The objectives of this study were to compare the efficacy, advantages, and disadvantages of insertable ureteral reimplantation (UC group) and ureteral end-to-side anastomosis (UU group) in the treatment of duplicated kidney and summarize the clinical experience in its diagnosis and treatment.The current retrospective study enrolled 20 cases with duplicated kidney in Anhui Provincial Children's Hospital from April 2016 to June 2021, including 11 in the UC group and 9 in the UU group. There were 8 boys and 12 girls, with 12 on the left side and 8 on the right side. Meanwhile, there were three cases with urinary tract infection and nine with urinary incontinence. The rest of them were found by B ultrasound during physical examination. The median age of these patients was 33.5 months. Later, preoperative and postoperative renal pelvis separation, ureteral dilation, operation time, and drainage tube indwelling time were compared between the two groups.P = 0.03), drainage time , and hospital stay  between the two groups. In addition, the degree of hydronephrosis  and ureteral dilatation  were statistically different between the two groups before and after surgery.There were statistically significant differences in operation time (282 ± 50.55 vs. 176 ± 61.92, Compared with the UC method, the UU method has the advantages of less trauma, faster recovery, and fewer complications. Double J tube or ureter stent placement is beneficial for finding and protecting the lower ureter intraoperatively, without increasing the difficulty in operation, which can also prevent anastomosis or ureteral orifice stenosis. Duplex pelvis and ureter malformation is a frequently seen urinary malformation in children, and its incidence rate is 0.8%–1%, with a higher incidence in girls . The patThe present retrospective study was carried out on 20 cases who had a complete duplicated kidney with sparing upper kidney in our hospital from April 2016 to June 2021, including 11 in the UC group and 9 in the UU group.(i)Complete duplicated kidney;(ii)No abnormality of the lower kidney or ureter;(iii)Upper renal hydronephrosis, and VUR or stenosis of the upper ureter;(iv)Symptoms of urinary incontinence or UTIs; and(v)Urinary computerized tomography (CT) and intraudio videoenous urography (IVU) revealing a certain of upper kidneys worth preserving.Exclusion criteria:(i)Incomplete duplicated kidney;(ii)VUR or terminal stenosis in the lower renal ureter; and(iii)Concurrent ureteropelvic junction obstruction (UPJO) in upper or lower ureter.There were 8 boys and 12 girls with the median age of 33.5 months enrolled into this study, including 12 cases on the left side and 8 on the right side. Moreover, three cases had urinary tract infection, nine had urinary incontinence, and the rest were found by B ultrasound during physical examination. All cases underwent urological B ultrasound, magnetic resonance urography (MRU), urological CT, IVU, and voiding cysto-urethra urography (VCU) examinations preoperatively. According to the excretion of contrast agent and the morphology displayed by urinary CT and IVU, it was possible to determine whether the duplicated upper kidney should be preserved. All the cases were diagnosed with complete duplicated kidney, with hydronephrosis of the upper kidney and tortuosity of the upper ureter, but with no obvious abnormality in the lower kidney or ureter. One patient had ipsilateral vesicoureteral reflux of the upper ureter (grade I), and two developed an ipsilateral ureteral terminal cyst of the upper ureter. Children with urinary tract infections received anti-infective treatment and underwent surgical intervention after reviewing a normal urine routine. Thereafter, preoperative and postoperative renal pelvis separation, degree of upper ureteral dilation, operation time, and drainage tube indwelling time were compared between two groups.Inclusion criteria:The two groups of surgeons were in the same treatment team with experienced laparoscopic skills.2 pneumoperitoneum construction, a small incision was made in the lower margin of the umbilicus, and then a 5-mm trocar was inserted. Thereafter, 3- and 5-mm trocars were inserted into the midline of the clavicle below the eyepiece, respectively. Then, the distal end of the upper renal ureter was exposed, ligated, and dissected. Attention should be paid not to hurt the lower renal ureter. The upper renal ureter was severed near the bladder , then the double J tube was placed into the upper renal ureter, and a bladder incision was made above the lower renal ureterovesical junction. Subsequently, the ureter was inserted 1–1.5 cm into the bladder, and the whole bladder layer and ureteral muscle layer were sutured and fixed with an absorbable line. A pelvic drainage tube was indwelled and fixed , and the lower renal ureter was found through a double J tube. Subsequently, a longitudinal incision of about 1 cm was made in the lower ureter beside the iliac vessel, while the upper renal ureter was cut diagonally, and the upper-lower ureters (end-to-side) were sutured intermittently with an absorbable line . A pelvic drainage tube was indwelled and fixed .t-test was employed to compare the operation time, diameter of the ureter, anteroposterior diameter (APD) before and after surgery, length of hospital stay (LOS), and pelvic drainage tube removal time between the two groups. Continuous measurement data on age and follow-up time were represented by medians. In our statistical analysis, P < 0.05 was regarded to be of significance.SPSS 16.0 software was adopted for performing data collection and analysis. The independent sample P = 0.03), drainage time (P = 0.02), LOS (P = 0.007), degree of APD , and ureteral dilatation  before and after surgery. The UU method had the shorter operation time, drainage time, and LOS. It was suggested that the long hospital stay in the UC group was related to the long postoperative drainage indwelling time, indicating the greater UC procedure-induced trauma than the UU procedure. There was no significant difference in the degree of preoperative and postoperative hydronephrosis or ureteral dilatation  between the two groups , anastomotic obstruction, vesicoureteral reflux, residual ureteral syndrome, or abdominal pain and discomfort. Recurrent cysts were not found in the two children with ureteroceles. In only one case, the drainage tube was left for a long period of time, since the standard for removal was not met. After 3 days of tube clamping and ultrasound examination, it was confirmed that there was no urine leakage and no discomfort in the child, and the drainage tube was removed. The patients were followed up for 1, 3, 6, 9, and 12 months after double J tube removal, with the average follow-up time of 20.55 (5–12) months. Hydronephrosis and tortuous ureter were reduced in 17 cases and remained unchanged in 3 cases, with no aggravation in the children. There were statistical differences between the two groups in the operation time  . Wong anIn conclusion, the two surgical methods have their own advantages and disadvantages, and it is essential to choose the appropriate method according to the situation of the children and the surgical experience of the surgeons. The UU procedure is less traumatic, and children can recover faster. For those with experienced laparoscopic operation, insertable ureterovesical reimplantation can be performed after forming the ureteral papillae in order to lower the incidence of vesicoureteral reflux and ureteral orifice stricture. The placement of a double J tube or a ureter stent is beneficial for finding and protecting the ureter during surgery, without increasing the difficulty in operation, and it can also prevent anastomosis (UU surgery) or new ureteral opening stenosis (UC surgery) postoperatively. However, the UU approach can provide the benefits of minimal invasiveness and less complications, making it even more appealing.


Tomato by-products from processing industries have a higher potential to be reused as a source of bioactive compounds. Reliable national data on tomato by-products and physicochemical characterisation that will inform and find effective planning on tomato waste management in Portugal is absent. To help obtain this knowledge, selected Portugal companies were recruited to obtain representative samples of by-products generation, and physicochemical composition was evaluated. Furthermore, an environmental-friendly method (the ohmic heating (OH) method, which allows the recovery of bioactive compounds in absence of hazardous reagents) was also used and compared with conventional methods to explore new safe value-added ingredients. Total antioxidant capacity and total and individual phenolic compounds were also evaluated by spectrophotometric and high-performance liquid chromatography (HPLC), respectively. Tomato processing by-products have revealed a higher potential since both collected samples from companies were rich in protein . In addition, these samples contain 17.0 g/100 g of fatty acids . Also, they present mainly chlorogenic acid and rutin as phenolic compounds. After understanding its composition, the OH was applied to determine added-value solutions to tomato by-products. With extractions, two types of fractions were obtained, namely liquid fraction rich in phenols, free sugars, and carotenoids and a solid fraction rich in fibre bound to phenols and carotenoids. This treatment has been shown to have the ability to preserve carotenoids, such as lycopene relative to conventional methods. Nevertheless, new molecules were identified by LC-ESI-UHR-OqTOF-MS analysis, such as phene-di-hexane and N-acethyl-D-tryptophan. According to the results, the OH boosts the potential of tomato by-products and can be directly introduced into the process, contributing to the circular economy and zero by-products. An expanding global human population, rapid urban development, and economic growth are increasing waste production at an alarming rate. By 2050, the world is predicted to generate 3.40 billion tons of waste per year, a significant increase from today’s 2.01 billion tons )The minerals contents were similar for C1 and C2, ranging from 2.90 to 3.35 g/100 g, respectively. These values are comparable with those reported by  . Reduced differences were found among producers, and the results were comparable to the results reported by [The differences in phytochemical profile obtained could occur for different reasons: tomato cultivars, growing conditions and the processing method , also by the differences in the processing conditions and methodologies employed by each company. As previously mentioned, the C1 was provided fresh as usually supplied for animal feeding to local farmers, and the C2 was pressed and dried under the sun to reduce the water content to considerably minimize transport costs associated with the final disposal ,31,32. Tp < 0.05). Other authors reported similar values of WSP, 7.0 g/100 DW of WSP extracted from tomato seeds [p < 0.05) compared to C1. found Higher values of CSP (7.0 ± 1.0 g/100 g GUAE) was found by [Cell walls of tomato by-products contain pectin, a structural branched heteropolysaccharide. The total pectin present in tomato by-products was 2.11 ± 1.24 for C1 and 15.56 ± 1.41 g GUAE/100 g DW for C2. Furthermore, there are significant differences between the amount of Water-soluble Pectin (WSP) from C2 and C1 .Compared to the solid fractions, the liquid fraction had more carbohydrates (73.53 to 74.99 g/100 g DW) and ashes (10.56 to 12.45 g/100 g DW).The increased nutritional value of SFOHs than RTB and SFCONV is due mainly to the heating process during OH treatment, which leads to the development of pores (electro-permeabilization) and intracellular diffusion of compounds which probably remained in the SF following extraction of LF.The significant differences observed in fat and ash content of liquid fraction, extract obtained with conventional method (LFCONV) compared to SFOH probably is due to the higher affinity of compounds with chemical solvents used to their recovery.The significantly higher protein content of SFOH than RTB and SFCONV might be associated with electric field interference, frequency, and consequently the temperature of the protein aggregation, denaturation, and soluble protein content of the matrix-induced by OH ,52,53. Ip < 0.05). The use of water in OH technique as a solvent is probably the principal cause for SFOH retention of higher fatty acids than SFCONV.SFOH also had more fatty acids than samples of RT and SFCONV (p < 0.05).An excellent predictor of the nutritional value of dietary fibre is neutral detergent fibre . Due to When comparing the extraction effects of OH and CONV techniques, ref.  showed cp < 0.05)  .The HPLC study for soluble sugars revealed the greater content of mannose and fructose as determined by the results for tomato by-products previously shown.The liquid fraction found that the quantity of mannose between LF and SF was considerably different. The higher concentration of mannose in LFCONV (4.10 g/100 g DW) than liquid fraction  and SFOH (6.5 g/100 g) can be explained by their higher fat content and a possibly higher degree of maturation of its tomatoes). At the same time, mannose rises as tomato mesocarp absorbs oil throughout the tomato ripening process.The intended separation by fractions technique often leads to a concentration of soluble sugars, mostly mannose, in the liquid fraction. Therefore, the LF was mainly a source of minerals and carbohydrates in nutrient composition (fructose and mannose). This composition may serve as an advantage in the formulation of sports food or health-benefited food items, particularly reducing carbohydrate intake (which increases blood glucose levels) .p < 0.05), see Regarding total phenolic compounds, differences were found between solid fractions obtained from OH and conventional extraction methods (p < 0.05). This may be due to the higher overall phenolic content in these bound phenolic extracts than those at these free phenolic extracts (p < 0.05). Higher values of ORAC were found for different fractions; nevertheless, the same trend was found for all samples.The antioxidant activity was evaluated using different methods (ABTS and ORAC), and the samples showed different behaviours . While ip < 0.05) were p-coumaric acid, gallic acid, syringic acid, vanillic acid, and catechin [The significant phenols identified as bound to fibres  from OH catechin . These pThe composition of bound phenols showed an antioxidant fibre-rich in phenolic compounds resultant of flour of tomato by-products, which allows all tomato waste  to produce a product with colour, antioxidant properties, dietary fibre and fatty acids.The samples were frozen to understand the impact on bioactive compounds since the immediate transformation of by-products is limited to the processing conditions, and tomato processing is also seasonal. Fractions in triplicate were frozen between −20 °C and 80 °C for 24 h and compared with fresh bagasse biomass, and the results are presented in Regarding antioxidant activity, better results were found in ohmic heating conditions with the frozen samples at −20 °C, followed by −80 °C. This result means that the frozen process improved the extraction capacity of the followed extraction processes. The freezing process generates the ice crystals within the water molecules inside of cells, and generally, the freezing through time leads to the increment of size of such crystals. The formation of crystals leads to the burst of the cellular membrane and release of inner content, but also release from the cellular membrane of phenols and bioactive molecules .A PCA  was perfIn the frozen samples, colour and carotenoids are correlated. The fresh samples had better results mainly in terms of phenolic compounds, and this variable has a behaviour less correlated with antioxidant activity (ABTS) and carotenoids and correlated with the behaviour above associated with the freezing process. Nevertheless, the increase in the total amount of phenolics does not directly correlate to higher antioxidant capacity and carotenoids in the extract. It is well reported that different phenolic compounds have different antioxidant activities, and the same has been reported with the different carotenoids. Also, during freezing, cell breakage can occur, leading to enzymatic reactions ,60.Considering the research results, evaluating the amount of value-added molecules extracted and valorised would be critical to overview the tomato by-products and natural ingredients markets.Tomato processing generates around 600 thousand to 2 million tonnes of by-products annually worldwide . ConsideNevertheless, further studies must be performed to understand in depth the food properties and the supply value chain of these sources coming from industry in order to be able to design an efficient system to improve the performance of the application of emergent technologies, such as OH into the revalorization by-products and place food product development. It is also critical to estimate dosage levels and improve cost-benefit efficiency for a variety of applications, including food and feed additives/ingredients, cosmetics, and natural insecticides. These applications result in the acquisition of value-added goods based on the circular economy, which may help to offset the negative impacts of tomato by-products accumulating in landfills. The introduction of OH in the tomato processing industry’s reactor system was regarded as an aseptic process. Coupling of OH treatment with aseptic filling is a straightforward industrial solution to simplify the processing line to prepare food preserves, due to this unnecessary additional thermal management of products after business. Also, the obtained ingredients could the use of OH in the time may be specified and contributes to moving the industry away from the extractive linear structure towards a more circular economy. As a result, the acquired by-products were critical and must be valued in accordance with the principles of the circular bioeconomy.One of the main goals of this research was to valorise by-products from tomato processing and characterize their main bioactive properties. All of the data collected is just the beginning of a series of experiments designed to improve an extraction process (on a food-grade basis), followed by a future application as food ingredients.Results showed that these tomato by-products contain good phytochemical properties associated with health claims, including being rich in protein, a source of fibre, and also polyunsaturated fatty acids such as oleic acid. On the other hand, this could answer the actual trends of the sustainable economy with zero waste production. The work showed that it is possible to reduce the environmental impact of extraction processes and process costs and generate more cleaned extracts with the OH process introduced when compared to conventional extraction methods. Also, the results showed two different perspectives. With extraction methods, two fractions are obtained (a liquid and solid fraction). In the LF, free compounds (sugars and phenols mainly) were obtained, with better total phenolic compounds and antioxidant capacity than the conventional method. The OH presented better results than CONV methods regarding solid samples (obtained after the extraction process). Thus, solid fractions can also be used with high potential as flour, for example, and incorporated as ingredients in food.Valuable by-products are disposed of annually, and this by-product is promising from a functional point of view as a good source of fibre and protein, fatty acids, carotenoids, and phenols for food formulations. Therefore, it is necessary to devise strategies for using by-products directly or obtaining different ingredients in an integral valorisation with zero waste. Thus, tomato by-products must be revalorized to improve the circular economy in this agro-industrial sector.


Objectives Health-seeking behavior through social media including orthodontics treatment has become popular among community in Indonesia. However, the characteristics of uploaded video in term of quality, reliability, and usefulness are unknown. This study aims to analyze the characteristics of Indonesian-language orthodontic-related YouTube videos uploaded.Materials and Methods This study adopted cross-sectional design and analyzed 300 videos as the sample. A final 100 related videos were included for analysis of the quality, usefulness, and reliability of the video uploaded as well as viewers' interaction in term of popularity and visibility. Mann–Whitney's test was used for the statistical analysis.Results The majority of the videos were uploaded by individual users (60%) with moderate quality, usefulness, and reliability. Statistical analysis showed that orthodontics-related YouTube videos uploaded by individuals have lower popularity and reliability compared with health professional (p < 0.05).Conclusion Most of the Indonesian-language orthodontic-related YouTube videos have moderate quality, usefulness, and reliability. There is a need from health professional to contribute more related video as main source of health information for the general to make healthy health-seeking behavior. Internet is useful for learning tools and also spreading health-related information and disease prevention campaign.Social media usage, such as video, provides chances to gain and assess contents that are relevant and could be trusted by the users.Nowadays, esthetics is a popular topic in many fields, both in dentistry and in modern society.Previous studies have been conducted to learn the use of video in providing health-related information.However, the majority of these studies assessed videos in English language, while the study on Indonesian-language videos is scarce. As Indonesia is the fourth most populated country in the world after China, India, and the United States, with Indonesian being used by more than 94% of the population,www.youtube.com) on September 21, 2020, by using “sort by relevance” filter. The search term used was “merapikan gigi,” a general term for orthodontic treatment in Indonesian language. We took the first 300 videos from the search results. Video selection for analysis followed the flow diagram (Orthodontics-related video in Indonesian language uploaded on YouTube in the last 12 months were searched and screened (diagram . VideosVideos were sorted according to inclusion and exclusion criteria as shown inTwo researchers (A.R. and D.A.M.) were independently assessed videos. Information extracted included the video's uploader, date of upload, the number of views, likes, dislikes, and duration of each video. The uploaders were categorized as individual users and health care professionals. Viewers' interactions with videos were evaluated based on the viewer's interaction index (popularity) and the viewing rate (visibility) formulas, as presented inThe quality, uniqueness, and reliability of the video were assessed using the Global Quality Scale,The quality of the videos was classified according to criteria proposed by Sorensen et alThe evaluation of the video's usefulness score was based on the content presence in eight nonmutually exclusive domains of information on orthodontics. Those domains include definition, indications, contraindications, advantages, procedures involved, complications, prognosis and survival, and cost.In analyzing the reliability of the videos, a questionnaire by Singh et al was used.p < 0.05.The research data of the video characteristics were collected in Microsoft Excel, then processed and analyzed using IBM SPSS 22.0. The inter- and intraobserver reliability tests were conducted with the intraclass correlation coefficient. Descriptive analysis using mean, median, and frequency was conducted to give general information related to the characteristics of video uploaded. The normality test and the Mann–Whitney's test were performed to determine the differences between video categories. The statistical significance was evaluated atThe first 300 videos by relevance were added to a YouTube playlist. Videos were screened by its title and there were 176 videos excluded because of irrelevant titles and duplication. There were 124 videos assessed and 24 videos were further excluded. The exclusion was because the videos were irrelevant (the title and content do not match), uploaded by health companies, without sound, and less than 1 minute in duration, had no information on likes and dislikes, and had duplicate contents with different titles. Therefore, the remaining 100 videos were included .n = 60, 60%) with the average duration of 493 seconds . The least viewed video had 71 views and the most viewed video had 847,395 views. The most popular video had 21,891 likes and 325 dislikes. The videos analyzed averagely had moderate quality and moderate usefulness.The reliability tests of 20 videos by two observers indicated excellent inter- and intra-observer agreement (>0.80).p = 0.010 andp = 0.001, respectively). On the other hand, a significant higher difference was found for likes (p = 0.027), popularity (p = 0.001), quality (p = 0.001), and usefulness (p = 0.001) in video more than 6 minutes than less than 6 minutes length.The characteristics of Indonesian-language orthodontic-related YouTube video based on its uploader and duration are presented inp = 0.001), in which videos with higher quality showed higher popularity. Videos with higher quality have a higher number of likes . However, videos with lower quality have a higher number of views . In terms of video's usefulness, there were significant differences in visibility between videos with low and high usefulness . Video with low usefulness have higher views and likes but lower popularity than high usefulness video .Visibility and popularity of the videos were not different according to their reliability.Further analysis is presented inYouTube, one of the social media platforms, has gained its popularity from people in seeking health-related information including orthodontics-related videos.In this study, the majority of the orthodontic-related videos have moderate quality. Videos with a moderate quality show a below ideal flow, have some important information discussed, and are quite useful to the viewers. The majority of Indonesian-language orthodontic-related videos still have insufficient information but can be used as information that is quite useful to the audience. Our finding supported previous research about orthodontic-related videos in other language.This study found that popularity and reliability were higher in videos uploaded by health professionals, supporting previous studies.Although duration has significant effect on viewing numbers,From the aspect of video reliability, it was found that there was no difference in visibility and popularity between videos with high or low reliability. This contradicts previous research showing that high-reliability videos have higher visibility and popularity.The video with the highest number of views and likes in this study is a video that discusses the orthodontic treatment process. The video is of excellent quality and a good usefulness score. The quality, flow, and completeness of the video information are excellent and very useful to the audience. Besides, the information on the video covers important topics. This is similar to previous findings, stating that the video with the most views and likes is a video with excellent quality.This study has several limitations. YouTube is a dynamic platform that allows videos to be uploaded and deleted at any time, resulting in different search results at different times.Most of the Indonesian-language orthodontics-related videos posted on YouTube were of moderate quality, moderate usefulness, and moderate reliability. Although most of the videos in this study uploaded by individual, significant popularity and reliability were marked among health professionals. Moreover, popularity and usefulness were significant for video more than 6 minutes. Health professional should contribute more quality, usefulness, and reliable health-related videos in social media platform for public seeking information in oral health.


Akili and Me is an animated children’s educational program available in Sub-Saharan Africa that provides age and culturally appropriate lessons. In 2018, the producers created socio-emotional and health content. This study examines the relationship between children’s exposure to the new Akili and Me content and socio-emotional and health outcomes. Participants included low-income school children  from Arusha, Tanzania. Researchers conducted one-on-one baseline and post-intervention surveys with each participant. Over 12 weeks, the children attended afterschool sessions with screenings of Akili and Me, with distinct content screened on different days. The research team recorded children’s attendance and assessed children’s receptivity to the program through character identification. Using MLM regression models with data from 411 participants from 10 public schools, the analyses showed that a greater exposure and receptivity to Akili and Me predicted improved outcomes scores on the socio-emotional and health outcomes, controlling for sex, age, baseline scores, and general media receptivity (non-Akili and Me characters). Contributing to the literature on educational media, this study shows that exposure to an animated program can teach vulnerable preschool children socio-emotional and health content.Around the world, well-produced television programming can engage vulnerable, hard-to-reach audiences by offering informal education and enrichment.  Along with physical and cognitive growth, young children develop important socio-emotional and health behavior skills early in life. Acquiring these skills is important. Children need aptitude in recognizing emotions and learning appropriate reactions to different scenarios. Children must be able to describe when they are feeling “mad”, “embarrassed”, “happy”, or “scared” . It has Despite this evidence on children’s capacity for socio-emotional and health learning and the importance of children’s learning from birth, many parents feel ill-equipped in terms of passing along appropriate knowledge and skills to their young children. This is especially true among low-income families in resource-poor environments ,8,9.In low- and middle-income countries, parents may lack the resources to offer preschool children important life skills. Parents’ time and attention are often focused on meeting more basic needs. When categorized into income quintiles, there is a pattern of decreasing proportional preschool attendance as income decreases in low- and middle-income countries .In Tanzania, pre-primary education prepares children for formal primary school and continued education; in these settings, there is a strong emphasis on academic skills such as literacy and numeracy. Often lessons for very young children use traditional rote learning delivered through didactic approaches. Holistic and playful approaches are rare, despite being commonly used and advocated for in other parts of the world . In contThere are strong beliefs and evidence that educational media can play a significant role in preschoolers’ development . Video aKilimani Sesame, as assessed through the accurate naming of the program’s characters [While some global research now evaluates the impact of different media on young children , historiaracters .Akili and Me. A study conducted in Morogoro, Tanzania, used a quasi-experimental design and considered children’s daily exposure to one of five episodes of Akili and Me over four weeks [Akili and Me and occurred outside the capital city of Kigali, Rwanda. In this work, researchers randomized a sample of 402 kindergarten, first, and second graders to see Akili and Me or a popular children’s program daily over two weeks. Children with higher levels of Akili and Me receptivity did significantly better on eight of the ten outcomes  [Ubongo is a relatively new educational media company based in Dar es Salaam, Tanzania . Since 2ur weeks . Among 5 skills) .Akili and Me, substantially changing how the show presented various content. The study presented in this manuscript explores whether this new Akili and Me programming more effectively taught preschool children socio-emotional and health lessons. It was hypothesized that exposure to this educational program could improve preschoolers’ socio-emotional and health skills.In 2018, Ubongo’s executives decided to address new content areas. Producers created a second season of The research team prepared culturally and age-appropriate protocols and instruments with a strong consideration of the ethical treatment of vulnerable subjects, children in this case. The study received approval from the Tanzanian Commission for Science and Technology (COSTECH), the Meru District Council, and the University of Maryland’s Institutional Review Board.In Tanzania, an in-country supervisor hired two separate teams, one for data collection and another for delivering the intervention. All team members came from the Arusha region and had experience conducting research and/or working with young children. The project’s principal investigator led formal training with both teams. This training involved in-person discussions around the ethics of conducting research with vulnerable populations, appropriate consent and assent procedures, and reliable and valid administration of question batteries.A five-member data collection team conducted interviews with the participating children at baseline and post-intervention. There were spot-checks of these interviews where supervisors would randomly prompt team members to digitally record interviews. The fourteen-member intervention team ensured that the correct video was being shown on the specified day and week. Intervention team members also recorded attendance, noting both study participants and other children in the viewing sessions. As quality control, intervention team members took photographs at the sites every day of the intervention.This study occurred in Arusha, Tanzania. Arusha is one of Tanzania’s 31 regions and is in the northeast of the country). Around 1.7 million people live in this region, in the shadow of Mount Kilimanjaro and Mount Meru.In Arusha, most adults lack formal education; around a third have completed primary school, and under 1% of adult males and females have completed secondary school . The mosThe poverty rate in Arusha is 48.4%, with 17.1% of the population living in extreme poverty. Only half (49.6%) of the population have improved sanitation facilities with flush toilets or improved latrines, and a majority (60.5%) rely on firewood for cooking instead of electricity. As of 2017, 78% of Tanzanian households owned a mobile phone, and this percentage has been growing .In Tanzania, pre-primary education is available, but not mandatory. Out of all children in the Arusha region in the relevant age range, less than half were enrolled in pre-primary school in 2018 (net enrollment ratio = 47.7%) .CountrywFor this study, the team recruited 10 public schools based on previous relationships with government and educational administrators in the region. All parents of children aged 5 or 6 years received written and oral information about the study. Parents provided active consent, but data collection was conducted with just 40 children, randomly selected from those who supplied parental consent. However, all children in the community were allowed to come to the screenings.Researchers conducted baseline and post-intervention surveys one-on-one with participating children. The surveys were conducted in Kiswahili and took, on average, 24 min. Researchers offered children the option of when and where they would like to do the survey, but practically all surveys happened at the child’s school. Question batteries were interactive, age-appropriate, and often allowed the child to point to responses rather than verbalize answers.In contrast to studies where intervention materials are delivered as part of the curriculum or during the school day schedule, this research involved an intervention where screenings occurred in an after-school community viewing setting. This situation more closely resembles how viewing might happen outside of a research study where children choose whether to show up. Each participant had autonomy in how much they would see of the programs. It was up to the individual child how often and on what days they would attend viewings.Akili and Me content) on Wednesdays. Children would see socio-emotional and health content on Thursdays and Fridays, respectively. In a viewing session lasting 40 min, the episodes were played twice. Intervention team members took strict attendance, recording not only the study participants who were present, but also the number of other children present. The intervention lasted 12 weeks. Viewings did not occur on two Wednesdays, Christmas and New Year’s Day.The intervention involved a weekly viewing schedule where the intervention team showed different content on different days. The intervention played literacy and numeracy content on Mondays and Tuesdays, respectively, and other children’s programming  and ice candy . After ensuring the participating children understood the exercise, the researcher handed the child eight cards with a recognizable/local food or beverage and instructed the child to sort the pictures into two stacks—one healthy and the other not healthy. The health score involved 19 questions .Akili and Me, this research used two approaches. The first was receptivity. Receptivity is a reliable and valid way to capture not only what a child has been exposed to, but also what is salient enough for the child to remember [Akili and Me receptivity involved naming four characters. The research also measured general media receptivity, assessing whether the children could name popular media characters . Including general media receptivity allows the researchers to control for a child’s cognitive ability to name characters.To measure exposure to remember ,31. As iAkili and Me material, noting how many times a child showed up on each day of the week. This led to an overall number of days attending when Akili and Me was airing . Additionally, the number and the percentage of each day a child attended  were assessed.Intervention team members recorded attendance as an additional way to assess the child’s exposure to The analyses included participants with data from both the baseline and post-intervention surveys, resulting in a total sample of 411 children. The team created scores for each measure. Typically, scores reflected the number of questions answered correctly, apart from some health behavior questions (hand washing and brushing teeth), which were scored on a scale of 0–3.t-test for the interval variables. Next, the team estimated multilevel random intercept models predicting the post-intervention scores, using sex, age (in years), baseline scores, general media receptivity, and Akili and Me receptivity as fixed effects. The intercept was allowed to vary by school, allowing for partial pooling, as was determined to be appropriate given the intraclass correlation values. The analyses used the Akili and Me receptivity measure, but the team also explored similar models using attendance on different days of the week.The analysis was completed using SAS 9.4 software . The team calculated the mean and standard deviation for each score. To compare baseline and post-intervention scores, the team used McNemar’s test for the categorical variables (correct versus incorrect) and the Student’s n = 69, 17%) had electricity in their households. Just 86 (21%) indicated that the family had regular access to television (either in their household or at a neighbor or relative’s home). The comparison of the final study sample to the dropout participants indicated no significant differences in gender (p = 0.45) or in age (p = 0.34).This sample included 221 (54%) male and 190 (46%) female children . ReferriAkili and Me characters; children could name on average 0.12 (SD = 0.45) characters, with no significant differences by sex or age. After the intervention period, children could name, on average, 3.0 (SD = 1.3) Akili and Me characters. There was not a significant difference by sex  nor age (F (df = 2) = 1.34, p = 0.26). At the end of the intervention, 225 (54.7%) could name all four characters, 16.6% three, 11.9% two, and 8.5% one. Just 8.3% of the sample were unable to name any of the characters.At baseline, fewer than 6% of the participating children could identify any of the During the intervention’s first week, participating children attended, on average, 2.10 days (SD = 1.94) of the five screening days. Participation on Monday (29%) was lower than on the other days (42% to 47%) during week 1. By the intervention’s 10th week, children attended on average 4.17 days (SD = 1.29) of the five screening days. Attendance during week 10 was generally high for all days (ranging from 80% to 87%). Participating children attended, on average, 40 (SD = 10) out of 58 potential sessions. Viewing increased over the weeks, with 63.3% attending at least one session in Week 1, 97.1% in Week 6, and 97.6% in Week 12. It should be noted that the number of non-study children also increased during the intervention. In a bivariate analysis of mean baseline and post-intervention scores (with school as a random intercept), there were significant increases in both socio-emotional and health scores and in the strategy and health behavior subcategories .p = 0.06). There was also a borderline significant difference for health behaviors (F (df = 2) = 2.59, p = 0.08), with older children performing better at baseline. Interestingly, baseline and post-intervention scores for food were not significantly correlated.There was a borderline significant difference for identifying socioemotional strategies, with the lowest mean score among the 5-year-old group and the highest mean score among those in the 6 and older group (F (df = 2) = 2.87, Akili and Me receptivity significantly added to overall socio-emotional and health scores. Akili and Me receptivity and daily attendance. Consistently, baseline scores and Akili and Me receptivity appear as the two significant predictors in these models  achieved significantly higher scores in naming emotions than children who attended fewer Thursdays. Children who attended more Fridays  had significantly better scores in overall health content than children who attended fewer Fridays.Additionally, children who attended more Thursdays  and attendance of This research has positive implications for the well-being of young children in resource-poor locations. The production of more culturally specific health and socio-emotional educational cartoons for such regions is supported and recommended based on this research.


SD = 1.57) years. Participants completed questionnaires regarding grit, depression, stressful life events, and life satisfaction. The results showed that 1) grit was correlated with life satisfaction ; 2) depression mediated the relationship between grit and life satisfaction ; 3) The relationship between grit and depression was moderated by stressful life events . The association between grit and depression became weaker for college students with high stressful life events. The results indicated that concerned about depression and stressful life events may be the main targets for improving life satisfaction among college students during the recurrent outbreak of COVID-19.The global recurrent outbreak of COVID-19 has brought immense psychological distress to those affected. We conducted this study to explore the relationship among grit, stressful life events, depression, and life satisfaction in college students during the recurrent outbreak of COVID-19. According to the properties of the bias-corrected bootstrap method, we surveyed 888 college students, with an average age of 20.84 ( Life satisfaction was first described in the psychological literature by Shin , was refBecause life satisfaction is so important to an individual's mental health, researchers are increasingly focusing on the factors that influence individual life satisfaction. People generally believe that individual traits explain why some are more satisfied with their lives than others in the same circumstances . CharactAlthough past research has accumulated lots of knowledge about the relation between grit and life satisfaction , 20, somGrit may affect depression, but not for everyone, so the process by which perseverance affects depression may be influenced by other factors. Previous studies on grit and depression only focused on the effect of grit on depression –31, and According to the organism-environment interaction model , stressfThis study constructed a moderated mediation model see  to test Hypothesis 1: depression mediates the relationship between grit and life satisfaction.Hypothesis 2: stressful life events moderate the association between grit and depression.M = 20.84, SD = 1.57). There were 306 (42.2%) rural residents and 647 (57.8%) urban residents.11.3% were 1st years, 30% were 2nd years, 29.7% were 3rd years, 21.7% were 4th years.A total of 907 college students from China were surveyed and all filled out the questionnaire, and 888 participants were left after deleting invalid participants . Therefore, the valid response rate of this study was 97.91%. Among them, there were 381 man (42.9%) and 507 women (57.1%), aged between 17 and 25. Participants rate each item on a 5-point scale (1 = strongly disagree to 5 = strongly agree). Individual with higher total scores indicating higher levels of grit. In this study, these 10 items were forward and back-translated by Chinese professors who were fluent in both Chinese and English. And we did some slight changes to make sure the items could be applied to typical Chinese cultures. The scale had good validity in this study and was in line with various psychometrics standards. The Cronbach's alpha of the scale in this study was 0.891. Validity information of Oviedo Grit Scale was CFI = 0.973, TLI = 0.965, RMSEA = 0.056, SRMR = 0.026.College students' grit was assessed with new version of the grit scale-Oviedo Grit Scale developed by Postigo et al. , which wfalling behind in study”). Each item represented a stressful event and participants reported whether or not these stressful events had occurred in the past year. Each item was rated on a 6-point scale (0 = did not occur to 5 = occurred and extremely stressful). The average score for each of the 16 items was calculated. The higher the score, the greater the number of stressful life events they experienced. The Cronbach's alpha of the scale in this study was 0.915.Stressful life events experienced by the participants were assessed with the Stressful Life Events Scale  which coFeeling down depressed or hopeless”), and each item was rated on a 4-point scale , with higher total scores indicating higher levels of depression. The Cronbach's alpha of the scale in this study was 0.922.Depression in this study was assessed with the Patient Health Questionnaire Depression Self-Rating Scale . Bian etIn most ways my life is close to ideal”). Participants rated their life satisfaction on a 7-point Likert scale (1 = strongly disagree to 7 = strongly agree). Higher total scores indicated higher level of life satisfaction. The Cronbach's alpha of the scale in this study was 0.888.The Chinese Version of the Life Satisfaction Scale , adaptedThe study was approved by the ethics committee of the first author's University. In this study, participants over the age of 18 provided informed consent, and participants under the age of 18 obtained the consent of their legal guardians. Because of the social distancing order issued by the government during the recurrent outbreak of COVID-19. The survey was hosted on Wenjuan Web  from December 18 to December 28, 2021. In this study, all responses were anonymous. There was no compensation for participating in this study, and the participants participated entirely voluntarily.First of all, SPSS26.0 were used to calculated the descriptive statistics for the study variables, and then their correlation between the study variables were calculated. Next, we tested the mediating effect of grit by using the PROCESS (Model 4) macro of SPSS26.0 software . ThirdlyThe results of Harman's single-factor test suggested that the variance for unrotated first factors was 26.69%, below the threshold of 40%, which indicated that there was no significant common method bias in the study .r = 0.426, p < 0.001) and negatively associated with depression . In addition, depression was negatively associated with life satisfaction . What's more, stressful life events were positively associated with depression .SE = 0.031, p < 0.001, 95% CI ] and negatively associated with depression . Depression was negatively associated with life satisfaction . The direct effect of grit on life satisfaction remained positive. Therefore, depression partially mediated the effect of grit on life satisfaction , accounting for 6.78% of the total effect. Therefore, Hypothesis 1 was supported.We analyzed the data after adding age, gender, and grade as covariates. In Hypothesis 1, we assumed that depression would mediate the relationship between grit and life satisfaction. We tested this hypothesis with Model 4 of the PROCESS . As TablSE = 0.028, p < 0.001, 95% CI ].We analyzed the data after adding age, gender, and grade as covariates. In Hypothesis 2, we assumed that stressful life events would moderate the association between grit and depression. The PROCESS of the SPSS macro program was used to test the moderated mediation model and evaluate the moderating effect. The results of the moderated mediation test were shown in Model 3 of simple = −0.004, t = −0.102, p > 0.05, 95% CI = , and as for college students with low stressful life events, grit had significant effect on depression, βsimple = −0.218, t = −5.867, p < 0.001, 95% CI . In summary, these results indicated that stressful life events moderated indirect associations between grit and depression.For description purposes, we plotted examined grit against depression, separately for low and high levels of gratitude. The interaction effect was visually plotted in The COVID-19 has had a dramatic impact on individual's daily lives, particularly in the area of mental health. Life satisfaction is a vital indicator of individual's mental health, and it can measure the quality of an individual's life. People all over the world are eager to live a better life in the pursuit of happiness. At the same time, life satisfaction is not only an important indicator of individual adaptation to society but also an important symbol of social harmony. As an important social group, college students' life satisfaction during the recurrent outbreak of COVID-19 should be paid attention to, as well as the factors and mechanisms that affect college students' life satisfaction. The current study examined the relationship among grit, depression, stressful life events, and life satisfaction. The results of this study showed that depression played a partial mediating role in the relation between grit and college students' life satisfaction. Moreover, the relationship between grit and depression was further moderated by stressful life events. Our findings further contributed to the literature by testing a moderated mediation model, showing that depression acted as a mediator in the relationship between grit and life satisfaction. Moreover, the relationship between grit and depression was further moderated by stressful life events.This study examined the relationship between grit and life satisfaction and found that grit was significantly positively correlated with life satisfaction, which was consistent with previous research results , 18. StuIn this study, we added depression to explore the specific mechanism by which grit affected life satisfaction during the recurrent outbreak of COVID-19. The results showed that depression had a significant negative relation to college students' life satisfaction, which was consistent with the previous research results , 28. MorFrom the perspective of the individual-environment interaction model , the infIn conclusion, grit affected college students' life satisfaction through depression during the recurrent outbreak of COVID-19, and the first half of this process was moderated by stressful life events. Schools and relevant social departments should create better living environment for college students, pay more attention to cultivating and improving individual grit, attach importance to students' depression and provide timely treatment, try to reduce the adverse effects of stressful life events that college students may encounter in their life, to improve the life satisfaction of college students.There are some limitations in the current study that need to be noted. First of all, the cross-sectional design of this study makes it impossible to infer the causal relationship between variables, so experimental and longitudinal designs could be utilized in future research. Second, the self-reported questionnaire survey used in this study may be affected by social desirability, especially for variables with very high social desirability such as life satisfaction. In the future, measures with less social desirability effect, such as forced selection questionnaire, can be considered. Family socioeconomic status (SES) or household income may have influenced the results, and future research should collect the information about SES or household income and consider the effect of SES or household income on the results. Moreover, the subjects in this study were all college students, and the results should be tested in more groups in the future. Finally, COVID-19 is currently spreading around the world, and we can conduct further investigations in other countries seriously affected by COVID-19 to further validate the result in diverse samples.Although there are some limitations, the contributions of the research are theoretical and practical. This study further extends previous research by examining the mediating role of depression and the moderating role of stressful life events. This study can inspire educators to pay attention to the cultivation of individuals' grit, promote their physical and mental health development, reduce the risk of depression and improve life satisfaction. Through this study, we found that stressful life events not only increase the risk of depression in college students but also reduce the level of life satisfaction in college students. Therefore, we should pay attention to improving the living environment of college students, and appropriately relieving pressure on college students, especially during this particular time of the recurrent outbreak of COVID-19.To sum up, the study was of great importance in exploring how grit was related to the Chinese college students' life satisfaction during the recurrent outbreak of COVID-19, even if further replication and extension were required. This study suggested that depression was an underlying mechanism through which grit was associated with life satisfaction. In addition, stressful life events moderated the relationship between grit and depression, and college students with high level of stressful life events had a weaker negative relationship between grit and depression during the recurrent outbreak of COVID-19.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 school of Psychology, Jiangxi Normal University. Written informed consent to participate in this study was provided by the participants' legal guardian/next of kin. Written informed consent was obtained from the individual(s), and minor(s)' legal guardian/next of kin, for the publication of any potentially identifiable images or data included in this article.HL: conceptualization, investigation, writing–original draft, visualization, and revised manuscript. ZY: conceptualization, writing–original draft. BY: conceptualization, methodology, investigation, statistical analysis, data curation, visualization. QY: project administration, and funding acquisition. All authors read and approved the final manuscript.This study was supported by the National Natural Science Foundation of China (72164018), National Social Science Fund Project (BFA200065), Jiangxi Social Science Foundation Project (21JY13), Jiangxi' Key Research Base Project of Humanities and Social Sciences (JD20068) and Science and Technology Research Project of Jiangxi' Department of Education (GJJ200306).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.


Balance disorders and falls are common in the elderly population. Regular balance exercises are an evidence-based physical intervention to prevent falls in older adults, while patient motivation and adherence are important factors for intervention outcome. Exergames are a relatively new, alternative intervention for physical rehabilitation as they improve balance and strength in older adults. The aims of this systematic review and meta-analysis were to assess the (1) effect of motivation factors as per the Capability, Opportunity and Motivation model of Behavior change (COM-B) on the effectiveness of exergame interventions in healthy older adults, (2) effectiveness of exergames to improve balance in older healthy adults and, (3) impact of exergames on cognitive outcomes. Results show that motivation and capability components influence the general outcome of the exergame training. Motivational factors should thus be considered when setting-up an exergame intervention. Furthermore, exergame intervention appears to be a promising training method in comparison to traditional exercise training. However, exergame training in itself might not be sufficient to improve fall risk and cognitive performance. Falls are common and a leading cause of disease and related disability in older adults –4. ChangExergames provide a combination of “exercise” and “gaming” and have been increasingly used to improve balance and strength in older adults , 14. ExeYang et al.  examinedExergames may also be beneficial for cognition –25, as wAdherence to balance exercises and exergaming is essential for these to provide benefit. Older adults at risk of falling report that lack of motivation to exercise is a significant barrier, but they can be motivated to adhere to balance exercises if they perceive potential exercise benefits, such as prospects of independence and physical balance and gait improvement . Recent The Capability, Opportunity and Motivation (COM-B) psychological model of behavior change has been used to identify factors related to successful behavioral change and specify targets to help modify health-related behavior  as well The purpose of this systematic review was to: (1) examine if exergames are effective in improving balance and preventing falls in older adults; (2) investigate the effects of exergames on cognitive outcomes; and (3) explore if motivation factors, identified by applying the COM-B behavior model and behavior change wheel, have an impact on the effectiveness of exergame interventions in older adults.This systematic review and meta-analysis were performed in accordance with PRISMA guidelines .Only full-text, peer reviewed, randomized control trials published in English were included in this study. Inclusion criteria were: (a) participants had to be at least 65 years of age (no higher age limit), (b) participants were healthy community-dwelling older adults without a diagnosis of neurological conditions affecting balance such as Parkinson's disease and stroke, mental or memories problems, (c) exergame interventions aimed at falls prevention and/or improvement of balance in older adults, (d) at least one control group who either received a conventional exercise intervention  or no intervention, and had a pre-post intervention assessment. The primary collected outcomes of this systematic review were the effectiveness of the exergames to improve balance and/or prevent falls. Appropriate gait, postural balance and cognitive function measures were used to evaluate efficacy by comparing pre-post outcome measure data for the intervention and control groups. Exclusion criteria were as follows: (a) participants with history of serious falls, chronic or acute orthopedic, mental health, balance, cardiac and/or visual impairment, (b) participants in hospital, care home, or institutional care, and (c) studies with no control group.Two searches were conducted using three electronic databases  to identify the highest number of eligible articles possible. These were searched by using the same keywords for each database and with searches limited to manuscripts printed in English. Each electronic database was searched from January 2000 to until May 2021.*ing or adult* or senior*”, “fall* or balance or vestibular OR train* OR exercis*”, “exergam* or exer-gam* or exergaming or virtual” and, “intervention or prevention”. The second search consisted of these keywords: “older or old or elderly or aged or aging or adult* or senior”, “fall* or balance or vestibular or train* or exercis*”, “exergam* or exer-gam* or exergaming or virtual”, and, “fall and intervention or prevention”.In this systematic review, the Boolean operators AND or OR were used in all database searches to combine search keywords. The first search included following keywords: “older or old or elderly or aged or agA first stage search identified 6,399 possible related papers in total. Descriptive data and study outcome details were synthesized and tabulated. First, 1,412 duplicates were removed, resulting in 4,987 remaining records, respectively. Potential relevant papers were then screened by two reviewers according to specified inclusion criteria, which led to 280 remaining records. These records were screened by reading the abstract resulting in the removal of 251 records for not meeting the inclusion criteria. Exclusion reasons are listed in the PRISMA diagram see . FinallySince the aim of this review was to explore the effectiveness of exergames, and which motivation factors of exergames have an impact on improving balance and preventing falls, interventions were identified and analyzed using the COM-B model. The COM-B model posits that the interaction between Capability, Opportunity and Motivation (COM) causes the changes in Behavior (B). Capability is the “individual's psychological and physical capacity to engage in the activity concerned”. Opportunity includes the “factors that lie outside the individual that make the behavior possible or prompt it”. Motivation includes Reflective Motivation  and Automatic Motivation (emotions and impulses arising from learning and innate dispositions) . Data inI2 measures of heterogeneity were used with values of 75, 50, and 25% indicating high, medium and low heterogeneity . Studies that had similar outcome measures were included in a random effects model. Meta-analysis effect sizes (reported as Standard Mean Differences = SMD) were calculated for pre-post intervention comparisons within each group. Interpretation of effect size values (SMD) was as follows: 0.20–0.49, 0.50–0.79, and > 0.80 indicated a small, medium, and large effect size, respectively . Forest ogeneity .Eighteen studies in total met the inclusion criteria and were assessed in this systematic review. Risk of bias for each study was assessed using the AXIS critical appraisal tool for cross-sectional studies . AbstracAll included studies aimed to evaluate the effect of exergame training on physical functions such as balance and muscle strength, and/or cognitive functions see –53 evaluA total of 909 participants were included in the eighteen studies. The samples included healthy community-dwelling participants age 65 years or older, with a mean age of 77.62 ± 5.78 years old, who were able to walk independently and were capable of conducting the exergames either without supervision after training, or with supervision depending on the study. For each study, the number of participants ranged from 20 to 153. The percentage of women was 60.64% . Two studies , 59 recrAll studies assessed the participants at baseline before starting the intervention to compare with post-intervention. The outcome measures were all validated measures commonly used in clinical practice. A diversity of outcome measures was used to evaluate the effect of the exergame intervention vs. the control group see .The most frequently used balance outcome measures in this review were the: Timed Up and Go test (TUG), Berg Balance Scale (BBS), Functional Reach Test (FRT), Physiological Profile Assessment (PPA) and Sit to Stand test (STS).The Timed Up and Go test (TUG) is a dynamic balance and physical function measure assessed in nine studies –51, 53. The Berg Balance Scale (BBS) is also a balance measure implemented in five studies , 48, 52.The Functional Reach Test (FRT) assesses static balance and was used in three studies , 48, 52.The Physiological Profile Assessment (PPA) estimates fall risk based on five sensory motor tasks and was used in four studies , 50, 53.The Sit to Stand test (STS), a muscle strength test, is measured in seconds and consists of five repetitions. This was included in two studies , 48. NorEight studies , 53–57 aThree studies , 46, 56 Another cognitive measure included in two studies , 46 was The Montreal Cognitive Assessment (MoCA), a clinical tool for screening mild cognitive impairment, was used in three studies , 55, 57.The Trial Making Test (TMT), examines psychomotor speed and executive functioning, and was included in four studies , 54, 57.A variety of different technologies and exergames were used as an intervention method to prevent falls and/or improve balance see  did a coAll studies included a control group who received conventional exercises  or no intervention. The exergame intervention duration varied across seventeen out of eighteen studies ranging from 4 to 24 weeks (Mean ± SD = 9.76 ± 5.33); one study  did not In nine studies, the control group did not receive any training intervention but was asked to perform daily activities as usual , 59, 60.Most studies used commercially available and popular gaming technologies, which are not tailored for older people but rather designed to entertain young people. Seven studies used the X-box Kinect games –52, 59, Nine studies were included in a separate meta-analysis for balance and muscle strength. Seven studies –60 evalumotivation components were incorporated within intervention in all studies, mostly consisting of auditory and visual feedback.In this systematic review, the eighteen identified studies were analyzed to evaluate the effect of motivational factors on the results of the exergame interventions using the COM-B model. Reflective and automatic opportunity component of the COM-B model. Four studies were conducted at home without supervision . Capability and motivation components indicated a large and significant effect . Motivation only indicated a medium significant effect , see Eight studies , 57, 58 n = 531) were included in a meta-analysis for the effectiveness of exergame intervention on balance using the TUG. A total of 237 participants were included in the exergame intervention group whereas 294 participants were included in a control group. However, note that one study , see Eight studies (ne study  includedBBS. Only three studies (n = 98) were included in a meta-analysis for the effectiveness of exercise intervention on balance using the BBS test, as two studies did not include sufficient information , see Five studies conducted the effect of dynamic balance using the ormation , 52. Then = 122) conducted the effect of static balance for the FRT test. The number of participants in the exercise intervention group was 63 and 59 in the control group. A large effect size was observed, where the exergaming intervention was significantly more efficacious than the control intervention for the FRT test , see Three studies (n = 409) were included in a meta-analysis for the effectiveness of exercise intervention on falls risk based on the PPA. I2 = 59%, Chi2 = 9.83, p = 0.05), see Four studies (n = 370) were included in a meta-analysis for the effectiveness of exercise intervention on muscle strength. STS. Only two studies conducted STS, however, one study , see Two studies (ne study  assessedn = 277) were included in a separate meta-analysis using two matching outcomes, namely the ANT. The outcomes were pooled for three attentional components; alerting, orienting and executive control. The total number of participants of the exercise intervention group was 141 and 197 in the control group. For all three components, small effects were observed . A variety of outcome measures were used across studies to assess cognitive function. It was not possible to conduct a meta-analysis with the eight studies that evaluated cognitive function, because they evaluated different cognitive tests. Five studies were therefore included in the meta-analysis. Two out of the five studies , see The same two studies were included in a meta-analysis to illustrate the effect of cognitive performance for the n = 144) were included in a meta-analysis for the effectiveness of exercise intervention on cognitive performance from the MoCA. The exercise intervention group consisted of 74 participants and the control group consisted of 70 participants. Exergame intervention showed a medium effect for MoCA cognitive performance compared with the control group, which was significant , see Another three out of the eight studies (TMT to assess cognitive function. One study (n = 271) were included , see Four out of the eight studies mentioned above conducted the ne study  did not included , 54, 57 To our knowledge, this is the first systematic review to evaluate the role of motivation during exergames and how it impacts the effectiveness of exergames on improving balance, cognition and preventing falls in healthy older adults by applying the COM-B model.Meta-analysis results indicated that, overall, motivational components might impact the effectiveness of exergames on improving TUG scores when motivation alone, or capability and motivation are considered: A large significant effect was observed when capability and motivation components are considered during intervention. Including motivational factors alone resulted in a medium significant effect on the TUG outcome. Only Sadeghi et al.  includedvan Het Reve et al.  found thDockx et al. showed that attitudes toward Virtual Reality exergames can positively change following exposure to it . Older pHughes et al.  conducteOverall, motivation is one of the most important factors to keep participants' adherence. Increasing enjoyment in exergames can be obtained via providing feedback and rewards, self-identification with the game characters , 85, andNevertheless, caution should be taken while interpreting the results of this study's meta-analysis, as the sample size was lower compared to the analysis with studies including all three components. When all three components of the COM-B model were included, a small, non-significant effect was seen. It is noteworthy that all measurements in the study of Lee et al.  significThe opportunity component of the COM-B model can be divided in physical opportunity and social opportunity. Three studies were home-based  and provided phone support or tablet support  , 46, 53.The results from this review revealed that providing immediate feedback, and/or including a capability component  in the exergaming training could potentially have a vital role in enhancing the effect of the exergames on TUG performance. Importantly, caution should be taken when interpreting the meta-analysis concerning the influence of motivation and capability components on exergame outcomes, because this analysis only included one study .Results of the meta-analyses indicated favorable outcomes for the exergaming intervention group compared to the control group for all balance measures. Statistically significant effects were found for the BBS, FRT, and PPA measures indicating a significant positive effect of exergame interventions on multiple balance measures. However, these findings should be interpreted with caution with regards to their clinical significance due to the rather small sample sizes. Nevertheless, the magnitude of effects sizes ranged from 0.35 to 0.96, suggesting medium to large effect sizes for these aforementioned tests. Although the Minimal Clinically Important Difference (MCID) of these tasks did not fall within the confidence interval (CI) ranges , we coul95 of the FRT test was determined as 4–11 cm . Chan et al. . However, in general, they found that exergames reduced the proportion of older adults who fall in the intervention group vs. those in the control groups. The systematic literature review of Choi et al. also suggests that the majority of exergames improve fall prevention, but that it remains inconclusive whether exergames are superior to conventional physical therapy . Exergaming intervention indicated also a moderate effect on TUG performance in the study of Fang et al.  (Favorable outcomes were observed in the exergaming group for muscle strength (STS test), but this did not reach statistical significance. MCIDs were identified as 2.3 s for the STS test . While tOverall, exergames have an effect on a number of balance measures, but this effect is not very large and does not reach what is normally thought as clinically significant. In addition, rather basic balance measures were included in the meta-analyses. Future studies might consider the need to incorporate outcomes for fear of falling, balance confidence, changes in physical activity, dynamic balance and gait measures, such as the Functional Gait Assessment or Mini-BEST, to have a more comprehensive understanding of the benefit of exergames. On the other hand, when looking more closely at the type of exergames used for balance exercises, the X-box Kinect and Nintendo Wii Fit seemed to induce more positive effects than the other exergames. The possible positive influence of exergames on balance performance and the preferable type of exergames to do so should therefore be further examined.S.E.M.) to 0.88 (1.96S.E.M.) for the DSB test  toward improvement of cognitive performance for ANT alerting, ANT executive function, DSB, TMT-A, and TMT-B scores, induced by exergaming intervention. In general, smaller effect sizes were observed for cognition (0.05–0.59) than for balance and physical measures. ANT, DSB, and TMT scores are unlikely to reach clinical significance due to point estimates closer to zero, uncertainty indicated by the large CI intervals, and MCIDs not falling into the CI ranges [not determined for the ANT and TMT yet; 0.45 . Participants in the intervention groups of Phirom et al. (p = 0.019)  .Gschwind et al. conducted a study that comprised two different exergame interventions, which had different outcomes . The SMTIn the systematic review of Stojan and Voelcker-Rehage  almost aSince the exergames used in the studies of these meta-analyses were primarily interested in balance improvement, the cognitive tests used might not have been optimal in terms of detecting cognitive benefits. Exergames which are designed for cognitive improvement might thus result in greater achievements.There were a number of limitations in the present study. First, the number of studies identified in this review was limited, thereby resulting in small sample sizes in most meta-analyses conducted. There was also marked heterogeneity across studies, with a variety of tools, methods and evaluation strategies used by different studies. This heterogeneity, particularly regarding outcome measures, precluded quantitative meta-analysis for some outcomes. Another limitation of the included studies was lack of long-term follow-up and lack of blinding of interventions or masking of outcome collection. Furthermore, some studies lacked active control intervention, and instead the control groups were asked to perform their usual activity and/or exercises during the trial period. The effectiveness of exergaming may therefore not be completely accurate as the control group can either increase the level of exercises or not perform any exercise regularly. In addition, we did not include languages other than English in our search. In the quantitative meta-analysis of the COM-B model subcomponents, we found that while motivation alone, and capability plus motivation, were associated with improvements in the effectiveness of the intervention, the combination of capability, opportunity and motivation elements in an intervention were not associated with statistically significant changes in effectiveness . We thinMotivational factors seem to have an impact on the results of the exergame intervention at least for balance (TUG) performance as examined in this study. Especially motivation components (like providing feedback) and capability components  appear to influence the general outcome of the exergame training. Motivational factors could thus be important to consider while setting-up an exergame intervention program for healthy elderly.This systematic review and meta-analysis suggests that exergame intervention appears to be a promising training method in comparison to traditional exercise training, with positive changes in balance and cognitive performance. However, caution should be taken when drawing conclusions because of heterogeneity in technologies, protocols, sample sizes and outcome evaluation across studies included in the systematic review. Exergame effects were modest to moderate so they may not be sufficient on their own to improve fall risk and cognitive outcomes to a clinically significant degree, but they might supplement traditional physical exercises, or be implemented as part of a multicomponent rehabilitation.The original contributions presented in the study are included in the article/MP and D-EB conceptualized and designed the study and double-rated included articles. MB and YJ collected, organized the data, reviewed the included articles, and conducted the analyses. MB drafted the initial manuscript. MP, SG, and D-EB critically reviewed and revised the manuscript. D-EB coordinated and supervised data collection. All authors read and approved the final manuscript.This work was supported by the European Commission Horizon 2020 grant to D-EB, MP, and SG (grant number 769574).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 proposed procedure allows for a contactless estimation of the HRV that could be beneficial for evaluating both cardiac and general health status in subjects or conditions where contact probe sensors cannot be used.Heart rate variability (HRV) is a reliable tool for the evaluation of several physiological factors modulating the heart rate (HR). Importantly, variations of HRV parameters may be indicative of cardiac diseases and altered psychophysiological conditions. Recently, several studies focused on procedures for contactless HR measurements from facial videos. However, the performances of these methods decrease when illumination is poor. Infrared thermography (IRT) could be useful to overcome this limitation. In fact, IRT can measure the infrared radiations emitted by the skin, working properly even in no visible light illumination conditions. This study investigated the capability of facial IRT to estimate HRV parameters through a face tracking algorithm and a cross-validated machine learning approach, employing photoplethysmography (PPG) as the gold standard for the HR evaluation. The results demonstrated a good capability of facial IRT in estimating HRV parameters. Particularly, strong correlations between the estimated and measured HR ( Heart rate variability (HRV) is the temporal variation of the period between consecutive heartbeats, which mainly depends on the regulation of the heart rate (HR). HRV analysis allows for assessing overall cardiac health and the condition of the autonomic nervous system (ANS) , 2. SpecWearable devices were developed to provide continuous monitoring of the heart rhythm through photoplethysmography (PPG) –21. PPG For instance, the root mean square of the successive differences (RMSSD) of the neighboring ECG R-peaks  is a time-domain feature sensitive to the ANS’s parasympathetic branch . The RMSConcerning the frequency domain, the ratio between power spectrum densities (PSDs) at low-frequency  and high-frequency  bands of the HRV is commonly employed . SpecifiTypically, HRV is evaluated using methods that require skin contact , but, although they are noninvasive, the contact with human skin can be detrimental to subjects with sensitive skin  and irritating or distracting when worn, for instance, in a professional environment. In these scenarios, measuring HRV through contactless technology would be beneficial. To overcome this limitation, several methods have been developed to assess HRV without skin contact. These techniques are commonly referred to as remote photoplethysmography (rPPG), and they exploit models based on red, green, and blue (RGB) imaging to assess periodic variation of the subject’s skin color, which depends on the cardiac cycle , 31. TheRecently, machine learning (ML) frameworks have been used to increase the capability of IRT in detecting pathologies and modulations of autonomic activity , 36.The aim of this study is to investigate the feasibility of estimating HRV parameters from facial IRT through an ML approach. Specifically, a support vector regression (SVR) was implemented to estimate time and frequency domain metrics  and the average HR and RR intervals from features evaluated on the temperature time course of facial ROIs.a priori hypothesis was the presence of a physiological link between HRV and skin temperature modulations. This assumption was tested a posteriori with the assessment of the generalization performance of the model, through a cross-validation approach. This model is useful for remote sensing of health conditions, which is fundamental to monitor patients’ improvements during rehabilitation and therapies . The paradigm induced modifications in the HRV of the participants through modulations of the breathing rate and intensity . In detaConcurrently, the facial temperature was recorded through a digital thermal infrared camera FLIR SC660  . The IRT device was placed 60 cm distant from the participant and pointed toward his/her face. The sampling frequency was 10 Hz. The camera was blackbody-calibrated in order to eliminate eventual drift/shift of the sensor’s response and optical artifacts.The study was approved by the Research Ethics Board of the University of Chieti-Pescara , and it followed the principles of the Declaration of Helsinki. Each participant signed the informed consent, and they could withdraw from the experiment at any time. The measurements were performed following the standard guidelines for thermal imaging acquisitions . Specifiz-score) signals. The performance of the algorithm was checked by visual inspection, but no correction had to be applied. The PPG peaks were used to evaluate the HRV metrics over the 1 min recording. Particularly, the following indices were computed: mean HR (beats/min), mean RR (ms), LF/HF, SDDN (ms), RMSSD (ms), pNN50 (%), and TINN (ms). Concerning PPG, the signals were band-pass filtered setting the cutoff frequencies at 0.2 and 10 Hz. A procedure for automatic peaks identification is employed for the PPG filtered and normalized (z-score) before being employed in the ML framework. A representative thermogram of one participant is reported in Regarding the IRT recordings, the quality of the signals was checked by visual inspection and no video was rejected. Three ROIs were selected on the glabella (G), nose tip (NT), and nostrils (N). Since the participants stayed quite still during the experiment, the algorithm did not fail in tracking any frames. The following features were computed from the temperature time course of each ROI to feed the machineries: mean value, SD, kurtosis, skewness, variation of the signal computed as the difference between the average of the first and last 5 s of the acquisition (delta), sample entropy (SampEn), 75° percentile, the power spectra density (PSD) of the thermal signal for the respiratory (PSD-breath), cardiac (PSD-cardiac), and myogenic (PSD-myo) frequency bands. In detail, mean value, SD, kurtosis, and skewness are different moments of the distributions, providing information on the central tendency, dispersion, and shape of the temporal evolution of the temperature. Concerning delta and 75° percentile, they are parameters indicative of the variability of the signal. The sample entropy is a measure of the predictability of the signals, which is defined as the negative natural logarithm of the conditional probability that signal subseries of length m (pattern length) that match pointwise within a tolerance r (similarity factor) also match at the m+1 point, and it evaluates nonlinear predictability of the signal . The PSDt-test. Data preprocessing and analysis were performed using MATLAB .An SVR approach was used as previously described . In thisr = 0.70), RR (r = 0.66), TINN (r = 0.71), and pNN50% (r = 0.70), while a moderate correlation was found for SDNN (r = 0.44) and LF/HF (r = 0.48).Concerning the correlation analysis results, To summarize the data and show the stability of the model, the average and associated SD of the correlation coefficients delivered by the bootstrap analysis for all the HRV metrics are reported in The models associated with the average correlation coefficient obtained with the bootstrap procedure were used for further analysis. r2) were found for HR (r2 = 0.48), RR (r2 = 0.43), TINN (r2 = 0.51), pNN50 (%) (r2 = 0.50), and RMSSD (r2 = 0.35). Moderate to weak r2 values were found for LF/HF (r2 = 0.23) and SDNN (r2 = 0.19), respectively.In addition, t-test between the measured HRV metrics and those predicted from IRT. No significant results were showed for HR , RR , TINN , pNN50 (%) , RMSSD , and SDNN , indicating no differences between the measured and predicted values. Conversely, a significant difference was highlighted for LH/HF .p = 0.19) with a lower limit of agreement (LoA) of −24.0 beats/min and an upper LoA of 19.0 beats/min. Regarding the RR intervals (p = 0.58) with a lower LoA of −210.0 ms and an upper LoA of 190.0 ms. The mean difference for the TINN (p = 0.09) with a lower LoA of −98.0 ms and an upper LoA of 140.0 ms. Concerning the pNN50 (%) (p = 0.29) while lower and upper LoA were −53.0 and 43.0 ms, respectively. Finally, the mean difference for the LF/HF was 11 (p = 0.02) with a lower LoA of −39.0 and an upper LoA of 61.0  , the meaNN50 (%)  showed aNN50 (%)  was −4.7 of 61.0 .t-test was used, and the Bland–Altmann plot was implemented to evaluate the agreement between the PPG- and IRT-derived parameters. In accordance with Cohen’s interpretation of the correlation coefficient , whereas the other metrics did not exhibit a bias when estimated from IRT signals features. Regarding the Bland–Altman plot results, a clear systematic error of the model is assessed for LF/HF, SDNN, and TINN. Considering the linear regression equation associated with each model to estimate the different HRV metrics, it is worth to highlight that a good model should deliver a linear equation with the slope around 1 and the constant term around 0 (t-test) of almost all the HRV metrics, although the slope is not close to 1. However, these features of the regression equation produce the systematic error assessed for some models.This study investigated the possibility of estimating HRV parameters from facial temperature skin oscillations by developing models based on SVR with a linear kernel. To test the generalization performance of the models, a five-fold cross-validation approach was implemented. Furthermore, to prevent a possible overfitting effect due to the choice of the folds used to train and test the model, a bootstrap procedure with 1,000 iterations was performed for each model. The performance of the models was tested through correlation analysis to investigate the relationship between the real and predicted metrics. To assess bias between the measured and estimated indices, the fficient , a stronaround 0 . The modConsidering all these aspects, the findings demonstrated the feasibility to develop an acceptable model from IRT data for HR, RR, pNN50 (%), and RMSSD.The employment of a model with a linear kernel allows to establish clear relationships between the predictors used as input and the output of the machinery through the analysis of the weights associated with each regressor . MoreoveThe proposed procedure could represent a valuable tool for continuous HRV monitoring also in poor environmental light conditions. The employment of IRT for HRV monitoring also allows to concurrently evaluate other physiological signals, such as breathing rate and sweat glands activity. These signals are indicative of the emotional status of the individual and can provide information on the wellbeing of the subject. This procedure could be highly suitable for clinical applications, such as bedside vital signs monitoring, particularly for those patients where contactless monitoring is preferred. The possibility to use IRT to predict HRV parameters is of main importance to investigate the health status of subjects with skin diseases, skin injury, and neonates. In fact, HRV values are associated with the risk, onset, and prognosis of a plethora of diseases. The short-term HRV recordings show that low values of RMSSD and SDNN were associated with an increased risk of coronary heart disease and death from different causes .Moreover, it could be employed to remotely assess the vital signs and the clinical conditions of patients, especially contagious patients, as during the COVID-19 pandemic . FurtherHowever, it is worth to highlight that the proposed procedure does not provide a highly accurate estimation of all the HRV metrics, and hence it could be worth to perform further studies to improve the accuracy of the method. In fact, the first limitation of the study is represented by the reduced number of participants. Enlarging the sample size could allow to obtain more accurate results and test more complex machineries, such as deep learning. However, the proposed model was developed employing a cross-validation procedure, hence guaranteeing the generalization performance of the model.Moreover, further studies are necessary to test the capability of estimating other HRV metrics from the facial temperature time course, also considering other ROIs or considering the whole face temperature oscillations. In addition, further studies should be performed in order to test the capability of IRT to estimate HRV metrics through ML and deep learning approaches also during resting-state condition, without the administration of a breathing task. Furthermore, the developed model can estimate HRV metrics integrating information over a temporal window of 1 min. In fact, further studies are needed to decrease the amplitude of the temporal window for the HRV prediction. Finally, it could be worth to test the feasibility to estimate the cardiac pulse signal itself, providing a valuable tool able to deliver performances similar to rPPG also in poor light conditions.Although preliminary, these results could pave the way to the employment of IRT for contactless HRV monitoring for cardiovascular medicine and neuroergonomic applications, to be exploited, for instance, in an Internet of Things context. Specifically, this model could be suitable for clinical applications when contact technique is not suitable , for human–machine interaction (HMI), automotive systems, and for monitoring the wellbeing of workers in the workplace.t-test. Models delivering a good estimation of HR, RR, pNN50 (%), and RMSSD on a temporal window of 1 min were implemented. These results could pave the way to the employment of IRT for a contactless HRV assessment suitable for cardiovascular medicine and neuroergonomic applications also with poor light conditions or in a situation in which contact methods are not implementable. Thus, our proposed method represents a new useful tool in the field of cardiovascular medicine in different situations in which methods that require skin contact are not possible to implement.This study proposed an innovative model based on linear SVR to estimate HRV metrics from facial temperature time course assessed by IRT. Specifically, ROIs from G, NT, and N were considered to compute thermal features used for the HRV indices prediction. The performances of the model were tested through correlation analysis, Bland–Altman plot, and paired The original contributions presented in the study are included in the article, further inquiries can be directed to the corresponding author.The studies involving human participants were reviewed and approved by Research Ethics Board of the University of Chieti - Pescara - approval number: 1479, date of approval: 03/05/2017. The patients/participants provided their written informed consent to participate in this study. Written informed consent was obtained from the individual(s) for the publication of any potentially identifiable images or data included in this article.ADC and DP: concept, design, analysis, and drafting of the study. GG, PI, DC, and CF: drafting. AM: revision. ADB and BG: revision, funding, and project administration. 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.