Risk communication and community engagement are among the key strategies used in response to pandemics. Effective risk communication and community engagement can be achieved when assisted by health learning materials. However, their utilization was not known in Ethiopia. Therefore, the present study aimed to assess the utilization of COVID-19 health learning materials (HLMs), and explore barriers and facilitating factors.A sequential explanatory mixed-methods study consisting of two phases was carried out. The first phase was a cross-sectional survey to assess the utilization of COVID-19 HLMs and their predictors. In this phase, a multistage sampling technique was used to select 530 health workers. A self-administered structured questionnaire was used for data collection. Epi-data manager version 4.6.0.2 and STATA version 16 were used for data entry and analyses, respectively. Descriptive analyses were carried out as necessary. Ordinal logistic regression analyses were done to identify the predictors of COVID-19 HLMs utilization. Phase two is a qualitative study to explore enablers and barriers to COVID-19 HLMs utilization. A judgmental sampling technique was used and 14 key informants were recruited. The collected data were uploaded into Atlas ti version 7.0.71. An inductive process of thematic analysis was employed and the data were coded, categorized, and thematized.Findings showed that out of the total 530 respondents, 210(39.6%), 117(22.1%), and 203(38.3%) of them never use COVID-19 HLMs, use sometimes, and always, respectively. Health workers’ perceived quality of COVID-19 HLMs [AOR = 6.44 (95% CI: 4.18–9.94)], health workers’ perceived usefulness of COVID-19 HLMs [AOR = 2.82 (95% CI: 1.88–4.22)], working facility [AOR = 1.83 (95% CI: 1.07–3.14)], educational level of the respondents [AOR = 1.73 (95% CI: 1.11–2.72)] and availability of COVID-19 HLMs [AOR = 1.45(95% CI: 1.01–2.08)] had statistically significant association with the utilization status of COVID-19 HLMs. Findings from the qualitative study showed that materials-related factors, and structure and health workers-related factors had influence on HLMs utilization.In this study, we found that only a few of the respondents were regularly utilizing COVID-19 HLMs. Perceived quality, usefulness, and availability of HLMs, and health workers’ educational status and working facility determined the level of COVID-19 HLMs utilization. There is a need for giving due attention to HLMs, evaluating their quality, availing them to health facilities, and providing training for health workers. Pandemic is a serious public health problem that has several negative consequences such as health, social, political, economic, psychological, educational, religious impacts, and national instability –5. In loThe world health organization and many countries have been designing different policies, programs, and strategies for the prevention and control of pandemics. Risk communication and community engagement are among some of the key strategies used in response to pandemics –17. EvidHealth learning materials (HLMs) are the most cost-effective strategies that serve to improve knowledge, perceptions, skills, attitudes, beliefs, and key health behaviors by communicating risks, quickly reaching information, providing detailed facts and raising public awareness, reminding of key messages, reinforcing communications, mobilizing the community, increasing motivation and self-efficacy of the target audiences, counteracting rumors, reducing fears, solving doubts and misconceptions, reducing stigma and discrimination –34. For To assess utilization of COVID-19 health learning materials and its predicting factors among health workers in Arsi zone, Oromia, Ethiopia, 2021.To explore facilitators and barriers related to COVID-19 health learning materials utilization among health workers in Arsi zone, Oromia, Ethiopia, 2021.The study was conducted from May 15 to June 25, 2021, in the Arsi zone. The Arsi Zone is one of the 20 zones found in Oromia Regional State, Southeast Ethiopia. The capital of the Arsi zone is Asella town, which is located about 175 km southeast of Addis Ababa. According to the 2021 report obtained from the Arsi Zone health office, the Zone has a total population of 3.5 million. The zone has 26 districts with five primary hospitals, one specialized teaching hospital, and 106 primary health care units (PHCUs) that provide disease prevention and health promotion services. A total of 2,032 health workers of different professions were found in the zone.In this study, a sequential explanatory mixed-method study design was used and both qualitative and quantitative data were collected, analyzed, and integrated. The sequential explanatory design is a mixed method that firstly collects and analyses quantitative data, and then qualitative data to explain and/or generalize quantitative data which leads to a better understanding of the problem ,43. In pThis phase was a cross-sectional survey, aimed to determine HLMs utilization and associated factors among health workers in Arsi Zone, Southeast Ethiopia, 2021.Source populations were all health workers of the Arsi zone. The study populations were all randomly selected health workers in the study area. All health workers who were working in the zone during the study period were included in the study. Health workers who were severely ill and did not exist in the zone due to different reasons during the data collection period were excluded.The sample size in the quantitative phase was calculated using a single population proportion formula with the assumption of 50% proportion of health learning materials since there were no studies in Ethiopia that can address these objectives, 1.96 standard normal distribution curve value for 95% level of confidence and 5% margin of error between the sample and the population. Using the formula, the sample size becomes 384. Since the source population is less than 10,000, the corrective formula was used to calculate the sample size and it becomes 323. After considering a 10% non-response rate and 1.5 design effects, the final sample size becomes 534.A multistage sampling technique was used to select the study participants as follows: In the first stage, among the 26 districts in the Arsi Zone, 8 districts were selected by a simple random sampling technique. Then, the health facilities were stratified into hospitals and primary health care units . In the second stage, four hospitals and four primary health care units (PHCUs) were selected using a simple random sampling technique. Then, the sample size was proportionally allocated to the selected 8 health facilities. Accordingly, a total of 534 health workers  were selected to take part in the study. The list of health workers was obtained from the master head of respective district health offices. Accordingly, a sampling frame of 620 health workers was constructed. Finally, a computer-generated simple random sampling technique was employed to identify the study participants.Do you use COVID-19 HLMs for risk communication and community engagement?) which was scored on a three-point Likert scale with response options “1 = never, 2 = sometimes, and 3 = always”. Health workers’ perceived usefulness of COVID-19 HLMs was measured using 16 items (e.g. I believe that COVID-19 HLMs are helpful reminders for key messages about the pandemic) on a five-point Likert scale with response options “1 = strongly disagree, 2 = disagree, 3 = undecided, 4 = agree, and 5 = strongly agree”. Health workers’ perceived quality of COVID-19 HLMs was measured using 29 items (e.g. Messages of COVID_19 HLMs are fact-based and up-to-date information) on a five-point Likert scale with response options “1 = strongly disagree, 2 = disagree, 3 = undecided, 4 = agree and 5 = strongly agree”.For the quantitative data collection, a structured questionnaire was adapted from relevant literature ,44–49. TA pretest was conducted on 5% of the total sample size in Shashamane Hospital and Dodola PHCU, which are located 70 km and 35 km away from the study area, respectively. Some modifications were done based on the findings. The internal consistency of the items was tested using Cronbach’s alpha. Accordingly, the alpha of the perceived quality of HLMs was 0.929, and the perceived usefulness of HLMs was 0.935, which was within the acceptable range ,51. The The data were collected through self-administered interviews. A total of 8 supervisors were recruited based on their previous experience in data collection and fluency in the local languages. Intensive training was given to the supervisors on the objective of the study, the data collection tools and procedures, approaches to the study participants, and respecting and maintaining the confidentiality of the respondents. As health workers were busy with serving clients, they were requested to fill out the questionnaire while they get free time which beats the health facility, waiting area, ward, unit, and staff cafeteria.The dependent variable was the level of COVID-19 HLMs utilization. The independent variables were socio-economic and demographic factors , HLMs related factors such as availability of COVD-19 HLMs, health workers perceived quality and usefulness of COVD-19 HLMs.Health workers: In the current study, health workers included medical doctors, nurses, public health officers, druggists or pharmacists, laboratory technicians or technologists, and health extension workers.Health learning materials (HLMs): In this study, HLMs included printed media , audio, and audio-visual messages, and materials found in health facilities for COVID-19 risk communication and community engagement.HLMs Utilization: In this study, the COVID-19 HLMs utilization status of health workers was ordered as never use COVID-19 HLMs, use them sometimes, and use them always(regularly) for the sake of risk communication and community engagement during the pandemic.Perceived quality: Health workers’ perceptions about the comprehensiveness, attractiveness, acceptability of the materials, involvement of target audiences, and materials’ ability to call the target audiences to carry out a particular action. In this study, the perceived quality of COVID-19 HLMs was measured by 29 items. The negatively worded items were reverse scored. Then, the composite perceived quality score was computed by summing all the 29 items. Finally, dichotomization was made by taking the mean score as a cut point. Scores above or equal to the mean (≥81.75) were considered as ‘COVID-19 HLMs have quality’ and scores below the mean (<81.75) were considered as ‘COVID-19 HLMs have no quality’.Perceived usefulness: Health workers’ perceptions about the benefits and roles of COVID-19 HLMs such as communicating risks, supplementing verbal messages, providing detailed facts and raising public awareness, increasing the self-efficacy of the target audiences, reducing rumors, fears, doubts, misconceptions, stigma, and discrimination related to the pandemic, serving as reminders for key messages, stimulating the community and helping them to comply with the COVID-19 preventive and control measures. In this study, the perceived quality of COVID-19 HLMs was measured by 16 items. The negatively worded items were reverse scored. Then, the composite perceived usefulness score was computed by summing all 16 items. Finally, dichotomization was made by taking the mean score as a cut point. Scores above or equal to the mean (≥45.46) were considered as ‘COVID-19 HLMs are useful’ and scores below the mean (<45.46) were considered as ‘COVID-19 HLMs are not useful’.Availability of HLMs: In this study, the COVID-19 HLMs were considered available if at least one type of HLMs were available in the health facility and health care providers were able to access it while they need to teach about COVID-19.The primary health care unit (PHCU): is the smallest division in the Ethiopian health tier system which usually includes one health center and five health posts.A pretested questionnaire was used for data collection. The tool was translated to local languages considering the significant difference in the educational level of the study participants. Intensive training was given to supervisors and the data collection was closely supervised. The internal consistency and some dimensions of validity of the tool were assured by experts.The quantitative data were entered into Epi-data manager version 4.6.0.2 software. Then, the data was transported to STATA version 16 for analyses and cleaning. In this study, outliers were identified based on the p-value. Descriptive statistics such as frequency, percentage, mean and standard deviation were done to describe the study participants in relation to relevant variables. Since the outcome variable was the ordinal type of categorical data, univariable and multivariable ordinal logistic regression analyses were carried out to test the association of COVID-19 HLMs utilization with explanatory variables. Crude and adjusted proportional odds ratio and 95% CI were used to determine the magnitude of the association. Variables that have a p-value <0.25 in the univariable ordinal regression were fitted into the multivariable ordinal logistic regression model to control the effect of confounding variables and identify predictors of COVID-19 HLMs utilization. The level of statistical significance was set at a p-value of < 0.05. Assumptions of ordinal logistic regression analyses were checked by likelihood ratio test, goodness-of-fit, and test of parallel lines before the attempt to interpret the final model, and no violation was sought. Finally, results were presented in the form of tables, figures, and narratives.A descriptive qualitative study was conducted following the quantitative study to explore enablers and barriers to the utilization of HLMs in Arsi zone, Oromia, Ethiopia. Health workers from hospitals, health centers, and health posts were included in the qualitative study. The study setting was detailed in phase one.A judgmental sampling technique was used in this phase and diversified key informants were recruited considering their educational level, professional category, work experience, working facility, and their specific working units. The author contacted key informants to recruit them, introduced himself, and clarified the reasons for the study before starting data collection. Accordingly, a total of 14 key informants  participated in the study. All the recruited informants participated in the study. In terms of educational level, 3 key informants were diploma holders, 5 degrees, and 6 master holders .would you tell me any health learning materials you know? Probe: Can be printed Media? Audio or audiovisuals? Folk media?) B) Availability and utilization of COVID-19 HLMs  C) Perceived quality of COVID-19 HLMs , and D) Perceived usefulness of COVID-19 HLMs . The recruitment of key informants was held five days before data collection. The date of the interview, time, and area was decided after discussion with the key informants. On the day of the interview, the investigator established good rapport, explained the aim of the study, and obtained consent from the informants. Face-to-face interviews were conducted in the workplace of key informants (in private rooms) in a way that maintains their confidentiality. Voices were recorded for all interviews. In addition, the interviewer also took note of verbal and non-verbal communication such as tone of voice and facial expressions. The interviews were averagely run for 34 minutes. In order to keep the consistency, all the interviews were conducted by one author. The data were collected until saturation was achieved.A semi-structured interview guide with open questions was prepared by the authors based on the research questions. In addition, outliers identified in the survey were fed into the development of the interview guide. The guide was first prepared in the English language. Then, it was translated to the local language and back-translated to English to ensure its consistency and accuracy. The interview guide has four main parts: A) General questions about HLMs  and non-verbal encouragers , and showing sincere interest in receiving their ideas. Qualitative experts and colleagues were involved in the analysis for auditing and verifying the findings and their interpretations. Each interview was summarized at the end session of key informant interviews. Indeed, interviewees were asked to check whether the summaries were their own ideas and requested to provide their feedback. The data collector stayed in the field all during the recruitment of the key informants and the data collection period. Each transcript was checked against audio-recorded data and field notes. All the research processes and methodological approaches were explained in detail which helps to ensure the thick description of the study and enables readers to understand how the authors reached study conclusions. Indeed, the chronology of research processes, analysis, and the findings was audited and validated by researchers who had rich experience of interviewing and qualitative data management skills. As best as possible, the authors intended only to answer the research question of the study with minimal interpretation bias. To ensure this, different people were involved in data coding, interviews were summarized at the end of each interviewing session, participants were asked for feedback, and authors audited and verified the research processes, audio-record data against transcripts, and analysis and interpretation of the findings. Furthermore, researchers’ reflexivity practices in this study were detailed as follows: Five out of the six authors were public health experts who had health education and promotion, and/or health behavior and communication educational background that have rich experience in the areas of HLMs, risk communication, community engagement, and social and behavioral change communication. One author is nursing in his educational background. Two of the authors are Ph.D. holders, one is a Ph.D. fellow and three authors had master’s educational levels. Five out of the six researchers are male. The authors have ample experience in conducting quantitative, qualitative, and mixed-method studies.Ethical clearance was obtained from the Research and Ethical Review Committee of Jimma University with the reference number: IHR-PGH/201/21. In addition, a permission letter was secured from the Arsi zone and district health offices. Written informed consent was taken from each study participant. All participants were informed about the objectives of the study. Furthermore, the participants were reassured that their responses were kept confidential, and anonymous.The main contents of the methods section are explained in a diagram .A total of 530 health workers participated, giving a response rate of 99.3%. The mean age of the respondents was 37.55(±5.65). Findings showed that most of the respondents, 486 (91.7%), 447 (84.3%), and 415 (78.3%) were urban residents, clinicians, and working in hospitals, respectively. More than three fourths (75.7%) had an educational status of degree and above. The majority of the respondents, 417 (78.7%) had work experience of greater than five years .In this study, only 55.7% of the respondents responded that COVID-19 HLMs were available in their health facilities. Nearly half, 231(43.6%) and 246(46.4%) perceived that COVID-19 HLMs had no quality and were not useful for risk communication and community engagement .In this study, out of the total 530 respondents, 210 (39.6%) of them never use COVID-19 HLMs for risk communication and community engagement. Findings showed that only 203 (38.3%) of the respondents always use COVID-19 HLMs for risk communication and community engagement. Nearly one-fifth, 117 (22.1%) of the respondents sometimes use COVID-19 HLMs for risk communication and community engagement .In this study, out of 530 respondents, nearly half, 291 (54.9%) and 282 (53.2%) of them utilize COVID-19 HLMs for caregivers and patients education at health facilities, respectively. One-fifth, 106 (20.0%) of the respondents utilize COVID-19 HLMs for announcements. Only 33 (6.2%) of the respondents utilize COVID-19 HLMs while providing training on the COVID-19 pandemic .2 = 562.873, P = 0.204) and Deviance chi-square test  suggested that a model exhibits a good fit to the data. The result from a test of parallel lines was non-significant (P = 0.830) indicating that the assumption was satisfied (The inter-correlations among independent variables were diagnosed using the variance inflation factor (VIF). In this study, the maximum VIF was 1.56 which was less than five  indicatiatisfied .The findings of this study were thematized into two major areas: Materials related factors, and structure and health workers-related factors.This theme has three categories which include availability and adequacy of COVID-19 HLMs, perceived quality, and usefulness of HLMs.Availability and adequacy of COVID-19 HLMs. The majority of key informants explained that COVID-19 HLMs were usually unavailable to utilize. However, some of them mentioned that they had audiovisual and printed HLMs such as posters, brochures, and leaflets. The study participants pointed out that even in areas where HLMs were available, they were not enough to utilize as per need. The study participants repeatedly mentioned that the unavailability and inadequacy of COVID 19 HLMs can be due to the lack of production of HLMs at the zonal level.“…I have only a poster at hand. Since I do not have other HLMs, our community has become familiar with this poster. Hence I am not regularly using it” “…In addition to printed COVID-19 HLMs, we have TV shows that broadcast news, panel discussions, public speech announcements, films, short dramas, comedy shows, and music video spots on COVID-19 at some units such as Diabetes, ART, Fistula, and MCH unit. However, there are scarcities to avail them at all units. This can be due to lack of HLMs production facility in Arsi zone “Perceived quality of HLMs. The majority of the key informants repeatedly mentioned that COVID-19 HLMs and messages are unclear and not easily understandable by target audiences, unattractive, culturally unacceptable, and do not represent the community of the study area. The study participants mentioned that this could be due to a lack of engaging communities during the development of materials. They also pointed out that the poor quality of HLMs and messages may be due to a lack of pretesting draft materials among primary target audiences. However, the majority of them mentioned that COVID-19 HLMs call the target audiences to do or not to do a particular action.The language needs to be clear and easy to understand, without ambiguities, abbreviations, jargon, and medical terminology. For example, ‘Wal bukkee hin dhaabatinaa’ ordering to ‘keep physical distance’ has more than two meanings and sensitive in Arsi zone"“… ..Yeah, the majority of the photographs, graphics, illumination, and animations in HLMs don’t represent our community’s local cultural background. For example, where is ethnic clothing such as ‘calle’, ‘cico’, and ‘sinqee’ for mother and ‘head towel’ and ‘boku’ for father? They do not reflect the ethnic and cultural background of the target audience. They are downloaded from the internet which is difficult to understand especially for rural communities where the majority are uneducated "."“COVID-19 HLMs can convey messages that increase awareness, inform benefits of taking COVID-19 preventive measures such as hand washing, keeping physical, distance, wearing masks” .Perceived usefulness of COVID-19 HLMs. The majority of the study participants perceived that the COVID-19 HLMs had no significant role in the prevention and control of the pandemic. They mentioned that the majority of the materials were poor at communicating risks, solving misconceptions, supplementing verbal communications, stimulating communities, and encouraging target audiences to comply with COVID-19 preventive and control measures. However, some of the study participants perceived that COVID-19 HLMs had a substantial contribution in raising public awareness and the quick reach of information on COVID-19 preventive measures.“I do not think COVID-19 HLMs help to solve rumors and misconceptions related to the pandemic. The majority of the pictures are not life pictures and I do not believe the materials can be able to motivate people to comply with the preventive measures” ."… .There are posters posted at public gathering areas such as at market, car station, and on main roads. I believe that the materials help to increase the communities’ awareness about COVID-19… ." .“COVID-19 HLMs can convey messages that increase awareness, inform benefits of taking COVID-19 preventive measures such as hand washing, keeping physical, distance, wearing masks .Under this theme, there are three main categories which include knowledge and competency, attention, and human resource and workload.Knowledge and competency of health workers. The majority of the study participants knew printed HLMs such as posters, brochures, leaflets, and flip charts. However, they didn’t know for what purpose and for whom they produced. Some of the key informants explained that training on the pandemic thought them about the roles of HLMs in communicating risks and engaging communities. Findings showed that some of the study participants didn’t consider audio and audiovisuals as health learning materials.“I have seen posters and banners posted at different sites. However, their roles in COVID-19 prevention and control are not clear for me” .“There is no ongoing capacity-building on health education in general and HLMs in particular. Currently, due to this pandemic, training was given to the majority of our staff on COVID-19 pandemic risk communication. We noticed the improvement of COVID-19 HLMs utilization after the training. This has to be strengthened” .Attention. Most of the study participants mentioned that attention hadn’t been given to health education including HLMs by all concerned bodies. There was no career structure for health education professionals at health posts and health centers, and can be coved by other health professionals. As a result, the health education and promotion activities can’t be scheduled and had no monitoring and evaluation.“… .It is due to the lack of a defined career structure with identified duties and responsibility of health education professionals at all levels of health institutions. Usually, we fail to place them in their appropriate positions……Only this year’s health education program received little attention because of COVID-19" “COVID-19 HLMs materials were provided to health facilities. However, no one monitors its implementation, effectiveness in meeting its objectives” Human resources and workload. The majority of participants explained that there was a shortage of health workers in many health facilities in the study area. They mentioned that health workers were with workload and had no time to provide health education for clients. As a result, they didn’t utilize HLMs, and materials were dumped somewhere in health facilities.The majority of the key informants mentioned that the absence of sufficient public health education staff at the zonal level for conducting effective planning, monitoring, evaluation, and re-planning of HLMs production leads to the inability of developing HLMs,“There is a shortage of health workers in many health facilities. Even health education provision, sometimes it is difficult to appropriately clerk clients due to their workload” .In this study, health workers who never utilize COVID-19 HLMs, utilize sometimes and always (regularly) the materials were 39.6%, 22.1%, and 38.3%, respectively. Findings showed that health workers’ perceived quality of COVID-19 HLMs, health workers’ perceived usefulness of COVID-19 HLMs, working facility, educational status, and availability of COVID-19 HLMs had a statistically significant association with the utilization status of COVID-19 HLMs. Findings obtained from key informant interviews also supplement the survey results which showed that materials related factors , and structure and health care providers related factors  were positively or negatively influence the utilization of COVID-19 HLMs.In this study, we found that nearly half, 43.6% 46.4%, and 44.3%, of the participants, perceived that the COVID-19 HLMs had no quality and were not useful and unavailable for utilization for risk communication and community engagement. This finding was supported by a cross-sectional study from Jimma Ethiopia where only 48.2% of the respondents mentioned that IEC materials were understandable and there was a chronic shortage of HLMs . This caThe current study identified factors that predicted the utilization status of COVID-19 HLMs.Study results indicate that health workers who perceived the quality of COVID-19 HLMs used them for risk communication and community engagement more often than their counterparts.This finding was supported by a qualitative study. The key informants explained that the poor quality of COVID-19 HLMs was due to a lack of engaging all the concerned stakeholders during materials production processes. The participants also mentioned it was due to a lack of passing through all the steps of material production. This finding was also supported by a study from Jimma zone , South AIn the current study type of health facility had a significant association with HLMs. Health workers who were working in hospitals were in the higher category of utilizing COVID-19 HLMs compared to those who were working in the primary health care unit. This can be due to the lack of a career structure for health education professionals in the primary health care unit. This finding was also supported by a qualitative study. The key informants repeatedly mentioned that health education professionals had a career structure at the PHCU level and health education and promotion activities were coved by other professionals. This implies the need for revision of health workers’ recruitment guidelines. In this study, we found that health workers who had a Diploma educational level were at a higher level of utilizing COVID-19 HLMs compared to those who had an educational level of degree and above. This can be due to the working unit. In Ethiopia, usually, health workers who had diploma educational levels had been assigned to areas related to health promotion and diseases prevention units such as cold outpatient departments and chronic diseases units  where health education activities are supposed to be given. Health workers who had higher educational status could be mainly assigned to critical areas such as the intensive care unit and admission wards. The availability of HLMs had also determined their utilization. The COVID-19 HLMs were at a higher utilization level in areas where the materials were available compared to in areas where HLMs were unavailable. This can be due to the fact that availability is the number point to be fulfilled for any service utilization. This finding was also supported by the findings of the qualitative study. The key informants pointed out that the availability and adequacy of HLMs are among the key barriers to the utilization of COVID-19 health learning materials.This study has several strengths. First, it is a mixed-method study that addresses the levels of materials utilization, enablers, and barriers related to materials utilization. Second, the behavior (utilization of HLMS) was well defined in which it was categorized based on stages . This can contribute to the robustness of the findings. Third, health workers were included from health posts, health centers, and hospitals which helped us to generalize the findings to health workers serving in the public health facilities of the study area. Fourth, different categories of key informants were included in the qualitative part for a holistic understanding of enablers and barriers related to COVID-19 HLMs utilization. Fifth, to the best of the authors’ knowledge, this was the first study on HLMs utilization for the prevention and control of the COVID19 pandemic. This study has also limitations. There may be information bias. In addition, as this is a cross-sectional study, it doesn’t identify the cause-effect relationship between the dependent and explanatory variables. Due to limited literature on the area, we were unable to compare our findings with others.In this study, we found that only a few of the respondents were regularly utilizing COVID-19 HLMs. Perceived quality, usefulness, and availability of HLMs, health workers’ educational status, and working facility determined health workers’ level of COVID-19 HLMs utilization. This implies that the utilization status of COVID-19 HLMs was influenced by materials-related factors and structure and health workers-related factors. Thus, HLMs designers have to give due attention to HLMs’ work towards the improvement of the quality of HLMs. This can be achieved when the production processes are guided by material production theories and models. The concerned bodies are advised to monitor and evaluate the availability and utilization of HLMs in health facilities, especially during the pandemic era where HLMs play significant roles in communicating risk and engaging communities in the prevention and control of pandemics. Indeed, the concerned bodies are strongly recommended to provide extensive training on HLMs and risk communications to all health workers of different levels to build their capacities. Furthermore, we also advise policymakers, program designers, and implementers to revise national guidelines such as career structures related to health education and health promotion. We also strongly advise researchers to give due attention to HLMs and explore their production processes, qualities, usefulness, and monitor and evaluate their implementation.Ethical clearance was obtained from the Research and Ethical Review Committee of Jimma University with the reference number: IHR-PGH/201/21. In addition, a permission letter was secured from the Arsi zone and district health offices. Written informed consent was taken from each study participant. All participants were informed about the objectives of the study. Furthermore, the participants were reassured that their responses were kept confidential, and anonymous.S1 File(PDF)Click here for additional data file.


As shown by the test results, compared to the prelockdown data, college students had an increased body mass index (BMI) (0.43 (SD 0.94) P = 0.004), decreased vital capacity (VC) (-128.98 (SD 310.13) ml P = 0.009), and lowered performance in the 800/1000 m endurance (-6.21 (SD 8.81) points P < 0.001) and standing long jump tests (-2.44 (SD 7.37) points P = 0.036) after the lockdown, and the differences in these regards all were significant. In addition, for the students in the overweight/obese group, their pre- and postlockdown physical fitness test results were found to have no statistically significant difference (P > 0.05), but the students in the control group showed a significantly increased BMI, as well as significantly decreased vital capacity and performance in the 800/1000 m endurance and standing long jump tests (P < 0.05). The findings of this study are expected to help government departments and policymakers better understand the impacts of school closures and online learning on the physical health of adolescents, while providing a basis for the formulation of measures that are aimed at reversing adolescents' physical health decline.The outbreak of the COVID-19 pandemic has caused negative impacts on people's lifestyles, as well as considerable indirect social impacts, which has even overshadowed the direct impact of virus infection itself. This study is aimed at examining the changes in physical health-related indexes of Chinese college students before and after the COVID-19 lockdown. The data of this study are from the National Physical Health Testing Program, covering 43 college students  from a class of a Chinese university. Paired  The coronavirus disease 2019 (COVID-19) was first identified in 2019 and then spread to most countries around the world within just a few months [One of the most important responsive policies taken by the Chinese government was to close schools and launch online teaching as an alternative. Although social distancing and lockdown policies are effective measures to contain the spread of the pandemic, they have dramatically changed the lifestyles of the public. Additionally, prolonged online learning and school closures have caused another unexpected consequence, that is, the sharp decline of children and adolescents in physical activity and the increased risk of their physical and mental health as a result . PhysicaThe research data came from Physical Activity and Fitness in China (PAFC), a physical fitness testing program for children and adolescents initiated by the Ministry of Education of China, which examined and assessed the physical fitness of school-age children and adolescents nationwide at the beginning of each academic year (September-November) using a cross-sectional design. This study is part of the program, focusing on the testing of adolescents in colleges and universities with the items specified in the 2014 National Standards for Physical Fitness. The test items can be classified into six parts: BMI, seated forward bends (flexibility), standing long jump (explosive strength), sit-ups for girls , pull-ups for boys (upper body muscle strength), 1000 m race for boys/800 m race for girls (cardiorespiratory endurance), and vital capacity (cardiorespiratory function). The subjects were from a university in China, and the test was conducted at a uniform time and place to maintain the consistency by physical education teachers of the university who received professional training and had rich experience.t-test method, this study compared the physical health test data in November 2019 before the COVID-19 pandemic and October 2020 after the release of school lockdown, with the aim of exploring the changes in physical health-related indexes such as BMI before and after school closure.With the paired This study protocol was approved by the Ethics Review Committee of Tianjin University of Sport, and the teachers and principal of the surveyed school granted their consent. In addition, all participating students were informed of the content and purpose of this study and granted their informed consent orally before the data were collected. The data were collected anonymously and then stored in an encrypted hard disk.P > 0.05), but the height and weight of male students were significantly higher than female ones (P < 0.05), as shown in The participants in this study were 43 students from the same class at a Chinese university, including 22 males and 21 females. All of them were Han Chinese, in good health with no disabilities. The first test was performed before the COVID-19 outbreak (November 2019), and the data collected would be used as the benchmark. After the pandemic was controlled in China and offline teaching was resumed (October 2020), the second test was conducted. This study longitudinally compared the test data in November 2019 and October 2020. The difference in BMI between male and female students was insignificant  and after it was lifted (October 2020). Pearson correlation analysis was utilized to identify the relations before and after COVID-19 lockdown in terms of BMI, flexibility, muscle strength, cardiopulmonary function, and cardiopulmonary endurance. All analyses were performed using Statistical Package or the Social Sciences Version 26.0 , and a bilateral P value of less than 0.05 was considered statistically significant.A paired The items specified in the 2014 National Student Physical Health Standards were used for physical fitness assessment. The items fall into five tests to measure different health dimensions, including BMI, seated forward bends, standing long jump, sit-ups for girls, pull-ups for boys, and 1000 m race for boys/800 m race for girls.2)). The data on height and weight were collected in a quiet room to protect personal privacy.The height and weight of students barefoot and wearing light clothes were measured using an integrated intelligent measuring device , with the values correct to 0.01 m and 0.1 kg, respectively. BMI is calculated by dividing a student's weight by the square of his/her height (BMI = weight (kg)/height . During the measurement, physical education teachers were responsible for race safety and quality supervision.The cardiopulmonary function of college students was represented by their vital capacity, which was measured and recorded by physical education teachers using a digital spirometer .The value was measured and recorded by physical education teachers using a seated forward bending tester  that could be correct to 0.1 cm.Items including standing long jump, 50 m sprint, pull-ups for boys, and sit-ups for girls were carried out for assessment. Standing long jump and 50 m sprint have been widely applied to explosive strength assessment. Pull-ups for boys had no time limit and were used to assess upper body strength, while sit-ups for girls were used to assess abdominal strength, with a time limit of 1 minute. All the test items were conducted under the supervision of physical education teachers, who were also responsible for the safety.All the aforesaid test items were given a final score in the range of 0-100 according to the National Student Physical Health Standards (2014 Edition).t-tests were carried out to compare the differences in physical health indexes of college students before and after the pandemic  P = 0.006). The vital capacity decreased significantly compared with the time before the pandemic (-128.98 (SD 310.13) ml P = 0.009), so did the scores of the 800/1000 m endurance races (-7.19 (SD 10.16) P < 0.001). The scores of standing long jump were lower than the time before the pandemic (-2.44 (SD 7.37) P = 0.036) as well, and the difference was statistically significant.The variables including BMI, vital capacity, cardiorespiratory endurance, flexibility, and strength quality were denoted as mean ± standard deviation (SD). All variables were normally distributed see . Paired emic see . The P vP > 0.05); but for the students in the control group, they experienced an increased BMI, decreased vital capacity and cardiorespiratory endurance, and worse performance in standing long jump, and the differences were statistically significant (P < 0.05), as shown in With the prepandemic physical fitness test data as the benchmark, the subjects were classified into an overweight/obese group (BMI ≥ 24) and a normal-weight control group (BMI < 24) according to the BMI reference norm for screening overweight and obesity in Chinese children and adolescents . The rest-tests were conducted to compare the physical health data (benchmark data) before the pandemic and those after the lockdown. It was found that the P values of BMI, vital capacity, endurance quality, and standing long jump were all less than 0.05, and the difference was statistically significant. However, the P values of pull-ups/sit-ups, flexibility, and 50 m race exceeded 0.05, and the difference was not statistically significant.This study is part of the research on the effects of school closures on the BMI, muscle strength, cardiopulmonary function, and flexibility of adolescents during the COVID-19 pandemic. In this study, all participants performed 15-18 weeks of online learning, and paired The results revealed that after social isolation and school closures, college students had significantly increased BMI and decreased vital capacity, endurance, and strength quality, suggesting that online learning in the months of the pandemic lockdown may affect adolescents' health-related indexes. This finding is consistent with the results of previous studies –10, whicAdditionally, the results of this study showed that college students' BMI increased by 0.43 ± 0.94 (0.14(0.72) 95% CI) after the lockdown was lifted, which was atypical compared with the situation reported before COVID-19. This is because the BMI of children and young people is usually controlled during the school year. Previous studies have shown that among college students, BMI would slightly drop during the school year –13.The increased BMI found in this study is not surprising given school closures, cancellation of sports activities, and sedentary lifestyles due to long-time online learning. Although such an analysis must be performed prudently, the rise of BMI is probably due to the month-long online learning and social isolation. At present, some areas of China are still subject to social isolation and school lockdown, which may prompt the reuse of online teaching in some schools in the future. Therefore, it is of great necessity to create safe and continuous physical activity opportunities for young people, in an effort to prevent students from physical inactivity.P > 0.05), but for the students in the control group (BMI < 24), their pre- and postlockdown performance in BMI, vital capacity, cardiorespiratory endurance, and standing long jump were all significantly different (P < 0.05). Contrary to the conclusion that overweight/obese children were more likely to be affected by schooling suspension or school closure [In addition, this study found that for the students in the overweight/obese group (BMI ≥ 24), the difference between pre- and postlockdown performance in the tests was statistically insignificant , and the participants were only the students of one class in a Chinese university. Hence, the sample size in future research needs to be expanded. Besides, some variables that might affect the results are not taken into account, such as dietary habits, sleep quality, and living habits like smoking and drinking.This study also has several limitations. First of all, the sample size was small (Moreover, since Chinese universities had resumed offline teaching in September 2020, September rather than October may be the most ideal month for the second test.In summary, the indirect impact of the COVID-19 pandemic has exceeded the impact caused by the virus infection itself. Measures taken against the pandemic such as social isolation and school closures have adversely affected the healthy lifestyle of people. However, having a clear understanding of the consequences brought about by lockdown is just the first step to taking preventive measures. This study provides preliminary data about the impact of COVID-19 lockdown on the physical fitness of Chinese college students. To the best of our knowledge, it is the first longitudinal study exploring the changes in the physical fitness of Chinese college students in the context of COVID-19. This study sheds new insights into the future exploration of the impact of school closures or online learning on the physical fitness of children and adolescents, and its findings are expected to provide a reference for government departments and policymakers to formulate countermeasures that are aimed at enhancing young people's health.


We aimed primarily to elucidate the effectiveness of NWT in improving UE motor and functional impaired abilities in children with CP, compared to conventional therapy or no intervention. The secondary aim was to assess if NWT is more effective when used alone or combined with conventional therapy. Methods: A systematic review with meta-analysis was conducted from a bibliographic search in PubMed, Scopus, PEDro, Web of Science, and CINHAL, ending in October 2021, in accordance with PRISMA guidelines. We included randomized controlled trials that compared NWT vs. conventional therapy or no intervention in terms of their impact on different UE impaired abilities  in children with CP. Effect size was calculated with standardized mean difference (SMD) and its 95% confidence interval (95% CI). Results: Nine studies (276 participants) were included. NWT is more effective than conventional therapy at improving grip strength , tip grip strength , and grasping ability . NWT is more effective than conventional therapy at improving functional capacity in daily living activities . For fine manual dexterity, NWT was better than no intervention . Conclusions: Our results indicate that NWT is effective at improving various UE impaired motor skills in children with CP.Background: Nintendo Cerebral palsy (CP) is defined as a group encompassing permanent, changeable movement, posture, and motor function disorders ,2 which ® Wii-based therapy (NWT) is one of the most widely used in children with CP. In this system, patients perform movements and interact with virtual objects displayed on a screen using a remote joystick, with or without a platform called the Wii Balance Board™ [®, Xbox® or Kinect®, NWT requires the active participation of the participant in performing different sports and recreational activities within the games in a standing up or sitting position and can adapt to the needs of each patient. Previous studies reported that NWT is easy to use, accessible, provides a way for children to socialize with their peers; and increases their motivation and leisure during therapy when it is added to conventional therapy [Conventional therapy aims to recover UE motor function in individuals with central nervous system diseases ,15. Conve Board™ . In addi therapy ,27. Meld therapy . Further therapy ,30. In a therapy ,32,33. To date, several systematic reviews have been carried out to analyze the effect of VR interventions (including non-immersive VR devices) on UE motor function in children with CP, with unclear conclusions due to the heterogeneity between studies in relation to the great variety of VR devices used ,35,36. AA systematic review with meta-analysis was conducted according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA)  and the ® Wii”, “virtual reality”, “cerebral palsy”, “upper extremity”, “hand”, “wrist”, “shoulder”, “arm”, and “elbow”, including other related MeSH and entry terms. For each database, a specific keyword combination was employed using the appropriate tags and the Boolean operators “and”/“or”. Filters related to publication date and language were not used. Concerns regarding the search strategy were raised with a third expertise author (M.C.O.-P.). Two authors (D.M.-C. and E.O.-G.) independently performed a literature search in PubMed Medline, Scopus, Web of Science, PEDro (Physiotherapy Evidence Database), and CINHAL, finishing in October 2021. The authors examined the reference lists from the retrieved full-text studies, previously published reviews, and grey literature . The PICOS tool proposed by the Cochrane Library  was usedThe study selection process was carried out independently by two authors (D.M.-C. and E.O.-G.), who reviewed all retrieved records by title and abstract. Each study was examined in detail by two reviewers. All disagreements that arose during this phase were resolved by a third author (M.C.O.-P.). A study was only included in our review if it met all the inclusion criteria: (1) RCTs; (2) including subjects diagnosed with CP; (3) with at least two groups of intervention, in which one received NWT in comparison with conventional therapy or no intervention; (4) studies that assessed the different outcomes related to UE motor function; and (6) studies that provided quantitative data of the outcomes of interest to carry out the meta-analysis. The exclusion criteria established were: (1) RCTs with groups of patients with different central nervous system diseases ; (2) outcomes that could not be unified when performing the meta-analysis; (3) RCT studies that did not provide sufficient data to be included in the quantitative synthesis of this review. Two authors (D.M.-C. and I.C.-P.) independently extracted data from the studies included using a Microsoft Excel standardized data-collection form designed specifically for this research, similar to that used in previous meta-analyses ,43,44. DSpecifically, in this review, from each selected study, the characteristics collected were the following: (1) overall characteristics ; (2) participant characteristics ; (3) characteristics of the experimental and control intervention ; (4) data from outcomes of interest (mean and standard deviation); and (5) follow-up period . When a study did not provide standard deviations, it was estimated using standardized transformations through the standard error, range, interquartile range, and median . The outcomes assessed in this systematic review with meta-analysis were the following: grip strength, tip grip strength, functional capacity in daily living activities and self-care, UE dissociated movements, gross manual dexterity, fine manual dexterity, and grasping ability. The risk of bias in the studies selected was assessed through the Cochrane Collaboration Risk of Bias Tool. This scale comprises seven items , and gives the labels of low, uncertain, and high risk of bias .The quality of evidence in each meta-analysis was evaluated using the Grading of Recommendations Assessment, Development and Evaluation (GRADE) system . We follp-value for the Egger test (where if p < 0.1 it indicates that risk of publication bias exists) [2) from Higgins  and p-value for Q-test (p < 0.1 indicates presence of heterogeneity) [Comprehensive Meta-Analysis 3.0   was used exists) . In addi exists) . To estigeneity) ,56.Initially, 508 references were retrieved from databases after the bibliographic search, and a further 3 studies from other resources. After duplicate studies were removed, 277 studies were screened by title/abstract. Of these, 23 records were excluded for not being relevant and 245 references were removed for not meeting the inclusion criteria. Finally, 9 studies were included in the quantitative synthesis ,63,64,65The studies included were carried out between 2012 and 2021 in Turkey ,59,60, Sp = 0.02) favoring NWT + conventional therapy vs. conventional therapy, with an increase of 1.8 points  in grip strength according to dynamometer measurement. The heterogeneity level was moderate  and the precision level was also low (48.5 participants per study). When NWT was compared to conventional therapy, no difference was found between therapies for improving grip strength . Three RCTs ,61,62 rep = 0.004) favored NWT + conventional therapy vs. conventional therapy, without heterogeneity. On the other hand, very low-quality evidence with a large effect  favored NWT vs. conventional therapy without heterogeneity.Two RCTs ,62 provip = 0.014) favoring NWT+ conventional therapy vs. conventional therapy, with an increase of 4.35%  in the “grasp” domain of the QUEST questionnaire. Heterogeneity was not found, and the precision level was low (24 participants per study).Two RCTs ,63 reporp = 0.074)) were found between NWT+ conventional therapy vs. conventional therapy without risk of publication bias (Egger p = 0.66 and 0% variation in the trim-and-fill method). However, very low-quality evidence of a large effect favored NWT  in comparison with conventional therapy.Four RCTs ,59,60,65p = 0.013) compared to conventional therapy, increasing the score of the domain “dissociated movements” of the QUEST questionnaire by 4.094% . Heterogeneity was not found  and the precision level was low (24 participants per study).Two RCTs ,63 reporp = 0.149) and between NWT vs. conventional therapy  were found without risk of publication bias. Heterogeneity was not present in any subgroup, and the precision level in both comparisons was low .Four RCTs ,60,61,63p = 0.82) were found between NWT+ conventional therapy vs. conventional therapy without heterogeneity. However, very low-quality evidence of a large effect  favored NWT vs. no intervention without heterogeneity. The precision level in both comparisons was low .Three studies ,61,64 prThe main aim of our meta-analysis was to evaluate the effect of NWT on UE motor function recovery in children with CP. We included nine RCTs that reported quantitative data from 274 subjects with CP to analyze seven abilities dependent on UE motor function. Our meta-analysis found the following: (1) NWT can be considered effective for the treatment of UE function in children with CP; (2) NWT plus conventional therapy is better than conventional therapy alone for recovering grip strength, tip grip strength, grasping ability, and UE-dissociated movements in children with CP; (3) NWT is better than conventional therapy to improve tip grip strength and functional capacity in daily living activities and self-care in children with CP; and (4) NWT is better than no intervention to improve fine manual dexterity in children with CP. Our study differs from previous reviews ,66 as itFor grip strength, our results showed that NWT is effective when used as complementary therapy with conventional therapy, leading to an increase of 1.8 points in dynamometer measurement. For this variable, both therapies are effective separately, without significant differences between them. For tip grip strength, our results showed that NWT is effective when it is used as a single therapy and when it is used combined with conventional therapy, both in comparison with conventional therapy. The improvement in grip strength and tip grip strength may be due to grasping the Nintendo joystick and pressing its buttons to play and interact with the virtual environment . The eff® Wii joystick constantly in a deliberate position between the hands. This continuous grip of the joystick and increase in grip strength may explain the improvement in grasping ability. This is of significant clinical interest as NWT may help patients with CP to better grip objects used in everyday life and may in this way increase personal autonomy and self-care.For grasping ability, our results showed that the use of NWT more conventional therapy is better than conventional therapy, with a medium-high effect. In this case, it was not possible to assess if NWT alone is better than conventional therapy or no intervention due to a lack of studies. The improvement in grasping ability can be also justified by the use of the remote control, as in grip strength and tip grip strength, since in order to perform the different functions requested by the games, it is necessary to hold the NintendoThe results obtained for functional capacity in daily living activities and self-care showed an improvement with a large effect for NWT compared to conventional therapy. When NWT plus conventional therapy was compared to conventional therapy, no significant differences were found between therapies. Both comparisons are at the limit of significance. Future studies will indicate if both therapies could be complementary. For now, the results indicate that NWT can be considered a good therapeutic option to improve functional capacity in activities of daily living and self-care. According to Avcil E et al. (2020), the improvements in this variable may be because the exercises performed in the chosen video games were similar to the gestures performed in day-to-day activities. The use of these video games, despite the fact that they were not developed for rehabilitation purposes, could indirectly produce an improvement in the gestures required for daily living activities. This could justify the use of NWT alone as a treatment option. ® Wii games require widely differing movements related to the affected UE to correctly complete the virtual activities, and to complete the virtual tasks it is necessary to be able to dissociate both UEs. These movements are carried out with a joystick and displayed on a screen. The continuous and repetitive exposition and training of the UE movements in these virtual environments may explain the improvement in the ability to dissociate UE movements in children with CP.For UE-dissociated movements, our results showed an improvement with a medium-large effect of the NWT more conventional therapy vs. conventional therapy. However, we could not analyze the effect of NWT vs. conventional therapy due to a lack of studies. Alrashidi, M and colleagues assessed the effect of non-immersive VR (NWT and Xbox) in UE abilities using QUEST, showing improvements in this outcome. However, it is difficult to compare our review with theirs, as our meta-analysis clarifies its findings, indicating that NWT combined with more conventional therapy is able to improve children’s UE abilities. NintendoWhen fine manual dexterity was assessed after application of NWT, our results showed that NWT is better than no intervention. However, we did not find a greater effect for NWT more conventional therapy or NWT over conventional therapy for fine or gross manual dexterity. Both types of therapies improve gross manual dexterity and fine manual dexterity, but neither therapy is superior to the other. Our results, although we only assessed NWT, may be in consonance with previous reviews that determined that non-immersive VR devices could be useful to improve fine manual dexterity in various non-traumatic neurological diseases, including CP ,68. ® Wii games help to immerse patients in virtual environments and allow them to dynamically interact with situations and activities that are impossible in the real world. In neuroimaging studies carried out in children with CP, it has been observed that the use of VR induces neuroplasticity and causes changes at the level of the cerebral cortex [® Wii games could comply with the principles of neuroplasticity and motor learning indicated above. Several studies have analyzed the effect of VR in patients with neurological disorders, concluding that repetitive exercises and multisensory stimulation focused on DLAs stimulate motor evoked potentials, influencing corticospinal interactions in the premotor and motor areas of the brain [The improvements that NWT can produce in the UE motor skills of children with CP may be based on neuroplasticity mechanisms and motor learning induced by multisensory stimulation during the use of NWT. Nintendol cortex . Using Nl cortex ,71. It al cortex ,73. Varihe brain . This alhe brain ,76, due he brain . Likewishe brain . In addihe brain , which che brain .Several authors have affirmed that, when a VR device is adapted to the patient, benefits are obtained in terms of UE mobility  and streThis systematic review has several limitations. First, generalization of our results may be affected by the small number of RCTs included in each meta-analysis. Additionally, the small number of comparisons regarding the type of intervention in each meta-analysis markedly reduced the quality of the evidence in our findings. Likewise, the effect of therapy could only be assessed on the affected side due to the absence of data for the non-affected side. Another limitation is the small number of participants per study, which reduces the precision of the findings, despite the fact that the sample size tends to be low in this type of study. The inability to blind participants and therapists, and in some cases assessors, may have led to the presence of selection and classification bias in the studies included in the meta-analysis. In addition, variations in the trim-and-fill method of more than 10% indicate the presence of publication bias, which also makes it difficult to generalize our results. The low level of evidence in each meta-analysis is an important limitation that may affect the generalization of our findings. However, a strength of this study is that there are not enough studies published that clarify or replicate other researchers’ results, so the meticulous analysis of each measurement instrument used by each of the RCTs included in this review, as well as the identification of the domains and subscales of each of the instruments, allowed us to delimit the different outcomes to be analyzed within the greater construct that is UE function. This effort to analyze and identify outcomes makes this the first systematic review with meta-analysis to focus on UE functioning in this type of patient. It would be interesting in future research to carry out RCTs of high methodological quality, with a larger sample size, in order to analyze in depth this type of intervention in children with CP.Our results showed that NWT can be considered effective for the treatment of UE motor function in children with CP. We also found that NWT plus conventional therapy may be better than conventional therapy to recover grip strength, tip grip strength, grasping ability, and UE-dissociated movements in children with CP. NWT is better than conventional therapy to improve tip grip strength and functional capacity in daily living activities and self-care in children with CP. Finally, NWT is better than no intervention to improve fine manual dexterity in children with CP, but no effectiveness of NWT alone or combined with conventional therapy was found for gross manual dexterity. Although more studies are needed to evaluate the effect of NWT on all outcomes related to UE function in children with CP, the findings presented in this meta-analysis may help clinicians to include NWT in the UE recovery of children with CP.


There is a paucity of data published on the clinicopathological features and prognosis of stage IV non-small cell lung cancer (NSCLC) patients aged ≤45 years. Herein, we evaluated a large clinical series in an effort to provide a clearer picture of this population.The least absolute shrinkage and selection operator (LASSO)-penalized Cox regression model was performed to identify prognostic factors for NSCLC among individuals aged ≤45 years. The Kaplan–Meier method with log-rank test was used to compare overall survival (OS) differences between groups. Competing risk analysis with the Fine–Gray test was used to analyze cancer-specific survival (CSS) differences. Propensity score matching (PSM) was used to minimize selection bias.Incidence-rate analyses, including 588,680 NSCLC cases  from 2004 to 2015, showed that the incidence of stage IV NSCLC among young individuals decreased over the years. In comparative analyses of clinical features and survival outcomes, a total of 48,607 eligible stage IV cases  were included. The results showed that although patients in the young cohort were more likely to be diagnosed at advanced stages, they were also more likely to receive aggressive treatments. In addition, the survival rates of the young patients were superior to those of the older patients both before and after PSM.Stage IV NSCLC patients aged ≤45 years comprise a relatively small but special NSCLC subgroup. Although this population had better survival outcomes than older patients, these patients deserve more attention due to their young age and the significant socioeconomic implications. Lung cancer is a serious global pandemic , 2. Non-Previous clinical series demonstrated that young NSCLC patients are more likely to be female, to be non-smokers, to have adenocarcinoma (ADC) subtypes, and to have advanced-stage diseases than older NSCLC patients , 5, 9–16Given the paucity of related studies, we sought to better understand stage IV NSCLC among young patients (age ≤ 45 years) by analyzing the data deposited in the Surveillance, Epidemiology, and End Results (SEER) Program with the purpose of sketching an outline of this population.https://seer.cancer.gov/). The inclusion criterion was a diagnosis of lung malignancy. The exclusion criteria were 1) lung tumors other than NSCLC and 2) stage I–III diseases . The flTo analyze clinicopathological features and survival outcomes, lung cancer patients from 2010 to 2015 were extracted from the SEER database. The inclusion criteria were as follows: 1) pathologically diagnosed as NSCLC and 2) stage IV diseases. The exclusion criteria were as follows: 1) unavailable TNM stage information, 2) unavailable survival information, 3) previous other cancers, and  age < 18Stage IV patients from 2004 to 2015 were included in the incidence-rate analysis because of the large number of cases, which could lead to a more reliable conclusion. Patients from 2010 to 2015 were included in the clinical characteristics and survival outcomes analysis because only the information about specific metastasis sites was available for the patients in this period, which is an important prognostic factor for metastatic NSCLC patients.We obtained permission to access the SEER dataset (reference number 12962-Nov2019) using SEER*Stat software version 8.3.4. The study was conducted in accordance with the Declaration of Helsinki. The Ethics Board of Peking University People’s Hospital approved this study. This was an open database study, and only non-identifiable information was used. Therefore, this study was dispensed with acquiring signed informed consent forms and ethical approval.This work was supported by the NationalNatural Science funds (grant number82173386).The following anonymized data, including age (continue), sex , ethnicity , marital status (married and other), tumor location , surgery (no and yes), chemotherapy (no and yes), radiotherapy (no and yes), grade , TNM stage , T category , N category , M category , bone metastasis (no and yes), brain metastasis (no and yes), liver metastasis (no and yes), intrapulmonary metastasis (no and yes), cause of death, patient status, and survival time, were retrieved. The current 8th edition of the TNM staging system  and cancer-specific survival (CSS). OS was calculated as the time interval from the date of initial diagnosis to the date of death or the date of the last follow-up evaluation. CSS was calculated as the time interval from the date of initial diagnosis to the date of death attributed to NSCLC or the date of the last follow-up evaluation. The survival information, including survival time, survival status, and cause of death, is available in the SEER database. NSCLC patients with an exact survival status and survival time were included, and those with a survival time = 0 months were excluded from this study. The median follow-up time of the entire stage IV cohort, age ≤ 45 years stage IV cohort, and age > 45 years stage IV cohort were 6 months , 12 months , and 6 months , respectively.http://www.r-project.org) and IBM SPSS Statistics  were applied to the statistical analysis. The Kaplan–Meier method with log-rank test was used to compare OS differences between groups. Competing risk analysis with the Fine–Gray test .From 2004 to 2015, 666,689 cases of lung malignancies were retrospectively reviewed. After the inclusion and exclusion criteria were applied, 233,881 eligible stage IV NSCLC cases  were selected. In the entire cohort, the crude incidence of stage IV diseases was stable between 2004 and 2009 (approximately 40.00%). However, it increased by approximately 6.00% between 2010 and 2015  were selected. The clinicopathological features are listed in p < 0.001). In addition, more patients received surgery, chemotherapy, and radiotherapy in the age ≤ 45 years stage IV NSCLC cohort . More patients in the age > 45 years stage IV NSCLC cohort suffered from intrathoracic metastasis . However, they were unlikely to have lymph node metastasis (p < 0.001). After PSM, there were 1,320 and 2,589 cases in the young and older patient groups, respectively. The covariates between these two groups were well-balanced .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.


Structural equation modeling analysis showed that coping strategies mediated the association between DoS and life satisfaction for both the maltreated and comparison groups. Hope appeared to have a significant mediating effect only among those in the comparison group. Conclusions: The current findings lend support to Bowen’s theoretical statement regarding the role of DoS on psychological well-being, with an incorporated viewpoint of Snyder’s hope theory.Background: Differentiation of self (DoS) is a core construct in Bowen family systems theory. At the interpersonal level, it represents the capacity to maintain rational thinking rather than reacting emotionally, especially while under stress. Previous studies have demonstrated the positive association between DoS and life satisfaction. The current study aims to investigate the mediating roles of hope and coping strategies on this association, and whether the mediation mechanism was moderated by participants’ experience of child maltreatment. Methods: The current sample consisted of 447 Chinese college students recruited from three Chinese universities. DoS, life satisfaction, hope and coping strategies, as well as childhood maltreatment history, were measured via self-report. Structural equation modeling was used to test the proposed mediation and moderation effect. Results: Participants who were maltreated in childhood ( Bowen family systems theory (BFST)  is one oDifferentiation of self, according to BFST, is the internalization of family relationships, which is defined by a balance of autonomy and connectedness . Bowen pSnyder defines hope as a positive motivational state based on an individual’s assessment of his or her own capacity to develop pathways toward a goal and to direct goal-oriented energy to pursue it . ContrarAccording to Bowen, one’s DoS level is related to one’s ability to cope with life stress . People Child maltreatment, such as child abuse and neglect, has long been recognized as a significant risk factor for psychological well-being ,24. ChilA great amount of research has investigated the moderation and mediation mechanisms between child maltreatment and child development, with an aim to shed more light on the prevention and intervention effort for this vulnerable subpopulation of children . NeverthWith an aim to broaden the knowledge of BFST and hope theory, in the current study, we investigated the prospective association between DoS and life satisfaction among a sample of Chinese college students. We hypothesized that (1) DoS would be positively associated with life satisfaction in 3 months; (2) the association between DoS and life satisfaction would be mediated through hope and coping strategies. The current study also hypothesized that (3) participants who were maltreated during childhood would exhibit lower levels of DoS, hope, positive coping strategies, and life satisfaction, as well as higher levels of negative coping strategies; and (4) the mediating effects would be different between participants who were maltreated during childhood and their counterparts who were never maltreated. Given the consistent findings in the literature regarding the relationship between self-esteem and childhood psychological maltreatment, as well as subjective well-being among Chinese emerging adults ,33, in tn = 193), and fewer than one-sixth of the sample was from non-intact families (n = 69). Regarding the parental educational level, 42.51% of the sample (n = 190) reported that their father had a degree of junior high school or below, 37.81% of the fathers (n = 169) had a high school degree, and 19.69% (n = 88) had a college or a postgraduate degree. In addition, 50.34% of participants’ mothers (n = 225) had a degree in junior high school or below, one-third had a degree in high school (n = 149), and 16.33% of participants (n = 73) reported that their mother had a bachelor or master degree. The number of participants who completed the follow-up assessment was 432; thus, the follow-up rate was 96.64%.Data were collected from three universities in a southeastern province in China from March to September 2020. A total of 453 students were assessed twice with a 3-month interval using the Wenjuanxing online survey tool. Six respondents had invalid answers at baseline. Thus, the final sample size was 447. The current sample consisted of 107 male emerging adults and 340 female emerging adults, with the average age being 20.05 years old (S.D. = 1.61). Less than half of the current sample was the only child in the family  to 6 (very true of me). In the current study, the Cronbach’s α of the subscale scores ranged from 0.66 to 0.86. The five subscales of DSI were used as indicators of a latent variable of DoS in the structural equation modeling analysis.DoS was measured with the Chinese version of the Differentiation of Self Inventory (DSI) at the baseline assessment ,35. The definitely false) to 4 (definitely true). The total score of HS was used in this study, with higher scores indicating higher levels of hope. The Cronbach’s α was 0.92 in the present sample.Hope was assessed using the Hope Scale (HS) at the baseline assessment . It inclCoping strategies were measured using the Simplified Coping Style Questionnaire (SCSQ) at the baseline assessment . The SCSThe Chinese version of the short form of the Childhood Trauma Questionnaire (CTQ-SF) was used to measure the maltreatment experience before the age of 16 ,40. The Self-esteem was assessed by the Rosenberg Self-esteem Scale , a widelstrongly disagree) to 7 (strongly agree). The sum of all item scores was used in the analysis, with higher scores indicating higher levels of overall life satisfaction. The Cronbach’s alpha of SWLS in this study was 0.86.Life satisfaction was assessed with the Satisfaction with Life Scale (SWLS) at the 3-month follow-up . It compt-tests were used to compare the differences in their DoS, hope, coping strategies, and life satisfaction based on gender, family condition (intact versus non-intact), and childhood maltreatment experience. Correlation analyses were used to examine the relations among the variables of interest. Structural equation modeling analysis was used to test the hypothesized relationships between DoS and life satisfaction as well as the mediating and moderating effects with AMOS 24.0 and the maximum likelihood method of parameter estimation. The model shown in a) and a dependent variable (path b) simultaneously, the significance of the mediation effect (the product of the point estimate of paths a and b) was estimated with a bootstrapping procedure [Descriptive analysis was conducted with SPSS version 22 . Independent sample rocedure . Specifit(444) = 3.20, p < 0.01) and “I” position from DSI (t(444) = 3.47, p < 0.01), as well as lower levels of hope (t(444) = 2.21, p < 0.05) than males. Age was significantly correlated with emotional cutoff (r(444) = 0.12, p < 0.05) and fusion with others (r(444) = 0.12, p < 0.05). There was no significant difference between those from intact families and their counterparts from non-intact families. Independent sample t-tests showed that participants in the maltreated group exhibited significantly lower levels of hope (t(444) = −4.56, p < 0.001), positive coping skills (t(444) = −2.93, p < 0.01), and self-esteem (t(431) = −4.17, p < 0.001) than the comparison group at baseline, and significant lower life satisfaction (t(287.48) = −5.59, p < 0.001) at the 3-month follow-up. In addition, those in the maltreated group also scored significantly lower in four of the five DSI subscales, including emotional reactivity, I position, emotional cutoff, and fusion with others (ps < 0.05). Results of correlation analysis are presented in Means and standard deviations of the variables are presented in 2(8) = 10.29, p > 0.05) but fit the data better than a model with equal measurement intercepts (χ2(9) = 31.35, p < 0.01). Therefore, the measurement weights model was retained as the final model, which showed an adequate fit to the data ). Path coefficient results of the measurement weights model are presented in The full model was analyzed using the multigroup analysis function in AMOS 24 with the child maltreatment history as the grouping variable. In this way, the parameter estimates were compared between the maltreated group and the non-maltreated group. Preliminary analysis showed that the path coefficients of demographic variables, including age, gender, and family structure were not significant for either group. Therefore, these paths were removed, and only the covariance paths between demographic variables and independent variables (DoS and self-esteem) were kept in the final model. Multigroup analysis showed that the model with equal measurement weights did not fit the data worse than an unconstrained model , as were coping and life satisfaction . The direct effect of DoS on life satisfaction was equally significant for both groups . Among the paths that were free to vary across the two groups, the associations between DoS and coping strategies were positive for the maltreated group  and the comparison group . Hope was positively associated with coping strategies for both groups . The relationship between hope and life satisfaction were not significant among the maltreated group (p = 0.058) but in fact reached statistical significance among the comparison group . The overall model explained 56% and 51% of the total variance in life satisfaction for the maltreated and comparison groups, respectively.Among the paths that were set to be equal across the two groups, DoS and hope were significantly associated ) and the comparison group ). The mediation effect of hope was significant among the comparison group ) but was insignificant among the maltreated group ). There was also a significant chain mediation through hope and coping among the non-maltreated group ).t-test results showed that those who were maltreated during childhood did exhibit significantly lower levels of DoS, hope, positive coping strategies, and life satisfaction than their counterparts without maltreated experience, as hypothesized. DoS was found to have both direct and indirect effects on life satisfaction regardless of participants’ child maltreatment experience in the structural equation modeling analysis. The mediating role of coping was significant for both groups, whereas the mediating role of hope was only significant for those without maltreatment experience.In the current study, we investigated the influence of one’s DoS on life satisfaction and the mediating effects of hope and coping strategies, as well as the moderating effect of child maltreatment history among a sample of Chinese college students. Independent The current study found that DoS was positively and prospectively associated with life satisfaction among a sample of Chinese young adults, which added to the line of research on the cross-cultural validity of the function of DoS. For instance, Tuason and Friedlander reported that DoS was associated with psychological well-being and anxiety in a Philippine sample . In addiRegardless of participants’ maltreatment history, coping strategies were found to be a significant mediator in the association between DoS and life satisfaction in this study. From the perspective of BFST, individuals who are well-differentiated are more likely to employ problem-focusing coping strategies rather than avoidant or emotion-oriented coping strategies . This stAmong the subsample of Chinese emerging adults without child maltreatment experience, hope was found to be a significant mediator in the association between DoS and life satisfaction. In addition, a significant chain mediation through hope and coping was found among the non-maltreated subsample. In other words, hope served as a protective factor of life satisfaction among this subgroup of emerging adults, which was consistent with previous research . The curSeveral limitations should be noted when interrupting the results. First, the current study only surveyed a sample of college students from a southeastern province in China. Over three-fourths of the current sample were females, possibly due to the fact that male Chinese college students were more reluctant to participate in surveys. Therefore, the generalizability of the current findings is limited. Second, although the current data were not merely cross-sectional, there was only a 3-month span between the two assessments. Future research with longitudinal data is needed to further examine the long-term influence of DoS on well-being. Third, the current study consolidated five forms of child abuse and neglect into one maltreated group due to the small sample size. Future research needs to further compare the effect of different types of abuse and neglect with a large sample. Last but not least, the current sample size was relatively small considering the group with child maltreatment history, which also restricted the ability to account for more variables that might influence one’s DoS and life satisfaction. Other influential variables that were not accounted for in the current study, such as personality traits and concurrent stress levels, may need further investigation.Bowen proposes that the ability to maintain rational thinking when facing life stressors plays an important role in individual adjustment. Snyder emphasized the positive motivational state and cognitive processes of hope on individual development. The current study showed that BFST’s statement regarding the function of DoS could be generalized to Chinese emerging adults. Moreover, the current study examined the mediating role of hope and coping on the association between DoS and life satisfaction. In particular, the current findings suggested that child abuse and neglect experience might impede the positive association between DoS and life satisfaction by weakening the mediation effect of hope. The mediation effect of coping strategies, on the other hand, did not differ in the history of child maltreatment. Future research on BFST is still needed, especially those focusing on at-risk subpopulations. Clinicians and practitioners might need to target improving the agency and pathway thinking of hope among those who were maltreated to promote their life satisfaction.