A notable conclusion is that variables such as income, education status and system of burning are determinants of wood fuel usage in the three villages, while income, water heating energy, types of wood and number of hours influence vulnerability to household emission and possible health risks in the use of solid energy sources.Emissions from residential solid fuels reduce ambient air quality and cause indoor air pollution resulting in adverse human health. The traditional solid fuels used for cooking include coal, straws, dung, and wood, with the latter identified as the prevalent energy source in developing countries. Emissions from such fuel sources appear to be significant hazards and risk factors for asthma and other respiratory diseases. This study aimed at reporting factors influencing the choice of dominant solid fuel for cooking and determine the emission risk from such solid fuel in three villages of Phalaborwa, Limpopo province, South Africa. The study used descriptive analysis to show the relationship between the socio-economic variables and the choice of cooking fuel at the household level. Multiple correspondence analysis (MCA) was used further to detect and represent underlying structures in the choice of dominant fuels. MCA shows the diversity and existing relationship of how variables are related analytically and graphically. Generalised linear logistic weight estimation procedure (WLS) was also used to investigate the factors influencing choice of fuel used and the inherent emission risks. In the three villages, wood was the prevalent cooking fuel with 76.8% of participant households using it during the summer and winter seasons. Variables such as low monthly income, level of education, and system of burning are revealed as strong predictors of wood fuel usage. Moreover, income, water heating energy, types of wood, and number of cooking hours are significant ( Since the 1952 classic episode of London smog with a record of about 4000 deaths within five days, air pollution has received great attention ,4,5. TheDifferent appliances ranging from traditional stoves to improved cooking techniques are used in developing countries. Such stoves include the three-stone stove used in different parts of Africa, the Jiko stove commonly used in Kenya, the Pulumusa stove used in Zambia, the Tsotso stove used in Zimbabwe, the Justa stove in Honduras, the Eccoina stove in Guatamela, the single mud stove in India, and the Kang stove in China ,8. The e10 and 58.67% of PM2.5. Research on residential fuel choice and the determinant factors is significant to understand the design and implementation of policymaking and energy transition [In South Africa, though more than 86% of households have physical access to electricity, low-income households and those without electricity still use diverse traditional solid fuels . Accordiansition . Therefore, this study investigates factors influencing the choice of solid fuel usage and emissions risk in three selected informal settlements of Limpopo Province, South Africa, with a view to inform policymakers on policy interventions that address health risks associated with such choices and emissions.This study was conducted in Phalaborwa. The sites named Lulekane, Majeje and Makushane are villages in the neighborhoods of Phalaborwa, Ba-Phalaborwa Local Municipality, Mopani District, located in Limpopo Province and situated in the north-eastern part of South Africa. The choice of these sites was explained by their demographic characteristics. The climate of Phalaborwa is characterised by hot, wet summers and mild, dry winters, having a mean summer temperature of 24 °C, a mean winter temperature of 18.5 °C, and a mean annual rainfall of 481 mm . The keyQualitative questionnaires were distributed randomly to test the prevailing fuel type and identify demographic factors, kitchen characteristics, types of cookstove used, and other factors that influence emissions. The questionnaires were pretested in a similar community and the errors were adjusted before starting the real household survey. The sample size was determined using Rao soft sample size calculator with an acceptable error of 5% and was increased by 10% to get a total of 411 questionnaires. The number of questionnaires for each village was estimated using their population and a total of 371 participants responded with 133, 124 and 114 questionnaires from Lulekani, Makhusane, and Majeje villages correspondingly. Interviewers were engaged and trained to administer the questionnaire through a one-on-one interviewer-administered method in the local language (Xitsonga) of the villages. The data were collected using stratified random sampling. The data collected were analysed using cross tabulation in IBM SPSS Statistic 27 and the results were presented in bar charts. Ethical clearance (SES/20/ERM/06/1412) for this study was granted by the University of Venda and the Research Ethics Committee before conducting the study.R SPSSR statistics version 27.0 . MCA allows relationships between both row and column variables, as well as between diverse levels of the individual variable, to be examined [Further statistical analysis was performed using multiple correspondence analysis (multivariate technique) to test the relationship that exists between the variables, using IBMexamined . MCA is examined . Howeverexamined .R SPSSR statistics version 27.0  to investigate variables influencing emission among the households using wood fuel. Weight estimation procedure computes the coefficients of a linear regression model using weighted least squares (WLS), to give greater weight to predictors with less variability in determining the regression coefficients [Statistical analysis was performed using generalised linear logistic weight estimation procedure in IBMficients ,39. WLS Ω is the probability of the event.e is the base of the natural logarithms (about 2.718).z is the linear combination and expressed as:1x1 + β2x2 + β3x3 … + βixiz = a + βa is a constant (intercept).βs = log odds coefficients estimated from the data.s = values are the predictors the log of the odds ratio E(β); z = log (p/(1 − p));xP = probability of occurrence; and1− p = probability of non-occurrenceThe demographic characteristics of the villages such as the education status, number of people in the household, and levels of income, as well as their type of kitchen, are presented in The results in p > 0.000. This indicates that income earned, and energy type are significantly correlated, while the Cramer’s V symmetrical measure  shows a moderate relationship between income and energy used. Rahut et al. [A Fisher’s exact test was administered to determine the relationship between monthly income earned and energy type, and has a value of 88.005, t et al.  reportedt et al. ,43,44.Thp < 0.000). This shows that there is a significant correlation between the level of education and energy use, while the Cramer’s V symmetrical measure  shows a moderate relationship between the level of education and energy use.The Fisher’s exact test result has the value , system of burning , and education level . Income correlated with system of burning , education level , and education correlated with system of burning . Similar correlations were found for dimension 2, except for household size which was not correlated. The correlations above 0.3 were considered only to have meaningful applied significance.The variation categories with larger values contribute the most to the definitions of dimension. For cooking fuel (0.871), system of burning (0.710), income (0.481) and education level (0.295) are the most correlated for dimension 1. Likewise, the variable household size is correlated with dimension 2. In dimension 1, cooking fuel correlated (transformed variables) significantly with income , water heating energy (p ≤ 0.05), types of wood (p ≤ 0.05) and number of hours (p ≤ 0.05) are significant predictors that influence emission risk from fuel sources at the household level. The influence of income is probably through the amount of wood consumed. The effect of the type of wood could be explained in terms of its calorific value. However, the calorific value of the wood was not the subject of investigation. Studies established that emission from wood-burning varies and depends on diverse factors including combustion appliances, combustion conditions, the type of wood, and stages of the combustion cycle [Model predictors with positive E(β) or odds ratios signifies increasing probability of emission risks in terms of type of fuel used, as you increase the predictor variables such as wood use per day, sources of wood, income, household size, and number of households in the compound . These pon cycle ,57. The on cycle ,59. Findon cycle . Most poon cycle . A recenon cycle ,62. Guo on cycle  studied on cycle . Therefoon cycle  have fouEpidemiological and toxicological studies provide overwhelming evidence that acute lower respiratory infections (ALRI), chronic obstructive pulmonary diseases (COPD) and lung cancer are among the major health risks from indoor air pollution associated with biomass-based fuel . Other hGioda et al.  observedA significant association is also found between the use of wood as cooking fuel and asthma, and increased daytime respiratory symptoms. Additionally, empirical reports revealed a significant relation between wood use and respiratory outcomes among different genders in South Africa and other counties in sub-Saharan Africa ,77,78. AGenerally, reduction in emissions from household wood fuel combustion is enormously important not only to improve health and air quality for lots of people in developing nations but also to alleviate regional and global climate change. Awareness is important to improve behavioural patterns of the user during the use of solid fuels. Awareness improves education status or knowledge level, which may contribute to an increase in income and high socio-economic status. Future studies could investigate the role of risk communication in the choice of energy type. Enforcement of local interventions that incorporate ventilation technology upgrading and national governmental policies should be pursued. Regardless of the knowledge on the health effect of wood and other solid fuels in developing countries, enough empirical evidence on household cooking wood and associated health effect is still lacking.Wood is found to be the dominant fuel for cooking among the residential solid fuels used in rural parts of developing countries, with either traditional three-stone or improved wood stove technology. In the studied villages, low monthly income, level of education, and system of burning are influencing their choice of using wood fuel for cooking purposes, while household size may not be a contributing factor. Emissions from these wood fuels appear to be a significant possible hazard for asthma and other respiratory diseases among households and represented demographics. A notable conclusion is therefore established that variables such as education status, income, and system of burning are the predictors contributing to the use of traditional energy sources. In addition, income, water heating energy, types of wood and number of hours are vulnerable factors to emission risk from households and possible health risks during wood usage as energy sources.


ED severely affects the eating habits of the athletes, who tend to use unhealthy approaches to control their body weight. The development of nutritional education and early interventions by training staff is essential, and these factors are widely perceived as beneficial in sports medicine. This study evaluates the frequency at which beach handball (BH) players develop ED, also comparing the differences by sex and age (junior: adolescents vs. senior: young adults). In addition, the relation between body composition variables and ED was studied. (2) Methods: A descriptive and cross-sectional study was carried out in 69 top elite handball players  from the Spanish National BH Team; who were separated by age (junior: adolescents and senior: young adults). The athletes completed the Eating Attitudes Test in its 26 item version (EAT-26). (3) Results: The prevalence of ED indicated that 11% of females had a high possibility of developing an ED, and 3% of males. Regarding the EAT-26 total score and subscales, no significant differences were found between female and male participants, or between the junior and senior categories. The correlations showed an association between body composition, in terms of body mass index, and the EAT-26 total score in both males and females. In the case of males, the correlation was negative. (4) Conclusions: Although there are no significant differences between sex or categories, it has been found that elite athletes are a population that is at high risk of developing ED. Eating disorders (ED) have a high probability of emerging in adolescence and adulthood rather than in childhood . In thisED are serious mental illnesses that are differentiated to others by the presence of disturbed eating behaviors combined with an altered perception of body composition or excessive concern about body image and weight. These disturbances lead to eating-related behaviors, such as vomiting, purging behaviors or extreme exercise, or restrictions. All of these actions negatively affect health, interpersonal relationships, mood, nutrition, and academic and work performance, as well as the quality of life of the affected individuals and their environment ,10,11,12ED commonly develop between late childhood and emerging adulthood, and are sometimes severe ,15,16. MAdolescents, women and high-income individuals are the groups at a higher risk of developing eating disorders . The sexElite athletes who are also at risk are those who practice sports with weight categories or where physical fitness has a high influence on their success . DiffereIt has been shown that athletes are a population with a higher risk of presenting or developing eating disorder behavior than the general population . DependiHowever, this does not mean that the sports mentioned above are the only ones affected, participants in other sports are also at risk of suffering EDs, finding cases of eating disorders in team sports such as football, volleyball, handball or basketball . MartinsAn example that shows this controversy is presented by beach handball (BH) players, who have high nutritional and water requirements to be able to perform well in training and competition. These demands require the athlete to ingest large amounts of food, which means that they spend more time thinking about diet and sports performance, which can be counterproductive. Moreover, when athletes need a high physical involvement to practice their sport, it compromises mental health, often leading to severe symptoms of anxiety and depression. These situations are common comorbidities of ED.The prevalence of athletes who reported severe or moderate dissatisfaction in ball sports such as handball is 20%, with 24.2% presenting mild dissatisfaction and 55.8% being categorized as having no dissatisfaction about their body . These fAs can be seen from the information explained above, elite BH players may be at risk of developing ED. However, no studies have been carried out in this population to date. Only one study has assessed the prevalence of ED in indoor handball players specifically, with results from the Eating Attitudes Test-26 (EAT-26) showing average scores of 9.92 ± 2.86 in male handball players and 11.55 ± 1.88 in female handball players, indicating a minimal risk of showing ED attitudes/behaviors . HoweverWhen there is continued exposure to sports culture and competition, it is possible that eating attitudes change and the risk of developing an ED increases with body maturation and puberty, which is related to body composition changes. Further research on the prevalence of ED in BH players is therefore needed to understand the risk to these athletes .The general objective of the current investigation was to study the prevalence of a possible predisposition to ED in elite BH players. In addition, we aimed to compare the results between age groups (junior: adolescents and seniors: young adults) and sex (women vs. men), and identify the relationship between the different variables of the EAT-26 screening questionnaire and the variables of age, weight, height and BMI. The hypothesis was that female players would report higher scores than males on EAT-26, which indicates higher eating disorder symptomatology, and that there would also be associations between body composition in terms of body mass index and eating disorders.A descriptive and cross-sectional design was used to analyze the influence of sex and age on the unhealthy eating patterns in BH players. Furthermore, these data will assure better ED prevention among athletes, which could ultimately lead to greater health- and performance-related outcomes. The study was carried out with the best international players in this sport modality, thus representing the elite of BH players worldwide. All procedures were carried out in accordance with the Declaration of Helsinki (revision of Hong Kong in September 1989 and Edinburgh in 2000), and also in accordance with the recommendations for Good Clinical Practice of the EEC (document 111/3976/88 of July 1990). The University Human Research Ethics Committee of University of Alicante (Spain) granted approval to conduct this study (UA-2019-04-09).A total of 69 BH players participated: 52.17% were males and 47.82% females, with a mean age of 20.9 ± 5.55 and 20.4 ± 5.18 years, respectively. All of the players that formed part of the current Spanish BH national teams, according to category and sex, participated. Exclusion criteria were the presence of chronic diseases, previously diagnosed mental illness, and refusal of informed consent. However, no athlete was excluded. All participants gave written informed consent before participating. In the present study, participants did not receive any compensation for their collaboration. In the case of participants who were underage, their parents or legal guardians gave the consent. Anonymity was preserved for all participants.2, Kg/m2). The height of the athletes was determined using a mobile anthropometer  to the nearest millimeter, and with the participant’s head maintained in the Frankfort Horizontal Plane position.Questions regarding sex, age, and date of birth were asked to each of the BH players. Anthropometric data such as height and weight were measured using high quality, calibrated equipment. These measures were determined with light clothing and no shoes early in the morning, having not consumed any food or drink. Weight was measured in Kg and height in cm, and body mass index (BMI) was calculated (BMI = weight/sizeElite BH players completed the EAT-26 . This isp > 0.05). Differences in BMI and EAT-26 scores between the different groups were analyzed using independent samples t-tests. The Student t-test was performed to compare sex differences in dieting. Analysis of covariance (ANCOVA) with the Bonferroni correction was used to compare differences between age groups (junior vs. senior), controlling the effect of BMI. Additionally, partial eta-squared (ηp2) was carried out with <0.25, 0.26–0.63, and >0.63 considering small, medium, and large effect sizes, respectively [2), and different scales of EAT-26 were determined using Pearson’s product-moment correlation coefficient (r), with 95% confidence intervals (CI).For the data analysis, the programs Jamovi  and SPSS  were used. First of all, the descriptive data (means and standard deviation) were calculated. For descriptive statistics (mean ± standard deviation) and inferential analysis, the Kolmogorov–Smirnov test was conducted to assess the normality of data followed by Levene’s test to determine the homogeneity  top elite BH players aged from 15 to 35 (mean (M) = 20.6, standard deviation (SD) = 5.34 years) participated in this study; there were thirty-six male BH players, including 18 juniors  and 18 seniors , and thirty-three female BH players, with 18 juniors  and 15 seniors . Standard deviations and means were calculated for the principal variables, for male and female BH players separately . The Stup > 0.05), there were no statistically significant differences between junior and senior female players. For male elite BH players, However, as shown in p < 0.05) are shown for the total sample, as well as for females and males individually between BMI, weight, height, age, EAT-26 total scores and EAT-26 subscale scores. Significant correlations between the basic body composition variables and the scores of the different EAT-26 scales were not observed. On the other hand, for females, the BMI and dieting subscale scores were positively correlated . Regarding weight, no statistically significant differences were observed, and in the dieting subscale, p = 0.073 was observed.In p < 0.05) between BMI, weight, height, age, EAT-26 total scores and EAT-26 subscale scores are shown. The total EAT-26 scores were positively associated with BMI (p = 0.028) and weight (p = 0.029). In addition, this correlation also exists with the oral control subscale score .For males, statistically significant correlations  of the BH players were prone to developing ED; this condition was not independent of nutritional status and body composition. These outcomes are similar to those reported by Kravchychyn et al.  and PeriIn contrast to the main hypothesis of this study, the results found no significant differences between male and female BH players on the EAT-26. However, in absolute values, there is a higher percentage in favor of elite female players. Studies have shown that females have more ED behaviors than males ,44,45, oAs far as the EAT-26 score is concerned, no research has analyzed the subscales of this questionnaire in handball; for this reason, there is no scientific evidence to compare. Nevertheless, there has been research into the total score. Fortes et al.  obtainedIn females, as can be seen in the correlations, there was a positive association between EAT-26 total score and BMI, in addition to the one between subscale dieting and BMI. Moreover, some studies found that overweight girls are more likely to present restrictive eating behaviors, worry about their weight and be less satisfied with their appearance ,45. On tThe results found are relevant for performance sports, since it is undesirable for an athlete who is looking for positive results and overcoming adversaries to become involved with problems of emotional wellbeing, developing a dissatisfaction with their body self-image and, subsequently, with the aggravated picture of ED . Among tNevertheless, the current findings need to be considered alongside the possible limitations of the study. Therefore, as the current participants were elite BH players and the sample and size were not large, it is not recommended to generalize these results when studying other groups. Nevertheless, these results seem to provide essential data regarding BH and ED. Another limitation of this study is that only the EAT-26 questionnaire was used to analyze the risk of ED. For these reasons, future studies will have to use other measurement methods in addition to assessing high-risk behaviors with a clinical interview. Moreover, it would be of special interest to perform a longitudinal study, assessing the impact of nutritional education. It would be also relevant to study the different variables and risk factors of ED in children, adolescents and young adults.All of this being said, the results from this manuscript and the comparison with previous works suggests that this study provides new information for the scientific field, specifically for research into psychological aspects of ED and factors that affect sports performance in BH.Future research should focus on the origins and consequences of disordered eating behaviors in elite athletes. It would be interesting to analyze sport-specific risks, including the frequency of the assessment of weight, dieting pressure, the importance of weight loss, overtraining, early start of sport-specific training, injuries, impression motivation, personality traits and the impact of coaching partners in competition.The results of the study indicate that there is a risk of ED in BH players, especially in females. Athletes tend to not seek support for adverse mental health situations because they perceive this action as a weakness . Unhealthy eating habits are becoming a public health problem, especially in adolescent female athletes who tend to engage in harmful eating behaviors more often than males .In order to make some progress in the prevention of ED, the identification and early treatment of mental health problems in elite athletes is a priority. In addition, investing in screening and nutritional education projects in all aspects of the athlete´s life is needed to promote a healthy lifestyle with appropriate eating behaviors. It is necessary the constant support of nutritionists in beach handball teams.


The study shows the relevance of understanding social factors to improve the uptake of public health interventions and calls for contextually adapted strategies for malaria elimination in ethnic minority populations in Vietnam and similar settings.Despite the scale-up of vector control, diagnosis and treatment, and health information campaigns, malaria persists in the forested areas of South-Central Vietnam, home to ethnic minority populations. A mixed-methods study using an exploratory sequential design was conducted in 10 Ra-glai villages in Bac Ai district of Ninh Thuan province to examine which social factors limited the effectiveness of the national malaria elimination strategy in the local setting. Territorial arrangements and mobility were found to directly limit the effectiveness of indoor residual spraying and long-lasting insectidical treated nets (LLINs). Households (n=410) were resettled in the “new villages” by the government, where they received brick houses (87.1%) and sufficient LLINs (97.3%). However, 97.6% of households went back to their “old villages” to continue slash-and-burn agriculture. In the old village, 48.5% of households lived in open-structured plot huts and only 5.7% of them had sufficient LLIN coverage. Household representatives believed malaria could be cured with antimalarials (57.8%), but also perceived non-malarial medicines, rituals, and vitamin supplements to be effective against malaria. Household members ( Plasmodium (single-celled parasites) transmitted to humans through the bites of infected female Anopheles mosquitoes (the vector) (Plasmodium vivax (P. vivax) and Plasmodium falciparum  are more common, with the latter causing more severe illness and the most malaria deaths  and outdoors (exophagic), and rests indoors (endophilic) and outdoors (exophilic)  , 12. Thiophilic) –20.Anopheles dirus, human activities in the forest were significantly associated with a higher malaria risk, particularly when staying overnight in the forest , free diagnostics and treatment to at risk populations combined with health information-education-communication (IEC) campaigns to boost the uptake of interventions . Effectie forest , 30–32. e forest –38. A miBac Ai district consists of nine communes with a total population of 26,440 inhabitants, according to the 2018 census . More thAnopheles dirus in the district. These mosquitoes bite mostly between 21:00 and 05:00, causing evening activities in the forest to be of very high risk  were conducted between July 2016 and May 2018. Collected data were participant observation (PO), informal conversations (ICs), group interviews (GIs), and in-depth interviews (IDIs). Interviews were conducted at people's home or at locations of their choice. Raw data were written as fieldnotes, then computerized, and stored in password-protected devices. The use of audio-recording was limited in interviews as it was frequently interpreted as a reason for mistrust by the study population. The data collection process was iterative, incorporating emerging questions and themes during fieldwork.The sampling strategy was based on a combination of existing social theory, including the PASS-model on health-seeking behavior and access to care, and emerging results . The selPreliminary data analysis was conducted during fieldwork whereby new themes and theoretical ideas were constantly added and tested until saturation. A retroductive approach to data analysis was used with raw data being assigned to meaning units for further coding and categorization in an emergent analytical framework. Qualitative data analysis was using NVivo 12 .The quantitative strands consisted of two cross-sectional surveys. The first survey was administered to household representatives (HHRs) and focused on territory, exposure to malaria vectors including housing and LLIN ownership, and knowledge of malaria. The second survey was administered to household members (HHMs). It aimed to quantify participant's mobility, territoriality, individual risk factors, exposure to the vector in the early morning (before 07:00) and evening h (after 21:00), and their uptake of malaria services. Territoriality refers to territorial human behavior in relation to land ownership, access to resources, social and geographical space . In thisData were collected via surveys from November to December 2018. Two structured paper-based questionnaires were developed, field-tested, and finalized in both Vietnamese and English languages. Interviews were conducted in Vietnamese language with the help of a Ra-glai translator when needed.The surveys aimed to include everyone living in selected villages. The local census conducted in 2017 was used as the sampling frame. One week before the surveys, an invitation to participate was communicated to households through village meetings and using the public speaker system. During the surveys, up to three reminders were communicated to households by the village health workers to ensure people were informed about their chance to participate. HHRs were 16 year-old or older participants who were nominated by their household to answer the first survey questionnaire. HHMs were participants from the rest of participating households. Blood samples were collected from all participants to confirm their malaria status. Malaria tests were confirmed using light microscopy and rapid diagnostic test .Completed questionnaires were computerized and cleaned using Epi Info 7 . Stata 12  was used for descriptive analysis while further analysis was implemented using R . The outcome variable was reported bednet use the week before the survey comparing participants who “usually” used the bednet to those who “sometimes” or “never” used them. Bednet use the night before the survey was not selected as the outcome variable due to expected socially desirable responses. Multinomial logistic regression was used to model the outcome variable taking “usually” as the reference category which therefore expresses explanatory variables as risk factors for inconsistent (either “sometimes” or “never”) bednet use. Seven explanatory factors were identified including age , sex, education, frequency of sleeping in the new village, sleeping in a stilt house as opposed to a brick house, slash-and-burn agricultural practices, and deep forest activities. Both crude (one predictor at the time) and adjusted odds ratios were reported for two arms of the multinomial logistic model. The hierarchical nature of the data, whereby HHMs were grouped into households and households were grouped into communes, was taken into account by modeling random effects with two levels of grouping. The village level was excluded because the model did not completely converge in the presence of all three levels. We chose a Bayesian approach to more reliably estimate the random effect variances and to easily gauge the amount of uncertainty around them. The priors used were those configured as the default in the R package brms : for theThe study protocol was jointly reviewed and approved by Ethical Review Boards of the Institute of Tropical Medicine in Antwerp (IRB/AB/ac/116), the National Institute of Malariology, Parasitology and Entomology in Hanoi (NIMPE), and the Vietnamese Ministry of Health . Before data collection, local authorities, representatives of the study villages, traditional leaders, and community health workers (CHWs) were sensitized about the study protocol. Participants in the quantitative strands who were 16 year-old and older were asked to consent to participate before answering the survey questionnaires. Parents or guardians of minors (those who were under 16 year-old) were asked to give consent on behalf of the minor. Verbal informed consent was sought and granted by participants in the qualitative study to limit mistrust among participants . All stuIn the qualitative strands, a total of 90 ICs, 86 IDIs and 13 GIs were conducted. In addition, 70 observation records were included. Participants were women and men from different ethnicities  and age groups such as children, adults, and elderly. Adult participants had diverse profiles including farmers, plantation and forest workers, teachers, forest guards, public health officials, private and informal health providers, local officials, traditional leaders, and respected individuals in the community.In the quantitative strands, 1,957 HHMs and 410 HHRs participated in the survey . Survey làng mới or the “new village” located in the lowlands with farmland to cultivate cash crops such as rice, cassava, and sugar cane. Their traditional territory, now referred to as làng cũ or the “old village” where their forest fields are, turned into government-controlled forest territory and a hydropower site. Of 410 households, 97.6% owned at least one forest field for slash-and-burn agriculture (n = 400), 88.0% of HHRs frequently went to their fields, and 48.5% had a plot hut there. Of HHRs who owned the forest field, 38.8% stored their crops there and 25.5% kept animals such as pigs, chickens, and cows at the field. Participants explained that unsuitable soil and limited farming land in the new villages were the reason they returned to the forest field for slash-and-burn farming. Going back to traditional territory additionally meant being closer to the spirits of their ancestors and maintaining the Ra-glai identity and way of life. In the traditional territory, farmers had various economic activities including planting maize, beans, or vegetables, as well as herding cows or goats and collecting forest products . These combined activities were economically more interesting than planting cash crops around the new villages. Forest farmland ownership and residency were, however, not officially recognized by the local government as they compensated Ra-glai households for the lost houses after the resettlement. Despite these barriers, in one of study villages, up to 25% of households had completely abandoned their new village houses  said they had a house there (2), featured brick walls, cement floors, tin roofs, and closable windows , 13.9% slept in the stilt house while staying in the new village; 13.3% of HHMs who slept in the stilt house said they slept after 21:00. HHMs reported on various number of evening activities, defined as social activites taking place after 18:00, including watching TV , drinking outdoors , and visiting relatives or friends (21.2%).There were two main housing styles: government subsidized brick houses and traditional stilt houses, with the latter made of wood, bamboo, and forest leaves. In the new village, 98.0% of HHRs (se there . Of thesse there . Brick h windows . The Ra- windows  to increN = 194) of plot huts were on stilts (2). At the forest field, 97.4% (n = 685) of HHMs slept before 21:00 and 97.8% got up before 07:00. Early morning activities outdoors  were reported by several HHMs including visiting the field (55.3%), feeding animals (46.4%), and collecting water (35.2%), wood (44.7%), or food (35.5%).Stilt houses were preferred by households as they are made of locally available construction materials, easily cleaned and maintained, and have open structures, allowing to cook indoors . At the n stilts . HousehoN = 1,957) of HHMs said they slept at the forest field as frequent as in the new village. Sixty five percent said they slept more often in the new village while 1.4% slept more often at the field  of HHMs reported to carry out subsistence forest activities and 6.6% stayed overnight in the forest. Young children, from the age of six onwards, were taught to carry out forest activities such as herding cows, guarding the crop against wild monkeys, fetching water, and picking vegetables for daily meals. More than 50% of households listed in the census were not present in the new villages during the two months the surveys took place. People explained that a drought had occurred early in the year destroying the most important crops of that time of year. This drove these households to live in their forest field to assure the second round of crops in the year. The drought also drove many farmers to take on agricultural work in other districts of Ninh Thuan and Lam Dong province (about 100 km away), leaving households short of labor for slash-and-burn agriculture. This necessitated longer stays in the field to get the work done, with less frequent commuting to the new villages.Complicated mobility between the forest field and the new village, with the purpose of slash-and-burn agriculture in the old village and social and economic activities in the new village, resulted in varied sleeping places. 33.6% .“N = 402) than in the plot huts  (N = 106) reported bringing different materials for sleeping, including hammocks (69.8%), bednets (66.0%), blankets (3.8%), plastic sheets (39.6%), and extra clothes to wear at night for warmth (7.5%). Additional cotton and polyester hammocks were observed to be used for sleeping at the plot hut, due to a lack of space indoors. When spending the night in the forest for hunting-gathering activities, people said they could not use LLINs because there was no space for hanging them up.Sufficient LLIN ownership, defined as having one LLIN per two persons, was reported to be higher in the new village houses  . When stN = 1,957), both during the week before the survey (87.3%) and the night before the survey (92.1%). Multinominal logistic regression shows that the odds of inconsistent LLIN use, defined as participants who said they “sometimes” or “never” slept under a LLIN, were lower among HHMs who “often” slept in the new village than those who “never” or “sometimes” slept in the new village (AOR≈0.5) (Self-reported use of LLINs was high (AOR≈0.5) . HHMs whDuring the ethnographic field work, people explained they knew about the necessity of sleeping under a LLIN to prevent malaria. However, this was not necessarily practiced due to (1) torn bednets, (2) insufficient space inside the stilt houses, (3) the heat inside the brick houses, (4) the lack of motivation at the plot huts where people perceived little mosquito nuisance, and (5) the preference for sleeping in a hammock both indoors and outdoors. Damaged LLINs were discarded, and pieces of LLIN used for fishing, rope, or garden fence were seen in both the old and new villages.e.g., people who moved in Ra-glai communities following the matrilineal kinship line and marriage, or people who exclusively lived at the field and therefore without official residency in the new village.Twice a year, the local malaria control program provided IRS to all houses in the new village. Households said that fumigating the house helped keep mosquitoes away and decrease their malaria risk. They specifically mentioned the benefit of IRS in protecting children's health. However, IRS was not provided to the plot huts due to the unrecognized residency status of people in the fields, the geographic difficulty in accessing the Ra-glai traditional territory, and insufficient funding to cover these additional logistic and transportation costs. Responding to previous findings on LLIN coverage , 30–32, đi rùng, ngủ rẫy or “forest going and sleeping at the forest field.” Forest going was considered a sensitive topic because people link mobility to their  traditional territory, while the government makes an association between slash-and-burn agriculture, ethnic minority living the forest, and lâm tặc or “illegal loggers and poachers.” Printed posters and banners with malaria prevention measures in Vietnamese language were hung up at commune health centers (CHCs) while similar messages were delivered to people via monthly village meetings. These messages were not entirely understood or accepted by the Ra-glai because of the sensitivity around territory, the high level of illiteracy, and the lack of Vietnamese language proficiency. Mobility and living in the plot huts limited people's access to health IEC as there were no village health workers or meetings organized in the old villages. Similarly, IEC materials that provided information about malaria in Kinh (Vietnamese language) were not perceived to be accessible.To inform the public, the NMCP organized IEC campaigns focusing on taking LLINs and LLHNs for sốt rét (in Kinh) or “malaria fever.” The Ra-glai used the term sa-ki in their own language to imply bodily discomfort and illness, which includes fevers, fatigue, and headache. Sốt rét and sa-ki were perceived to be undistinguishable, and knowledge of malaria was considered a medical domain of public health professionals. In the survey, 65.7% (N = 410) HHRs had heard of sốt rét with the two most commonly recognized symptoms being chills and fevers  (89.0%), over-the-counter medication  (14.3%), animistic rituals to appease the spirits (9.7%), and taking injections of antibiotics or intravenous drips containing fluids, vitamins, or minerals (20.7%). Up to 97.5% (N=237) of HHRs answered that antimalarials from a public health facility could treat sốt rét, however, 62.0% of them stated taking antimalarials was the only treatment option. Participants explained that knowledge of malaria is a privilege of medical doctors, therefore when someone had fevers, regardless of it being a malaria fever or not, the patient needed “western” medicines to treat the symptoms and spiritual rituals with the help of a shaman to solve the underlying cause of the illness.There was no equivalent word in Ra-glai language for d fevers . 57.8% oIn the malariometric survey, 1.6%  of participants had fever symptoms, 0.2% (3/31) of whom, had a positive diagnostic test result . The thrFree diagnostic testings and antimalarials were only provided at public health facilities, including the CHC, the district health center (DHC), and the district or provincial hospital. 62.9% of HHMs sought public health services for their most recent illness, with lower use observed among HHMs who were younger than 15 years old . The medThis study shows how the effectiveness of the Vietnamese malaria elimination strategy is directly related to the way in which the program is embedded in the local social context and highlights the need to critically examine the assumptions of the program. Territorial arrangements and human mobility were key factors for the uptake of vector control measures and public health services among the Ra-glai in Bac Ai, Ninh Thuan. Almost a decade ago, research showed that mobility patterns between the new villages and the forest fields, double residency related to slash-and-burn agriculture, limited knowledge of malaria, and low uptake of LLINs among ethnic minorities were the key to malaria persistence in certain hotspots in the GMS , 35, 37.i.e. accessing the field, practicing slash-and-burn agriculture, sleeping in a stilt house, less frequently sleeping in the new village) were risk factors associated with inconsistent LLIN use. The effects of household characteristics on reported inconsistent LLIN use suggested that (i) living in small-sized stilted houses, (ii) poor ventilation inside brick houses, and (iii) sleeping outdoors, including for (il)legal forest work, are additional risk factors. We did not find evidence that demographic characteristics such as age, sex and most of the education categories had an influence on consistent bednet use. The study implies that the variability in housing and sleeping places continue to challenge the standardized approach for vector control.In Vietnam and the GMS, the distribution of LLINs has been considered as a main tool for vector control . DespiteThe Vietnamese NMCP has implemented early detection and treatment and health campaigns to boost the uptake of testing and treatment. This study illustrates the interplay of several social factors such as forest mobility and dwelling, insensitive health messages, complex inter-ethnic relation and the doctor-patient hierarchy, and the uptake of malaria testing and treatment. Existing malaria studies in the GMS point to different approaches to increase the uptake of biomedical interventions such as scaling up malaria testing in the private sector, community engagement to promote the uptake of mass drug administration, or active community and engagement with forest workers to promote the uptake of malaria prophylaxis –58. SomeThis study highlights the need to unpack the assumptions on which the local and national malaria control and elimination interventions are based. These assumptions include the expectation that the relocation of the Ra-glai to the new villages with brick and concrete housing would directly result in an assimilated lowland Kinh lifestyle, including abandoning slash-and-burn agriculture, the full adoption of sedentary farming, and also sleeping under a bednet. The “villagization,” or the regroupment of scattered rural populations into villages by governments , 68, hasThis study shows the interdependence of socio-political/ecological factors and malaria transmission dynamics and the relevance of understanding social factors to increase the effectiveness of public health interventions. Complex human mobility patterns, territorial arrangements, and inter-ethnic relations continue to influence how and to what extent the Ra-glai use vector control tools and public health services. The study highlights the relevance of locally adapted and contextually-informed interventions and the need for further studies on how to engage vulnerable communities in the local malaria elimination strategy.For the qualitative strand, the NVivo database with excerpts of the transcripts relevant to the study is available from the corresponding author on reasonable request. For the quantitative strand, the datasets used and/or analyzed during the current study are available from the corresponding author on reasonable request.The studies involving human participants were reviewed and approved by Ethical Review Boards of the Institute of Tropical Medicine in Antwerp, National Institute of Malaria, Parasitology and Entomology in Hanoi (NIMPE), and the Vietnamese Ministry of Health. Informed consent to participate in this study was provided by the participants' legal guardian/next of kin.KP, XN, and TN: conceptualization and methodology. TN and TS: software and formal analysis. CG, XN, and KP: validation and supervision. TN: investigation, writing—original draft preparation and visualization. XN and KP: resources. TN, CG, and KP: data curation. CG, KP, RG, and XN: writing—review and editing. XN and DT: projection administration. KP and XN: funding acquisition. All authors have read and agreed to the published version of the manuscript.The study was funded by Belgian Directorate of Development Cooperation (DGD) for the Framework Agreement 4. TN is funded with a PhD scholarship from the DGD; CG is funded through a framework agreement between the Belgian Directorate for Development Cooperation and the Institute of Tropical Medicine.The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.All claims expressed in this article are solely those of the authors and do not necessarily represent those of their affiliated organizations, or those of the publisher, the editors and the reviewers. Any product that may be evaluated in this article, or claim that may be made by its manufacturer, is not guaranteed or endorsed by the publisher.


The therapeutic effect of extended pelvic lymph node dissection (PLND) in prostate cancer (PCa) patients is still controversial. The aim of this study was to identify the PCa patients who may benefit from extended PLND based on the 2012 Briganti nomogram.PCa patients who underwent radical prostatectomy (RP) plus PLND between 2010 and 2015 were identified from the Surveillance, Epidemiology, and End Results (SEER) database. The probability of lymph node invasion (LNI), determined using the 2012 Briganti nomogram, was used to stratify the patients. The endpoints were overall survival (OS) and cancer-specific survival (CSS). Propensity score matching (PSM) was performed to account for potential differences between patients with and without extended PLND. Univariable and multivariable Cox regression was used to analyze the association between the number of removed nodes (NRN) and survival. Kaplan–Meier analysis was performed to estimate OS and CSS. Extended PLND was defined as NRN >75th percentile.A total of 27,690 patients were included in the study. NRN was not an independent predictor of OS (p = 0.564). However, in patients with probability of LNI ≥37, multivariable analyses showed that increased NRN was associated with improved OS . The 5-y OS rate was significantly higher for patients with NRN ≥12 than those with NRN <12 . In the PSM cohort, among patients with probability of LNI ≥37, multivariable analyses showed that increased NRN was associated with improved OS . In addition, the 5-y OS rate was significantly higher for patients with NRN ≥12 than those with NRN <12 . However, NRN was not an independent predictor of CSS in any LNI risk subgroup .Extensive PLND might be associated with improved survival in PCa patients with a high risk of LNI, which supports the use of extended PLND in highly selected PCa patients. The results need to be validated in prospective studies with long-term follow-up. Current imaging techniques have low sensitivity for detecting lymph node metastasis in prostate cancer (PCa) patients. Therefore, pelvic lymph node dissection (PLND) is considered the best method to stage the disease and determine the ideal treatment , 2. AlthA number of studies and reviews have reported that extended PLND does not improve the outcomes and leads to a higher risk of complications –9. ResulBased on these considerations, we used the 2012 Briganti nomogram to select patients for extended PLND and investigated the relationship between NRNs and OS. The results of this study will help to identify PCa patients who may benefit from extended PLND before surgery.PCa patients were identified in the Surveillance Epidemiology and End Results (SEER) database. The SEER database is published by the National Cancer Institute, which collects cancer incidence data from population-based cancer registries covering approximately 28% of the U.S. population .Cases of prostate adenocarcinoma  diagnosed between 2010 and 2015 were included. All of the patients had complete clinicopathological data, namely, clinical T stage, prostate-specific antigen (PSA), Gleason score at biopsy, percentage of positive cores, lymph node status, and survival information. All of the patients underwent radical prostatectomy (surgery code 50) and lymph node dissection. Patients with PSA >50 ng/ml and clinical T4 stage  were excluded. Furthermore, the PSA value corresponded to the highest lab value documented in the medical record prior to biopsy and treatment.Categorical variables are presented as frequencies and proportions. Medians and interquartile ranges (IQRs) are reported for continuously coded variables. Group differences in categorical variables and continuous variables were analyzed using the chi-square test and t-test, respectively.Extended PLND was defined as NRN >75th percentile (≥12). Propensity score matching (PSM) was used to balance the baseline characteristics with a caliper distance of 0.001 between patients with and without extended PLND based on the age at diagnosis, PSA, Gleason score at biopsy, percentage of positive cores, clinical T stage, and race.The probability of LNI was calculated using the 2012 Briganti nomogram. First, patients were stratified according to the probability of LNI. Second, univariable and multivariable Cox regression analyses were performed to test the relationship between NRN and survival in patients with values higher and lower than the cutoff value. All of the analyses were repeated using categorical NRN (≥12 vs. <12) and continuously coded NRN. Third, Kaplan–Meier analysis was performed to plot survival curves and determine the 5-year overall survival (OS) and cancer-specific survival (CSS) rates.SPSS  and R software  were used for statistical analyses. P <0.05 was considered to be statistically significant.A total of 27,690 eligible patients, with a median age of 62 years, were included in the study. Among them, 25,952 had pN0 and 1,738 had pN1 PCa. The clinical and pathological characteristics of participants are summarized in ). Although patients with NRN <12 had a faster decline in 5-y CSS rate than those with NRN ≥12, there was no statistical difference between LNI risk subgroups . Therefore, we selected OS as the end point for further analysis. Subgroup analyses showed that continuously coded NRN was associated with improved OS only in the subgroup with LNI risk ≥37  was decreased with an increase in the probability of LNI, and continuously coded NRN was a significant predictor of OS when the cutoff value of probability of LNI ≥37 was used in the entire cohort  and categorical NRN  were independently associated with OS in the population with LNI risk ≥37 after adjustment for all of the covariates, namely, biopsy Gleason score, clinical T stage, PSA, age at diagnosis, percentage of positive cores, and lymph node status Table 2.In the entire cohort, no significant difference in survival was found between patients with NRN ≥12 and those with NRN <12 . When the cutoff LNI risk value of 57 was used in the PSM cohort, the 5-y CSS rates were 92.6 and 96.3% for patients with NRN <12 and NRN ≥12, respectively (p = 0.110). The lack of effect on CSS rate may be due to the short follow-up duration. Moschini et al. found that a higher NRN was associated with a lower CSM rate in locally advanced PCa with a median follow-up duration of 72 months . AdditioOur study results demonstrate OS benefit with extensive PLND in patients with LNI risk ≥37. These results are important to select patients who may benefit from extended PLND. Even so, the results were limited because patients were stratified based on clinical variables. A novel nomogram, namely, multiparametric magnetic resonance imaging to identify patients for extended PLND and a model, had high accuracy for predicting LNI . MoreoveSeveral unavoidable limitations existed in our study. First, there was no information in the SEER database about preoperative or postoperative treatment, including ADT, chemotherapy time and dosage, and site-specific radiation therapy. Therefore, the effects of these treatments on the survival of PCa patient needs further investigation. Second, extended PLND was defined using the NRNs rather than an anatomical template, owing to the lack of information on anatomical template in the SEER database. Although several studies indicated that NRNs may serve as a surrogate for the anatomical template , 40, 41,Extensive PLND may be associated with improved survival in PCa patients with LNI probability ≥37. The results support the use of extended PLND for highly selected PCa patients. The Briganti nomogram can be used to identify patients who may benefit from extended PLND before surgery. Prospective trials with long-term follow up are needed to further evaluate the role of extended PLND in PCa patients with a high LNI risk.The original contributions presented in the study are included in the article/Conception and design: BY, XY, and GY. Acquisition of data: GY, JX, and YG. Analysis and interpretation of data: GY, JY, RW, and CG. Writing, review, and/or revision of the manuscript: GY, BY, and JX. Administrative, technical, or material support: XY and BP. Study supervision: BY and XY. All authors contributed to the article and approved the submitted version.This work was partly supported by the National Natural Science Foundation of China (grant No. 31570993) and the Shanghai Pujiang Program (grant No. 15PJ1407000).The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.All claims expressed in this article are solely those of the authors and do not necessarily represent those of their affiliated organizations, or those of the publisher, the editors and the reviewers. Any product that may be evaluated in this article, or claim that may be made by its manufacturer, is not guaranteed or endorsed by the publisher.


This study evaluated the effect of a health belief model (HBM) educational intervention on the self-perception of and complications related to disease in elderly gynaecological malignancy patients.  This randomized controlled trial was conducted at the Fujian Maternal and Child Health Hospital, China. A total of 301 women aged 60 years and older who were diagnosed with gynaecological malignancies from January 2019 to August 2020 were recruited. Participants were randomly divided into the HBM education and basic nursing groups. The participants in the HBM education group received perioperative rehabilitation education based on the HBM, and the participants in the basic nursing group received routine basic nursing. Rehabilitation training compliance, psychological resilience, psychological flexibility, self-efficacy, self-care ability, and lower extremity deep venous thrombosis (LEDVT) incidence were assessed before and after the intervention. P = 0.738), psychological flexibility , self-efficacy , or rehabilitation training compliance  between the two groups. After HBM education, the scores of training compliance , psychological resilience , psychological flexibility , self-efficacy , self-care knowledge , self-concept , self-care responsibility , and self-care skills  were higher in the HBM education group than those in the basic nursing group. Additionally, the incidence of LEDVT was lower in the HBM group than that in the basic nursing group .  Thirty-three women were excluded based on the exclusion criteria, and 268 participants were eventually included and randomly divided into two groups: 134 participants in the HBM education group and 134 participants in the basic nursing group. Before HBM education, there were no significant differences in the mean scores of psychological resilience (50.43 ± 3.29 vs. 50.55 ± 2.29,  This study indicated that perioperative HBM education can improve the cognition and self-care ability of elderly gynaecological malignancy patients and reduce postoperative complications. In recent years, the incidence of cervical cancer, endometrial cancer, and ovarian cancer in China has increased substantially ; in partData show that many elderly patients with gynaecological malignancies die not from the disease itself but from unawareness of their own health and unhealthy lifestyle factors . The memThe health belief model (HBM) was developed by Rosenstock  in the 1Many studies , 11 haveIn this study, we aimed to explore the effect of perioperative HBM-based education interventions on the postoperative rehabilitation of elderly patients with gynaecological malignant tumours, providing evidence for the application of HBM-based interventions in elderly patients with gynaecological malignant tumours.The present study, a randomized controlled trial, was conducted from January 2019 to August 2020. Elderly (60 years and older) women with gynaecological malignant tumours who were treated in Fujian Maternity and Child Health Hospital were included in this study. All participants were required to meet the following inclusion criteria: (1) initially diagnosed with gynaecological malignant tumours  by histopathology and (2) age 60 years or older. Participants meeting the following criteria were excluded: (1) diagnosed with benign gynaecological tumour by postoperative pathology, (2) had LEDVT before the operation, (3) did not know their disease status, (4) suffered other major life events (such as divorce or widowhood) or traumatic events  in the previous six months, (5) had previously had other malignancies, (6) had mental disorders or mental retardation, (7) were unable to communicate normally in the Chinese language, and (8) were lost to follow-up. All eligible participants were randomly divided into an HBM education intervention group and a basic nursing group using a randomized comparison table. We performed a sample size calculation according to two independent design data calculation formulas:κ=nA/nB is the matching ratio, σ is the standard deviation, and Φ is the standard normal distribution function. The result we obtained was that each group needed at least 63 patients. The sample size calculated was sufficient, and the power was 0.8. HBM indicators were assessed twice for all participants before and after the intervention. The data of this study came from the Hospital Information System (HIS). The HIS system is an automatic recording system of medical data generated in the process of diagnosis and treatment of patients. The HIS system can record all the treatment processes of patients, including treatment method, treatment time, treatment effect, prognosis, and follow-up. In China, the HIS system is an automatic data recording system that is purchased by the government and widely used in all government-sponsored hospitals , the aim of the educational component was to enhance health awareness, change cognitive bias, and carry out a cognitive evaluation. The details were as follows. (1) According to the patients' own specific status, they might be given individualized psychological response education, HBM guidance, or self-coping methods. (2) After assessing the inner thoughts of the depressed patients and obtaining support and cooperation from their families, the patients were encouraged to face the disease positively and optimistically, strengthening their confidence in overcoming the disease and their educational compliance. (3) The causes, diagnosis, treatment, nursing, and postoperative complications of common gynaecological malignant tumours were explained to the patients, helping them understand the disease and correct any misunderstanding.In the second stage (2–5 days after the operation), the aim of the educational component was to implement and evaluate the health behaviours of patients and establish a sense of self-efficacy. The details were as follows. (1) Successful experiences were shared, the patients' subjective initiative in the treatment process was encouraged, and participants were made to consciously realize that proactive health behaviour can reduce postoperative complications. (2) Patients were encouraged to actively participate in the management of their own diseases, and psychological adjustment methods such as emotional transfer and transformation, relaxation training, and discussion methods were explained and demonstrated to patients. (3) The patients were allowed to continue to watch the health exercise videos from their beds and were guided through the exercises. The individual pain threshold and psychological characteristics of patients were determined, the flow chart of the bed health exercise training plan was formulated, the purpose and method of health exercise were explained to patients and their families by the intervention nurse, and a targeted demonstration of the operation and guidance was provided to patients. (4) The patients were guided and encouraged to put the acquired knowledge into action and to play the video twice a day with “one-to-one” guidance and training assistance. The nurse often evaluated and guided the patients' rehabilitation training again, urging them to conduct the training according to the programme.In the third stage (from the 5th day after operation to discharge), the educational theme was to implement and evaluate health education. The details were as follows. (1) Based on the theoretical framework of the HBM, questions and answers were formulated to help patients establish health beliefs and engage in healthy behaviours to promote postoperative rehabilitation. For patients with incorrect answers and training, the intervention nurse provided additional explanations and demonstrations until most of the patients answered more than 80% of the questions correctly. (2) On the day of discharge, the intervention nurse reassessed the patient's mastery of the content of healthy behaviours and patiently answered the questions raised by the patient. Further striving for the cooperation and support of relatives and society, patients were urged to continue to establish health beliefs and adopt healthy behaviours and were directed to review the material regularly and to enhance their self-care ability. (3) The nurse made a rehabilitation training plan for the discharged patients, and the family members urged the patients to complete the plan. The patients were followed up 1–2 times/week by telephone.Indicators included compliance with training, psychological resilience, self-care ability, self-efficacy, psychological flexibility, and incidence of LEDVT. All the indicator questionnaires have been used in China, and their validity and reliability have been verified –19. We oα = 0.83). The incidence of postoperative LEDVT was assessed as follows [Training compliance was assessed as follows: (a) complete compliance: patients actively participated in the exercise and actively completed more than 80% of the rehabilitation exercises after being reminded. (b) Partial compliance: patients actively participated in the exercise, but they needed the supervision and inspection of nursing staff or family members to complete 31–79% of the rehabilitation exercises. (c) Noncompliance: patients did not actively participate in exercise or chose to reduce exercise time, and they completed only 30% or less of the rehabilitation exercise content. Partial compliance and noncompliance represented low compliance. Psychological resilience was assessed as follows. The Chinese version of the Connor Davidson Resilience Scale (CD-RISC) was used to assess the level of psychological resilience of patients . Psychol follows . From thT-test was used for those with a normal distribution, and a nonparametric test was used for those with nonnormal distribution. The X2 test or Fisher's test was used to analyse the differences in enumeration data. Categorical data are expressed as percentages, and measurement data are described as the means ± standard deviations (SDs). The differences were considered statistically significant when P < 0.05.Statistical analysis was performed using SPSS 20.0 software . In the statistical analysis of the difference between the two groups, a normality test was first performed for the measurement data, a P = 0.603), BMI (P = 0.656), educational level (P = 0.475), marital status (P = 0.509), medical expenses (P = 0.715), tumour type (P = 0.755), International Federation of Gynecology and Obstetrics (FIGO) stage (P = 0.668), hospitalization time (P = 0.614), or basic venous thromboembolism (VTE) risk (P = 0.02) between the two groups. The I-CVI of the HBM indicator ranged from 0.82 to 0.96, and the S-CVI was 0.93. Cronbach's alpha coefficients of each subscale ranged from 0.72 to 0.93, and the values for the total score were 0.86 and 0.85 in the HBM group and control group, respectively.The study originally recruited 301 participants; 33 were excluded based on the exclusion criteria, and 268 eligible participants  were eventually included in the study. According to the randomized comparison table, we divided 268 eligible participants into two groups: 134 women were included in the HBM education intervention group, and 134 women were included in the basic nursing group. One woman in the basic nursing group was lost to follow-up, and 133 women were eventually included in the basic nursing group analysis. We analysed the characteristics of participants between the two groups. As shown in P > 0.05).Before the educational intervention, HBM indicator scores were compared between the two groups , and theP < 0.001), psychological resilience scores , psychological flexibility scores , self-care knowledge scores , self-concept scores , self-care responsibility scores , self-care skills scores , and self-efficacy scores  than those in the basic nursing group. Additionally, the incidence of LEDVT decreased .The results in P < 0.001), psychological resilience scores , psychological flexibility scores , self-care knowledge scores , self-concept scores , self-care responsibility scores , self-care skills scores , and self-efficacy scores  after the educational intervention than before the intervention. However, there was no such change in the basic nursing group (In the HBM education group, women had higher training compliance (80.6% vs. 28.4%, ng group .Elderly patients' cognition is relatively poor, and their psychological flexibility level is low. When confronted with disease challenges, they often cannot fully and correctly understand the disease and make reasonable and positive self-adjustments in time . GynaecoIn this study, according to the characteristics of cognitive bias and a low level of psychological flexibility of elderly patients with gynaecological cancer, rehabilitation education based on the HBM and positive psychological counselling were used to improve their cognition of the disease, alleviate their negative emotions, realize their potential, and play the subjective and active role of patients in the treatment process. Moreover, by actively organizing and continuously guiding patients to perform health exercise training in bed, we consolidated and deepened patients' grasp of intervention information and skills, which allowed patients to gradually establish a positive psychological state and actively participate in and cooperate with rehabilitation treatment. Our results indicated that the level of psychological resilience of elderly patients with gynaecological cancer was significantly increased after rehabilitation based on the HBM, which suggested that rehabilitation based on the HBM was an important measure to improve the psychological resilience of patients with gynaecological cancer. Rehabilitation based on the HBM can enhance the psychological resilience and rehabilitation compliance of patients, leading patients to actively participate in postoperative rehabilitation treatment and achieve a more ideal rehabilitation effect. Previous studies , 27 haveThere is likely to be a certain correlation between physical health and treatment compliance. Early psychological intervention can improve treatment compliance in cancer patients . PatientSelf-efficacy is an important factor in maintaining or changing health behaviours. The higher the level of self-efficacy, the higher the level of adopting, maintaining, and striving for healthy behaviours and the stronger the self-nursing ability . AccordiThe decline in the learning and memory abilities of elderly patients can impact their self-efficacy and self-nursing abilities. In the context of special diseases, patients can build and strengthen their self-efficacy and self-nursing skills only through active intervention, reconstruction of their self-confidence to overcome difficulties, and continuous demonstrative learning . In lighLEDVT is one of the most common complications in gynaecological patients . It can There are still some potential limitations to this study. First, the number of participants in this study was small, and we will add more participants in the next stage to further verify the effectiveness of the HBM education intervention. Second, this study was conducted in a single centre, and the reproducibility of the results is still unclear, so it will be extended to multiple centres to verify the applicability of the HBM in the future. Finally, the follow-up data of the participants were not analysed in this study because our follow-up work is ongoing, and we will analyse the results after the follow-up is completed.Evidence from this study suggests that perioperative HBM-based educational interventions benefit mental health and disease outcomes in elderly women with gynaecological malignancies by improving self-efficacy, self-care ability, and compliance.


As compared to individuals with FXS without seizures, those with seizures were more likely to have autism spectrum disorder, current sleep apnea, later acquisition of expressive language, more severe intellectual disability, hyperactivity, irritability, and stereotyped movements. The mean age of seizure onset was 6.4 (SD 6.1) years of age with the great majority (>80%) having onset of seizures which was before 10. For those with epilepsy, about half (52%) had seizures for more than 3 years. This group was found to have greater cognitive and language impairment, but not behavioral disruptions, compared with those with seizures for <3 years. Antiepileptic drugs were more often used in males (60.6%) than females (34.8%), and females more often required more than one medication. The most commonly used anticonvulsants were oxcarbazepine, valproic acid, lamotrigine, and levetiracetam. The current study is the largest and first longitudinal study ever conducted to describe seizures in FXS. Overall, this study confirms previous reports of seizures in FXS and extends previous findings by further defining the cognitive and behavioral phenotype of those with epilepsy in FXS. Future studies should further investigate the natural history of seizures in FXS and the characteristics of seizures in FXS in adulthood.Fragile X syndrome (FXS), the most common inherited cause of intellectual disability, learning disability, and autism spectrum disorder, is associated with an increased prevalence of certain medical conditions including seizures. The goal of this study was to better understand seizures in individuals with FXS using the Fragile X Online Registry with Accessible Research Database, a multisite observational study initiated in 2012 involving FXS clinics in the Fragile X Clinic and Research Consortium. Seizure data were available for 1,607 participants, mostly male (77%) and white (74.5%). The overall prevalence of at least one seizure was 12%, with this rate being significantly higher in males than females (13.7 vs. 6.2%,  Fragile X syndrome (FXS) is the most common known inherited cause of intellectual disability, learning disability, and autism spectrum disorder (ASD), with an estimated prevalence of about 1/4,000 .FMR1  gene  (Fmr1 knockout (k/o) mouse model of FXS, there is immature dendritic spine morphology and region- and cell-dependent deficits in synaptic plasticity (Fmr1 k/o mouse (FXS results from a trinucleotide repeat (CGG) expansion mutation of >200 repeats (full mutation) in the promoter of  1) gene  which leprotein) . FMRP isprotein) –7. In thasticity . Accordiasticity  and a hi/o mouse , presumaPast reports have identified seizures in 4.4%-40% of males with FXS , 11–19 wStudies investigating the association of seizures with other disease features in FXS include a small cohort which showed a trend toward an increased rate of seizures in individuals who were also diagnosed with ASD  and a seThe Fragile X Clinic and Research Consortium (FXCRC) initial database collected data from 260 participants with FXS from 9 FXS Clinics from 2005 to 2011 and showed a seizure frequency of 10%  , from 20Data analyzed for this report were derived from FORWARD. As described previously , FORWARDFX)  at seizure onset, age when seizures resolved if the participant had been 2 years without seizures, type of seizures , whether antiepileptic medication was used for seizures at the time of the visit, and, if so, which antiepileptic medication(s) the participant was taking. Antiepileptic medication use was tracked at all visits and was reported in this paper based on use described at any visit over the course of follow-up. Other data from the Clinician Report form about problems that could potentially be associated with seizures were also utilized, including level of intellectual disability (ID), presence of ASD, presence of sleep apnea, severity of behaviors on the ABC-C adjusted for FXS (ABCFX) , and sevt-tests for continuous variables, as appropriate.Frequency tabulations and proportions for categorical variables, and means and standard deviations for continuous variables, were used for the descriptive analyses. The chi-square test or Fisher's exact test for categorical variables, and analysis of variance (ANOVA) for continuous variables were used to compare characteristics of those with and without seizure experience and to compare males and females with seizures. Using longitudinal data, subjects were divided into three groups based on seizure experience. Participants who reported no seizures ever and who were observed at least once at or over the age of 15 comprised one group; participants who reported having seizures but only for a period <3 years and were followed at least 2 years after the last reported seizure comprised a second group; and participants who reported seizures over a period >3 years comprised the third group. Comparisons of demographic and clinical variables between these three groups were made using chi-square tests or Fisher's exact tests, for categorical variables, and Wilcoxon rank-sum test and Student's Kaplan–Meier survival estimates were produced to model and plot time to first reported seizure for the full sample. Mixed-effect logistic regression models were fit to estimate the rate of current seizures for age groups, using the longitudinal data, across the full sample. This model featured random intercepts for subject.Analyses were performed using SPSS version 26 and SAS version 9.4. In each analysis reported in this paper, data were used for all individuals who had valid values for the variables used in that analysis. Statistical significance level was set at 5%.Characteristics of the 1,607 FORWARD participants with available seizure data used for this study are shown in p < 0.0001). Seizures occurred more often in severely affected patients, with 68.7% of patients with seizures having moderate, severe, or profound ID, while only 43% of patients without seizures had this level of ID . Those with seizures were more likely to have an ASD diagnosis compared to those without seizures , although not statistically significant, and increased severity of ASD symptoms by SRS-2 . Current symptoms of obstructive sleep apnea were seen more often in those with seizures (4.2 vs. 2.5%) which led to a chi-square of p = 0.001 for the distribution of sleep apnea category between those with and without seizures. However, if one considered past history of sleep apnea, the distribution of seizures was similar in those with and without sleep apnea, making it unclear whether there is a true association. There were no effects of race/ethnicity, place of residence, household income, or level of education of parents on the likelihood of patients manifesting seizures at any time.In the entire cohort, there were a higher proportion of males with FXS relative to females who had current or past seizures at any time prior to baseline or during follow-up, 13.7 and 6.2%, respectively (Fisher's exact p < 0.0001 for age distribution between those with and without seizures), thought likely to be related to being past the typical age of onset of seizures in FXS. There was no effect of the number of evaluations in FORWARD.Patients were more likely to have reported seizures if they were older at the first and last evaluations (chi-square N = 170), 96% had the first seizure by age 15, with only 4% presenting after age 15. For females (N = 23), 18.2% had their first seizure after age 15, a trend in age distribution with borderline significance (p = 0.058). The age of the last seizure followed a similar distribution to age of onset of seizures with 70.9% and 63.6% of seizures resolving by age 10 in males and females, respectively , and 23 and 22%, respectively, requiring two or more medications. The most commonly used anticonvulsant was oxcarbazepine, followed by valproic acid, lamotrigine, and levetiracetam , were compared with those with seizures lasting <3 years (N = 70) and those without seizures who had reached age 15 (N = 514) , were more likely to have partial seizures and less likely to have febrile seizures , made less language progress during follow-up, had more severe language impairment at the most recent visit (p = 0.03), and had a higher proportion of severe/profound ID , but did not have higher prevalence of ASD, sleep apnea, or severity of behavioral issues on any subscale of the ABCFX. The lack of language progress in the group with seizures lasting >3 years was remarkable, with 25% non-verbal at the initial visit and 21.4% remaining non-verbal at the last visit compared to 14.4% non-verbal at the initial visit and 5.7% at the last visit for those with seizures lasting <3 years. Underscoring the phenotypical severity associated with having seizures regardless of duration, those with no seizures had significantly less severe ID than the <3 year seizure group (p = 0.003), less severe language impairment at the first but not the last visit for those with seizures <3 years , less severe language impairment than those with seizures >3 years at both visits , a higher percent with sustained conversation ability at both visits than those with seizures <3 years at both visits , a lower proportion with ASD diagnosis than both seizure groups at both visits (p = 0.009 for both groups at the last visit), and lower scores on the ABCFX Hyperactivity, Irritability, and Stereotypy subscales than both seizure groups at both visits .Patients with persistent seizures, operationally defined as those with seizures lasting over 3 years (N = 514) . The groFX . Availability of longitudinal data allowed the delineation of key aspects in the evolution of seizures in FXS and their association with other features of the disorder. A longer course of epilepsy in FXS was associated with greater overall cognitive and language impairments, but not more severe behavioral problems.In this study, we characterized seizures in the largest clinically evaluated cohort of individuals with FXS. In addition, this is the only longitudinal study of seizures to date in FXS and thus the only study ever to evaluate incident onset of seizures prospectively in this syndrome. In addition to confirming previously reported characteristics of individuals with FXS and seizures, such as prevalence, sex distribution , and association with ASD , 26, 33,In this FORWARD cohort, individuals with FXS and seizures were more likely to have ASD diagnosed by the clinician based on DSM5 criteria. The association between seizures and a clinical diagnosis of ASD in children with FXS is supported by the finding that this subset has more severe ASD symptoms on the SCQ and SRS-2. Consistent with our findings, previous studies have found an association between the diagnosis of ASD and seizures and children with ASD with seizures have been found to have more severe ASD symptoms , 35. Howp = 0.058) for a different male–female distribution of age of seizure onset may be due to the relatively small number of females with seizures in the cohort. Consequently, a larger cohort would be needed to confirm that females with FXS have a larger proportion of late-onset seizures than males. There is a new concern in adolescents and adults with idiopathic ASD of having new-onset seizures  below age 10, with a very low proportion of males having seizure onset after age 15 years. A higher percent of females had seizure onset after age 15 years, which suggests a slightly different pattern for seizure onset in females, although females with first seizure at age >15 represented only four patients. Thus, the marginally significant chi-square  seizures were rare, with risk being only approximately 1% per patient year of follow-up in FORWARD. Risk of change in seizure type was only approximately 4% per patient year. The Kaplan–Meier plot  shows riWhen patients with longer duration of seizures (>3 years) were compared with those with shorter duration (<3 years), only a few differences emerged, including increased use of anticonvulsants, higher prevalence of partial seizures, and lower prevalence of febrile seizures and, most importantly, more severe language outcomes despite lack of differences in behavioral abnormalities (including ASD) and non-significant increases in ID severity. This suggests that a longer course of seizures in FXS is an index of severity linked to more severe outcome in this some functional domains. It is possible that the division of the groups at 3 years of persistent seizures did not isolate those with the most severe phenotypes and a 5 year cutoff might have been better to more fully explore this concept. Nonetheless, there were not enough patients in FORWARD with 5 years of longitudinal data at present to support such an analysis.Strengths of this study are the size of the subject sample, very large for rare disease standards, and the ability to examine longitudinal data. Weaknesses include lack of availability of follow-up visits into the late teenage years in about half the cohort, lack of complete evaluations of seizure type (many were undefined), and a relatively small population of adults in the current FORWARD database. Additionally, as participants with FXS were not a randomly selected, sampling biases inherent to clinic-based samples cannot be discounted.Based on the data from this study, the prototypical individual with FXS and seizures would be male, with moderate or severe ID and expressive language delay, with a DSM-5 diagnosis of ASD and a corresponding SCQ >15 and SRS-2 in the severe range, who had a first evaluation at a FORWARD (perhaps any FXS) clinic after age 5. Females with FXS and seizures would show similar characteristics; however, among females a subgroup with a distinctive but uncommon profile of onset of seizures after age 15 is identified. It appears that this subgroup has greater cognitive impairment than other females with or without seizures and had a first evaluation at a FORWARD clinic after age 15. The duration of seizures also seems to be a parameter associated with worse outcomes, particularly in cognitive function.via multiple neural mechanisms which are likely to vary between patients, thus resulting in variable penetrance and severity of seizures in FXS. However, likely the presence of seizures is a signal of more problematic neural and synaptic dysfunction related to variation in FMRP deficits in cells, and variation in these multiple interacting pathways. The present study adds to the understanding of the characteristics, risk factors, and course of seizures in FXS and provides a basis for anticipatory guidance for clinicians and families. The study also defines gaps and additional areas of investigation that could answer further questions about seizures, their neural underpinnings, and their evolution across the lifespan in FXS.FMRP has been linked to seizures in FXS through excessive mGluR5 signaling of dendritic translation, based on reversal of audiogenic seizures by mGluR5 blockers in the fmr1 knockout mouse . FMRP alThe raw data supporting the conclusions of this article will be made available by the authors, without undue reservation.The studies involving human participants were reviewed and approved by Institutional IRBs at all FORWARD academic sites. Written informed consent to participate in this study was provided by the participant's legal guardian/next of kin.Elizabeth Berry-Kravis , Milen Velinov , Amy L. Talboy (Emory University School of Medicine), Stephanie L. Sherman (Emory University School of Medicine), Walter E. Kaufmann (Emory University School of Medicine), Marcy Schuster (Elwyn Inc), Nicole Tartaglia , Robyn A. Filipink (University of Pittsburgh School of Medicine), Dejan B. Budimirovic , Deborah Barbouth , Amy Lightbody (Stanford University School of Medicine), Allan Reiss (Stanford University School of Medicine), Carol M. Delahunty , Randi J. Hagerman , David Hessl , Craig A. Erickson , Gary Feldman , Jonathan D. Picker , Ave M. Lachiewicz , Holly K. Harris , Amy Esler (University of Minnesota), Richard E. Frye , Patricia A. Evans , Mary Ann Morris , Barbara A. Haas-Givler , Andrea L. Gropman , Ryan S. Uy , Reymundo Lozano (Icahn School of Medicine at Mount Sinai), Carrie Buchanan (Greenwood Genetic Center), Jean A. Frazier , Stephanie M. Morris (Washington University in St. Louis).EB-K, RFi, RFr, SG, SM, HA, T-HC, and WK: study concept and design, acquisition, analysis, and interpretation of data, drafting and critical revision of the manuscript, and have approved it for publication. All authors contributed to the article and approved the submitted version.Work on this publication was supported by cooperative agreements , funded by the Centers for Disease Control and Prevention.Its contents are solely the responsibility of the authors and do not necessarily represent the official views of the Centers for Disease Control and Prevention or the Department of Health and Human Services.The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.All claims expressed in this article are solely those of the authors and do not necessarily represent those of their affiliated organizations, or those of the publisher, the editors and the reviewers. Any product that may be evaluated in this article, or claim that may be made by its manufacturer, is not guaranteed or endorsed by the publisher.