The objective of this study was to determine whether depression and anxiety are mediators between perceived stress and demoralization via a loss of the cognitive map to get out of the predicament manifesting as subjective incompetence.a priori. Mediators between perceived stress and demoralization were examined using path analysis.Ninety-five consecutive outpatients with Parkinson's disease were evaluated for perceived stress, depression, anxiety, subjective incompetence, and demoralization using reliable and valid scales. Inclusion criteria were ages 40–90, intact cognition, and no current history of substance use. The setting was a Movement Disorders Clinic at a university-affiliated hospital. The outcome variable was demoralization, selected p < 0.001), whereas anxiety bypassed subjective incompetence , connecting directly to demoralization .Depression, anxiety, and subjective incompetence were mediators between perceived stress and demoralization. Among all variables, subjective incompetence was the largest contributor to demoralization. Depression connected to demoralization indirectly via subjective incompetence (β = 0.25, Early treatment and reversal of subjective incompetence and anxiety could potentially prevent the escalation of demoralization and the associated disruption in health-related quality of life and eventual suicide. Parkinson's disease is the second most common neurodegenerative disease in the United States and the fastest growing neurological disease , 2. AlthBy generalizing and modifying slightly a definition proposed for cancer patients, distress may be defined as follows: “An unpleasant emotional experience of a psychological, social, and/or spiritual nature that may interfere with the ability to cope effectively with a stressful situation. Distress extends along a spectrum, ranging from common non-pathological feelings of vulnerability, sadness, and fears to problems that can become disabling, such as depression, anxiety, panic, social isolation, and spiritual crisis” , 5. DistDemoralization is a transdiagnostic categorization, i.e., a condition that may occur in patients with a variety of psychiatric and non-psychiatric medical diagnoses. Demoralization occurs in one-third of patients or more in medical settings, with a prevalence of 20–30% in community settings , 23. DepResearch by our team found that in Parkinson's disease, demoralization is highly associated with depression, but not completely; lifetime histories of both depression and demoralization are more likely in patients than in controls; demoralization explains disruptions in health-related quality of life better than depression; and demoralized patients are more likely than controls to have suicidal ideation –27. HereConsecutive outpatients with Parkinson's disease were recruited from the Movement Disorders Clinic at Yale-New Haven Hospital. Parkinson's disease was diagnosed by a movement-disorders neurologist (A.P.) using the UK Brain Bank Society criteria .Inclusion criteria were age of 40 to 90 years and English comprehension/literacy. Exclusion criteria were substance abuse, history of dementia, and terminal illness. A total of 133 eligible patients were invited to participate. Of these, 38 declined (not interested). Those who declined were similar to the participants in terms of age and sex distributions but were more likely to be in Hoehn and Yahr stages III or IV .Questionnaires were administered in person by trained research assistants after clinic appointments. Participants reported their age, sex, race/ethnicity, marital status, education, household size, cigarette smoking, and drinking habits. A chart review validated the self-reported information about years since Parkinson's disease diagnosis and treatment with deep brain stimulation, antiparkinsonian medications, and levodopa. Other diseases or disorders were reported with a standard systems-review form.Participants were classified according to the Hoehn and Yahr stage , assesseA rule to establish the sample size for path analysis is multiplying the number of measurement variables by 10 . With 5 p ≤ 0.05, and all statistical tests were two-tailed.Structural equation modeling with path analysis (SEMPA) was conducted using AMOS version 23 . The varThe medians and interquartile ranges (IQRs) were used to summarize the data on the variables measured because the distributions were not normal. Their inter-correlations were examined by calculating Spearman's rho correlation coefficients. SEMPA was used to obtain: (1) the direct effects of subjective incompetence, anxiety, depression, and perceived stress to demoralization; and (2) intermediary effects of (a) depression on demoralization through subjective incompetence, (b) anxiety on demoralization through subjective incompetence; and (c) perceived stress on demoralization through anxiety, depression, and subjective incompetence. All residuals of endogenous variables were assumed to be uncorrelated except for the residuals of anxiety and depression, which were assumed to be correlated. To obtain an over-identified model, the coefficient was preset to the partial covariance between anxiety and depression controlled for subjective incompetence.2) statistic, Tucker Lewis index (TLI), comparative fit index (CFI), and Root Mean Square Error of Approximation (RMSEA). An excellent fit is indicated if the χ2 statistic is non-significant with CFI and TLI ≥ 0.95 and RMSEA ≤ 0.05. Given the non-normal distribution in the measured variables, p values and confidence intervals were estimated using bias-corrected bootstrapping with 5,000 re-samples to test the significance of proposed direct and intermediary effects.The model fit was evaluated by a set of fit indices, including the chi-squared (χN = 91); 60 (84.2%) were treated with L-dopa; and 17 (22.1%) had received deep brain stimulation. There were no dropouts or missing data.There were 95 participants in this study (participation rate = 71.4%). The majority were male (66.3%), white (91.6%), married (70.5%), and had a college degree or higher (70.5%). The age range of the sample was 44–84 years . Only 2 subjects (2.1%) were cigarette smokers; 34 (35.8%) reported drinking alcoholic beverages; and none had a history of mental disorder. The average time since Parkinson's disease diagnosis was 2.87 ± 1.12 years, and the participants were mostly in Hoehn and Yahr stages I or II (87.4%). Dyskinesia was noted in 21 (22.1%) and hypertension in 45 (47.8%). All but 4 were treated with antiparkinsonian medications . Both subjective incompetence  and anxiety  had a positive and significant direct effect on demoralization. However, the direct effects of perceived stress  and of depression  on demoralization were non-significant , whereas a similar indirect effect was not observed from anxiety on demoralization . Furthermore, the total indirect effect of perceived stress on demoralization was found to be significant and positive . This total indirect effect consisted of five specific paths: (a) via subjective incompetence to demoralization ; (b) via anxiety to demoralization ; (c) via depression to demoralization ; (d) via depression to subjective incompetence to demoralization ; and (e) via anxiety to subjective incompetence to demoralization . Neither perceived stress nor depression had a significant direct effect on demoralization, thus leading to the conclusion that their relationships to demoralization were fully mediated  was statistically significant and completely mediated by subjective incompetence, depression, and anxiety. Among all variables, subjective incompetence was the largest contributor to demoralization. Subjective incompetence fully mediated the path from depression to demoralization but it was not a mediator in the path from anxiety to demoralization. These findings are consistent with the hypotheses that (a) in the differential diagnosis between depression and demoralization, subjective incompetence is the clinical hallmark of demoralization  and (b) A second, minor path was discovered, independent of subjective incompetence, going from perceived stress to demoralization via anxiety. Some studies indicate that anxiety levels are an important predictor of hopelessness . More reThe pathophysiology of subjective incompetence and demoralization is incompletely understood. Available evidence suggests that subjective incompetence may be viewed as a manifestation of a “top-down” process triggered by a failure of cortical mood regulation (emotion modulation) . SuboptiSeveral psychotherapeutic approaches have been developed to modify the perception of stress and replace negative cognitive distortions of self and stressful situations with positive, more precise, and more realistic appraisals. Examples are cognitive-behavioral psychotherapy, wellbeing therapy, and meaning-centered psychotherapy –56. The Participants were outpatients at a single academic hospital, thereby limiting generalizations to patients with mild and moderate disability in similar centers. The study sample consisted mainly of people who were older, white, male, married, and had a college degree. Results may have been different with a more diverse sample. The iatrogenic effects of medications used to treat Parkinson's disease might be unmeasured confounders. Positive scores on the scales employed are not the same as clinician diagnoses. The depression and anxiety scales used in this study (PHQ-9 and GAD-7) correlate only with major depressive disorder and generalized anxiety disorder respectively, and not with other types of depression or anxiety. A specific scale to assess the presence and intensity of suicidal ideation, such as the Scale for Suicide Ideation (SSI), was not used –61.a priori.The cross-sectional design precludes causal inferences. Although we used the word “effect” to describe the results because it is the appropriate statistical term, path analysis clarifies the correlations and indicates the strength of the hypothesized causal model but it does not establish causation. In order to establish the direction of causality, an experiment has to be conducted in which participants are randomly assigned to a treatment and a control group. Rather than demonstrating causality, path analysis exposes the logical consequences of a causal model assumed Participants were evaluated and diagnosed by a movement disorders neurologist (A.P.). A wide range of demographic, clinical, and treatment-related variables was assessed with valid and reliable scales that have previously been widely used in research and have been used in patients with Parkinson's disease. The research is timely, given that (a) demoralized patients with Parkinson's disease are more likely to have suicidal ideation than controls , and (b)Two paths from perceived stress to demoralization were identified, a major one via subjective incompetence and a minor one via anxiety. Our results invite further study of how they differ and their interrelations in a diverse sample including patients with more advanced disease. The contribution of certain variables known to intervene between perceived stress and demoralization and not assessed in this research, such as resilience and perceived social support, should be examined , 64. TheClinical trials should identify the most efficacious combination of treatment modalities aimed at reducing demoralization. Early treatment and reversal of subjective incompetence and anxiety in Parkinson's disease could potentially prevent the escalation of demoralization and its adverse impact on health-related quality of life and eventual suicide.The raw data supporting the conclusions of this article will be made available by the authors, without undue reservation.The studies involving human participants were reviewed and approved by Yale University Institutional Review Board. The patients/participants provided their written informed consent to participate in this study.JdF was the primary investigator and author, contributions included developing the hypothesis, reviewing the literature, formulating the research protocol, formulating the statistical analysis, interpreting the findings, and writing and editing the manuscript. BZ contributed with formulating the analyses, interpreting the data output, helping with writing and editing the manuscript, performing the statistical analysis, and making all tables and figures. RK contributed with inputting the data, developing the hypothesis, interpreting the findings, and editing the manuscript. AP contributed with participant recruitment, screening potential participant, performing the UPDRS-m scoring, and editing the manuscript. BK and EL contributed with interpreting the findings and writing and editing the manuscript. All authors contributed to the article and approved the submitted version.The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.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.


In terms of working memory, a small but positive significant effect was noted for the intervention group compared to the control group (effect size (ES) = 0.35, 95% confidence interval (CI) = 0.04–0.67; p = 0.029; I2 = 36.7%); in terms of inhibition, the intervention had a small favoring but no significant effect compared to the control group ; and in terms of cognitive flexibility, the intervention had a small favoring but no significant effect compared to the control group . Our findings suggest that healthy older adults should be encouraged to participate in sports to improve their working memory; however, more studies are required in this area to reach more robust conclusions. This systematic review was registered with the International Prospective Register of Systematic Reviews (registration number: CRD42022284788).Exercise programs of moderate-to-vigorous intensity have been shown to improve the cognitive performance of older people. However, the specific effects of sports-based exercise programs on cognitive performance, particularly executive functions, remain unclear. Therefore, the purpose of this study is to clarify the effects of sports-based exercise programs on executive functions in older adults using a systematic review and meta-analysis of the scientific literature. A systematic review was conducted between 1 March and 1 July 2022, to look for published scientific evidence that analyzed different sports programs that may have affected executive function in healthy older adults. Longitudinal studies, which assessed the effects of sports interventions on healthy older adults, were identified through a systematic search of the four principal electronic databases: Web of Science, PubMed, Scopus, and EBSCO. A total of nine studies with a total of 398 subjects met the inclusion criteria and were classified based on one or more of the following categories: working memory, inhibition, and cognitive flexibility. The DerSimonian and Laird random-effects model was performed using the Comprehensive Meta-Analysis software to facilitate the analysis of the studies. Statistical significance was set at  Executive functions are a set of mental processes that are responsible for the monitoring and controlling of the mechanisms that mediate information use and allow for the regulation of thoughts and actions during goal-directed behavior . There iFrom an early age, executive functions are associated with physical activity ,12,13,14Physical exercise has been described as an intervention capable of providing cognitive benefits to older adults in order to maintain brain health ,30,31,32p < 0.05), resistance exercise , aerobic exercise , and combined exercise . Xiong et al. [The types of exercise usually employed in chronic intervention programs for the elderly include aerobics, resistance training, mind–body exercise, and multimodal exercise , and there are systematic reviews and meta-analyses that have attempted to determine the specific effects of these modalities on executive functions ,42,43. Ig et al. ,43. Howeg et al. ,42.In terms of its benefits on executive function in older people, a type of intervention that has not been specifically assessed in previous reviews thus far are those that are structured upon a sport modality, such as combat sports (taekwondo or karate) ,46,47,48While physical activity involves movements producing an increase in energy expenditure  above resting conditions, exercise  usually entails specific movement patterns performed systematically over a planned schedule to achieve a desired aim in line with improvement in fitness and health-related outcomes . RegardiThus, this study aims to systematically collect the available scientific evidence and analyze the effects of sports interventions on the main dimensions of executive functions in healthy older adults compared to their control peers.What are the effects of sports-based interventions on the main dimensions of the executive functions of healthy older adults compared with active or passive control conditions?This review was conducted between 1 March and 1 July 2022, according to the guidelines established by Preferred Reporting Items for Systematic Reviews and Meta-Analysis  Figure . We pre-The following electronic databases were used: Web of Science, PubMed, Scopus, and EBSCO. We combined different keywords and medical subject headings to identify and evaluate relevant studies from inception until June 2022. No filters or limits  were used to conduct the search. See https://www.expertscape.com/ex/executive+function (accessed on 16 May 2022).Additionally, reference lists of previous reviews and all included trials were hand-searched to identify potentially eligible studies. Systematic reviews were searched in the same databases with the filters (or terms) “systematic review” OR “reviews” after the regular search strategy. We also consulted two external experts in executive functions  to examine the inclusion list of articles and to identify possible articles missing from the list. The experts were identified and included based on their Expertscape rank for “Executive + function,” which can be found at Studies that have been published as original articles in peer-reviewed journals were selected. The studies were available in full text and contained sufficient data to calculate the effect size (ES).Eligible studies reported pre- and postintervention changes in one or more measures associated with the executive functions of working memory, inhibition, or cognitive flexibility. These tasks were directly applied to participants using instruments validated for the respective population. Some examples of tasks included in the studies are the N-back task  to assesArticles were imported into a reference management system, and duplicates were removed.Two independent authors (FCO and CCJ) examined the titles and abstracts of the articles found in the databases, using “yes” and “no” instructions to apply the inclusion criteria. If there were disagreements among the authors, the assessment was discussed with a third author (RRC), who worked together to reach a consensus.The bibliographies of previous reviews and studies ultimately selected were reviewed using the same process described above to identify potential new studies that met the inclusion criteria.Data extraction was completed independently by one reviewer (FCO) and verified by a second reviewer (CCJ) for the following: author, publication year, sample size, study characteristics, participants , description of the sports training program (structure or stages), sport, intervention length, weekly frequency, session length and intensity, control condition, dimensions of executive function evaluated, tasks completed, reliability indices reported, and a description of the measurement protocol used in each study.The averages and standard deviations of the dependent variables were extracted before and after the sports interventions in the included studies using Microsoft Excel . When the requested data were not communicated clearly or completely, the authors were contacted to obtain clarifications. When the authors’ responses were not obtained , the results of these studies were excluded from the analysis. The authors (FCO and CCJ) extracted data independently, and any discrepancies between them  were resolved through consensus with a third author (RRC).The Physiotherapy Evidence Database (PEDro) scale was used to assess the methodological quality of the included studies, which were rated from 0  to 10 . The validity and reliability of the PEDro scale have been established previously ,72,73. IRegardless of their methodological quality, all studies that fulfilled the inclusion criteria were incorporated into the review.2 statistic, with values of <25%, 25–75%, and >75% representing low, moderate, and high levels of heterogeneity, respectively [p ≤ 0.05.Although meta-analyses can be performed with as few as two studies , becauseectively . The risectively ,85 usingectively . To adjuectively , with L0ectively . All anan = 2255), the titles and summaries of the remaining studies were reviewed, and another 7399 studies were eliminated. Next, the full text versions of 27 studies were reviewed, and 15 were rejected because they did not include a control group (n = 4), included the recruitment of participants of other ages (n = 4), evaluated other dimensions of executive functions (n = 1), or evaluated other cognitive skills (n = 6). Subsequently, data were requested from the authors of five studies because they were insufficient to calculate the ES, and three of them were eliminated because of lack of response. This systematic review and meta-analysis included the nine remaining studies [The electronic search process identified 9681 studies . Duplicate studies were eliminated , and seven control groups (n = 116). Compared to the control group, a small but favoring significant effect was observed in the intervention group . A sensitivity analysis  indicated that the exclusion of three studies [p = 0.052–0.127; I2 = 30.6–47.3%)  .n = 108), and five control groups (n = 87). Compared to the control group, the intervention had a small favoring but no significant effect . A sensitivity analysis  indicated that the exclusion of one study [p = 0.029; I2 = 54.9%)  .n = 146), and five control groups (n = 134). Compared to the control group, the intervention had a small favoring but no significant effect . The results remained consistent during the sensitivity analysis   .None of the included studies reported soreness, pain, fatigue, injury, damage, or related adverse effects resulting from the sports-based interventions.In this meta-analysis, we analyzed the results of nine longitudinal studies that included at least one experimental group and one control group as well as pre- and postintervention measurements. The results of our systematic review showed that there are few controlled studies of sufficient methodological quality. The available studies show that sports interventions have a small but favoring significant effect on working memory in healthy older adults when compared to control participants. Furthermore, the effect on inhibition and cognitive flexibility dimensions was not significant.This systematic review provides innovative results in terms of the type of intervention used, which differs from the physical exercises analyzed in previous studies, which were classified as resistance exercise, aerobic exercise, coordination exercise, multi-component exercise, and mind–body exercise  ,39,42,43This investigation is aimed at highlighting the importance of regular sports practice in old age in order to provide tools for maintaining executive functions and counteracting the normal functional slope that accompanies it ,92,93. Tp = 0.029; I2 = 36.7%) for the intervention group compared to the control group. These results are consistent with a previous meta-analysis conducted by Xiong et al. [p < 0.001, I2 = 0%). They also detected a significant improvement in aerobic exercise when the exercise mode was examined as a moderator . Only three new studies reported information on the intensity of their programs regarding the aerobic component of sports interventions, with a range between 40% and 80% of maximum heart rate, which are considered activities of moderate-to-vigorous intensity [Working memory is an essential system for activities of daily living because it allows for the temporal storage and simultaneous manipulation of information in order to perform complex cognitive tasks in a variety of contexts ,94. The g et al. , who assntensity ,49,54. p = 0.517; I2 = 78.8%). The sensitivity analysis, however, indicated that the exclusion of a study [p = 0.029; I2 = 54.9%). This suggests that the conclusions drawn from this result should be approached with caution in anticipation of future research that will shed light on the effects of sports on inhibition capacity in older adults. The findings of Reddy et al. [Inhibitory control is the ability to manage attention, behavior, thoughts, and emotions in order to suppress internal or external stimuli that interfere with our ability to choose the best response in a given context . The fin a study  affectedy et al. ,96.p = 0.107). According to the authors, this could be due to the limited number of studies considered in the research field (13 studies). This factor may also have reduced the possibility of obtaining significant values in our study because the meta-analysis on the inhibition included only five studies. In contrast, the meta-analysis by Xiong et al. [p = 0.001, I2 = 0%) in cognitively healthy older adults, including a total of 15 studies for this cognitive dimension. The meta-analysis conducted by Wollesen et al. [p = 0.0003). The increased magnitude of the ES and significance obtained in the above-mentioned meta-analysis can be attributed to the inclusion of studies incorporating a component of cognitive intervention aimed specifically at inhibitory control [In the recent review by Ren et al. , the effg et al.  identifin et al.  of the e control ,100,101. control ,103,104,p = 0.131; I2 = 75.5%). This skill is essential for achieving optimal performance in situations related to sports, especially when the environment and priorities change rapidly [Cognitive flexibility makes it possible to shift attention between multiple tasks based on the demands of the environment or previously established priorities . In term rapidly . This wo rapidly  examinin rapidly ,50,51,88 rapidly , who fou rapidly  and Xion rapidly  found ev rapidly ,50.In terms of the methodological quality of the included studies, none of the analyzed cognitive dimensions received a rating of >7. This suggests that efforts should be made to improve the methodological quality of future studies that address this subject, such as focusing on blinding both subjects and those who administer the therapy. These are flaws in the studies included in our investigation, with which none of them complied satisfactorily. This is a critical factor that can be improved, as highlighted by Wollesen et al. , becausen = 5), the intensity of sports activities (n = 6), and the physical activity levels of their participants (n = 3). We suggest that future investigations consider reporting this information in greater detail to facilitate analysis of the effects of their intervention programs. (2) The small number of available studies limits the possibility of conducting additional analyses of potential moderators; however, future investigations could examine the possible differences in the effects of sports-based exercise programs for elderly men and women. (3) Although the investigations included in the specification did not specify any adverse events associated with the sports-based intervention exercises, it is unclear whether the studies did not report them because no cases were registered or whether they simply did not report the information because this aspect was not evaluated. Therefore, we recommend that future studies collect data and describe possible injuries, pain, and/or any other potential adverse effects in detail because this would increase our understanding of the safety of sports-based exercise interventions for older adults.Certain limitations must be considered when interpreting the results: (1) Some of the analyzed studies provided information on relevant variables such as sports experience (2) values. This would allow for addressing more specific variables, such as the type of sport used in the interventions, considering that the cognitive effects of open- and closed-skill sports may differ [We suggest further investigations in this area to generate more robust conclusions, considering that the reports are based on a small number of selected studies and that the sensitivity analysis suggests that the exclusion of some studies for both working memory and inhibition affects the results of the meta-analysis as well as the presence of moderate–high heterogeneity . Future studies should clarify the role of sports-based exercise interventions on inhibition and cognitive flexibility owing to the high impact of heterogeneity and limited number of studies.Sports-based exercise interventions are more effective in improving measures of working memory compared to control conditions involving active and non-active participants . These findings are derived from nine studies of moderate-to-high methodological quality and a moderate impact of heterogeneity (I


Interactive Whiteboard (IWB) has recently been used to replace the TWB , with many of its features being observed to help teachers in educational activities. This is based on effectively and efficiently increasing the teacher-student interaction. Therefore, this study aims to analyze the determinants of Behavioral Intention (BI) and the use of interactive whiteboards by K-12 teachers, in remote and rural Chinese areas. The Modified-Unified Theory of Acceptance and Use of Technology 2 (UTAUT2) model was used in this analysis, as a learning medium to deliver the subject matter to students. The sample and population were also the teachers in the Guangxi Zhuang Autonomous Region, China, where 171 voluntary respondents participated in this study. Furthermore, the obtained data were processed using a Structural Equation Model (SEM) approach, through the Smart-PLS software. The results showed that Habit and Hedonic Motivation had a significant influence on the Behavioral Intention (BI) of teachers, toward the utilization of IWB in remote and rural areas. Besides this, Facilitating Conditions (FCs) and BI also had a significant positive effect on Usage Behavior. Based on these results, important information was provided to school principals, local governments, and teachers for education quality improvement, regarding the patterns of increasing IWB utilization in remote and rural areas. All factors are found to be influenced by information technology in the 21st Century, including the education sector. In developing countries, the government also focuses on improving the quality of education in rural and remote areas, which is one of the main priorities of the Ministry of Education in China . In thisIWB is one of the potential technology-based media used to improve the quality of learning activities when the embedded features are maximally utilized . However•What factors influence the Behavioral Intention of K-12 teachers to use IWB in remote and rural areas?•What is the biggest significant positive factor influencing the Behavioral Intention of teachers in remote and rural areas, based on using IWB in teaching and learning activities?•What factors influence the K-12 teachers’ usage behaviors in using IWB within remote and rural areas?•What is the biggest significant positive factor influencing the Usage Behavior of K-12 teachers in remote and rural areas, based on the utilization of IWB in teaching and learning activities?Interactive whiteboard (IWB) has reportedly shown significant changes and feature additions in recent years, with the first version being a virtual electronic of the traditional blackboard . This isMany previous studies showed that IWB was recognized by various teachers as one of the technology-based presentation and learning media, which had many advanced and easily-operated features to improve the quality of educational activities . Using cThe Chinese government shows great importance to the development of educational information technology in remote and rural areas, due to the numerous visitations to observe the quality of education . This isInteractive whiteboard is one of the easiest digital learning media utilized by novice teachers and in urban-rural areas . This isBased on previous reviews, technological acceptance theories and models were developed to explain and analyze the factors influencing users’ intentions toward new technologies. According to Davis , the TecUTAUT is considered to be more suitable and useful for analyzing the factors within the use of new educational technology . This exDue to government investment, the remote and rural area schools installed free-to-use interactive electronic whiteboards, indicating that Price Value did not influence teachers in utilizing IWB. This led to the removal of PV. Besides, although the UTAUT model was more stable and widely used to predict the users’ intention (UI) of new technology utilization, the early related techniques were developed from digital and business worlds. This caused the reset of some constructs and moderators when used to predict the usage intentions in other fields . These oThe UTAUT-2 model is divided into the following variables:1.Independent Variables: PE (Performance Expectancy), EE (Effort Expectancy), SI , FC (Facilitating Condition), HM (Hedonic Motivation), and HB (Habit).2.Intermediate Variable: Behavioral Intention (BI)3.Dependent variable: Usage Behavior (UB)The six independent variables were found to casually affect the use of interactive electronic whiteboards in remote and rural areas, as comprehensively observed as follows,(1) Performance Expectancy (PE)Performance Expectancy is defined as the degree to which individuals believe that new technology helps to improve their job performances. According to Venkatesh , a signi(2) Effort Expectancy (EE)Effort Expectancy is the level of ease associated with the use of information technology . In this(3) Social Influence (SI)Social Influence is the influence of people around the user, which indicates that the new technology should be used . In prev(4) Facilitating Conditions (FCs)Facilitating Conditions are the teacher’s complete perception of the various technical support conditions needed for the successful use of information technology . Accordi(5) Hedonic Motivation (HM)Hedonic Motivation is the sense of fun and pleasure felt by the users when integrating new technology . When an(6) Habit (HB)Habit is an additional variable in UTAUT-2, which has the strongest significant positive factor influencing the UB to use technology . This wa(7) Behavior Intention (BI)Behavior Intention influences an individual’s decision whether to use new technology in the future, with several previous studies showing a relationship between BI and UB . This in(8) Usage Behavior (UB)Usage Behavior is the actual use of IWB by frontline primary and secondary school teachers during teaching processes.Based on these descriptions, the influential relationships between 6 independent, 1 intermediate, and 1 dependent variable were combined into 8 hypotheses, as shown in Based on the influential factors, a quantitative approach was used to test the hypotheses of this report . The UTAThe objects were the primary and secondary school teachers in China’s remote and rural areas, such as Guangxi Zhuang Autonomous Region. Under these conditions, a valid sample of 171 people participated in the study, with questionnaire distribution adopting a combination of the online and on-site methods due to the pandemic. This was conducted to ensure the efficiency and quality of the data instrument recovery. According to The questionnaire contained two parts as follows: (1) the demographic information of respondents, including gender, age, teaching experience and period, subject, weekly utilization frequency of IWB, interactive smart whiteboards proficiency, and other basic information and (2) a UTAUT-2 questionnaire to determine the BI and Usage Behavior of IWB for remote and rural teachers. A total of 24 measurement items were also observed for PE, EE, SI, FC, HM, HB, BI, and UB, as they were adopted from previous reports and modified according to these experiments. P-value, with the influential factors of each variable being explored  were used to test the proposed model and evaluate the statistical significance of the path coefficients. According to explored . In addiTo analyze the overall situation of the questionnaire and the effect of all independent variables, descriptive statistics were initially used to test the normality of the data. This indicated that the mean score, standard deviation, kurtosis, and other basic information were derived from the 24 measurement items . The meaThe analysis of the instrument’s reliability and validity was carried out using the Smart-PLS 3.0 software. This showed that the convergent validity was verified from the measurement model, by testing the item and composite reliabilities, average variance extracted (AVE), and Cronbach’s alpha .A certain correlation was also observed among the model variables, which led to the necessity for a collinearity test in regression analysis . This wa2) and SRMR, path coefficient, and effect size  was also used , respectively.Based on lso used . Accordiectively . In thisThe Standardized Root-Mean Square Residuals (SRMRs) are appropriate for assessing the suitability of the PLS model , where ap-value, to verify the hypotheses of the theoretical method and empirical data, as shown in The assumptions of the model’s latent variables were subsequently tested, especially the path coefficient, t-value, and p-value). This proved that H5, H6, H7, and H8 had t-statistics > 1.96 and p-values < 0.05, subsequently indicating that they had a significant effect.t = 1.34 < 1.96, p = 0.18 > 0.05; β = −0.09, t = 0.834 < 1.96, p = 0.40 > 0.05; β = 0.108, t = 1.26 < 1.96, p = 0.21 > 0.05; and β = 0.06, t = 0.74 < 1.96, p = 0.46 > 0.05), indicating the rejection of H1, H2, H3, and H4, respectively. Meanwhile, HM and HB had positive effects on BI by using IWB , leading to the acceptance of H5 and H6, respectively. For Usage Behavior (UB), FC and BI were also observed to have positive effects by using IWB , verifying the acceptance of H7 and H8, respectively.Based on these results, PE, EE, SI, and FC had no positive effects on BI by using IWB . Of the 8 analyzed hypotheses, only HM/HB and FC/BI had significant positive effects on Behavioral Intentions and Usage Behaviors, respectively. Therefore, the government and schools should have practical and constructive solutions to increase the use of IWB in remote and rural areas. In this case, the principals and government need to provide teachers with training and design learning models, which have the capability of being combined with the use of IWB. Through the performance of some training processes, schools should also popularize the ease of using IWB and other technology-based interactive learning media. Therefore, these processes take a long time for teachers to believe that IWB has the ability to improve their learning performances. The government should also form a group or community capable of supporting teachers to use IWB in remote and rural areas. This group should be useful when the teachers have complaints or difficulties in using the learning media during the performance of educational activities. The community should also create social influence, toward the improvement of using IWB to teach. Considering continuous facilities and support from the government and schools, the use of technology-based learning media should essentially increase in remote and rural areas, especially the utilization of IWB.First, despite the results, several limitations were still observed, including the relatively small scope of the questionnaire obtained from the K-12 teachers, where the data obtained did not sufficiently represent all of them in China. Second, the data were only analyzed using a quantitative approach and a structural equation model. This indicates that subsequent reports need to use qualitative and quantitative methods to deeply explain the factors influencing the teachers’ BI and UB toward the utilization of IWB in teaching and learning activities. Third, future studies should extend UTAUT-2 and provide several moderator variables to affect the Behavioral Intention and Usage Behavior of teachers. Finally, comparative reports need to be carried out in rural and developed areas, to deepen the understanding of the analysis and different suggestions provided for each region.202139130001@mail.bnu.edu.cn.The data analyzed in this study is subject to the following licenses/restrictions: the data will available by request. Requests to access these datasets should be directed to TW, The studies involving human participants were reviewed and approved by Guangxi Normal University. The ethics committee waived the requirement of written informed consent for participation.TW and XL conceived the study. YZ contributed to the supervision. XL conducted the experiment and collected the data. TW and YZ analyzed and interpreted the data and contributed to the writing of the manuscript. All authors have read and agreed to the published version of the manuscript.The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.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.


Multiple sclerosis (MS) is an inflammatory disease associated with adverse effects: including depression, anxiety, fatigue, which may affect physical activity and the quality of life (QoL) among patients with MS (pwMS).This study aims to assess the prevalence of depression, anxiety, and fatigue among pwMS who have no physical disability in Saudi Arabia, and demonstrate any correlation between these factors and physical activity as well as the QoL.A cross-sectional study was conducted in the Neuroimmunology outpatient clinics in King Fahad Medical City (KFMC) and King Saud University Medical City (KSUMC) in Riyadh City, KSA. The Arabic version of the Hospital Anxiety and Depression Scale (HADS) was used to measure anxiety and depression levels. The HADS scores were then categorized into three levels according to the total points: normal (0–7 points), borderline (7–10 points), and anxiety/depression (11 – 21 points). The Arabic version of the Fatigue Severity Scale (FSS) was used to measure fatigue (cut-off point ≥5). The physical activity was measured by the Arabic version of the short form of the International Physical Activity Questionnaire (IPAQ), which measure time spent walking, moderate- and vigorous-intensity physical activity of at least 10 minutes duration. The QoL was also measured by the Arabic version of the EuroQOL five-dimensional (EQ-5D-3L) instrument .A total of 323 pwMS participated in this study, 83 had scores that indicated anxiety (25.7%) and 44 had depression (13.6%). The majority of patients had scores with the normal range of depression and anxiety (70% and 57% respectively). The mean of EuroQol Group visual analogue scale (EQ-VAS) score was 80.43 (SD=19.8). 156 (48.3%) out of 323 pwMS reported fatigue while the remainder had no fatigue . The results indicate that only 143 patients (44.3%) had participated in vigorous physical activity during the last 70 days, with a median of 3 days per week (IQR= 5–3) and a median of 60 minutes per day 0 (Interquartile range: IQR = 60–30). Only 149 patients (49.2%) had patricpated in moderate physical activities during the previous week with a median of 3 days per week (IQR = 5–3) and a median of 40 minutes per day (IQR = 60–30). 194 patients had participated in walking activities (60.0%) with a median of 5 days per week (IQR = 7–3) and a median of 45 minutes per day (IQR = 60–30). The results revealed that fatigue was positively correlated with depression  and anxiety .The current study shows depression, anxiety, and fatigue tend to be correlated and clustered together among pwMS in our cohort. However, fatigue is not associated with the intensity of physical activity undertaken. The results of this study are important for the improvement of the clinical management of MS patients. One of the most common neurological disorders that can affect young adults is multiple sclerosis (MS) . It is aDepression, anxiety, and fatigue are common among patients with MS (pwMS) and do affect their quality of life (QoL) and physical activity –11. In sThe impact of fatigue, depression and anxiety symptoms on patients QoL should not be ignored. Several studies have investigated the relationship between QoL and depression, anxiety, stress, and fatigue –25. The Therefore, focusing on improving and alleviating these adverse MS-related symptoms is crucial. However, the prevalence of depression, anxiety, and fatigue in pwMS is not thoroughly studied in Saudi Arabia. Thus, the purpose of this study is to identify the prevalence of depression, anxiety, and fatigue among ambulating pwMS in Saudi Arabia. Furthermore, this study intends to examine the correlations between QoL, physical activity and these symptoms.This is a cross-sectional study, conducted in the Neuroimmunology outpatient clinics in King Fahad Medical City (KFMC) and King Saud University Medical City (KSUMC) in Riyadh, KSA. Patients were also recruited from a database provided by the ARFA MS association. ARFA association is a non-profit organization helping pwMS approved by the Saudi Ministry of Human Resources and Social Development. The ARFA MS association accepts MS patients with medical report to confirm the diagnosis.The study population consisted of patients diagnosed with MS based on the McDonald Criteria (2017) by a neurologist attending KFMC or KSUMC neurology clinics. All patients were aged 18 years and above, with at least a 1-year history of MS with no walking difficulty based on the EQ-5D-3L questionnaire, had no history of relapse in the previous eight weeks, were deemed eligible to participate in this study. Those patients with difficulty in walking and/or those who had a relapse within the previous 8 weeks were excluded from this study since they will probably report high fatigue levels to avoid bais. As well as patients who are illiterate or non-arabic speakers were excluded.A total number of 2,313 patients have enrolled in the National MS Registry (NMSR), which is approximately 38% of the estimated number of patients with MS in KSA. More than a half of the patients (80%) have no or minimal disability  and clinical details (number of years since diagnosis and date of last MS relapse) The remaining sections measure the outcomes of this study. These outcome measures are aim to ascertain many life domains such as physical activity, depression, anxiety, fatigue, disability, and QoL. These outcomes are provided in more detail below.Hospital Anxiety and Depression Scale (HADS)  includeswww.ipaq.ki.se)  . Which cq.ki.se) . The Araq.ki.se) .The EuroQOL five-dimension questionnaire EQ-5D-3L is widely-used globally and has been translated into approximately 150 of languages . It is aFatigue is measured by the Fatigue Severity Scale (FSS), which was found to be sensitive, reliable, and consistent in pwMS with a good response rate of 0 . It is avia a Google Forms link which was distributed to the patients, the respondents were asked to self-report the questionnaire within 24 hours of receiving the link. The questionnaire link was distributed to the participants through social media platforms such as WhatsApp, Twitter, and Emails.The questionnaire of the current study was available online Demographic and clinical characteristics of the study participants are reported as mean  or median  for continuous variables as appropriate. Additionally, categorical variables were reported as counts and percentages or in bar charts as appropriate. Chi-square tests of association were performed to examine the association between two categorical variables. Additionally, the normality of data distribution was examined by the Kolmogorov-Smirnov test. Differences in mean or median scores of each scale were examined using non-parametric tests because the distribution of outcome variables was not normally distributed. Specifically, the Mann-Whitney test was used to assess the differences in outcomes between two independent samples, and the Kruskal Wallis test was used to test for differences in the mean scores of each scale because in involves more than two independent samples. For Kruskal Wallis test with the statistically significant results, the Dunn procedure was used, which accounts for type I error and thus reduces the likelihood of false positive-results . The corAn electronic informed consent was obtained before filling out the questionnaires. All data has been kept confidential and has only been analyzed after the subjects‘ approval without any personal identifiers.SD ± 4.7) years, while the average number of years since the last MS relapse was 2.46 (SD ± 2.3) , Saudis , and resided in the central region of KSA . One hundred and forty-five patients (44.9%) belonged to the 18-29 years age group. More than one-half of the respondents were married  and had university education . Approximately one-half of the participants were currently employed . The average length of time senice diagnosis was 5.5 . However, they were statistically significant differences for anxiety by age groups  but not for depression . Specifically, patients aged 18 – 29 years or 50 years and above had a higher mean score of anxiety than those aged 30 – 39 years . Also, statistically significant differences in mean scores of depression and anxiety were evident among pwMS by region of residence . Patients who lived in the central and western regions had significantly higher depression and anxiety scores than those who lived in the eastern region . The duration in time snice diagnosis of MS and the number of years since the last MS relapse were significantly and negatively correlated with anxiety but not with depression.In this study, the participants exhibited a mean score of depression of 5.63 (SD=4.2) and a mean score for anxiety of 7.34 (SD=4.9), as indicated in According to EQ-5D-3L, a Full Health State was reported in eighty-one participants (25.1%) , while no participants exhibited the worst health state . No respondents had issues with mobility . the vast majority of the participants had no problems in self-care , or usual activities . On the other hand, more than one-half had reported having pain or discomfort . While half of the patients (n = 163) had no reported problems with anxiety or depression  out of 323 pwMS reported fatigue as measured by FSS. This study also stratifies fatigue prevalence by patients’ groups as indicated in The descriptive statistics for the five measures of physical activity for the patients with MS are shown in The scores of IPAQ were also calculated to measure the prevalence of the three categories of physical activities as well as the total physical activities for patients. The median vigorous MET-minutes/week score was 960 (IQR = 480 – 2880), median moderate MET-minutes/week was 600 (IQR = 1200 – 240), and median walking MET-minutes/week was 594 (IQR = 1039 – 239). The median total physical activity MET-minutes/week score was 2838 (4802 – 1364). Physical activities from IPAQ were also categorized into high , moderate , and low  as indicated in P-value < 0.001), which indicates that a higher FSS level is associated with a higher level of depression. Similarly, a positive and significant correlation between the FSS and anxiety levels was detected , which suggests that higher FSS scores are associated with higher scores of anxiety. Furthermore, the correlation between depression and anxiety was significant and positive indicating that a higher score of depression is associated with a higher score of anxiety . However, the total IPAQ score was not significantly correlated with depression , anxiety , or fatigue . Moreover, a negative and significant correlation was found between EQ-VAS and depression , anxiety , and FSS  but was not significantly associated with IPAQ  and time since disease diagnosis .The correlation between the measures used in this study are shown in This study shows that patients in our cohort report anxiety or depression as measured by the HADS instrument. Moreover, the average score of depression falls within the normal category. However, the average score of anxiety falls within the symptoms of a borderline case. This suggests that patients in our cohort were more likely to be anxious rather than depressed. The findings of this study are in accordance with previously published research , 16, 37 The results of this study also indicate that depression and anxiety scores did not correlate with gender, marital status, nationality, education, or work status. However, pwMS from central and western regions exhibited higher mean scores of depression and anxiety than those from the eastern region, which might be attributed to the highly urban and increased industrialized lifestyle in the eastern region compared to the western and central region. Patients in the youngest and oldest age groups in our study exhibited higher average anxiety scores than those aged 30 – 39 years but they reported similar depression levels. Furthermore, disease duration was negatively associated with anxiety but not with depression. Łabuz-Roszak et al. found that in pwMS, depression correlated significantly with age, professional status, and educational levels, while anxiety was significantly associated with age and professional status. Nonetheless, they showed that both depression and anxiety were not significantly associated with gender or disease duration . HoweverIn this study, the QoL was also assessed by the EQ-5D-3L instrument. Most participants exhibited a healthy state as measured by EQ-5D-3L VAS with a mean score of 80.43 (SD = 19.8), which is higher than that reported by Algahtani et al., who estimated it as 73.87 SD = 23.41) among pwMS in King Abul-Aziz Medical City in Saudi Arabia . The fin.41 amongThe present study also shows that the prevalence of fatigue was 48.3% of pwMS, whereby it was more present in women, younger patients, married, Saudis, those living in the central region, university educated, and in patients with normal depression and anxiety. However, fatigue was not significantly associated with age, gender, marital status, nationality, region, education, work status, and disease duration but was significantly associated with anxiety and depression measured by HADS and QoL measured by EQ-VAS. The findings are, to some extent, consistent with other research , 23, 41.Moreover, the present study also indicates that 96 out of 133 (72.2%) pwMS in Saudi Arabia were engaged with a high level of physical activity. The total IPAQ score was positively and significantly correlated with disease duration, but it was not significantly associated with depression, anxiety, FSS, and EQ-VAS, as well as did not significantly differ by age, gender, marital status, nationality, region, education, and work status. This could be due to the low number of respondents on the IPAQ, where only 133 out of 323 patients had answered that part of the questionnaire. A study in Poland indicated that the prevalence of high physical activity among pwMS was 45%, which is lower than our findings. Moreover, a significant correlation between IPAQ and FSS scores was detected, which contradicted our results . A studyThe correlations between depression, anxiety, and fatigue were also assessed in our cohort of patients. The results of this study suggested moderate correlations between depression and anxiety as well as depression and fatigue but a weak correlation was found between anxiety and fatigue. Previous studies reported significant inter-correlation between depression, anxiety, and fatigue in terms of symptoms cluster approach , 45–51. It is important to note that the MS-related literature has tried to illustrate the associations between these adverse outcomes from different perspectives and mechanisms that underlie them . From a The results reveal that about one-half of respondents were not engaged in physical activity. This could be resolved by educational programs for pwMS to improve their coping with the disease. Therefore, further research is needed to identify this problem. Furthermore, it would be useful to conduct longitudinal research with follow-up pwMS and better to include variables like coping strategies, resilience, sense of cohesion, and some more precise physical capacities rehabilitated by the disease. It is important to note that depression, anxiety, and fatigue will be probably higher if pwMS who have a motor disability were included.The current study has some limitations. First, this study measures only self-reported assessments of fatigue, depression, anxiety, QoL, and physical activity among patients with MS, not actual psychiatric diagnoses. Nevertheless, the instruments exhibited robust psychometric characteristics that have been applied across a wide range of studies , 61, 62.The current study shows that depression, anxiety, and fatigue, are frequent among pwMS in Saudi Arabia. Moreover, fatigue is associated positively with anxiety and depression, negatively with EQ-VAS, but not with physical activity. The results of this study are important for the improvement of the clinical management of MS patients. Furthermore, potential clinicians should have more focus on anxiety and depression symptoms among people with MS disease to develop appropriate treatments for those patients. Finally, support programs should be made available for pwMS to ensure adequate coping with the disease.The original contributions presented in the study are included in the article/supplementary material. Further inquiries can be directed to the corresponding author.SAS and NA conceived of the presented idea. AA, TA and SAS planned and carried out the simulations. RA, HA and SAS developed the theory and performed the computations. NA contributed to the interpretation of the results. NA and SAJ verified the analytical methods. RA and SAS investigate and supervised the findings of this work. SAS carried out the experiment. SAS and NA wrote the manuscript. All authors provided critical feedback and helped shape the research, analysis and manuscript. All authors discussed the results and contributed to the final manuscript.King Fahad Medical City (Grand number 019-058).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.


P < 0.05). Age, gender, occupational status, annual household income and the duration of hemodialysis were found to be the main factors related to stigma in young and middle-aged maintenance hemodialysis patients by multiple regression analysis. Perceptions of hemodialysis-related stigma were common in our sample. Patients who had low income, were younger, were male, had long-term hemodialysis and were employed had a higher level of stigma, which deserves attention from clinical medical workers. Replication studies are needed to confirm these findings.Many young and middle-aged maintenance hemodialysis patients suffer a poor prognosis, experience a series of problems during long-term treatment and are thus prone to stigma. This study was designed to analyze stigma in young and middle-aged maintenance hemodialysis patients and explore its influencing factors. This study was conducted as a cross-sectional descriptive study with a convenience sampling method and included 97 patients from Shanghai Jiao Tong University Affiliated Sixth People’s Hospital between November 2020 and February 2021. The Social Impact Scale, a demographic questionnaire, and hemodialysis indicators were used in the investigation. Patient biochemical indexes from hemodialysis were compared. Young and middle-aged maintenance hemodialysis patients had a medium level of stigma. Patients who had low income, were younger, were male, had long-term hemodialysis and were unemployed had significantly higher stigma scores than other patients ( Stigma, which originates from the Greek word “stizein,” is a negative perception that something about a person is abnormal, out of the ordinary or bad . Self-stWith the worldwide incidence of renal failure caused by chronic kidney disease and other chronic diseases continuing to rise, the number of hemodialysis patients is increasing year by year. Recent epidemiological studies have found that the population of young and middle-aged maintenance hemodialysis (MHD) survivors has gradually increased . MHD is In addition, most MHD patients have a series of symptoms and complex complications, such as fatigue, nausea, vomiting, pruritus, body aches, chest pain, cramps, hypotension, hypertension, acute hemolysis, dialysis imbalance syndrome, and painful muscle spasms . These sAlthough some studies have mentioned that MHD patients have a sense of stigma, there are few studies on the level of stigma of MHD patients, especially young and middle-aged MHD patients. In addition, some studies have found that some hemodialysis indicators, such as dialysis adequacy, are positively correlated with the nutritional status and quality of life of MHD patients . DialysiThis study was conducted as a cross-sectional descriptive study. A convenience sampling method was used to collect information from 97 young and middle-aged patients at Shanghai Sixth People’s Hospital between November 2020 and February 2021. All patients were given adequate pain assessment and analgesic treatment before dialysis and during catheter maintenance operations. The inclusion criteria were as follows: (1) patients who were 18∼59 years old and had regular dialysis for more than 3 months; (2) patients who had no cognitive impairment; and (3) patients who consented to voluntary participation in the study. The exclusion criteria were as follows: (1) patients with other serious diseases or tumors; (2) patients with mental illness preventing their cooperation; or (3) patients diagnosed with depression and receiving antidepressant treatment.An 11-item questionnaire on the demographic characteristics of medical staff was administered. The questionnaire collected information on age, gender, education level, marital status, occupation, annual household income, family residence, disease-related data (such as primary diseases and comorbidities), and vascular access types.The Social Impact Scale (SIS) is part of a universal scale for evaluating the stigma associated with two or more types of diseases; it was compiled by This study was approved by the Hospital Ethics Committee of Shanghai Jiao Tong University Affiliated Sixth People’s Hospital [No. 2021-KY-064(K)]. Consent for participation in the research study was obtained from all patients in written form. The study was conducted in compliance with the Declaration of Helsinki.The participants were recruited from the outpatient clinics of a hemodialysis center of a municipal hospital in Shanghai. Before the study, a research assistant explained the purpose of the study and obtained written informed consent from each participant. The participants were guided by researchers to fill out the electronic questionnaire or paper questionnaire according to their own situations. The data from the web-based questionnaires and paper questionnaires were anonymously submitted to the central database. Only the research team had access to the central database for academic research. The answers were checked immediately after questionnaire completion, and missing items were identified and completed to ensure the validity of the questionnaire. Finally, 105 questionnaires were distributed, and 97 valid questionnaires were collected for an effective recovery rate of 92.3%.t test. The effects of the general conditions on the stigma score of young and middle-aged MHD patients were compared by independent samples t test and single-factor analysis of variance (ANOVA). Multiple regressions were used to further analyze the predictive effect of the general data on the stigma of the population. All statistical tests were performed bilaterally, and P < 0.05 was considered statistically significant.After the elimination of invalid questionnaires, the data were entered and numbered. SPSS 26.0 was used for the statistical analyses. We used descriptive statistical analyses (measurement data with the mean and standard deviation). Count data were described as the frequency and composition ratio to describe the general data. Comparisons between the average SIS score and the norm were performed by independent samples P < 0.05). The details are shown in P > 0.1). The results of the one-way ANOVA showed that the SIS scores of young and middle-aged MHD patients varied significantly by age, gender, family residence, annual household income, duration of hemodialysis and Kt/V value (P < 0.05), as shown in The total SIS score was 43.69 ± 8.62 points, which was at the middle level. The four dimension scores were as follows: social rejection (13.20 ± 4.18), economic insecurity (6.29 ± 2.11), internalized shame (9.65 ± 2.97), and social isolation (14.58 ± 3.99). The average item score was 1.82 ± 0.36. The SIS scores of the young and middle-aged MHD patients were lower than the norm for China , and theP < 0.05), they explained 39.6% of the variation in stigma . As shown in P < 0.05). MHD patients with lower income had a significantly higher level of stigma (P < 0.05). In addition, male young and middle-aged MHD patients who were working had a higher stigma score. The duration of hemodialysis positively predicted stigma in young and middle-aged MHD patients.The SIS scores of young and middle-aged MHD patients were used as the dependent variable, and the variables with significant differences in the univariate analysis as well as occupational status were used as independent variables to perform multiple linear regression analysis. Continuous variables were input according to the original value (age), and classified variables were treated as dummy variables. The results showed that when age, family income, gender, working status and the duration of hemodialysis were entered into the regression model , indicating that the stigma among young patients was stronger than that among older patients, which was basically consistent with the results of other studies (Age: The results of this study showed that the stigma scores of young MHD patients (18–44 years old) were significantly higher than those of the middle-aged group . A previous study found that dialysis adequacy was positively correlated with commonly used nutritional indicators ]. The patients/participants provided their written informed consent to participate in this study.All authors made significant contributions to the work reported, whether in the conception, study design, execution, acquisition of data, analysis and interpretation, or in all these areas, participated in drafting, revising or critically reviewing the article; gave final approval of the version to be published; agreed on the journal to which the article has been submitted; and agreed to be accountable for all aspects of the work.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.


Cigar consumption has increased in the U.S. over the past decade, yet gaps remain in research on cigar promotion in print magazines. This study examines ad placement, volume, ad characteristics, and associated expenditures for cigars from 2018–2021, and readership data for magazines containing cigar ads. We merged content analysis data with Kantar Media data on magazine placement and expenditures and used magazine readership data from MRI-Simmons. The only brand in print magazines was Black & Mild (B & M), a top cigar brand in the U.S. There were 30 unique B & M magazine ads and 284 occurrences , translating to $46,504,578 in expenditures. All ads featured the word “enjoy/enjoyment” and a warning label. Filtered cigars were the most featured cigar type (75%) and sweets was the most featured flavor (78%). Nearly half of the publications in which B & M were advertised in have substantial Black/African American readership and were featured in publications with disproportionate young adult and Hispanic/Latino readership. This study identified tactics used in print advertising for a top cigar brand. Future research should examine how these tactics impact consumer perceptions. Findings of cigar ads reaching vulnerable populations may inform the FDA’s efforts to reduce health disparities through regulations and public education. Like cigarette smoking, cigar smoking can lead to a range of life-threatening conditions, such as cancer . The cigThe popularity of cigars among vulnerable populations in the U.S. is well-documented. Indeed, cigar use, especially use of cigarillos and filtered cigars, is disproportionately common among Black/African American individuals ,5,6,7,8.Cigar products are marketed through a variety of channels, including magazines, social media, point-of-sale, websites, and musical events, and often feature appealing flavors, human models, music imagery and language, price promotions, and descriptors that highlight certain natural themes and language ,15,16,17Cigar marketing is a contributing factor in the persistent disparities observed in cigar smoking prevalence, as previous research has shown that cigar marketing often targets Black/African American communities ,27. For Monitoring cigar marketing in print magazines is important for several reasons. First, print magazines have become increasingly popular. Between 2012 and 2020, the number of magazine readers who were 18 years and older steadily increased from 211 million to 229 million, with print magazines being the preferred magazine format despite a growing interest in online versions . FurtherThis study aims to provide a comprehensive examination of print magazine ad placement, volume, characteristics, and associated expenditures for cigars over a four-year period (2018–2021). This study also examines print magazine readership data for publications that contain ads for cigars to understand if cigar companies are reaching vulnerable populations with their print magazine ads, like they have with other channels .Print magazine ad data were obtained from Kantar Media for January 2018 to December 2021. Kantar monitors 209 print magazines and tracks ad placement and expenditures for ads in monitored publications. Tracked information includes the magazine in which the ad was found, date of printing, and estimated expenditures of running the ad. Each unique ad can have multiple observations, as it can appear in different magazines and/or different issues of the same magazine. During the study period, Black & Mild was the only cigar brand advertised in print magazines, with a total of 30 unique ads and 284 observations of these ads .n = 76,831), which is designed to assess media exposure/use and oversamples for young adults and Black/African American and Hispanic adults. Data were collected from March 2019 to May 2021.Print magazine readership data came from the 2021 MRI-Simmons Spring Doublebase USA Survey, a national area, probability-based sample of US adults  then discussed all discrepancies until 100% agreement was reached, and the coding guide was revised accordingly. The full sample of advertisements was coded by two coders, and discrepancies were discussed by the coders and project lead. Agreement across codes was high (84–100%). The five categories of codes were: (1) product characteristics, (2) ad imagery and language, (3) descriptors, (4) warning label characteristics, and (5) miscellaneous.Product characteristics. We coded all ads for the presence of any cigar pack, individual cigar(s), lit cigar(s), lighters, matches or ashtrays. We also coded for whether a “limited-edition” product was featured, a flavor was featured, what flavor(s) and the type of cigar . Flavors and cigar types could be shown either on the pack/cigar or mentioned in the ad text.Ad imagery and language. We coded for urban imagery , alcohol-related imagery  and music-related imagery and text (the latter did not include Black & Mild flavors Jazz and Blues). We also coded for whether people were featured in the ad, their perceived sex and race, and whether the person was shown holding, smoking, or lighting a cigar.Descriptors. We coded for the use of the following descriptors on the cigar packs or in the ad text: enjoy/enjoyment, taste, aroma, natural, smooth, and short.Warning label characteristics. We also coded for whether a warning label was present on the ad (other than on a cigar pack pictured), warning label background color , whether the warning label was compliant with FDA’s voluntary guidance on label placement and size for cigar ads  , and warMiscellaneous. Lastly, we coded for the language of the ad (English or Spanish) and whether the ad featured a link or QR code to the brand website.n = 30) and all the observations (n = 284), and we assessed the expenditures associated with each code and the proportion of total expenditures for each code. Lastly, we examined occurrences for, and expenditures associated with ads in each publication, as well as readership data for each publication. This included total number of readers, total expenditures, percent of readership and total number of readers who are young adults (ages 18–24), Black/African American, Hispanic, and LGBT. We compared readership data with population-level prevalence estimates of each group to identify whether readership across groups for each publication was disproportionately high. If the proportion of readership was greater than the proportion of a population for a given group, we considered readership to be disproportionately high among that group. These groups were selected due to research showing that they have historically been the targets of cigar marketing [The content analysis data and occurrence/expenditure data from Kantar were merged in Stata/MP 17.1  for analarketing ,27,29. RAs noted above, all observed cigar ads were for Black & Mild. Black & Mild spent $46,504,578 on print magazine ads from 2018 through 2021; they spent the most money in 2018 , followed by 2019 . Expenditures for 2020  and 2021  were similar.Ad expenditures and occurrences by quarter can be found in From Q2 to Q4 of 2018, all ad occurrences promoted wood tip cigars . FiltereNo ad occurrences prior to 2020 featured a warning label that was voluntarily compliant with FDA’s size/placement guidelines . CompliaAbout one-third of the ad occurrences featured music-related imagery or language, totaling $18,814,669 over the study period. Urban imagery  and alcohol imagery  were less frequent. About one-third of occurrences featured a person  and 36.6% featured a person either holding, smoking, or lighting a cigar . The presence of female  versus male  individuals was about the same. However, 36.6% of ad occurrences featured a Black/African American person , while only 3.2% of occurrences featured a white person . All ad occurrences featured the words “enjoy” or “enjoyment.” Less than 10% of occurrences featured the remaining descriptors examined .All occurrences featured a warning label, but only 22.9% of occurrences featured a warning label that was compliant with FDA’s voluntary guidance for warning size and placement . Most occurrences contained warning labels with a white background  and 57% were coded as having high contrast with the ad . Almost all ad occurrences were in English  and a total of 5.6% of ad occurrences featured a link or QR code to the brand’s website .Black & Mild ads were identified in 26 publications, with readership figures ranging from approximately 2 to 11.9 million . Almost Our study is the first to report on the content, placement, and expenditures for cigar advertising in print magazines. Over a four-year period, we found that only one cigar brand advertised in consumer print magazines—Black & Mild. Black & Mild is the top-selling cigar brand in the U.S. and increased in popularity from 2009 to 2020 . Its advInterestingly, expenditures and occurrences indicating prominent codes in the ads did not always align. For example, 75.5% of occurrences promoted filtered cigars, yet when looking at expenditures, only 53.8% of expenditures were associated with ads promoting filtered cigars. This likely reflects the varying costs of advertising in different publications, as magazines with greater readership are likely more expensive to advertise in. This finding highlights the importance of examining both ad occurrences and expenditures, as one cannot assume that they tell the same story about a brand’s advertising strategy.Our finding that most ad occurrences featured the brand’s cigar pack is noteworthy given the importance of brand recognition for purchasing at the point-of-sale, and the emerging literature on the impact of cigar packaging on consumer perceptions and intentions ,44,45,46Our study found that the phrases “enjoy” or “enjoyment,” which have been used frequently in premium cigar advertising , were fewww.blackandmild.com, accessed on 15 June 2022). As such, Black & Mild may be pushing their largely unflavored, filtered cigar in anticipation of the ban on characterizing flavors in cigars.Most ad occurrences (75.5%) and about half of all ad expenditures were devoted to filtered cigars and from 2020–2021, filtered cigars were the only cigar type featured in Black & Mild ads. Filtered cigars look nearly identical to cigarettes and are typically sold in larger pack sizes , whereas other types of cigars, like cigarillos, are usually sold in packs of five or less . HistoriIn terms of warning labels, we did not observe any adoption of the new voluntary labeling guidelines until the second quarter of 2020. Furthermore, after the key lawsuit decision in July 2020 ruled in favor of the industry and the warning requirements were not upheld, Black & Mild’s voluntary compliance with the warning provisions dropped and then ceased. These findings suggest that the company was aware of the new FDA warning guidelines and capable of implementing them, but was not interested in doing so if not required. This underscores the need for cigar-specific research on warning label effectiveness to support relevant future policy and implementation efforts ,54,55,56Taken together, findings on readership data as well as ad content illustrate a concerning pattern. Specifically, nearly half of the publications in which Black & Mild advertised have substantial Black/African American readership. Correspondingly, over 10 times as many Black & Mild ad occurrences in the study period featured Black/African American people than white people. Considering the disproportionate prevalence and burden of cigar smoking on Black/African American individuals ,5,6, theOur study has limitations. First, although print magazines are still the preferred format among most readers, our study did not include ads or readership data for digital versions of the publications, and therefore we may not have captured additional exposure to cigar ads via digital issues. Those who prefer print magazines over digital tend to be older and of higher socioeconomic status (SES) , therefoThe influence of advertising on tobacco use can be exacerbated by communication inequalities, which are differences in the ability to access, understand, and act upon health information . FindingOverall, this study fills an important gap in the literature by helping to demystify a piece of the cigar marketing mix, by providing analysis of the content, expenditures, and reach of cigar marketing via print magazines in the U.S. Our study also exposes future research needs related to cigar marketing. Indeed, research is needed to understand how the strategies identified in our study influence consumer perceptions and intentions among both users and non-users, and among different population groups . Furthermore, as the tobacco marketplace continues to change and as cigar companies adjust their marketing strategies in response to the forthcoming ban on characterizing flavors, continued surveillance of cigar marketing in print magazines, as well as other channels, is warranted. Lastly, findings from our study may inform the FDA’s educational efforts related to communicating the risks of cigars to consumers.