The aim of our study was to analyze the attitudes of employees toward food offered in staff canteens, to analyze their eating behavior and the factors determining the choice of meals in staff canteens. The survey was conducted on a sample of 600 adult respondents, who patronize staff canteens in Warsaw, Poland. The research enabled a detailed and comprehensive assessment of consumer behavior toward the use of staff canteens, as well as their opinions on the functioning of the canteens and meals offered. Factors determining the frequency of use of canteens, type of meals, and factors influencing the use of such establishments were identified. Respondents assessed the quality and variety of meals, with the size of portion being the most valued. They were satisfied with the functioning of the canteens and had very few comments. However, they pointed out the need for an increase in the variety of meals, including the availability of vegetarian and vegan dishes. Our research enabled us to establish consumer profiles based on the reasons for not using staff canteens and comments about staff canteens. Patrons of staff canteens were referred to as “canteen enthusiasts” or “canteen medium-enthusiasts”, who are “snack lovers”, as well as “food choice-oriented” or “quality-oriented”. The results provide the basis for practical implications for owners or managers of staff canteens, part of whose work it is to analyze the needs and expectations of their potential customers. The staff canteen is defined as a place where food is served in a company or enterprise so that employees can eat during their working hours . They coThe increased importance of workplace nutrition is attributed to the fact that workplaces are one of the key channels of interventions to reduce the incidence of chronic diseases in adult populations and improve public health via direct and indirect measures ,6,7,8,9.As previously mentioned, staff canteens are a good place to shape eating behavior and develop proper attitudes toward healthy nutrition. A study conducted among full-time employed females suggested that having lunch at the staff canteen improved their eating habits, and meals served at the staff canteen may serve as a model for an optimal diet . At the Previous studies were mainly related to the restaurant and suggested that food quality  and quality of services ,24, not What are the motives (factors) of employees choosing staff canteens?What consumer profiles can be identified according to the frequency of using staff canteens?How do employees evaluate the canteens in terms of equipment, service, and menu attractiveness?Therefore, the aim of our research was to analyze the attitudes of employees toward food offered in staff canteens, as well as to analyze their eating behavior and the factors determining the choice of meals in staff canteens. The following research questions were formulated:The research was conducted in five staff canteens in Warsaw, which were located in office buildings. They were similar in terms of the size of consumer rooms, the number of places for consumers (75–100), and the number of meals served daily (200–300).The number of operating staff present in the consumer room was related to the lunchtime and ranged from 2–4 people. The canteens were open from 9:00 a.m. to 4:00 p.m. Most people participated in customer service between 12:00 and 2:00 p.m. Dietary dishes (one set each) were offered by only two restaurants. The daily menu of each restaurant offered two soups, from 3–5 meat dishes, based on various types of meat , in various forms: main courses, special dishes, chef’s dishes, and fish and vegetarian dishes. In addition, there were days when oven-baked dishes, grilled dishes, pasta, and pancakes were prepared in front of customers, as well as weeks with national cuisine from around the world.Our research was conducted using a sample of 600 adults from canteens in office buildings in Warsaw, Poland, which was managed by an international catering operator. In 2018, there were 2653 catering establishments in Warsaw, of which there were 408 canteens, located mainly in schools and universities . The intn) was determined using a single population proportion formula [p = 0.313) of studied staff canteens on the basis of all canteens served this catering company 31.3% (p = 0.313), among 408 canteens in Warsaw [az/2) (1.96), and margin of error (d) = 0.05. Taking 5% as the response, the minimal total sample size became 330. We achieved 600 completed questionnaires, which exceeds the minimum number of participants.Sample size  was performed within the population of interest. This group was not added to the main research. All problems were identified, and the questionnaire was completed and corrected. The data were collected by the authors using the PAPI (pen-and-paper interview) method. Inclusion criteria of respondents were as follows:Each respondent who agreed to participate in the survey was invited to complete the questionnaire. If necessary, explanations were provided.Adults over 18 years of age, regularly using the full offer of the canteen, not suffering from diseases requiring a special menu offer.A pretest of the questionnaire through a pilot study . The ANOVA test and multi-dimensional cluster analysis were used. Significance of differences between the values was determined at a significance level of Two multi-dimensional cluster analysis calculations were performed: hierarchical cluster analysis and principal component analysis (PCA). The goal of our cluster analysis calculation was to build a tree diagram where the answers given by participants were most similar in the specific cluster. We used the cluster analysis to determine consumer profiles based on the reasons for not using staff canteens and their opinions about restaurants. In the cluster analysis of consumer profiles, some of the reasons given for not using staff canteens included fast food preferences, skipping a meal, other restaurant preferences, eating home-made food, food delivery, eating at home, snacking, and cafeteria preferences. In the cluster analysis of consumer opinion profiles, features such as price, service, hygiene, promotion, organization, and quality were taken into account. PCA was used to identify sociodemographic factors  affecting the staff’s requirements of food. We established the number of main components based on the scree plot (scree test). As a part of data pre-treatment, correlation eigenvalues were calculated. Then, the eigenvectors of the correlation matrix were calculated. The values and signs of eigenvectors provided information about the direction strength of the correlation between individual component variables. On the other hand, a five-point scale was applied for 10 items in the assessment of material factors in canteens, for eight items in the evaluation of customer service, and for 21 items in menu assessment.p > 0.05).The respondents used the services of staff canteens with varying frequencies. Gender, age, financial status, and workplace did not influence the frequency of using canteen services (p = 0.004);Canteen enthusiast—consumers very often (4–5 times a week) used canteens, with higher education ;Canteen medium-enthusiast—respondents used the staff canteens three times a week and belonged to various sociodemographic groups ;Occasional canteen consumers—consumers used canteen services twice a week, once a week, or less than once a week, having secondary education  and age of the respondents (p = 0.0486). Women and people aged 31–50 were more likely to use canteens at the beginning of lunchtime or had no fixed time, while men were more likely to come inside at the end of this time. People under 30 years used the canteen at half the lunchtime period.Respondents used staff canteens at lunchtime, but at different times of serving. Lunchtime in Poland is between 12:00 and 3:00 p.m. This was usually at the beginning (31.2%) or at the middle of lunch break (33.3%). The other customers (17.3%) usually came to the canteen at the end or had no fixed time for a meal (18.2%). The choice of time to use the canteen depended on the gender (p = 0.0313). Other sociodemographic data did not influence the time spent in a canteen (p > 0.05).Respondents usually spent 15–30 min (71.33%) or 15 min (18.83%) in staff canteens. Few people spent more time on a meal: 31–45 min (8.3%), 46–60 min (1.54%). The time spent on a meal in a staff canteen depended on the age of customers (n = 554) with the highest frequency (three times a week) and main courses (n = 381) at a lower frequency (once or less than once), as shown in The typical components for lunch in Poland are soup and a main course including meat, a portion of carbohydrates, and salad. In staff canteens, the respondents most often bought vegetarian dishes (n = 81), respondents mentioned no other alternative and time to look for other places to eat a meal (n = 24), discounts bought by employers, possibility to get coupons, discounts (n = 11) for regular customers, and professional training in which they attended in the building where the canteen is located (n = 18). Moreover, they indicated the quality of dishes and services, the speed of service (n = 17), the freedom of use of the canteen, and a large selection of dishes, including the possibility of creating their own sets (n = 9), as well as the possibility of different portion sizes (n = 2).The respondents used the services of staff canteens mainly due to their location close to the workplace (76.5%), price (33.3%), and quality of services (33.2%). A smaller percentage of respondents indicated habits (19.7%), meetings (7.33%), and possibility of eating in a pleasant atmosphere (3%). Among other factors , vegetarian meals (13.0%), fat-reduced meals (12.17%), cholesterol-reduced meals (30.8%), sodium-reduced meals (21.2%), simple carbohydrate-reduced meals (15.2%), meals enriched with vitamins and minerals (15.7%), high-fiber meals (24.8%), gluten-free meals (16.7%), lactose-free meals (1%), and others (0.5%). PCA calculations indicated sociodemographic factors differentiating the requirements for meals in staff canteens .Only women a and indRespondents rated the quality of services in staff canteens which they use most often. Material factors, customer service, and menu were evaluated .Most material and customer service factors were rated as good (median 4). The location of the canteen was rated as very good (median 5). The features of staff canteen menu such as the attractiveness of the offer and availability of the menu, as well as taste, temperature, the appearance of dishes and size of portions, quality and prices of soups and main course, variety of meals, breakfast offer, meals prepared using the pro-healthy cuisine method, possibility of receiving various discounts, and ordering additional services were rated as good (median 4). Salad offer, variety of meals in the daily menu, opportunity to buy commercial products such as yogurt, prices in relation to the quality offered, readability and visibility of prices in the menu card, and information about discounts and promotions were rated as average (median 3). The lowest rates were achieved for the option of ordering take-out dishes (median 2).In summary, 63.5% of the respondents were satisfied with the staff canteen services. The opinion of other respondents about services was different. About 25.3% of consumers were partially satisfied (answer: “neither yes nor no”), but 11.2% of respondents were rather not satisfied (“no” or “definitely no”) with the services. Recommendations for canteens were similar, whereby 55.3% would recommend canteens to others and 28.8% were hesitant, but 15.8% of respondents did not recommend canteens.Multidimensional calculations  were used to analyze respondents’ opinions on staff canteens . This leIt should be emphasized that canteen consumers focused on the health-promoting features of the food offered. They postulated the idea of increasing the variety of meals, including vegetarian and vegan dishes, salads, cooked vegetables, egg dishes, fish and poultry dishes, fresh fruits, and fresh fruit juices, as well as reducing the number of meat and flour meals, in favor of health-promoting light and low-fat dishes. Customers suggested reducing the number of dishes fried in favor of baked and cooked dishes, including steamed and grilled ones. The respondents pointed out that some elements of dishes are not tasty or too salty, or that they even have an unnatural taste, which suggests preparation from concentrates. According to the respondents, the use of additional substances was a cause of malaise and stomach problems after eating meals in staff canteens.The interest in catering services, especially staff canteens, in Poland is increasing due to insufficient time, returning home late, and too many professional duties, as well as the increased income of the Poles .The conducted research enabled a detailed and comprehensive assessment of consumer habits concerning the use of staff canteens, as well as their opinions on the operations of those establishments and meals offered. Factors determining the frequency of use of staff canteens, type of meals consumed, and factors influencing the use of such canteens were identified. Above 50% of respondents, who we called “canteen enthusiasts” or “canteen medium-enthusiasts” used the staff canteens regularly, every day or a minimum of three times a week. Other people used the canteen occasionally, whom we called “occasional canteen consumers”. Employees used staff canteens primarily for lunch. The use of this type of restaurant was primarily influenced by the workplace (76.5%), price (33.3%), and quality of services (33.2%). The four profiles of consumers who used staff canteens, in view of food choices, were identified as “snack lovers”, “foodservice lovers”, “junk food lovers”, and “homemade meals lovers”.The behavior and habits of Polish consumers in staff canteens presented in our research are similar to those in other European countries, especially in large cities characterized by large populations. Over 50% of respondents used staff canteens regularly, every day or a minimum of three times a week. This is similar to the study in Helsinki, Finland (48–54%) , but morIn our study, gender did not influence the frequency of using canteen services. In previous studies, men used food services more often than women ,38,51,52These differences were also due to consumer education and financial status, especially high income. In our research, 81.7% of respondents had higher education and 78% had a very good or good financial situation. As indicated by other authors, a higher level of education and income ,54,55,56In our study, we made a thorough analysis  of the reasons for not using the canteen and established specific consumer profiles related to these causes. Getting to know them has great practical implications and may contribute to increasing the use of canteens and even improving the eating habits of Poles. Our research shows that the main reason for not using staff restaurants was frequent dietary mistakes, i.e., snacking. It is worth emphasizing that financial status influences employee behavior regarding the use of canteens. For example, people who declared good financial status indicated different solutions in the area of food during their work . However, people whose financial status were “not good, not bad” preferred to eat at home. This is valuable information for canteen owners to extend the offer to employees of various financial status.In our research, the main factors influencing the use of staff canteens were location, price (including promotions and discounts), service quality, and consumer habits. Other factors  were less important for the respondents. These results are similar to the results presented by other authors who also indicated location , price, It seems to be that food in staff canteens is the most important for consumers. Based on the research result, the expectation of consumers in staff canteens is different from customers of a full-service restaurant, especially for upscale restaurants, which clients usually use for social contact . CustomeIn our study, the respondents expected a pro-healthy menu in staff canteens. Employees with higher education, as in our research, are more aware of health issues according to other authors ,55. As pSome of our respondents wanted traditional meals containing fats, sugar, and salt. This is similar to the results of other authors . ConsumeIdentifying the reasons for customer dissatisfaction is a method of assessing consumer satisfaction. The calculations made by means of multidimensional cluster analysis showed high consumer satisfaction and a positive situation concerning small comments by employees on the operation of staff. In fact, they had very few remarks in all examined aspects. Hygiene in the areas visible to employees  was evaluated very positively. This may indicate the implementation of the obligatory hygiene requirements in food production in the canteens . The atmUnderstanding consumer expectations will help managers to meet them. The use of PCA allowed for the analysis of expectations in the context of consumer metrics. The respondents would like an increase in the variety of meals, including vegetarian and vegan dishes, salads, cooked vegetables, eggs, fish and poultry dishes, fruit, and fresh fruit juices in the menu of staff canteens. They also proposed reducing the number of pork and flour dishes, characteristic of Polish cuisine, in favor of pro-healthy, low-fat, light dishes. Thus, the trend characteristic of other countries is visible in the behavior of Polish consumers. The analysis of consumer expectations can be an inspiration for canteen managers to perform similar activities in order to enhance what they offer and increase customer satisfaction. Eating at work is often associated with increased energy and fat intake and decreased consumption of fruits and vegetables ,60. CantThe positive association between increased consumption of food prepared outside the home and the increasing prevalence of obesity is described as a major social challenge for health and well-being ,84. As iThe selection of the sample was a limitation of the obtained test results. Nutritional behaviors in employee canteens were assessed, and consumer opinions of only a capital city were obtained, which may not translate into opinions from smaller cities and villages. The results relate rather to people with good financial status, while people with lower financial status may have a different opinion.To assess consumer attitudes and behavior on the operation of staff canteens, including their expectations and comments, multidimensional statistical calculations were successfully used. Among consumers of staff canteens, four groups were distinguished, because of their expectations; “choice-oriented consumers” and “quality-oriented consumers” were the main groups, followed by “cost-oriented consumers” and “satisfied consumers” of staff canteens. It was revealed that the surveyed customers mostly valued the quality and variety of meals, as well as the portion size. Canteen customers follow global megatrends regarding “healthy” diets and a sustainable approach, and they expect changes toward the offer of healthy meals. They pointed out the need for an increase in the variety of meals, including the availability of vegetarian and vegan dishes, as well as health-promoting dishes. At the same time, customers make typical mistakes in nutrition by refusing to eat meals offered by canteens. The results provide the basis for practical implications for owners or managers of staff canteens, as they analyzed the needs and expectations of their potential customers. The results allowed us to analyze the current situation with regard to staff nutrition toward healthy living and to define assumptions for public health.Our research results are practical. In employee canteens, the menu offered for employees of different financial status is important, as well as the choice of different meal sizes. This can be a reason to improve dietary behavior, with customers giving up on snacks and overeating in the future.


Being male was consistently correlated with SB. Other sociodemographic correlates differed depending on time-of-day and day-of-the-week. For instance, desk-based workstyles and urban residential area were associated with SB during workday mornings and afternoons, being single was related to mornings and evenings, workdays and nonworkdays. Initiatives to address SB should focus not only on work-related but time-of-day contexts, especially for at-risk subgroups during each period.Increased sedentary behavior (SB) can adversely affect health. Understanding time-dependent patterns of SB and its correlates can inform targeted approaches for prevention. This study examined diurnal patterns of SB and its sociodemographic associations among Japanese workers. The proportion of sedentary time (% of wear time) and the number of breaks in SB (times/sedentary hour) of 405 workers (aged 40–64 years) were assessed using an accelerometer. SB patterns and sociodemographic associations between each time period  on workdays and nonworkdays were examined in a series of multivariate regression analyses, adjusting for other sociodemographic associations. On both workdays and nonworkdays, the proportion of sedentary time was lowest in the morning and increased towards evening ( Longer time spent in sedentary behavior (SB), which is distinct from lack of physical activity, is associated with poor health outcomes, such as the higher risk of all-cause mortality, type 2 diabetes mellitus, some types of cancer, and cardiovascular diseases . The recCharacterizing SB patterns and their sociodemographic associations may play a key role in planning effective intervention strategies such as targeting particular SB patterns and subgroups that require intervention . Among wNevertheless, to our knowledge, there is no previous research comparing the quantitative differences in the diurnal pattern of sedentary time across different subgroups of workers. Understanding the diurnal patterns of SB and their sociodemographic associations provide useful information to identify the potential or suitable timing for reducing SB throughout the day among workers. Therefore, this study examined diurnal patterns and their sociodemographic correlates in objectively measured SB among Japanese workers.This study used a cross-sectional survey distributed between July and December 2013 and from April 2014 to February 2015, as a part of a project aimed at examining the associations between social and urban design attributes and SB among middle-aged Japanese adults. A total of 6000 residents, aged 40–64 years living in two Japanese cities , were randomly selected from the residential registries of each area, stratified by sex and age group. For the selection of study sites, two cities with similar population size but typically different population density (approximately ten times difference) were chosen from popular cities in Japan. An invitation letter was sent to all potential participants. About two weeks later, a reminder letter was sent to the nonrespondents. A questionnaire and an accelerometer (with a log diary) were sent to those who agreed to participate in this study. Participants were asked to complete the questionnaire and the diary and return them within two weeks. A reminder letter was sent to nonresponders up to three times, and a 1000-yen book voucher was offered to those who completed the questionnaire and wore the accelerometer with the diary. A total of 779 participants completed the survey . Of these, day-time workers were included for this study (n = 616), because the majority of workers in Japan work during day-time and have different work and sleep patterns from night workers. Those who had insufficient accelerometer data (n = 187) or missing or invalid data for sociodemographic factors (n = 24) were excluded. The final sample size was 405. The flowchart of participant recruitment is shown in SB and physical activity were measured by a triaxial accelerometer . This device was reported to have high validity  and reliThree measures of SB and physical activity were designated for the total and each time period—sedentary, light-intensity physical activity (LPA), and moderate-to-vigorous physical activity (MVPA) time (minutes/period), the proportion of sedentary, LPA and MVPA time (% of wear time), and the number of breaks in SB (times/sedentary hour). SB, LPA, and MVPA were defined as wear time for any activity with an accelerometer-estimated intensity of ≤ 1.5, 1.5 and < 3.0, and 3.0 or more METs, respectively . A break2) was calculated from self-reported height and weight. The residential area was classified into urban (Koto) and suburban (Matsuyama).Sex and age were obtained from residential registries. Height, weight, marital status , household income , educational attainment , employment status , workstyle , smoking status , and alcohol consumption  were reported by participants. Body mass index  and each period  were reported. The diurnal differences in the proportion of sedentary time (% of wear time) and the number of breaks (times/sedentary hour) were examined using the multilevel mixed-effects linear regression models  with random intercepts, adjusting for sociodemographic variables. Differences in the proportion of sedentary time (% of wear time) and the number of breaks (times/sedentary hour) between subgroups in a whole day or each time period were examined using multiple regression analysis, adjusting for other sociodemographic variables. Interaction effects between sociodemographic variables and time period were examined using multilevel mixed-effects linear regression models with random intercepts. Stratified analysis was conducted for variables which demonstrated significant interactions. Several graphs were also created to facilitate the interpretation of the interaction effects. Statistical analyses were performed using STATA 15.0 , and the level of significance was set at 2), smokers and half reported alcohol consumption one or more times per week. On workdays, the average length of time wearing the accelerometer was 937.0 (69.4) minutes overall, of which 352.4 (126.7) minutes were LPA and 77.4 (47.7) minutes were MVPA. On nonworkdays, mean time wearing the accelerometer was 880.6 (90.2) minutes throughout the day, of which 313.2 (109.5) and 56.7 (36.0) minutes were LPA and MVPA, respectively. Averaged minutes of accelerometer wearing time, LPA, and MVPA on three time periods of work and nonworkdays are presented in the b = 5.86, 95% CI: 4.19 to 7.53, p < 0.001; 55.6%, b = 2.97, 95% CI: 1.39 to 4.54, p < 0.001) and evening . The difference between afternoon and evening was also significant . In contrast, the number of breaks on workdays and nonworkdays were the highest in the morning and lowest in the evening. The number of breaks in the morning was 12.8 times/sedentary hour and 10.4 times/sedentary hour, respectively. This number was significantly lower in the afternoon  and evening . Significant differences between the afternoon and evening were also observed .The mean (SD) sedentary time during the whole day (06:00–23:59) was 507.3 (140.2) minutes on workdays and 510.7 (127.5) minutes on nonworkdays, accounting for 54.2% (14.9%) and 58.0% (13.5%) of wearing time, respectively . Both onFor the whole day, the proportion of sedentary time was significantly higher in men, singles, those with higher educational attainment, desk-based workstyles, and those living in the urban area. On the other hand, women, participants who are married, those with non-desk-based workstyles, participants whose weight was in the normal range, and those participants who live in the suburban area reported higher numbers of breaks.2) were also significantly associated with higher numbers of breaks during morning and afternoon periods, respectively. During the evening period, smokers were the only sociodemographic group that was significantly associated with more breaks.In analyses stratified by the time periods, the proportion of sedentary time was significantly higher in men and those with desk-based workstyles, during all three time periods. Additionally, being single and living in an urban area were significantly associated with a higher proportion of sedentary time during the morning period. Those participants with higher educational attainment, individuals with a full-time job, and those living in the urban area were more likely to spend time in SB during the afternoon period. There were no additional sociodemographic attributes significantly associated with the proportion of sedentary time during the evening period. Regarding the number of breaks, woman, non-desk-based workstyles, and the suburban residential area were significantly associated with taking more breaks during both the morning and the afternoon periods. Married participants and those with normal weight status , part-time job , non-desk-based workstyles , low frequency of alcohol consumption , and living in a suburban area .Interaction effects with diurnal patterns, on workdays, were significant for educational attainment a, employb = 3.35; 95% CI, 0.02 to 6.69; p = 0.049), non-desk-based workstyles , and high frequency of alcohol consumption . A significant increment in the proportion of sedentary time was observed from afternoon to evening for participants who were aged ≥ 50 years .On nonworkdays, there were significant interactions with the diurnal pattern for educational attainment f, workstThe present study examined the diurnal patterns of SB and its associations with sociodemographic attributes among Japanese workers. This study found that the proportion of sedentary time among day-time workers was lowest in the morning, increased over the time periods, and was the highest in the evening on both workdays and nonworkdays. This trend was less clear on nonworkdays due to the higher proportion of SB during the morning period. This is similar to some previous studies which have shown such a trend by the graphical illustrations of diurnal SB patterns among workers ,11,12,13Our findings showed that even during nonworking (leisure) time, the patterns of SB were different—the least SB was observed in the morning, whereas most were in the evening. These patterns may be partly due to the interaction of physical and psychological conditions (less fatigued and more energetic in the morning after sleep), basic lifestyle , and social structure , which could be affected or set by general human circadian rhythms ,21. ThisThis study also demonstrated different associations in different sociodemographic attributes for each time period of SB. Regardless of the time of day and days of the week, men spent more time in SB and took fewer breaks than women throughout the day. This may reflect the difference in social and domestic roles by sex in Japan. The social situation for Japanese women, even if they are working, is characterized by a higher engagement rate for household tasks and childcare , which mRegarding mornings and evenings, which are mostly categorized as leisure time, marital status was consistently associated with total sedentary time and breaks (except during the evening on workdays). These results may reflect the social roles as a parent and partner. Single adults have higher levels of sedentary leisure activities ,31, whicDuring the workday afternoon, persons with desk-based workstyles, those with higher educational attainment, those in full-time employment, and those living in a urban residential area were related to longer time spent in SB and/or fewer breaks. These results indicate that the SB on the workday afternoon (most of which is working time) could be more influenced by work-related sociodemographic attributes. Furthermore, there are previous studies that reveal positive associations of occupational sedentary time with office workers  and fullThis study had several limitations. First, having a cross-sectional design, this study is unable to determine causal relationships between variables. Second, the accelerometer devices used in this study were unable to measure water-based activity or activity that involves the movements of legs and arms and to distinguish sitting or static standing postures accurately. Finally, since there were variations in participants’ accelerometer wearing time (due to different times of waking up or going to sleep), this study cannot describe the diurnal variation of absolute time spent in SB. Future studies can also conduct cluster analysis to identify distinct subgroups of individuals with similar characteristics of diurnal sedentary patterns.This was the first study, to our knowledge, to explore the diurnal patterns of objectively measured SB among workers and their sociodemographic associations. Another strength was the use of objectively measured SB that enabled us to investigate the accurate proportion of sedentary time and breaks during each time period.In summary, the proportion of sedentary time was lowest in the morning  and highest in the evening  both on workdays and nonworkdays, with an inverse trend for breaks. Although being male was a consistent factor related to SB and breaks throughout the day and week, associations between other sociodemographic attributes and these SB measures differed depending on time periods of the day and the days of the week. SB and/or breaks seem to be mainly associated with work-related attributes such as workstyle, educational attainment, and employment status on workday afternoons, whereas social and domestic-related attributes such as marital status are related to mornings and evenings of workdays and nonworkdays.


The pandemic of Coronavirus Disease 2019 (COVID-19) has burdened an unprecedented psychological stress on the front-line medical staff, who are at high risk of depression. While existing studies and theories suggest that factors such as gratitude, social support, and hope play a role in the risk of depression, few studies have combined these factors to explore the relationship between them.This study examined the mediating roles of social support and hope in the relationship between gratitude and depression among front-line medical staff during the pandemic of COVID-19.This study used the Gratitude Questionnaire, the Perceived Social Support Scale (PSSS), the State Hope Scale (SHS), and the Center for Epidemiologic Studies Depression Scale to examine the gratitude, social support, hope, and depression among 344 front-line medical workers in Wuhan, which was the hardest-hit area of COVID-19 in China.gratitude–social support–depression = −0.096, 95%CI(−0.129 to −0.064); βgratitude–hope–depression = −0.034, 95%CI(−0.055 to −0.013)], as well as via an indirect path from social support to hope .The results showed that the prevalence of mild depressive disorder was 40.12% and the prevalence of major depressive disorder was 9.59% among front-line medical staff during the pandemic of COVID-19; gratitude has a direct and negative effect on depression. Gratitude was negative predictors of depression through the mediating variables of social support and hope [βThe study findings indicate that gratitude as a positive emotion can reduce depression in medical staff by promoting social support and hope, respectively. Gratitude also reduced depression in health care workers through a chain mediating effect of social support and hope. Overall, gratitude can directly foster social support and hope, and protect people from stress and depression, which has implications for clinical interventions among front-line medical staff during the pandemic of COVID-19. Previous studies have found that in high-risk and stressful pandemic environments, medical staff are prone to have a range of psychological problems . CoronavWithin the field of gratitude research, there is a lack of agreement about the nature of the concept. Gratitude has been conceptualized as an emotion, an attitude, a moral virtue, a habit, a personality trait, or a coping response . In partThe broaden-and-build theory of positive emotions argues that gratitude may build up social resources and psychological resources . These rThe experience of gratitude and the actions stimulated by it build and strengthen social bonds and friendships. Moreover, encouraging people to focus on the benefits they have received from others leads them to feel loved and cared for by others . TherefoIn addition to building up social resources, gratitude can also reduce depression by building up psychological resources, such as hope . GratituSocial support not only provides material support to make up for the resources that individuals lose in coping with stress, but also improves their sense of meaning and sense of purpose . AccordiSince the COVID-19 outbreak, the growing number of patients has put tremendous pressure on the local medical system and medical staff in Wuhan. Medical workers in Wuhan have been facing many challenges . At the In recent years, with the rise of positive psychology, more and more researchers have begun to pay attention to the positive influence that negative events may bring to individuals. Participants in this study involved 344 front-line medical workers in Wuhan, which was the hardest-hit area of COVID-19 in China. The medical workers were from a medical team from Gansu province that aimed to assist Wuhan city. The research team recruited them online and offline after obtaining the consent of the leader of the assistance medical team. These medical workers had been on the frontline of treating COVID-19 for more than 2 months prior to participating in the present study. The period of data collection lasted 10 days and was undertaken between April 27, 2020 and May 6, 2020. A total of 360 medical workers participated in our survey, and 344 (95.56%) of them completed all the questionnaires.The Institutional Ethics Committee approved all the procedures. The purpose of the study and the autonomy of medical workers were highlighted before the survey. Written informed consent forms were obtained from each participant, and the participants were free to withdraw from the survey at any time. Once recruited and consented, the participants then completed the survey through the Wenjuanxing platform which is an online survey tool.Gratitude was measured using Gratitude Questionnaire-6 GQ-6, . This quPerceived social support was measured by the Perceived Social Support Scale PSSS; , which wHope was assessed using the State Hope Scale SHS; . This scDepressive symptoms were measured by the Center for Epidemiological Studies-Depression Scale CES-D, . This scData analyses were conducted via SPSS 17.0 and Mplus 7.0. First, descriptive analyses were conducted for the variables of interest for the total sample. Structural Equation Model (SEM) was carried out to examine the mediating role of social support and hope in the relationship between gratitude and depression among front-line medical staff during the pandemic of COVID-19. Missing data were handled with full-information maximum likelihood (FIML) estimates in structural models. We used chi-square values to evaluate model fit, the comparative fit index (CFI), the Tucker–Lewis index (TLI), the RMSEA, and the standardized root-mean residual (SRMR). A non-significant chi-square indicates good model-data fit. The general cutoffs for accepting a model are equal to or greater than 0.90 for the CFI and TLI, and less than 0.08 for the SRMR and RMSEA .Measurement model fit should be evaluated before proceeding to an evaluation of the full model . This stSD = 7.25; min 20 years old—max 57 years old). Of the 344 participants included in this study, 40.1% were medical doctors and 59.9% were nurses.Sample characteristics data from 344 front-line medical workers were included in the analysis. The mean age was 34.05 years , 65.4% of the participants were females, 34.6% were males, average age were 34.05 years  = 0.035(0.011–0.059).First, the measurement model was tested. It consisted of two latent variables: social support and hope. The social support latent variable has three subscales: family support, friends support, and other support. The hope latent variable has two subscales: agency thinking and pathways thinking. The measurement model fit was acceptable: χ2/df = 2.521, CFI = 0.948, TLI = 0.972, RMSEA (90%CI) = 0.052 (0.033–0.071)]. The results of the path analysis indicated that the path coefficient of gratitude direct effect on depression was β = 0.372 (p < 0.001).Prior to testing the mediating effect, we examined the direct effect of gratitude on depression. The direct effects model demonstrated a good fit: . The results of the model are shown in gratitude–social support–depression = −0.096, 95%CI (−0.129 to −0.064); βgratitude–hope–depression = −0.034, 95%CI(−0.055 to −0.013)], as well as via an indirect path from social support to hope .In order to further probe into the predictive mechanism of gratitude on depression, in this study, social support and hope were simultaneously included as mediating variables in the direct effect model based on a direct model. The fit index of the model was considered ideal [χThis study found that the depression was common among front-line medical staffs during the pandemic of COVID-19. Medical staffs have to identify the people infected with the disease, respond to their treatment needs, carry out the severe and difficult treatment processes in hospitalized patients, face the psychological breakdown caused by each patient passed away, and also face the risk of developing the disease at any time . These fHowever, this study found that gratitude can reduce the depression of medical staff, which is consistent with previous studies . From thThis study found that gratitude can reduce depression by promoting social support. The promotion of gratitude to social support is consistent with previous studies . GratituBy analyzing the influence of gratitude on depression path through hope, we can find that gratitude may lower the occurrence of depression by improving the hope of medical staff. From the relationship between gratitude and hope, gratitude is a positive evaluation of what has happened, while hope is a positive expectation of what has not happened . People This study also found that gratitude can reduce depression through the chain mediation of social support and hope. During the pandemic period, the sense of belonging of medical staff with more social support will be better satisfied, and their goal-oriented behavior will be fully stimulated, which will help to enhance the hope of medical staff for future life .This study suggests that psychological intervention workers should not only pay attention to alleviating the negative psychological problems of medical staff, but also pay attention to the positive psychological growth of medical staff. Practices such as gratitude writing and gratitude visit can be used to promote gratitude and to guide medical staff to the people and things for which they are grateful . It can However, there are some limitations in this study. First of all, this study focuses on the medical staff aiding Wuhan who are affected by the pandemic situation, and these medical staff have different degrees of trauma exposure in the pandemic situation. The study does not adequately control for other factors that may influence depression, such as whether the medical staff was in a satisfying relationship. Second, cross-sectional data are used in this study, which makes it difficult to explain the causal relationship between variables. Previous studies, for example, have suggested that closer social connections may help people develop gratitude . Future The study findings indicate that gratitude as a positive emotion can reduce depression in medical staff by promoting social support and hope, respectively. Gratitude also reduces depression in health care workers through a chain mediating effect of social support and hope. Overall, gratitude can directly foster social support and hope, and to protect people from stress and depression, which has implications for clinical interventions among front-line medical staff during the pandemic of COVID-19.The original contributions presented in the study are included in the article/supplementary material. Further inquiries can be directed to the corresponding author/s.The studies involving human participants were reviewed and approved by the Ethics Committee of Northwest Minzu University, Lanzhou, China. The patients/participants provided their written informed consent to participate in this study.LF developed the study design, participated in and supervised data collection, performed the statistical analysis, and drafted the manuscript. RY conceived the study and revised the manuscript critically for important intellectual content. Both authors gave their final approval of the current version of the manuscript.The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.


We determined ED conversion factors for 11 CT protocols using CT data obtained from a nationwide survey in Korea and Monte Carlo-based dose calculations.The aim of this study was to determine the conversion factors for the effective dose (ED) per dose length product (DLP) for various computed tomography (CT) protocols based on the 2007 recommendations of the International Commission on Radiological Protection (ICRP). CT dose data from 369 CT scanners and 13,625 patients were collected through a nationwide survey. Data from 3793 patients with a difference in height within 5% of computational human phantoms were selected to calculate ED and DLP. The anatomical CT scan ranges for 11 scan protocols  were determined by experts, and scan lengths were obtained by matching scan ranges to computational phantoms. ED and DLP were calculated using the NCICT program. For each CT protocol, ED/DLP conversion factors were calculated from ED and DLP. Estimated ED conversion factors were 0.00172, 0.00751, 0.00858, 0.01843, 0.01103, 0.02532, 0.01794, 0.02811, 0.02815, 0.02175, 0.00626, 0.00458, 0.00308, and 0.00233 mSv∙mGy Advances in computed tomography (CT) have led to an increase in its diagnostic capabilities and therefore its utilization, which in turn has led to an increase in patient exposure to radiation. Diagnostic reference levels apply to the radiation exposure of patients resulting from procedures performed for medical imaging and are used in medical imaging to determine whether the radiation dose was unusually high or low for a specific procedure. Alternatively, effective dose (ED) can be beneficial to compare the relative doses of different diagnostic procedures and technologies in different hospitals and countries. Furthermore, ED can also be used to study the use of different technologies for the same medical examination. However, it should be noted that ED is not used to determine individual risk . Thus, cAccording to the International Commission on Radiological Protection (ICRP), ED represents a weighted sum of the equivalent doses in all tissues and organs of the body, where the equivalent doses for an organ represent the sum of absorbed doses averaged over a tissue or an organ weighted by the radiation weighting factor. Generally, ED is computed by using Monte Carlo dose simulation tools for reference human phantoms. The ED evaluation method for CT examinations in the clinical setting has been defined using dose-length product (DLP) and the effective dose conversion factor (ED/DLP). In the year 1999, the European Commission published a set of conversion factors for different regions of the adult body . ShrimptIn this study, we developed CT ED conversion factors for 11 CT protocols, utilizing a nationwide survey data conducted in the Republic of Korea. We used the Monte Carlo-based dose calculation program, which adopts hybrid computational phantoms representing individuals with a reference organ mass and body dimensions ranging from newborns to adults, including six age groups that include children and both sexes .Data required for the calculation of ED conversion factors were extracted from data collected through a nationwide survey carried out from October 2016 to August 2017 in the Republic of Korea [We assumed that the physical characteristics of the patients would be similar to those of the virtual phantoms used for the dosimetry calculator and established the following conditions for extracting patient data from the survey: (1) data of adult patients with heights in the following ranges: 169–187 cm for men and 159–176 cm for women; (2) data of pediatric patients belonging to the four age groups as follows: 0–2, 4–6, 9–11, and 13–15 years. We extracted data for a total of 3793 CT examinations for this study, which included examinations of 1942 adult men, 1107 adult women, and 744 pediatric patients. The number of examinations for each CT protocol is listed in http://ncidose.cancer.gov/#ncict; accessed on 10 September 2020) based on a Monte Carlo simulation, which was developed by the U.S. National Cancer Institute [The CT ED conversion factor is defined as ED per DLP. Therefore, DLP and ED must be calculated for each CT examination. Since ED is not a physical quantity that can be measured, a CT dosimetry calculation program is required. In this study, we used the NCICT  program  values for 11 CT protocols are summarized in −1∙cm−1 for adult brain, intra-cranial angiography, C-spine, L-spine, neck, chest, abdomen & pelvis, coronary angiography, calcium scoring, aortography, and CT examinations of pediatric brain of <2 years, 4–6 years, 9–11 years, and 13–15 years, respectively.The estimated ED conversion factors are summarized in Compared to previous studies ,3,12,13 Recently most of the CT scanners report the DLP. Although the DLP is related to patient dose and risk, it is unique to CT and is not useful for comparisons with other modalities. DLP to ED conversion factors are useful for quickly estimating patient risk based on the DLP values reported by CT systems .vol, age, tube voltage, scan range, sex, and type of head/body filter. The data required for the calculation of ED conversion factors were extracted from data collected in a nationwide survey in the Republic of Korea. The data of patients similar in size to the computational phantom size were used when calculating ED so that it was possible to estimate a proximal value of ED received by the patient.In the present work, we developed DLP to ED conversion factors for a greater number of CT protocols than those used in prior studies. These conversion factors are necessary for the current medical fields where various CT protocols are used. We calculated DLP and ED received by a patient from a CT examination using the Monte Carlo-based NCICT program with CT examination data on CTDIIn addition to the four CT protocols  used in the previous study, our study presented conversion factors for six additional CT protocols . In our study, ED conversion factors for neck and chest protocols are higher than those used in previous studies. This is related to the differences in organ-weighting factors and ED calculation between the ICRP publications 60 and 103. For the ICRP publication 60, the highest organ-weighting factors were found for the pelvic region, whereas for the ICRP publication 103, the highest values were obtained for the abdominal region. The conversion factors for the brain CT protocol for children are higher than those for adults. This result was expected, since the organs  responsible for the main contribution to ED receive higher doses in children than the organs of adults due to their smaller cross sections . The comvol represents x-ray output from a CT scanner. However, the average conversion factor does not provide scanner-specific results. The ED is an estimate of relative biologic risk and is not a physical parameter that can be measured. Indeed, the ED is a derived parameter and is always computed through multiple steps and approximations. Martin [CTDI. Martin  reported. Martin . DevelopWe determine ED conversion factors that reflect the new ICRP recommendations. We specified these factors separately for both sexes for 11 CT examination protocols. These factors were based on CT examination data obtained from a nationwide survey in the Republic of Korea and developed using the Monte Carlo-based dose calculation program. These CT protocol-specific conversion factors will allow for a more accurate benefit-risk assessment of CT imaging strategies and optimization of patient radiation safety.


Vu Gia-Thu Bon (VGTB) river basin is an area where flash flood and heavy flood events occur frequently, negatively impacting the local community and socio-economic development of Quang Nam Province. In recent years, structural and non–structural solutions have been implemented to mitigate damages due to floods. However, under the impact of climate change, natural disasters continue to happen unpredictably day by day. It is, therefore, necessary to develop a spatial decision support system for real-time flood warnings in the VGTB river basin, which will support in ensuring the area’s socio-economic development. The main purpose of this study is to develop an online flood warning system in real-time based on Internet-of-Things (IoT) technologies, GIS, telecommunications, and modeling (Soil and Water Assessment Tool (SWAT) and Hydrologic Engineering Center’s River Analysis System (HEC–RAS)) in order to support the local community in the vulnerable downstream areas in the event of heavy rainfall upstream. The structure of the designed system consists of these following components: (1) real-time hydro-meteorological monitoring network, (2) IoT communication infrastructure , General Packet Radio Service (GPRS), wireless networks), (3) database management system , (4) simulating and predicting model , (5) automated simulating and predicting module, (6) flood warning module via short message service (SMS), (7) WebGIS, application for providing and managing hydro-meteorological and inundation data, and (8) users (citizens and government officers). The entire operating processes of the flood warning system  are automated. A complete flood warning system for the VGTB river basin has been developed as an outcome of this study, which enables the prediction of flood events 5 h in advance and with high accuracy of 80%. Among the countries in the world most affected by extreme weather events in the period from 1996 to 2015, Vietnam is ranked eighth ,4,5,6. TWith respect to hydrologic models, distributed hydrologic models such as Soil and Water Assessment Tool (SWAT) have more advantages over lumped hydrologic models thanks to their ability to capture the diverse characteristics of river basins and hydro-meteorological forcings, and as a result, are widely used to illustrate the physical mechanisms of floods in reality . In flooSWAT and HEC–RAS models have been extensively adopted in real-time flood modeling and forecasting. Rainfall distribution algorithms were proposed to project precipitation using data from auto weather stations and rainfall/runoff hydrological models in SWAT . The HECIn a parallel research stream, flooding in the VGTB has received considerate attention via the applications of various flood simulation models, for instance, using SWAT in flood control with an emphasis on the role of forests; applying HEC–HMS and HEC–RAS models in flood simulation at VGTB ,16,17; uHence, our research attempts to address this need at the VGTB river basin by designing a flood warning system through the Geographic Information System–Information Technology (GIS–IT) and integrating the SWAT and HEC–RAS model approach. The deployment of a flood warning system is very urgent to ensure the social-economic development sustainability of the VGTB river basin in the context of climate change. The objectives of this study are to determine vulnerability flood areas and peak flooding in the VGTB river basin and support farmers in vulnerable flood areas.2, lies approximately between 14°95′ and 16°06′N in latitude and 107°21′ and 108°46′E in longitude, encompassing Da Nang City, Quang Nam Province, Quang Ngai Province, and part of Kon Tum Province  for real-time flood warnings in the VGTB river basin. We built upon our previous work ,22 to deThe flood warning system in the VGTB river basin includes 3 components: real-time hydro-meteorological (HM) data monitoring network, data processing center, and telecommunication infrastructure. The real-time hydro-meteorological data monitoring network includes a data logger for recording data every 5 min, rain gauges, and sensors  from 20 meteorological stations, and water level data recorded every 5 min from 5 hydrological stations. All data is transmitted every 30 min to the data center by Global System for Mobile Communications (GSM)/ General Packet Radio Service (GPRS). The data processing center includes a data server and will receive and store data from stations. This is also where the automatic flood simulation and forecast based on SWAT and HEC–RAS models were calibrated and validated.In practice, there are 9 stations at the VGTB river basin including in Ai Nghia, Hien, Hiep Duc, Hoi Khach, Kham Duc, Nong Son, Tien Phuoc, Thanh My, and Tra My. The statistic record of annual rainfall (1980-2013) has pointed out that there are several inaccuracies in the previous works with an error of about 7.47%. To lower this error rate to an acceptable level of 5%, data from at least 20 additional rain gauges  were reqMore importantly, our analysis using Thiessen’s interpolation method has also shown that the VGTB river basin has 9 different rainfall zones. Thus, based on the weight of rainfall zone areas, the number of stations should be different for each rainfall zone. Specifically, the additional numbers of stations for nine zones of large rainfall areas in the VGTB river basin were set as 1, 5, 1, 1, 3, 2, 4, 1, and 2 for Ai Nghia, Hien, Hiep Duc, Hoi Khach, Kham Duc, Nong Son, Tien Phuoc, Thanh My, and Tra My, respectively. Next, embedded maps on GIS environments such as hydrography, wind directions, transportation, and sub-basin were exploited to determine appropriate locations for the required stations. As a result, the optimum numbers and locations of meteorological stations have been achieved in our study, with suitable places to set up our station for each range of rainfall areas, as shown in From the previous analysis, the optimal number of stations was set as 5 based on the hydrological station criteria as in the research of . These cThe SWAT model is a semi-distributed model with the purpose of simulating the hydrology, sediment, and nutrient yield in large agricultural catchments with various agro-climatic conditions . In thisInput/output files of the SWAT model are organized as follows. Input files are classified into two categories: configuration files  and data input files . Concerning flood flow simulation, the relevant input files include master River Basin file (file.cio), and weather input files . After each SWAT simulation, the input.std file, the output.std file, the output.hru file, the output.sub file, and the output.rch file are generated in the output. Meanwhile, the print codes of the master River Basin file (file.cio) manage the detail of the data printed out in the above files. Thus, the output files may aggregate daily, monthly, yearly, or for the entire simulation period based on the selected print code. For flood flow simulation, the reach output files are considered.The input/output files of the HEC–RAS model are organized as follows: For unsteady flow simulation, the input files include geometry (*.g01), unsteady flow  (*.u01), and plan files (*.p01). The output files include water surface profiles, storage–outflow information, computed rating curves, etc., in a separate binary format (HEC and HDF5) or DSS format.The automated procedure for streamflow simulation in SWAT consists of three steps, differentiated by season  monitored. Once the first SWAT scenario is completed, the entire input and output files will be stored in the TxtInOut folder in ASCII format. Users can easily interact with them through the use of simple scripts of reading or writing input files.The SWAT model requires a large amount of input data such as topography, land-use, soil, and weather in order to run. For flood warnings, weather data needs to be monitored in real-time due to its continuous change. Meanwhile, the other data can be updated periodically (yearly) due to its slow change. After completing the first SWAT scenario, the entire input and output files are stored in the TxtInOut folder in ASCII format. The user can easily interact with them by using simple scripts of reading or writing input files. Input files relevant to this study include the master configuration file and weather data input files. The rainfall data at each station is stored for a given time: 30 min, or daily. To run SWAT, the script System.Diagnostics.Process.Start  is used for active SWAT executable. The reach output file is one of the output files generated in every SWAT simulation. By using simple scripts of reading input files in the library System.IO.Files, the user can extract streamflow data from the reach output file to write HEC–RAS input files.The input files of the HEC–RAS model are also stored in ASCII format. Users may interact with the input files by using simple scripts of reading or writing input files. For flood warning, the related input files are plan file (*.p01), and unsteady flow  (*.u01).Unlike SWAT, HEC–RAS runs on Windows Forms, which is different from Console scripts. As a result, users are required to interact with HEC–RAS on its interface, making the automation of active HEC–RAS process quite complex. To execute HEC–RAS automatically, this study uses the HEC–RAS Controller Code module that controls HEC–RAS through the macros written in VBA and embedded in file HECRASControllerCode_h2ls.xlsm. After the input data of HEC–RAS is created, the library Microsoft.Office.Interop.Excel is used to read file HECRASControllerCode_h2ls.xlsm and activate a macro Compute_CurrentPlan in order to run the HEC–RAS model.Once the calculation of water level at cross-sections is finished, the Mouse Tracking technique is used to collect the users’ mouse cursor positions on the computer when they perform inundation mapping in the RAS Mapper tool manually. This is to automatically estimate flood depth in this application.The results from running RAS Mapper application is shown flood depth in GeoTiff format. This file is then uploaded to WebGIS by using the GeoTIFF module of GeoServer.The general SWAT HEC–RAS module for real-time flood forecasting is shown in The application’s interface is organized as follows: Firstly, the model is set up by declaring start time, end time, time step (30 min/daily), and running mode . By default, the start time is date 2015/09/01 , end time is assigned to the system’s current time. Secondly, the start/stop is turned on and automatic running mode is turned on/off. Thirdly, auto SWAT is activated by creating input files, running model, linking to input files , errors report of input data (Error Data), and link to output file (output.rch). Then input files, run model, link to input files , and results report of running model (p01.computeMsgs) are created using the auto HEC–RAS. Next, we use the auto RAS Mapper to run the application, link to configuration file “Mouse Tracking”, result folder. After that, it is necessary to view the online flood map by using “Connect to WebGIS” function to view the flood depth map. Lastly, logs display timeline for step-by-step implementation and start/finish status of the whole process.2 = 0.93, NSI = 0.92, PBIAS = −0.64; and for validation, a 10 year period was selected (2005–2014) with R2 = 0.92, NSI = 0.91, PBIAS = 3.77, as shown in 2 = 0.82, NSI = 0.63, PBIAS = 5.5 and validation on water level at the Cau Lau hydrological station in the VGTB river basin during October 31–November 7, 2016 flood event with R2 = 0.85, NSI = 0.66, PBIAS = 6.20, as shown in The objective of this study was to integrate SWAT and HEC–RAS models in real-time flood simulation in the VGTB river basin and based on the time series analysis of 20 meteorological stations. For the result of SWAT model calibration, a 10-year period was selected (1995–2004) at the Nong Son hydrological station in the VGTB river basin with RBased on the time series analysis of 20 meteorological stations and five hydrological stations in the VGTB river basin as shown in Flood data from HEC–RAS is built according to a raster data structure with * .tif file format. Currently, the PostGIS’s spatial data structure integrated into the PostgreSQL database only supports the conversion from raster data in * .tif format to a manual database structure. Because of that, the research team had difficulty in updating automatically raster data into the PostgreSQL database. During the research process, the research team found a solution to overcome this problem. The solution was to convert the raster (* .tif) format to ASCII format (* .txt) with three value fields, XYZ, in which Z is the flood level value with the GDAL command line library . After the data processing starts in the text file, this data will be used and connected to the SMS module to alert the risk of flooding to households in the area and they can be more active in responding to flooding.The module automatically collects the location of the household  with the flood map and sends flood warning information via SMS. The entire operating procedure of the module is illustrated in This paper has presented an automated procedure for forecasting flood events in the VGTB river basin on a sub-daily basis by integrating the SWAT and HEC–RAS models. The whole procedure  was packaged into a single, fully automated module that meets strict constraints on accuracy and processing time.Emergency agencies can make optimal decision-making from the proposed spatial decision support system designed by combining the SWAT and HEC–RAS models. A conceptual framework for implementing the system with interoperability standards has been used. The achieved SDSS results demonstrated the ability to combine real-time meteorological and hydrological models for flood forecasting in the Vu Gia-Thu Bon river basin under a real scenario. Our proposed interoperable standards were appropriate to address the interoperability of heterogeneous data sources, allowing easy addition of new data sources, reuse of data, and access to integrating more data for potential data users. The improvement of the maintainability and assessment of WSN, as well as providing data from poorly gauged or ungauged areas through VGI in the proposed system, can enhance the support of the decision-making.The SDSS demonstrated accurate prediction of peak flows not only in a long-term assessment (2005–2014) but also in two specific flood events in 2015 and 2016. The accurate prediction of water stages at peak flows and the timing of peaks is key information toward providing early warnings of impending flooding events accurately to the relevant people in the flood zones. These two models are the most popular tools that have been used in a number of watershed studies and river hydraulic analyses. The proposed procedure can be widely adopted and applied to other river basins using both the SWAT and HEC–RAS models.


The data concerning the association between dengue viruses (DV) infection and autoimmune diseases (ADs) remain unclear and are scarce. This nationwide population-based cohort study assessed the risk of ADs among patients with DV infection. We analyzed Taiwanese medical data from the Registry of the National Notifiable Disease Reporting System of Taiwan’s Centers for Disease Control between 1998 and 2015 and identified patients with DV infection. From the entire general population data in the National Health Insurance Research Database, we randomly selected a comparison cohort that was individual matching by age, sex, residence, and index date. We analyzed the risk of ADs using a Cox proportional hazards regression model stratified by sex, age, and residence. We enrolled 29,365 patients with DV infection  and 117,460 age-, sex-, and residence-matched controls in the present study. The incidence rates of organ-specific ADs were nonsignificantly higher in the DV cohort than in the non-DV control cohort. An approximately 70% lower risk of primary Sjogren syndrome (pSS) was evident in the DV cohort than in the non-DV control cohort with an adjusted hazard ratio of 0.30  after adjusting for comorbidities in matched design. By contrast, the other systemic ADs were nonsignificantly lower in the DV cohort than in the non-DV control cohort. This nationwide long-term cohort study demonstrated that patients with DV infection had a lower risk of primary Sjogren syndrome than those without DV infection.The online version of this article (10.1007/s10067-020-05282-2) contains supplementary material, which is available to authorized users. Dengue viruses (DVs), a group of four serologically distinct but related flaviviruses, are responsible for a major emerging viral disease . This moWhen a DV infects a host, it may induce the production of autoantibodies because of the structural antigen similarity between viral proteins and self-antigens . The molSome evidence suggests that DVs play key roles in the pathogenesis of autoimmune diseases (ADs), and various mechanisms have been invoked to explain these observations, including molecular mimicry and an increase in the immunogenicity of autoantigens caused by inflammation in the target organ . ParadoxBecause of the high prevalence of DV infections in Taiwan, we have debated whether DV infection is associated with the development of ADs. In Taiwan, patients with dengue are placed under the surveillance of the Centers for Disease Control, R.O.C.  which entails being subject to a routine laboratory-based screening and diagnosis system . All hosMedical claims data were obtained from the National Health Research Institutes (NHRI). After receiving approval for this study from the NHRI, we used scrambled patient identification numbers to assess the data, including inpatient care claims and the Registry for Beneficiaries. The NHRI maintains and updates the National Health Insurance (NHI) Research Database (NHIRD). The insurance program maintains contracts with 97% of the hospitals and clinics in Taiwan . The accDengue fever is a category 2 notifiable infectious disease in Taiwan and must be reported to the Taiwan CDC by physicians within 24 h of identifying a suspected case. Suspected dengue cases are confirmed by the Taiwan CDC on the basis of the presence of anti-dengue IgM, nucleotide sequence, or viral isolation. Since 2014, nonstructural protein 1 antigen detection has been used as a rapid diagnostic technique in Taiwan. The patient’s travel history is also obtained to clarify whether the case was imported or locally acquired. Only indigenous cases retrieved from the National Notifiable Disease Reporting System of the CDC between 1998 and 2015 were included in the study. The historical medical records (both inpatient and outpatient) of the dengue-confirmed cases can be accessed from the NHIRD. The index date for the DV cohort was identified as the date on which a patient received the first diagnosis of DV infection, as documented in the Registry of the National Notifiable Disease Reporting System. Patients who had been diagnosed with ADs before or within 1 year of DV diagnosis were excluded from this study. The data consolidation and control group selection were processed anonymously in the Department of Statistics, Ministry of Health and Welfare.For each patient with a diagnosis of DV infection, a maximum of four comparisons was randomly selected from the NHIRD, a pool of approximately 23.7 million individuals. For the comparison cohort, the index date corresponded to the date on which controls utilized the NHI services. The comparison cohort was age (±2 years), sex (exact), residence (exact), and index date-matched to the DV cohort. Patients diagnosed with an AD before were excluded. The objective of this matching process by propensity score was to guarantee a similar baseline follow-up duration.Each study patient was followed until one of the following outcomes occurred: an AD was diagnosed, the patient was lost to follow-up, the patient died, and the patient withdrew from the NHI system. We identified patients with ADs using ICD-9-CM codes. ADs in this study were categorized into two broad types: systemic and organ-specific ADs . The sysIn addition, patients with the comorbidities of SLE, RA, scleroderma, PM, DM, a history of head and neck radiation treatment, hepatitis C infection, AIDS, pre-existing lymphoma, sarcoidosis, graft versus host disease, and anticholinergic drug use were excluded to limit our study sample to primary SS (pSS). Therefore, the catastrophic illness patient data are highly accurate and reliable , 26.t test. The standardized mean differences (SMD) in a matched sample were also shown. The incidence rates of organ-specific and systemic ADs were estimated during the follow-up duration in the DV and non-DV cohorts. The stratified Cox proportional hazards regression model was used to estimate the corresponding hazard ratios (HRs) and 95% confidence intervals (CIs). The matched age, gender, and residence are stratified, and CCI score and periodontitis are adjusted in the Cox regression model. Besides, for the type 1 error problem of multi-outcomes especially under the category of systemic autoimmune diseases, the Hochberg corrected p was calculated.We compared the frequency or mean of demographic status  between the DV and non-DV cohorts using the chi-squared test or p < 0.05 was considered statistically significant.Finally, the cumulative incidences of organ-specific and systemic ADs were estimated using the Kaplan–Meier estimator, known as the product limit estimator, in the DV and non-DV cohorts. SAS  was used for all the data analyses, and A total of 29,365 patients with DV infection were selected from the Registry of Disease Reporting System of the Taiwan CDC and 117,460 control subjects were selected from the NHIRD. The mean follow-up duration in patients with DV infection and without DV infection cohorts was 4.52 ± 4.36 and 4.56 ± 4.32 years, respectively.The flowchart of the study population selection is presented in Fig. n = 80 and n = 7 patients in the non-DV and DV cohorts, respectively, developed pSS. The incidence rate of pSS was lower in the DV cohort than in the non-DV cohort (0.51 vs 1.47), with an adjusted HR of 0.30 (95% CI 0.13–0.67) after matching age, gender, residence, and adjusting for comorbidities. It demonstrated DV patients had 70% less likely to have pSS than control groups significantly (Hochberg p < 0.001). By contrast, the other systemic ADs were nonsignificantly lower in the DV cohort than in the non-DV control cohort  with an adjusted HR of 0.81 (95% CI 0.69–0.96) after matching age, gender, residence, and adjusting for comorbidities  epithelial cells and B and T lymphocytic infiltrates. These findings have long encouraged the hypothesis that persistent viral infection of the MSG epithelial cells may drive the autoimmune response; however, the identity of that virus has remained elusive. Over the past decades, an extensive debate has developed concerning the possible role of various viral strains in the induction or maintenance of several ADs, including pSS , 44. InfThe strengths of the present study include large sample size, a large validation cohort, and the long-term ascertainment of concurrent ADs. However, the present study has some limitations. First, although the Bureau of NHI routinely and randomly monitors patient charts to ensure the quality of claims from all medical institutions, the possibility of miscoding or misclassification cannot be completely ruled out. However, such bias would apply to both the DV and control cohorts, and therefore, the present findings are expected to underestimate rather than overestimate the magnitude of the association between DVs and ADs. Second, the relationship between the severity of DVs and ADs could not be analyzed. Additional prospective studies are warranted to confirm whether the severity of DVs increases the risk of ADs. Finally, some important information regarding laboratory or clinical data was not readily available in the administrative database, such as DV infection subtype data. Therefore, the relationship between the various subtypes of DV infection (dengue fever or dengue hemorrhagic fever) and ADs remains unclear. Additional studies are warranted to explore this association.In conclusion, this nationwide long-term cohort study revealed an association between DV infection and a lower risk of pSS. The protective immune mechanisms of DVs require elucidation. These findings may lead to the development of novel therapeutic strategies for ADs.ESM 1(DOCX 152 kb)