Guided by the conviction that “Clear waters and green mountains are as good as mountains of gold and silver”, China highly values sustainable economic and social development through innovation and Internet technology. Regression analysis is performed to examine the impact of corporate information disclosure environment proxied by the Internet penetration rate on innovation. Leveraging from the city-level Internet penetration rates data in China from 2003 to 2017, this study gets the following findings: (1) Firms headquartered in cities with high Internet penetration rates tend to be more innovative, i.e. they invest more in research and development. (2) This result is supported by several robustness checks, such as alternative measures of key variables, alternative empirical specifications, and tests to mitigate identification concerns. (3) "financing constraint" and "tolerance of innovation failure" are two channels that influence firms’ innovative endeavors. (4) Additional tests show that Internet penetration rates facilitate a firm’s output efficiency of innovation input, total factor productivity, and human capital environment for innovation. The above conclusions not only enrich the relevant literature on the influencing factors of corporate innovation from the perspective of the firm information disclosure environment but also provide an important reference for further understanding the positive role of macro technology development on social and economic development. So, it is vital to strengthen the ability of reform and innovation, maintain an enterprising spirit, combine actual and creative work, and especially, use the Internet technology and information technology to carry out work. It can be seen that combining the two critical areas of Internet development and corporate innovation and exploring the relationship between the two has important significance."Sustainable development" is the guiding concept of development in the 21st century [Internet technology has increasingly become a new driving force for global economic growth. An important feature of the new generation of information technology represented by the Internet is the interconnection of information. It breaks the constraints of time and space and significantly reduces the asymmetry of Information between external investors and companies. With the increase in Internet penetration, investors can quickly obtain and publish information about listed companies with only one device connected to the Internet . For exaR&D  intensity. This effect is still valid after a series of robustness tests, such as alternatives of key variables, regression model, fixed effects and standard deviation clustering methods; and treatments of endogeneity, both via propensity score matching (PSM) and Heckman two stages model. Secondly, based on the above empirical conclusions, two mechanisms of "financing constraints" and "innovation failure tolerance" have been proposed and proved. Finally, with the increase in the penetration rate of the regional Internet, the transformation rate of innovation achievements and production efficiency faced by firms has been improved. Meanwhile, the high-end element combination required for research and development; that is, the human capital environment has been improved.Leveraging from the city-level Internet penetration rates data in China from 2003 to 2017, this paper conducts an in-depth discussion on the relationship between Internet penetration and corporate innovation. The main finding are as follows: First, firms headquartered in cities with high Internet penetration rates tend to be more innovative, i.e. they have higher This paper provides at least three major contributions to the literature. First, the results in this article contribute to our understanding of the relationship between Internet technology and corporate innovation. Existing literature mainly focuses on the Internetization of corporate entities , while tThe structure of the other parts of the article is arranged as follows: the second part, literature review and research hypotheses; the third part, research design; the fourth part, the analysis of empirical results; the fifth part, the conclusions.Based on our topic, two types of literature have been reviewed. The details are as follows: First, this paper combs the literature on the relationship between the Internet penetration rate and the corporate information disclosure environment. Next, the literature is reviewed about the relationship between the information disclosure environment and corporate innovation.http://www.cnnic.net.cn/hlwfzyj/hlwxzbg/hlwtjbg/202004/P020200428596599037028.pdf). With the rapid development of Internet penetration, the role of the Internet in reducing the cost of information search has also been widely confirmed [The first type of literature: the relationship between Internet penetration rate and corporate information disclosure environment. In recent years, China’s Internet penetration rate has increased rapidly, and it has shown a prosperous development trend. From about 0% in the early 1990s, it has risen to 64.5% in March 2020. The number of Internet users has reached 904 million, and the digital divide keeps shrinking  . EconomiH1b: The increase in Internet penetration rate will significantly reduce the level of innovation input by firms.The sample selection procedure is as follows: (1) Excluding financial listed companies; (2) Deleting firms with missing information; (3) To eliminate the influence of outliers, the continuous variables are winsorized at the 1% and 99% levels. After the above sample screening, the final sample has 27,234 firm-year observations from 2003 to 2017.The city-level Internet penetration rate data and some particular firm-level indicators come from the Chinese Research Data Services (CNRDS) Platform database. R&D data comes from the WIND database, and other financial data mainly come from the China Securities Markets and Accounting Research (CSMAR) database. For specific definitions of variables, see R&D). This paper focuses on the impact of the information disclosure environment on corporate innovation motivation. Therefore, it is not appropriate to use innovation output as an explained variable. By following the common practices of the existing literature and the intensity of innovation investment R&D is used to proxy innovation motivation [R&D is specifically defined as the ratio of the company’s annual R&D expenditure to the total assets at the beginning of the year [The variable of interest is the firm’s R&D investment intensity , firm age (Age), capital intensity , Tobin’s Q (Q), return on assets (ROA), financial leverage (Lev), free cash flow (CF), firm growth (Growth), financial distress (Loss), CEO duality , board size (Board), the proportion of independent director (Indd), major shareholder’s shareholding ratio (TOPHOLD) and the Herfindahl-Hirschman Index (HHI). Following previous literature , 33, 34,R&D, following Koh, Reeb [R&D indicators is replaced with 0. The explanatory variable is the Internet penetration rate Internet. Controls represent control variables. Since R&D investment intensity (R&D) is a non-negative, continuous value censored variable (Censored variable), there is a zero-point censoring problem, so it is more appropriate to use the Tobit model for regression analysis [α represents three types of fixed effects, including the year(ηt), industry(ηind) and region(ηarea) level fixed effects respectively [H1a (H1b) is valid, then β1 is positive (negative).The following multiple regression model is used to examine the impact of Internet penetration rate on corporate innovation:oh, Reeb , the misanalysis , 36. α rectively , 37, 38.ectively , and cluectively –42. If HR&D is 0.010, and the standard deviation is 0.019, indicating that there is considerable variation of R&D among firms. This is consistent with the findings of Lu, Dang [Internet is 0.377 (0.282), and the standard deviation is 0.412, suggesting that the Internet penetration rate of prefecture-level cities in China is about 37.7%, and there is a large variation of Internet penetration rate in different regions, which helps to identify the impact of Internet penetration rates of different regions on corporate innovation. The summary statistics of control variables are consistent with previous literature [The summary statistics of the sample are presented in Lu, Dang , Ni, ZhuLu, Dang . The meaterature .Internet are positive and significant at the 1% level. The results are economically significant. Using Eq  is redefined as R&D/Sale. R&D/Sale represents the ratio of expenditure R&D expenditure to annual sales revenue [Internet) is re-measured as Internet2, which represents the number of Internet broadband access users in prefecture-level cities divided by the annual average population in each city. The robustness test results of this part are shown in columns (1) and (2) in Internet are positive and significant at the 1% level. Overall, using alternative core variables does not change our baseline findings in For robustness, firstly, the explanatory variable  test is conducted.The Internet penetration indicator is relatively exogenous to firms, as neither an individual firm can determine regional technology development. Therefore, the endogeneity between the Internet) is used as a benchmark and classify the full sample into high vs. low subsample by using this benchmark. Treat equals to 1 if Internet value is greater than the benchmark, which means treatment group, and 0 otherwise.This study follows Ni, Zhu  and He ePSM’s first step to calculating the propensity score. In the process, It is required that the distributions of treatment and control firms meet the common support assumption [PSM procedure mitigates the impact of unobservable variables on our findings.Then, our paper chooses the nearest neighbor matching method of 1:1, keep the set of control variables in Eq  describes the distribution of propensity scores before matching; (b) describes the distribution of propensity scores after matching. The horizontal axis is the propensity score and the vertical axis is the kernel density. By comparing the distribution of propensity scores before and after matching, it can be found intuitively that the propensity score matching (PSM) method significantly corrected the propensity score deviation between the treatment group and the control group. The matching result is more in line with expectations.PSM are presented in column (1) in Internet is positive and significant at the 1% level, which is similar to the results in The results of IMR. R&D dummyit+1, is a dummy variable, which equals 1 if R&D investment is greater than 0, and 0 otherwise. Controlsi,t are consistent with Eq  regression on Eq , which is still significantly positive at the 1% level, and consistent with the baseline result. It is confirmed once again that the increase in the penetration rate of the regional Internet helps to promote the R&D investment intensity and stimulate corporate innovation motivation.The result of the Heckman two-stage model is reported in column (2) in The information disclosure environment is an important factor that affects corporate innovation. For external investors, the perception of the corporate information disclosure quantity and quality will directly affect their recognition of innovative projects, and the firm’s financing behavior. Moreover, financing constraints and investors’ tolerance for management innovation failure will also be shaped. Specifically, with the increase in Internet penetration, investors’ information acquisition and supervision capabilities will be improved, the informational asymmetries between investors and management will be further alleviated. For one thing, with the reduction of corporate unsymmetrical information, the risk of corporate expected returns is reducing , which hThe first key feature of innovation activities is the high risk of failure and uncertainty of output , 49. ThiCR)" and "financing constraint (SA index)".However, the increase in Internet penetration rate can help investors more conveniently obtain corporate information, evaluate corporate innovation investment projects, and finally decide whether to invest or not. For external investors, especially creditors, the mitigation effect of Internet penetration rate on the degree of asymmetric information is undoubtedly important protection. Jiang et al.  argue thKZ index [WW index [SA index [KZ index and the WW index contain many endogenous financial variables, such as cash flow, financial leverage, etc. [SA index can weaken this endogenous problem to a certain extent. Hadlock, Pierce [SA index based on firm size and age, which has a small variation over time and are relatively exogenous. This index has the advantage of describing the characteristics of financing constraints from a long-term perspective. Besides, existing literature suggests that the SA index can reasonably measure the degree of financing constraints of Chinese firms [SA index is chosen to proxy corporate financing constraints.Total Assets = log ), Age = the number of years the firm has been on the list. The larger the SA, the higher the level of financing constraints of the firm.The common corporate financing constraints indicators include the KZ index , the WW WW index , and theSA index . Howeverge, etc. –60. The , Pierce  construcse firms , 61. TheDebtcost, which is computed as the ratio of financial expenses to the average corporate debt in year t and year t-1.Additionally, it can be seen that a more direct evidence of the reduction of financing constraints is the reduction of corporate debt financing costs. Therefore, a new empirical test is added by following Ferrer et al. ’ s debt Internet are 0.068 (t = 2.29) in columns (1) and -0.002 (t = -2.33) in columns (2), both significant at the 5% level. Additionally, the coefficients of Internet in columns (3) is -0.006 (t = -4.40), negative and significant at the 1% level. The above results indicate that the "financing constraint" mechanism is supported. Specifically, the Internet penetration rate not only improves firms’ credit rating, reduces corporate debt financing costs, but also alleviates the financing constraint directly. It can be seen that the improvement of the information disclosure environment has significantly reduced the level of corporate financing constraints, and provided financial support for corporate innovation investment.The results are presented in In general, firms are often reluctant to invest in innovation activities, because these projects tend to have a high risk of failure, and the innovation process will also be interfered with by some unpredictable and heterogeneous events . And thuInternet×Droa) is expected to be significant and positive, which means that the Internet penetration rate has weakened the sensitivity between manager’s forced change and performance. External investors have increased their tolerance for innovation failure. On the contrary, they have reduced the tolerance for innovation failure.This study follows Aghion et al. , Luong eStock Volatility to proxy management risk taking. Stock Volatility is annualized volatility of daily stock returns over the fiscal year [In addition, if investors’ tolerance for management’s innovation failure increases, then the level of management’s risk taking will rise accordingly. So two common management’s risk taking indicators are used to test the "tolerance of innovation failure" channels. Bernile et al.  argue thcal year .Yu et alcal year  use the n is the total number of corporate in a certain industry, and k is the kth corporate in the industry. When calculating the volatility of ROA to measure the level of corporate risk taking, the calculation is based on the rolling year. Since the term of top management of listed companies in Chinese country is generally 3 years, this paper uses 3 years (N = 3) as an observation period for rolling calculations [Where, i represents the corporate, and n is the year in the observation period, with a value of 1–3. Xulations .Internet×Droa) in columns (4) is 0.004 (t = 1.77), which is significantly positive at the 10% level. It shows that the increase in Internet penetration weakens the manager’s forced change-performance sensitivity, and improves investors’ tolerance for innovation failure. The coefficients of Internet is 0.024 (t = 2.32) in columns (5), positive and significant at the 5% level. The coefficients of Internet is 0.004 (t = 2.68) in columns (6), positive and significant at the 1% level. It shows that the increase in Internet penetration improves managerial risk-taking. The above results support the "innovation failure tolerance" mechanism.The results are presented in R&D investment create value for corporate and the national economy. Therefore, our paper further examines the impact of Internet penetration on R&D efficiency (Inno_Eff), namely, the output efficiency of R&D investment. R&D efficiency(Inno_Eff) is used as an indicator to measure corporate innovation capacity by following Zhao et al. [Inno_Eff equals 0; for firms whose R&D expenses are 0 but the number of patent applications is not 0, the value of this variable is recorded as missing [Inno_Eff is in Corporate innovation is a long-term and complex process, and R&D investment is only part of the whole process. Not until transformed into actual achievement, will o et al. , Pan et o et al. , and Quao et al. . It repr missing . The speTFP) level by increasing the R&D intensity. In the context of Chinese research, the OP method has more advantages than the LP method and the ACF method. Therefore, the OP method is used to estimate the total factor productivity (TFP) [TFP as the explained variable to examine the impact of Internet penetration on firms’ total factor productivity (TFP).Our paper also concerns whether the Internet penetration will promote corporates’ total factor productivity (ty (TFP)  and use the Internet are 0.004 (t = 2.59) and 0.090 (t = 4.35) respectively, which are both significantly positive at the 1% level. The above results show that the increase in Internet penetration rate not only increases the R&D intensity, but also further improves the innovation output efficiency and production efficiency of firms, and creates a good information technology environment for firms’ long-term development.The results are presented in In corporate innovation investment expenditure, usually, more than 50% is used to pay R&D personnel’s salary . Their RInternet are 0.722 (t = 4.31) and 0.227 (t = 12.05) respectively, which are both significantly positive at the 1% level. The above results indicate that the Internet penetration rate has significantly improved the human capital environment of firms, promoted the concentration of high-end R&D elements (R&D personnel) at the firm level, increased the salary incentives for R&D personnel, and created a favorable environment for corporate to actively engage in innovation activities.The results are reported in PSM) and Heckman two stages model. Then two possible mechanisms, "financing constraints" and "innovation failure tolerance" are further proposed and confirmed. It is found that, with the reduction of information opacity between external investors and firms, the external financing constraints faced by firms have decreased, and investors’ tolerance for management innovation failure has increased significantly, which both stimulate higher innovation motivation of firms. Finally, to shed further light on the economic implications of our findings, two additional tests have been done. It is found that the Internet penetration rate plays an important role in promoting the transformation rate of corporate innovation input and corporate production efficiency. And it also facilitates the concentration of high-end elements required for research and development at the firm level, which means the human capital environment of the firm has been greatly improved.Innovation is critical for firm value and sustainable economic growth, recent academic research, and public policy discussion have both focused on identifying factors that lead to more and better innovation , 71. LevGiven the corroborating results of this paper, our conclusions have several important theoretical and practical significance. First of all, the literature is enriched on the relationship between Internet technology and corporate innovation and the relationship between information disclosure environment and corporate innovation. Different from the previous literature, which mainly starts from the subject of firms, and explores the active Internetization of firms. The Internet penetration rate can help external investors to obtain company information, and promote corporate innovation , 20. SecThe existing literature mainly uses innovation input or innovation output to measure corporate innovation performance , 72. ourS1 Appendix. Variable definitions(DOCX)Click here for additional data file.S1 Dataset(RAR)Click here for additional data file.


Bradypus variegatus) is widely distributed in three biomes: The Amazon, Atlantic Forest, and Caatinga. Some subpopulations are isolated in urban areas in Brazil, usually in squares and small woods. Due to the scarcity of reference values, an investigation was carried out on the hematology and blood biochemistry of brown-throated sloths from urban areas.The brown-throated sloth  (Minas Gerais State) and Rio Tinto (RT) (Paraíba state), in the Atlantic Forest biome, Brazil. The samples were analyzed in specialized veterinary laboratories using automatic cell counters and slide fixation staining methods.The two subpopulations of brown-throated sloths had no significant differences in most hematological values, with the exception of a higher leukocyte concentration (p<0.01) in the RT sub-population. The difference in leukocyte concentration suggests an idiosyncratic effect, as the animals were healthy and the stress of the capture was acute, not chronic. The concentrations of urea, creatinine, and alkaline phosphatase (ALP) were similar (p<0.05) in brown-throated sloths from TO and RT. Likewise, the liver enzyme concentrations  did not differ between the two subpopulations (p<0.05).Compared to another study, brown-throated sloths from TO and RT have higher plasma concentrations of ALT and ALP, suggestive of a hepatic overload. Hematological and blood biochemical findings of TO and RT can be used as clinical reference values for brown-throated sloths living in an urban environment. Improving knowledge of animal physiology is a constant task for wildlife researchers to determine benchmarks for assessing the health of wild animals . In addiBradypus variegatus) have a wide geographical distribution, inhabiting forests in the Caatinga, Cerrado, Amazon, and Atlantic Forest biomes [Brown-throated sloths (t biomes . Althougt biomes .Sarcoptes scabiei), with Leishmania spp. [Leiuris leptocephalus [Trypanosoma cruzi, and Trypanosoma leeuwenhoek [As a result of cultural aspects and the lack of management , in somenia spp. ,10, Leiucephalus , Trypanouwenhoek . Sarcoptuwenhoek ,14. RefeThe aim of this study was to understand the ecology and biology of brown-throated sloths, aiming at defining the best practice of conservation medicine. Therefore, this work aims to describe the hematological and serum biochemical patterns in two subpopulations of brown-throated sloths living in an isolated urban area.The project was approved by the Animal Use Ethics Committee of the Federal University of Viçosa (authorization number 412013) and by the Biodiversity Authorization and Information System (authorization number 42162-3).The study was carried out in the Tiradentes and João Pessoa squares in the towns of Teófilo Otoni (TO) and Rio Tinto (RT), respectively. Both TO and RT are located in the Atlantic Forest biome, but the towns are located 1400 km apart. The Tiradentes square is located in the downtown area of TO, Minas Gerais, Brazil (17°51’52.73″S 41º30’29.48″O). TO is a town in the northeast of Minas Gerais, in the Mucuri Valley, considered the macro-regional center of commerce and has an estimated population of 140,000 inhabitants . TO city2 of area. The town of RT has a tropical climate and an average temperature of 25.9°C. The average annual rainfall is 1398 mm [The João Pessoa Square is located in the downtown area of RT, Paraíba (06°48′10″S 35°04′51″O). Its population, in 2012, was estimated by the IBGE at 23,431 inhabitants, spread over 466 km 1398 mm . At the Eight adult sloths were captured in TO and 11 in RT, in October 2013 and October 2014, respectively. We have no way of knowing the precise age, but all the animals captured were considered adults due to their morphological characteristics. Using rappel techniques, the sloths were carefully removed from the trees by one of the researchers. The claws were immobilized using masking tape, and they were transported to the ground using a cotton bag and ropes. After manual containment without the use of anesthesia, 2–3 mL of blood was collected by venipuncture from the cephalic vein of the thoracic limb. A part of the sample was stored in tubes with ethylenediaminetetraacetic acid  to analyze the blood count, and the other part in tubes without EDTA  for biochemical analysis. Immediately after collection, the animals were released into the same tree in which they were captured. The samples were transported in cooled containers for the blood count and biochemistry analysis. Each collection procedure lasted a maximum of 30 min/sloth. Two veterinarians performed the venipuncture and clinically evaluated the sloths through visual inspection and palpation.The blood counts of the samples of TO’s brown-throated sloths were performed at the Promed laboratory , and the RT samples were analyzed at the Pharmacy Laboratory of the Federal University of Paraíba . The samples without EDTA were centrifuged and sent to the Veterinary Clinical Laboratory of the Veterinary Hospital of the Federal University of Viçosa, for analysis of the biochemical parameters of the serum, using an automated clinical chemistry analyzer . The analysis was performed to detect the concentrations of urea, creatinine, alkaline phosphatase (ALP), alanine transaminase (ALT), and aspartate transaminase (AST).For data analysis, all animals were considered to be adults and we did not differentiate between male and female animals. The data were analyzed using SPSS 20.0 for Windows . The hematology and blood biochemistry data did not present a normal distribution and were, therefore, analyzed using non-parametric statistics (Mann–Whitney). The level of significance was set at <5%.Tables-Brown-throated sloths in both municipalities had similar hematological levels, except for the total number of leukocytes, which were higher in brown-throated sloths from the RT group. Regarding the biochemical values of urea, creatinine, AST, and ALP, there were no significant differences between the brown-throated sloths from RT and TO. Biochemical comparisons of ALT were not performed due to a failure in processing the plasma aliquots of the TO group.The main objective of this work was to establish standards of hematological and biochemical values for free-range brown-throated sloths in urban areas. Apart from total leukocytes, which were significantly higher in brown-throated sloths in the RT than in the TO group, the hematological and biochemical values were similar between the two subpopulations studied.3 (third quartile), while the maximum concentration in the TO group was 9700 cells/mm3 (second quartile). Therefore, when in the absence of disease or chronic stress, an idiosyncratic effect is expected on the leukocyte concentration, such as is seen in the sloth subpopulations from RT and TO.Elevations in the leukocyte count may generally occur because of chronic stress or disease . The broFicus leaves) could elicit the same metabolic responses in both TO and RT brown-throated sloths. Indeed, some of us have observed a high intake of mature leaves by TO and RT sloths [The observed values were similar between the two subpopulations of brown-throated sloths for concentrations of urea, creatinine, AST, and ALP . It was T sloths ,19.Divergence was verified in relation to the enzyme values Tables- and 4 deThe ALT of RT brown-throated sloths was 3.8 times higher than that of urban sloths from a place in the state of Rio de Janeiro . CompareFicus [Ficus sp. were described to correspond only to 19.51% of the brown-throated sloth’s natural diet, which is supplemented with other trees [Toxic compounds can cause liver changes in animals without necessarily causing jaundice or other disease symptoms . ChangesFicus ,21, whicer trees . The leaer trees . Diet reB. variegatus [The values obtained in this study should be interpreted with caution, when compared to those of the previous studies ,18. Severiegatus ,18. The riegatus  was perfAlthough our study aimed to describe the hematological and biochemical parameters of urban free-range brown-throated sloths, the data refer mostly to males because few females were captured. Therefore, caution should be exercised if a physiological or clinical evaluation considering the sex of the sloths is needed. There are similar challenges to living in squares or small woods in urban areas such as pollution, human disturbance, and low vegetal diversity. Therefore, the hematology and blood biochemistry data presented in this study could be considered as clinical reference indices for adult brown-throated sloths living in urban spaces.In this study, the leukocyte concentration showed a wide physiological range, probably resulting from an idiosyncratic effect in brown-throated sloths. High hepatic enzyme levels led to the suspicion of liver disorders in sloths from both RT and TO. The descriptions of hematological and biochemical profiles for brown-throated sloths are scarce, making comparison difficult. The current study is a source of clinical reference data for urban sloths living in cities of the Atlantic Forest biome.KFP: Background theory, design of experiment, methodology, data collection, data analysis and interpretation, writing and reviewing the text. IOS and VB: Coordinator, background theory, design of experiment, methodology, data collection, data analysis and interpretation, writing and reviewing the text. FFRS and VHDS: Methodology, data collection, data analysis and interpretation. CSSC: Coordinator, methodology, data collection, data analysis and interpretation, writing and reviewing of the text. All authors have read and approved the final manuscript.


Background and Aims: Social interaction in the online games has been found to predict gaming disorder, but little research has examined the mechanism of this association. Drawing on the social capital theory, the present study investigated the mediating role of online social capital on the relationship between in-game social interaction and gaming disorder and the moderating role of alienation on the relationship between online social capital and gaming disorder.Methods: A sample of 457 Chinese massively multiplayer online role-playing game gamers was recruited to complete the In-game Social Interaction Questionnaire, Online Social Capital Scale, Alienation Scale, and Pathological Gaming Scale.Results: The results showed that online social capital was a mediator in the relationship between in-game social interaction and gaming disorder. Moreover, for individuals with low alienation, the effect of online social capital on gaming disorder was weaker than for those with high alienation.Conclusions: The present study provides new insight into the complex processes involved in the effect of in-game social interaction on gaming disorder, and the results have important theoretical and practical implications. International Classification of Diseases  are assM = 19.81, SD = 1.36). The participants completed a survey to collect information regarding demographic variables, in-game social interaction, online social capital, alienation, and gaming disorder.Based on the comprehensive consideration of research accuracy and cost, a total of 495 MMORPG gamers were recruited through convenience sampling method from four universities in China during the 2018 fall semester. After excluding invalid questionnaires (with incomplete data), 457 valid questionnaires were collected ; the effective rate was 92.32%. Their ages ranged from 18 to 23 years old . Cronbach's α in the current study was 0.75.Based on this, Zhong  developeOnline social capital was measured with a translated version of the Internet Social Capital Scales , which wAlienation was measured by the 15-item Alienation Scale developed by Yang et al. . The scaA translated version of the 11-item Pathological Gaming Scale  was usedSurveys were conducted in classes by trained psychology graduate students after obtaining a written informed consent from participants. All participants were told that their participation was voluntary and that their privacy would be protected. The data collectors explained the requirements to the participants with standard instructions. At the end of the study, the participants were thanked for their participation. SPSS 21.0 was used for statistical analyses, descriptive statistics, correlational analyses, and examining the interaction effects and mediation effects.The study was approved by the institutional review board of the Institute of Education, Henan Normal University, China. Written informed consent was obtained from all participants prior to assessment. This study did not involve human and/or animal experimentation and conformed to all guidelines according to the Declaration of Helsinki.r = 0.39, p < 0.01; r = 0.18, p < 0.01). In addition, online social capital was positively correlated with gaming disorder . Finally, alienation was positively associated with gaming disorder .The means, standard deviations, and Pearson correlational analyses for all variables are presented in via online social capital. We used the macro PROCESS (model 4) for SPSS  and online social capital ; when in-game social interaction was controlled, online social capital was significantly associated with gaming disorder . Finally, the bias-corrected percentile bootstrap method indicated that the indirect effect of in-game social interaction on gaming disorder through online social capital was significant, ab =.16, SE =.03, 95% CI= . Therefore, hypothesis 1 was supported.We expected that alienation would moderate the mediation effect of online social capital on gaming disorder. According to Muller et al. , the parp < 0.01), but the interaction effect was not significant . Model 2 indicated that the main effect of in-game social interaction on online social capital was significant , but the main effect of alienation and the interaction effect were not significant . In model 3, alienation and online social capital both had a significant effect on gaming disorder , and the interaction effect of online social capital and alienation on gaming disorder was also significant .As simple =.35, p < 0.001). However, for individuals with low alienation, the effect of online social capital on gaming disorder was still significant but much weaker .To facilitate the interpretation of this interaction effect, we plotted predicted gaming disorder against online social capital separately for low and high levels of alienation  , which hThis research has several important theoretical implications. First, the present study provided further evidence that in-game social interaction can influence gamers' problematic video game play . Second,Aside from the theoretical contributions, this research also has important practical implications. First, this study confirms that online gaming is a double-edged sword . For somThis study is an important step in unpacking how in-game social interactions relate to college students' gaming disorder. The findings suggest that the positive impact of in-game social interactions on gaming disorder can be partially explained by increased online social capital. Moreover, this indirect link was moderated by alienation in the second stage of the mediation process, such that the path from social capital to gaming disorder was stronger for more highly alienated individuals. This moderated mediation model is important because it provides a more comprehensive understanding of “how” and “when” in-game social interactions may increase gaming disorder.The datasets generated for this study are available on request to the corresponding author.The study was approved by the institutional review board of the Institute of Education, Henan Normal University, China. Written informed consent was obtained from all participants prior to assessment. This study did not involve human and/or animal experimentation and conformed to all guidelines according to the Declaration of Helsinki.All authors listed have made a substantial, direct and intellectual contribution to the work, and approved it for publication. MW make substantial contributions to the acquisition, analysis, or interpretation of data for the work.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.


Determining subclinical Brain stroke (BS) risk factors may allow for early and more operative BS prevention measures to find the main risk factors and moderating effects of survival in patients with BS. In this prospective study, a total of 332 patients were recruited from 2004 up to 2018. Cox's proportional hazard regressions were used to analyze the predictors of survival and the moderating effect by introducing the interaction effects. The survival probability 1-, 5- and 10-year death rates were 0.254, 0.053, and 0. 023, respectively. The most important risk factors for predicting BS were age category, sex, history of blood pressure, history of diabetes, history of hyperlipoproteinemia, oral contraceptive pill, hemorrhagic cerebrovascular accident. Interestingly, the age category and education level, smoking and using oral contraceptive pill moderates the relationship between the history of cerebrovascular accident, history of heart disease, and history of blood pressure with the hazard of BS, respectively. Instead of considerable advances in the treatment of the patient with BS, effective BS prevention remains the best means for dropping the BS load regarding the related factors found in this study. Of these numbers, 5 million dies, and the other 5 million are permanently disabled. High blood pressure contributes to more than 12.7 million strokes worldwide. Europe averages approximately 650,000 BS death each year. These figures indicate the importance of studying BS.Brain stroke (BS) is among the primary sources of mortality and permanent disability in the world. BS is the second leading cause of death in Iran. Besides, it causes more long-standing severe disabilities than any other disease. More than half of patients with BS will die within the subsequent eight years. An approximately three-quarters of all strokes arise in the community over the age of 65. The risk of developing BS would double more than per decade after the age of 55 (U.S. Centers for Disease Control and Prevention). According to the World Health Organization3. It has been suggested that the history of hyperlipoproteinemia is a risk factor for BS and that the increased stroke incidence in persons with long term exposure to the risk factors promotes atherosclerosis and subsequently develops BS Diabetes increases the risk of cardiovascular and cerebrovascular diseases (such as ischemic BS)4. Around 30% of BS patients have diabetes4 neurological deficits and death rates are meaningfully higher in patients with BS who also have diabetes 5. Smoking and passive smoking, as one of the main risk factors for BS, has been identified by some studies7 passive smoking increases the risk of overall BS 30%7. Determining BS risk factors may allow for early and possibly more operative BS prevention.Modifiable factors to support endorse survival among patients with BS are of central public health importance. Hypertension is the most potent risk factor for BS. Age and the existence of other risk factors may alter or improve the result of increased blood pressure on BS incidence 2–5. According to the common risk factors among patients with BS, in developed countries, the incidence of stroke is declining, mainly due to efforts to lower blood pressure and reduce smoking. However, the overall rate of stroke remains high due to the aging of the population. Impaired cardiac function growths stroke incidence at all levels of blood pressureBased on an extensive search, no study was found (if any) to model the risk factors of the hazard of death and their possible moderating effects among patients with BS in Ardabil, Iran. Therefore, this study aimed to model the main predictors of survival in patients with BS, along with the moderating effects of these factors in a period of 10-years follow up.In the current prospective longitudinal study, data were acquired from the BS registry of the Imam Khomeini Hospital, Ardabil, Iran. All patients complied with the International Coding System ICD-10 according to the Computerized Tomography (CT) scan and Magnetic Resonance Imaging (MRI). A total of 332 patients were entered in the ten-year follow-up study (defined as the date of diagnosis from June 2004 up to June 2018). The follow-up time was calculated from the date of hospitalization by acute BS until the death or end of follow-up, whichever came first. Telephone interviews managed post-BS death outcomes only through one of the main authors/researchers (FF) of the study. An exact date of death and cause of death were recorded, except for cases that did not receive a response after multiple follow-ups, and those who died due to non-BS.For all patients and based on hospital document, the demographic variables included age category at diagnosis , sex , employment status , place of residence , education level , smoking , former smoking , waterpipe smoking , history of heart disease , diabetes , oral contraceptive pill use , physical activates , history of cerebrovascular accident type , history of blood pressure history , history of hyperlipoproteinemia , history of myocardial infraction  were used in the analysis.The protocol of the study was approved by the institutional review board of Tabriz University of Medical Sciences (ethics code: IR.TBZMED.REC.1398.667). Every person was free to participate in the study, and the privacy of participants was also preserved. All participants filled and signed the consentment and also, informed consent has been taken from all participants. All methods were carried out in accordance with relevant guidelines and regulations.p < 0.1) was utilized. Adjustments were made for background variables including age category, sex, employment status, place of residence, education level and physical activity for the interested BS risk factors including history of hypertension, history of diabetes, history of cerebrovascular accident, history of myocardial infraction, history of blood pressure history, history of heart disease, history of hyperlipoproteinemia history, smoking, oral contraceptive pill use, and cerebrovascular accident type. Also to assess the moderating effect, the interaction effect of the risk factor of BS with background variables were tested in the model8.Statistical analysis was done by STATA software [ver.15] . Data were presented using mean (SD), median (min–max) for the numeric normal and non-normal variables respectively, and frequency (percent/rate) for categorical variables. Survival time was calculated in months and was expressed as the median ). Data were described with frequency, rate, and proportion. The Kaplan–Meier method was used to estimate the rates of BS The survival probabilities were compared in groups by the Log-rank test. Cox proportional hazards regression analysis has been conducted to determine the relationship among related BS risk factors, by estimation of its hazard ratio (HR) and 90% CI. In the multivariate analysis, a backward elimination strategy with  and all individual variables tests (All p > 0.05).Furthermore, Harrell's C index was computed as a measure of concordance between model predictions and real outcomes . The missing data ranged over 0.33%—2.01% which were ignorable and were deleted listwise in the analysis. The Proportional Hazard (PH) assumption was assessed by Shoenfield residuals' testThe study protocol was approved by the institutional review board of Tabriz University of Medical Sciences (IRB No.: TBAMED.REC. 1397.286).Of the 480 patients enrolled in this study, 332 were eligible to participate in this study, 32 (13%) persons were censored within 10-years of follow up. The median follows up time was 81.3  months, respectively. The mean age at diagnosis was 77.42 (SD 10.4) months in BS patients. In these patients, 1-, 5- and 10-year survival probability (95% CI) were 68% (63–72), 59% (53—64), 39% (34—45), respectively. The median survival time (95% CI) of these patients was 77.42 (62.07—104.48).The distribution and comparison of death rate based on demographics of the study participants are presented in Table p < 0.05).Table p < 0.05). Other factors, i.e., employment status, education, were not associated with the survival probability in patients with BS. (p > 0.05). Also, physical activity was inversely and significantly related to the hazard of the event (p < 0.05).For demographic characteristics, higher age categories and being male were significantly related to death rate (p < 0.05), but other clinical variables such as cerebrovascular accident history, myocardial infraction, blood pressure, heart disease, smoking, former smoking, passive smoking, waterpipe smoking were not significantly related to the hazard of the event (p > 0.05)  Table .Table 3Rp < 0.001). Furthermore, Harrell's C index (= 0.71), indicating a fair level of concordance between observed and predicted death in the study sample.The results of the multivariate Cox regression for patients with BS are shown in Table The results to assess the interaction effect of the significant risk factor of BS with background variables are presented in Table The plot of KM survival probability displays that after 2-months of follow up, the survival rate declined to 75%. Then the mortality rate has dropped steadily until 160 months, and later a sudden fall in survival probability was observed .The results of testing the PH assumption indicated that all predictors had satisfied the PH assumption in all cox regression models , having a hemorrhagic cerebrovascular accident, and not being physically active directly predicted the survival in patients with BS. Interestingly, the interaction effect of cerebrovascular accident history with age category and education level, the interaction effect of history of heart disease with smoking, and the interaction effect of history of blood pressure with oral contraceptive pill use were significant on the hazard of BS, indicating that age category and education level moderates the relationship between the history of cerebrovascular accident and hazard of BS, smoking moderates the relationship between a history of heart disease and hazard of BS, oral contraceptive pill use moderates the relationship between a history of blood pressure and hazard of BS.9, however, some controversies could be explained so that confounders have not been adjusted, and also, women were older when they get their first BS10. Other demographic characteristics, i.e., employment status, place of residence, and education level, weren't the significant predictors of survival for BS. Physical activity was a significant prognostic factor of BS based on the results of univariate and multivariate analysis. BS patients with physical activity had a 0.35% hazard rate of less than inactive patients. There is controversy so that Willey et al. reported that any physical activity was not associated with ischemic BS in univariate or multivariable analyses 11. Differences in methodology, study populations, and interferences are expected to have contributed to these dissimilarities.The results of univariate analysis for demographic characteristics showed that the age category and sex of the participants were prognostic factors of BS Although, the sex wasn't significant in multivariate analysis. Still, the male patients were more likely to die from BS than the female patients (about 40%). Although the finding of some studies confirms this result13. History of diabetes was a significant risk factor of BS in univariate analysis. Though it wasn't statistically significant in multivariate analysis, however, a suggestive effect of this variable has been observed so that diabetes develops BS 29% more likely than non-diabetes3, Ji et al. confirms the same result3. Having the history of hyperlipoproteinemia was a significant risk factor of BS in univariate analysis. Patients without a history of hyperlipoproteinemia develop BS about 36% more than patients with a history of hyperlipoproteinemia, there is a finding in line with our study2. Using the oral contraceptive pill was a significant risk factor of BS in female patients in the univariate analysis, the same finding has been assessed from the studies5. Oral contraceptive pill users were at increased risk of myocardial infarction or BS compared with non‐users: relative risk (RR) 1.6 (95% CI = 1.3‐1.9)5. The overall summary odds ratio for first-ever ischemic stroke risk associated with current oral contraceptive pill use compared with noncurrent oral contraceptive pill use was 2.47 [95% CI = 2.04–2.99]. Hemorrhagic cerebrovascular accident was significant for BS according to the results of univariate and multivariate analysis. However, BS patients with hemorrhagic cerebrovascular accident had 1.5 times worse outcomes than those with Ischemic. There are finding that confirms the results of our study5.Based on the results of univariate analysis for clinical characteristics, having the history of blood pressure was a significant prognostic factor of BS Patients with a history of blood pressure had a worse outcome. Still, it wasn't statistically significant in multivariate analysis. Some studies support this claim15. Fifthly, regular care, living conditions, and the quality of receiving essential care couldn't be considered in the assessments. To implement the concerns as a bias in the statistical models, introducing frailty in the model to account for unobserved heterogeneity can be recommended. Such models, along with the cox model, require some assumptions like PH and the independent censoring, which can be relaxed by statistical learning procedures. In this regard, we recommend the deep learning of artificial neural networks as our future program.The strength of this study is the prospective setting; original features are the instant evaluation of the effect of risk factors on outcomes, allowing assessment of the relative impact of each predictor of survival. However, there are some limitations to this study, and the results should be concluded considering these limitations. Firstly, there may be some evidence of inaccurate responding of the person who accompanied the patients with severe/critical conditions. As the second limitation, some cases of BS immediately lead in death at the time they had been admitted to the hospital that was not included in the study. Thirdly, we hadn’t the NIHSS at baseline in our database as NIHSS may improve the findings and make them more conclusive. Fourthly, we used a simple procedure for follow up over telephone, and there were neither reliability criteria for this nor additional technical/medical work-ups. The telephone-based follow-up is a regular task in survival studiesAccording to the results, age category, sex, employment status, place of residence, education level, physical activity, history of blood pressure, history of diabetes, history of hyperlipoproteinemia, oral contraceptive pill use, cerebrovascular accident were significant risk factors of BS. Also, the age and education, smoking, and using oral contraceptive pill moderates the relationship between cerebrovascular accident history, history of heart disease, and blood pressure history with the hazard of BS, respectively. According to the results obtained in this study, recognizing the BS risk factors provide early and probably more effective BS prevention procedures. Rather than substantial advances for the treatment of a patient with BS, operative BS prevention remains the best action for reducing the BS burden. Also, as modifiable risk factors, increasing physical activity and smoking cessation, the control of high blood pressure, preventing diabetes, and hyperlipoproteinemia may be useful in decreasing the risk of BS for different ages and sexes.


Depression is a common mood disorder in people living with human immunodeficiency virus (PLWH) and is associated with risk-taking sexual behaviour.This study examines depression, sleep quality and condom usage amongst PLWH in Tehran, Iran.This cross-sectional study was undertaken between October and November 2019 on 298 PLWH referred to voluntary counselling and testing centres (VCTs) in Tehran. Participants provided information as per the following questionnaires: the Depression, Anxiety, Stress Scale (DASS), the Pittsburgh Sleep Quality Index Questionnaire and a demographic questionnaire that evaluated condom use.not to use condoms than those who were not depressed . The adjusted OR for not using a condom amongst the depressed was 7.12 times greater  than in those without depression.A total of 298 PLWH, of whom 202 (67.8%) were men with a mean age of 39.81 years, were enrolled in the study. The DASS classified 57% with depression. Fewer than 20% of these used condoms regularly. The majority of depressed patients were men (68.6%) and 31.4% were women. The depressed patients were more likely Our findings suggest that depression is common amongst PLWH in Tehran and is associated with risk-taking sexual behaviour. Appropriate interventions are needed to address mental disorders in PLWH. It is recommended that patients be screened regularly for symptoms of depression and, where indicated, counselled and managed. Mental disorders are common in this group and include depression, mania, psychosis, anxiety, substance abuse and the risk of suicide.3The World Health Organization (WHO) reports that at the end of 2018, approximately 38 million people were living with human immunodeficiency virus (HIV) globally.6 These behaviours are also associated with the acquisition of HIV.7 Depression has been linked to unreliable adherence to antiretroviral therapy (ART) and treatment failure. Indeed, risk-taking sexual behaviour, poor adherence to treatment and ART failure require the exclusion of depression as a cause.9 The correct and consistent use of condoms reduces HIV transmission and other sexually transmitted infections (STIs).12 Condom use is influenced by depression. In a study of 278 Chinese women at high risk of HIV infection, 62% had high levels of depression. Those with more severe depression were more likely not to use a condom or to misuse it.13Multiple sexual partners and drug and alcohol abuse are more likely amongst depressed than non-depressed people.16 Given the importance of condoms in preventing STIs, this study aimed to identify associations between depression, sleep quality and condom use in this cohort of PLWH.Although studies of condom use have been conducted in various countries, the generalisability of these to Iranian PLWH is uncertain in view of significant cultural, social and economic differences. Furthermore, Iranian studies of condom use in PLWH and other at-risk groups with mood disorders are few.This study was performed as a cross-sectional study on 298 PLWH referred to voluntary counselling and testing centres (VCTs) in Tehran, the capital of Iran, from October to November 2019. We evaluated depression, sleep quality and condom use in PLWH and assessed the presence of independent associations between these factors.As Tehran is a large city, to ensure the random selection of VCTs from all regions of the city, it was divided into four geographical areas – north, south, east and west. After that, a list of these centres was prepared separately for each of the four regions. In each area, two VCTs were randomly selected, for a total of eight centres. Finally, the existing files in each centre were randomly selected, and people were invited to participate in the study.17A demographic questionnaire, the Depression Anxiety Stress Scale (DASS) and the Pittsburgh Sleep Quality Index Questionnaire (PSQI) were used for data collection. The DASS questionnaire is designed to address depression and anxiety overlap. This scale has two different versions. In the main version, which has 42 questions, each of the psychological structures  is evaluated by 14 different questions, but in its abbreviated version, there are 21 questions, and each psychological structure is measured by seven questions. Each question can be answered by ‘never’, ‘sometimes’, ‘often’ or ‘almost always’. Various studies indicate that the DASS questionnaire provides valid assessments of the three structures of depression, anxiety and stress and can significantly differentiate between different contexts.19 To assess the quality of sleep in patients in the last month, the PSQI was used. This questionnaire has seven components: quality of sleep, sleep delay, sleep duration, sleep efficiency, sleep disorders, sleeping pill use and daily dysfunction. Many studies have confirmed the validity and reliability of this questionnaire.21 Each component can be scored from 0 to 3, and an overall score of 5 and above indicates inappropriate or poor quality of sleep.22 Background demographic data also collected included gender, age, education, marital status, body mass index (BMI), employment status, CD4 count, time since HIV diagnosis, route of transmission, concurrent hepatitis B and C and tuberculosis infections and duration of ART. Participants were asked about condom use during the past year. The response was divided into three parts: people who never used a condom, people who used it sometimes and people who always used a condom.In this study, the Persian translation of the abbreviated version of the questionnaire was used. The validity and reliability of the Persian version have been confirmed in several studies.n = 8) were excluded from the sample. Other participants were included in the study.Our inclusion criteria were (1) confirmation of HIV infection by rapid and enzyme-linked immunosorbent assay HIV tests, (2) a history of sexual intercourse at least once over the past 12 months, (3) age 18 years or older and (4) informed consent to participate in the study. Participants whose condom use status was unclear . The interviewers provided participants with an explanation of the study and its objectives and invited participants to consider enrolling. Participants were assured of confidentiality and an ‘opt-out option’ if they did not wish to continue with the study. Informed consent was obtained from participants prior to the study.t-test were used to evaluate the differences between depressed and non-depressed individuals in terms of age, BMI, duration since the HIV diagnosis, CD4 count and duration of ART. We used a chi-square test to evaluate differences between depressed and non-depressed individuals in terms of gender, educational level, marital status, condom use status, sleep quality, anxiety, stress, route of HIV transmission and coinfections.For quantitative data, mean and standard deviation (SD) were used; frequency and percentage were reported for the qualitative variables. One-way analysis of variance and p-value of less than 0.05 was considered significant.The multinomial logistic regression method was used to determine the relationship between depression, age, sex, marital status, duration since the diagnosis of HIV and the use of condoms, and people who always used condoms were defined as a reference. All analyses were performed with Stata software, and a This study was approved by the ethical committee of Tehran University of Medical Sciences .2. In all, 30% of participants never used condoms, 32% sometimes used condoms and 37.1% always used condoms. The demographics of the participants, their condom use status and their sleep quality are tabulated in A total of 298 HIV-positive patients, including 96 women (32.2%) and 202 men (67.8%), participated in the study. The average age of participants was 39.81 (SD = 9.67) years. More than half were married. About half of the participants were illiterate or had less than 12 years of formal education, namely, ‘under diploma’ status. The mean BMI of the participants was 24.5 kg/mp < 0.05). The depressed group had a significantly higher BMI than the non-depressed group. Amongst 169 depressed individuals, only 32 (18.9%) always used condoms, whilst 71 (42%) never used condoms. Almost 70% of the participants had a PSQI of > 5, which means that they had poor sleep quality. Eighty-two per cent (n = 139) of PLWH with depression suffered from poor sleep quality. Similarly, 75% and 91% of depressed people had symptoms of anxiety and stress, respectively. The overall prevalence of depression was 56.7%. Almost 70% of those with depression were men, and more than half of the depressed patients were unemployed and had not completed formal education .31It also appears that depression is more common in patients with lower educational levels, those who are unemployed and those who are overweight . Having a job and sufficient income is one of the most important social factors affecting health and has a significant impact on the mental state of individuals. Unemployment or low-income work promote the cycle of poverty and limit access to healthcare.32 It is also a risk factor for mood disorders.33 Downing et al. found that good sleep quality is associated with less depression and anxiety and more self-efficient condom use in PLWH.34Eighty-two per cent of depressed PLWH had poor sleep quality. Poor sleep quality can lead to daily drowsiness, mood swings, decreased quality of social interaction, exacerbation of depression, anxiety and increased high-risk behaviours.Lack of questions about the reasons for not using condoms in patients is one limitation of our study, as identifying the barriers to protective behaviour could play an essential role in planning strategies to remove these barriers. Another limitation is the use of face-to-face interviews for data collecting, which was challenging in some cases, given Iran’s cultural, religious and social context. This may have led to various biases . Thirdly, it was a cross-sectional study, and we could not evaluate the transmission of the virus to sexual partners in the depressed and non-depressed patients. Fourthly, we did not assess the patients’ viral load, which can also affect the transmission of the virus to patients’ sexual partners. Fifthly, we used a questionnaire to see whether the patients were depressed or not, which is another limitation of our study as confirmation of depression by a psychologist could give a more accurate assessment.In this study, we evaluated the prevalence of depression in PLWH and its associations with sleep quality and condom use. The prevalence of depression in Iranian PLWH is relatively high, and interventions are needed to address this problem. Furthermore, depressed PLWH have worse sleep quality and use condoms less frequently compared to non-depressed PLWH. Interventions to improve the sleep quality and mood of PLWH may be valuable considering their associations with condom use.


The areas under the ROC curve for thinness, overweight, obesity, and stunting were 0.88, 0.97, 0.97, and 0.77, respectively. The optimal MUAC cutoff values for predicting thinness and stunting were 167.5 mm and 162.5 mm, respectively; the optimal cutoffs for predicting overweight and obesity were 190.5 mm and 218.0 mm, respectively. These cutoffs differed after stratification by age group and birth weight. Our results confirm MUAC to be a useful tool for monitoring growth in schoolchildren.The double burden of malnutrition (under- and overnutrition) is a serious public health issue in childhood. The mid-upper arm circumference (MUAC) is a simple tool for screening nutritional status, but studies of the optimal cutoff to define malnutrition are limited. This study aimed to explore the prediction of malnutrition by MUAC in Sri Lankan schoolchildren. The participants were 538 students  aged 5–10 years. Spearman’s rank correlation was calculated for MUAC and both body-mass-index-for-age z-score (BAZ) and height-for-age z-score (HAZ). Receiver operating characteristic (ROC) analysis was conducted to assess the ability of MUAC to correctly classify malnutrition, after stratifying for age and birth weight. MUAC correlated significantly with BAZ ( Child malnutrition is a serious public health concern worldwide . In urbaMeasurement of mid-upper arm circumference (MUAC) provides a simple and reliable tool for screening nutritional status and also enables rapid assessment of large populations in epidemiological field study. Traditionally, MUAC has served as a practical proxy measure of undernutrition and in particular, of severe acute malnutrition among infants, children under 5 years , and preRecently, MUAC was found to be highly accurate for detecting overweight in schoolchildren in South Africa  and the In this study, we aimed to identify the MUAC cutoff values that best predict malnutrition (under- and overnutrition) in primary school children aged 5–10 years. The second aim was to obtain more accurate MUAC cutoff values for school children in Sri Lanka, where low birth weight is prevalent.Data were collected in primary schools with grades 1–5 in the Gampaha district, an urban area of Sri Lanka, in September 2017. We categorized all primary schools into four types, according to the educational system in Sri Lanka: Type 1AB (13-year education with arts and science), Type 1C (13-year education with arts), Type 2 (11-year education), and Type 3 (5-year education). The school and class for each grade were randomly sampled from each school type. Students were selected from the index number of the attendance register using a random number table. Details of the sampling procedure have been described elsewhere [The study was approved by the Ethical Review Committee of the University of Kelaniya in Sri Lanka, the Institutional Review Board of the National Institutes of Biomedical Innovation, Health and Nutrition in Japan , and by the Department of Education, Western Province, Sri Lanka. Informed written consent was obtained from the parents or guardians of participating children prior to participation in the study.The anthropometric indicators measured were height, weight, and MUAC. Height (cm) was measured to the closest 0.1 cm using a portable stadiometer , with children standing in bare feet. Weight (kg) was measured to the closest 0.1 kg using a digital scale , with children in light clothing. BAZ and HAZ were determined using the WHO growth curves . ThinnesMUAC (cm) was measured using a colored plastic tape . The trained data collectors marked the midpoint of the subject’s upper arm, located between the tips of the shoulder and elbow, then wrapped the measuring tape around the subject’s arm at the midpoint and recorded the MUAC to the nearest 0.1 cm. All measurements were performed according to the standardized protocol  by trainAdditionally, birth weight data were obtained from participants’ mothers, who were asked to bring the Child Health and Development Record booklet given at birth, to refer to birth weight. Of the students who reported birth weight, 96.6% were confirmed by the booklets.For the subsequent analyses, participants were grouped into younger children (age 5–7 years) or older children (age 8–10 years). Spearman’s rank correlations were calculated for MUAC and both BAZ and HAZ to evaluate the strength and direction of any linear relationship between them. Receiver operating characteristic (ROC) curves were plotted and the area under the curve (AUC) computed to assess the sensitivity and specificity of various cutoffs for thinness, overweight, obesity, and stunting. Finally, the Youden Index was used to identify optimal cutoffs, which were stratified by age group (younger or older) and birth weight (<2500 g or ≥2500 g). The statistical analysis was performed with the Stata Statistical Software Release 15.1 macro package .A total of 538 schoolchildren (202 boys and 336 girls) aged 5–10 years were included in the analysis. The anthropometric characteristics of the study population, stratified by sex and age, are described in The distributions of their BMI by sex are presented in r = 0.87 and 0.89 for the younger and older group, respectively) (p < 0.001). Meanwhile, there was a significant but weak correlation between MUAC and HAZ  (p < 0.001).This study explored the use of MUAC and sought to identify cutoff values for the prediction of thinness, overweight, obesity, and stunting, in Sri Lankan schoolchildren aged 5–10 years. MUAC was found to be a highly accurate predictor of overweight and obesity and a moderately accurate predictor of thinness and stunting. Of note, different MUAC optimal cutoff values were obtained after stratifying by age group and birth weight.With respect to the prediction of undernutrition, MUAC more accurately identified thinness than stunting. This is since MUAC measures the sum of muscle, bone, and fat in the midpoint of the arm, which are not necessarily affected by height alone. The optimal MUAC cutoff for thinness (167.5 mm) found in the Sri Lankan schoolchildren was higher than that (145 mm) previously found in African children aged 5–9 years . This inRegarding the prediction of overnutrition, the optimal MUAC cutoffs for overweight  proposed for Sri Lankan schoolchildren were consistent with the sex‒age specific MUAC cutoff values range (192–230 mm) for overweight demonstrated in Dutch children aged 5–10 years . The couOngoing growth monitoring using this simple MUAC tool in the school setting will be helpful for all children over age 5 years in regularly checking their nutritional status. Late childhood is a critical period for healthy growth during which appropriate lifestyle habits may be learned according to nutritional status. Furthermore, in Sri Lanka, as in other Asian countries, maternal obesity has been increasing alongside the double burden of malnutrition in schoolchildren. Additional studies are also needed to determine Asian-specific cutoffs that predict malnutrition throughout life.The results of the present study must be interpreted in light of its limitations. Firstly, the present study did not consider the influence of health status or potential morbidity/mortality risks (apart from birth weight). Moreover, as MUAC does not consider body composition, it may be a limited tool in identifying overweight and obesity in children with low skeletal muscle mass. Certainly, MUAC has often been used in extreme conditions, such as those found in refugee camps or natural disasters, where nutritional problems may be more likely; however, MUAC can be equally and easily enlisted to identify malnutrition that may occur  in otherwise stable situations. Therefore, our findings reflecting the general population, as opposed to at-risk populations, are meaningful. Secondly, the study sample was drawn from a single district and was not necessarily representative of the wider Sri Lankan population, even though the participants were randomly selected in each school. Nevertheless, in the absence of international consensus on the optimal MUAC threshold for malnutrition in children over 5 years, the findings of this study provide an important contribution.Our findings showed that MUAC is a good predictor of malnutrition (under- and overnutrition) in Sri Lankan schoolchildren and that MUAC cutoff values for malnutrition differ according to age group and birth weight. Easily performed, regular growth monitoring with the MUAC should be undertaken for ongoing assessment of nutritional status in schoolchildren.


The combination of student Self-Regulation (SR) and the context of Regulatory Teaching (RT), each in varying degree, has recently been demonstrated to have effects on achievement emotions, factors and symptoms of stress, and coping strategies. The aim of the present research study is to verify its possible further effects, on academic behavioral confidence and procrastination. A total of 1193 university students completed validated online questionnaires with regard to specific subjects in their degree program. Using an ex post facto design, multivariate analyses and structural equation modeling (SEM) were carried out in order to test the relationships predicted by the model. SR and RT had a significant joint effect in determining the degree of academic behavioral confidence and of procrastination. Academic behavioral confidence also significantly predicted reasons for procrastinating, and these in turn predicted activities of procrastination. Conclusions are discussed, insisting on the combined weight of the two variables in determining academic behavioral confidence, reasons for procrastinating and activities subject to procrastination, in university students. Implications for guidance and educational support of university students and teachers are analyzed. This study forms part of a series whose aim is to determine the combined effect of student self-regulation and of regulatory teaching on other academic variables. The aim of the present study, therefore, was to establish the combined effect of the student’s level of self-regulation (SR) and the level of regulatory teaching (RT) on students’ degree of academic behavioral confidence, as a precursor to reasons for procrastinating and to activities of procrastination. This study, then, would complete the body of published evidence that consistently indicates a joint effect of the two variables, self-regulation and regulatory teaching, in this Research Topic .3P model Very Unfavorable combination (type 1) refers to a classroom combination of a student with low self-regulation (SR) and a teaching process low in external regulation (RT). In this case, the model predicts low academic behavioral confidence and high procrastination.The worst, (2)Unfavorable combination (type 2) refers to a classroom combination of a student with low SR and a teacher with medium RT, or the inverse. Here, the model predicts medium-low academic behavioral confidence and medium-high procrastination.An (3)Medium combination (type 3) refers to the combination of a student with medium SR and a teacher with medium RT. The model predicts medium academic behavioral confidence and a medium level of procrastination.A (4)Favorable combination (type 4) refers to the combination of a student with medium SR and a teacher with high RT, or the inverse. The model predicts medium-high academic behavioral confidence and a medium-low level of procrastination.A (5)Most Favorable combination (type 5) refers to the combination of a student with high SR and a teacher with high RT. The model predicts high academic behavioral confidence and a low level of procrastination.The Previous research has consistently shown this heuristic to establish significant differences in the factors and symptoms of stress , coping academic behavioral confidence has been defined as an eminently personal and attitudinal construct  and direction (approach vs. avoidance), while frequency describes the intensity of procrastination in different activities.Procrastination has been studied and described for general matters of daily life as well as for specific areas, such as the contexts of health and academics. Procrastination is understood to be a failure in motivation that creates a gap between intention and action, with negative consequences for the individual , and hasmotives or reasons for procrastinating has established certain commonalities, such as attraction/uncertainty about the task, fear of failure or fear of evaluation  to establish whether the combination levels defined in SRL vs. ERL Theory  determinhypotheses were stated. (1) A graded increase in level of regulation  would give rise to an increase in academic behavioral confidence, and a proportionate decrease in reasons for and activities of procrastination. By contrast, a graded decrease in level of regulation  would give rise to a decrease in academic behavioral confidence, and a proportionate increase in reasons for and activities of procrastination. (2) Regulation factors in students and in the teaching would be positive, significant predictors of academic behavioral confidence; the latter would in turn negatively predict reasons for and activities of procrastination.From these objectives, the following Self-Regulation (SR) and Regulatory Teaching (RT), we used a total sample of 1193 undergraduate students from two public universities of Spain, taken through convenience sampling. The sample contained students majoring in Psychology, Primary Education, and Educational Psychology; 85.5% were women and 14.5% were men. The age range was 19 to 25 years, and mean age was 21.33 (σ = 2.26) years.To establish interdependence relations between low-medium-high levels of Short Self-Regulation Questionnaire (SSRQ)  than for the original, long SRQ .The e (SSRQ)  was usede (SSRQ) , 2018, sAssessment of the Teaching-Learning Process, ATLP, student version . Internal consistency is also adequate . The ATLP is a self-report instrument that collects data from students and teachers and is available in Spanish and English. External validity results are also consistent, since there are several interdependent relationships between the reported perceptions of variables in an academic setting.The  version  was used version , 2020c, p ≤ 0.001; NFI = 0.916; RFI = 0.904; IFI = 0.927; TLI = 0.909, CFI = 0.927; RMSEA = 0.062; HOELTER = 276 (p < 0.05) and 302 (p < 0.01)]. There is also good internal consistency for the total scale .This was measured by the Academic Behavioral Confidence Scale , 2009 inProcrastination Assessment Scale-Students, in its Spanish version . This scFor the present study, we considered procrastination frequency in the academic activities addressed by the PASS: writing a term paper, studying for an exam, keeping up with weekly assigned reading, performing administrative tasks, attendance. Each activity also included the question: To what degree is procrastination in this area a problem for you? and, To what degree would you like to decrease your procrastination in this area? For this section, the test uses a five-point Likert scale: 1 (Never), 2 (Almost never), 3 (Sometimes), 4  and 5 (Always). Reasons for procrastinating were grouped into five factors: arousal seeking, low self-control, perfectionism, test anxiety and low self-confidence.1. This research platform allows teachers and students to register online and give their informed consent. Each questionnaire is completed independently; students then have access to their scores for the total construct and for its factors. Additionally, the student can access self-help feedback, based on their scores, to work on aspects of their learning process. This platform is presently available in Spanish and English, but the number of available languages for questionnaire completion is currently being expanded, following validation of each tool in each language. Self-regulation and Academic Behavioral Confidence were evaluated in October-November of 2018 and 2019; Procrastination Behavior and Regulatory Teaching in March-April 2018 and 2019.Participants voluntarily completed the scales using an online platform . The assStudents signed their informed consent and received a certificate of Project participation for completing the inventories outside of regular class hours. The procedure was approved by the respective Ethics Committees of the two universities, in the context of an R&D Project (see Funding).ex post facto design was used, collecting the data and manipulating it by selection.In line with the method of sample selection, an M = 3.48, SD = 0.60); Kolmogoroff-Smirnoff = 0.25, p < 0.200; RT ; Kolmogoroff-Smirnoff = 0.37, p < 0.3501]. ANOVAs and MANOVAs were conducted, with Self-Regulation and Regulatory Teaching as independent Variables (IV), while Academic Behavioral Confidence and Procrastination were the dependent Variables. In all cases, error variance differences were confirmed to be non-significant , p > 0.05). The multivariate analyses (MANOVAs) showed a statistically significant main effect of the five interaction types on low-medium-high levels of the dependent variables . Preliminary analyses were carried out to determine the distribution of the variables, and so be able to perform analyses of variance [SR . The average regulation level is 1.0, and its regulation rank is 1. The regulation trend is low SR and low RT; this is associated with a high level of dysregulation. The effects would be a low level of academic behavioral confidence and a high level of procrastination reasons and activities.Combination 2 represents a statistically significant low level in SR and medium level in RT, or vice versa . The average regulation level is 1.5, and its regulation rank is 2. The regulation trend is low SR and medium RT, or vice versa; associated in turn with a medium-low level of dysregulation. The effects, then, would be a low-medium level of academic behavioral confidence and a medium-high level of procrastination reasons and activities.Combination 3 represents a statistically significant medium level of SR and medium level of RT (2 and 2). The average regulation level is 2.0, and its regulation rank is 3. The regulation trend is medium SR and medium RT; this is associated with a medium level of dysregulation. The effects, then, would be a medium level of academic behavioral confidence and a medium level of procrastination reasons and activities.Combination 4 represents a statistically significant medium level in SR and high level in RT, or vice versa . The average regulation level is 2.5, and its regulation rank is 4. The regulation trend is high SR and medium RT, or medium SR and high RT; this is associated with a good level of regulation. The effects, then, would be a medium-high level of academic behavioral confidence and a medium-low level of procrastination reasons and activities.Combination 5 represents statistically significant high levels of SR and RT (3 and 3). The average regulation level is 3.0, and its regulation rank is 5. The regulation trend is high SR and high RT; this is associated with a high level of regulation. The effects, then, would be a high level of academic behavioral confidence and a low level of procrastination reasons and activities.For analysis of SEM model fit, the comparative adjustment index (CFI) and the mean square approximation error (RMSEA) were used. CFI values equal to or greater than 0.90 and 0.95, respectively, were taken to indicate acceptable and close fit to the data . RMSEA vAcademic Behavioral Confidence . Complementarily, there was a statistically significant main effect of RT  on total Academic Behavioral Confidence . A statistically significant effect of SR levels and RT levels was noted in all factors of Academic Behavioral Confidence. There was no statistically significant SR × RT interaction effect. The most powerful effect of SR was produced on the factors of Grades and Verbalization, while the most powerful effect of RT was on the factors of Grades, Verbalization, and Attendance. See There was a statistically significant main effect of SR levels  on total Reasons for Procrastination . Complementarily, a statistically significant main effect of RT levels  was noted on total Reasons for Procrastination . Complementary, a statistically significant main effect of SR levels was noted on the factors of Reasons for Procrastination. The main partial effects of SR appeared in the procrastination reasons of low self-control, perfectionism and test anxiety , while the main partial effects of RT appeared in the reasons low self-control and test anxiety . See A statistically significant main effect of SR levels  was noted on total Procrastination Activities . Complementarily, a statistically significant main effect of RT was noted on total Procrastination Activities . Also, a statistically significant main effect of SR levels  was noted on the factors of Procrastination Activities. The main partial effects of SR levels  appeared in the procrastination activities of writing a term paper, studying for an exam, and keeping up with weekly reading , while the RT levels  variable did not carry sufficient statistical strength to determine differences in any specific procrastination activity. See A statistically significant main effect of SR levels  was noted on total The MANOVA that was carried out showed statistically significant differences, in all levels of the SR and RT variables, among the five groups. SR and RT are adequately configured as established in five combination of SR levels and RT levels . Complementarily, a significant main effect of the five combinations of SR levels and RT levels was noted on the factors of Academic Behavioral Confidence . See A statistically significant main effect of the five combinations of SR levels and RT levels was noted on total Reasons for Procrastination . Regarding the factors of Reasons for Procrastination, a statistically significant main effect of the five combination of SR and RT was noted in all .A statistically significant main effect of the Activities of Procrastination, a statistically significant main effect of the five combinations of SR and RT levels was observed . For all factors of Activities of Procrastination, a statistically significant main effect of the five combinations of SR and RT levels was noted, with particular statistical strength in Writing term papers, Studying for exams and Keeping up with weekly reading . See For total model 1 the relationships Combination-> Academic confidence -> Activities of procrastination were tested, while in model 2 the relationships Combination-> Academic confidence -> Reasons to procrastinate-> Activities of Procrastination The second model produced more consistent results and was taken as definitive. See Pathway analysis (SEM) revealed an acceptable model of the relationships between variables. The relationship parameters of the two models are presented below. Both models were tested. In B = 0.62) and RT (B = 0.33) on the latent variable COMBINATION. The Model reflected that the combination of regulation factors (COMB) was a significant, positive predictor of academic behavioral confidence (CONFIDENCE) (B = 0.93). CONFIDENCE was also a significant, negative predictor of procrastination reasons (RAZPROCRAST) (B = −0.46) and procrastination activities (FACTPROCRAST) (B = −0.25). Finally, reasons for procrastinating appeared as a significant, positive predictor of procrastination activities (B = 0.32). See Of particular interest was the differential weight of SR (The combination of SR and RT (COMBINATION) had statistically significant effects on the totals for procrastination reasons and procrastination activities and on their factors. Academic behavioral confidence (CONFIDENCE) also had an indirect negative, predictive effect on each of the factors and total of procrastination activities. See A graphic representation of the final structural model is seen in self-regulation and by the level of contextual, external regulation from the teaching process. Furthermore, this type of interaction could be understood as the combination of the low-medium-high level of the two factors, and is supported by prior evidence in this direction, in reference to achievement emotions  gave rise to an increase in academic behavioral confidence, and a proportionate decrease in reasons for and activities of procrastination. By contrast, a graded decrease in level of regulation  would lead to a decrease in academic behavioral confidence, and a proportionate increase in reasons for and activities of procrastination  in a model that integrates the cumulative evidence. In addition, further study could be made of the critical components of student self-regulation and of regulatory teaching, components that account for the important differences between the groups compared in this study. A clear understanding of these practices, habits and competencies would make it possible to develop guidance programs or classroom interventions that offer specific training in personal self-regulation and teaching regulation, and would promote application of these principles in educational contexts of university .Interventions that seek to increase self-regulation or to decrease procrastination describe three types of action strategies: therapeutic treatment, therapeutic prevention and teacher/counselor intervention . Along tThese results once again confirm the importance of prior student variables (SR) in students’ academic behavioral confidence, and in their reasons for procrastination and procrastination activities. Hence the importance of understanding individual characteristics  for prevOne may also infer the need to intervene with teaching processes, offering training and guidance to help teachers design and develop more regulatory teaching processes, and reduce teaching processes that are non-regulatory or dysregulatory . Some meThe raw data supporting the conclusions of this article will be made available by the authors, without undue reservation.http://www.estres.investigacion-psicopedagogica.org/lib/pdf/CERTIFICADO_COMITE_DE_ETICA_UNAV.pdf. The patients/participants provided their written informed consent to participate in this study.The studies involving human participants were reviewed and approved by JF and AG-U contributed to conceptualization, design and analysis of data and contributed to first writing. PS wrote the final and revised the article. MV-M, SF, and MG contributed to data collection. 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.