Origanum vulgare ssp. hirtum (Link) Ietswaart) and soil characteristics. The system had a total surface area of 100 m2 and was planted with giant reed and umbrella sedge. An experimental open field of oregano was set up close to the system. Two years and two different sources of irrigation water were tested in a split-plot design for a two-factor experiment. Treated wastewater was characterized by higher values of mineral and organic constituents than freshwater. The results highlight that short-term irrigation with freshwater and treated wastewater, in both years, led to increased plant growth, dry weight and essential oil yield of oregano plants. However, it did not significantly affect the essential oil content and composition in comparison with the control. Furthermore, the year and source of irrigation water did not significantly vary the chemical composition of the soil. Our results suggest that treated wastewater can be considered an alternative to freshwater for the cultivation of oregano due to the fact that it does not greatly influence the yield quality and quantity of this species in the short-term.Aromatic plants can benefit from the use of treated wastewater to satisfy their water requirements, but the effects on the essential oil yield and quality need an assessment. The aims of this study were to assess the effects of freshwater and treated wastewater obtained from a Sicilian  pilot-scale horizontal subsurface flow constructed wetland system on plant growth and yield, essential oil yield and composition of oregano ( Origanum vulgare ssp. hirtum (Link) Ietswaart is an aromatic plant that grows wild in various areas of the Southern Mediterranean region [n region , and it n region ,5,6,7,8.v/w, depending on the habitat) and can exhibit oil concentration, which is approximately 10 times higher than other subspecies of Origanum vulgare [This perennial shrub is extremely rich in EO  in comparison with potable water irrigation. It was also demonstrated [Aloysia citriodora Palau) and a change in the main compounds of the EO in the species. In another study [Ocimum basilicum L.). In Egypt, five aromatic species were monitored for two years in order to evaluate the effect of TWW on EO quantity and quality, and it was reported that TWW irrigation of geranium (Pelargonium graveolens L’Hér) and fennel (Foeniculum vulgare Mill.) plants led to an increment in EO concentration, but to a reduction in peppermint (Mentha piperita L.) and sweet marjoram (Origanum majorana L.) plants [In areas with prolonged water shortage, as is found in the Mediterranean region, the use of treated wastewater (TWW) for combined irrigation and fertilization represents a sustainable cultivation practice also for aromatic plants. Many studies have examined the effects of TWW on horticultural and open field crops, evaluating how TWW affects plant growth and soil characteristics both in the short and long-term period ,45,46,47nstrated  that TWWer study , it was ) plants . It is w) plants ,44,45,46) plants . HoweverIn Sicily, oregano is usually grown without the use of irrigation. The species tends, in fact, to complete the main growth stages during spring, exploiting the water accumulated in the soil during autumn, winter and spring rainfall. However, irrigation can be required in certain conditions, when, for example, rainfall is not uniformly distributed. As natural water resources are often insufficient to carry out this practice, the use of nonconventional water such as TWW can be of considerable interest.The main aims of the paper were to assess the effects of irrigation using TWW from a pilot horizontal subsurface flow system constructed wetland (HSSFs CW), compared to irrigation with FW, on (i) morphological and production characteristics of oregano, (ii) EO yield and quality, (iii) chemical soil characteristics.In the test site, rainfall was far higher in 2018 than in 2017. Rainfall levels were, in fact, 534 mm and 894 mm for 2017 and 2018, respectively .When observing all the months, the most significant levels of rainfall were recorded in the first 10-day period of November 2018 (188 mm). However, considering the period of greatest water requirement for plant growth (March to May) in the two years, rainfall levels showed a different trend . In this period, rainfall levels were well distributed throughout the growing season in 2018, and this permitted an increase in soil moisture levels for a longer period compared to the 2017 growing season. Mean minimum and maximum temperatures in 2017 and 2018 were similar and consistent with the ten-year average temperature (16.0 °C).Oregano plants did not show any frost damage during the winter months despite minimum temperatures falling below 3 °C in each growing season. Furthermore, heat damage was recorded in the plants when maximum daily temperatures rose over 35 °C, and rainfall was absent, confirming the high drought tolerance of oregano.The main chemical and microbiological characteristics of FW and TWW used in this study are shown in E. coli often exceeded legal limits. When comparing the FW and TWW concentrations during the test period, we observed great differences for most parameters. The lowest variations in nutrients and salts between FW and TWW were determined in spring and summer when the two macrophytes in the system grew fast and contributed significantly to WW treatment in terms of pollutant removal efficiency due to filtering, oxygen release and root exudates and uptake. The N level in TWW was much higher than that of FW during all sampling campaigns. This means that TWW represents an important source of N despite the removal processes carried out by plants, microorganisms and the medium in the pilot HSSFs CW. However, if we focus on the alkali metal levels in TWW in the study, we can affirm that TWW can be considered a source of macro and micronutrients, in accordance with study references [The average values of the chemical and microbiological parameters at the outlet of the pilot HSSFs CW were not all within the threshold values established for TWW reuse for irrigation purposes by the Italian Ministerial Decree 152/2006. The age (old) and hydraulic conditions of the system affected, in fact, the removal of some parameters such as TSS and TP. Furthermore, the concentration levels of ferences ,42,43,44ferences  (Table 2−1) and TWW (0.60 dS m−1) were found to be lower than those of the threshold values in the guidelines and were not critical for oregano growth.When observing nutrient concentrations in the effluent of the HSSFs CW, we noted that the average levels of ammonium were high in the TWW and could determine increasing problems in plants and soil when used in irrigation. Average Na concentrations were found to cause increasing problems in irrigation, while that of Cl did not cause either minor or severe problems when used for irrigation purposes. Finally, average concentrations of EC in FW  to 64.04 cm (2018) on average. Furthermore, FW- and TWW-irrigated plants were taller than unirrigated plants on average. All the interactions between the main factors determined significant differences in plant height. The highest average values for plant height were obtained for year-by-FW and year-by-TWW interactions. On the contrary, the lowest average value for plant height was recorded for year-by-control interaction. Significant differences in plant diameter were found only with respect to the source of irrigation water. The highest average values of plant diameter were recorded for FW- and TWW-irrigated plants. Similar to plant height results, the highest values for plant diameter were obtained for year-by-FW and year-by-TWW interactions. Significant differences in the total number of branches per plant, however, were found regarding year and source of irrigation water. The highest average values for this morphological trait were obtained in 2018 and recorded for FW- and TWW-irrigated plants. Interactions between year and FW- and TWW treatments revealed the highest value for the total number of branches per plant.Concerning yield parameters in the study, results were obtained in the second and third years of the study. The highest average values for dry weight and EO yield were recorded in 2018 compared to 2017. The source of irrigation water significantly affected dry weight and EO yield . More spOur results highlight the fact that FW- and TWW-irrigated plants showed greater growth in comparison with unirrigated plants in both years. This means that irrigation practice positively influenced the morphological development of oregano with respect to rainfed conditions. However, TWW was characterized by higher levels of macro and microelements, organic compounds and salts compared to FW. Despite this, irrigation with TWW did not compromise oregano plant growth. This fact could be explained by considering that, in particular, the amount of mineral and organic constituents in the TWW-irrigated plots was not significantly higher than that of the FW-irrigated plots.Previous studies carried out on oregano, and other aromatic plants confirm our findings. In a study on oregano and rosemary , it was Literature highlights the importance of water as an essential factor for plant productivity ,57,58,59In our study, the main productive parameters did not differ significantly in both TWW- and FW-irrigated plants. This was in agreement with the findings of Bernstein et al.  and confData of the most representative EO compounds in response to the year and the source of irrigation water are shown in Twenty-nine compounds were identified in total for the oregano EO .Year and source of irrigation water did not alter the composition of the essential oil of the oregano plants throughout the entire study period. When comparing the two years, no significant differences were found for any EO compound. Furthermore, the percentage amounts of the most representative EO compounds were similar for FW-, TWW-irrigated plants and unirrigated plants. In the case of year and irrigation, thymol (ranging from 39.31% to 41.03%) was the main component of oregano EO, as it has been previously reported in many studies carried out in Sicily ,16,17,24Our findings highlight that FW- and TWW-irrigation does not have any significant effect on the composition of oregano EO. This was partially in agreement with the literature. Previous studies conducted in other regions ,34,48 shThe chemical characteristics of the FW-irrigated soil, TWW-irrigated soil and unirrigated soil are reported in The year and source of irrigation water did not lead to significant changes in the chemical composition of the soil during the study period.No significant variations in topsoil pH of the FW- and TWW-irrigated soils were recorded in comparison with unirrigated soil. Our results were in accordance with findings in the literature. Bernstein et al. , in a 3-Despite the high EC level of TWW compared to FW, the EC of TWW-irrigated soils was not significantly different from that of FW-irrigated soils. Only a light accumulation of salts originating from TWW was apparent in the topsoil, despite the moderate percentage of clay in the soil structure. Furthermore, non-significant differences were found between FW-, TWW-irrigated soils and the control due to limited exposure to higher EC levels in TWW, in particular. For this reason, no signs of salinity damage were observed in the plants. Oregano is, in fact, sensitive to soil salinity; therefore, increasing salinity of the water causes a significant decrease in biomass and EO yields, as reported by Hancioglu et al. .TOC increased with TWW irrigation, but no significant differences were found with respect to FW-irrigation and the control. It is reasonable to suppose that the effects of TWW irrigation on topsoil organic matter are highly correlated to the irrigation duration and the amount of organic compounds in the TWW. Thus, the greater the levels of TOC in TWW and the longer TWW is used for irrigation, the more the topsoil TOC increases .With regard to N, P and K levels in the soil, it is evident that nutrient accumulation in the topsoil can be linked to the original levels in FW and TWW, but these soil levels tend to change due to irrigation duration and the main actions conducted by plants and soil microorganisms, in particular. In this study, FW and TWW irrigation increased N, P and K levels in the topsoil; however, differences found between the main factors were not significant due to the short-term irrigation period in both years. Similar results were also found by Bernstein et al. , who staRegarding the alkali metals contained in the irrigation water, Na is of concern due to its negative effects on soil properties. It is well-known that an excess of Na in the soil can displace divalent cations, such as Ca and Mg, leading to soil structure deterioration . In our Trials were carried out in the experimental area of the pilot HSSFs CW in Raffadali , the South-West of Sicily , during the growing seasons of 2016–2018. An experimental open field of oregano was set up close to the pilot HSSFs CW. According to the Köppen–Geiger climate classification , the stuThe pilot HSSFs CW is located in an open urban park vegetated with turfgrass and ornamental plant species .2. The two units are separately planted with giant reed (Arundo donax L.) and umbrella sedge . The functional and technical characteristics of the system were previously described by the authors [The system consists of two independent units in parallel (50 m-long and 1 m-wide) and provides a total surface area of 100 m authors .3 of WW per day. TWW was evenly distributed in the units, and the pumping of TWW was continuous throughout the day without variations in time. The outflow TWW flowed downhill into four storage tanks of 5 m3 each, the last of the tanks was connected to a drip system for irrigation purposes. The two planted units operated under the same hydraulic conditions. Hydraulic loading rate (HLR) was 6 cm day−1, and hydraulic retention time (HRT) was 8.3 per day.During the test period, the system was fed with urban WW from the wastewater treatment plant (WWTP) in the town. It was designed to receive a total of 6 mThe layout of the HSSFs CW for the treatment of the wastewater is shown in 5), chemical oxygen demand (COD), total Kjeldahl nitrogen (TKN), ammonia nitrogen (NH4-N), total phosphorus (TP), sodium (Na), potassium (K), calcium (Ca), magnesium (Mg) and chloride (Cl) levels were determined in the laboratory [Escherichia coli (E. coli) and Salmonella spp. levels were determined by membrane filter technique, based on standard methods for water testing [In HSSFs CW, sampling campaigns were carried out monthly during the period April–September for each year. A total of 48 samples were taken and analyzed. A liter of wastewater was collected at the inlet (0 m) and the outlet (50 m) of each unit during each sampling. The influent and effluent samples were instantaneous samples. Sampling always occurred at the same time as 9:00 a.m. per day. The pH value (± 0.01 pH), electrical conductivity (EC) , temperature (T), and dissolved oxygen levels (DO)  were determined directly on-site at the time of sampling using a portable universal meter (Multiline WTW P4), in compliance with the calibration protocol for each of the four parameters. Total suspended solids (TSS), biochemical oxygen demand  Ietswaart was used for the tests. This biotype was named “Monrealease” and showed an erect growth, green oval leaves and flowers with a white corolla. In November 2015, the herbaceous cuttings were taken from mother plants and placed in a cold greenhouse for rooting. In the first decade of January 2016, the rooted cuttings were manually transplanted into the experimental field. Plant density was 2.6 plants m−2. The distance between rows and within rows was 1.50 m and 0.25 m, respectively. The single plot size was 45 m2.An oregano biotype gathered from Monreale   and classified as 3 ha−1 of water during each event. The irrigation events were planned during the maximum plant growth stages and were carried out on a monthly basis from the third 10-day period of March, both in 2017 and 2018. In contrast, unirrigated plants exploited rainfall only. Before transplanting, the experimental field received a total of 30 kg ha−1 N and 90 kg ha−1 P2O5. During the two growing seasons, all irrigated and unirrigated treatments received 60 kg N ha−1: a commonly used fertilization program for oregano in Sicily.The experimental field was equipped with two drip irrigation systems, one for each source of irrigation water used in the study (FW and TWW). Self-compensating drippers were used for the tests and were located 0.25 m apart. The use of this type of dripper guaranteed a constant flow rate and ensured the distribution of the precise amount of water and nutrients into the plot. In both years and for FW- and TWW-irrigated plots, 2 drip irrigation events were effectuated, supplying 400 mWeeds were controlled mechanically, and no pesticides were used in both years. Harvest was carried out when most plants were at the full blooming stage. In this stage, plants were cut at approximately 0.10 m above the ground, in accordance with conventional agronomic practices. In 2017, above-ground plant parts were manually harvested on 10th June for unirrigated plants and on 25th June for FW- and TWW-irrigated plants. In 2018, harvesting dates were 8th June for unirrigated plants and 22nd June for FW- and TWW-irrigated plants.Plant height was measured from the soil surface to the tip of the tallest flowering stem at the full blooming stage. The fresh matter weight of above-ground plant parts (data not shown) was determined by harvesting ten randomly selected plants from the center rows of every single plot to avoid any border effect. The harvested plant material was then dried in an oven at 65 °C for 48 h until it reached a constant weight. The plant dry matter weight was then calculated. The proportion of inflorescences, leaves and stems were separately determined by weighing these components with a digital balance. Plant diameter and the total number of branches per plant were also determined in the laboratory. For all morphological and yield parameters, the second and third growing seasons only were considered due to the fact that in the first growing season, the plants were young, and the main yields were not significant.2 until required. Determination of EO composition was performed by gas chromatography–mass spectrometry (GC–MS) analyses. GC analyses were run on a Shimadzu gas chromatograph, Model 17-A , equipped with a flame ionization detector (FID). Analytical conditions: SPB-5 capillary column (15 m × 0.10 mm × 0.15 μm), helium as carrier gas (1 mL min−1). Injection in split mode (1:200), injected volume 1 μL , injector and detector temperature 250 and 280 °C, respectively. The oven temperature was held at 60 °C for 1 min, then programmed from 60 to 280 °C at 10 °C min−1, then 280 °C for 1 min. Percentages of compounds were determined from their peak areas. GC–MS was carried out in the fast mode on a Shimadzu GC–MS model. GCMS-QP5050A, with the same analytical conditions used for GC-FID. Ionization voltage 70 eV, electron multiplier 900 V, ion source temperature 180 °C. Mass spectra data were acquired in the scan mode in m/z range 40–400. The same oil solutions (1 μL) were injected in the split mode (1:96). All analyses were carried out in triplicate. Identification of the compounds was based on GC retention index , computer matching of spectral MS data with those from the National Institute of Standards and Technology (NIST) MS libraries [Essential oil content was obtained by hydrodistillation of air-dried plant material (50–100 g) for 3 h in accordance with international guidelines . EO contibraries , compari3), magnesium (Mg) and sodium (Na) content were the main soil parameters analyzed in the study. Sampling was carried out in a soil layer ranging from 0 to 40 cm, having oregano plants an average depth of the root system equal to 35 cm. Four sampling spots per plot were combined for the plot sample. Soil samples were subsequently air-dried, ground, sieved through a 2-mm sieve screen and then analyzed for chemical and physical characteristics. The samples were analyzed for pH and EC in the ratio of 1:2 dry soil: water extract; pH was determined with a calibrated pH-meter, EC with a calibrated conductivimeter, TOC with the Walkley and Black method [PH, electrical conductivity (EC), total organic carbon (TOC), total nitrogen (TKN), assimilable phosphorus (P), assimilable potassium (K), active total calcareous ; Y2 (2018). The subplot factor was irrigation water (IW) with three treatment levels: IW1 (FW), IW2 (TWW), IW3 (rainfed), as control. Three replications for each sub-plot were considered. Statistical analyses were performed using the package MINITAB 17 for Windows. Data were compared using analysis of variance. The difference between means was carried out using Tukey’s test. For FW and TWW, all the representative values were presented using mean ± standard error calculation.A split-plot design for a two-factor experiment was used with three replications. The main plot factor was the year (Y) with two treatment levels: YThe results of this study highlight that irrigation with treated wastewater represents a sustainable practice for growing oregano in areas with prolonged water shortages. In the short-term, irrigation with treated wastewater does not affect plant growth and production or the essential oil content and yield in comparison with freshwater. Furthermore, the percentage of the main compounds such as thymol and γ-terpinene remains unaffected. When also considering the rainfed treatment, irrigation with freshwater and treated wastewater affects the biomass and EO yields, but it does not significantly influence the essential oil quality and quantity of oregano plants.As the quality of aromatic plants is determined both by the content and composition of its essential oil, it is evident that treated wastewater obtained by eco-technologies, such as constructed wetland systems, can be a useful tool both to save fresh water and to obtain promising agronomic results in qualitative and quantitative terms.In this study, the chemical characteristics of soil were not significantly affected by irrigation treatments, and the mineral and organic constituents provided by treated wastewater, in particular, did not negatively modify the soil fertility and, thus, damage the plants.However, further research is required to assess the effect of irrigation with treated wastewater on morphological and productive characteristics of oregano, also in the long term, to avoid the possible accumulation of mineral and organic compounds in the topsoil, provoking salt injury to the plants.


There is a lack of prospective studies that test pre-specified hypotheses on the role of personality traits in outpatient psychotherapy. A total of 47 patients with a broad range of psychopathological syndromes were enrolled in a prospective 6-month observational study conducted in Zurich, Switzerland. We found evidence for remarkably high differential stability in all Big Five personality traits during the first 6 months of psychotherapy. Mean-level stability was very high in agreeableness and conscientiousness, while modest changes were observed in neuroticism, extraversion and openness. Baseline scores in neuroticism and conscientiousness at the beginning of therapy predicted modest change in self-reported severity of psychopathology over 6 months, but no effect was found in association with therapist-rated functional deficits. We conclude that personality trait levels may change slightly over the course of 6 months of psychotherapy and that both neuroticism and conscientiousness may have weak associations with the self-perceived improvement in psychopathology. Second, all Big Five traits will demonstrate moderate-to-high mean-level stability (mean change: d < 0.5). More specifically, for neuroticism we predicted d < 0.5 (moderate stability), and for all other traits d < 0.2 (high stability). Third, baseline scores in neuroticism and conscientiousness relate strongly to change in psychopathology and functioning (d > 0.5). Fourth, mean-level change over time in Big Five traits correlate weakly, if at all, with change in psychopathology and functioning (r < 0.3). These hypothesized effect size estimates were derived from the literature reviewed in d > 0.5).First, we hypothesized that all Big Five traits would show high differential stability  for psychological therapy in Zurich, Switzerland. This is a private outpatient psychotherapy centre offering psychological therapy and counseling according to 1 and the study protocol was pre-specified and published online  scale . This meT-tests and differential stability with Pearson correlations between baseline and follow-up scores. The associations between baseline personality trait scores and changes in psychopathology and functioning over time were examined with a series of Generalized Estimating Equations (GEE)  . These rns (GEE) , the infBaseline characteristics of the sample are shown in T = −2.251, df = 45, p = 0.029). Significant increases in mean scores were observed for extraversion  and openness , but not for agreeableness  and conscientiousness . Accordingly, mean level stability was very high for agreeableness and conscientiousness  and somewhat lower for neuroticism (d = 0.28), extraversion (d = 0.23) and openness (d = 0.28). Differential stability was high to very high and ranged from r = 0.65 for neuroticism to r = 0.85 for openness .Personality trait scores at beginning (T0) and after 6 months of therapy (T1) are depicted in b = −0.334, p = 0.012), whereas higher scores in conscientiousness were related to higher symptom reduction over time . The effect sizes corresponded approximately to d = 0.45 for neuroticism and to d = 0.30 for conscientiousness. Both associations remained almost unaltered and statistically significant when adjusted for the presence of a psychiatric diagnosis in an exploratory post hoc analysis.The results for the association of baseline personality with the outcome of therapy are reported in r = 0.33, p = 0.028).Finally, the results for correlation between change scores of personality and psychopathology are shown in 2 and pre-specified in an open-access research protocol  , but somThese different aspects of trait stability, and their association with the outcome of psychotherapy, were also discussed by We found no evidence that baseline personality trait scores predict change in global functioning over 6 months of therapy as rated by the therapists. This finding was rather surprising, given that several reviews have stressed that in particular neuroticism and conscientiousness are influential for social functioning, general health, and quality of life . We founWe would like to highlight some important limitations. First, and perhaps most importantly, the final sample was just half the size we initially planned to collect. The reason for this discrepancy is that when planning the study we considerably overestimated the proportion of treatment beginners who would remain in therapy for at least 6 months. As it turned out, the vast majority of therapies and counseling sessions did not last 6 months. Main reasons included a high percentage of short-time interventions and counseling services, and a rather low proportion of clients with severe mental health problems that required at least 6 months of therapy. Second, we did not include an observer-rating of the Big Five traits, as we did not want to further occupy the patients’ time. Third, although the sample was representative for this private outpatient psychotherapy institute, it is important to acknowledge that most clients were highly educated, of high socio-economic background and most presented with relatively good psychosocial functioning. The study results thus do not necessarily generalize to the broader population of psychotherapy users and to the clients with more severe mental disorders seen in public inpatient psychiatric services. Fourth, since this study did not include a control group, changes observed in the psychotherapy group are not necessarily attributable to therapy effects and thus could also reflect regression to the mean and spontaneous remission .Despite these limitations we conclude that personality trait levels may change over the course of 6 months of psychotherapy. However, differential stability, that is, an individual’s standing relative to others, appears to be highly stable. Finally, there was no evidence that baseline personality traits predict changes in global functioning over time, but both neuroticism and conscientiousness moderately predicted changes in subjective symptom severity. These findings indicate that the association between personality traits and psychopathology is rather weak and possibly inflated due to common method bias.https://osf.io/ukbs5/).The datasets generated for this study are freely available via open science framework (The studies involving human participants were reviewed and approved by the Cantonal Ethics Committee of Zurich. The patients/participants provided their written informed consent to participate in this study.MH was the principal investigator, designed the study, analyzed the data, wrote, and revised the manuscript. MY-A participated in design and conduct of the study, interpretation of the data, writing, and revision of the manuscript. AW and BH participated in writing and revision of the manuscript.The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.


Chile is one of several countries that recently implemented a fiscal policy to reduce soft drink (SD) intake and obesity. In 2014 the government increased the existing ad-valorem tax on high-sugar SD by 5% and decreased by 3% the tax on low-sugar SD, based on a 6.25gr/100 ml sugar threshold. This study aims to evaluate the tax modification passed-on to consumers through prices, and to calculate changes in affordability of SDs. We analysed nationally representative consumer price index data of 41 soft drinks within 6 beverage categories between 2009 and 2016. Price change post-tax implementation was estimated for different categories , using time-series analyses. In addition, changes in affordability were evaluated by estimating the changes in prices relative to wages. The price of carbonates increased by 5.60% (CI 95% 3.18–8.03%) immediately after the tax was implemented. A sustained increase in the prices of concentrates was observed after the implementation. Unexpectedly, a smaller increase was also seen for the price of bottled water – a category that saw no tax change. There were no effects for juices and energy-sports drinks. There was a reduction in affordability for carbonates, concentrates and waters. Overall, the fiscal policy was effective in increasing prices and there are some signs of reduced affordability. Results varied substantially among categories directly affected by the tax policy. While for carbonates the price increase exceeded the tax change (‘over-shifting’), in other categories subject to a tax cut, a price reduction was expected but the opposite occurred. As the effect of the tax on prices differed between categories, the effects of the tax policy on consumption patterns are likely to be mixed. Our findings underline the need to better understand and anticipate price setting behaviour of firms in response to a tax. •Chile implemented a tax policy on soft drinks (SD) to promote healthier diets in 2014.•It consists in a 5% tax increase on high-sugar SD and 3% reduction on low-sugar SD.•Using consumer price index data we estimate policy impact on SD price/affordability.•Overall, the policy was effective to increase prices and reduce affordability.•Results varied substantially among SD categories, with some counterintuitive effects. In one comprehensive study, Malik et al.  synthesiThere is growing interest in the importance of prices for controlling soft drinks consumption. A standard metric to assess changes in purchasing as a response to changes in prices is the price elasticity of the demand, and several studies show that SSB consumption is responsive to price changes, ranging from inelastic (<1) to moderately elastic estimates (>1) . More elPurchasing patterns are not only influenced by prices, but also by other factors, including consumer income. For this reason, a consideration of affordability – a measure that combines both prices and income in a single indicator – has been proposed as a relevant approach E. . AffordaA growing number of countries has implemented tax policies in order to reduce soft drink consumption. Evaluations of these policies have been published for Mexico , the UniImpuesto Adicional a las Bebidas Analcohólicas , an ad valorem tax implemented since 1933 with the last important modification coming in 1976. The tax reform was enacted in October 2014, affecting any non-alcoholic beverages to which colourants, flavourings or sweeteners have been added. For beverages above a sugar concentration of at least 6.25 gr per 100 ml , the tax was increased from 13% to 18%, while for those below this threshold the tax was decreased to 10%, producing an 8% point tax difference between these beverage groups., juices, concentrates (powder juices), bottled waters, energy and sports drinks, and milk. Carbonated drinks, juices, concentrates, and energy drinks were affected by the tax policy. While a small proportion of bottled waters (i.e. flavoured waters) were affected by the tax modification, most of the products in this category (i.e. plain water) were unaffected. Milk and dairy products were excluded from the taxation, regardless of their added sugar content. Furthermore, other non-beverage products that were unaffected by the policy were analysed separately for comparison purposes. These included: dish detergents, laundry detergents, napkins and toilet paper.2.1Aggregated longitudinal monthly data of prices for each product category were obtained from the Laspeyres Consumer Price Index (CPI), provided by the Chilean National Institute of Statistics for the 93-month period between January 2009 and September 2016. We limited the data used for the analysis to two years after the policy implementation (24 months) to reduce a potential bias in the estimated effects that might result from other policies implemented after the tax (such as the front of package labelling law). Price data were collected every two weeks in 15 major cities , incorporating 9629 stores in the sample. Products were sampled in proportion to their frequency of consumption and their expenditure share within the household budget based on nationally representative surveys. From this micro-level price data, an aggregate Laspeyres Price Index is calculated for each food and beverage product category by estimating an arithmetic mean weighted by the expenditure share of each product (e.g. soda of a particular brand) over the overall beverage consumption category (e.g. carbonates) observed in a nationally representative sample of households . Price dIn order to estimate the change in affordability of soft drinks, prices for these products were compared with general trends in the purchasing power of the population. Data on wages were used  comprising monthly survey data of wages from all economic sectors in Chile . Finally2.1.1it) for each product i in month t. The prices represent the market prices (as faced by consumers) of the most frequently purchased products within the soft drinks in supermarkets and other grocery stores. Importantly, the prices capture potential discounts offered by the stores. In Chile, the Value Added Tax (VAT) is already reflected in the posted prices. To account for real price changes within the observed period, nominal prices were adjusted by the national inflation rate. The January 2014 price data was used as the base period for the CPI estimates.The outcome variable of our main analysis is the price index  in each product category, we estimated a weighted average of the expected price change based on the share of products by tax rate in each category assuming a complete pass-through of the tax (See Supporting Information – SI1 – Market share and expected price increase). No data for the distribution of the sports and energy drinks data was available. Nevertheless, this category had a 0% rate before the tax, therefore all sports and energy drinks were subject to either a 10% or 18% net increase in the tax rate, and we assumed 10% as the most conservative estimate. Based on these calculations, we expected the following net price effects per CPI category: carbonates 4.0%; concentrates −2.8%; juices 3.8%; bottled waters −1.2%; sports and energy drinks 18%.2.1.2t/pit), where wt is the national wage index for each month t and pit is the real price index for the product category i for each month t. Upward (downward) secular trends in this index can be interpreted as an increase (decrease) in the affordability of the product i. This measure is analogous to the affordability index used in a previous study on alcoholic beverages  models with exogenous variables (ARIMAX), incorporating dummy variables assigning pre/post-intervention periods and continuous variables to estimate differences in pre/post-intervention trends. Univariate series were analysed for each product in order to test the taxation effect. For these models, the parameter identification followed the Box-Jenkins approach  to identi in month t. Tax is the policy dummy variable taking the value of 1 in the period starting in October 2014 and 0 before, and the parameter ARIMAX  models for price . Finally, models were also adjusted by food inflation were also included to test the robustness of our estimates .Statistical analysis was performed using STATA 14.1  and R 3.3.2. Datasets, R scripts and do-files are available upon request from the authors.33.1In our regression analysis, we found a consistent price level increase immediately after the tax implementation only for the carbonates and bottled water products . In our As expected, and providing more confidence in our findings, the analysis for milk and other non-taxed unrelated categories such as dish detergents, laundry detergents, napkins and toilet paper showed no consistent price-effects after the tax announcement or implementation .3.2Regarding affordability of beverage products, the descriptive Our results confirmed that, upon tax implementation, there was a downward change in the affordability index at least for carbonates, concentrates and bottled water . There w3.3In order to examine potential structural uncertainty underlying the model selection, we tested alternative methodological approaches and, overall, our results were robust. First, we conducted an exploratory analysis for sudden changes in the price series (See Supporting Information – SI3 Placebo test). This analysis confirmed for the carbonates and juice categories that an unexpected change occurred in October 2014, concordant with the hypothesis that an exogenous event affected the overall trends. Moreover, using different estimation methods, the effect in prices found were consistent with our main results based on the ARIMAX model . Also, concordantly to our model estimates, prices of concentrates showed an increase after the implementation of the tax, with a particularly sharp increase in December 2014. Interestingly, the outlier explorations suggest that the post-tax increase in prices of waters exhibited a decreasing trend, nearly converging with pre-tax price trajectories.Secondly, alternative regression methods for interrupted time series analysis using non-related products (i.e. detergents) as a comparison group were implemented . The results obtained largely confirmed our ARIMAX effect estimates. For the categories in which significant effects were found, the magnitude of the price level change was even larger when we used panel-data estimation methods, particularly fixed-effect models for each product: prices of carbonates were found to have increased by 8.46%  after the tax implementation. In the juice category, all alternative models pointed to an increase of nearly 3% in prices post-implementation, similar to the effect predicted by the ARIMAX model without the inclusion of the announcement effect indicator variable . Estimates from models adjusting by food inflation showed similar results .4To our knowledge, this is the first study to evaluate the effects on market prices and consumer's affordability of soft drinks at the population level, comparing pre and post-tax time trends. We used nationally representative, official price data from Chile, analysed using ARIMA models with exogenous variables to estimate the policy effects based on the time-series of different soft drink categories. After adjustment for time-trends, inflation and external economic shocks; our analysis shows changes in prices attributable to the implementation of the policy.Considering that the expected average net price effect of the tax for carbonates assuming a 100% pass-through was 4%, the observed 5.6% price increase in this product category represents an over-shifting (140%). These results were robust to different empirical estimation approaches. Reports by main carbonates manufacturers largely confirm that the industry increased its prices in response to the tax  and thatThe pass-through of soft drink taxes has been found to be highly variable across countries and states that had implemented such policies. Evidence from the tax in Berkeley, California showed a modest pass-through of the tax – only 27.1%  or 47%  of the tOur results differ in some ways compared with two recent studies , one of For beverages subject to a tax increase, Caro et al. found a significant 2.0%  and 3.9%  increase in the prices for carbonates and non-carbonates drinks, respectively. The study of Nakamura et al. found a significant increase of 1.9% (SE 0.01) in the price of the high-tax products associated with the announcement of the policy, while no significant effect was observed at the time of implementation of the tax policy. Moreover, the latter study does not provide aggregated information for carbonates and non-carbonates drinks. Our results for carbonates are concordant with the findings of Caro et al. in terms of the direction of the change; however, we found a higher magnitude of the effect. In the case of juices, which would correspond to the category of non-carbonated drinks in Caro et al. our results differ since we did not find consistent evidence of a price increase.For the low-sugar soft drinks, Nakamura et al. found a significant 1.7% (SE 0.01) decrease in the price after the implementation of the tax reform. In the case of Caro et al. the authors found a non-significant change for ready-to-drink beverages and a significant decrease of 6.7%  for concentrates. Our results are different compared with both studies, since we found a significant increase in the price for concentrates.Compared to the aforementioned studies, our analysis has both strengths and limitations that could drive the observed differences. The main strength is that we use data that contains information from posted prices in stores, while Nakamura et al. and Caro et al. used data from take-home purchases. Compared to the prices collected from purchase records, the data obtained directly from stores are a more reliable source of information and are less prone to bias. This is because if consumers do not buy products that become more expensive after the tax increase, the price estimations from purchase data would underestimate the real effect of the price changes due to searching behaviours or shifts towards cheaper alternative brands. The opposite could occur in the case of the products affected by a tax decrease. Moreover, take-home purchase data could suffer from measurement error because consumers may not always report purchases accurately.Our study has several limitations. First, as was already mentioned, in our data it was not possible to discriminate the tax category for each product, which is a limitation compared to the data used by the two recent impact studies. Therefore, our observed effects on carbonates could mask differences in subgroup responses. The price of regular sodas (affected by a tax increment) may have risen more than the price of their diet versions (affected by a tax reduction), thus underestimating the true effect on soda products that were affected by the tax increase. This limitation implies that our absolute price effect estimates are likely conservative. Nevertheless, we still found a larger effect than in previous studies. To account for this potential problem, we use a reference expected price change based on the market share of low and high sugar products within each category. Secondly, due to the characteristic of the implemented policy, the estimates rely on an observational study design in which unobservable confounders could not be completely controlled. To address this problem, we implemented models to account for before and after variations. Alternatively, we used non-related products as control groups to test the robustness of our results. Thirdly, in other contexts, an increase in distributors’ margins was reported after changes in soft drink taxes . This is4.1We found an increasing trend for soft drinks affordability prior to the tax change, which is in line with recent findings in the international literature E. . FollowiSome considerations regarding the Chilean market and the implementation of the tax are worth noting to interpret our findings from a policy perspective. In Chile, two manufacturers held 82% of the soft drinks market-share during 2014 . In a co5Due to the likely contribution of soft drink consumption to obesity and other non-communicable disease, several countries are implementing new policies to cut down their consumption, such as via soft drink taxes. Learning from the policy experiences of other countries has the potential to provide relevant evidence for policymakers considering interventions. The Chilean experience showcases that a mixed tax modification, affecting differentially high sugar and low sugar soft drinks, produced changes in both market prices and affordability of taxed products. Nevertheless, effects were heterogeneous across product categories, and sometimes different from what might have been expected. Both policy design and market structure could be potential explanations for this phenomenon and should be carefully considered by policymakers before implementation of a similar tax in other settings.Conceptualization: CC, JD, NS, AM, RN, MS, Methodology: CC, JD, NS, Software: CC, JD, Validation: CC, NS, Formal analysis: CC, Investigation: CC, Data curation: CC, JD, Writing – original draft preparation: CC, NS, JD, Writing - review and editing: CC, JD, NS, AM, RN, MS, Visualization: CC, Supervision: CC, MS, Funding acquisition: CC, NS, AM, RN, MSEthics approval and consent to participate: Ethical approval was not required for this study due to the aggregate and public nature of the data used.Consent for publication: All authors declare to have approved the final version of the manuscript and consent its publication.Availability of data and material: Datasets and R scripts are available upon request to the authors.Competing interests: Authors declare no conflicts of interest related to the content of this article.


Evidence suggests that countries with neoliberal political and economic philosophical underpinnings have greater health inequalities compared to less neoliberal countries. But few studies examine how neoliberalism specifically impacts health inequalities involving highly vulnerable populations, such as Indigenous groups. Even fewer take this perspective from an oral health viewpoint. From a lens of indigenous groups in five countries , this commentary provides critical insights of how neoliberalism, in domains including colonialism, racism, inter-generational trauma and health service provision, shapes oral health inequalities among Indigenous societies at a global level. We posit that all socially marginalised groups are disadvantaged under neoliberalism agendas, but that this is amplified among Indigenous groups because of ongoing legacies of colonialism, institutional racism and intergenerational trauma. Neoliberalism, a political orientation influenced by economists Friedman and Hayek, is the dominant economic and philosophical model underpinning the operation of many Organisation for Economic Co-operation and Development (OECD) governments . It is cIndigenous peoples, as defined by the United Nations Indigenous Peoples’ Partnership, includes those with a history of invasion and colonialism on their lands that are sustained to this day . IdentifOral health offers an exquisite mirror of social injustice. Indeed, some of the largest health inequalities documented at an international level involve oral health status . This isFrom a lens of Indigenous groups in five countries , this commentary provides critical insights of how neoliberalism, in domains including colonialism, racism, inter-generational trauma and health service provision, shapes oral health inequalities among Indigenous societies at a global level. The authors chose these five countries because of consistencies in the respective histories of neoliberalism, impacts of colonialism on the Indigenous populations and health service provision models ,24.Nature of the engagement, involvement and leadership by Indigenous people: Four of the five authors identify as Indigenous and represent each of the countries included in the commentary (with the exception of Norway). All are recognised leaders in Indigenous rights and advocacy broadly, and in the provision of culturally-safe health care services specifically. Whose priorities are being addressed by the study: Priorities that are highlighted in the commentary reflect what is reported in the literature, but also reflect concerns shared by all authors, many of whom have lived experience of the types of oral health inequities described.Ethics approval was not required due to the commentary nature of the work.Neoliberalism in the United States: The foundational roots of neoliberalism in the United States were established in the 1970s during the Carter administration [stration . Initialstration . Under tstration . In 1981stration . Neolibestration . In the stration . Indigenous Populations in the United States: Historic boarding schools for American Indian or Alaskan Native (AI/AN) persons were established in the 1870s by European colonisers to detribalize and assimilate Indigenous peoples into Euro-American culture [ culture . The sch culture . Contemp culture . Today mEstimates from the US Census Bureau indicate that, in 2018, approximately 2.2% of the total US population identified as being AI/AN , with apAlthough a relationship of trust with the US government, through federal policies, is meant to improve the AI/AN–US government relationship via the provision of health, education and other social services, the forced assimilation into mainstream America of AI/AN people from their traditional lands and customs due to past government initiatives, sustained poverty, historical and intergenerational trauma, and increasing inequalities in health, education and justice have resulted in AI/AN peoples having much higher rates of unemployment, incarceration, alcohol use disorders, substance misuse, poor mental health, chronic diseases, infections and overall mortality compared with non-AI/AN people ,36. TwenDental Disease and Dental Health Service Provision for Indigenous Persons in the US: Like almost all other health outcomes, dental disease levels among AI/AN populations are high. Over two-thirds (70%) of Navajo children, who comprise the second largest tribe in the United States, have teeth with untreated dental caries [l caries , around l caries . Around l caries .The Indian Health Service (IHS)—which operates within the US Department of Health and Human Services—provides medical and other health care services to AI/AN people who are members of federally recognised tribes. This is means-tested and orchestrated through IHS clinics located specifically on tribal lands. Urban programs are also available, serving around 600,000 people . Several tribes are actively involved in IHS program implementation, while others operate their own health systems independent of the IHS. The service at many, but not all, IHSs include provision of dental care. However, dental services provided by the IHS are severely underfunded, with 90% of its services being provision of basic, emergency care . PreventNeoliberalism in Canada: A shift in the emphasis of monetary policy in Canada commenced in the early 1980s, with the Trudeau government (in 1982) leading a wide-ranging commission into Canada’s economic prospects that subsequently resulted in a highly neoliberal and globalised vision of economic policy [c policy . Free trIndigenous Populations in Canada: The Indigenous peoples of Canada are those who identify as First Nations, Inuit and/or Métis (of mixed Indigenous and Euro-American ancestry). In the 2016 census, Indigenous peoples in Canada represented 4.9% of the total population, with almost half being aged 25 years or less. Around 56% of Indigenous Canadians reside in metropolitan locations, with the remainder living on reserves. In 2016, Indigenous Canadian children aged 0–14 years accounted for 7.7% of Canada’s total child population, with 52% of children in foster care being Indigenous (meaning approximately 4% of Indigenous children are in foster care) [er care) ,45. In CUnder the guise of ‘cultural assimilation’, from 1847 to 1996, and in partnership with Christian churches, the Canadian government administered, throughout Canada, a system of residential boarding schools for Indigenous children, who were removed forcibly from their homes and families . While tDental Disease and Dental Health Service Provision for Indigenous Persons in Canada: Indigenous Canadians experience poorer oral health than non-Indigenous Canadians. Using data from the 2007-09 Canadian Health Measures Survey, the prevalence of untreated dental caries among those identifying as First Nations, Métis or Inuit was 38%, compared with 19% among those identifying as being non-Indigenous; a two-fold difference [fference . Around fference .The dental health care system in Canada is predominately financed privately. This is largely through benefit plans that are employment-based. Around 6% of the population (which includes a large proportion of Indigenous Canadians) is covered by public dental insurance . First NA framework developed to better enable the assumption of health services control by Indigenous Canadians—The Indian Health Transfer Policy—has a strong focus on self-determination . ThroughNeoliberalism in Australia: Neoliberal policies in Australia have been embraced by both major government parties  since the 1980s. The Hawke and Keating governments (both Labor) from 1983 to 1996 set in train a large program of reform that emphasised economic liberalisation. This involved privatisation of government corporations, deregulation of markets, floating the Australian dollar and reducing trade protections [tections . In 1992tections . Indigenous Populations in Australia: Indigenous Australians include those who identify as being Aboriginal and/or Torres Strait Islander. Indigenous Australians have resided in Australia for over 65,000 years, with their numbers decimated following introduced diseases and massacres resulting from colonisation in the 1780s. Contemporary Indigenous Australians represent 3.3% of the total Australian population [pulation . At the pulation . This haThroughout most of the 19th and 20th centuries, Indigenous Australians lived under the shadow of a range of state- and territory-based protection laws. Various Acts of Parliament approved both ‘Protectors of Aborigines’ and ‘Aboriginal Protection Boards’. The purpose of these roles was to ensure the apparent safety of Indigenous Australians, but in reality they served to control the lives and decisions of Indigenous Australians in all matters ranging from employment, marriage and childcare. The Protectors controlled wages, with many Indigenous Australians receiving no income, and others receiving less than their non-Indigenous counterparts in similar employment roles . From 18Dental Disease and Dental Health Service Provision for Indigenous Persons in Australia: Indigenous Australian children had better oral health than their non-Indigenous counterparts prior to the 1980s [he 1980s ,63,64,65he 1980s ,67. In ahe 1980s . Around In Australia, dental care for adults is predominantly provided through the private sector. Provision of publically-funded dental care is available for those eligible through means-testing. This comprises a large proportion of Aboriginal Australians. There are long wait lists in the public dental sector, however, with most services requiring co-payments and a limited range of services. Health care for Indigenous Australians is predominantly provided through federally-funded Aboriginal Community Controlled Health Organisations (ACCHOs). Approximately one-third of ACCHOs provide dental services, but usually for a small out-of-pocket cost . In the Neoliberalism in Aotearoa/New Zealand: Arising from the knock-on effects of the Great Depression in the 1930s, Aotearoa/New Zealand legislated comprehensive welfare state policies in 1938. However, by the 1970s, political models embracing neoliberal frameworks including economic restructuring, increased market competition and privatisation, limited public expenditure on social services, and deregulation and promotion of individual responsibility were taking hold. By the mid-late 1980s, many producer subsidies and import tariffs were phased out, the financial market was deregulated and the exchange rate was floated. Severe cuts to welfare occurred in 1991, alongside wholesale health reform policies that aimed to, though a competitive market and privatization, expand opportunities for innovation and maximize efficiency [ficiency . The impficiency . In 2015ficiency .Indigenous Populations in Aotearoa/New Zealand: Māori are the Indigenous people of Aotearoa/New Zealand, with the Māori language officially recognised as an Aotearoa/New Zealand national language. The Māori arrived via canoe from eastern Polynesia between 1320 and 1350. European colonisation, commencing in the 1780s, caused large changes to Māori way of life [ of life . Initial of life . In cont of life . Māori N of life . Dental Disease and Dental Health Service Provision for Indigenous Persons in Aotearoa/New Zealand: Using data from the 2009 New Zealand Oral Health Survey, half (50%) of those identifying as Māori had untreated dental caries, compared with 34% of those identifying as non-Māori [on-Māori . Almost on-Māori . Aotearoon-Māori .Neoliberalism in Norway: Norway, like other Scandinavian countries , has not embraced neoliberal ideologies as conclusively as many other OECD countries. The so-called ‘Nordic Model’ instead embraces income support and social services, including health, to be funded predominantly from taxation. The Nordic model’s origins are from the 1930s, with its foundations considered to be a compromise between worker and employer parties. Although social security and collective wage bargaining policies were reduced following economic imbalances and financial crises of the 1980s and 1990s, welfare expenditure remains high compared with the European and other OECD average [ average . The Nor average , with No average . The Norwegian state today has a multitude of ownership positions in sectors that include fresh water, seafood, timber, minerals, natural gas and petroleum. It also owns 37% of the Oslo stock market. One-quarter of the country’s GDP is accounted for by the petroleum industry alone .Indigenous Populations in Norway: The Sámi people are the Indigenous Finno-Ugric group who inhabit large northern regions of Norway, Sweden, Finland and Russia’s Kola Peninsula. There is evidence of Sámi having inhabited this region for the last 3500 years [00 years . Approxi00 years . Indeed,00 years . Although the Sámi language and reindeer husbandry are still the cornerstone of contemporary Sámi culture , most Sámi are in fact assimilated into Western ways of living. Historical processes of assimilation have, as with almost all other Indigenous cultures at a global level, not always been positive. For example, in the 18th and especially 19th centuries, the Sámi people were forced to speak Norwegian, with policies from the Norwegian state devaluing and restructuring Sámi culture and identity . There wThe Sámi population today is mostly urbanised, although a substantial proportion live in rural areas in the northernmost part of Norway . In the Compared with the profound inequalities experienced between Indigenous and non-Indigenous people globally, a lower magnitude of differences in life expectancy, health, nutrition and socioeconomic status have been reported between the Sámi in Norway and their non-Indigenous counterparts ,92,93. TDental Disease and Dental Health Service Provision for Indigenous Persons in Norway: In Norway’s Dental Health in the North Study, there were no reported differences in the prevalence of periodontal disease between Sámi and non-Sámi (50% vs. 49%). However, the Sámi had a higher prevalence of deep periodontal pockets and a higher probability of having more severe stages of periodontal disease compared to non-Sámi [non-Sámi . Sámi panon-Sámi . The dental service provision model in Norway is a mixture of public and private. All Norwegians up to the age of 19 years receive dental care free-of-charge. Public dental care is also available for certain high-risk groups including the mentally unwell, older persons, those with a disability or chronic condition, and the incarcerated. Most dental care to adults residing in core Sámi areas is provided through the public dental sector. A recently established dental school in Tromsø, Troms and Finnmark County (county with one-quarter of its population Sámi) has substantially improved access to culturally-appropriate dental care for Sámi in this region .The socio-economic context in which people live their lives influences all aspects of health, including oral health . The corIndigenous populations in the five countries in this study carry a disproportionate burden of oral health inequalities, with the possible exception of the Sámi people in Norway. We contend that neoliberalism has overwhelmingly contributed to these inequities in five main ways: (1) increased disparities in wealth; (2) increased dominance of transnational corporations; (3) privatisation of health; (4) the neoliberal emphasis on personal responsibility and; (5) influences on systemic racism.Increased Disparities in Wealth: Neoliberalism contributes to greater wealth inequities. This disproportionately impacts Indigenous populations who, irrespective of country (with the exception of Norway), are massively over-represented in lower income, under- and unemployment, and abject poverty statistics. Neoliberalism’s emphasis on ‘the self, for the self’ denies Indigenous holistic views of community sharing, participation and ownership; qualities that lead to strong social cohesion but which are cannot succeed in an environment of competition and global marketization. Increased Dominance of Transnational Corporations Without Adequate Regulation or Oversight: Transnational corporations’ products and marketing manifestly impact the oral health of Indigenous populations. Examples include the tobacco and sugar industries. Tobacco smoking rates are 70% in some Indigenous Australian communities, including among children as young as 8 years [ 8 years . In a na 8 years . In Cana 8 years . Over ha 8 years . This is 8 years . Consump 8 years . Many In 8 years . Because 8 years . In Cana 8 years . The sam 8 years . Freely  8 years . The inc 8 years .Privatization of Health: Under the guise of free markets, powerful groups can influence access to dental care through promotion of specific dental service models. The US Department of Health and Human Services described how 36,000 Oglala Lakota in the United States were being serviced by only nine dentists [dentists . In the dentists . Differedentists . The negDomination of Concepts of Personal Autonomy and Responsibility: Indigenous populations are collectivistic and have higher rates of external locus of control and responsibility due in large part to colonisation and oppression. However, neoliberal ideology promotes personal autonomy and responsibility, often resulting in classist social derision of the lifestyles, purchasing decisions and subsequent health outcomes of the socially disadvantaged [vantaged . Neolibevantaged . One exavantaged . The expvantaged .Influences on Systemic Racism: Systemic racism is directly influenced by neoliberal policies, which by nature promote competition and supports groups in power [in power . Systemiin power ,124. It in power . Systemiin power . Racism in power , with itin power ,129. A bterra nullius . This led, in turn, to nation-level dispossession of Indigenous lands and persistent refusal by the settler colonies to engage equally with the country’s First Peoples.The United States, Canada, Australia, Aotearoa/New Zealand and Norway share many similarities. All five countries have similar legal bases, with broadly similar economic systems as mixed-market, capital-based economies. The post-World War II development of a welfare state in each country was largely based on similar social policy priorities. The countries also share broadly common health system characteristics, such as universal access to health care for the socially disadvantaged, although this varies widely regarding population coverage. However, the countries differ dramatically with respect to their histories of colonisation, Indigenous reconciliation, uptake of neoliberal policies and dental health service utilisation. Although the 1763 Royal Proclamation in Canada prevented colonists from directly dealing with the Indigenous population for land, it established the precedent for subsequent treaty and land rights claims ,131. TheThe 1967 Referendum in Australia was a vote to change the Constitution to give the federal parliament the power to make laws in relation to Indigenous Australians, and to allow for Indigenous Australians to be included in the census. An example of how social welfare programs exacerbate the negative impacts of neoliberal policies can be demonstrated by the different outcomes in the United States  and Canada  from the 1980s to 2008 . Canada Some of our findings are no doubt a reflection of health system differences in each country. However, they also reflect considerable differences in the neoliberal influences on the social determinants of health/oral health among those societies. These, in turn, reflect inequities in the distribution of experiences of discrimination, social and material security, jobs and income, and educational attainment for Indigenous and non-Indigenous groups. It is important to bear in mind that the Indigenous groups reflect a small proportion of total country population, with a scarcity of Indigenous doctors, dentists and health care workers, along with funding inadequacies, recognized in each country . The posIn all five countries, Indigenous people rely heavily on government funding sources for health care. Empowerment is an important influence on health, and Indigenous aspirations of greater self-governance have been reflected in changes to the health care systems in all five countries, but with varying degrees of success. Whilst personal empowerment and self-determination notionally reflect neoliberal tenets of individual responsibility for health and health-related behaviours, the pervasive social and commercial determinants of health that impact on the day-to-day lives of all peoples, frequently override the positive contributions of personal empowerment. Using dental service provision as just one example, Indigenous persons throughout the world may well be empowered to seek timely and appropriate dental care, but face unique challenges in many Indigenous health centres not providing dental care, or dental care which is not culturally sensitive, or being unable to afford or attract appropriate dental personnel. This may be compounded by additional geographic and logistical factors, for example, extreme remoteness of Inuit communities in Canada and difficulties with transport in the winter months, and extreme heat in Australia. While the process of colonisation in all five countries differed, one common feature until the mid-to-late 20th century was the substantial restrictions on Indigenous people’s civil rights . The excThus, neoliberalism not only impacts Indigenous oral health globally through policies structuring social resources, but also through more insidious psychosocial processes and constructs of shame . These jLimitations of our commentary are that only five countries were included and all authors are academics and/or dental health service providers. Our views may thus not reflect those of the wider Indigenous global population of whom we write, specifically those experiencing profound social vulnerability . Although limited to five countries, our findings may have relevance to the broader Indigenous international setting. Almost every country has a history of both colonisation and neoliberalism, including all of Latin America and many countries in Asia. Despite important differences, we assert that the Indigenous groups share many similarities with respect to neo-colonial influences on dispossession, disrespect and despair, and that these markers of social injustice are inextricably linked with poor oral health outcomes such as those reflected in our paper. Norway was a notable exception, although it is likely that the oral and general health of Indigenous peoples in that country are still influenced by the sustained legacies of social injustices from the past.


Allergic rhinitis (AR) is a noninfectious inflammatory disease caused by allergic individuals exposed to allergens. Western medicine therapy for treating AR causes obvious adverse events, while thunder fire moxibustion (TFM) is known as a safe and effective treatment for AR. Therefore, we conducted this meta-analysis to evaluate the effectiveness and safety of TFM for treating AR.  PubMed, Web of Science, Embase, the Cochrane Library, CNKI, WanFang, VIP, and CBM from inception to April 5, 2020, were searched without any language restriction. Reviewers identified studies, extracted data, and assessed the quality, independently. The primary outcomes were the total effective rate and the TNSS. The secondary outcomes included TNNSS, RQLQ, VAS, serum IgE, IgA, or IgG level, and adverse events. Randomized controlled trials (RCTs) were collected; methodological quality was evaluated using the Cochrane risk of bias assessment tool (RoB), and the level of evidence was rated using the GRADE approach. Meta-analysis was performed using the RevMan5.3.0 software. P = 0.45; I2 = 0%) and T = TFM + other treatments . In addition, TFM intervention also showed significant difference in total symptom score (T = TFM + other treatments)  in patients with AR.  A total of 18 RCTs were included, including 1600 patients. The results of this meta-analysis showed a statistically significant effect in a total effective rate of T = TFM (RR = 1.07; 95% CI ;  Existing evidence shows that TFM is safe and effective for AR. Due to the universal low quality of the eligible trials and low evidence level, we should draw our conclusions with caution. Therefore, clinical researchers should carry out more large-sample, multicentre, high-quality randomized controlled clinical trials in the future to verify the clinical efficacy of TFM in treating AR. Allergic rhinitis (AR) is a serious global health problem affecting people of all ages in most countries of the world. It is a chronic nasal inflammation caused by exposure of allergic individuals to allergens and can occur within minutes of exposure . Among tCurrently, the treatment methods for AR are mainly western medicines . Among tThunder fire moxibustion (TFM) is a traditional Chinese medicine (TCM) treatment. It is made of moxa sticks with traditional Chinese medicine powder and moxa wool. It is like a big firecracker. After lighting, ten layers of cotton paper were placed on the acupuncture points to press and warm moxibustion. It produces heat to stimulate specific acupuncture points or parts of the body surface, regulates the function of visceral organs by stimulating meridian qi with the help of thermal radiation, and improves the circulation by penetrating deep tissue through heat .Although several clinical trials have been conducted on TFM for treating AR, no systematic review and meta-analysis of TFM or TFM combined with other treatments for treating AR are yet reported. Intriguingly, many high-quality clinical trials have reported that western medicine has severe adverse reactions, and long-term use is prone to drug resistance. Still, TFM has fewer adverse reactions and higher safety. Hence, the goal of this study was to evaluate the quality of these RCTs to assess the effectiveness and safety of TFM in treating AR and guide clinicians better.http://www.crd.york.ac.uk/PROSPERO/display_record.php?ID=CRD42019141113.We conducted a systematic review and meta-analysis in strict accordance with PRISMA  statement . The PRIAll relevant randomized controlled trials (RCTs) or quasi-RCTs of TFM for AR were collected.Participants diagnosed with AR according to the allergic rhinitis and its impact on asthma (ARIA)  were incFor the trial group, TFM alone or TFM combined with other positive interventions  were eligible. Excluded therapies were the RCTs of TFM not as a primary therapy. For the control group, positive comparators , no treatment, and placebo or sham TFM were eligible.Primary outcomes were the total effective rate and the total nasal symptom score (TNSS) , which wPubMed, Web of Science, Embase, the Cochrane Library, China National Knowledge Infrastructure (CNKI), WanFang, VIP, and CBM from the inception to April 5, 2020, were searched without any language restriction, but involving only the human subjects. The main keywords included “thunder fire moxibustion,” “allergic rhinitis,” and “RCT.” Also, the searches were rerun before the final analysis that followed the PRISMA checklist. Besides, the grey literature and the references of all included literatures were retrieved manually. The full-search strategy for PubMed is shown in Three independent researchers  selected qualified literature strictly according to Cochrane Collaborative System Evaluator's Handbook 5.2.0. . DisagreBased on the PICOS principle, we set up the standard data extraction table in advance. Before the formal data extraction, preextraction was conducted twice to ensure the smooth progress of the formal extraction. Data extraction was carried out independently by three researchers  and cross-checked repeatedly. Disagreement was resolved by a tripartite discussion or the fourth researcher (JX). Meanwhile, the intention-to-treat (ITT) analysis was applied to the missing data. Excel 2007 was used for data extraction. Relevant contents of data extraction included title, author, publication time, average age, sample size, disease type, course of treatment, intervention measures, control measures, adverse reactions, and outcome indicators. When essential data in the literature was missing or incomplete, the study author was contacted by phone or e-mail.We evaluated the methodological quality of qualified RCTs using the Cochrane risk assessment tool  accordinI2 value were used to test the degree of heterogeneity. When P < 0.1, I2 > 50%, no heterogeneity was considered among the trials, and the fixed effect model was used for statistical analysis; otherwise, the random effect model was used. When the clinical heterogeneity between the two studies was substantial, only descriptive analysis was performed. The potential publication bias was tested by using an inverted funnel chart developed by Egger when the number of qualified RCTs was more than 10  contained 0, suggesting that the possibility of publication bias was small. Based on the total effective rate , the results showed that P = 0.027 < 0.05, and the 95% CI  did not contain 0, suggesting that the possibility of publication bias was bigger, as shown in Figures Based on the total effective rate  of STATA 12.0 software, we analyzed publication bias through Egger's test, and the results showed that Because there was no enough data, we did not conduct a subgroup analysis for different groups.P = 0.161, I2 = 33.4%) by omitting the study by Ding conducted in 2016 [Sensitivity analysis was used to evaluate the stability of meta-analysis. We performed a sensitivity analysis by using STATA 12.0 software, such as the effective rate. Sensitivity analysis showed that the results of the effective rate were not stable. We found that the results of heterogeneity comparing the effective rate were significantly reduced  and trial group = TFM + other treatments . In addition, TFM intervention also showed significant differences in the total symptom score   in patients with AR. Although the preset outcome indicators of VAS score, RQLQ score, and serum IgE and IgG levels were included in this study, only one RCT was included, and then, only descriptive analysis was conducted. And the results showed that the score of the treatment group was lower than the control group. Besides, TFM intervention has fewer adverse reactions. Therefore, TFM treatment for AR is safe and effective, worthy of clinical application.The results of this meta-analysis showed a statistically significant effect in total effective rate of trial group = TFM . To trace its causes, we found that it had problems of low quality and small sample size. This suggests that the results of this meta-analysis were to some extent influenced by the risk of bias.The total effective rate of TFM for treating AR showed apparent heterogeneity. To find the source of heterogeneity, we conducted sensitive analysis and found that, after excluding the study by Ding conducted in 2016 , the resThe present study presented several limitations, as follows.Firstly, although we collected the abundant literature without any language restriction through a comprehensive searching strategy of nine different databases, we could not be sure that all relevant RCTs were included.Secondly, limited by the retrieval conditions, only the Chinese and English databases were searched, rendering some language biases. All included studies were published in Chinese and none in English, which restricts the generalizability of the findings due to the context in terms of tradition and culture.Thirdly, the methodological quality of most eligible trials was low, and there was a severe risk of bias, which reduced the authenticity and reliability of TFM evidence for AR in this study. Although the “random word” was used in 14 of the 18 studies, only 5 correctly described the random method. At the same time, almost all eligible studies did not implement allocation concealment and blind method, which may result in severe implementation of bias and selective bias.Finally, most of the meta-analysis in this review showed high heterogeneity. And due to the small number of studies included in some outcome indicators and the lack of data in some studies, the subgroup analysis was not carried out according to the preset possible variables.The study also presented some glaring advantages, as follows.Most importantly, there are no systematic reviews and meta-analysis of TFM for the treatment of AR. This is the first systematic review designed to evaluate the effectiveness and safety of TFM for AR patients. Finally, we strictly followed the PRISMA guideline for this systematic review and meta-analysis, and the content met the standards. Thus, we speculated that the results of this review could provide evidence on the efficiency and safety of TFM in treating AR, which would benefit the patients and practitioners.This is the first systematic review and meta-analysis designed to assess the effectiveness and safety of TFM for AR patients. And this review included a comprehensive assessment of methodological quality and the level of evidence. Existing evidence shows that TFM is safe and effective in the treatment of AR. Due to the universally low-quality eligible trials and low evidence level, we should draw our conclusions with caution. And clinical researchers should carry out more large-sample, multicentre, high-quality randomized controlled clinical trials in the future to verify the clinical efficacy of TFM in treating AR.


Alterations in cell morphology (f-actin staining and SEM) and in expression of the focal adhesion marker were analysed after 1, 7, and 14 days. Statistical analysis was performed by one-way ANOVA with a statistical significance at p = 0.05. Cell morphology and cytoskeleton were strongly affected by surface texture. Actin beta and vimentin expressions were higher on rough surfaces (p < 0.01). Vinculin and FAK expressions were significant (p < 0.05) and increased over time. Fibronectin and laminin expressions were significant (p < 0.01) and did not alter over time. Strength of cell/material binding is influenced by surface structure and not by material. Meanwhile, the kind of cell/material binding is regulated by cell type and implant material.A fundamental step for cell growth and differentiation is the cell adhesion. The purpose of this study was to determine the adhesion of different cell lineages, adipose derived stromal cells, osteoblasts, and gingival fibroblast to titanium and zirconia dental implants with different surface treatments. Primary cells were cultured on smooth/polished surfaces (titanium with a smooth surface texture (Ti-PT) and machined zirconia (ZrO Despite the high success rate of titanium and zirconia dental, a peri-implant inflammatory reaction can occur and lead to bone loss around implants. In these cases, regenerative procedures are usually required to restore the bone defect and to prevent the implant failure ,2,3,4.Although autogenous graft is still considered the gold standard for bone regeneration due to its capacity to promote osteogenesis, complexity and morbidity related to the surgical procedure are limiting factors for its use . TherefoNonetheless, tissue regeneration is a process involving not only hard but, also, soft tissues. Whereas hADSCs and primary human osteoblasts (hOB) are known for their bone differentiation properties, human gingival fibroblasts cells (HGFs) are essential for the regeneration of peri-implant soft tissue . In thisLikewise, cell adhesion regulates the interaction between cells and implant surface, since the protein attachment to their receptor indicates how osteogenic cells interact with the dental implant surface . HoweverConsidering that cell adhesion, such as related protein expressions, vary according to the material properties , the purAlterations on cells’ arrangement and morphology were summarised in p < 0.05.Changes in the gene and protein expressions of the focal adhesion marker and extracellular matrix marker were analysed by RT-qPCR and ELISA. Alterations in the fold change from day one to day seven and from day one to day 14 were shown in p = 0.006) and for vimentin (p < 0.01). As shown in Expression alterations were significant for actin beta (p < 0.01) and FAK (p = 0.042) were statistically significant. In hADSC, both markers showed a strong expression that increased over time. The expression of vinculin was higher on titanium, whereas the expression of focal adhesion kinase was higher on zirconia , main marker of the focal contacts, were shown in zirconia . The numzirconia . In HGF,zirconia . This cozirconia .p = 0.0002) and of laminin (p < 0.01) were significant. For hOB and HGF cells, fibronectin expression was not dependent on time, material, or surface texture. Likewise, for hADSCs and HGF cells, the laminin expression did not alter over time, such as in relation to the material or surface. Titanium surfaces showed the strongest alterations  as more rounded cells, with filopodia extending into the micropits on the surface. Unlike cells on titanium with a smooth surface texture (Ti-PT), as flattened cells and the cell morphology were comparable with cells on cell culture plate surfaces . This waInterestingly, the cell morphology of HGF cells was not influenced by surface structure or material, since this was similar on all tested surfaces. The nonalteration of HGF cell morphology by surface texture was also described in other studies ,19,20. IA fundamental step in tissue regeneration is cells binding to the implant surface. In order to optimise the regeneration, it is important to understand the cell binding strength to the implant material surface. When thinking about guided tissue regeneration, hADSC is a promising cell source. However, it is still unclear how hADSC binds to a dental implant surface, such as if the binding is comparable with hard tissue cells, as osteoblasts, or with soft tissue cells, as gingivafibroblasts. This study put us in a position to compare directly hard tissue cells (hOB), soft tissue cells (HGF), and alternative mesenchymal stem cells (hADSC). Cell adhesion is regulated by the extracellular matrix (ECM). Cells adhere to the ECM via an integrin-mediated adhesion that links the EMC to the cytoskeleton, and integrins serve as receptors for ECM proteins .In this study, the main and typical markers of ECM  and cytoskeleton markers (actin and vimentin) were analysed. Furthermore, the expression alterations between the cell types and implant materials or surface structures were compared. One result of this study is that the kind of cell binding to the material via focal contacts is heterogeneous. Like the observed effects of cell morphology, it seems that the surface structure is the factor of influence and not the implant material. Generally, marker expressions increased stronger on rough surfaces compared to smooth surfaces. In the control group, the expression of markers decreased over time. These results endorse the conclusion that the strength of the cell/material binding increases on rough surfaces compared to smooth surfaces. Further studies with osteoblasts confirmed this prediction, showing a relation between the surface roughness and cell adhesion ,23. One marker for strengthening the cell adhesion to the dental material surface is an increasing FAK expression, which was shown in osteoblasts growing on rough titanium surface textures . A contiApart from this, the kind of cell/material binding seems to be regulated by the implant material. The cell/material binding differs between hard and soft tissue cells. In this comparative study, we observed differences in the expression patterns between hOB and HGF cells. Whereas many studies investigated the osteoblast binding to the implant material, there is no sufficient evidence about the kind of cell/material binding of hADSC to either dental implant materials or surface structures. According to the authors’ knowledge, this is the first study assessing the hADSCs’ binding. In osteoblasts, the cell/material binding occur in 60–70% via fibronectin and in 40–50% via laminin . We obseIn hADSC, laminin expression remains constant, whereas fibronectin expression increases over time and with the strongest alteration on zirconia material (ZrO2-ZLA™). In HGF cells, both laminin and fibronectin expressions remained constant, which was already confirmed in other studies. Only slight differences in the gene expression of fibronectin was found comparing HGF cells growing on Laser-Lok, titanium, and zirconia surfaces . FurtherThe study evaluated cell morphology and cell binding of hADSCs, hOBs, and HGFs on titanium and zirconia dental implants with polished/machined and rough surfaces. Cell morphology was recorded based on staining of the cytoskeleton and SEM analysis, whereas cell binding was recorded based on gene and protein expression analysis. Experimental design was conducted in accordance with the “Declaration of Helsinki” and approved by the Ethics Committee of the Faculty of Medicine, University of Muenster (#2016-624-f-S). Previous to the cell isolation, a written informed consent was obtained from all donors. Isolation and culture techniques of human primary cell cultures were described before ,34. AddiFor control, cells were cultivated as a monolayer in cell culture plates. Samples were analysed one, seven, and 14 days after the beginning of the experiment. Cell culture part was repeated three times.2 according to the standard procedure. Subsequently, the samples were mounted on an aluminum specimen holder by using conductive adhesive tabs  and sputter-coated with a gold layer having a thickness of approximately 15 nm. Imaging was performed with a S800 SEM  at the Institute of Medical Physics and Biophysics .For the f-actin staining of the cytoskeleton cytopainter, Phalloidin iFluor 488 reagent  was used. Cells were fixed with 4% formalin in phosphate-buffered saline (PBS) without methanol according to the manufacturer’s protocols. Staining was performed directly with a 1:1000 dilution in 1% bovine serum albumin (BSA) for osteoblasts, a 1:700 dilution for hADSC, and a 1:500 dilution for HGF. Stained cells were examined with the fluorescence microscope Axioplan 2 . For SEM analysis, cells cultures were fixed in glutaraldehyde ; washed with PBS; and dehydrated in a graded ethanol series . Then, the samples were subjected to critical-point drying with liquid COp < 0.05). Post-hoc analysis was performed with Bonferroni-Holm test  [Method for gene expression analysis and for protein expression analysis was descripted before . The userge.net) .Cell morphology is affected by surface texture. A distinct statement on differences in mode and strength of cell/matrix attachment between titanium and zirconium dioxide could not been made. However, kind of attachment is regulated by cell type and used material. And strength of attachment is affected by surface texture.