The effects of having a child with Autism Spectrum Disorder (ASD) on parents are multifaceted and pervasive. While ample evidence has been provided that these families are under severe stress, there are still several knowledge gaps and unresolved questions.This study aimed at quantifying the subjective and objective burden of ASD in mothers and fathers, and at improving the understanding of the interplay between parental burden, child’s characteristics, and parents’ coping resources and strategies.The parents of 359 children/adolescents with ASD were compared to parents of age-matched patients with Down syndrome (N=145) and Type 1 diabetes mellitus (N=155). Child’s clinical characteristics and parents’ caregiving burden, psychological distress, coping resources and strategies were assessed.The parents of children with ASD reported higher objective and subjective burden, more frequent psychological distress, lower social support. Mothers reported greater subjective burden than fathers. Structural equation modeling showed that the most consistent positive and negative predictors of objective and subjective burden were ASD symptom severity and social support, respectively. Other positive predictors were engagement, distraction and disengagement coping, intellectual disability, and adaptive functioning. Other negative predictors were spiritual wellbeing and hardiness. Some effects were indirect through social support and coping strategies.This study confirmed that parents of children with ASD carry a huge caregiving burden, and added to our understanding of the factors associated with burden. The findings may help inform the design of effective interventions aimed at reducing burden among the parents of children with ASD. A recenThe effects of having a child with ASD on parents and families are, like the disorder itself, multifaceted and pervasive. Meeting the high care demands of affected children requires much time, effort and patience. Caring for children with ASD is challenging due to the severity and chronicity of ASD, their extensive developmental and physical comorbidities, and the difficulties of health services in making widely available the integrated and intensive interventions needed by persons with ASD . The huge.g., disturbed family relationships; constraints in social, leisure and work activities; financial difficulties), and subjective burden, which refers to caregivers’ psychological reactions  , we employed the Satorra-Bentler [2) and standard error, which takes into account the non-normal distribution of the data (Mplus estimator = MLM: Maximum Likelihood estimation with Satorra-Bentler corrections). As a sensitivity test, we also ran some of the models using the WLS estimator. As the parameter estimates were nearly identical, we present the results obtained using the MLM estimator.Whereas there has been considerable debate in the literature concerning the use of maximum likelihood estimation (ML) with ordinally-scaled variables treated as continuous , differe-Bentler  scaled c2χ likelihood ratio statistic was supplemented with other indices of model fit, such as the Comparative Fit Index (CFI) and the Root Mean Square Error of Approximation (RMSEA) with associated 95% confidence interval. We accepted CFI values greater than .95 and RMSEA values lower than .08 [Because the chi-square is highly sensitive to sample size, the SBthan .08 .To investigate mediation, we used the asymmetric confidence interval method to formally test the significance of indirect effects . The crii.e., p< .05), and constrained to zero non-significant paths if this did not decrease model fit (both for main variables and covariates), In doing so, we followed a “one-step” procedure aimed at decreasing the risk of capitalizing on chance. First, we estimated the model; then, we determined which parameters were above the threshold of statistical significance (p = .05); finally, in a single step, we fixed all parameters above this threshold to zero. As the difference between two scaled chi-squares for nested models is not distributed as a chi-square, the tenability of the constraints imposed for testing measurement invariance was examined with the scaled difference chi-square (SB-DCHI) [To be parsimonious and increase the subject/parameters ratio, we maintained in the model only significant paths (SB-DCHI) .33.11.Overall, a total of 644 mothers and 536 fathers, belonging to 659 families, were involved in the study. On average, they were in their forties and were well educated, as most of them had senior high school education or higher; the majority of parents were employed in paid work, and only a few were unmarried, separated, or divorced. For 521 families , both parents took part in the study, while for 123  and 15  families only the mother or father was involved, respectively. Parents’ sociodemographic characteristics are detailed in Table 2 and 3, respectively.A total of 659 children took part in the study; 359 were affected by ASD, 145 by DS and 155 by T1DM. As expected given the epidemiology of ASD, males were markedly over-represented in the ASD group, while the gender distribution was more balanced in the T1DM group and especially the DS group. Most children had one or more siblings, and only very few lived in a single-parent family. Patients’ sociodemographic and clinical characteristics are shown in detail in Tables 3.23.2.14 summarizes the mean scores on the FPQ and GHQ-12 by group. The FPQ was completed by all fathers and by all mothers, except two (99.7%). The parents of children with ASD reported significantly higher levels of both objective and subjective burden than the parents of children with DS or T1DM. Parents of children with ASD displayed higher scores on all the items pertaining to these scales, which suggests that their greater burden was not linked to specific parenting experiences. Also, the adverse impact on other children and parental work was significantly greater in the families with a child affected by ASD than in the families with a child affected by DS or T1DM. Moreover, child health-related expenses were markedly higher in the families with a child affected by ASD than in the families with a child affected by T1DM and, to a less marked but still significant extent, the families with a child affected by DS.Table All except a few parents  completed the GHQ-12. Significant depressive and anxiety symptoms were found in a high proportion of parents of children with ASD, as 113 (33.0%) of 342 mothers and 85 (29.9%) of 284 fathers scored above the threshold for probable psychiatric caseness on the GHQ-12. As compared with the ASD group, the proportion of participants with significant depressive and anxiety symptoms was lower among mothers  and fathers  of children with DS. The difference is significant for both mothers and fathers after adjustment for age and child’s age but loses significance in mothers after adjusting also for child’s sex, due to the absence of between-group differences in mothers of female children. The parents of children with T1DM occupied an intermediate position  with no significant differences from the two other groups.3.2.2In the families where both parents took part in the study, the ratings of both subjective and objective burden were found to be moderately to strongly correlated between mothers and fathers . The severity of symptoms of depression and anxiety as expressed by the GHQ-12 total score, too, showed a significant, though lower, correlation between mothers and fathers . vs. 12.76±4.11; p=0.008), while the difference fell short of statistical significance in families of children with DS  and T1DM . Objective burden did not significantly differ between mothers and fathers either in families of children with ASD  or with DS  or T1DM . Mothers and fathers did not differ with regard to the severity of depressive and anxiety symptoms, as in all parent groups the proportion of mothers scoring above the threshold for probable psychiatric caseness on the GHQ-12 did not significantly differ from the proportion of fathers  and there was no significant difference between mothers and fathers in GHQ-12 mean score .Regarding the between-gender comparison, subjective burden was found to be significantly higher in mothers as compared with fathers in families of children with ASD  and observer . Below, we describe the major results separately for type of burden and observer.The mediational model was fitted in a single step in all groups simultaneously, as a multiple-group structural equation modeling, separately for type of burden (3.4.13.4.1.12χ(172) = 191.27, p = .15, CFI = .99, TLI = .98, RMSEA = .023 , SRMR = .059. Fig. (1), Panel A presents model estimates obtained in the mothers of children with ASD. The objective burden was significantly and positively predicted by engagement and disengagement coping, and negatively predicted by social support that was the stronger direct predictor. In turn, engagement coping was significantly and negatively predicted by hardiness and significantly and negatively predicted by the child’s adaptive functioning; disengagement coping by spiritual wellbeing; distraction and cognitive reframing coping; perceived social support by hardiness and spiritual wellbeing. There were significant total indirect effects on objective burden of: (1) hardiness trough engagement coping  and perceived social support ; (2) of spiritual wellbeing through disengagement coping , and through social support . The indirect effect of adaptive functioning on objective burden through engagement coping was instead not significant . Significant covariate effects were those of maternal age on disengagement coping , of child gender on reframing coping , and of child’s age on global clinical severity , and global functioning .The multiple group mediational model for mothers fitted the data well: 1), Panel C. As it can be seen, only a direct effect of perceived social support on the objective burden, and of global clinical severity on engagement coping were found. No indirect effects were found. Significant covariate effects were those of maternal age  and child’s age  on objective burden, of maternal age  on global functioning, and of child’s age  on adaptive functioning.Results for mothers of children with T1DM are presented in Fig. (1), Panel E. In this case, we found a significant direct and positive path linking engagement coping to objective burden, and a negative direct path linking perceived social support to objective burden. Moreover, there were significant positive predictions of engagement coping with hardiness and spiritual wellbeing, and a positive prediction of distraction coping by hardiness. Cognitive reframing coping was significantly and positively predicted by global clinical severity and spiritual wellbeing, but negatively predicted by global functioning; finally, perceived social support was significantly and positively predicted by hardiness. There were significant indirect effects on objective burden of (1) hardiness on burden trough engagement coping . The indirect effects of hardiness through engagement coping and of spiritual wellbeing on objective burden were instead not significant. The only significant covariate effect was that of child’s age  on adaptive functioning.Results for mothers of children with DS are presented in Fig. , as indicated by a partial chi-square test: SB-DCHI = 7.55(2), p = .06. There were also three other paths that were analogous across the ASD and DS groups: (1) hardiness to engagement coping, (2) hardiness to distraction coping, (3) hardiness to perceived social support. Among the above paths, however, only the one linking hardiness to distraction coping was statistically equivalent across the two groups: SB-DCHI = 2.01(1), p = .17.The structure of the mediational model was quite different across groups, as shown by the different pattern of significant paths. Nonetheless, there was an equivalent path across the three groups (3.4.1.22χ (172) = 190.70, p = .17, CFI = .99, TLI = .98, RMSEA = .024 , SRMR = .064. Fig. (1), Panel B presents the model estimates obtained in fathers of children with ASD. Objective burden was significantly and positively predicted by engagement and disengagement coping, and negatively and significantly predicted by adaptive functioning, and by perceived social support, which was the stronger direct predictor. Spiritual wellbeing significantly predicted engagement, disengagement, and cognitive reframing coping, and perceived social support. The latter was also significantly predicted by hardiness. There were significant indirect effects of (1) spiritual wellbeing through engagement  and disengagement  coping strategies, and social support , and (2) of hardiness through social support . Significant covariate effects were those of paternal age  on hardiness, and of child’s age on global clinical severity , global functioning , and adaptive functioning .The multiple group mediational model for fathers fitted the data well: 1), Panel D. Objective burden was significantly predicted by engagement and disengagement coping. In turn, engagement coping was predicted by hardiness, disengagement coping by global functioning, cognitive reframing coping by hardiness, and perceived social support by spiritual wellbeing. The indirect effect of hardiness on burden though engagement coping  was not statistically significant. Significant covariate effects were those of child’s age  on objective burden and adaptive functioning , and of gender on hardiness ,Results for fathers of children with T1DM are presented in Fig. (1), Panel F. Objective burden was significantly predicted only by distraction coping. In turn, distraction coping was predicted by global functioning, cognitive reframing coping by spiritual wellbeing, and perceived social support by global clinical severity, hardiness, and spiritual wellbeing. The indirect effect of global functioning on objective burden through distraction coping was significant . Significant covariate effects were those of child’s age on disengagement coping , and on adaptive functioning .Finally, the mediational model for fathers of children with DS is presented in Fig.  differed significantly across groups (SB-DCHI = 21.55(2), p < .001). It emerged as statistically equivalent only across the ASD and the DS groups (SB-DCHI = 2.51(1), p = .11).The structure of the mediational model was quite different across groups, as shown by the different pattern of significant paths. Moreover, the only path that consistently emerged across groups (3.4.23.4.2.12χ(166) = 155.61, p = .70, CFI = 1.00, TLI = 1.01, RMSEA = .00 , SRMR = .050. Fig. (2), Panel A presents model estimates obtained in the mothers of children with ASD. Their subjective burden was significantly and positively predicted by global clinical severity and distraction coping, and negatively and significantly predicted by disengagement coping, perceived social support, hardiness, and spiritual wellbeing. In turn, engagement coping was positively predicted by adaptive functioning and negatively predicted by hardiness; disengagement coping was negatively predicted by spiritual wellbeing; social support and distraction and cognitive reframing coping were predicted by hardiness and spiritual wellbeing.The multiple group mediational model for mothers fitted the data well: p = .019), gender on reframing coping , child’s age on global clinical severity  and global functioning .There were also significant and positive indirect effects of hardiness on objective burden trough distraction coping , and negative indirect effects through perceived social support . Spiritual wellbeing revealed a negative indirect effect on objective burden trough disengagement coping , through distraction coping  and trough perceived social support . Significant covariate effects were those of maternal age on disengagement coping , Panel C. As it can be seen, we found only two direct negative predictions of subjective burden by perceived social support and global clinical severity. The latter significantly and positively predicted engagement coping. Significant covariate effects were those of child’s age on subjective burden  and adaptive functioning , and of maternal age on global functioning .Results for mothers of children with diabetes are presented in Fig. (2), Panel E. In this case, we found significant and positive direct predictions of subjective burden by engagement and disengagement coping, and a negative prediction by spiritual wellbeing. Moreover, engagement coping was significantly and positively predicted by hardiness and spiritual wellbeing; distraction coping was significantly and positively predicted by global functioning and hardiness; Cognitive reframing coping was significantly and positively predicted by global clinical severity and spiritual wellbeing, but negatively and significantly predicted by global functioning; finally, perceived social support was significantly predicted by hardiness. There were significant and positive indirect effects of hardiness on objective burden through engagement coping  and negative effects through perceived social support . There was a significant covariate effect of child’s age on adaptive functioning .Finally, results for mothers of children with Down syndrome were presented in Fig. , and proved to be statistically equivalent SB-2∆χ = 3.98(2), p = .14. No other path was statistically equivalent across groups, except those predicting distraction and engagement coping by hardiness in the ASD and DS groups: SB-2∆χ = 4.10 (2) p = .13The structure of the mediational model was quite different across groups, as indicated by the different pattern of significant paths. Only one path consistently emerged across groups (3.4.2.22χ (173) = 206.33, p = .04, CFI = .97, TLI = .96, RMSEA = .033 , SRMR = .067. Fig. (1), Panel B presents the model estimates obtained in the fathers of children with ASD. Subjective burden was significantly predicted by engagement and disengagement coping, perceived social support, and hardiness. Spiritual wellbeing significantly predicted perceived social support and all coping strategies except distraction. Perceived social support was also significantly predicted by hardiness. There were significant and positive indirect effects of (1) spiritual wellbeing on objective burden through engagement coping , and negative indirect effects through disengagement coping  and perceived social support ; (2) hardiness had a negative indirect effect on subjective burden through social support . Significant covariate effects were those of paternal age on hardiness , and of child's age on global clinical severity , global functioning , and adaptive functioning .The multiple group mediational model for fathers fitted the data well: 2), Panel D. Subjective burden was significantly predicted only by cognitive reframing coping. In turn, engagement coping was predicted by hardiness; disengagement coping by global functioning; cognitive reframing coping by hardiness; and perceived social support by spiritual wellbeing. There was a significant and negative indirect effect of hardiness on subjective burden through cognitive reframing . There were significant covariate effects of gender on hardiness , and of child’s age on spiritual wellbeing  and adaptive functioning .Results for fathers of children with diabetes are presented in Fig. (2), Panel F. Objective burden was significantly predicted by distraction coping and hardiness. In turn, distraction coping was predicted by global functioning; cognitive reframing coping by spiritual wellbeing; and social support by hardiness and spiritual wellbeing. There was a significant and negative indirect effect of global functioning  on objective burden though distraction coping. There was a significant covariate effect of child’s age on adaptive functioning .Finally, the mediational model for fathers of children with DS is presented in Fig. (2χ = 2.42(1), p = .12) . No other path was statistically equivalent across groups.The structure of the mediational model was quite different across groups, as shown by the different pattern of significant paths. Only the path from spiritual wellbeing to cognitive reframing across the ASD and DS groups was statistically equivalent  = 131.58, p = <.01, CFI = .96, TLI = .92, RMSEA = .052 , SRMR = .060. This model is shown in Fig. (3), Panel A. Mother’s objective burden was significantly and positively predicted by engagement and disengagement coping, child’s intellectual disability, and autism symptom severity; on the other hand, it was significantly and negatively predicted by the perceived social support. In turn, engagement coping was significantly positively predicted by autism symptom severity, while it was significantly negatively predicted by adaptive functioning and hardiness; disengagement coping was negatively predicted by spiritual wellbeing; distraction coping was significantly positively predicted by hardiness, whereas it was negatively and significantly predicted by spiritual wellbeing; cognitive reframing coping was significantly predicted by hardiness and spiritual wellbeing; perceived social support was significantly predicted by global functioning, hardiness, and spiritual wellbeing. There were significant negative indirect effects on objective burden of: (1) global functioning through perceived social support , (2) adaptive functioning through engagement coping ; (3) hardiness through perceived social support ; (4) spiritual wellbeing through disengagement  and through perceived social support . Instead, hardiness revealed a significant but positive indirect effect on objective burden through engagement .The mediational model for objective burden fitted the data well: 2χ(59) = 97.59, p = <.01, CFI = .98, TLI = .96, RMSEA = .038 , SRMR = .056. This model is shown in Fig. (3), Panel C. Mother’s subjective burden was significantly and positively predicted by disengagement and distraction coping, and by autism symptom severity. Instead, it was negatively and significantly predicted by global functioning, spiritual wellbeing, and perceived social support. In turn, engagement coping was positively and significantly predicted by hardiness and autism symptom severity; disengagement coping was negatively and significantly predicted by spiritual wellbeing; distraction coping was positively and significantly predicted by hardiness, and negatively by spiritual wellbeing; cognitive reframing coping was positively and significantly predicted by hardiness and spiritual wellbeing; and perceived social support was positively and significantly predicted by global functioning, hardiness, and spiritual wellbeing. There were also significant and negative indirect effects on burden of global functioning through perceived social support ; of hardiness trough social support ; and of spiritual wellbeing through disengagement , distraction coping , and social support . Hardiness, instead, revealed a significant and positive indirect effect on subjective burden trough distraction coping .The fit of the mediational model for subjective burden was acceptable: 3.4.3.22χ (56) = 57.64, p =.41, CFI = 1.00, TLI = 1.00, RMSEA = .011 , SRMR = .048. This model is shown in Fig. (3), Panel B. Objective burden was significantly and positively predicted by engagement and disengagement coping, autism symptom severity, and intellectual disability; on the other hand, it was significantly and negatively predicted by the perceived social support. Spiritual wellbeing significantly negatively predicted engagement and disengagement coping, while it significantly positively predicted cognitive reframing coping. Social support was significantly and positively predicted by hardiness and spiritual wellbeing.The mediational model for objective burden fitted the data well: There were significant and negative indirect effects of hardiness on objective burden through perceived social support , and of spiritual well-being through engagement  and disengagement coping , and through perceived social support .2χ (56) = 62.83, p< .001, CFI = .99, TLI = .98, RMSEA = .022 , SRMR = .050. This model is presented in Fig. (3), Panel D. There were direct positive and significant paths from disengagement coping and autism symptom severity to the subjective burden. Perceived social support, instead, significantly negatively predicted subjective burden. Spiritual wellbeing significantly and positively predicted perceived social support, engagement coping, and cognitive reframing coping, while it significantly negatively predicted disengagement coping. Hardiness significantly positively predicted perceived social support. There were significant and negative indirect effects on subjective burden of hardiness  through social support, and of spiritual wellbeing through disengagement coping  and perceived social support .The model for subjective burden fitted the data well: 44.1Consistently with previous literature , 8, thisThe parents of children and adolescents with ASD reported significantly higher levels of both objective and subjective burden than the parents of children and adolescents with DS or T1DM. The mean level of objective burden observed in the parents of children with ASD was higher than the level reported by parents  of children, adolescents, and young adults affected by muscular dystrophies , and wasAlso, specific aspects of burden such as child health-related expenses and the adverse impact on parental work and on other children were significantly greater in the families with a child affected by ASD than in the families with a child affected by DS or T1DM. Most previous studies, with few exceptions , have reSignificant symptoms of depression and anxiety were also found to be quite common among parents of children with ASD, as almost one-third of them scored above the threshold for probable psychiatric morbidity on the GHQ-12. For mothers of male children and for fathers, the proportion of high scorers on the GHQ-12 was significantly higher in the ASD group than in the DS group, and was also higher than in the T1DM group, though the difference did not reach significance.In agreement with our findings, previous studies on mothers and fathers of children with ASD , 10 and 4.2A distinctive feature of this study is that in most families both parents were involved. This is important because in Italy and numerous other countries many fathers are substantially involved in caring for their children. However, with very few exceptions, previous studies on parenting stress and burden in parents of children with ASD have included only mothers or mothers with a small minority of fathers. This creates a knowledge gap, as research carried out on mothers of children with ASD may not be generalizable to fathers, given common differences between mothers’ and fathers’ domestic roles.Previous research carried out to date suggests that both in western and eastern countries the mothers of children with ASD suffer from increased levels of stress -126, anxIn this study, we observed in all three groups a significant correlation between mothers’ and fathers’ ratings of subjective and objective burden, as well as of depressive and anxiety symptoms. The correlation was particularly strong for the ratings of burden, which corroborates the validity of the assessment of this key variable and suggests that mothers and fathers share a similar view of the challenges and difficulties faced by the family.Only few mother-father differences in parental burden were identified. In the families with a child affected by ASD, the mothers reported greater subjective burden than fathers, while no difference between mothers and fathers was found for objective burden and depressive and anxiety symptoms. In the other two groups, no differences between mothers and fathers were observed in subjective and objective burden and in depressive and anxiety symptoms. This pattern of findings suggests that, overall, the mothers and fathers of children with ASD, DS, and T1DM experience similar levels of burden, but that mothers may more often feel overwhelmed when facing the particularly heavy caregiving demands associated with parenting a child with ASD.4.3i.e., the perceived personal controllability of life events, was found to be lower in parents of children with ASD than in parents of children with DS and of children with no developmental disorder [Previous studies of coping resources other than social support among parents of children with ASD have been scarce. Differences in spiritual wellbeing between parents of children with ASD and other parent groups were not previously investigated. Hardiness was examined in one study, which found that mothers of children with ASD reported less hardiness than mothers of children with intellectual disabilities or typically developing children . Some stdisorder .In our study, the mothers and fathers of children with ASD displayed levels of hardiness and spiritual well-being that were similar to those observed in the parents of children with DS and T1DM, which suggests that the parents of children with ASD do not lack personal coping resources and are remarkably resilient.Also, our findings, overall, do not suggest that the parents of children with ASD are more likely to use coping strategies commonly regarded as less beneficial for wellbeing in the long term, such as passive or avoidant emotion-focused coping, or less likely to use strategies assumed to be more beneficial, such as active, problem-focused coping. In fact, both mothers and fathers of children with ASD reported greater use of active, problem-focused strategies such as engagement coping than the parents of children with T1DM. They also reported greater use of the supposedly beneficial cognitive reframing coping. Also, they did not differ in the use of disengagement coping from the other parent groups. The only finding suggesting greater use by them of a strategy assumed to be less beneficial was the observation of a greater use of distraction coping in the mothers of children with ASD as compared with the other groups.This finding is consistent with the previous literature. Among persons with a child diagnosed with ASD, the coping scores were found to be similar to the norms for the instrument used . In a LeThe finding of presumably functional coping in combination with average levels of hardiness and spiritual wellbeing, in the context of severe caregiving burden, creates a picture that resembles the ‘resilient disruption’ model of family adaptation developed to account for the impressive resilience of many families to the stress associated with disability, which posits that families are both disrupted by and resilient to the stress associated with raising a child with disability .On the other hand, social support was found to be a critical issue for the parents of children with ASD. The pattern of findings suggests that it was support from family and friends, rather than from the spouse, to be perceived as poor by parents of children with ASD. In fact, they reported reduced levels of perceived social support from family and friends, both in absolute terms and relative to the other groups.This finding of low social support from the extended family and friends is consistent with those of qualitative studies, in which many parents of children with ASD stated that family members did not understand the disorder, even if they accepted the diagnosis, and thus could not provide the needed support. Isolation was a common experience, as friends avoided parents, thus leaving them with a sense of diminished support , 133.4.4We used structural equation modeling to investigate the relations between parental burden and a number of child and parent characteristics deemed as relevant based on previous research and theoretical considerations. We tested the direct effect of all variables on the parental burden and the possible mediating role of social support and coping strategies.As far as the parents of children with ASD are concerned, given the close similarity in findings between the models obtained in the multi-group and single-group analyses, we discuss the latter models, which are more informative as they included intellectual disability and autism symptom severity as measured by the CARS. The findings of multi-group models are discussed with respect to the issue of whether the processes active in the families of children with ASD operated in similar ways in the other two groups.4.4.14.4.1.1Some previous studies suggested a negative relationship between child’s age and maternal burden, with mothers of older children with ASD reporting lower stress levels -29. Howe4.4.1.2In mothers of children with ASD, the child’s global and adaptive functioning displayed a negative indirect effect on objective burden through perceived social support and through engagement coping, respectively. The child’s global functioning also displayed a direct negative association with the subjective burden and had also a negative indirect effect on subjective burden through perceived social support.These findings are in agreement with most of the literature. All previous studies, with only one exception  reported4.4.1.3Previous studies examining the association between the child’s intellectual disability and parental burden provided inconsistent findings. On one hand, a number of studies reported an association between child’s cognitive abilities , 40, 41,Our findings concerning subjective burden are in agreement with the previous negative studies, as the severity of the child’s intellectual disability was not associated with subjective burden. However, in both mothers and fathers of children with ASD, the severity of the child’s intellectual disability was directly associated with increased objective burden. This pattern of findings suggests that although the parents of intellectually disabled children with ASD face greater practical problems, the influence of intellectual disability on their emotional wellbeing is relatively mild when compared with the impact of autistic symptoms and impaired adaptive functioning, which seem to be the main child-related sources of parental subjective burden.4.4.1.4The most consistent predictor of burden was the severity of autistic symptoms, that was directly associated with objective and subjective burden in both mothers and fathers of children with ASD. The use of the CARS as a measure of severity suggests that the association between ASD severity and parental burden cannot be explained by information bias.This finding is consistent with the many previous studies reporting an association between ASD symptom severity and parental stress or psychological distress , 37, 134However, not all previous studies are in agreement. A number of studies found no relation between severity of autistic symptoms and parental stress , 45-47 oSeveral issues may account for the discrepancies between these studies regarding the association between parental burden and severity of autistic symptoms. First, given that children with ASD as a group are highly heterogeneous, differences between studies in children’s age range, ASD symptom severity, and diagnostic category significantly complicate the comparison of results across studies. Another factor potentially affecting the results lies in differences across studies in the methodology (observer-rated or self-report instruments) and the specific instruments used to measure the relevant variables. Also, studies have often analysed the contribution of only one or two child factors to the parental burden. Furthermore, differences in the samples of parents  make comparisons between studies difficult, as mothers and fathers may differ in terms of what child characteristics contribute most to their burden. These considerations may also account for the previously mentioned discrepancies between studies concerning the association between parental burden and other child factors such as age, adaptive functioning, and cognitive impairment.Overall, our findings corroborate the view that the challenging symptoms of ASD contribute substantially to the experience of stress in parents. Greater symptom severity is likely to result in higher levels of dependency on parents, increasing the strain associated with caring for the child. Indeed, some studies reported an association between parental stress and two of the key diagnostic traits of ASD, namely impairments in social communication , and res4.4.24.4.2.1The strongest and most consistent predictor of burden was perceived social support, which was negatively associated with subjective burden, and even more strongly with the objective burden, in both mothers and fathers of children with ASD. Indeed, all previous studies except one  have sugOur finding of a strong association between perceived social support and parental burden corroborates the notion that substantial support from external sources is critical to meet the huge demands associated with raising a child with a disability . The key4.4.2.2The differential effectiveness of coping strategies is not a simple issue. Likely, no coping strategy is effective in all situations, and coping effectiveness is heavily dependent on the type of stressful situation that the individual faces . A classOverall, emotion-focused coping strategies were positively associated with burden in this study. Both in mothers and fathers, disengagement coping showed a positive association with the objective and subjective burden. Also, though in mothers only, distraction coping showed a positive association with the subjective burden. These findings are consistent with previous literature, as in several studies parental burden correlated with the use of disengagement and distraction coping strategies, such as self-distraction, denial, behavioural disengagement, venting of emotions, and self-blame , 53, 58.However, in both mothers and fathers, we also found a positive association between objective burden and a problem-focused coping dimension, such as engagement coping. This finding suggests that there is no easy recipe for coping with ASD in a child based on a simple dichotomization of strategies. Parents of children with ASD need to handle both situational demands and their emotional reactions to those demands. Therefore, they have to use both problem-focused and emotion-focused coping strategies, and even the best of efforts may not be enough to solve all problems, given the severe difficulties they face.Our finding that most coping strategies were associated with burden in some models is likely to be ascribed, at least in part, to the presence of a severely stressful situation lasting for years before the assessment, and it should be considered in light of the frequent finding across studies that coping strategies seem to have damaging rather than beneficial effects on well-being . In this4.4.2.3Among personal coping resources, spiritual well-being was the most consistently associated with lower burden in parents of children with ASD, with a direct negative association with the maternal subjective burden and a variety of indirect effects. Both in mothers and fathers of children with ASD, it had an indirect negative effect not only on subjective but also on objective burden through perceived social support and through disengagement coping. In mothers only, it showed a negative indirect effect on subjective burden through distraction coping. In fathers only, it had a negative indirect effect on objective burden through engagement coping. These findings suggest that parents high in spiritual wellbeing perceive their social support to be greater, and likely elicit more support from others, which in turn leads to a reduced burden. The importance of this process is corroborated by the observation that a statistically equivalent association between spiritual well-being and perceived social support was also observed in fathers of children with DS. Parents high in spiritual wellbeing seem to engage in less strenuous coping efforts, which also leads to a lower burden. Interestingly, in all models, spiritual well-being was positively associated with cognitive reframing coping, which is the only coping dimension that was not associated with increased burden, and this association was identified as statistically equivalent across the fathers of children with ASD and DS.This pattern of results suggests that spirituality, religion, and personal principles exert a positive influence on parents’ sense of meaning and purpose in life, which is consistent with theoretical perspectives emphasizing that meaning-making is a central aspect of coping with adversity . Indeed,The other personal resource investigated was hardiness, which showed mixed effects. On one hand, in mothers of children with ASD hardiness displayed a positive indirect effect on objective burden through engagement coping, and on subjective burden through distraction coping. The first finding reflects a consistent process, as the association between hardiness and engagement coping in mothers was statistically equivalent across the families of children with ASD and DS. It is consistent with the notion that individuals high in hardiness, who have a greater sense of control and mastery over life, are more likely to use problem-focused coping responses. The second finding is less straightforward to interpret. However, it should be noted that the association between hardiness and distraction coping in mothers was statistically equivalent across the families of children with ASD and DS, which suggests that it is not a negligible process. Possibly, the high perceived control of individuals high in hardiness gives them enough confidence to distract themselves from the stressful situation and attend to other duties or challenges.On the other hand, the most consistent effect of hardiness was in the expected direction of a decrease in burden, as in both mothers and fathers of children with ASD hardiness had an indirect negative effect on both objective and subjective burden through perceived social support. This effect is similar to what was observed for spiritual well-being and suggests that parents high in hardiness tend to perceive greater social support, and likely to attract more support from others, which in turn leads to a lower burden. This finding is consistent with, and elaborates upon, a number of earlier studies. In mothers of children with autism, hardiness was found to be associated with less psychological distress , 142 and5This study has some limitations that should be kept in mind when looking at the findings. First, the samples were non-random, which may limit the generalizability of the results and might have introduced some sort of bias, as the levels of burden experienced by the parents may have affected their interest in and their capacity for participation in the study. Second, parent variables, such as burden, depressive and anxiety symptoms, hardiness, social support, spiritual well-being, and coping strategies, were all measured with self-report instruments. Although this choice is appropriate for most of these variables because self-reports are crucial when assessing internal states and private events, it may nevertheless raise concerns about common method bias. However, there is evidence of construct validity for the instruments used, which rules out substantial method effects. Also, there was limited conceptual overlap in the items used to measure most of the different constructs. Moreover, the inflation of relationships between variables by shared method variance is often completely offset by the attenuating effects of measurement error . Third, Despite its limitations, this study confirmed that mothers and fathers of children with ASD carry a huge caregiving burden in the form of objective difficulties, subjective distress, and symptoms of depression and anxiety. This study added to our understanding of the factors that are associated with burden. Given that caregiving burden and stress may affect service utilization and reduce the effectiveness of interventions for young children with ASD , identifHealth professionals working with these families should be alert to the possible presence of clinically significant depressive and anxiety symptoms in parents, which need to be promptly recognized and treated. In addition to common treatment options such as individual psychotherapy or medication, a recent study suggests that group treatments aimed at decreasing stress, depression, and anxiety, such as Mindfulness-Based Stress Reduction and positive psychology practice, may also be of help to these parents .The parents who are raising children with ASD may also benefit from interventions designed to regain or improve their coping abilities through cognitive-behavioural approaches , from inFinally, and probably most importantly, this study suggests that increasing the level of social support available to parents might be quite beneficial to them, as perceived social support was the strongest and most consistent negative predictor of objective and subjective burden. While the parents of children with ASD who participated in this study showed substantial resilience and ability to cope with stress, social support was found to be a really critical issue for them, as they reported lower levels of social support from family and friends than other groups. Traditional support interventions, such as respite care, may contribute to decrease parenting stress . HoweverFuture work in this area should involve prospective longitudinal studies, a few of which are already underway , 28, 154


Different criteria, such as the life cycle stage included, cut-off criteria, biogenic carbon treatment, and other requirements, were discussed. A cradle-to-gate life cycle assessment (LCA) for MDF was conducted. The CF values were −667.75, −658.42, and 816.92 kg of carbon dioxide equivalent (CO2e) with PAS 2050, GHG protocol, and ISO 14067, respectively. The main reasons for the different results obtained were the application of different cut-off criteria, exclusion rules, and the treatment of carbon storage. A cradle-to-grave assessment (end-of-life scenarios: landfill and incineration) was also performed to identify opportunities for improving MDF production. A sensitivity analysis to assess the implications of different end-of-life disposals was conducted, indicating that landfill may be preferable from a GHG standpoint. The comparison of these three protocols provides insights for adopting appropriate methods to calculate GHG emissions for the MDF industry. A key finding is that for both LCA practitioners and policy-makers, PAS 2050 is preferentially recommended to assess the CF of MDF.Carbon footprint (CF) analysis is widely used to quantify the greenhouse gas (GHG) emissions of a product during its life cycle. A number of protocols, such as Publicly Available Specification (PAS) 2050, GHG Protocol Product Standard (GHG Protocol), and ISO 14067 Carbon Footprint of Products (ISO 14067), have been developed for CF calculations. This study aims to compare the criteria and implications of the three protocols. The medium-density fiberboard (MDF) (functional unit: 1 m Carbon footprint  per unit of gross domestic production by 40–45% compared with that in 2005, numerous industries are actively pursuing the reduction of GHG emissions [2e) from the atmosphere. Through harvesting practices, stored CO2e can be transferred to wood products for extended periods, especially long-living products, such as wood-based panels [Given that China has committed to decreasing its carbon dioxide (COmissions . Regardimissions . The rold panels . Althoug3) is currently produced and utilized worldwide. MDF represents approximately 88.77% of the fiberboard industry, with a total production of 59.04 million m3 in 2016. This amount is considerably higher than in Turkey (5.07 million m3/a), the world’s second largest country [Medium-density fiberboard (MDF)  through comparisons and evaluate the CF of MDF based on PAS 2050 with end-of-life scenarios (cradle-to-grave). These three protocols were to be compared using the same manufacturing plant. The results have been applied to identify the main hotspots that provide the most contribution to environmental impacts. By considering the characteristics of wood production chains, this study provides insights for adopting appropriate methods to calculate GHG emissions for the MDF industry.3/a, which is at the forefront of the industry. We employed three protocols to calculate CF, namely PAS 2050, GHG Protocol, and ISO 14067. These protocols follow the life cycle thinking approach [3 with a moisture content of 30%.This study was conducted for a “state-of-the-art” MDF manufacturing company in China. The production system is in line with GB/T 11718−2009 Medium-Density Fiberboard, which is a national standard for China’s MDF. Since the start of the production, the annual production capacity reached 210,000 mapproach . Therefof,GHGE is the GHG emissions from fuel combustion in the stationary sources (kg CO2e), f denotes the types of energy used, fFC is the consumption of energy f (MJ−1), and f,GHGEF is the emission factor for the energy f per GHG (kg CO2e MJ−1).E is the GHG emissions from mobile sources (kg CO2e), a denotes the types of fuel used, aFuel is the total use of fuel a (MJ), and aEF is GHG emissions from one MJ of fuel a (kg CO2e MJ−1).e,GHGE is the GHG emissions from electricity use in the stationary sources (kg CO2e), eFC is the consumption of purchases electricity e (kWh−1), and e,GHGEF is the emission factor for electricity f per GHG (kg CO2e kWh−1).CF is calculated by summing up the GHG emissions that are directly or indirectly attributed to the product during its life cycle ,32. EquaIn the following subsections, the specifications and requirements for CF calculations provided in PAS 2050, GHG Protocol, and ISO 14067 were discussed to compare their differences. The goal of PAS 2050 and ISO 14067 is to initiate uniform methods to calculate CF, whereas the GHG Protocol aims to provide guidelines on accounting and reporting. An overview of the different aspects that affect the results are provided in An important characteristic of wood production chains is their multi-functionality, which addresses the allocation of the environmental performance between products and their co-products . HoweverA system boundary determines which processes shall be included in the assessments . PAS 205Consistent with findings by Hussain et al. , the craOn-site industrial process. All of the input amounts were reported by the surveyed company. The general steps used to produce MDF include the mechanical pulping of wood chips to fibers, blending fibers with resin and paraffin wax, drying, forming the resined material into a mat, prepressing, trimming, hot pressing, and post-processing.Off-site operations and raw material extraction. The surveyed company typically used branch woods as the raw material. Among the chemicals, urea-formaldehyde (UF) resin was the most widely used material, and was self-produced by the aforementioned company. Wood fuels were obtained from the internal recycling of wood residues and purchase from other factories and forest operations. Therefore, the waste remained in the technosphere, and no allocation was conducted. Raw materials were delivered to the company through highway transportation. This subsystem includes energy for forestry extraction process, chemical production, and raw material transportation.For cradle-to-grave assessment, this study focused on the life cycle of MDF itself, excluding the environmental impacts of its downstream industry chain. In the use stage, only carbon storage and delayed emissions were considered, because there was no energy consumption in this process. The service life (20 years) and disposal treatment pathways for MDF  were in line with other authors that addressed the life cycle carbon flow of wood-based panels in China . A sensiCut-off criteria specify the exclusions of materials, energy flow, or levels of environmental significance related to a product system . By settThe term capital goods is a generic label for the goods used in the life cycle of products, such as machines, equipment, and buildings . PAS 2052e and deducted from the total results. ISO 14067 allows carbon storage to be separately documented. Based on the average carbon content of 52% [3 of MDF is approximately 377.52 kg, which is equal to 1384.24 kg CO2e per m3 (by multiplying 44/12). Regarding emissions, the amount of CO2 uptake of biomass and the equivalent amount of CO2 emissions from the biomass at the point of complete oxidation results in zero net CO2 emissions. In the current study, CO2 emissions arising from the wood fuels are accounted as neutral and exclude from the CF assessment [Biogenic carbon is carbon derived from renewable sources, such as wood . Biogenit of 52% , the amosessment .Owing to the relatively long service life of MDF, the effect of delayed emissions of carbon storage may be important to CF calculations. Among the analyzed protocols, only PAS 2050 applies a dual approach to calculate carbon storage by focusing on the effect of delaying an emission on the radiative force within the 100-year assessment period. The incineration scenario that represents carbon storage is released after the service life, that is, the time of carbon storage is the same as that of the service life. For the landfill treatment, 98.9% of the biogenic carbon can be permanently stored, and only 1.1% of carbon is released into the atmosphere .Emissions and removals associated with changes in land management practices are also specified in the analyzed protocols. GHG emissions from direct land-use change are all included in the three protocols analyzed. Furthermore, ISO 14067 allows GHG emissions that are derived from direct land-use change to be separately documented. Meanwhile, indirect land-use change is not a requirement in PAS 2050 and GHG Protocol. In ISO 14067, indirect land-use change should be considered when an internationally agreed procedure exists .Other exclusions include the transport of workers to their workplace and of consumers to purchase sites, human energy inputs to the process, and animals providing transport services .High-quality data are essential to provide a reliable evaluation . The thrThe inventory analysis in this study mainly used primary data collected from the surveyed company complemented with secondary data from the national reports and the corresponding literature. The data sources used for data activity and emission factors were summarized. GHG emissions from UF resin were assumed to be those calculated by Zhang , because2e with PAS 2050, GHG Protocol, and ISO 14067, respectively. The difference mainly depended on the inclusion of carbon storage in PAS 2050 and GHG Protocol as a deduction. The only difference between PAS 2050 and GHG Protocol is the cut-off criteria. In terms of net balance, the result obtained with the ISO 14067 was −567.32 kg CO2e. The results obtained from this protocol were the largest not only because ISO 14067 separately reported biogenic carbon storage, but also because the protocol included GHG emissions from capital goods. As ISO 14067 required, capital goods were included in the CF result and contributed to 93.31 kg CO2e. Considering net CF balance, the inclusion or exclusion of capital goods was one of the main factors responsible for the differences in results. The similarities between PAS 2050 and ISO 14067 were created by cut-off criteria, because they all excluded the production of ammonium chloride, sodium hydroxide, and paraffin wax. Allocation rules exhibited a negligible contribution to the differences in the results, because of the consistent approach applied in the MDF life cycle.2e per m3 by using GHG Protocol and 180.20 kg of CO2e per m3 by using ISO 14067 and PAS 2050, and approximately 15% were derived from urea production. Although wood provides fuels from neutral carbon in this study, the GHG emissions from the production of these materials were included [In order to identify how much each life stage and emission source contributed to the CF, a cradle-to-grave assessment was also performed. Only PAS 2050 provides a method for calculating delayed emissions. Thus, this study followed the PAS 2050 to evaluate the whole life cycle of CF. included . In the 2e. If non-renewable fuels of coal and natural gas are used for heating, then the total CF is expected to be 1.05 and 1.25 times higher in natural gas and coal, respectively, than in wood fuels.The net GHG emissions for manufacturing were 20.77%, 20.71%, and 18.40% for PAS 2050, GHG Protocol, and ISO 14067, respectively. The main source of GHG emissions according to all of the protocols for on-site industrial processes was the electricity use, which contributed to 150.31 kg CO2e. For the landfill scenario (S1), accounting for the delayed emissions having less of an impact on global warming, a negative CF was calculated (−589.82 kg CO2e). Carbon storage in landfills was evaluated to be about −1369.01 kg CO2e. The scenario with incineration disposal had a higher CF than the landfill one, resulting in 238.29% more compared to the benchmark scenario. MDF with landfill disposal can act as a carbon sink. Thus, landfill would be preferable from a GHG standpoint.Discrepancies between CF methodologies cause confusion and hinder the acceptance of CF results. The comparison of the CF results highlights the importance of following a uniform protocol for quantifying GHG emissions. A key finding is that for both the production system used and the decisions taken by the person carrying out the CF result, PAS 2050 is the most suitable protocol to quantify the CF of MDF. PAS 2050 provides more specific guidance on cut-off criteria and other exclusion rules. When the CF calculation of one product is carried out using PAS 2050, the results would be lower compared to the results according to the GHG Protocol and ISO 14067 due to different cut-off criteria. PAS 2050 also adds specific requirements for collecting data in some special cases to narrow the errors. According to the Intergovernmental Panel on Climate Change (IPCC), carbon storage in wood products should be included in the national GHG inventories after the second commitment period of the Kyoto Protocol , furnituGHG Protocol is based on the first version of PAS 2050 and is unlikely to result in significant differences in outcomes. Compared with PAS 2050 and GHG Protocol, ISO 14067 has limitations, including the carbon storage of products. One of its major differences from PAS 2050 is that ISO 14067 focuses on the communication of CF results . Under IIn terms of communication, ISO 14067 allows transparent communication and can be used as the uniform standard for communicating GHG results. However, for reporting national GHG inventories and meeting GHG emission reduction targets, PAS 2050 is preferentially recommended to assess the CF of MDF and other forest products in China.3 of MDF, consumed 125 kg of UF resin in China, and only 44.44, 70.30, 83.30, and 85.3 kg of UF resin were required in Spain, Brazil, the USA, and Canada, respectively [For meeting the GHG emission reduction target, some measures should be taken in the MDF industry. UF resin provided the largest contribution to the total CF in the MDF production chain. Resins are integral components and contributors to the performance of wood composites . Compareectively ,27,39. MMoreover, additional energy is consumed in transporting raw materials, given that the raw materials of companies are outsourced. In China, only approximately 14% of wood-based panel enterprises operate the management mode of “forest-panel integration”, that is, the self-sufficiency of raw wood materials by the company to independently manage the timber forest upstream. Therefore, most companies outsource to realize the supply of wood raw materials with an average transportation distance of 300 km . The redThe current study compared the CF of a forest product according to three protocols. Given the fact that the inclusion (negative) or exclusion (positive) of carbon storage dominated the difference in the results, it would be more interesting to consider other products that do not store carbon for comparison. This study also excluded a few sources of GHG emissions, such as fuel consumption for operating machines and field transportation. Owing to the lack of accurate data, these exclusions could undervalue the total CF of MDF. Moreover, GHG emissions from the production of capital goods were calculated based on data from Frischknecht et al. , which m2e kg of CO2e with PAS 2050, GHG protocol, and ISO 14067, respectively. As the first study to focus on the CF of the MDF industry in China, UF resin production is the major hotspot in MDF manufacturing due to backward technologies for production. Moreover, the raw materials of companies are outsourced; thus, the transportation of raw materials consumed additional energy. The mode of forest–panel integration in the MDF manufacturing enterprises in China should be established. The cradle-to-grave CF of MDF quantified by PAS 2050 was 229.10 kg CO2e (end-of-life: 40% landfill and 60% incineration). A negative CF was calculated with the landfill scenario, meaning that MDF may act as a carbon sink.This study discussed the outcomes of different CF protocols, using MDF as a case study. Firstly, a cradle-to-gate model was established as the basis of comparisons. Secondly, the cradle-to-grave CF was calculated considering end-of-life disposal scenarios: landfill and incineration. The main conclusions can be drawn as follows. Three CF methodologies  can be applied to the MDF production of China from a cradle-to-gate life cycle. Each methodology provides a different result, although the same input data are used. The net balances of CF were −667.75, −658.42, and −567.32 kg COThe discrepancy in the results can be attributed to different methodological issues, particularly the cut-off criteria, inclusion or exclusion of capital goods, and other boundary issues, and the inclusion or exclusion of biogenic carbon storage and emissions. For assessing GHG emissions in the MDF industry, discrepancies among CF methodologies cause confusion and hinder the acceptance of CF results. PAS 2050 provides more specific guidance on cut-off criteria and other exclusion rules. This protocol includes carbon storage in the CF calculations of forest products as a deduction, thereby favoring the environmental benefits of forest products compared with products that do not store carbon. For both LCA practitioners and policy-makers, PAS 2050 is preferentially recommended to assess the CF of MDF and other forest products.


There has been an incremental increase in the use of technology in health care delivery. Feasibility, acceptability, and efficacy of interventions based on internet technologies are supported by a growing body of evidence.The aim of this study was to investigate use and preferences in the general adult population in Germany for remote, internet-based interaction .A nationwide cross-sectional questionnaire survey in adults that was representative in terms of age, sex and educational level was carried out.A total of 22.16% (538/2428) of survey participants reported not using the internet for work or private use. The nonuser phenotype can be described as being older, having lower educational and income status, and living in less populated areas. The majority of participants within the cohort of internet users reported that they would not consider using electronic medical records , apps , or emails to report symptoms ; teleconference with one  or more experts ; or participate in video psychotherapy  for the purpose of medical consultation or treatment. Older age and lower educational level were the most robust predictors of assumed future denial of use.Our results point toward low use and preference rates among the general population for the use of telemedicine. It also seems that those who might benefit from telemedical interventions the most, are, in fact, those who are most hesitating. These low use and preference rates of eHealth should be considered prior to designing and providing future telemedical care, supporting the need for easy-to-use, data secure solutions. With technological innovations permeating all aspects of life, there has been an incremental increase in the use of technology in health care delivery. Feasibility, acceptability, and efficacy in terms of symptom improvement or improvements in quality of life using interventions based on internet technologies are supported by a growing body of evidence -4. PatieBeside the implementation of internet-based interventions used by patients on their own independent of any patient-physician interaction, the actual  practice of medicine through the internet involving a physician-patient interaction, known as telemedicine, presents an opportunity to revolutionize health care delivery on a global scale . While eIn many countries, direct-to-consumer telehealth companies offer patients with minor illnesses around-the-clock access to a physician. In Germany, health insurance companies offer telephone or guided internet support for specific illnesses such as depression or tinnitus, while an increasing financial grant support is dedicated to the investigation of the potential benefits of different types of telemedicine services . In otheIn order to facilitate a safe, timely, efficient, effective, and equitable delivery of internet-based health care, assessment of needs of all stakeholders involved is crucial . Most stParticipants in the study were part of a larger cross-sectional survey on physical and mental well-being in a random sample of German residents aged 14 years and older (range 14 to 91 years). The demographic consulting company USUMA  assisted with sampling and data collection. The procedure was designed to yield a nationwide sample representative in terms of age, sex, and educational level over the fieldwork period from May to July 2018. Sociodemographic data were collected in person by trained interviewers. In addition, participants returned a battery of self-report questionnaires including the telemedicine questions. This study was part of a larger survey assessing different issues in the general population for research purposes in Germany. For the purposes of this study, we assessed adults only. Thus, only participants aged 18 years and older were included in the analyses.In Germany, no directory is generally available containing the addresses of all private households or individuals that can be used by market research agencies as a sampling frame. The data collected by the local authorities are only available for surveys considered to be of major public interest.The consortium Arbeitsgemeinschaft ADM-Stichproben closes this gap by providing a sampling frame, the ADM Sampling System for Face-to-Face Surveys, to member agencies. The demographic consulting company, USUMA, supporting this study is a member agency and has access to this sampling system . This frThe ADM Sampling System is organized as an area sample comprising all populated areas in Germany, organized by state, county, and community with the statistical areas within communities described by public data and the geographical data taken from traffic navigation systems. Taken together, the area sample consists of about 53,000 areas, each containing a minimum of 350 and an average of 700 private households. All areas were first regionally stratified resulting in approximately 1500 strata. Next, 128 nonoverlapping nets were randomly extracted containing a total of 258 areas across Germany. These 258 areas were drawn proportionally to the distribution of private households. Since the sampling is done randomly in three steps , this method for face-to-face surveys is based entirely on random sampling and fully meets the scientific requirements regarding randomization based on statistical theory .The participation rate was 47.3%, taking into account all refusals to participate as well as interviews that failed to take place due to respondent illness or being otherwise unavailable during the fieldwork. All participants provided their written informed consent in accordance with the Helsinki declaration. The study was approved by the ethics committee of the University of Leipzig.The following sociodemographic data were assessed: Sex , age , educational level (<12 and ≥12 years of education), monthly income , population size .Participants were first asked about their internet use, email use, and use of videoconference technologies  in general. Participants were asked to choose between never, rarely (sporadic), frequently (on single days of the week), regularly (on most days of the weeks), and daily (every day) for internet use and yes or no for email and videoconference use.Participants who reported at least sporadic use of the internet (internet users) were then asked a series of 7 pairs of questions about the medical context of consultation or treatment. Questions were constructed and chosen from a larger pool by physicians and psychologists at the Department of Psychosomatic Medicine and Psychotherapy at Hannover Medical School who have previously been involved in internet-based studies ,25-27. AWould you use/have you used email to schedule visits with your physician?Would you use/have you used email to report symptoms to your physician?Would you use/have you used videoconferencing with your physician?Would you use/have you used videoconferencing with more than one physician  at the same time?Would you use/have you used videoconferencing for psychotherapy?Would you use/have you used electronic medical records you can access at any time to see your exam results and leave messages?Would you use/have you used an app that offers personalized information about your condition and recommends exercises and support?t tests for comparisons between groups were performed appropriately with sociodemographic data as between-subject factors or independent variables, respectively. In order to examine the predictive value of the independent variables, binary logistic regressions and multiple linear regressions were performed for dependent variables consisting of two or more than two categories, respectively. The level of significance was set at P ≤.05, but a Bonferroni correction for multiple testing was performed according to the number of independent variables in each hypothesis testing.Statistical analyses were performed using SPSS Statistics for Windows version 25.0 (IBM Corp). Analyses of variance or A total of 2516 individuals participated in the study. Of those, 77 were excluded for being younger than 18 years. Thus, data from a total of 2439 adults were analyzed. This cohort consisted of 45.10% (1100/2439) males and 54.90% (1339/2439) females. Mean age was 49.04 (SD 16.87) years, and 40.01% (976/2439) of participants were aged older than 55 years. Almost 4 out of 5 participants  had less than 12 years of education, with 27.71% (662/2439) belonging to a low-income group and the majority  having an average income of 1000 to <2500 euros per month. More details on sociodemographics of the cohort are shown in When asked if they used the internet in general for work or for private purposes, 2428 responded (11 participants with missing data). Of these, 22.16% (538/2428) denied using the internet (nonusers), while 77.84% (1890/2428) said they used the internet for work or in private (internet users); 43.2% use the internet on a daily basis.P=.30). However, age group revealed a significant main effect , with linearly declining internet use frequency parallel to increasing age. Similarly, a significant main effect was found for educational level (P<.001), with lower rates of internet use frequency in individuals with less than 12 years compared to those with 12 years or more of education. In fact, there was a significant interaction between age group and educational level   .2,2375=25.33, P<.001; Games-Howell post hoc: highest income group > middle-income group = low-income group) (data not shown). Finally, there was also a significant main effect for population size , with higher rates of internet use in larger cities (data not shown).Higher income corresponded to higher internet use frequency , with an R2 of .31. Age, educational level, income , and population size (P=.001) were significant predictors of internet use frequency and remained significant even after Bonferroni correction with the new level of significance set at .05/5=.01. However, sex was not a significant predictor of internet use frequency . More details are shown in Within the group of internet users, 6.85%  stated they did not use email, while 93.15% (1755/1884) did. Within the same group of internet users, the majority  did not use videoconference programs, and 41.29% (766/1855) were familiar with their use.1,1889=10,664.20, P<.001) and educational level was significantly different with regard to the total years of education (P<.001). Similarly, age had a significant main effect  and educational level was significantly different with regard to the total years of education (P<.001) within the group of nonusers. These results are displayed in Within the group of internet users, age had a significant main effect , although the majority of participants have not used email for this purpose so far . In contrast, most participants would not use email for reporting symptoms to their physicians , and few participants  have done this in the past.The majority of internet users also proved to be reluctant to use videoconferencing for consultations with their physician , and only 0.76% (14/1836) reported having had experience with it. Similarly, consultation with more than one physician at once by means of videoconference would not be considered by most internet users . Only 1.35% (19/1836) had actual experience with psychotherapy using videoconference technology, and most users reported low preference rates for online video-psychotherapy . Electronic patient charts were not familiar to most users , but a slight majority would consider electronic patient charts as a future option . Almost half of internet users would use a medical app ; however, just 1.85% (34/1836) have already done so.In Next, binary logistic regression analyses were performed for the use of internet technology within a medical context based on sex, age, educational level, income, population size, and previous experience with the respective online tool under investigation. Due to the insertion of 6 independent variables in the regression equation, the new level of significance was set at .05/6=.008.212=296.4, P<.001. Age, educational level, and previous experience with email for this purpose were significant predictors (P<.001) as was population size (P=.007). Sex and income (following Bonferroni correction) were not significant predictors.Regarding email use for scheduling future medical visits, a significant regression model was found, χ212=137.5, P<.001. Age, educational level, and previous email use for reporting symptoms were significant predictors . Sex, income, and population size were not significant predictors at the new level of statistical significance.For using email for reporting symptoms, the logistic regression model turned out to be significant, χ212=62.8, P<.001. Age (P=.03), educational level (P<.001), and income (P=.005) were significant predictors whereas sex, population size, and previous experience with teleconference were not.For videoconference use to communicate with a physician, the regression model was significant, χ212=77.0, P<.001. Age (P=.001), educational level (P<.001), and previous experience with group teleconference in a medical context (P=.008) were significant predictors. Sex, income and population size were not significant predictors.The regression equation for the possibility of videoconference use with more than one physician at once turned out to be significant χ212=60.1, P<.001. Here, only educational level (P=.002) and previous experience with online video psychotherapy (P<.001) were significant predictors.The regression model for prediction of psychotherapy to be considered by means of videoconference also proved to be significant χP=.001), educational level (P<.001) as well as previous use of electronic patient files (P=.006) in a significant regression equation χ212=77.0, P<.001.Preferences regarding the use of electronic patient files were statistically predicted by age (P<.001) as well as previous app experience (P=.001) in a significant regression model χ212=90.5, P<.001.Finally, considering app use within a medical context was once more statistically predicted by age and educational level  in Germany, internet use was above 90% in all age groups except age 65 and older, in which the respective percentage was 55% . We explIn addition, and also rather surprisingly, the majority of participants within the subcohort of internet users reported that they would not consider the use of email, videoconference, video psychotherapy, electronic medical records, or apps for the purpose of medical consultation or treatment, with the exception of using emails to schedule medical visits. This finding may point toward the fact that internet use has not been associated with the idea of a tool helping to address medical issues and needs within the same context by the general population—not even by its very own regular consumers. There is a mismatch between everyday use of internet-based technologies  and willingness to use the exact same technologies for the sake of delivering health care. This is important to consider prior to implementing internet-based health care delivery solutions in Germany. Many individuals may not be able to anticipate how such systems would function with success. Data security may also be an issue; a recent market research study in Germany revealed that 95.2% of all respondents indicated fearing a possibly fraudulent use of their personal data on the internet . With olThis is a study examining use and preferences regarding a variety of internet-based technologies for health care delivery in a large representative sample in Germany. A limited number of similar studies have been performed in convenience samples, with the associated risks of sampling error and lack of representativeness inherent in convenience samples. Apolinário-Hagen et al  performeIn our study, a significantly higher proportion of the population reported interest in using new telemedical technologies compared to the small minority that reported actual previous experience. Prior use was dependent on whether such technology-based solutions were provided by their practitioners and whether the need for such a use had actually existed in the past. This fact could be interpreted as insufficient exposure to the respective technologies so far; in other words, specific offers might increase specific demand. If recipients of telemedical care solutions were to experience short-term advantages of such systems  in an uncomplicated manner combined with maximum security of the systems, higher levels of actual use would be expected. Countries such as Estonia have shown that user-friendly internet-based health solutions are accepted by the majority of the population. It may therefore be expected that the implementation of simple-to-use, data-secure systems in Germany might lead to much higher use rates than shown here.Another survey in Germany investigated preferences for online interventions in psychiatry and psychotherapy between health care professionals and nonprofessionals and found that, overall, nonprofessionals were more skeptical in their ratings than professionals . More faBlended treatments—the use of online tools  combined with face-to-face psychotherapy—are already part of clinical routines aimed at increasing the impact of psychotherapy . NeverthStrengths of this study clearly include the large number of participants and representativeness of the cohort. However, our survey also has limitations. First, we asked the general population to express their opinions on the use of email, videoconferencing, apps, and electronic patient files, all of which are internet-based instruments intended to deliver health care. The assessment of differences between these instruments was not part of our protocol, which aimed at assessing global preferences for a variety of new technologies that may provide future meaningful contributions to improve health care delivery in the general population. In addition, the reasons for or against considering the use of internet-based telemedicine interventions were not assessed  and may only be assumed. Other predictors should also be investigated in future studies ; in addition, reasearch has shown that a health-related information seeking personality was a significant positive predictor of the willingness to undergo online treatment . FurtherAmong internet users, the majority reported that they would not consider using internet technology for the purposes of medical consultation or treatment. Internet-based health care approaches using the right tools aimed at the right recipients may prove to be of great benefit. Our results emphasize the importance of developing solutions able to convince the general population to make proper use of and benefit from the potential telemedicine has to offer. As a putative practicable future way to increase acceptance and promote implementation of internet-based approaches in routine care, it is crucial to provide continuous, large-scale information on newer technological possibilities in health care delivery and ensure that concerns  are adequately addressed. In addition, policy makers should be focus on outreach to the elderly and those with lower income and educational level, as it is those groups who are more likely to report lower use of and preferences for internet-based health care delivery. Such an approach includes easy-to-use solutions and facilitation of access to internet-based services.


This study aimed to determine the association between chronic periodontitis (CP) and community-acquired pneumonia (CAP) according to CP severity in the Korean population based on the National Health Insurance Service database.Data from the National Health Insurance Service-National Health Screening Cohort (NHIS-HEALS), conducted from 2002 to 2013, were analyzed. A total of 363,541 participants were enrolled in this retrospective cohort study. Data on socio-demographic characteristics and CAP-related variables were collected. Participants were divided into 4 groups according to CP severity. Cox proportional hazards regression was performed after adjusting for sociodemographic and related covariates.3 person-years). The hazard ratio for CAP was not significant in any of the models regardless of the presence or absence of CP. On stratification analysis by sex, smoking and Charlson comorbidity index, there were no significant differences between CAP and CP in any of the models.A total of 363,541 participants were included in the analysis. The number of CAP cases in the index period was 14,838 (4.1%). Among the 4 groups, the mean age was significantly higher in the severe CP group. The incidence rates of severe and non-severe CP were 5.68 and 4.99, respectively (per 10The results of this study show that CP may not be a potential risk factor for CAP. Periodontal disease is a chronic inflammatory disease of the periodontal tissue that affects approximately 20 to 50% of the world’s population . It is cPneumonia is one of the most common serious infections and causes significant morbidity and mortality in both healthy and vulnerable individuals . PneumonMost previous studies on periodontal disease and pneumonia were case-control or cross-sectional studies and did not involve the general population, just elderly or vulnerable populations such as patients who have HAP or ventilator-associated pneumonia. Additionally, these studies were limited to HAP and not CAP. Moreover, the relationship between periodontal disease and CAP has yet to be established by longitudinal studies. This study aimed to analyze the relationship between CAP and CP using the Korean National Health Insurance Service-National Health Screening Cohort (NHIS-HEALS) data.This was designed as a retrospective cohort study following participants from 2002 to 2013 and was conducted using the NHIS-HEALS data. The NHIS has provided compulsory social insurance for all Korean individuals since 1989, with an enrollment rate of nearly 98% . The NHIA total of 424,453 subjects were selected, excluding those who had CP in 2002. Among these individuals, 25,391 who were diagnosed with pneumonia before follow-up  according to the International Classification of Diseases (ICD) codes (10th revision) by the World Health Organization for pneumonia were excluded from the study. A further 4628 participants who died and 29,597 participants with missing screening data were excluded. We also excluded those who had Problems related to care-provider dependency who were likely to be exposed to the healthcare system, such as those undergoing regular dialysis and those who living in nursing homes . FinallyThe study population was divided into 4 groups according to the severity of periodontitis . CP was defined by the ICD-10 codes , and severity of periodontal disease was classified according to periodontal surgery performance. Patients with periodontitis who underwent scaling and root planing were classified into the mild CP group, while patients who only received subgingival curettage were classified into the moderate periodontitis group. Patients who underwent tooth extraction and severe dental treatment such as periodontal flap operation, bone graft for alveolar bone defects, and guided tissue regeneration, were assigned to the severe CP group , body mass index , smoking status , alcohol consumption , physical activity , total cholesterol level (mg/dL), and Charlson comorbidity index . CCI is the most widely used tool for predicting the prognosis of comorbid disease .P-value < 0.05.For each CP group, the association between CP and CAP was assessed with an adjusted Cox proportional hazards regression model. Among the covariates, age, BMI, total cholesterol level, and fasting serum glucose level were considered continuous variables. Participants who did not develop CP and CAP were included as the reference group. To identify potential subgroups with significant associations between CP and pneumonia, we performed stratification analysis that included sex, smoking status, and CCI. Four Cox proportional hazards regression models were hierarchically designed to analyze the influence of each group of covariates. All data collection and statistical analysis in this study were performed using SAS 9.4 . Statistical significance in this study was defined as a n = 109,322) had CP. The number of CAP cases during the follow-up period was 14,838 (4.1%). The mean age of the participants was 57.8 years, and the mean age of the severe CP group was significantly higher than that of the Non-CP group. Table n = 2798), while the moderate group (n = 568). The hazard ratio (HR) for CAP was not significant in any of the models regardless of the presence or absence of CP. Table A total of 363,541 participants were followed for an average of 7.6 years , resulting in 2,782,453 person-years. Table As a prospective study on a large Korean adult population over a long follow-up period, this study has advantages. To the best of our knowledge, no cohort study has previously examined the association between admission due to pneumonia and CP.Streptococcus pneumoniae and Haemophilus influenzae. CAP is also caused by the spread of viral bacterial pathogens such as Mycoplasma pneumoniae, Chlamydia pneumoniae, and Legionella pneumophila. Porphyromonas gingivalis and Treponema denticola, which are the bacteria involved in CP [CP was not found to significantly affect CAP, even after adjustment for important health characteristics. Our results were consistent with those of Brown’s study, which reported that CAP was not related to dental biofilms . The maied in CP , and areMany studies have investigated periodontal disease as a risk factor for various types of pneumonia, including aspiration pneumonia, HAP, and ventilator-associated pneumonia , 21–26. Several hypotheses have been posited to explain the likelihood of developing periodontal disease and several types of pneumonia. Periodontal disease with periodontal pockets promotes accumulation of dental plaque, which can promote the growth and reproduction of pathogenic bacteria. Various pathogenic bacteria have been found in patients with deep periodontal pockets , 32. TheFew studies have been conducted on oral health and pneumonia when distinguishing between CAP and aspiration pneumonia. CAP and aspiration pneumonia share common risk factors such as diabetes mellitus, malnutrition, alcohol consumption, smoking status, and aging; however, the major risk factors for CAP are chronic obstructive pulmonary disease, heart disease, chronic bronchitis, functional impairment, chronic renal failure, cancer, and human immunodeficiency virus , 28, 42.There were several limitations to this study, mostly stemming from the use of claims data based on ICD-10 and treatment codes. First, the definition of CP based on treatment codes could underestimate the actual number of CP cases, especially in the mild and moderate periodontal disease groups. Several people seldom visit dental clinics or hospital because of lack of awareness regarding oral health and economic reasons. However, codes associated with severe CP treatment such as tooth extraction and periodontal surgery can be reliably used as identifying variables because severe CP is typically more painful for patients than mild or moderate CP. Therefore, we dichotomized the 4 groups of CP in Table This study suggested that CP is not a potential risk factor for CAP. The etiology and causality between periodontal disease and CAP remain unclear, and little is known about the underlying mechanism. In future studies, collection of clinical and epidemiological evidence is needed using a prospective study design to better understand the relationship between oral health and CAP. This study can be a starting point for discussion of the relationship between CP and CAP.