P < 0.05) during transport, most notably between the assembly center and lairage. Reference ranges were available for 18 variables; 11 of these variables exceeded the reference ranges at the lairage, whilst 10 variables exceeded the reference ranges on arrival at the veal farm. However, health variables did not change during transport. A journey-to-journey comparison indicated much variation; 18 out of 25 variables differed significantly on at least one time point. In total, J1 calves experienced a more severe change in BHB, potassium, strong-ion-difference, L-lactate, and eye and nose discharge than J2 calves. The source of calves also affected their physiology; 12 out of 25 variables studied differed significantly, all of which were confined to the first time point. Specifically, MA calves had elevated levels of NEFA, urea, haematocrit, L-lactate, cortisol, white blood cell, neutrophil, and monocyte counts and lower levels of corrected chloride and lymphocyte count. Overall, calves in this study showed a generalized physiological disturbance beyond reference limits during long-distance transport, but no animal died during transport or for 3 weeks post-arrival.This study aimed to establish baseline variables for calves transported by road and ferry from Ireland to the Netherlands and to investigate the effect of journey [two comparable journeys in April (J1) and May (J2) 2022] and source [source farm or mart (SF/MA)] on these variables. A total of 66 calves from the SF/MA were transported from Ireland to commercial veal farms in the Netherlands. Blood samples were collected at the SF/MA, assembly center (Ireland), lairage (France), and on arrival on the veal farm (Netherlands). They were analyzed for indicator variables related to energy balance, hydration/electrolytes, physical/muscular stress, immunity, and inflammation . Health variables eye and nose discharge, skin tent (a measure of dehydration), and navel inflammation were scored by a trained observer, and calves were weighed at every blood-sampling time point. All blood variables and body weight changed significantly ( Globally, the transport of young calves is a critical component of the dairy industry. Dairy cows have a calf annually to produce milk; surplus calves, in particular males, which cannot be used to produce milk, are typically raised for veal or beef or sold for early slaughter and must be transported to reach the rearing facility or slaughterhouse . In IrelEach year, more than 120,000 mostly male calves of <6 weeks of age are exported from Ireland to other EU member states  has been shown to negatively alter hematology  and biocThis observational study aimed to establish baseline blood variables of unweaned dairy-bred calves during transport from Ireland to veal farms in the Netherlands. Furthermore, we aimed to assess the effect of the source of the calf , as well as the effect of two transports on different dates (journeys) on blood variables in calves during this transport.This trial was performed during two commercial shipments of calves between Ireland and the Netherlands in April (J1) and May (J2) 2022 using calves collected at source farms (SFs) or commercial livestock MAs. SFs were selected by the livestock exporter based on the availability of at least two calves for export for the set departure date. All healthy Holstein-Friesian and Holstein-Friesian x beef calves over 14 days of age, regardless of sex and breed, that were presented for transport at the SFs or purchased at the MA, were included.For J1, a total of 17 calves  from four SFs  were included in the study. An additional 20 MA calves  sourced from a commercial MA  were also enrolled.For J2, a total of 10 calves  from four SFs  were included in the study. In addition, 19 MA calves  sourced from a commercial MA  were also enrolled.All calves arrived at the exporter's assembly center  the night before ferry transport, and the estimated transport times between the SF/MA and assembly center were 6 to 12 h.A display of transport routes is shown in For J2, transport conditions were similar, but calves departed the assembly center at T ≈ 25 h and boarded the ferry at Rosslare port at T ≈ 31 h. The ferry arrived in Cherbourg, France at T ≈ 49 h, and calves were offloaded at the lairage at T ≈ 50 h. They were re-loaded onto the livestock lorry at T ≈ 63 h and arrived at the veal farm in Eibergen, the Netherlands at T ≈ 80 h. During the ferry journey, the weather was mild with a slight overcast , and the sea was rough . BetweeA schematic display of transport, sampling, and feeding times is shown in Clinical health scores included various variables. Scoring protocols were based on the Wisconsin calf health scorer  and adapFor each journey between Ireland and France, as well as between France and the Netherlands, absolute temperature and relative humidity were measured inside and outside the livestock lorry using TinyTags .At each time point, four blood samples per calf were collected in four different tubes containing 6 ml EDTA, 6 ml heparin, 6 ml glycolytic inhibitor, and 8.5 ml serum separator tubes (SST). EDTA tubes were refrigerated, and hematology  was analyzed using the Advia 2120 system  at Teagasc Grange  or using fluorescence flow cytometry  at Rimondia .All remaining samples were spun at 3,000 rpm for 5 min (heparin and glycolytic inhibitors) or 10 min (SST), decanted into serum tubes, and stored in a freezer (−20°C). All serum tubes were sent to Teagasc Grange  for biochemistry  analysis using a colourmetric AU 480 chemistry analyser , except for magnesium, potassium, and chloride, which were analyzed using the ISE AU 480 chemistry analyser . ELISA was used to analyse cortisol  and serum amyloid-A .Prior to statistical analysis, one measurement for BHB and NEFA showed a negative value, which was deemed the laboratory analysis's fault and thus removed. Electrolyte values  for four calves were deemed too low to be correct and were eliminated from the dataset. Strong ion difference (SID) was calculated based on the formula [SID = Na + K – Cl].All statistical analyses were performed in SAS On Demand . RepeateFor both the linear mixed model and the generalized linear mixed model, the following model was used:i , Journeyj , Sourcek , and Breedl  are fixed effects. The model also included interactions between time and journey as well as between time and source. Agen , and WeightStartm  were included as continuous covariates. Interactions were considered significant when a P < 0.05. Non-significant interactions were manually removed from the model in a step-wise fashion  to improve the power of the remaining variables. Least squares means were used to assess pairwise comparisons between time and journey and between time and source when relevant interactions were significant (P < 0.05). The model was run a second time without including the interactive effects of time and journey and time and source to assess the main effect of Time; a post-hoc test (Tukey) was conducted to adjust for multiple comparisons in the least squares means of this analysis. Model estimates, confidence limits, and standard errors (where applicable) from log- and square root-transformed data were back-transformed  for use in figures and tables. Raw data were used to present binary data.where μ is the population mean, and TimeThe experiment was approved by the Teagasc Animal Ethics Committee  and the Health Products Regulatory Authority .All calves that commenced the international section of the journey reached the veal farms in the Netherlands, and veterinary care was not sought for any animal at any stage of the journey or on arrival.Mean values of all physiological variables per time point, significant changes over time, and reference ranges published in previous research are shown in Variables that are indicators for energy balance changed over time; glucose was the lowest at the lairage and veal farm, where 74% and 68% of calves, respectively, fell below the lower reference limit. BHB and NEFA were low at the SF/MA and the assembly center but increased between the assembly center and lairage and remained high thereafter; the upper reference limits were exceeded by more than 96% of calves at the lairage and veal farm.Electrolytes potassium, sodium, and corrected chloride showed an increase over time. At the lairage, 100% of calves exceeded the upper reference limits for potassium and sodium. Changes in magnesium and SID over time were variable, although SID increased between the assembly center and lairage and decreased between the lairage and veal farm.The hydration indicator variable urea showed an increase over time as the duration of transport increased; the upper reference limits were exceeded by some calves at all time points but most frequently at the veal farm, where 68% of calves had urea concentrations above the upper reference limit. Haematocrit and total protein showed the respective highest and lowest values at the lairage, but the reference limits were rarely exceeded, most often for haematocrit at the lairage, where 23% of calves had levels above the upper reference limit. Skin tent showed the greatest increase over time, most notably between the lairage and veal farm, where more than 41% of calves showed dehydration based on skin tent.In terms of variables that are related to muscle fatigue/stress, creatine kinase was the highest on arrival at the veal farm, whilst L-lactate was the highest at the SF/MA. Changes in cortisol over time were variable. The upper reference limits were exceeded by more than 50% of calves at all time points but most frequently at the lairage  or veal farm .All variables that are related to immunity status showed a general decrease during transport, except for monocyte count, which increased. The upper and lower reference limits were rarely exceeded. Monocyte count exceeded the upper reference limit most often, notably so at the lairage .For inflammation, serum amyloid-A increased between the SF/MA and the assembly center but remained similar thereafter. Haptoglobin was the lowest at the lairage but showed a stabilizing pattern at the veal farm. The upper reference limit for serum amyloid-A was rarely exceeded, most frequently at the lairage , whilst the upper reference limit for haptoglobin was exceeded by more than 96% of calves at all time points.P-values: eye discharge = 0.0766, nose discharge = 0.1552, and navel inflammation = 0.4972). Body weight changed between all time points, the largest decrease in body weight was seen between the assembly center and lairage. Body weight increased slightly between the lairage and veal farm but remained lower than that before transport.There was minimal evidence that health scores changed significantly over time (P = 0.0004) and BHB (P = 0.0047). Glucose and BHB showed roughly opposing patterns. Glucose increased between the SF/MA and assembly center, where J2 had higher glucose. A drop was observed thereafter, but the levels remained similar between groups. BHB increased between the assembly center and lairage, and J1 continued to increase until the veal farm, where the journeys were different. There was minimal evidence that the journey significantly affected NEFA (P = 0.4001).The results for interactions between journey and time are shown in P-values: potassium = 0.0230, sodium = 0.0018, magnesium = 0.0202, corrected chloride = 0.0002, and SID < 0.0001). J1 had higher potassium at the lairage and veal farm but lower sodium at the assembly center. SID was the lowest, and corrected chloride was the highest at the veal farm. J1 had higher corrected chloride but lower SID at the assembly center, lairage, and veal farm than J2. Magnesium was variable over time and showed no consistent changes, but J1 had higher magnesium at the SF/MA.For electrolyte variables, an interaction between journey and time was found for all variables (P < 0.0001), total protein (P = 0.0003), and skin tent (P = 0.0049). J1 had lower haematocrit at the SF/MA but lower total protein at the lairage; differences between journeys were not found at other times. Skin tent was the highest at the lairage for J1 but peaked at the veal farm for J2. There was no evidence that journeys significantly differed in the levels of urea (P = 0.8431).For hydration-related variables, an interaction between journey and time was found for haematocrit (P < 0.0001) and cortisol (P = 0.0007). A decrease in L-lactate between the SF/MA and any subsequent time points was found for J2, whilst this change was not as pronounced for J1. J1 had lower L-lactate at the SF/MA and higher L-lactate at the veal farm. Cortisol was generally higher for J2 , but standard deviations for cortisol within J2 were large. The overall mean values of creatine kinase differed between journeys .For variables related to muscle fatigue/stress, an interaction between journey and time was found for L-lactate (P = 0.0102). J2 started off with lower lymphocyte counts at the SF/MA, but changes in lymphocyte count over time were similar between journeys thereafter. There was no evidence that the overall means of WBC, neutrophil count, and monocyte count significantly differed between journeys (P > 0.05).For immunity-related variables, an interaction between journey and time was found for lymphocyte count (P = 0.0007). Haptoglobin values were higher for J1 than for J2 calves at the SF/MA and lairage. There was no evidence that the overall mean values of serum amyloid-A significantly differed between journeys (P = 0.8463).For inflammation-related variables, an interaction between journey and time was found for haptoglobin . Mean body weight was higher for J2 at the assembly center, but this was not significant at any other time. For J1, frequencies of eye discharge and nose discharge were the highest at the veal farm; for J2, eye discharge was the lowest at the veal farm, and nose discharge did not change over time. Journeys showed roughly opposite patterns for navel inflammation, and differences in the prevalence of navel inflammation were found at the assembly center, where J1 had a higher prevalence of navel inflammation, and veal farm, where J2 showed a higher prevalence.For health scores and weight, an interaction between journey and time was found for all variables (P = 0.0007). NEFA was higher for MA calves at the SF/MA, but sources showed similar patterns thereafter. There was no evidence of a significant difference between sources in glucose (P = 0.7378) and BHB (P = 0.9572).The results for interactions between source and time are shown in P = 0.0029) and SID (P = 0.0005). SID and corrected chloride were lower for SF than for MA at the SF/MA. Sources  tended to differ in potassium  and sodium , but there was no evidence that source significantly affected magnesium (P = 0.8006).For electrolyte-related variables, an interaction between source and time was found for corrected chloride (P < 0.0001), haematocrit (P = 0.0034), and total protein (P = 0.0409). Urea and haematocrit were higher for MA calves at the SF/MA, but sources showed similar patterns thereafter. Total protein was variable over time, and sources did not differ at any one time point. There was no evidence that source significantly affected skin tent (P = 0.9108).For hydration-related variables, an interaction between source and time was found for urea (P < 0.0001) and cortisol (P = 0.0409). L-lactate was high for MA calves at the SF/MA, which differed from SF calves. L-lactate remained low for both sources thereafter. Changes in cortisol over time were variable, and sources did not differ at any time. There was no evidence that the overall mean values of creatine kinase significantly differed between sources (P = 0.1845).For variables related to muscle fatigue/stress, an interaction between source and time was found for L-lactate . WBC, neutrophil, and monocyte count were higher for J2 at the SF/MA, but the lymphocyte count for J2 was lower at this time. Sources did not differ in any immunity-related variable thereafter.For immunity-related variables, a difference between source and time was found for all variables  and tended to differ for eye discharge . There was no evidence that the overall means for nose discharge (P = 0.2194) and body weight (P = 0.1432) were significantly affected by the source of the calves.For health scores and weight, there were no significant interactions between source and time for any variable. The overall means of the two sources were different for navel inflammation  exceeded the reference ranges published by previous studies after long fasting periods –26. JourPerhaps being the most obvious effect in this study, calves showed a negative energy balance at the lairage and veal farm. A negative energy balance has been reported following long fasting durations and transport , 14–16, In this study, electrolytes and other hydration-related variables showed an increase in concentrations beyond the upper reference limit at the lairage or veal farm ; the percentage of calves with a positive skin tent also increased. Due to transport and prolonged fasting, a decrease in the total blood volume and resulting dehydration could be expected . ElectroIn contrast to findings in previous research , 30, neiCortisol and lactate levels in this study, as indicators of (muscle) stress, were above the reference limit but showed inconsistent changes during the journey. Both cortisol and lactate have been shown to increase in response to transport in calves , 17, 30,There was no evidence of significant shifts in immune  or inflammatory variables. With the exception of haptoglobin, the mean values of all variables in these two variable groups remained within reference ranges, despite some minor but significant changes over time. In parallel to this, health scores  did not change during transport, even though visual observations hinted at an increase in eye and nose discharge throughout the study. It must be noted that a single observer performed all health scores throughout the study, except for the veal farm, where there were two observers; the effect of this is unknown. The evidence from the markers of inflammation was ambiguous with serum amyloid-A showing no change over time and remaining within reference ranges, whilst haptoglobin levels were above the reference limit throughout. Transport, in most cases, involves the commingling of calves, and this poses a high risk for the spread of pathogens . Immune The accumulative effects of transport over time prevent conclusions from being drawn on the individual effect of ferry (sea) transport vs. road transport on the physiology of calves. The physiological status of calves at the lairage (after the ferry journey) and veal farm (after road transport) are different in many cases , with the veal farm observations not always more negative, as one might expect, given the longer cumulative journey duration. Given Ireland's geographical constraints, a ferry journey is an unavoidable component of transporting Irish calves to mainland Europe. Elucidating the effect of a sea journey alone, and determining if this represents a critical point in their overall journey, is a future aim of this overall research.inter alia, prevailing weather, handling at loading and unloading, delays, driver experience, position within a truck, and parked position on the ferry (exposed or sheltered). Previous studies have also reported that using a conditioned versus an open truck influenced immune cell subsets , with more extremely prevailing weather conditions (rough sea and heavy downpours). However, unexpectedly, J1 calves were visibly worse on arrival (reflected in eye and nose discharge) and showed a more severe decline in BHB, potassium, SID, L-lactate, and eye and nose discharge than J2 calves. The only variable that was visibly exacerbated by the long transport duration in J2 was skin tent, which was recorded twice as often in the second journey on arrival at the veal farm. Whilst further studies are required, this analysis suggests that journey-to-journey variation is an important factor and plays a significant role in disturbing the physiological status of calves, but the transport conditions that cause this are unknown.The source of calves, whether SF or MA, was a significant cause of variation in 12 of the variables examined. However, in all cases, this difference was only evident at the first time point (SF/MA). In contrast to the SF calves, the MA calves encountered an added trip from the SF to the MA, albeit of short duration, in addition to the associated handling at the livestock MA. Whilst it could be assumed that these MA calves were fed prior to departure from the farm , the average NEFA value for this group was almost double that of the SF calves. Also, all indicators of immunity were different from those observed in SF calves. This observation, in addition to the fact that the average cortisol levels were also elevated, but not significantly so, in the MA cohort, is suggestive of an elevated stress and hunger profile in these calves prior to sampling at the SF/MA. This novel finding indicates that the source of calves affects their baseline levels.However, whilst impacting the calves at the SF/MA, the effect of source in this study did not transcend beyond this time point, evidenced by the fact that source was not significant at any time point beyond the SF/MA. In fact, by the assembly center sampling, following transport to, and feeding at, the assembly center, both cohorts displayed comparable physiological results, a trend that continued for the remainder of the journey. The long-term impact of source was not a focus of this report; however, the cumulative effect of an additional feed withdrawal and transport of MA calves relative to SF calves requires analysis.At the start of the study, SF calves were sampled 1 day prior to commencing their transport journey, in contrast to MA calves who were sampled on the day. As this sample was taken as a baseline sample, it was not expected to change in a day as calves remained on their farm of birth. A greater limitation was the timing of sampling around feeding, particularly at the assembly center where sampling was conducted after feeding, unlike the other timepoints. Unfortunately, this feature could not be overcome on the day.Overall, calves showed a decline in their physiological status during the journey between Ireland and the Netherlands; the changes were most obvious during the ferry journey between Ireland and France, and minimal changes were observed between the lairage in Cherbourg and the veal farm. The current dataset indicates that the calves sold and transported through a commercial livestock MA prior to international transport had physiological variables that were affected at the MA, but feeding at the assembly center seemed to “reset” these changes. Furthermore, differences between SF and MA calves were not found at other time points. There were definite differences between different consignments (journeys) of calves transported on a similar journey, although each journey affected the variables in different ways. A general agreement on calves that arrived in a worse state could not be concluded, despite a difference in transport time and conditions.The raw data supporting the conclusions of this article will be made available by the authors, without undue reservation.The animal studies were approved by Teagasc Animal Ethics Committee and the Health Products Regulatory Authority. The studies were conducted in accordance with the local legislation and institutional requirements. Written informed consent was obtained from the owners for the participation of their animals in this study.LD carried out trial work, data analysis, and writing of manuscript. SS carried out trial work. NF supervised during trial work and data analysis. KS, CR, and EB equally contributed to planning and assisting in trial work. GS assisted in data analysis and writing of manuscript. MC supervised during trial work. All authors contributed to the article and approved the submitted version.


Various interventions, programs and policies have been implemented to improve physical activity (PA) levels worldwide. However, countries continue to face barriers and challenges in achieving their targets. To date, there is a lack of study on the evaluation of physical activity (PA) promotion and how it’s associated with public participation.This study assessed PA promotion in eight different settings in terms of policy availability, policy implementation, and public participation in PA programs. Policy availability was assessed by reviewing 384 policy and strategy documents, rules, regulations, legislation, and guidelines on PA. We scored the documents by using the Comprehensive Analysis of Policy on Physical Activity (CAPPA) framework. Data to assess policy implementation and public participation were taken from the Thailand Report Card Survey 2021 (TRC2021), and the Thailand Surveillance on Physical Activity (SPA) 2021. Both surveys comprised over 5,000 nationally-representative samples from on-screen, face-to-face interviews, and an online self-administered survey. We scored the policy implementation and public participation based on respondents’ response towards policy implementation and participation indicators. A grading scheme was applied to indicate how successful an investment has been made.Public education and mass media received the highest average score in policy availability, implementation and public participation in PA program , followed by active urban design  and active transport . Workplace, whole-of-school, and community-wide initiatives were the investments with the lowest scores, implying low availability, limited implementation, and less accessibility to public. Females were less likely to participate in active transport, active urban design, sports/recreation for all, workplace activity, and community-wide initiatives. Age and educational attainment were consistent predictors of utilization in all investments.With varying degrees of policy availability and accessibility, public participation in PA investments is likely to be constrained by biological and socioeconomic inequality. Future investments should aim at providing generalized or tailored interventions to ensure equal access and participation for all segments of the population.The online version contains supplementary material available at 10.1186/s12889-023-16690-9. Studies have documented growing physical inactivity worldwide. Globally, 28% of adults and 81% of adolescents were insufficiently physically active in 2016 –6. PhysiEight investments that work for physical activity” [Various interventions, programs, and policies have been implemented in different settings to improve PA level. The International Society for Physical Activity and Health (ISPAH) has proposed a package of investment strategies to promote PA known as “ctivity” . The eigctivity” . The 8-ictivity” .While the recommendation on ‘8-investments that works for PA’ were driven from empirical evidence and GAPPA as guidelines to improve PA of the population, to date, there has been no study reported on how to assess or evaluate the implementation of policies/investments corresponding with the two strategies as a comprehensive analysis. There is also a lack of evidence pertaining to the coverage of each investment and the causes of gaps in the policy planning/development. The existing studies mostly focused on research into the effectiveness of the interventions (investments), i.e., the effect of the whole-of-school program in improving PA of the student population –14; or hThis study assessed the implementation of PA promotion in different settings following the 8-investments recommended by ISPAH. More specifically, we assessed the policy implementation , and also public participation in PA programs. We developed a grading system to facilitate comparison of each population group by access to and benefit from the implementation of different PA policies across the 8-investment areas. The analysis categorizes policy domain following the GAPPA framework to ensure all strategies in PA promotion are covered. The results from the study should be beneficial for countries, particularly policymakers and government, in planning and assessing the impact of PA promotion/policy implementation. This study also provides guidelines for countries to align their PA promotion investments with global targets and indicators. Further, the results of this study should add to the body of knowledge in the policy evaluation field by demonstrating a new method of analysis involving WHO’s GAPPA and ISPAH’s 8-investments for PA.This study is a policy evaluation of PA promotion in eight different settings, based on ISPAH’s recommendation of strategic investments. We assessed the PA promotion strategies in three dimensions: (1) Policy availability; (2) Status of implementation; and (3) Public participation in PA programs.n = 47) of which the three experts failed to reach agreement on the scoring. We employed three indicators Type of policy, Stage of policy cycle, and Policy resources and defined each category following Pogrmilovic, et.al [types of policy into 1) Formal written – if the documents comprise of strategies, plans, or regulations that have been officially enacted and/or endorsed; 2) Unwritten formal – official statements made in public by an official that were not documented in formal writing ; 3) Written standard/ guidelines– a set of guide choices, recommendation to perform certain behaviors, practices, or processes but do not create an obligation for stakeholder adherence ; 4) Formal procedures – formal actions conducted or authorized by an official body that are indicative of commitment regarding PA ; 5) Informal policies – include norms, actions, voluntary codes of practice supported by an official body that are indicative of the body’s commitment regarding PA ; or 9) Unclear – if the policy falls outside the 8 categories. We scored category 1–4 as 1, and the rest as 0. We categorized the stages of policy cycle into 1) Agenda setting, 2) Formulation, 3) Endorsement/legitimization, 4) Implementation, 5) Evaluation, 6) Maintenance, 7) Termination, and 8) Succession. Category 4–6 were scored as 1, whereas the rest as 0. Policy resource allocation was categorized into 1) Management resources, and 2) Budget resources. Score 1 was assigned to policies with both resources available, otherwise was scored 0. In the final stage, we counted the number of policies that met the CAPPA criteria in each domain, assigned an equal weight (0–3), and calculated the final score (expressed as a percentage) for policy availability  Actc, et.al . We catelability .Data for evaluating policy implementation was derived from the Thailand Report Card Survey 2021 (TRC2021), and the Thailand Surveillance on Physical Activity (SPA) 2021. Both surveys were conducted by the authors’ institute. TRC2021 was employed to analyze policy implementation and accessibility in the domain of whole-of-school programs for Thai youth age 5–17 years. This survey involved nationally-representative samples of 6,078 students from 121 schools, disaggregated by region, residential area, school size, gender, and age group. To comply with COVID-19 prevention measures, data was collected by using on-screen, face-to-face interviews where the interviewer, respondents and their guardian interacted in real time mediated by screen media . SPA2021 was used to assess policy accessibility and implementation on the rest of PA promotion in 7 domains. A total of 7,847 nationally-representative samples from all 77 provinces in Thailand were included in the analysis. The data was collected as an online survey where the respondents – and their guardian if the respondents were children – entered their responses into a LimeSurvey web application.N = 6,078) for the whole-of-school domain; working aged Thais  for the workplace domain; and the general public  for the rest of the domains. The questions to assess policy implementation in each domain of the 8-investments are shown in Table We measured policy implementation as the percentage of policies on PA being implemented either at the national or community level, based on the perspective of the beneficiaries: Thai children and adolescents  as the eligible respondents; 2) SPA2021 for the workplace domain, with working aged Thais  as the sample; and 3) SPA2021 for the general public which comprised of Thais aged 5 years and over  for the rest of the domains. Questions to assess public participation in each domain are shown in Table Similar to the policy implementation, data for evaluation of public participation in PA programs were employed from: 1) TRC2021 for the whole-of-school domain, with children and adolescents , age , marital status , educational attainment , occupation . Income was grouped into no income, < 3,500 THB (< 100 USD), 3,500–10,000 THB (100–288 USD), 10,001–15,000 THB (288–433 USD), 15,001–30,000 THB (433–866 USD), or > 30,000 THB (> 866 USD). Health status inquired whether the respondents has NCD or not. Area of residence was grouped into urban or rural, and region was categorized into North, Northeast, Central, South, or Bangkok. A to F) and adopting the Global Matrix 3.0 [In the final stage, we developed a grading scheme   for binaAll 384 policy and strategy documents, rules, regulations, legislation, and guidelines on PA collected were successfully reviewed and evaluated. A total of 47 policies were excluded from the analysis because there was no consensus reached by the experts in determining the scores. Overall, policies related to 8-investments on PA obtained a score of 69.8% for its availability, indicating the majority of policies have met the three criteria of CAPPA framework. Among the available policies, 51.8% policies have been implemented at the local or national level, with an average of 38.7% in the public participation rate.Of the total 337 policies/investment being assessed using CAPPA framework, public education and mass media received the highest availability score (95.1%) followed by sports/recreation for all (85.5%). This means that there have been adequate amounts of policies/programs related to both domains, available either at the national or community level, in various policy stages , and in any format . Community-wide initiative investments scored lower 62.7%) than whole-of-school, active transport, and active urban design (73.8%). The workplace and healthcare domains received the lowest score, , reflecting a lack of investment in both sectors  and active urban design (72.3%), whereas the lowest score was for the whole-of-school approach (11.6%). In terms of public participation, this study found that members of the Thai public mostly participated in active urban design, active transport, and sports/recreation domains . Only 8.7% of the sample reported participating in community-wide initiatives  and older adolescents in secondary schools  were less likely to participate in the whole-of-school domain compared to boys and primary school students. Compared to Bangkok residents, those who resided in the south , north , and northeast  regions of Thailand were more likely to have better access to the whole-of-school investment. There was only a slight difference in the average PA participation rate among those with and without a non-communicable disease (NCD)  (Table The researchers further examined factors associated with the level of participation in each domain. The whole-of-school programs (IV1) were implemented in primary and secondary schools and, thus, the users of this investment are limited to youth aged 5–17 years. This study found that only 26.9% of youth had access to or participated in the PA program. Girls  and more likely to have been exposed to public education/mass media , but were less likely to utilize active transport, active urban design, sports/recreation for all, and workplace investments. Children and adolescents, on the other hand, were more likely to participate in the active urban design , sports/recreation for all , and workplace  programs, and less likely to use health care, public education, and community-wide initiatives. Marital status served as a less consistent predictor of participation in seven domains of investment. Being single meant that one was 1.8 times more likely to use the workplace facilities  and 1.168 times more likely  to participate in active urban design-related initiatives. By contrast, being a widow(er) meant that one was 1.293 times more likely  to use sports/recreation for all amenities. The probability of using workplace facilities/program was also 1.638 times higher  among divorced individuals (Table For the rest of the investment domains (IV2-IV8), sociodemographic characteristics were found to be associated with participation rate. Sex was significantly associated with participation rate in active transport, active urban design, sports/recreation for all, workplace, and community-wide initiatives. Females were less likely to participate in those domains compared to their male counterparts, but there was no significant association between sex and participation rate in the healthcare and public education/mass media campaign investments. Age was also a consistent predictor of utilization in IV2-8. Compared to the working-aged group, older adults were more likely to use health care facilities . Public education/mass media was more likely to be used by full-time students , and less by those in the informal employment sector . Full-time students, the self-employed, those who worked in the formal- and informal sectors also had a higher likelihood of using sports/recreational facilities than their unemployed counterparts. Being the least utilized, participation in community-wide initiatives was also associated with occupation. Being a full-time student, working in agriculture, or employed in the formal or informal sector meant that one had a higher likelihood of using community-wide initiatives , whereas active urban design amenities were utilized by those who were employed in the formal- or informal sector, self-employed (except those working in agriculture), or were full-time students. Health care investments interestingly, was only significantly associated with formal-sector employees  were 1.338 times more likely (OR 0.000) to use public education investments and were less likely to participate in healthcare and workplace programs than the highest earners .p-value 0.000) and workplace investments , while region of residence was associated with overall participation across the seven domains (IV2-8). Compared to those who lived in the capital region (Bangkok), individuals who resided in south, north, and northeast were more likely to participate in all seven investments, whereas those who lived in the central region were more likely to participate in only four domains .Public participation was also significantly associated with area of residence . Living in an urban area was only significantly associated with participation in active urban design , which is an agency that facilitates cooperation with partners to carry out its missions. One of these missions is to support and promote PA for Thais in order to achieve and maintain good health. PA has also been entered as a national agenda under the country’s Promotion Plan for 2018–30, with an interim plan for the period of 2018–20.The results of this study found that, of 337 policies across the eight investment domains, 69.8% were readily available, and 51.8% were implemented either at the local or national level, with an average of 38. 7% public participation rate. Public education and mass media received the highest grade (B) among domains. The grading highlighted the comparative levels of policy availability, implementation and public participation, but also revealed gaps in between the three indices. Although the score for public education and mass media is remarkably high in terms of availability (95.1%), only 62.4% of policies were implemented, and less than half the sample 46.3% said they had seen information from the PA campaigns and practiced more health behavior following the promotional messages. The gaps between policy availability with implementation and public participation indicate inequality of access to information on PA, and in the proportion of the sample who said they could apply various strategies to practice PA safely at home and in the community. As the public education delivered through mass media were intended for the general public, children and adolescents were less likely to be exposed to the content, or less interested in following the recommendations in the messages.‘Workplace’ received the lowest grade among the eight investments , indicating that there is a lack of investment in both the formal and informal labor sectors in terms of policy availability, implementation, and public participation. Workplace PA has not been a priority in Thailand, as reflected by the low policy score in the implementation aspect. A previous study found that there were some efforts by employers to provide afterhours sports and recreational PA at the workplace however, that was usually targeted to those workers whose jobs required sedentary behavior . AlthougIn is noteworthy that the whole-of-school investment scored the second lowest . Although up to 73.5% of PA intervention and policies on whole-of-school were found, only 11.6% were found to be implemented by schools, and only 26.9% of children and adolescents in schools have access to and benefit from the whole-of-school investment. The participation rate was lower among girls, older children and those who resided in an urban area. It should be noted, however, that PA of Thai children and adolescents has been very low for many years. The TRC on PA of children and adolescents found that, on average, only 1 in 4 youth had sufficient MVPA in 2016–22 –42. FurtThis study found that only 8.7% of community-wide initiative investments were utilized by the public. The low participation in the program indicates that the existing investments were unable to serve the needs and preferences of their intended beneficiaries. Ideally, community-wide investments would involve all community members in the planning and implementation of the initiatives to ensure sustainability and produce a long-term benefit for all community members . StudiesWith an overall score of 57.5% (grade C +), investments in healthcare were utilized by 49% of the sample in the survey. The higher likelihood of utilization among older adults and people with an NCD is not surprising since this group of the population may have a higher concern for their health than the younger and healthy individuals. However, this study also found that only those who worked in formal sector were more likely to use healthcare facilities, whereas those in other occupations were not. Participation/utilization was also low among individuals with lower or medium income. It should be noted that Thailand passed its Social Security Act in 1990 (which covers both public and private sector employees) as well as the Universal Health Coverage Scheme (UCS) (enacted in 2001) which covers any Thai citizen without health insurance from another provider . The lowActive urban design and active transport are the most utilized investments in Thailand (both graded B-), followed by sports/recreation for all (grade C +). The patterns of participation and users of the three investments are similar, except that the effect of area of residence  was only significant in the active urban design investment. Females and older adults were less likely to use the three investments, whereas children and adolescents were more likely to participate in PA related to the active urban design and sports/recreation domains. Inequality in PA access has been acknowledged widely, and the existing PA amenities and programs favored the socially-advantaged groups, e.g., males and working-aged adults, rather than for females or older adults , 50, 51.This study offers a simple yet comprehensive method to add to the body of knowledge in policy evaluation, particularly in relation to the 8-investments strategy that is recommended to boost PA. Each investment was assessed comprehensively, and evaluated across three different dimensions: Availability, extent of implementation, and accessibility to the public. The use of the CAPPA framework to score policy availability also served as one of the strengths of this study. The data used to evaluate policy implementation and public participation were derived from national samples of the Thai population, thus allowing some generalization of the findings. This comprehensive policy evaluation of ISPAH’s 8-investments took into account WHO’s GAPPA, and the methods should aid countries in aligning the policies and programs to meet the global indicator targets and goals. However, there are some limitations of the study. The evaluation of policy implementation relied on the perceptions of the intended beneficiaries, instead of objective observation of the actual programs. Another limitation is that data collection occurred during the COVID-19 epidemic and, therefore, the findings do not necessarily represent the situation in the absence of epidemic conditions. For the policy resources allocation, identical scores were given for both having management resources and having budget allocated due to limited access to budget documents. It should be noted however, although the documents may not be accessible to the public, there is clear evidence that the budget is available for particular investments. Lastly, behavioral and health outcomes could not be determined due to the cross-sectional nature of the survey.Workplace, whole-of-school approach, and community-wide initiatives scored the lowest in this policy evaluation, while public education and mass media ranked the highest. The findings suggest that future policy and programs should focus on the least accessible and least utilized investments because successful investments in the 8 domains will influence PA level of the population. This study showed, with a varying degree of policy availability and accessibility, public participation in PA investments is likely to be constrained by biological and socioeconomic inequality. Future investments should, therefore, expand coverage and inclusivity. Target-specific and tailored programs should be designed so that they are appropriate to the needs and lifestyle of each group of the population, since that should increase accessibility and opportunity. Collective action for PA should be promoted, extending from the policy level to frontlines to ensure equal access and participation of all segments of the population in need.Additional file 1:Supplementary material. Summary table for policy availability.


The aim of this study is to determine the risk of cancer in patients with primary Sjögren syndrome (pSS) from a single center in Turkey.Clinical data of the subjects with pSS were retrospectively analyzed. The incidence of cancer for general population was obtained from GLOBOCAN 2018. Age- and sex-specific standardized incidence ratios (SIR) of solid and hematological cancers were calculated compared with the general population.Four hundred thirty patients with pSS were included in the study. The majority of the patients were female , and the mean age was 58.6 ± 12.0 years. Thirty-four patients (7.9 %) were diagnosed with cancer  during follow-up. The SIR for all cancers was 2.45 . The SIR was 2.42  for solid cancers and 8.42  for hematological cancers. The most diagnosed malignancies were breast cancer (n = 6), ovarian cancer (n = 6), and non-Hodgkin lymphoma (NHL) (n = 4). There was an increased risk for ovarian cancer . The SIR values were 2.08  and 10.81  for breast cancer and NHL, respectively.The risk of hematological and solid cancers was higher in the patients with pSS when compared to general population. In our pSS cohort, the risk for ovarian cancer was found to be increased, which has not been previously reported in the literature. Primary Sjögren syndrome (pSS) is a systemic autoimmune disease that mainly affects secretory glands . Most paClinical studies to clarify whether the survival of the patients with pSS is similar to the general population are in progress. The prognosis varies depending on disease severity, extent, and comorbidities. Systemic organ involvements and malignancies, including lymphoma, may contribute to an increase in mortality rates. Our clinical data revealed that the mortality rate of the patients with pSS was higher than that of the general population, the patients with interstitial lung disease had lower survival rates, and malignancy may also be associated with a worse prognosis .It is known that the risk of lymphoma and solid organ cancers is increased in patients with pSS –10. ManyThe frequency of malignant diseases may be different among populations depending on the genetic and environmental factors . The devPatients who were diagnosed with pSS according to American College of Rheumatology 2012 criteria at Akdeniz University Hospital between January 2004 and December 2018 were included in the study . PatientHistopathologically detected cancers were determined and classified according to the International Classification of Diseases (ICD 10) criteria, and cancers developed after the diagnosis of pSS were included in the analysis.9/L, and a thrombocyte count less than 100×109/L. If ESR and CRP values were over 20 mm/h and 0.5 mg/dL, respectively, they were considered as high. The cut-off value for ANA positivity was considered as > 1/100 titer. The presence of anti-Ro/anti-La antibodies was determined by extractable nuclear antigen panel, and RF positivity was determined by nephelometric test method. Cut-off levels for C3 and C4 were 80 mg/dL and 10 mg/dL, respectively.Clinical variables such as age, sex, disease duration, and follow-up period of the patients were analyzed. In addition, the presence of dry eyes or dry mouth, joint symptoms/findings, Raynaud phenomenon, and lung involvement were recorded. Laboratory findings including complete blood counts, biochemical tests, erythrocyte sedimentation rate (ESR), C-reactive protein (CRP), antinuclear antibodies (ANA), rheumatoid factor (RF), anti-ro and anti-La antibodies, complement 3 (C3), complement 4 (C4), and immunoglobulin levels were recorded after review of electronic medical records. Normal laboratory values were defined according to our laboratory reference values. Anemia, leukopenia, and thrombocytopenia were defined as hemoglobin level less than 12 mg/dL, a leukocyte count less than 4.0×10This study was approved by the medical ethics committee of Akdeniz University Hospital and complied with the principles of the Declaration of Helsinki.Statistical analyses were performed using SPSS software, version 13.0 . The data were expressed as means ± standard deviation (SD) for continuous variables. Continuous variables were compared using the Student’s t-test. Categorical variables were compared using a chi-square test. Logistic regression analyses were used to determine the risk factors associated with the development of malignancy. A value of p < 0.05 was considered significant.The person-years of follow-up for patients with pSS were calculated from the date of diagnosis to the last visit or cancer diagnosis (whichever occurred earliest). Cancer data of the Turkish population were determined from GLOBOCAN 2018 . The staThere were 430 patients with pSS who were older than 18 years and diagnosed between the years 2004–2018 . The meaThe clinical characteristics and laboratory data of the patients with and without cancer were compared . The patThe rates of cancer incidence for this cohort and Turkish population in general, both expressed as 100,000 patient-years, were given in Compared with the general population, the SIR was 2.45 (95% CI 1.625–3.275) for all cancers and was higher in men than in women (2.96 vs. 2.91) . The SIRThe logistic regression analysis indicated that older age (p = 0.005), presence of leukopenia (p = 0.30) and thrombocytopenia (p < 0.01), and use of corticosteroids (p < 0.01) were independent risk factors of developing malignancies in pSS patients .This study was conducted to determine the risk of cancer in patients with pSS. The results revealed that the overall cancer incidence rates, both for solid and hematologic cancers, were higher in the patients with pSS when compared to age and gender-matched populations. There was a 2.45-fold overall increased risk for cancer . This study is the first report on the risk of cancer and cancer types detected in Turkish patients with pSS.Although it is already known that the incidence of cancers, especially lymphomas, is increased in the patients with pSS, the exact rates are unknown. Igoe et al. reported that the patients with pSS had a greater risk for developing lymphoma SIR, 10.5–44), multiple myeloma , and lung cancer SIR,1.29–4.5) when compared to healthy individuals . The ris–4.5 when.5–44, muLymphocytic infiltration in target tissues and chronic lymphocyte activation are key features of pSS. B cell-activating factor (BAFF), cytokines, activation of Nf-kB, and germinal center-like (GC-like) structures are important for the development of lymphoma in pSS . Our resThe current evidence about the development of NHL in pSS is increasingly growing. The clinical and laboratory predictors, such as the presence of salivary gland enlargement, lymphadenopathy, Raynaud phenomenon, anti-Ro/SSA or/and anti-La/SSB autoantibodies, RF positivity, monoclonal gammopathy, and hypocomplementemia were identified to be independent predictors for the development of NHL . The reaIn contrast to hematologic malignancies, data on solid cancers seen in the subjects with pSS are not consistent. There are incompatible data in the literature regarding solid tumors and their incidence in patients with pSS. Some studies revealed a high incidence of several organ-specific malignancies such as thyroid, breast, lung, oral cavity, and stomach cancers. A recently published study showed an elevated risk for oropharyngeal cancer, as well as lung cancer in males, and thyroid cancer in female patients . AnotherThere is an increased risk for the development of hematological malignancies in autoimmune diseases, which provide a perfect environment for tumor development via loss of self-tolerance and chronic immune dysregulation . The immOvarian cancer risk increases with older ages, and it is more prevalent in western countries. It can be related to reproductive period, the number of births, breastfeeding, genetics, and environmental factors such as diet . ChronicThere are some limitations of this study; first, the limited number of patients made statistical analysis difficult. Especially, the number of male patients with pSS was low in this cohort. It was impossible to calculate the SIR of cancer types with less than four patients because of the wide range of confidence intervals and the standard error. Secondly, the study was conducted retrospectively, therefore, data on comorbidities known to be associated with cancers such as smoking and drinking habits, physical activity, and disease activity could not be collected and analyzed. Thirdly, since disease activity for pSS could not be calculated for all patients, the relationship between disease severity and cancers could not be examined. Fourthly, due to lack of information about regional cancer incidence in Antalya, where the data were collected, cancer incidence in the general population was obtained from GLOBOCAN 2018 Turkey database. Nevertheless, since this study was conducted in a wide region of Turkey with 2.5 million people, the results may reflect the situation of the Turkish population with pSS.In conclusion, data on the development of solid and hematological malignancies in our pSS cohort are presented in this article. The prevalence of malignancy in the patients with pSS was found to be 7.9%, and the overall cancer risk was found to increased by 2.45-fold. The risk for the development of ovarian cancer was significantly increased in the subjects with pSS. Further studies are required to reveal pSS-related factors playing a role in the development of ovarian cancer.


The COVID-19 pandemic not only posed a serious threat to public life and health but also had a serious impact on people's mental health, especially that of medical staff. Perceived social support is an important factor in one's sense of security.Following the COVID-19 pandemic, the goal is to explore the potential mediating role of resilience in the relationship between perceived social support and the sense of security of Chinese medical personnel.The multi-stage proportionally stratified convenience sampling method was adopted to select 4,076 medical professionals from 29 hospitals in Guangdong Province between September 2020 and October 2020. The Sense of Security Scale for Medical Staff, the Chinese version of the Connor-Davidson Resilience Scale, and the Perceived Social Support Scale were employed in this study. For statistical analysis and structural equation modeling (SEM), the SPSS 23.0 and Amos 24.0 software packages were used. Regression analysis was used to select the control variables to be included in the SEM. SEM analysis was conducted to verify the mediating effect of resilience on the relationship between perceived social support and a sense of security.P < 0.01), and perceived social support  was positively associated with resilience. Structural equation modeling revealed that resilience played a partial mediating role in the association between perceived social support and a sense of security .Pearson's correlation analysis showed that perceived social support and resilience were positively associated with a sense of security (correlation coefficients range from 0.350 to 0.607, Hospital managers should make efforts to develop resilience. Interventions based on resilience should be developed to enhance the perception of social support and strengthen one's sense of security. On 30/01/2020, the World Health Organization (WHO) declared the coronavirus outbreak an international health emergency . Such ciA sense of security is defined as a feeling of confidence, safety, and freedom from fear and anxiety, especially the feeling of being able to meet one's various needs now and in the future . SecuritMedical staff serve as health guardians and play a vital role in global health systems. Chinese healthcare workers are increasingly important to policymakers hoping to achieve the Healthy China 2030 targets. However, healthcare workers face low social support at work, overtime, high workloads, and exposure to harmful body fluids, odors, and noises, which can lead to job insecurity , 9. InseExperiencing social support is a subjective feeling that represents the sum of all social support perceived by the individual . AccordiThe term “resilience” refers to the ability and quality of an individual to adapt to a changing environment . Some stAccording to the job demand-resource model, all job characteristics can be divided into two categories: resources and demands. Social support can be regarded as a job resource and an important predictor of security . PsycholA cross-sectional design was used in this study. We collected data between September 2020 and October 2020. The samples were obtained using a multi-stage proportionally stratified convenience sampling procedure. In the first stage, hospitals were sampled according to the sampling ratio ≈2:1:1 . The sampling ratio was determined according to the number of tertiary, secondary, and primary public hospitals in Guangdong Province and the composition ratio of hospitals in the four regions of Guangdong Province. In the second stage, medical staff  were sampled according to the sampling ratio ≈4:8:1:1 based on the number of doctors, nurses, pharmacists, and technicians in Guangdong Province. Participants were eligible if they were (a) registered or licensed medical staff or (b) had more than 1 year of experience working in healthcare. Medical personnel who were off duty, suffering from mental illness, or who were unwilling to participate in the study were excluded. To achieve 80% power, with alpha set at 0.05, a sample size of 247 medical staff would be required , 32. Convia email with an invitation to participate in this study. Once they agreed, they were asked to send the work group. The researchers explained the goals of the study to the participants and assured them that the data would be kept confidential. After they decided to participate in the study, informed consent was obtained. Only those who agreed to participate and completed the questionnaire could submit it.The survey was completed through an online survey platform  that did not allow respondents to take the survey more than once. We contacted hospital managers The 12-item PSSS was developed by Zimet  and tranThe Connor-Davidson Resilience Scale (CD-RISC) was developed by Connor and Davidson  and Yu aThe scale was developed by the research group in the early stages, with a total of 22 items, including five dimensions: Environment, Patients, Self, Organizational management, and Social support . The LikGender, age, work experience (in years), educational level , job position, marital status , and hospital level were all collected demographic characteristics. The study population was divided into four age groups: ≤ 30, 31–35, 36–40, and ≥41 years. The participants were divided into four work experience groups: 1–5, 6–10, 11–20, and ≥21 years. The positions include doctors (whose job is to treat people who are ill or injured), nurses (whose job is to provide care for people who are ill or injured), pharmacists , and technicians . Three types of hospitals were considered: tertiary hospitals, secondary hospitals, and primary hospitals. Tertiary hospitals are the largest type, typically with more than 500 beds and cutting-edge technology. Primary hospitals are the smallest hospitals, usually with fewer than 100 beds and limited technology. Apart from tertiary hospitals and primary hospitals, the others belong to the Secondary hospitals.For statistical analysis, SPSS Statistics version 23.0  and AMOS version 24.0  were used. SPSS was used for descriptive statistics, Pearson's correlation, and regression analysis. AMOS was used for structural equation modeling (SEM). SEM is a method for specifying and testing linear relationship models between observed and latent variables. Regression analysis was used among the demographic variables to select the control variables to be included in the SEM.In order to obtain the model, the first phase included confirmatory factor analysis (CFA) of the Perceived Social Support Scale (PSSS), Connor-Davidson Resilience Scale (CD-RISC), and Sense of Security Scale for Medical Staff (SSS-MS). The internal reliability of the measurement tools was tested using Cronbach's α coefficient and composite construct reliability, and its validity was examined by CFA.2/df), goodness-of-fit index (GFI), adjusted goodness-of-fit index (AGFI), root mean square error of approximation (RMSEA), comparative fitting index (CFI), normed fit index (NFI), Tucker-Lewis index (TLI), and the incremental fit index (IFI). The following values were regarded as acceptable: χ2/df < 3, GFI > 0.90, AGFI > 0.90, CFI > 0.90, NFI > 0.90, TLI > 0.90, RMSEA ≤ 0.08 . Before implementation, the respondents were informed of the research objectives and signed an informed consent form, which clearly stated that the survey would be completed anonymously. The data obtained were protected by the researchers in order to maintain confidentiality and prevent any potential unintended uses.The sample consisted of 4,076 licensed and registered medical professionals  from 29 public hospitals, which included 14 tertiary hospitals, eight secondary hospitals, and seven primary hospitals spread across the four regions  of Guangdong Province. Of the 4,076 medical staff, 1,019 (25.0%) were doctors, 2,238 (54.9%) were nurses, 438 (10.7%) were pharmacists, and 381 (9.3%) were technicians. Among them, 231 (5.7%) were from primary hospitals, 1,462 (35.9%) were from secondary hospitals, and 2,383 (58.5%) were from tertiary hospitals. The average age of the 4,076 participants was (32.46 ± 9.06) years, with 1,484 (36.4%) men and 2,592 (63.6%) women. In terms of education, 1,781 (43.7%) had a junior college or lower degree, 1,363 (33.4%) had a bachelor's degree, and 943 (22.9%) had a master's degree or higher. The other demographic characteristics of this sample have been presented in Standardized factor loading in measurement mode should be between 0 and 1, with higher values suggesting better indications of the observed variables for the latent variables. To represent the validity and reliability of each construct, three measurements specific to SEM were used in this study: factor loading, composite reliability (CR), and average variance extract (AVE). The CRs of all the constructs were >0.85 (as shown in P < 0.01). Of the three dimensions of perceived social support, the correlation between other support (such as from coworkers and supervisors) and security is the strongest, followed by family support and friend support. Resilience had a positive and significant association with each subscale and total score of the SSS-MS, respectively , job position , and marital status  had a significant effect on the sense of security, which was addressed as a control variable later in the final model. The model fit showed that χ2/df = 1.02 (< 3), RMSEA = 0.01 (< 0.08), and the relative and absolute indices values were all >0.90.The model explained 55.6% of the variance in the general sense of security. P < 0.001), perceived social support was positively related to resilience , and resilience was positively related to a sense of security . Additionally, perceived social support had an indirect protective effect on the sense of security as it influenced resilience , which in turn led to a significant effect on the sense of security. As a result, the total effect of perceived social support against security was 0.627. The results indicated that resilience played a partial mediating role in the relationship between perceived social support and a sense of security. The ratio of mediating effect to total effect was 39.7%. In other words, psychological resilience mediated 39.7% of the effect of perceived social support on security, while 60.3% was a direct effect.As seen in via a partial mediating role of resilience. The mediating effect accounts for 39.7% of the total effect.The main purpose of this study was to explore the potential mediating role of resilience in the association between perceived social support and a sense of security among Chinese medical staff following the COVID-19 pandemic. Furthermore, perceived social support was a significant predictor of a sense of security. Our study found that perceived social support, sense of security, and resilience are all significantly positively correlated with one another. According to the results, perceived social support not only directly affects medical personnel's sense of security but also indirectly influences it Previous research identified a variety of security-related factors, such as interpersonal relationships [e.g., individual characteristics , coping We found that improved perceived social support provides the medical staff with more psychological resilience, which further promotes their sense of security. Until now, few studies have analyzed the impact of resilience on perceived social support and a sense of security among healthcare workers. Security was once considered as important as mental health. There was some evidence that the relationship between perceived social support and mental health is mediated by resilience in nursing students  and juniThe exploration of the relationship among perceived social support, resilience and sense of security has provided new insights for hospital administrators in managing perceived social support and a sense of security among medical staff. The findings revealed that perceived social support can help medical professionals identify the meaning of their work, increase their resilience, and strengthen their impact on the sense of security. The findings suggest that hospital managers may facilitate the resilience of medical staff, which may be an effective method to improve their sense of security. Meanwhile, reasonable evidence for the resilience-enhancing effects of workshops and cognitive behavioral interventions has been discovered . Some inThe COVID-19 pandemic continues to spread around the world. However, it is accompanied by an increase in people's sense of insecurity. The problems resulting from a low sense of security may pose a major psychological threat to medical personnel. It is necessary to be aware of the adverse consequences caused by a reduced sense of security. This study indicated that perceived social support was significantly associated with healthcare workers' sense of security, and resilience mediated the relationship between this and perceived social support. Our findings suggest that perceived social support may play an important role in increasing one's sense of security. Hospital managers should make efforts to develop perceived social support. Interventions based on perceived social support should be developed to increase resilience and strengthen one's sense of security.This study has some limitations. Firstly, this is a cross-sectional study that only analyzed the relationship among perceived social support, resilience, and sense of security. However, the causality between the core variables in our study could not be determined. A future longitudinal study will be required to confirm this. Secondly, convenience sampling limits the generalizability of the results. However, the 29 hospitals we selected are distributed in the four regions of Guangdong Province: Pearl River Delta, eastern Guangdong, western Guangdong, and northern Guangdong, and the sampling was carried out according to the proportion of the number of hospitals covered by the four regions. At the same time, the sampling ratio of doctors, nurses, pharmacists, and technicians is strictly adhered to. Therefore, the representativeness of the sample can be ensured by considering both proportional samplings of hospitals and medical staff. Finally, due to time and financial restraints, all measurements are self-reported. It is still possible for information bias to have occurred due to over- and under-reporting. Although all the scales are self-reported, they all have good psychometric properties and are widely recognized and used. Despite these limitations, the current study contributes to the previous literature both theoretically and practically. Theoretically, this study adds to the previous research by exploring the mediation model, which would help further understand the relationship between perceived social support and a sense of security. Practically, these findings are essential for improving the sense of security among healthcare workers.The original contributions presented in the study are included in the article/supplementary material, further inquiries can be directed to the corresponding author.The studies involving human participants were reviewed and approved by Guangdong Provincial People's Hospital Ethics Committee. The patients/participants provided their written informed consent to participate in this study.QH: conception of the study, data analysis, and drafting of the manuscript. HH: study design, critical review, and revision of the manuscript. PX, HW, and SW: data collection, review, and revision of the manuscript. LY and ZB: data collection and review of the manuscript. All authors contributed to this study and approved the final version of the manuscript.


Objectives: To analyze anxiety in older people practitioners and non-practitioners of physical activity; (2) Methods: ample composed of 690 older people of both genders, unselected volunteers, residing in Brazil, present (as participants or observers) in selected street races in the state of Rio de Janeiro, Brazil, between 30 October 2019, and 12 March 2020. An instrument composed of the sociodemographic questionnaire and questions from the Beck Anxiety Inventory, BAI, and the Physical Activity Inventory for older people, Baecke-Old. Design: Ex-post-facto observational analytical descriptive research; (3) Results: The average age of the sample was in the range of 65 to 69y, 74% female, 94% completed high school, 69% living with the family, 84% practicing physical activity. Anxiety levels were 26% (without), 35% (mild), 21% (moderate), and 18% (severe). The comparison of anxiety showed a difference between the groups of active and sedentary elderly. Logistic regression analysis considering anxiety  and physical activity  and Odds Ratio were performed to identify possible influences of the independent variables PA, gender, marital status, and education on anxiety. Only physical activity was associated with anxiety. (4) Conclusions: The sample data of this research point to the conclusion that physical activity influences anxiety levels with 98% certainty, and it is suggested that it be enriched in the future with different studies with different designs. The older people practitioners of physical activity with a high level of education presented as 26% without, 35% mild, 21% moderate, and 18% severe anxiety. More active individuals are less likely to develop anxiety. The burden of disease among older people is high and tends to increase, as one in five people will be over 60 years old, according to projections by the World Health Organization (WHO) . The perAging is also associated with reduced independence and performance and generally increases the vulnerability of older people, while physical activity benefits healthy aging by increasing psychological stability and physical functioning . PhysicaIn its global PA recommendation for healthy aging, the World Health Organization (WHO) states that older people should include “recreational, leisure and occupational, domestic, transportation, games, sports and physical exercises” in a minimum of 150 min per week of moderate aerobic exercise, and for additional benefits gradually double this time and practice weight training at least twice a week . It is eThe G*Power software version 3.1.9.4  was usedOlder people living in Brazil aged 60 or more years volunteered to participate in this research, present (as a participant or observer) in the attended street races, and did not have a problem that prevented them from answering the instrument properly. The exclusion criterion was cognitive impairment, which could hinder their ability to answer the instrument. ex post facto research attending the Helsinki Declaration had been approved by the Research Ethics Board—Federal University of State of Rio de Janeiro—UNIRIO, on 30 October 2019, # 3.670.727, Certificate of Presentation for Ethical Appreciation generated by Plataforma Brasil, # CAAE 11053318.0.0000.5285.All participants were informed, and all signed a voluntary consent form to participate in the research. This descriptive inquiry analytical observational The instrument composed for this research started with a sociodemographic profile, followed by six selected questions from The Beck Anxiety Inventory, BAI, then five selected questions from Baecke–Old Inventory. From the BAI and Baecke–Old Inventory, essential questions were selected, in order to guarantee that the subject was essentially answered, without, however, the applied questionnaire having to contain a very large number of questions that would make access to a more robust sample impossible. The reason behind choosing these questions, in particular, was that they summarized the perception of anxiety and PA. Presenting the proposed research questionnaire to the Research Ethics Committee of the Federal University of the State of Rio de Janeiro and the doctoral council analyzed the feasibility of the doctoral research; the researcher began by questioning whether there are other methods that can be used to investigate a problem, in addition to the use of a full questionnaire, which will produce the same type of results as the complete questionnaire, underlining that all questionnaires can be prone to bias. Next, the researcher stated that, in her understanding, the most important part of the doctoral research process might be the creation of questions that accurately measure the opinions, experiences, and behaviors of the sample. Creating good measures involves writing good questions and arranging them to form the questionnaire, so the variables of interest in questionnaire-based studies are operationalized through a series of items that constitute a newly developed scale, relying on another previously established. The Research Ethics Committee of the Federal University of the State of Rio de Janeiro and the doctoral council approved the use of this questionnaire as the main instrument of this doctoral research.The sociodemographic questions were: a. full name encoding; b. gender; c. age range; d. who you live with; e. marital status; f. schooling. The age ranges were 60–64, 65–69, 70–74, 75–79, 80–84, 85–89, and over 90. The Beck Anxiety Inventory, BAI, internationally validated , allows p < 0.05 were considered statistically significant.The double-blind statistical methodology was adopted with the results obtained by the researcher and statisticians both neutral and without prior knowledge of the hypotheses tested, and the older people without access to details of the hypotheses that would lead them to bias; and there was testing for intra and inter errors . The datThe sociodemographic profile of older people is shown in Among 690 older people subjects that composed this sample, 582 (84%) were actives, while 108 (16%) were sedentary, characterizing that sample as mostly active. Physical signs of anxiety  were the lowest complaints, while emotional signs (irritability and fear) were the highest . Older people showed a significant association of anxiety with education, gender, and housing status. p = 0.02); anxiety and schooling were associated (p = 0.027); anxiety and marital status were not associated (p = 0.761); anxiety and age group showed no association (p = 0.944). The Chi-square test associations between sociodemographic variables and PA reported that PA and age range were associated (p = 0.001); PA and education were not associated (p = 0.436); PA and marital status showed no association (p = 0.211); PA and gender showed no association (p = 0.217).The Chi-square to test associations between sociodemographics and anxiety reported that: anxiety and gender were associated  resulted in a level of certainty of ≈99% , informing that the difference found is significant, with the chi-square higher than the critical value, 3.4793 > 2.99, and p < 0.05.In the statistical comparison of anxiety between active and sedentary, Pearson’s chi-square Test, the hypothesis test Chi2 = 3.4793, p < 0.05). Only physical activity was associated with anxiety (p = 0.004). More active individuals are less likely to develop anxiety.Logistic regression analysis  and physical activity ) and Odds Ratio were performed to identify possible adjusted associations. The model did not consider the gender variable as a variable that influences anxiety. The other variables were also not significant. Only physical activity was influential (p = 0.027). The study suggests that older people living in their own homes report lower levels of anxiety, family support in one’s own home can improve physical and mental health, and gender is also associated with anxiety [This research confirms the association between anxiety and PA and shows that 18% of the interviewed older people declared suffering from severe anxiety and 21% from moderate anxiety. The comparison of anxiety among active and sedentary older people showed a high level of certainty, 98%, that PA influences anxiety. The older people in the sample revealed a lower level of anxiety among married people (3.26 versus 5.14), women (3.84 versus 4.9), those living with their families (3.14 versus 5.2), and those with university-level education and above (3.16 versus 5.12). Anxiety and schooling were associated .This research confirms the influence of PA on anxiety. The comparison of anxiety between active and sedentary older people revealed that PA influences anxiety levels with 98% certainty. The study suggests that older people living in their own homes report lower levels of anxiety, family support in one’s own home can improve physical and mental health, and gender, education level, and marriage are also associated with anxiety. The most common anxiety symptoms reported by older people were emotional, irritability, and fear. Promoting active aging is both an individual and a health system challenge, whereas the aged voice must be sought in reaching operational definitions for the levels of anxiety and as reporters on the levels of anxiety of their own lives.Some practical implications derived from this study to the real-world setting are the complexity and heterogeneity of aging justify a multidimensional approach to health care to promote successful aging; anxiety is an inevitable aspect of fast-paced life, and the way it’s managed can have a great impact on mental and physical health; coping strategy resources of the older people, such as education and aspects of health care aimed at successful aging, affect the potential for anxiety, can influence the likelihood of experiencing anxiety; a sedentary lifestyle is associated with higher levels of anxiety; the most common anxiety symptoms reported by older people are the emotional ones (irritability and fear), while the least intense symptoms are physical manifestations of anxiety .


Two 500-s resting-state fMRI scans were acquired before and after intervention, respectively. The functional connectivity (FC) was calculated between autonomic nerve system-regulation associated brainstem structures and other brain regions. Compared to other dosages, the FC between rostral ventrolateral medulla and orbitofrontal cortex has more enhanced; the FC between caudal ventrolateral medulla, nucleus of the solitary tract/nucleus ambiguus, and dorsal motor nucleus of the vagus and somatosensory area has more weakened when ED was 23.87 J/cm2. Different dosages of LA have demonstrated varied regions of FC changes between regions of interest and other brain areas, which indicated that variations in EDs might influence the clinical efficacy and subsequent impacts through distinct neural pathways within the brain.Previous studies indicated that laser acupuncture (LA) may effectively treat various medical conditions. However, brain responses associated with LA intervention have not been fully investigated. This study is focused on the effect of LA with different energy density (ED) in brain using resting-state functional magnetic resonance imaging (fMRI). We hypothesized that different ED would elicit various brain responses. We enrolled healthy adults participants and selected bilateral PC6 (Neiguan) as the intervention points. LA was applied, respectively, with ED of 0, 7.96, or 23.87 J/cm Contrar2 for the target tissue  of LA stimulation follow Arndt–Schulz law and can produce distinct effects or with biphasic response . Some put tissue . Additioactivity . For exaactivity , but othactivity . Previouactivity .Despite the increasing awareness and publication of the varying biological effects induced by LA stimulation with different EDs, there has been limited discussion regarding the effects of differential stimulations on corresponding regions of the brain, such as the regions in medulla that responsible for regulating the ANS, or the functional connectivity (FC) between these region and various parts of the brain after LA intervention. The stimulation of PC6 has already been demonstrated in a published article to modulate the amplitude of the intrinsic cortical activity in the brain . SeveralFurthermore, changes in ANS and sympathovagal balance are mainly related to the rostral ventrolateral medulla (RVLM) in medulla. The RVLM is considered as one of the main structures responsible for regulating the sympathetic nervous system (SNS) in response to maintaining a constant heartbeat and blood pressure regulation of the ejection mechanism. Besides, the RVLM also receives signals from the caudal ventrolateral medulla (CVLM) to balance parasympathetic activity. The CVLM activity is captured by the nucleus of the solitary tract (NTS), and NTS affects the parasympathetic nervous system (PNS) through the dorsal motor nucleus of the vagus (DMV) and nucleus ambiguus (NA) . Conside2.2.1.ClinicalTrials.gov (Identifier: NCT05458713).The implementation of this clinical trial program abides by the Declaration of Helsinki, stipulated by the World Medical Association, so as to ensure the life and safety of clinical trial subjects’ health, personal privacy, and dignity. Furthermore, the research project had approved by the Research Ethics Committee of China Medical University and hospital, with the case number CMUH110-REC2-252, prior to commencement. The protocol had also been registered at 2.2.2. To ensure the safety of participants and the stability of data collection, other exclusion criteria included: (1) subjects with chronic diseases such as coronary artery disease, hypertension, diabetes mellitus, hyperlipidemia, and history of cancer; (2) subjects experiencing recent carpal tunnel syndrome or similar symptoms; (3) subjects with functional or organic diseases related to the CNS; (4) subjects unable to follow instructions or comply with study requirements; (5) pregnant women or subjects with metal implants or pacemakers; (6) subjects who had taken nerve activity-inhibiting medications such as psychiatric medications or analgesics within the past 3 months; and (7) subjects with open wounds or scar tissue around the PC6 area that may interfere with the LA intervention.In this pilot study, our primary focus is to investigate the potential cerebral responses of individuals with normal health to diverse LA EDs. To mitigate the potential influence of cardiovascular disease risk factors on study, we recruited healthy male and female, with postmenopausal female participants excluded because of the markedly heightened risk linked to cardiovascular disease , subject2.3.In this study, the experiment has been designed with 1 control group and 2 experimental groups, each group comprising varying ED of LA. Upon random assignment of participants to respective groups using a random number table generated by Excel , the participants were subjected to execute bilateral PC 6 LA stimulation and undergo resting-state fMRI scanning before and after the intervention. The MRI built-in photoplethysmography (PPG) equipment was utilized to monitor the subject’s vital signs such as pulse rate. The purpose of these settings was to facilitate the acquisition of spontaneous brain activity during the resting state, and the obtained data was analyzed to assess the alterations in brain activity pre- and post-intervention. The experimental protocol is depicted in The experimental protocol comprises 3 distinct sections, during which the participants undergo a total of three sessions of fMRI scans. In Section A, the patient is positioned supine on the fMRI platform with the head secured in place. This section involves the execution of a structural scan and a functional scan. The purpose of the whole-brain anatomical image scan is to verify the absence of any structural abnormalities within the brain existed. Section B involves the administration of the LA intervention, whereas Section C comprises the third fMRI scan. This scan is performed after the LA intervention to enable the comparison of effects before and after the intervention.2.4.2 and 23.87 J/cm2 respectively, by varying the duration of exposure time in 20 and 60 s.The LA equipment used in this project was the RJ laser . The complete details of the LA parameter set-tings are presented in LA was administered bilaterally at the PC6 acupoints  . Further2.5.3), followed by a resting-state functional MRI scan before LA stimulation with 200 continuous whole-brain scans using an ascending interleaved echo-planar imaging (EPI) sequence, each lasting 2.5 s, total duration: 8 min and 40 s . After receiving LA stimulation in Section B, the participants undergo another resting-state fMRI scan in Section C. Experimental process would suspend in the event of subject discomfort occurring during any section.FMRI imaging was conducted utilizing a 3 T magnetic resonance imaging system  housed in the Medical Imaging Department of the China Medical University-affiliated hospital. To enter the scanning room, participants must discard all metallic and magnetic objects  and utilize earplugs to safeguard their ears. During the scan, participants are instructed to remain still with their eyes opened and to relax without any movement. Following positioning, the magnetic field gradient is shimming automatically, and tri-pilot images are acquired to determine the field of view’s position. In Section A, a whole-brain anatomical image scan is performed approximately in 5 min with an 3-dimensional spoiled gradient echo sequence  was utilized, which been written on the Matlab 2021b  library. The fMRI images were first corrected for slice acquisition times and realignment with other images to minimize the effects of head movement during scanning. Afterward, the EPI template in DPARSF was utilized for the spatial normalization of functional images. The normalized fMRI images were smoothed with a three-dimensional Gaussian kernel . Finally, in the preprocessed images, voxel-wise brain activities were detrended linearly, confounding variables such as six head movement parameters, white matter signals, cerebrospinal fluid signals, and global mean signal were regressed out , and subAfter completing preprocessing, an analysis of the ANS modulation network was conducted. We selected distinct structures located in the brainstem, which are functionally associated with the regulation of the ANS, as the ROIs for FC analysis. The coordinates of the bilateral RVLM, CVLM, NTS, DMV and NA obtained from previous literature would be used as the center of the ROIs , and a rThe time-series activity in the ROI was averaged and correlated with other brain regions by voxel-by-voxel manner. The resulting r value was standardized by converting it to a z value using Fisher’s r-to-z transformation to measure the FC strength between the ROI and other brain regions. This approach would help understand any changes in the brain’s autonomic neural regulation network.2.7.p < 0.05 (the cluster forming threshold is in uncorrected voxel p < 0.005). A significance level of p < 0.05 would be used to determine statistical significance in other analyses.For statistical analysis, we used SPSS version 22 to examine the demographic data variability  between groups using ANOVA or Chi-square test to assess group comparability. In regards to brain imaging, we utilized SPM12 software for the analysis. The study employed a flexible factorial design with between-subject factors for groups and subject, and a within-subject factor for time. Our primary focus was on the effect of the intervention over time, so the statistical model included the interaction effect between the group and time factors, as well as the main effect of all three factors. To identify changes related to the intervention, a difference of differences analysis was performed between groups and times  using t-contrasts in the model. In addition, correlation analyses were performed to assess the relationships between the FC maps of ROIs and both the percentage of high-frequency  power of HRV as well as the ratio of low-frequency  power percentage to HF power percentage of HRV, respectively. Given the frequently observed limited statistical power in fMRI studies , the cha3.3.1.2 accounted for the most, a total of 19 people, accounting for 37%. The remaining basic information of the subjects, including gender, age, and BMI distribution, is shown in We recruited 51 healthy subjects in the final and separated into 3 groups in randomize sequence. Among them, there were 31 female subjects and 20 male subjects. The subjects aged 20 to 29 accounted for the most, 26 subjects in total, accounting for 51%; the BMI distribution of subjects was relatively average, 20.0 to 21.4 kg/cm3.2.2 group when compared to the control group  to the NTS, DMV, and RVLM have been experimentally verified with neuroanatomy basis . Traditial gyrus ,G,H, in al gyrus . This suSignificant alterations in the FC between the OFC and the pre/postcentral gyrus have been documented in individuals with chronic ankle instability (CAI) . In the Based on the design and results of this experiment, while there may be some shortcomings, it is imperative to recognize its significant impact as it makes three notable contributions. First, to our knowledge, this is the first study to examine the effects of different LA EDs in conjunction with fMRI, providing insights into the potential differential responses of the brain to various intensities. These results have significant implications for understanding the potential neural mechanisms underlying the therapeutic effects of LA, and may inform future clinical applications of this technique. Second, currently empirical medical research on LA predominantly emphasizes the clinical application and intervention effects of specific diseases, as well as comparing it with other intervention methods, such as traditional acupuncture. Our study diverges from this trend by recruiting individuals from the general population and investigating the potential physiological follow-up effects resulting from stimulation of different EDs, an area that has received comparatively little attention. Our achievement is not only consistent with the usage methodology and parameter settings recommended by prior related journals , but alsNevertheless, it is important to acknowledge certain limitations that should be taken into consideration. When conducting an analysis of research pertaining to RVLM, alterations in blood pressure (BP) are commonly employed as indicators of changes in the ANS or SNS . Neverth5.2, at PC6 resulted in significantly enhanced FC of the OFC, which is involved in regulating visceral sensation, compared to the control group. Moreover, compared to a lower ED intervention, 7.96 J/cm2, and the control group, the higher ED intervention resulted in reduced FC in the postcentral gyrus, which is associated with somatosensory regulation. The correlation analysis results further indicate significant associations between variations in HRV indicators, particularly HF% and LF/HF ratio induced by different LA EDs stimulation, and alterations in brain FC between groups. Additionally, it is noteworthy that the performance of SNS and PNS performance exhibits opposing correlation changes in specific areas. These results probably indicated that differences in EDs can impact clinical benefits and subsequent outcomes by modulating distinct neural pathways in the brain. The results of this pilot study may be a basis for further discussion of the potential effects and alterations of various LA parameters or EDs on other brain regions. Future studies could investigate the optimal parameters for LA interventions and how they may vary depending on different conditions. Additionally, studies could explore the long-term effects of LA using fMRI and other physiological markers to determine it’s yet to be explored potential.Different dosages of LA have demonstrated varied regions of enhanced or weakened FC between nuclei related to the regulation of the ANS and other brain areas. Over all, the findings suggest that the higher ED intervention, 23.87 J/cmThe original contributions presented in the study are included in the article/Supplementary material, further inquiries can be directed to the corresponding authors.The studies involving humans were approved by the Research Ethics Committee of China Medical University and Hospital. The studies were conducted in accordance with the local legislation and institutional requirements. The participants provided their written informed consent to participate in this study.Y-CC: Conceptualization, Formal analysis, Investigation, Visualization, Writing – original draft. C-MC: Data curation, Software, Writing – review & editing. I-SL: Resources, Supervision, Writing – review & editing. Y-CL: Supervision, Validation, Writing – review & editing. C-HT: Conceptualization, Data curation, Formal analysis, Funding acquisition, Investigation, Methodology, Project administration, Resources, Validation, Writing – review & editing.