The adequate myotomy length during peroral endoscopic myotomy (POEM) is still controversial. We performed this systematic review and meta-analysis to determine the efficacy and safety of the modified POEM with shorter myotomy (SM) and compare the outcomes between SM and longer myotomy (LM) in achalasia patients.  A comprehensive literature search was conducted in PubMed, EMBASE, Cochrane Library, and Web of Science databases from inception to May 28, 2021. The primary outcome was clinical success rate and incidence of reflux-relative adverse events (AEs). Fixed- or random-effect models were adopted for the analysis according to the heterogeneity. P = 0.41, I2 = 0%). Based on the abnormal acid reflux by pH monitoring, its incidence was significantly lower in the SM group than that in the LM group . With respect to procedure-related parameters, the total procedure time of SM was significantly shorter than that of LM (mean difference (MD) -16.30, 95% CI -23.10 to -9.49, P < 0.001, I2 = 68%).  Five studies involving 225 patients in SM group and 222 patients in LM group were included. The overall clinical success of SM was 96.6%  92.7 to 98.4%). SM showed noninferior response as compared to LM (risk ratio (RR) 1.02, 95% CI 0.98 to 1.06,  SM and LM are comparable in providing treatment efficacy for achalasia patients, whereas less operation time and lower incidence of post-POEM abnormal esophageal acid exposure are observed in SM. Achalasia is a relatively rare motility disorder of the esophagus characterized by insufficient lower esophageal sphincter (LES) relaxation and abnormal peristalsis, resulting in progressive dysphagia to liquids and solids, regurgitation of undigested food, noncardiac chest pain, and different degrees of weight loss . AchalasPOEM was first performed by Inoue et al. in 17 patients with achalasia nearly a decade ago . For thePresently, the optimal myotomy length remains unknown due to the lack of evidence, but a few papers have reported the promising clinical outcomes of the modified POEM with SM for achalasia patients , 11–14. The Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) 2020 statement  was follPrespecified inclusion criteria were as follows: 1) population: adult individuals (age greater than 18 years) who were diagnosed with achalasia based on symptoms, endoscopy, barium swallow, and high-resolution manometry (HRM)  populati; (3) comPrespecified exclusion criteria were as follows: (1) meta-analysis, reviews, case reports, case series, experimental studies in animal models, conference abstracts, editorials, letters to the editor, and expert comments; (2) studies with incomplete data or ongoing trials without reported clinical outcomes; and (3) duplicate studies with overlapped patients except for the most recent publication with the largest population.Two authors (Shu Huang and Huifang Xia) independently conducted a comprehensive literature search in PubMed, EMBASE, Cochrane Library, and Web of Science [v.5.35] databases from inception to May 28, 2021, without language restriction. The following search keywords were adopted: “POEM” and “achalasia”. Disagreements were resolved by consensus. The detailed search strategies and identified items in each database are presented in Supplementary Table After using an automated tool to remove duplicates, the authors (Shi Lei and Xia Huifang) independently screened all titles and abstracts with retained records found in a literature search. Irrelevant studies were excluded. The steps so far have been done in the EndNote software. The authors then independently reviewed the full text of the remaining records and identified eligible studies according to our inclusion and exclusion criteria items. Mismatched studies were excluded. Differences of opinion on the choice of research at the level of title/abstract or full text should be resolved through consensus and discussion with the third author (Zhang Han). To summarize the study selection process, we used a modified PRISMA flowchart .Two authors (Jiao Jiang and Wensen Ren) independently used a standardized spreadsheet that had been developed in advance to extract the data from the eligible studies. Disagreements were resolved by consensus and discussion with a third author (Han Zhang). When an included study failed to supply us with relevant information, we contacted the authors of the paper by email to seek extra details.The primary outcomes were as follows: (1) the overall clinical success rate in SM group and the difference of clinical success rate between SM and LM groups. We restricted the Eckardt score as a measure of clinical success in our analysis. The Eckardt score consists of four symptoms  that are graded according to severity, and the clinical success is defined as a score ≤ 3 . (2) Pos443191590@qq.com) upon reasonable request.The following data were extracted from each article: (1) study characteristics: first author, year of publication, study design, study period, study location, and follow-up duration; (2) patients' demographics in both the SM and LM groups: sample size, age, sex, symptoms duration, Chicago classification, and previous treatments; (3) POEM procedure details in both the SM and LM groups: total procedure time, myotomy direction, tunnel length, myotomy length, and hospital stay; and (4) reported primary and secondary outcomes. The data that support the results of this study are available from Dr. Han Zhang (Two authors (Jiao Jiang and Wensen Ren) independently identified and evaluated the risk of bias of the included studies. The methodological quality of the observational studies was assessed using the Newcastle-Ottawa scale (NOS) , which aTo detect outcome reporting bias, we examined the trial protocols to see if the specified outcomes were reported in the corresponding trial publications. When trial protocols were not available, we compared the outcomes reported in the methods and results sections of the trial publications. We did not statistically perform funnel plot asymmetry test and Egger's test to assess publication bias because there were only five papers included.Two reviewers (Yan Peng and Muhan Lü) independently assessed the quality of the evidence for results from the meta-analysis using the Grading of Recommendations Assessment, Development and Evaluation Working Group (GRADE) system . The sysχ2 test (P < 0.10 indicated the presence of heterogeneity) and I2 statistic. I2 values of 0-50%, 51-74%, and 75% or more were considered to indicate a low, moderate, and high degree of heterogeneity, respectively. In the presence of substantial heterogeneity (I2 > 50%), a random-effect model was used as a pooling method; otherwise, a fixed-effect model was adopted. We were unable to perform subgroup analyses of characteristics such as symptom duration, achalasia subtype, and previous treatments owing to insufficient data. Sensitivity analyses were also conducted by using the leave-one-out method to test the influence of each individual study on pooled estimates. All P values were 2-tailed, and P values < 0.05 were considered statistically significant in all tests except for the χ2 test. All statistical procedures were conducted using the statistical software Review Manager 5.3 with the exception of the pooled event rate, which was performed in Comprehensive Meta-Analysis software.We performed a meta-analysis if data were available for more than one study. For meta-analyses of continuous variables , the mean differences (MD) between pre- and post-POEM data or between SM and LM data were calculated with 95% confidence intervals (CIs). All continuous data reported as mean/median (range) values were converted to mean ± SD before analysis according to the method of Hozo et al. . For metThe initial literature databases search yielded 4254 potential related records, of which 930 on PubMed, 2048 on EMBASE, 138 on Cochrane Library, and 1138 on Web of Science. The records were transferred to the EndNote for screening, and 1973 duplicates were removed using automation tools. Then, out of the 2281 remaining studies, 2249 irrelevant studies were eliminated after assessing their title and abstract. Finally, out of the 32 remaining studies, 27 studies were excluded after the examination of their full text based on the inclusion and exclusion criteria. No additional study was retrieved from the references of the screened records. The reasons and references for the excluded studies after full text review were available in Supplementary Table The main characteristics of the included studies and patients are described in NOS was used to assess the risk of bias for 3 cohort studies. All cohort studies were given a score of 6-7 stars, representing the high quality of studies. Cochrane Collaboration's tool was used to assess the risk of bias for 2 RCTs, and only other bias was unclear in both two studies, representing that all RCTs were of high quality. The results of NOS and Cochrane Collaboration's tool quality assessment are summarized in Supplementary Table I2 = 0%, P = 0.775), and the pooled clinical success rate of POEM with SM for achalasia patients was estimated at 96.6% (95% CI 92.7 to 98.4%)  . For tecI2 = 87%, P < 0.001; I2 = 87%, P < 0.001; I2 = 0%, P = 0.005, respectively), we used random-effect model for the analysis. While the heterogeneity among studies was low in IRP , we used fixed-effect model for the analysis. In terms of the Eckardt score, achalasia patients treated with SM showed significant response as compared to pre-POEM , we used fixed-effect model for the analysis. Achalasia patients treated with SM showed noninferior response as compared to LM , we used random-effect model for the analysis. Meanwhile, as the heterogeneity among studies with regard to the length of hospital stay was low , we used fixed-effect model for the analysis. The total procedure time of SM was significantly shorter than that of LM , we used fixed-effect model for the analysis.Postoperative reflux-related events including symptomatic reflux, reflux esophagitis on endoscopy, and abnormal acid reflux based on pH monitoring were evaluated, respectively. As for the symptomatic reflux, SM showed no significant difference compared with LM , such as subcutaneous emphysema, pneumothorax, and pneumoperitoneum. Other common adverse events include bleeding (n = 9.3%) and mucosal injury/perforation (n = 4.9%). All adverse events were resolved with conservative or endoscopic treatment. No surgery intervention was required and no death was reported.We did not carry out meta-analysis in procedure-related adverse events due to insufficient data publication. But we performed a detailed summary of all adverse events, which are available in Comparing the trial protocols with reported outcomes in the corresponding trial publications and comparing the outcomes reported in the methods and results sections of the trial publications, no reporting bias was found. The sensitivity analysis demonstrated the robustness of all the results by using the leave-one-out method.Based on GRADE, the certainty of evidence that the clinical success of SM was noninferior to LM was low due to the limitation of observational studies, which signified that further research was very likely to have an important impact on our confidence in the estimate of effect and was likely to change the estimate. The certainty of evidence that the SM decreased post-POEM GERD incidence compared with LM was moderate due to the nature of RCT and inconsistency of the results, which signified that further research was likely to have an important impact on our confidence in the estimate of effect and may change the estimate. The certainty of evidence that the SM decreased the total procedure time compared with LM was very low due to the limitation of observational studies and significant heterogeneity, which signified that any estimate of effect was very uncertain.To our knowledge, this is a systematic review and meta-analysis to evaluate the efficacy and safety of SM and compare the clinical outcomes between SM and LM for achalasia. Based on our analysis, we demonstrated that the SM was noninferior to LM in terms of providing clinical success, and it could even lower the incidence of post-POEM GERD regarding to abnormal acid reflux and shorten the total procedure time.POEM is a novel, minimally invasive, and natural orifice endoscopic technology, involving the process of distal esophagus myotomy via a submucosal tunneling approach . Over thAt this time, the research has proven that POEM is both effective and safe, with a reported overall clinical success rate more than 90% , 26. ConHowever, POEM has been especially challenging and time-consuming in complex achalasia such as sigmoid-type esophagus, prior treatments, and presence of submucosal fibrosis. Our current study found that the SM significantly shortened the total procedure time compared with LM. Shorter operating time can potentially reduce the overall expense of the procedure by avoiding the need for additional endoscopic tools. In addition, perioperative AEs, especially gas-related events, have been shown to be fewer in cases with shorter procedure duration , 27. BecAs is well known, acquired GERD is a notable deficiency in the development of POEM. Based on the objective measurements, the incidence of post-POEM GERD is reported between 10% and 57%, and it appears to be the main challenge of the operation , 29. IdeBy making use of functional lumen imaging and endoscopic esophageal topography, adjustments and customization to the POEM technique have been made much easier. The increased use of this technology is allowing patients to gain more accurate assessments of the sufficiency of a myotomy by having access to real-time measurements of pressure and compliance of the esophagus. At the present time, there are no set optimal distensibility targets; however, this adjuvant technology will play a significant role in the procedure's future .In this study, there are several limitations. Firstly, it was conducted with only five studies, of which four studies were performed in China, meaning that our results may not applicable universally. Meanwhile, the types of studies included in the meta-analysis were heterogenous with only 2 RCTs and others were observational studies. Secondly, most enrolled individuals are adult type I and type II achalasia meaning that our results may not apply to the type III achalasia. Thirdly, we are unable to compare the long-term efficacy and safety between SM and LM due to the short-term and various follow-up. Therefore, there are several suggestions in future studies. Firstly, large prospective multicenter RCTs with long-term follow-up are needed. Secondly, we recommend that an additional analysis to determine whether there is a difference in the above results between different countries or Asian and Western populations. Thirdly, double scope technique can be utilized to detect the length of esophageal and gastric myotomy to avoid underestimated or overestimated the outcomes .In conclusion, based on our analysis, SM and LM of POEM are comparable in terms of providing treatment efficacy for achalasia patients, whereas less operation time and lower incidence of post-POEM abnormal esophageal acid exposure are observed in SM.


However, ChEI treatment significantly decreased step or stride variability during the single task . Regarding fall and balance, trending but nonsignificant beneficial effects were observed with ChEI treatment. In conclusion, although ChEI treatment did not significantly improve gait speed and reduce fall, it can significantly reduce step or stride variability. Considering that gait disorder is a challenging issue in patients with PD and that ChEIs are generally tolerable, the present meta-analysis may provide more evidence for the benefit of ChEIs on PD gait disturbance as an alternative treatment consideration.Gait disturbance and imbalance are the major symptoms of Parkinson disease (PD), with fall being the most undesirable consequence. However, few effective evidence-based treatments are available for alleviating these symptoms and preventing falls. Cholinesterase inhibitors (ChEIs) are a well-established treatment for PD dementia with possible impacts on gait, balance, and fall reduction. The present study involved a meta-analysis of randomized controlled trials (RCTs) to investigate the effects of ChEIs on gait, balance, and fall in patients with PD. We searched for studies using the PubMed, Embase, and Web of Science databases. The major outcomes were effects on gait parameters, balance, and fall. This study was registered with PROSPERO (CRD42021254733). Five RCTs were included in the present meta-analysis. ChEIs did not significantly increase gait speed in PD patients (mean difference [MD]: 0.03 m/s, 95% confidence interval [CI]: −0.02 to 0.07,  The cardinal motor symptoms of PD include rigidity, tremor, bradykinesia, and gait disturbance. Unlike the first three symptoms, gait disturbance does not respond well to dopaminergic replacement therapy2. The postural instability and gait disturbance subtype of PD deteriorated rapidly compared with the other subtypes3. Traditional subthalamic deep brain stimulation usually does not alleviate gait disturbance and sometimes may even worsen it4. The most devastating consequence of gait disturbance and imbalance is fall, which results in fracture, traumatic brain injury, and fear of walking. Gait disturbance and fall are substantial threats to the quality of life and mortality of individuals with PD5.Parkinson disease (PD) is the second most common neurodegenerative disease6. In people with PD, cognitive dysfunction is a major contributor to gait disturbance and fall, especially the most detrimental form of gait disturbance, that is, freezing of gait (FOG)8. The signature manifestation of cognitive dysfunction-related FOG is a remarkable worsening of gait during dual-task challenges, which are usually a gait test accompanied by a calculation9.The risk factors for gait disturbance and falls in PD are variable. It could be age-related, such as anxiety, depression, osteoporosis, polypharmacy, weakness, or due to PD-related symptoms such as rigidity, cognitive impairment, dyskinesia, postural instability, and slow mobility10. Similar results are also demonstrated in risk of falls that older adults with moderate to the severe cognitive impairment have a higher risk11. Attention and executive function are thought to be responsible for postural and gait stability13. According to the pre-clinical studies, cortical cholinergic neurons-lesioned parkinsonism mice demonstrated great gait disturbance and fall propensity14, which is suspected to result from the disruption of cortical processing of task and movement cues for the striatum15. In addition, augmentation of cholinergic effect by either rivastigmine or donepezil partially attenuated the symptoms in this dual-lesioned model17. More than cognitive dysfunction, degeneration of the brainstem cholinergic neurons, pedunculopontine nucleus (PPN), and laterodorsal tegmental nucleus (LDT) are also proposed as one of causative t for gait disturbance in individuals with PD18.Evidence of cognitive contributions to gait and fall are well-acknowledged, but the precise mechanisms are not completely understood. In those people with dementia, gait impairments are more prevalent than in normal aging and are related to the severity of cognitive impairment15. Numerous studies have examined the effects of ChEIs on patients with PD, but most have focused on cognition and dementia22. Some pre-clinical studies investigated the impact of gait, balance, and fall and demonstrated possible benefits17. However, most were small-scale clinical studies, providing low evidence for benefits. The present study aimed to summarize the effect of ChEIs on gait, balance and falls in patients with PD.Cholinesterase inhibitors (ChEIs) are widely used for the management of dementia, including Alzheimer disease and vascular dementia. Regarding PD dementia, at present, only rivastigmine provides a significant evidence-based therapeutic effect27 were included in our analysis. These RCTs were published between 2010 and 2020 and had sample sizes ranging from 20 to 130. The mean age of patients was approximately 70 years, and all study cohorts had male preponderance. All five studies recruited patients diagnosed as having idiopathic PD. Two studies specifically enrolled patients with a history of fall. Rivastigmine was prescribed in two studies, and in the remaining three, donepezil was prescribed . The heterogeneity of this analysis was nonsignificant  was demonstrated. The heterogeneity of this analysis was nonsignificant, with I2 being 48%  and nonsignificant results of balance improvement . The effect of ChEIs on fall reduction was not significant .Regarding balance and fall, trending but nonsignificant beneficial effects were conferred. Two studies were added into the quantitative analysis for balance improvement, which revealed highly heterogenous , and the substantia innominata project to the cerebral cortex, thalamus, and striatum. PD dementia is associated with NBM degeneration29, and patients with PD dementia converted from PD-related mild cognitive impairment exhibited more significant loss of the NBM30, which may be responsible for worse gait performance. In people with PD, cognitive impairment in PD also limits the execution of complex tasks, such as gait. The severity of PD-FOG, the most devastating gait disturbance in PD, is inversely associated with the set-shifting performance. For those with PD, their dual-task (simultaneous cognitive load) walk test demonstrated low gait speed31, increased gait variability32, and poor coordination33. ChEIs improve cognition in patients with PD dementia through the cholinergic augmentation effect19, which may further improve gait disturbance. The cholinergic system is also present in the brainstem PPN and LDT that control the gait performance. A lesion in the PPN impaired motor coordination in experimental animals34, and the loss of cholinergic neurons in the PPN was correlated with falls in people with PD35. In addition, the thalamus is a projection of the PPN, and the reduction of thalamic cholinergic projection was greater in those with PD-related falls36. Central-acting ChEIs enhance brain cholinergic activity, modulating gait through cognitive and motor coordination aspects.Gait is a complex task involving the cognitive, sensorimotor, and cerebellar systems37. People with PD usually lost the ability to regulate the stride-to-stride fluctuations while walking, especially in those with FOG38. Disability in stride variability is also considered a risk factor of cognitive decline39, and the relationship between step time variability and falls has been identified40. The present study demonstrated that ChEIs improved step or stride variability in patients with PD, both of which are highly associated with cognition41. This effect was observed in all included studies, especially that conducted by Stuart et al.27. On the other hand, only an increasing trending in gait speed was observed upon ChEI treatment. The slowness of gait in PD may result from bradykinesia, FOG, and hesitation. The latter two conditions may be triggered by anxiety or fear of fall, and they were more responsive to anxiolytic agents than ChEIs42.Step or stride variability is a cardinal feature of gait disorders in PD and is distinctly affected by stride length and frequency43. For patients with PD, rigidity, bradykinesia, impaired sensory integration, and cognitive impairment contribute to imbalance, and the latter two factors are dopamine insensitive44. Poorer balance was associated with the PPN–thalamic cholinergic system35, and the PPN deep brain stimulation may confer beneficial effects on balance in patients with PD45. The present meta-analysis was on balance from two RCTs24, and the improvement was only marginal. Another RCT conducted by Handerson et al.26 reported a significant benefit of rivastigmine on balance, assessed by controlled leaning balance. However, the authors presented only the categorical outcome of the tests as low, medium, high, and very high, which made a quantitative meta-analysis impossible.Balance control on movement (dynamic movement) and stillness  requires integrating all levels of the nervous system. The basal ganglia are involved in controlling balance via the thalamic–cortical–spinal loops and via the brainstem PPN, cholinergic neurons, and the reticulospinal system23 revealed inconsistent results. However, it demonstrated the relative benefit of donepezil on balance assessed by the Activities of Balance Confidence, but no difference was noted when the Berg Balance Scale was used. Throughout the present meta-analysis, a significant benefit of ChEIs on balance in patients with PD was not demonstrated.Furthermore, Chung et al.46. The risk factors of fall in PD can be categorized into generic  and PD-related aspects 6. ChEI treatment was speculated to alleviate cognitive impairment and FOG; however, it is not effective against other factors. The present analysis included two studies on treatment with rivastigmine, demonstrating a trending but nonsignificant effect on fall prevention. One of the studies conducted by Li et al.25 recruited PD patients with different cognition statuses  without mentioning previous fall history and found a significant reduction in the number of falls compared with the placebo group . The rivastigmine group also had a better cognitive performance at study completion.Falls are common among people with PD, and some have recurrent falls26 recruited PD patients with at least one fall, the strongest fall predictor, in the previous year. At baseline, rivastigmine and placebo groups exhibited nonsignificant differences in the number of falls . At study completion, the rivastigmine group had 1.4 ± 2.47 falls per month  compared with 2.4 ± 4.40 falls per month  in the placebo group. Although a significant difference was noted in the number of falls between groups, both groups showed a remarkable increase in the number of falls compared with baseline. The number of falls was greater than that reported by Li et al.25. Because of the highly variable number of falls, the present meta-analysis failed to demonstrate significant fall prevention from the two notable results. In addition, one study included in the meta-analysis, conducted by Chung et al.23. investigated the number of falls in the placebo and donepezil groups. They found that fall frequency per day in the placebo group was 0.25  compared with 0.13 in the group  taking donepezil (p < 0.05). However, that study did not provide information on the baseline number of falls, which limits the utility of its inclusion into a quantitative meta-analysis.On the other hand, Handerson et al.In summary, three studies reported significant fall prevention associated with ChEI treatment in PD patients. However, a considerable difference in the number of falls per year (1.82–91.25) between the three studies rendered it difficult to confirm a significant and homogenous result from the meta-analysis. We argued that ChEIs might prevent falls in PD patients; however, further studies are required to clarify the benefit among a specific group of people with PD.47, which indicated greater contribution of cholinergic system. On the other hand, gait speed, balance, and fall are affected by the combination of multiple neurotransmitters systems, and the augmentation of single system cannot result in significant impact48. Considering that gait disturbance is challenging in the management of PD, a tolerable and possibly effective treatment involving ChEIs may be considered. Rivastigmine, which is effective for PD dementia management49, is the preferred treatment of choice with dual benefits for people with PD. However, the adverse effect of rivastigmine, such as nausea, vomiting, and tremor aggravation19, should be cautiously monitored. Further RCTs are warranted to clearly delineate the cognition-based and non-cognition-based therapeutic benefits of ChEIs on PD.The strength of the present study was that it analyzed not only fall but also gait parameters and balance. Although not all five studies had complete information, with the help of a meta-analysis, we identified the significant benefit of the ChEIs rivastigmine and donepezil on gait variability and the trending benefit on gait speed and fall reduction. The discrepancy of the response upon ChEI treatment among the gait parameters and falls is noted. The possible explanation is that the gait variability is highly cognition-depended26. Finally, to conduct a gait analysis, the recruited PD patients had to be at least able to walk independently, which excluded PD patients with the most severe gait disturbance and highest risk of fall.This study had some limitations, and heterogeneity was inevitable. Although rivastigmine and donepezil are both ChEIs, their effects on PD dementia are distinct. Only rivastigmine is effective for PDD, and its inhibition of both butyrylcholinesterase and acetylcholinesterase explains its difference from donepezil, which only inhibits acetylcholinesterase. Merging the results from these two ChEIs introduces heterogeneity. PD patients were also not uniformly selected. Some researchers have specifically recruited PD patients with falls, whereas others have included general PD patients. Besides, although FOG is the most notorious gait disturbance in PD, only one study assessed the effect of ChEI on PD-FOG by the FOG questionnaire, which demonstrated no significant benefitIn conclusion, ChEI treatment significantly improved gait variability in PD patients and provided trending benefits in terms of gait speed and fall prevention. Considering the tolerability and cognitive benefits, ChEIs may be considered an alternative medical treatment for gait disturbance in PD patients. Future RCTs are warranted to compare the effect between rivastigmine and donepezil and the anatomical origin, either NBM or PPN cholinergic neurons, of gait benefit.This study included only randomized controlled trials (RCTs) that investigated the effects of ChEIs  on gait, balance, and fall in patients with idiopathic PD. RCTs were required to clearly report the patient inclusion and exclusion criteria; the process of randomization; method, dosage, and duration of ChEIs; and a comprehensive assessment of gait, balance, and fall. This study was registered with PROSPERO (CRD42021254733).We searched for RCTs published before May 2021 in the PubMed, Embase, and Web of Science databases following the Preferred Reporting Items for Systematic Review and Meta-Analysis (PRISMA) guidelines. The search keywords are as follows: (“Parkinson’s disease” [title/abstract] OR “Parkinson disease” [title/abstract]) AND  AND . Only studies published in English were included.Baseline and outcome data were independently retrieved by two reviewers (J-H.C. and T-W.H.). Furthermore, data on study designs, study population characteristics, and inclusion and exclusion criteria were extracted. Decisions recorded individually by the reviewers were compared, and disagreements were resolved by a third reviewer (C-T.H.).The primary outcome was the effect of ChEIs on gait parameters, including speed and variability. The secondary outcome was changes in balance and fall. If more than one assessments on balance scale was used in a single study, the more commonly used scale was selected for outcome analysis.Two reviewers (C-T.H. and H-T.H.) independently assessed the methodological quality of each study using the revised risk of bias (version 2.0) method, as recommended by the Cochrane Collaboration. The included studies were scored to determine whether they had a high, medium, or low overall risk of bias. The risk of bias was calculated through the assessment of five domains: bias resulting from the randomization process, bias resulting from deviations from intended interventions, bias resulting from missing outcome data, bias in the measurement of outcomes, and bias in the selection of reported results.p value of <0.05 or a 95% CI that did not include 1 in the relative risk ratio and 0 in the WMD estimation. Statistical heterogeneity and inconsistency in treatment effects across the studies were evaluated using the Cochrane Q-test and I2 statistic, respectively. Statistical significance was set at a p value of <0.10 for the Cochrane Q-test. Statistical heterogeneity across the studies was assessed using the I2 statistic, which quantifies the proportion of total outcome variability across studies.Data were entered and analyzed using Review Manager 5.3 . A meta-analysis was performed following the PRISMA guidelines. The standard deviation was calculated using the provided confidence interval (CI) limits, standard errors, or interquartile ranges, where appropriate. The effect sizes of continuous outcomes were reported as the standardized mean difference (SMD). The precision of effect sizes was reported using a 95% CI. A pooled estimate of weighted mean difference (WMD) was computed using the DerSimonian and Laird random-effects method. A statistically significant result was indicated by a


This public mental health study highlights the interactions among social determinants and resilience on mental health, PTSD and acculturation among Iraqi refugees in Sweden 2012-2013.Objectives: The study aims to understand participants' health, resilience and acculturation, paying specific attention to gender differences.Design: The study, using a convenience sampling survey design , included measures on social determinants, general health, coping, CD-RISC, selected questions from the EMIC, PC-PTSD, and acculturation.Results: Gender differences and reported differences between life experiences in Iraq and Sweden were strong. In Sweden, religious activity was more widespread among women, whereas activity reflecting religion and spirituality as a coping mechanism decreased significantly among men. A sense of belonging both to a Swedish and an Iraqi ethnic identity was frequent. Positive self-evaluation in personal and social areas and goals in life was strong. The strongest perceived source of social support was from parents and siblings, while support from authorities generally was perceived as low. Self-rated health was high and the incidence of PTSD was low. A clear majority identified multiple social determinants contributing to mental health problems. Social or situational and emotional or developmental explanations were the most common. In general, resilience (as measured with CD-RISC) was low, with women's scores lower than that of men.Conclusions: Vulnerability manifested itself in unemployment after a long period in Sweden, weak social networks outside the family, unsupportive authorities, gender differences in acculturation, and women showing more mental health problems. Though low socially determined personal scores of resilience were found, we also identified a strong level of resilience, when using a culture-sensitive approach and appraising resilience as expressed in coping, meaning, and goals in life. Clinicians need to be aware of the risks of poorer mental health among refugees in general and women in particular, although mental health problems should not be presumed in the individual patient. Instead clinicians need to find ways of exploring the cultural and social worlds and needs of refugee patients. Authorities need to address the described post-migration problems and unmet needs of social support, together comprising the well-established area of the social determinants of health. In the Roadmap for Mental Health in Europe (ROAMER) article, on behalf of the ROAMER consortium funded by the European Commission, under the Seventh Framework Programme  relevant for public mental health.Following these recommendations, we in this study explore aspects of the migration process of Iraqi refugees who arrived in Sweden between 2010 and 2013. In accord with the ROAMER priorities, our aim was to elucidate enabling factors  as well as conceivable barriers to mental health and acculturation in this cohort. The study's theoretical foundation therefore rests on a two-domain model of mental health where mental ill-health and subjective well-being are distinct constructs .Further, Mawani  showed aperception of illness and help-seeking behavior.Kirmayer et al.  objectedFollowing a society's value system adds to a person's social resilience in that societal context. In contemporary Sweden, gender equality, secular-rational worldviews, and a high esteem of self-expression are predominant values Welzel, . If a miN = 366) 2007–2010. In a mental health screening of 8,149 refugees of different nationalities in Kentucky, 22.13% screened positively for emotional distress on Refugee Health Screener-15 (RHS-15), predicting depression, anxiety, and PTSD. Almost half of the Iraqi participants had positive scores; higher age and females predicted positive scores. A systematic literature review by Bogic et al.  were significantly younger than the men  (p < 0.001). Equal fractions of the respondents (33–34%) resided in each of the three cities.The studied group of refugees was a convenience sample, recruited through written information material, key persons in community networks, associations, organizations, schools, and workplaces. Our inclusion criteria were being Iraqi, having moved to Sweden between 2000 and 2013, and residing in the cities of Stockholm, Uppsala or Södertälje. The survey comprised items linked to the outlined theoretical themes. To explore the material social determinants, we included items on education, employment, economy, and physical safety. For the interpersonal variables, we included items on Swedish language proficiency, aspects of religion, and social support   with different subgroups of respondents: two female and two male representatives from each of the three main religious denominations—Christian, Muslim, and Mandaean . Surveys were conducted in Arabic, English or Swedish, depending on the preference of the participants. It took on the average 30–40 min to complete the survey, but longer, up to 90 min, for individuals who needed help in reading and writing. Although designed as a self-administered questionnaire, most of the surveys were filled out in the presence of an Arabic-speaking research assistant (who provided language support). The setting for filling in the questionnaire was at the choice of the study person, for example, at school, work, cafés, and similar.The survey study data were analyzed with SPSS (version 27), limited to descriptive analyses using gender and country as independent variables.Participants were informed of the availability, through our auspices, of a psychiatric consultant, if needed. An interpreter would also be available as needed. Ethical approval was granted by the Uppsala Regional Ethical Review Board (reg. no. Dnr 2011/394).As shown in p = 0.042, in Sweden: p = 0.065). A majority of the total sample (app. 91%) felt either “very” (69%) or “somewhat” (22%) safe at home as well in their neighborhood (86%).As to reported lack of support, 16.4% of the participants reported no support at all and an additional 14.1% no concrete support . In the In open responses, the respondents described the educational opportunities in Sweden as very positive, whereas work life was often regarded as discriminating and difficult. They generally appreciated the stability, equality, and justice they encountered in their new country. Concerning safety, one person said: “I feel much safer here than in Iraq. I have not been humiliated based on my Christian religion.” Another person was more ambivalent: “I feel safe, but sometimes I experience things that make me feel depressed, when I compare myself to a Sweden.” Some women reported facing discrimination for wearing a veil. Despite their perception of the situation in Sweden as better than in Iraq, and their attesting to feeling safe, some respondents were markedly concerned about physical security and criminality in society, which negatively affected their total sense of security.M = 0.74, SD = 0.44 and M = 0.75, SD = 0.43, respectively, and in Sweden, M = 0.59, SD = 0.49 and M = 0.57, SD = 0.49, respectively. An overall significant ability to adapt to new situations was found nonetheless (p = 0.025). The women evaluated themselves as working more in Sweden than in Iraq, they worked both at home and were employed or pursued an education.etheless . This efThe respondents reported that the influence of family, relatives, friends, and neighbors both in Iraq and Sweden was “positive” or “very positive.” The largest negative differences in this regard between Iraq and Sweden concerned the change in the rates of “positive” and “very positive” influence of neighbors (reported in 84.3% cases in Iraq and 73.8% in Sweden). The smallest change was observed for the influence of family (from 97.4% in Iraq to 96.7% in Sweden).p = 0.026): women more often than men tended to rely on religion in making sense of life—in Iraq as well as in Sweden.Differences between men and women in experienced social support before and after migration were stark. For men there were no significant differences between living in Iraq or Sweden, neither in any of the items referring to family, friends, religion, and spirituality, nor in items about work and school in stable times . There wp = 0.047).Many respondents described problems with health , finances , and discrimination  as barriers to achieving their goals in life. Men more often emphasized health issues than did women , foremost financial difficulties and unemployment (68.4%), were the most commonly given explanations of mental ill health . Difficup = 0.002).Emotional and developmental explanations (86.6%) were almost as common as social explanations. Problems in close relationships, failures in life, and the death of or separation from a significant other were frequently mentioned. Death or separation was the most common explanations for women (52.4%), who significantly differed from the men in this respect (p = 0.01). Religious or spiritual explanations were given by 19.8% of the respondents. Significantly more women than men explained mental health problems as caused by religious and spiritual forces.Medical or biological explanations of psychological problems or mental health issues were indicated by 66.8% of the respondents. Significantly more women than men believed that biochemical changes in the body caused mental health problems . Additionally, 36.3% (71 men and 66 women) reported having experienced moderate to extreme pain that interfered with their work during the past 4 weeks. Problems with work or other regular daily activities caused by emotional problems (such as feeling depressed or anxious) were reported by 31.8% (61 men and 59 women) or to not carrying out work or other activities as diligently as usual by 27.5% (47 men and 52 women). Forty-three participants  met the criteria for PTSD.Almost 75% of the respondents evaluated their health as either “good,” “very good,” or “excellent” . As is cThe ethnic labels used by the respondents were very diverse, frequently employing combinations of national and ethnic or religious subcategories, such as Iraqi- Arab-, or Suriani- (indicating Assyrian-Christian), Chaldean, and Kurdish. The majority of the respondents  felt that they belonged both to their culture of origin as well as to Swedish culture and society; about 50% clarified that this double sense of self was an integrated (relatively conflict-free) experience. Yet at least half of the respondents (50.5%) reported having been treated unfairly based on their ethnic background or lack of language skills.Acculturation outcomes were observed by asking about gender values, education, and family roles. A third of the sample responded that men make better political leaders than women . As to tFinally, both men and women perceived that their role in the family had changed “somewhat” in Sweden compared to how it was in Iraq.Our study results with this group of Iraqi individuals, who had lived longer in their new country than subjects in comparable studies, illuminated the role played by social and psychological determinants of mental health, both pre- and post-migration, as well as the association of self-evaluated health, resilience, and benign acculturation processes among them. The widespread, dynamic bicultural, to varying degrees, sense of identity in our sample as in other immigrants should be acknowledged in integration policies by providing space for the realization and interaction of both the original and the new host culture. Similarly our finding that women showed greater adaptability and acculturation, yet at the same time lower mental health, which highlights the stress of the refugee's acculturation, deserves being taken to heart in integration policies. The family remained the most important source of social support in the new country, while support from other sources deteriorated.A substantial proportion of the respondents did not receive either informational or emotional support from anyone. Combined with the fact that support from the authorities was generally perceived as very low, this finding indicates an unmet basic need and a challenge for Swedish society.In earlier studies, other scales than those that we applied were used to rate social support, which makes comparisons difficult. We note, however, that in two studies social support was found to be low for both asylum seekers and refugees in general, with lower figures for asylum seekers .N = 410) from a wide range of aspects. We did not aspire to cover the larger population of Iraqi refugees, who migrated at different time periods during the late 20th and early 21st centuries, but focused on a delimited population of Iraqis, who arrived soon after the year 2000. We hope the results might be useful in other contexts, as new refugee populations from other conflicted regions continue to face similar issues.There are some limitations to our study. The use of convenience sampling limits the representativity of our sample and the generalizability of our results: the observed high rates of self-perceived health, the low levels of PTSD as well as of aspects of resilience, compared to what was reported in studies of other refugee samples, may reflect a selection bias. But there are also arguments in favor of convenience sampling as appropriate for exploratory research in which new theoretical ideas and hypotheses may be generated Bryman, . Our aimAnother limitation was technical. The survey involved many questions and some complicated instruments, which may have resulted in lower reliability. An example of a disruptive constellation of questions was when we asked the respondents to select only one alternative response to one type of question and this was followed by questions with several response alternatives. There were indications in the material that this approach led to misunderstandings.The group of Iraqi individuals in this study, who had lived longer in their new country than subjects of comparable studies, showed relatively low levels of general mental health problems, including PTSD. Nevertheless, they remained vulnerable in some respects, notably with regard to individual and long-term psychological resilience.Unemployment was high among the participants, even after a long period of living in Sweden. Social networks outside the family were weak, and authorities were not perceived as supportive. Authorities therefore need to address the challenge of answering the unmet needs of informational and concrete support.Women evinced poor mental health in spite of signs of strong adaptation in other respects. Clinicians need to be aware of the risks and variations of psychosocial maladaptation and ill-health in refugees in general and women in particular.The post-migration situation and the refugee's ways of managing need to be better understood in order to avoid too schematic views of the acculturation process. Variations in illness perception point to the importance for clinicians to avoid stereotyping in the encounter with refugee patients. The exploration of the individual's social world and subjective perceptions is crucial. The cultural formulation interview in the DSM-5 is a supportive tool in that exploration (Lewis-Fernández et al., The gender differences found in our study should be viewed within a context of acculturation, where several determining single factors and patterns of interacting social and individual strengths and vulnerabilities play a central role. In a highly secularized society such as that in Sweden, with a strong individual goal-orientation and focus on self-reliance and gender equality, Iraqi women's comparatively strong ability to adapt to new situations and to evaluate themselves as hard-working members of Swedish society, may reflect—or have provided a basis for—a positive acculturation process. The same societal context may have been a greater challenge for the men. This difference may impact family acculturation processes in subsequent generations too.-It is important to provide women and men with practical resources and frameworks for self-fulfillment in education and work, at the same time as they are supported in using cultural coping mechanisms, such as religion and nature.-In the framework of social integration in work and education, caregivers need to be aware of the high prevalence of negative psychosocial and mental ill-health among women and of the differing needs for support in women and men.-Culturally and locally adapted social information and support by authorities, together with support to maintain links with and to form new social networks is important for integration of newcomers in society.cetrez@teol.uu.se.The datasets presented in this article are not readily available because by the time of the data collection, participants were not informed about the possibility of making data available to outside researchers. Requests to access the datasets should be directed to Önver Cetrez, The studies involving human participants were reviewed and approved by Swedish Ethical Review Authority. The patients/participants provided their written informed consent to participate in this study.ÖÇ, VD, MS, and MG contributed conception and design of the study. ÖÇ organized the database and wrote the first draft of the manuscript. LB performed the statistical analysis. VD, MS, DT, and LB wrote sections of the manuscript. ÖÇ, VD, MS, DT, and LB contributed to manuscript revision, read, and approved the submitted version. All authors contributed to the article and approved the submitted version.The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.


As for the SF-36 mental (MCS) and physical (PCS) component summary scores, probable sarcopenia, as well as depression and anxiety, remained associated with MCS (adjusted R2 = 0.518), and these three variables, together with age, were linked to PCS (adjusted R2 = 0.340). (4) Conclusions: Probable sarcopenia, but not confirmed or severe sarcopenia, was independently associated with poor HRQoL. More precisely, it was related to PCS and MCS, as well as to the physical role, general health, and social functioning of SF-36 domains.(1) Background: The aim of this study was to analyze the associations between severity of sarcopenia and health-related quality of life (HRQoL) among community-dwelling middle-aged and older adults. (2) Methods: A cross-sectional study involving 304 older-adult participants was used to assess the severity of sarcopenia by measuring muscle strength (handgrip dynamometer), muscle mass , and physical performance (Timed Up-and-Go test). The generic 36-item Short-Form Health Survey (SF-36) was used to evaluate HRQoL. Anxiety and depression  as well as age were considered as possible confounders. Probable sarcopenia was determined by low muscle strength; confirmed sarcopenia was defined by the presence of both low muscle strength and muscle mass; and severe sarcopenia was defined by low muscle strength and mass along with poor physical performance. (3) Results: The linear regression analysis showed that the presence of probable sarcopenia was associated with the SF-36 domains physical role (adjusted R Sarcopenia is defined as the generalized and progressive loss of skeletal muscle strength and mass, which can lead to adverse outcomes such as physical disability, reduced physical functions, and poor quality of life . AlthougSarcopenia has been associated with multiple adverse physical effects  and psyAll the previous factors, together with sarcopenia, may contribute to a decrease in quality of life to the extent that it is conditioned by the physical and mental state and symptoms of elderly individuals . Poor quFor all this, one of the main goals of healthcare efforts concerning the elderly is the maintenance or improvement of their quality of life, a trend that has sparked widespread international interest and is supported by many action plans addressing the consequences of aging .The objective of this study was to analyze the associations between the severity of sarcopenia and health-related quality of life (HRQL) in community-living older and middle-aged adults.This was a cross-sectional analytical study that involved a total of 304 elderly and middle-aged adults. It was approved by the Research Ethics Committee of the University of Jaén (TES 18/22 November) and carried out according to the Declaration of Helsinki, good clinical practices, and all applicable laws and regulations. Before the start of the study, all participants gave informed written consent.To be included in the study, participants had to be community-based outpatient adults aged 50 years or older, have the ability to understand and complete the questionnaires, and signed an informed consent form. All subjects who suffered from limitations in physical activity, a chronic or severe illness, or any neuropsychiatric disorder that could influence their responses to the questionnaires were excluded.Sarcopenia was defined following the guidelines published in 2019 by the European Working Group on Sarcopenia in Older People (EWGSOP-2) . ProbablMuscle strength (kg) was determined by an analogue handgrip dynamometer  following a previously described protocol . Measure2/resistance) + (3.825 × sex) − (0.071 × age) + 5.102]. Height was assessed in cm and resistance in ohms. Resistance depended on the water contained in the body, which has a constant proportion in muscle mass, since 73% of muscles are water. By relating this data to the age, sex and height of the individual, the muscle mass of the entire body could be calculated. The R represents the resistance of the tissues to the passage of an electric current. The resistance is proportional to the length of the body  and inversely proportional to the sectional area  [2). To determine low muscle mass, thresholds of 6.42 kg/m2 (women) and 8.87 kg/m2 (men) for the SMI were used [Muscle mass was assessed by bioelectrical impedance analysis . Skeletal muscle mass  was calculated using the following BIA equation [egments) . The Skeere used .Physical performance was assessed by gait speed through the Timed Up-and-Go (TUG) test . The resThe Hospital Anxiety and Depression Scale (HADS) was used to assess the participants’ level of depression and anxiety ,25. ThisThe SF-36 questionnaire was also completed by all participants. It is a widely used questionnaire to assess generic health-related quality of life , and thet test was used. Pearson’s correlation analysis was employed to evaluate associations of HRQoL with possible confounders . A stepwise linear regression model was used to determine independent associations. To evaluate the effect size coefficient of multiple determinations, adjusted R2 was used, which can be classified as follows: <0.02, insignificant; between 0.02 and 0.15, small; between 0.15 and 0.35, as medium; and >0.35, large [p < 0.05. Data analysis was carried out using the SPSS statistical package for social sciences for Windows .Continuous and categorical variables were expressed by means and standard deviations and by frequencies and percentages, respectively. Variable normality was assessed with the Kolmogorov–Smirnov test. To study possible individual differences in HRQoL as assessed by the SF-36 domains and component summaries scores (dependent variables) between groups according to the severity of sarcopenia (independent variables), a Student’s 5, large . ResultsIn total, 304 participants (83.88% women) took part in this study. Regarding the confounding variables, the analysis of the bivariate correlation  showed t2 = 0.523), and these three variables, together with sex and age, were independently related to PCS (adjusted R2 = 0.358). Depression and anxiety remained as independent predictors of a worse HRQoL in all domains except for vitality, where depression was the only associated factor (adjusted R2 = 0.231). In fact, these were the only factors associated with an emotional role (adjusted R2 = 0.212), and mental health (adjusted R2 = 0.582), and, along with higher age, were independently related to general health (adjusted R2 = 0.316). Together with other factors, the presence of probable sarcopenia was associated with the SF-36 domains physical functioning (adjusted R2 = 0.301), physical role (adjusted R2 = 0.186), pain (adjusted R2 = 0.191), and social functioning (adjusted R2 = 0.306).The linear regression analysis was employed to detect any variable that was independently associated with HRQoL . As for The purpose of this study was to analyze the association between sarcopenia and its levels of severity, anxiety, and depression on the one hand, and the health-related quality of life in older adults on the other. The main findings of the study showed that the probability of having sarcopenia is associated with a poorer quality of life. The SF-36 domains that displayed significant associations were PCS, MCS, physical role, general health, and social functioning. Probable sarcopenia was associated with HRQoL, which is a big step for primary care diagnosis, for example. Thus, from the first stage, the detection of sarcopenia can be carried out in a simple way, and could represent an important advance by establishing treatment early. Its increased severity would mean a worse quality of life, according to our results, but more studies are needed.The percentages of probable, confirmed, and severe sarcopenia varied across the studies. Hu et al.  reportedAs far as mood alterations are concerned, the results were similar to those described in a study carried out in Spain that analyzed two different cohorts of community-living groups over 60 years of age (2376 and 1911 participants) . In compIn this study, an association was found between the diagnosis of sarcopenia and the domains of physical function, the role-physical, pain, PCS, and MCS. Severe sarcopenia was associated with general health and social function. In our case, probable sarcopenia was associated with poorer quality of life except for the domains of general health, vitality, and emotional role. When a regression analysis was performed, the association with the role-physical, general health, and social function domains of SF-36 was maintained. Other authors have reported similar results, such as Kull et al. , who fouThe mean age of the participants was 64.92 ± 5.74 years and, despite the fact that no statistically significant differences were found between quality of life and the variables studied among the participants suffering from sarcopenia or sarcopenic obesity, the values were lower in those affected by the condition. These results were similar to those of Marques et al. , who useAs for anxiety and depression, our study revealed that they were associated with a worse HRQoL in all SF-36 domains and component summaries. Depression and anxiety remained independent predictors of poor HRQoL in all domains except for the emotional role, where depression was the only associated factor. Furthermore, depression and anxiety were the only variables independently associated to pain and vitality. With similar results, a longitudinal study  looking Older age only appeared to be related to a worse HRQoL in physical functioning, general health, vitality, and PCS. In the regression analysis, age was associated with physical functioning, mental health, and general health. In the study by Cho et al. , sarcopeSome sex differences were revealed by our study, as women had a better HRQoL in the physical role, physical function, and mental health domains of the SF-36 questionnaire and sex was revealed to be related to mental and general health. Silva Neto et al.  found, iOur study suffered from some limitations that should be taken into consideration. Densitometry could not be used to evaluate the muscle mass although BIA has been recommended for this purpose . FurtherThe findings of this study suggest that, in community-dwelling middle-aged and older adults, probable sarcopenia, but not confirmed or severe sarcopenia, was independently associated with a poor HRQoL. Our results showed that probable sarcopenia, anxiety and depression were associated with the MCS summary component, and these three, together with sex and age, were independently associated with PCS. Probable sarcopenia was also associated with physical functioning, physical role, pain, and social functioning. Depression and anxiety were independent predictors of a worse HRQoL in all domains except for vitality, where depression was the only associated factor. They were also associated with emotional role, and mental health and, along with higher age, were independently related to general health. These findings allowed us to suggest that, considering its effects on quality of life, diagnoses of probable sarcopenia (its first degree) should be considered as an important warning regarding programs for the prevention and treatment of this condition among community-dwelling middle-aged and older adults.


The current study investigates the possibility that athletes have more parallel ADHD symptoms than non-athletes. High-level youth sport athletes were compared with non-athletes in leisure time  and in the school in ADHD symptoms. Athletes and students were evaluated by a trained psychotherapist using Adult ADHD Self-Report Scale (ASRS) on activities at school and during activities in leisure/sports time. They also filled in the Autism Spectrum Questionnaire (AQ) as a self-report assessment. Results showed significant differences in ASRS-scores for athletes in school and in their sport, with high scores in school and low scores in sport. No differences were found in AQ between the groups. The findings indicate that many athletes might display a cognitive profile of parallel of ADHD criteria. Future research needs to further investigate potential benefits of the cognitive profile in athletes and how they handle different contexts including sport and school settings. Attention deficit hyperactivity disorder (ADHD) is considered a disorder that can cause behavioral and emotional problems for the individual . StudiesAttention deficit hyperactivity disorder involves distractibility, and difficulty with attention, impulse control, and activity control, in reference to what the situation requires . For an An interesting theory is Hartmans anthropological/sociological theory where ADHD is described as hunter in a farmer society. In this model, it is stated that ADHD traits of hunter–gatherers would have been environmentally advantageous. This includes hyperactivity, thus being energetic and tireless behaviour, and having high impulsivity, and the ability to change the strategy quickly. Accordingly, the very attributes that render ADHD individuals good “hunters” , are less compatible with modern, daily demands of the “farmer society.” The potentially advantageous traits from hunters are easily translated into sports where being energetic, monitoring the field of play and being ready to take action are effective in many situations and types of sports.Difficulties in focusing and keeping attention have been well studied in ADHD. Another area that has been researched is selective attention although few studies have considered how selective attention can be an advantage, i.e., in terms of hyper focusing, which has been reported as a phenomenon of ADHD ,18. HypeFurthermore, studies have shown that reward, in neurofeedback, has a positive influence on ADHD and, furthermore, a positive effect on endurance, which is a difficulty for ADHD children . In sporResearch in ADHD in athletes has mainly focused on the negative effects of ADHD. This includes studies reporting an increased risk of injury , and higInterestingly, it has been suggested that ADHD may be more common in competitive athletes than in the general population ,38. In aIn conclusion, some common symptoms of ADHD may enhance athletic performance. Many children with ADHD report to ‘hyperfocus’ on their enjoyable sporting activities without being distracted . It has The aim of the current study was to compare athletes to non-athletes, both of school-going age, in terms of Adult ADHD Self-Report Scale (ASRS) criteria , i.e., AMage 16.94 years, age range 16–19 years), were recruited from two high schools in Sweden, one group being athletes  and another, non-athletes . The athlete group were enrolled in the Swedish national sports talent program  and intensively involved in their sport and are considered among the most talented in the country and are not having any diagnosis nor do they have disability service at the sport academies. They competed at club/local (11.2%), regional (23.4%), national (52.3%), and international (13.1%) level and represented a variety of sports including team sports  and individual sports . The athletes invested 12.20 (standard deviation (SD) 4.46; range 2–24) hours per week in training and competition and had participated in sport for a median of 9.29  years. Both groups were matched in age and school programs, thus studying at the same theoretical educational program.A total of 200 students, 112 female and 88 male  was selected because several studies have shown that Autism Spectrum Disorder (ASD) symptoms coexist in individuals with ADHD , especiaThe AQ is one of the most widely used measures of ASD and has been found to be predictive of diagnosis of ASD in a clinical setting . QuestioThe Regional Ethics Review Board in Uppsala (Dnr. 2016/451) approved the study and after informed consent participants were interviewed by a trained psychotherapist with long experience and good knowledge of ADHD and autism spectrum disorder (ASD). In the interview, they were estimated on ASRS regarding school activity and leisure time/their sport activity time. The athlete themselves also filled in the AQ. The instruments were collected by the interviewer at the end of the interview. All text on the instruments about diagnoses was excluded and all questions were answered without mentioning of ADHD and ASD. The purpose of the evaluations was to identify parallel criteria between the two instruments, and not to identify a diagnosis. The instruments were named 1 and 2, in order for the students to be less influenced by their own preconceived opinion about diagnoses.Data analysis was carried out to compare the two groups in terms of ASRS criteria, in leisure time and in the school environment. The processing of data was conducted using IBM SPSS Statistics for Windows, Version 24.0.  A two-way analysis of variance (ANOVA) F-test was used to analyse differences between the groups (athletes vs. non-athletes) and pair-wise post-hoc comparisons with Tukey’s HSD test was used to compare the sport athletes during sports activities and school. Data were screened for normality and homogeneity of variances was tested using the Levene statistic.p > 0.05) differences between club/local, regional, national, or international levels, in terms of hours invested in training and competitions.Means and standard deviation are shown in p < 0.001), as well as within-group differences in school- and leisure activities  = 335.7, p < 0.001). Also, the interaction term for ADHD criteria vs. school- and leisure/sport activities was significant  = 365.9, p < 0.001).Two-way ANOVA (split-plot design) showed statistically significant between-group differences in ADHD criteria  = 157.3, p < 0.001) difference between the groups during school activities, but not during leisure/sport activities (p > 0.05), with higher scores for the athlete group (see p < 0.001) differences between the activities, i.e., leisure/sports activities and school activities [Cohen’s d = 2.19].Pair-wise post-hoc comparisons with Tukey’s HSD test showed the significant  was large . For theIn Hartmann’s sociological/anthropological theory, the ADHD cognitive profile is described as a hunter in a farming society  and baseSeveral studies indicate that physical activity and environmental factors have a positive effect on inattention and hyperactivity, which are considered core symptoms of ADHD , and alsChildren/adolescents involved in sport often demonstrate discipline and commitment , and eviBased on the discussion above, a question for future research would be whether we can learn from these studies and, instead of over diagnosing and overtreating children/adults ,60, lookThis study has focused on investigating a cognitive profile of ADHD in young athletes and how it differs in different contexts . There is an evident need for more studies concerning young individuals with the cognitive profile of ADHD and how they best develop a functional daily life in school and in leisure time. There is a need to learn more about how sport, with its physical exercise and stimulation, structure, consistent patterns of behavior and the positive reinforcement, can be useful in other areas such as school ,64.Looking at the strength of this study, although more comprehensive evaluation has been suggested for athletes seeking help , researcIn conclusion, in this study, we report that ADHD criteria are highly presented in the athlete group in the school environment and very low during leisure time compared to the non-athlete group. This supports the suggestion that ADHD symptoms might be more prevalent in an athlete population , but impThe ADHD criteria might turn into an advantage rather than a disadvantage for the athletes in their sport achievement . Based o


Mental disorders are increasing worldwide. Previous research has reported an association between mental health and facial expressions. Face-to-face communication, specifically, is majorly affected when wearing face masks for a long time because of the COVID-19 pandemic. However, there have been no systematic reviews of facial muscles exercise intervention studies for mental health. Thus, evidence of their effect on mental health is unclear. This review aimed to evaluate the current evidence of the effectiveness of voluntary facial muscles exercise to improve some parameters of mental health. We implemented a systematic review of experimental studies . Of the 61,096 references screened, seven studies reported that facial muscles exercise may help to improve some parameters of mental health. Moreover, the study quality was assessed, and we extracted sub outcomes for mental health. Non-coherent results of seven experimental studies were included in this review. Voluntary facial muscles exercise may help improve depressive symptoms, mood, and reduce the level of chronic stress. However, due to the low quality of analyzed studies, further studies are needed to confirm the mental health benefits of a facial muscles exercise program. The COVID-19 outbreak is stressful for people and communities in the world. Specifically, face-to-face communication is majorly affected by wearing face masks for a long time because of the COVID-19 pandemic. A high prevalence of psychological morbidities has been reported among individuals who are directly or vicariously exposed to life-threatening situations ,3.Mental disorders are increasing worldwide not only due to the COVID-19 but also to other causes. Between 1990 and 2013, the number of people with depression and/or anxiety increased by nearly 50%, from 416 million to 615 million. In 2016, close to 10% of the world’s population was affected, and mental disorders accounted for 30% of the global, nonfatal disease burden [The facial feedback hypothesis ,8 statesFacial movements are unique and present considerable differences compared with the rest of the human motor repertoire, in particular with movements of the upper limbs . The cenThe aim of this systematic review was to evaluate the current evidence of the effectiveness of voluntary facial muscles exercise on improving mental health.This systematic review was conducted according to the Preferred Reporting Items for Systematic Reviews and Meta-Analysis (PRISMA) statement . A predeTwo investigators (RO and TM) independently searched for eligible studies in PubMed and Ichu-shi Web, which is a Japanese journal database  publisheStudies fulfilling the following selection criteria were included in the systematic review: (1) study design and language: randomized controlled trials (RCT), quasi-experimental studies, and before and after studies in English language publications; (2) population: people with or without clinical diagnoses of a physical or mental illness; (3) primary outcome variables: the effectiveness of facial exercises for mental health.Studies were excluded based on the following criteria: (1) studies that only had abstracts; (2) studies where the outcome variable was not reported; (3) studies that tested smiling and laughing.Two reviewers extracted the data independently. After removing redundant articles, titles, and abstracts, full-text articles were investigated. We extracted the following data: study design, study period, study site, study setting , inclusion/exclusion criteria of each study, information source, type of facial exercises (exercise or training with massage or breathing), and general background. The outcome variables were extracted into predesigned data collection forms. We verified data accuracy by comparing the collection forms of each investigator; any discrepancies were resolved through discussion together with the other author (KM).Due to the high degree of heterogeneity relating to the study outcome measures, study populations, and intervention length/intensity, a meta-analysis was not performed.A PRISMA flow diagram for the search process and results .Of the 61,096 references screened, seven studies reported the effectiveness of facial exercises for mental health. These 61,096 articles were screened after excluding the duplicates. After reading the titles and abstracts, 61,057 articles were excluded. Then, 20 articles were excluded for lack of facial exercise, and a further 10 articles were excluded after reading the full texts for eligibility. Seven studies   evaluateOverall, the evidence generated by the studies involved was weak. All studies had relatively small sample sizes, and the risk of selection bias was unclear but possible. And all of the studies included were also affected by a variety of other potential biases, as they provided little information about the in-depth content of the intervention, participant compliance, or adverse events.p = 0.00003). In the study of Konecny et al. (2011) [p < 0.001). We showed that the change in the GHQ-12 scores was significant in the IG (p = 0.003) [In Uchida and Arai’s study (2010) , the SDS. (2011) , signifi= 0.003) .p < 0.00).Chang et al. (2013)  assessedTwo studies ,34 reporp = 0.004), and one of the subscales of the CHS, Humor Creativity (HC), also showed a significant increase for the IG from 39.59 (± 11.46) to 44.38 (± 12.30) after facial exercise (p = 0.003). The ANCOVA results showed a significant influence of facial exercise on CHS (p = 0.01) and HC (p = 0.01). There were no significant changes in the CG for any of the psychological measures.In the study of Chang et al. (2013) , the expp = 0.001) in the IG. The ANCOVA results showed no significant changes (p = 0.058).In the study of Chang et al. , cortisoThe study of Nomura et al. (2007) reported responses such as “I relaxed the stiffness of the face after facial exercise”, “I wanted to do facial exercise a little longer”; however, on the other hand, negative responses, such as “I can’t feel the effects of facial exercise”, were also reported . In our This systematic review was performed to compare the effectiveness of the facial muscles exercise on mental health. There was a significant impact on the SDS, BDI-Ⅱ, CHS, CES-D, GHQ-12, and Face Scale. However, with the BJSQ, Self-Restricted Type Behavior Traits Scale, Emotional Support Network Scale, RSE, SPST-60, and PGC not statistically significant changes were noted. As a result, we extracted the sub-outcomes of the improvements to depression, mood, stress, and humor, and a decrease in cortisol levels. Improvement by the scales  in the research extracted in this systematic review suggested facial muscles exercise have an effect on depressive symptoms. These findings of voluntary movements are similar to the previous study that showed passive movements have an effect on mental health .Future facial muscles exercise studies should include more participants and consider measuring mental health as a major consequence. In addition, it is important to coordinate the duration and intensity of the intervention with the same program as in previous studies to continue the study. To minimize the effects of performance bias, future studies should also consider the use of objective physiological measurements related to mental health. Studies should also use a follow-up period of up to six months to confirm the sustainability of the benefits to mental health. Future studies should consider incorporating a monitoring system and using participant interviews to investigate the participant’s experience, as the review did not report information on adverse effects. It also requires clear information about the specific content of the facial muscles exercise group  so that other researchers can faithfully reproduce the intervention in future studies. In addition, this information should include a detailed description of each session content, optimal group size, number of sessions, session frequency, length of time for each session, and possible flexibility or steps in facilitating the group.Our review had some limitations. First, studies without standardized results measurements and papers published outside of English were excluded. Second, we adopted strict criteria for “facial muscles movement” to increase the comparability of the study. As a result, we excluded studies that described the interventions such as “laughter yoga” or “laughter therapy”, but some of these interventions may have resembled facial muscles movements. In addition, a meta-analysis could not be performed due to the small number of studies and the large heterogeneity associated with the study population, facial muscles exercise program, and measured results. In addition, this conclusion should be interpreted with caution, as the systematic review included a number of low-quality studies  and studies at high risk of bias.Therefore, although a summary of these studies suggests the facial muscles exercise improve some parameters of mental health, the methodological shortcomings of these studies make it hard to assert the effects on mental health. As some of the included studies in this systematic review used nonrandomized study designs, had very small sample sizes, or were otherwise at high risk of bias, many of these results could be spurious findings or other statistical artefacts, such as regression to the mean or nonspecific factors. For the future, it is important to continue study of high quality.As far as we know, this is the first review of the effects of facial muscles exercise on mental health. The results of this systematic review suggested that voluntary facial muscles exercise may help improve depressive symptoms, mood, and reduce level of chronic stress. However, due to the lack of available evidence, it was difficult to determine whether facial muscles exercise was effected on mental health. Further studies could implement to evaluate the effects of other mental health . It is also necessary to consider positive mental health effects such as self-esteem and well-being. Facial muscles exercise showed potential as a treatment, however, currently there is insufficient evidence to support its effectiveness in improving mental health compared with other group-based facial movement interventions. In the future, continued research, which is rigorously designed, and pile up evidence of high quality are required.


This study uses the partial least squares structural equation modeling (PLS-SEM) approach to analyse the data and to confirm the hypothesis proposed in the research model. The empirical findings show that trust in social commerce influences behavioural intention. In addition, trust in the SC platform, the SC community, and online payment influence the trust in SC. Likewise, SA and trust in the SC platform have a significant relationship with trust in sellers, the SC community, and online payment. Finally, this study discusses the theoretical contributions and practical insights to several limitations and suggests directions for future research.With the rapid increase in social media users and netizens globally, the proclivity for online shopping using social commerce (SC) platforms cannot be ignored. Trust has been recognised as a constant challenge in the context of social commerce due to the lack of face-to-face interaction. Therefore, there is a dire need to enhance the trust of consumers in social commerce platforms. However, the research in the formation of trust in social commerce and antecedents remains limited. In addition, the existing SC research failed to include its multidimensional view to investigate user behaviour. This study fills this gap and extends existing knowledge by developing a model exploring the antecedents of trust in social commerce. Drawing upon the social-technical theory and trust lens, this study attempts to identify the role of (i) structural assurance (SA) and SC platforms as an institution-based trust, (ii) trust in sellers and trust in SC community as trusting beliefs, and (iii) trust in online payment as a cognitive trust on trust and intention of the social commerce. This research employs a dataset ( Social media sites such as Instagram, Twitter, and Facebook have become ubiquitous, creating possibilities for electronic business models usually known as social commerce (SC). Social commerce provides new opportunities for incorporating social inputs into financial operations . Social Progressing to social commerce from e-commerce has helped in the role reversal of sellers and buyers, where the bargaining power is now in the hands of the latter . Social There might be a shift of trust to social commerce from e-commerce . Trust, Moreover, social commerce decision making that is related to purchases and transactions is greatly affected by researching trust models and influences that are becoming imperative . HoweverTrust is an important factor in the purchasing behaviour of customers. Thus, trust is a multifaceted concept in e-commerce that includes trust in the supplier, website, and community members . TrustinAccording to our in-depth research, the study done by RQ. In social commerce, which dimension of trust is more linked with customer behaviour?On the basis of social-technical theory , this stThis paper is structured in the following way. First, an outline of social commerce, the social-technical theory, and trust is provided. Second, social commerce trust formation is presented. The research model and hypothesis formulation are discussed in the fourth section. Following that, the research technique used in this study and the data analysis outcomes are explained. Finally, we discuss the implications and limitations of the study, along with future research prospects.via websites and online communities. Social commerce is a term used to define an e-commerce practice involving social media and social networks  trust in website, (2) trust in network operator, and (3) trust in community members . Howeverg intent . This mog intent .Trust in social commerce or SC trust is defined as the user’s beliefs that SC systems are reliable, and a feeling of being protected and being concerned in the online purchasing transaction . The phrAs per the model of trust-based acceptance by Trust in the Internet and SC platforms is the pre-existing trust based on institutions . InstituThe critical components of people supporting social interactions and relationships in social commerce are the sellers, online community members, and features . AccordiThe idea of technology has typically been characterised as a component of trust . AccordiFirst, based on the SC studies that have evaluated trust, social media offers fundamentals for the technological competence of social commerce . FurtherFinally, SA, or trust in the Internet, has been recognised as a critical characteristic of technology in various online situations . It has Based on the social-technical theory and trust lenses, the proposed research model was developed as shown in The suggested model analyses the relation between trust in the SC platform and the Internet. According to cognitive dissonance theory , individPrior IT adoption research discovered a tangible link between SA and trust . MoreoveH1: Structural assurance has an influence on trust in social commerce.H2: Structural assurance has an influence on trust in social commerce platforms.H3: Trust in SC platforms has an influence on trust in social commerce.Prior trust studies have shown that SA of the platform of the context has a more significant effect on trusting views . MoreoveH4: Structural assurance has an influence on trust in sellers.H5: Structural assurance has an influence on trust in the social commerce community.H6: Structural assurance has an influence on trust in online payment.The safety, security, and guarantees provided by the e-commerce site or place of business of the seller form the basis of trust . When cuH7: Trust in SC platforms has an influence on trust in sellers.via the members and features of the online community on social commerce platforms and Internet technologies . Social networks sites (SNS), specifically, Facebook and Instagram users, were the target population. There are several reasons to choose this sample set. First, SNS is very popular, with millions of actual and potential SC users . Second,Facebook and Instagram are commonly used in almost every country in various languages. Moreover, data collection in different countries and cultures is challenging due to the language and cultural differences . Therefovia advertising. Therefore, this study employs a banner advertisement placed through Facebook Adv and Instagram Adv as a technique to recruit subjects  did not complete the questionnaire and exited the survey at some point before completion, and only 585 individuals completed the questionnaire. Furthermore, knowing whether an individual has a prior online shopping experience with SC platforms, the filtering question of “Have you been involved in social commerce  before?” was asked . Among 5The measurement items were adopted from previous well-known researches to sustain construct and content validity see . Gefen eA priori procedural remedy by This study implemented some methods to assess and mitigate the influence of common method bias (CMB), as recommended by t-test at a 5% significance level was assessed to compare these two sub-sample groups  between the constructs  constructs , two hierarchical (second-order) constructs . Previous studies on trust in online contexts  and sociTo verify the reliability of the measurement model, Composite reliability (CR), Rho-A, and Cronbach’s alpha (α) values were measured, as shown in In addition, a heterotrait-monotrait (HTMT) criterion test was assessed to test the discriminant validity . As presThis study estimated the measurement of higher-order constructs, that is, the second-order trust in the SC platform and trust in sellers. This study followed the repeated indicator approach to test the measurement proprieties of higher-order constructs [it has also been familiarised by a term called hierarchical component model (HCM)] . Its usap < 0.001. The study confirmed that all loadings of the first-order latent factors on the second-order constructs (trust in SC platform and trust in Sellers) were above 0.70  has a positive impact on SC trust. Therefore, H1 was not supported while H3 was supported. In addition, the proposed influence of SA on the trust in SC platform (H2)  was significant. SA was positively related to trust in sellers , trust in SC community members , and online payment  . Moreover, H7, H8, and H9 were all supported with the positive relationships found to be significant between trust in SC platform and trust in sellers , trust in community members , and online payment . The positive associations between trust in SC community  and online payment , and SC trust were significant, whereas the relationships between trust in sellers and SC trust (β = 0.16) were not significant. Thus H11 and H12 were supported, whereas H10 was not accepted. Finally, the hypothesised relationships related to the effect of SC trust on behavioural intention (H13)  were supported.Our findings suggest that the institution-based trust, SA (β = 0.031), has no influence on SC trust, whereas trust in SC platform , Trust in SC platform (TSCP) , Trust in SC community (TSCC) , and Trust in online Payment (CTOP)  on behavioural intention. Nevertheless, TSC does not mediate the trust in the seller on behavioural intention. Therefore, these findings indicate that whereas trust has an indirect effect on behavioural intention through most of its dimensions, it has no indirect impact through other factors.The mediation effect of SC trust on the relationship between the dimensions of identified trust dimensions and behavioural intention was also tested. As this study does not approve of direct correlations between trust dimensions and behavioural intention, examining the mediating and indirect effects is appropriate . As show(R2) to confirm whether the model achieved acceptable goodness of fit as illustrated; there was no other overall parametric criterion in PLS (This study relied on Explained Variance n in PLS . The ovef2) test for first-order constructs in the model. The sizes of effects are small, medium, and large with f2 values of 0.02, 0.15, and 0.35, respectively (f2 effect size on the trust in seller was largest for trust in SC platform (1.73) and lowest for SA (0.046), indicating high and medium effects, respectively. Similarly, the effect size on the online payment was largest for trust in the SC platform (0.442) and lowest for SA (0.043), indicating high and medium effects, respectively. Moreover, the f2 effect size on the trust in the SC community was largest for trust in the SC platform (0.296) and lowest for SA (0.098), indicating medium and small effects, respectively.This study also adopts ectively . The effThis study evaluated further testation in this regard and rigorously determined the implications of predictive relevance (Q2). The predictive relevance, or the predictive sample reuse technique, is vital for testing the predictive validity of a complex model. It also helps measure how well-examined values are replicated by the model . A blindFurthermore, the PLS predicted algorithm was assessed to measure the predictive power . The pret-value for endogenous variables, as shown in This study has linked the control variables to all the endogenous variables in the model as recommended by Previous research argues that the online environment is always impregnated with a sense of risk for users to opt for online activities and transactions . Risk isThe results confirmed that trust in SC was a significant determining factor for social commerce. It explained 46% of the variance in behavioural intention. This finding aligns with SC studies that revealed the critical role and effect of trust in SC . The resTo confirm the reliability of an employing institution on SC, this study revealed that institution-based trust, i.e., SA and trust in the SC platform, is a salient antecedent to SC trust. Remarkably, there is no significant relationship between SA and SC trust. This result contradicts the findings of previous studies . The posThis study showed that the second-order trust in the SC platform was reflected by the benevolence (β = 0.876), competence (β = 0.896), and integrity (β = 0.822) of the SC platform which explained 61% of the variance in trust in SC platform. The significant loadings of the three perceptions indicate that all of them hold capacity for trust in the SC platform. The results found out that trust in the SC platform has a highly significant effect on SC trust. This finding is consistent with recent studies in which trust in the SC platforms, such as social media and e-commerce sites, had played a direct role in SC . In addiThe second-order trust in seller analysis indicated that the trust in seller factor had three significant facets: benevolence (β = 0.815), competence (β = 0.904), and integrity (β = 0.870). Surprisingly, trust in sellers was not found to have an effect on SC trust. This discovery leads to a conflict with previous studies that shaped the trust of the consumer in online sellers . This fiTrust in SC community members was found to be significantly affecting SC trust. This finding supports previous results in the literature . MoreoveThis study confirms that demographic factors are not necessary to establish trust in social commerce. Well-educated gender and age groups were validated to have no confounding effect on trust in SC. This finding has provided a validation of previous research . The emeThis study provides several theoretical contributions and implications. First, this study offers a new conceptualisation of SC trust and demonstrates its significance by investigating trust factors and the relationships between its related antecedents, which has been limited in existing literature . Our finSecond, this study contributes to and adopts the social-technical theory in the SC context. It also shows that both technological and social facets play essential roles in building trust in SC. A study by Third, this study enhances our understanding of trust formation in SC. Specifically, the direct effects of different trust factors were explored and empirically tested. Different trust factors have been addressed in SC literature . HoweverFinally, this study does not emphasise a specific SC platform distinct from prior research that focussed on specific SC websites and addressed the limited setting e.g., . In addiThis study provides an essential practical insight on the significance of building institution-based trust, as there is limited SC research on an institution-based trust . Our empMoreover, our findings show that cognitive trust in online payment significantly influences trust in SC. Therefore, SC platform providers should ensure that SC users feel secure, incorporate payment features, and contribute to the rise of consistency of different payments methods and services to point out the technical faults during the payment transaction processes. Careful investigation and elimination of important related issues, such as offering service warranty and ensuring full refund for incomplete transactions could enhance the trust and reduce the risk of the SC users.Finally, education level significantly influences behavioural intention and some trust constructs such as trust in the SC platform and community members. Therefore, this study suggests that it is not suitable for SC providers and operators to apply a “one size for all” strategy to enhance the levels of trust . DiffereThis study has a number of limitations that could be further addressed in future research. First, trust in the SC platform was conceptualised and was tested through the limited dimensions of SC platforms . This study had a shortcoming of differentiating trust issues in various SC platforms. Different SC platforms, such as e-commerce websites, social media platforms, and SC mobile applications, could be tested separately to investigate their effects on SC trust and behavioural intention. Second, trust in sellers was not found to be significant on trust in SC. This possibly reflected the limited assessment of this factor which was only evaluated concerning the integrity and reliability of the sellers. Incorporating and examining more factors toward trust in sellers, such as information technology affordance  and symbFinally, this study evaluated and confirmed the best fit of the research model using a single SEM-PLS analysis method. Future studies may confirm the model validity and predict the performance of the variables using a dual-approach analysis employing machine learning tools such as artificial neural networks (ANN). Dual-approach (PLS_ANN) analysis has been recently suggested in social commerce  and infoN = 406) from three different countries, the empirical results contribute to theory and practice by explaining the relationships identified in the model. The findings of this study enhance our understanding of SC trust and open new debate in social commerce research.Due to the increased number of social commerce users, existing researches have been conducted to consider the consumer behaviour on different SC websites. However, research paid little attention to the investigation of multi-facets trust attributes in social commerce. Hence, this study developed a research model based on social-technical theory and identified different trust facets to examine the importance of trust dimensions in social commerce. Using online surveys and data (The raw data supporting the conclusions of this article will be made available by the authors, without undue reservation.The studies involving human participants were reviewed and approved by the Committee of Health Research Ethics, Deanship of Scientific Research, Qassim University. The patients/participants provided their written informed consent to participate in this study.AA was the principal investigator of the study, conceptualization to the data analysis, and conducted the experiments.The author declares 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.