires a longitudinal study design. Nevertheless, we believe that the present study sheds light on the prevalence and predictors of stunting and underweight among school-aged children in the DHDSSS, South Africa. The results of this study cannot be generalized to other areas in South Africa, since this site is a very small rural area in one specific province and the situation may vary considerably in urban areas.In conclusion, the prevalence of stunting and underweight were high among schoolchildren while their mothers were overweight and obese, indicating a household double burden of malnutrition. Thus, the need for an evidence-based and feasible nutrition program for primary school children, especially those in rural schools, cannot be over-emphasized. The study also found that the child’s age, maternal stature and, BMI were significant predictors of stunting, while maternal age, maternal BMI, access to water, and not having a refrigerator were predictors of underweight. This study advocates a dedicated effort by the South African government to further address stunting and underweight among schoolchildren in rural areas, toward achieving goal two of the Sustainable Development Goals, while considering ongoing school nutrition services. Furthermore, public health campaigns on the consumption of balanced diets that involve nutritionists at schools and the education of mothers to enhance the acceptability of health interventions are paramount to improve the nutritional status of children.


Good sleep is essential to human health. Insufficient quality sleep may compromise the wellness of nurses and even jeopardize the safety of patients. Although the contributors of sleep quality in nurses have been previously studied, the direct and indirect effects of modifiable work-related predictors remain uncertain.The study was designed to explore the direct and indirect effects of modifiable work-related factors on sleep quality in Chinese nurses.A multistage sampling method was employed in this cross-sectional study to recruit 923 participants. An evidence-based predicting model was postulated and then subsequently tested and optimized using path analysis.The final model fit the data well, with the involved predictors accounting for 34.1% of the variance in sleep quality of the participants. Shift work, job demands, exposure to hazards in work environments, chronic fatigue, and inter-shift recovery were identified as direct predictors, while whereas job satisfaction, job control, support at work, and acute fatigue were identified as indirect predictors.Sleep quality in Chinese nurses is influenced directly and indirectly by various modifiable work-related factors. Interventions such as adjusting work shifts and reducing job burdens should be prioritized by administrative staff to ensure the sleep quality and clinical performance of Chinese nurses and to subsequently improve nursing care quality. Although “sleep quality” is widely used, this term lacks definitional consensus. A panel of experts that was recently assembled to address this intellectual enquiry drew the conclusion that sleep continuity variables such as sleep latency, length of sleep, and frequency of awakenings as well as sleep efficiency are appropriate indicators of good sleep quality across the human life-span . AdequatThe Centers for Diseases Control and Prevention have declared that “sleep is essential for good health; it is a vital necessity, not a luxury.” However, inherently involved in intense and hectic work, nurses are always at a high risk of insufficient sleep and sleep disorders . In an aAfter a thorough literature review, an initial model incorporating nine explanatory variables was established Figure . Except Shift work was identified repeatedly as one of the significant factors affecting sleep quality in nurses . BecauseA synthesis of job demands , job control (decision latitude), and support at work (support available from coworkers and supervisors) has been shown to credibly predict job strain , which hHazardous work environments are presumed to be associated with an elevated risk of physical injury and a lowered degree of safety support, and the cumulative effects of prolonged exposure to these environments carry a higher risk of adverse impacts. A recent literature review  on the eJob satisfaction is a noteworthy construct, especially in the realm of administration, that may predict work behaviors such as organizational citizenship and withdrawal behaviors such as absenteeism and turnover. The effects of poor job satisfaction may be so far-reaching that the overall feelings from one's job experience may even affect everyday (non-job-related) life activities. As reported by Fatigue in nursing staffs is a long-standing problem that comprises both chronic (long-term) and acute (short-term) aspects. Numerous studies have validated the significant correlation between employee fatigue and sleep quality . KorompeThe problem of sleep quality among nurses has become a critical issue for healthcare systems because of its high prevalence, negative effects on individual health and patient care quality, and associated costs. The modifiable work-related factors that impinge on sleep quality in nurses merit further exploration to evaluate and enhance the current situation. This study was designed to explore and describe the modifiable work-related factors that are capable of predicting sleep quality in Chinese nurses, to differentiate the direct and indirect effects of these identified factors, and to provide research-based evidence to help guide the future development of strategies to improve the sleep quality of nurses.2 + k + 1 , and k = the number of predictors for multiple correlation testing. When Type I error = 0.05 and power = 0.8, the L value was found to be 15.65 . Taking the number of variables and nonresponse rate into consideration, 1,071 nurses were invited to participate in this study.This cross-sectional design study was conducted in Chengdu, China. The inclusion criteria for participants were (a) working in inpatient departments, (b) providing direct patient care, and (c) working 8-hour/night shifts, whereas exclusion criteria were otherwise qualified nurses who were currently on maternity leave, had physical/mental diseases, or were taking medications during the data collection period. The sample size of the path analysis was determined using the formula: N = L/f + k + 1 , where Nbe 15.65 . Accordibe 15.65  on sleepA multistage sampling process was implemented to recruit participants. First, one general hospital was selected from each of the five districts in Chengdu by simple, random sampling. Second, we collected the lists of all eligible nurses from the selected hospitals and randomly sequenced each nurse by computer. Then, the nurses who would be invited to participate were selected from this list using systematic sampling.Ethical approval was obtained before commencing the study from the Institutional Review Board for Clinical Trials and Biomedical Research at the West China Hospital, Sichuan University (No. 2008SCU086). Official permission was granted by the targeted nursing departments, and written informed consent was obtained from all of the participants. Permissions from the original authors who had developed the scales that were used in this study were obtained by e-mail. The questionnaires used in this study contained no identifiable information. Data were analyzed at an aggregated level, and the authors were not able to identify the data of individual participants during or after data collection. Questionnaires were distributed by trained staff from each nursing department between December 2012 and April 2013. Upon distributing, every participant was informed about the study objectives and given detailed instructions. They were required to take his or her own time to complete and then seal the questionnaire and then to submit the sealed questionnaire within 3 days to the box outside their wards. One thousand nineteen completed questionnaires were returned, of which 923 were considered valid, giving an overall effective response rate of 86.18% .Demographics including age, marital status, education, professional and position title, years of working as a nurse, working unit, and number of night/evening shifts per month were collected.The PSQI is a psychometrically sound instrument that is widely used to quantify the subjective sleep quality of respondents over the immediately preceding 1-month period. The Chinese version, validated by strongly disagree” and 4 indicating “strongly agree.” In this study, the Cronbach's alpha for the three subscales were .76, .68, and .90, respectively.The Job Content Questionnaire, developed by never, 5 = always). This study presented good internal consistency  and test–retest reliability (.76 within a 2-week period), and the content validity index was rated at .87.The Exposure to Hazards in Hospital Work Environments scale is our modified Chinese version of the Hospital Occupational Hazards Scale , which wThe Job Satisfaction Scale  was desistrongly disagree, 6 = strongly agree). The Cronbach's alphas were .81 and .82 for the Chronic and Acute Fatigue Subscales, respectively, and .86 for the Intershift Recovery Subscale.The Occupational Fatigue Exhaustion Recovery scale , origina2, χ2/df, root mean square error of approximation (RMSEA), normed fit index (NFI), comparative fit index (CFI), and goodness of fit index (GFI). A nonsignificant χ2 and χ2/df remaining in between 1 and 2 indicate an acceptable model fit, and the RMSEA should be less than .05. With regard to NFI, CFI, and GFI, values no less than .90 indicate a good model fit, whereas values above .95 indicate an excellent fit (R2) was estimated to identify the variance in sleep quality that was explained by proposed factors.Data were analyzed using SPSS Version 23.0 and Amos Version 23.0 . Considering the different scales used by each instrument, all of the data, with the exception of demographic information, were transformed into a 0–100 ranking scale. Descriptive analyses were then used to delineate the sample characteristics. Pearson correlation analyses were first conducted to test if the associations among the variables met the prerequisites for performing path analysis. Next, path analysis was applied to test and modify the model. The model-data fit was evaluated using χlent fit . The boolent fit . Typicallent fit . This stThe participants had a mean age of 29.73 years; most were married (62.3%); 70.6% held an associate degree, and 17.5% held a baccalaureate or higher degree; nearly half were junior nurses (49.2%); and the overwhelming majority (92.6%) were staff nurses. The median year of professional nursing experience was 8.00. Nearly half (44.6%) of the participants worked more than eight night/evening shifts per month, and the largest percentages worked in the medical department (32.1%) and surgical department  failed to reach statistical significance. Thus, this pathway was ruled out in the following analyses, as per the prerequisite of conducting path analysis. Next, path analysis was performed to test, trim, and modify the hypothesized model. On the basis of theoretical reasoning and modification indices, three pathways  were added to generate a much improved fit, whereas two nonsignificant pathways  were removed to guarantee the parsimony of the final model. Multiple tests were conducted to compare the modified models, which yielded the best data-fit model , which echoed our stated hypotheses. In addition, the mediating role of chronic fatigue was confirmed. Contrary to our initial expectation, intershift recovery was also found to exert a direct influence over sleep quality . Job satisfaction, the only indirect predictor of outcome that was identified , should thus be regarded as a distal mediator. Contrary to our initial assumption, job control and support at work were found to have an indirect influence on sleep quality , whereas, in line with our initial assumption, the effect of acute fatigue  was found to be fully indirect. In addition, statistical significance was approached by all of the direct and indirect effects of sleep quality on the grounds of bootstrapping results  appropriately arranging work shifts and human resource allocations, (b) utilizing effective tactics to alleviate stress and reverse fatigue, and (c) optimizing the physical and psychosocial work environment.


Previous research has indicated that only children  have higher odds of obesity during childhood and young adulthood, compared with those living with siblings. However, little is known about whether the developing difference in overweight/obesity is accompanied by a difference in mental health .The subjects for this prospective study were a randomly generated cohort of 1348 high-school students in Guangzhou, China. Participants completed assessments of anthropometric indices, lipid profiles, family-based factors, lifestyle, and internalization of symptoms (including those of depression and anxiety).Compared to their peers with siblings, only children  had significantly higher risk for obesity. However, only children with overweight/obesity had lower OR for depression at follow-up , compared to individuals who were overweight/obese with siblings. This relationship was not significant for non-overweight individuals. No significant relationship between the number of siblings and anxiety at follow-up was observed, regardless of body mass index (BMI).Although being an only child was significantly associated with overweight and obesity among adolescents in China, participants with history of overweight/obesity are less likely to experience symptoms of depression associated with being an only child. Adolescent obesity is a major public health concern that has recently increased in prevalence , 2. AmonAlthough only children may be blessed with relatively more family and social resources, those who have no siblings for company may face physical and socio-psychological problems during development , 12. ComTo address this gap in knowledge, we sought to design a cohort study that included “community-based sample”. In other words, we followed a cohort of young people, including only children and those with siblings, who were free of anxiety and depression screened via a health survey at baseline but varied in terms of overweight/obesity status. Mental health outcomes were assessed at the end of the follow-up period. This prospective study sought to: (1) examine risk for overweight and obesity among children with siblings, compared to only children; (2) investigate how overweight/obesity status in children with siblings, compared with only children, affects mental health. Based on the results of prior studies, we hypothesized that only children would have an increased risk for overweight and obesity, compared to those with siblings. We also hypothesized that only children who were free of anxiety and depression but also exhibited overweight/obesity would have higher risk for anxiety and depression, compared with non-only children with overweight/obesity.This longitudinal health survey was conducted in Guangzhou city, Guangdong Province, southeast China. Guangdong Province is the most populous province in China; Guangzhou city is the capital of Guangdong Province. The investigation were based on two projects, one is titled as multidimensional assessment standards of sub-health in adolescents supported by the national high-tech research and development program (2006AA02Z427) and another project is named mental health in adolescents in Guangdong province supported by the Department of Psychological Education of Elementary and Secondary Schools of the Guangdong Province Administration. The participants were recruited from July 2008 to December 2009. We carry out the investigation according to the following steps. First, we signed informed consent with each participating school and the principal of each selected classroom. Then, the parents or guardians of the students were informed of the study through a written notice sent home from the schools asking them to contact the teachers by phone if they did not wish their child to participate in the survey before one week on screening day. Next, the team members explained the anonymous and confidential nature of the data to the students, and provided an opportunity for them to ask questions prior to the formal investigation. If they were not willing to participate, they were allowed to withdraw from the study. It will take approximately 40 minutes to completion of the self-reported questionnaire. A teacher and team member were always present in the classroom but was not permitted to intervene in the research procedure. The same investigation carried out after six months. Approval for the design and data collection procedures was obtained by the Department of Psychological Education of Elementary and Secondary Schools of the Guangdong Province Administration.Study participants were randomly selected from among the total student population attending high school within the region and were registered with the Guangzhou secondary school registry. A stratified random sampling method  was used for sample generation. At baseline, 1618 high school students provided usable information. Data were collected via health survey. Anthropometric indices and lipid profiles were evaluated within 1 week of survey administration. The cohort was then followed up for 6 months, with the survey conducted again to evaluate mental health outcomes at the end of follow-up. For the present study, a “community-based sample” cohort was generated from the larger cohort by screening for anxiety and depression at baseline. After data merging and cleaning, 1348 study participants, aged 12–18 yr, with an average age of 15.34 (± 1.81) yr, completed both pre-test and post-test phases of the study.Health survey information was collected using a self-administered questionnaire, which investigated demographics, family-based factors, and lifestyle factors. Questions pertained to age, gender, grade level, number of siblings, place of residence, perceptions of familial financial situation, parental education, time spent with parents during elementary school, skipping breakfast, sleeping hours, and physical activity.2). Participants were classified as overweight/obese or non-overweight, based on baseline measurements of weight. Overweight and obesity categories were defined according to the Working Group on Obesity in China (WGOC) BMI cutoff points based on age- and sex-specific screening criteria[2. Average BMI in the non-overweight group was 18.48 ± 2.04 kg/m2. This difference was statistically significant .Anthropometric measurements were performed by experienced technicians in a quiet room. Each participant’s height and weight was measured with lightly clothed and barefoot using an automatic instrument . Body mass index (BMI) was calculated as weight divided by height squared  at 6-month follow-up was used for multivariate analysis. The same analyses as described previously were carried out.Data were analyzed using IBM SPSS Statistics 19.0 for Windows. The numerical variables were expressed by the means of the calculation of means and standard deviations. First, Chi-squared or the Wilcoxon rank-sum test was conducted to examine differences, such a number of siblings, and all variables of interest between the overweight/obesity group and the non-overweight group. Logistic regression analysis was performed to identify potential risk factors for overweight/obesity, including number of siblings. Potential confounding variables were entered in the model based on the significance level of these variables in bivariate analysis. Variables with t-test to compare other anthropometric indices and lipid profile between only children and children with siblings  and 5.9% of girls (n = 45) being only children and respectively 1.9% (n = 11) and 3.3% (n = 25) belonging to non-only children were overweight/obesity. To better assess the effects of obesity, we performed Student’s siblings . Anthropsiblings .χ2 = 13.21 P<0.001). In addition, overweight/obesity was significantly higher among adolescents having no siblings in boys (P<0.001) (P = 0.01) than were those living in semirural (9.2%) or rural areas (1.7%). No association between perceived family financial situation and overweight/obesity was observed. After stratification for family financial situation, higher prevalence of overweight/obesity was observed among families with higher socioeconomic status, for both only children as well as children with siblings (P<0.001) . Adolescsiblings .χ2 = 6.72 P<0.05), from 4.7% for children of fathers who had left school before senior high school, to 9.0% of children with fathers who had completed senior high or technical school, to 13.4% of children whose fathers had completed college or an advanced degree. However, mother’s education level was not associated with overweight/obesity. Students in elementary school who spent more than half their time with parents were frequently overweight/obese(Ps<0.01). In terms of lifestyle factors, students who skipped breakfast were also frequently overweight/obese. A marginally significant difference between the overweight and non-overweight groups was observed regarding vigorous and moderate physical activities. Sleeping hours were not associated with overweight and obesity.Interestingly, as the father's level of education improved, the rate of overweight/obesity increased . However, there was no significant association between number of siblings and depression in the non-overweight group. For all non-overweight, overweight, and obese individuals, no significant relationship between number of siblings and anxiety was observed at follow-up.After stratifying study participants based on weight status, we calculated adjusted ORs for number of siblings and depression and anxiety at the end of the 6-month follow-up period in Tables The aims of this study were to investigate effects of sib-size and obesity status on adolescent mental health, including anxiety and depression, using a community-based sample in Southeast China. These relationships were evaluated over a 6-mo period. The present results support our main hypothesis suggesting that only children had significantly higher odds of obesity in young adulthood, compared with children with siblings. However, after adjusting for potential confounding factors, only children who were overweight and/or obese had a lower OR for depression at the 6-mo follow-up. No such relationship was demonstrated for non-overweight individuals. This study is the first to demonstrate that mental health sequelae associated with obesity differ between only children and those living with siblings.The present study found that the overweight/obesity rate of only children was 11.8%, significantly higher than that of having siblings (6.0%). Only children also had higher odds of obesity than adolescents with siblings. This result was consistent with the previous studies. The inverse relationship was generally found between number of siblings and the prevalence of overweight/obesity , 17, 24.Furthermore, the existence of more siblings leads to an increase in family size, which has an inverse effect on family income and, consequently, on obesity. A study conducted in Brazil demonstrated a direct association between income and obesity in adolescents of both sexes . We alsoThe results presented above indicate that only children who were initially free of mental health problems but who were overweight/obesity had lower risk for depression, which runs counter to our hypothesis that only children with obesity would also have a higher risk for anxiety and depression at the end of the 6-mo follow-up period. This implies that non-only-children with overweight and obesity, additional sibling(s) may be an adverse situation that is more likely to result in adolescents’ ongoing mental health problems. This is surprising; given previous studies found that only children, especially, have variously been depicted as disadvantaged as a result of “sibling deprivation,” which may lead to poorer mental health outcomes including lower subjective well-being, more pessimistic, more depressed and less happy , 18.One possible explanation for this discrepancy is that children who come from a larger family experience negative social consequences due to the social stigma around having more than one child in China. Only children are portrayed as good, whereas children with siblings are portrayed as bad. It seems like that these children, rather than only children, have higher risk for poor adjustment and subsequent psychopathology . Status Another potential explanation for the observed results is that the presence of siblings in a family may indirectly affect the adolescent’s mental health outcomes through effects on the behavior of parents. According to the resource dilution theory , a largeThe OCP has lasted more than 30 years and has significantly controlled population growth . The youThe primary strength of the present study is its nature as a cohort study. The results provide further information that adolescents with overweight and obesity, additional sibling(s) is a possible risk factor for the development of mental health, particularly depression. This finding seems to demonstrate a relationship between the existence of siblings and symptoms of depression among adolescents. However, the study has certain limitations. First, not all potential confounders were measured and adjusted in the analysis. As overweight and obesity are complex phenomena, the main causes of overweight and obesity are multifactorial and include genetic variation, history of familial obesity, birth weight, and social and environmental determinants , which were not assessed in this study. An additional limitation of the study is that six months of follow-up is not sufficient time to assess the prevalence of overweight and obesity in the context of maturation, which is the approach recommended by the World Health Organization .The current study suggests an effect of obesity on mental health among only children. Being an only child was associated with overweight and obesity among adolescents and negatively associated with symptoms of depression at follow-up. These findings support the need to design evidence-based adolescent health policy and to implement targeted interventions to address adolescent adiposity and mental health problems, considering the impact of family-based factors.Institutional ethics approval for the study was granted by the Department of Psychological Education of Elementary and Secondary Schools of the Guangdong Province Administration. Parents did not provide written consent, but students younger than 16 yr were instructed to obtain verbal consent from parents before filling in the self-reporting questionnaire. For students > 16 yr (age of self-consent), consent was implicated by a voluntary response to the questionnaire. In addition, students with severe depression or anxiety in pre-test and post-test were referred for appropriate care. The institutional review board approved this consent procedure.S1 Text(DOCX)Click here for additional data file.S2 Text(XLSX)Click here for additional data file.