User-centered design processes are infrequently employed and not fully explored for building mobile health  apps that are particularly targeted to health professionals as end users. The authors have used a user-centered design–based approach to build an mHealth app for health professionals, tasked to deliver medical laboratory-related information on a daily basis.Our objective is to generate a simple and functional user-centered design process for mHealth apps for health professionals. This paper presents the key learnings from design activities.A stratified random sample of doctors and nurses was recruited for the study. The design activities were planned in the following sequence: focus group discussion for situation analysis and information architecture, design activity 1 for wireframe designing, design activity 2 for wireframe testing, and user testing sessions 1 and 2.The final design and functions of the app, information architecture, and interactive elements were largely influenced by the participatory design–based user-centered design activities. As a result of the design process, we could identify the mental models of processing requests for information and personal preferences based on the experience. These findings were directly or indirectly incorporated into the app design. Furthermore, finding alternative ways of working within time constraints and cultural barriers and the methods employed to manage the challenges of interdisciplinary discourse stood out among the lessons learned.We recommend a user-centered design process based on a participatory design approach in mHealth app design, enriched with focus group discussions where possible. The term mobile health  is defined as emerging mobile communications and network technologies for health care systems, which is an exponentially growing market in the smartphone era ,2. CurreMany current mHealth interventions for health care–related issues are designed on the basis of existing healthcare system constructs, and they may not be as effective as those that involve end users in the design process . In receDespite the growth of user-centered design–based mHealth apps built for patients and the general public, there has been little exploration of how to use them for health professionals as end users. Hence, little is known about the unique challenges and opportunities for applying user-centered design to build apps for health professionals.Our findings are drawn upon a real-world design process where the authors have employed a participatory design–based user-centered design approach to build an mHealth app targeting health professionals. Traditionally, laboratory-related information is made available to the staff through a laboratory service manual, which is a 217-page document accessed via the hospital intranet, describing over 525 laboratory investigations and procedures available at the hospital. The idea of delivering this information through an mHealth app was conceived as a result of an audit conducted to describe the phone call patterns received at the laboratory and a follow-up survey conducted among health professionals that revealed the towering demand for laboratory-related information and the infrequent use of the laboratory service manual by end users who were inclined toward an mHealth intervention . CombineHealth professionals’ frequent dilemmas related to laboratory tests in clinical practice take many forms: deciding the adequacy of the size of a specimen according to laboratory’s rejection criteria, clarifying the correct method of collection and specimen container, decisions related to the urgency of investigations and results, etc. In these scenarios, laboratory-related information such as specimen type, minimum sample size, appropriate specimen container or tube, method of collection, special instructions , turnaround time, price, etc, play an important role in decision making.The contribution of this paper is twofold: first, we describe our methods, materials, results, and outcomes. Then, by reflecting on our own experiences, we discuss the insights and implications of our work through the challenges faced, lessons learned, and strategies adopted to overcome challenges.Our objective is to generate a simple and functional user-centered design process for mHealth apps for health professionals .To achieve our objective, we aimed to employ (a) an intermediate approach to user-centered design and participatory design by direct and indirect involvement of our end users (doctors and nurses) at various stages of the design process and (b) multiple user-centered design methods and to tailor the whole process according to the unique needs of our end users. In this section, we describe the methods in sampling, data analysis, and designing activities and sessions, as well as the design procedures.A stratified random sampling model was employed by the study team—the project team and a human-computer interaction (HCI) consultant—to select participants for the sessions. Strata were defined to include inpatient settings  and outpatient settings or clinics. We recruited doctors and nurses in rough proportion to their workforce ratios. However, the emergency department was excluded in view of significant time constraints and perceived manpower shortage . InformeStatistical analysis of demographic data was carried out on IBM SPSS, version 23.0 (IBM Corp). Categorical variables were expressed as frequencies and percentages, and continuous variables were expressed using means and standard deviation.Following each session, all study data, including audio recordings and handwritten notes, were transcribed verbatim without participant identifiers and annotated with pauses and nonverbal expressions. Anonymized transcripts were analyzed by the study team to create and examine codes, themes, and categories. Transcripts were coded independently by two individuals using line-by-line coding technique. The codes were compared, and the differences were discussed among them. Affinity mapping technique was employed for thematic analysis and establishing categories, and the findings, outcomes, and insights were generated based on this analysis.To further ensure reliability of the study, effective session facilitating techniques were utilized: well-prepared facilitators  and rapport building with the participants.The objective of the first session was to understand the existing user behavior and practices related to laboratory information usage  and obtain initial user inputs to determine what laboratory information should be presented and how it should be structured and highlighted in the app (information architecture). In addition, we used this session as a means of building rapport and goodwill between participants and the facilitators.This session was designed to be conducted in a span of an hour. First, we randomly divided all the participants into three subgroups by counting numbers; the same method has been used in the activities mentioned throughout the paper. In the first activity, the participants were given a scenario of a less frequently used laboratory investigation requested by a physician during a busy morning ward round. We asked them to write down the first things that came to their minds on sticky notes while they were fulfilling this task. We requested them to produce at least five responses per group. Following this activity, one group member from each group was asked to share the responses on the whiteboard.In the next activity, the same groups were asked to draw a flowchart to explain the process of dispatching a blood sample as part of their routine daily work. Groups were given an example of how to perform this task, and they were encouraged to simulate a real-life scenario of their choice. Members were asked to describe their flowcharts to other groups and were given the opportunity to ask questions.The third activity was designed to prioritize the information available in the laboratory service manual to be included in the app based on user input. We provided details of 10 uncommon laboratory tests available in the laboratory service manual and asked participants to use color codes  to highlight information based on following criteria: green for details that they already knew from memory, red for details that they did not know unless they referred to the manual, and yellow for details for which they needed reassurance or confirmation. We carefully handpicked 10 tests, considering the scarcity of information on the type of specimen, tube or container, use of preservatives or transport media, dispatch instructions, other special instructions, etc.Finally, we prioritized the information based on the user responses using a four-quadrant matrix under two main domains (how frequently it is used and how well it is known to the user) in order to summarize them .The first design activity was planned in the form of a co-design activity. The same cohort of participants was present in the second session, except for 1 participant who had called in sick. She was replaced by another member from the same ward.This session was an hour-long design activity. It consisted of three main activities focused on determining the information architecture and designing the initial wireframes . Participants were randomly divided into two groups, and each group was given a set of selected laboratory investigations written on A5-size papers. It had a balanced representation of the mainstream disciplines of laboratory medicine: chemical pathology, microbiology, anatomic pathology, hematology, immunology, genetics, and molecular diagnostics. The set of tests given to each group were not identical but comparable. They were asked to classify all the tests handed to them within 10 minutes. Following this, they were asked to share the principles of the classification that they employed, and each group was given a chance to ask questions of the other group. Both groups were given another chance to reclassify investigations in a different way and in a shorter period of time (5 minutes).Following this activity, we asked participants to jot down at least five different keywords that they would use to search for each investigation on the reverse side of each paper. This was aimed at gathering user inputs toward designing the search function of the app.In the third activity, both groups were asked to sketch wireframes depicting how they envisioned the app's home page, visual representation of test details, and search functionality. An in-depth discussion was carried out to understand the reasons behind each wireframe design.The same cohort of participants from the previous design activity attended the third session, with the addition of 2 new participants. Data from the previous session were analyzed and discussed with the study team. Based on the outcomes of the previous session, two sets of wireframe mockups were created by the HCI consultant: one with a home page containing the categories of tests (categorized by discipline and by specimen type) and a directly accessible list of frequently used tests and the other with a home page with links to go to “categories” and “all tests” and a list of frequently used tests.Once again, the participants were randomly divided into two groups. An open discussion on design, ease of use, order and presentation of information, user-friendliness, and specific functions was conducted among groups with open-ended questions . We alsoWithin 5 months from the third session, the first functional prototype of the app was developed based on the user inputs gathered since inception. The first user testing session was conducted to evaluate the usability of the first functional prototype. An all-new group of nurses and doctors were recruited using stratified random sampling methods. Out of 10 participants, 5 used iOS and 5 used Android operating systems. One Android user dropped out of the study due to privacy concerns related to installing an unpublished external app on the phone. This incident did not have an impact on the final design of the app as the process of publishing spontaneously resolves the concern.All the participants were given a copy of the prototype laboratory mobile app downloaded on their mobile phones. They were asked to perform a set of specific tasks in the shortest possible time, and the time taken by each participant was recorded. A discussion was carried out with each group using open-ended questions. Furthermore, at the end of the session, we obtained feedback from the participants on general topics .Within 3 months from the first user testing session, the second prototype of the app was prepared. The same cohort of participants who took part in user testing session 1 were invited to take part in this activity. A total of 9 participants took part in this session.Participants were asked to download a copy of the latest version of the laboratory mobile app, to use it at work, and to try to replace their daily work process with the app. After allowing them to use the app for a week, we interviewed them individually using an open-ended questionnaire.The mean ages of our participants were 35.4 and 34.8 years for the group that participated in focus group discussions and design activities and for the group that participated in user testing sessions, respectively. The youngest member of the whole cohort was a 24-year-old medical officer, while the oldest member was a 53-year-old assistant nurse clinician. Singapore being a multiethnic, multicultural city-state, we observed a representation of all three major ethnic groups  as well as a fair representation of migrant workers who contribute to Singapore health care from the following countries of origin: China, India, the Philippines, Malaysia, South Korea, and Sri Lanka . MoreoveFrom this session, we identified existing behaviors and habits of our users. We also observed significant differences in the use of terminology and work processes between nurses and doctors, which in turn generated valuable insights into ensuring a greater level of customizability of the app. In addition, we identified that the levels of importance related to variables of laboratory tests  are understood by all subgroups in similar patterns, making certain pieces of information salient while making the remainder less important. This information was directly used in determining the visual layouts of the ‘test-details’ page.These activities helped to foreground two commonly used criteria to classify laboratory tests: by specimen and by discipline. These outcomes were directly incorporated into the design of the home page . FurtherSurprisingly, the wireframe designs of the “home page” and “test-details” page were strikingly similar between the two groups. They both suggested to include categories of tests and a search button on the home page, assuming that users will mostly use the search button instead of looking for tests in categories, and a starred or quick access list. Both groups prioritized details such as special instructions, pictures of relevant test tubes, containers, and preservatives, and the price of the tests, in that order. One group suggested that it would be useful to display a list of related tests under each test, and the other group was in agreement.Participatory wireframe design activities helped the study team to further identify the features that can be useful for users. For example, a periodically updated list of commonly ordered tests was eventually added to the app based on the ideas generated from wireframe designing sessions, as it can be useful for new staff as reference material.Wireframe testing triggered the participants to express their preferences and comment on potential improvements that can be made to the wireframe designs presented to them. For example, participants preferred to see a home page with all the test categories displayed on it, as opposed to the alternative wireframe. In addition, reference ranges were added, and a photograph of the tube or container was suggested over an illustration with regard to the “test-details” page. Outcomes of the third session are shown in We identified the specific pain points for users when they perform certain tasks with the mobile app through this session. For example, users pointed out the process of creating categories as a cumbersome workflow and suggested changes. In addition, they suggested moving the hamburger menu icon that was placed on the right-lower corner to the left-upper corner, as it is commonly observed in popular local e-commerce apps. Outcomes of the fourth session are shown in The second user testing session revealed that the users were generally satisfied with the functions and user interface of the app, and there were no specific suggestions to ameliorate the design . Hence, The final design of the app, including the features, functions, information architecture, interactive elements, and aesthetics, were largely influenced by the participatory design–based user-centered design activities. As a result of the design process, we could identify the existing mental models of the end users related to laboratory tests, level of significance of laboratory-related information, how requests for information are dealt with, and how additional information is requested via telephone calls. There were personal preferences depending on the knowledge base, experience, setting, and job scope. These findings were directly or indirectly incorporated in the final design of the app. Furthermore, it triggered the need for in-depth customization while maintaining generally used mental models in the user interface of the app.In parallel to the outcomes of the user-centered design activities, the final design of the app was influenced by the inputs from the HCI specialist based on universal user experience design principles. These inputs were incorporated in implementing several key features of the app. For example, simplified illustrations of specimen containers  were used in place of actual photographs to avoid information overload and to emphasize distinct features of each container type. Similarly, a quick access one-touch search function and the ability to assign custom labels to tests were also added based on the HCI specialist’s suggestions.By reflecting on our user-centered design process and our own experience of working with multiple stakeholders including the project team, an HCI consultant, health professionals, and an external developer team, we discuss key takeaways of this case study under four categories below.Despite the hierarchy that is observed in the medical culture , we obseThese behavioral patterns were prominent during the first session, but during design sessions, they were noted to have eventually diminished. Possible reasons could be enhanced group dynamics over the course of the sessions and the nature of activities during different sessions. For example, the first focus group discussion was more dependent on technical knowledge and experience, whereas medical or technical knowledge did not have a bearing on the design activities.While attempting to make focus group discussions, design sessions, and user testing sessions equally accessible and ensure fair participation, we faced major challenges with time constraints, making it the most significant challenge to mention ,25.In response to these legitimate limitations, the study team conducted a mock focus group discussion with elective nursing students who were rotated to the Department of Laboratory Medicine as part of their polytechnic training. Furthermore, facilitators trained themselves with each other while giving running commentary and feedback. These activities were carried out to see how well the participants could understand quick instructions, as well as to evaluate timeliness of activities and discussions. Mock focus group discussions helped us to fine-tune the construction and wording of questions and instructions to better relate with our participants culturally ,27 and tWe also carried out a quick feedback activity after each focus group discussion and design session to better understand the concerns of the participants. As a result of the feedback, snacks were arranged for subsequent sessions, which further encouraged participation. It was also conveyed by the participants that it’s important to commence and conclude sessions right on time in view of serious time constraints that they were facing ,25.A well-designed information architecture helps users find information efficiently and complete tasks easily . In our case, information that is intended to be presented in the proposed mHealth app  has already been stored in end users’ memories to various degrees as they refer to that information during daily hospital routines. Therefore, the key goal of co-designing the information architecture with end users was to understand their existing mental models of this information and try to build upon them. The outcomes of the co-design activity, where the end users categorized and labeled a selected set of laboratory tests, provided valuable insights to this end.While there are many instances where co-designing approaches have been successfully utilized for designing information architecture ,29, our Due to highly domain-specific content and medical terminology related to the laboratory tests, the developer team and HCI consultant had to go through a steep learning curve to familiarize themselves with the context of the mHealth app. The hierarchy, organizational structure, and bureaucracy of the hospital environment also made this process somewhat challenging for these external stakeholders. To this end, having a medical professional with experience in participatory and qualitative research as a facilitator significantly helped the external parties to overcome those challenges and understand the context quickly. Provision of an overview of the organizational structure, culture, and existing workflows, coordinating with internal stakeholders, co-conducting activities, and working around cultural barriers are some examples of the roles of the facilitator.We highly recommend a user-centered design process, based on a participatory design approach to designing mHealth apps for health professionals. Focus group discussions will be an added advantage in the design process, provided opportunity is materialized. A broad understanding of the culture, hierarchy, and bureaucracy is pivotal in planning participatory design activities; however, working on team dynamics through ice breaking and building rapport is a cornerstone of success.In addition, a test run for polishing and fine-tuning the process is certainly a strength. Furthermore, the role of a facilitator with a medical and qualitative research background could most likely add value as well as convenience in situations where there is a steep learning curve and a race against time.


Medical errors are the third leading cause of death in the United States. Reporting of all medical errors is important to better understand the problem and to implement solutions based on root causes. Underreporting of medical errors is a common and a challenging obstacle in the fight for patient safety. The goal of this study is to review common barriers to reporting medical errors.  We systematically reviewed the literature by searching the MEDLINE and SCOPUS databases for studies on barriers to reporting medical errors. The preferred reporting items for systematic reviews and meta-analyses guideline was followed in selecting eligible studies.  Thirty studies were included in the final review, 8 of which were from the United States. The majority of the studies used self-administered questionnaires (75%) to collect data. Nurses were the most studied providers (87%), followed by physicians (27%). Fear of consequences is the most reported barrier (63%), followed by lack of feedback (27%) and work climate/culture (27%). Barriers to reporting were highly variable between different centers. Medical errors (ME) are among the most important patient safety challenges facing hospitals and healthcare systems nowadays. Since the Institute of Medicine (IOM) report in 1999 “To Err is Human,” an increasing number of studies have shown how prevalent and deleterious ME are, especially in hospital medicine .A medical error is defined as “an incidence when there is an omission or commission in planning or execution that leads or could lead to unintended result” . While tMedical errors are the third leading cause of death in the United States after heart diseases and cancer . It is eThe first step in combating ME and improving patient safety is to study the different types of medical errors to better understand why medical errors happen. The causes, types, and rates of ME can vary from one institution to the other and change over time, especially as we implement changes in our healthcare delivery. Therefore, it is important to capture, track, and analyze all medical errors as possible at the institutional level , 9, 10.As most of the nonmedication medical errors are hard to capture electronically and manual chart review is both cumbersome and time consuming, self-reporting is still the most reliable approach to capture ME . UnfortuMost of the reports on barriers to reporting ME are single centers; in this systematic review of the literature, we try to investigate whether the barriers to reporting ME varies from institution to the other or not and what common barriers are reported.We conducted a systemic review in accordance with the preferred reporting items for systematic reviews and meta-analyses (PRISMA) guideline .We queried MEDLINE (2000–2020) and SCOPUS (2000–2020) databases for eligible studies. The year 2000 was chosen as the start date for eligibility as the vast of majority of publications regarding ME came after the IOM report in 1999 [On MEDLLINE, a combination of the following search terms was used: (i) errors ), medication errors (MeSH) or near mess, and healthcare (MeSH), (ii) hospitals (MeSH), and (iii) disclosure (MeSH), “report$” (in the title), “ident$” (in the title), or “recog$” (in the title).∗ AND error) AND (report∗ OR captur∗)) AND ) AND ) AND )).On Scopus, the following search string was used:  English language, (ii) the focus of the research is to identify barriers to ME reporting, (iii) medical errors as defined above, not diagnostic errors or management errors, (iv) in hospital settings, and (v) full-text articles. The overview of the selection process is summarized in The following data elements were extracted from the final list of eligible studies: primary objective, study design, sample size, study setting, study subjects, country of the study, year of publication, recruitment of subjects, response rate in survey studies, pertinent results, primary outcomes, and limitations of the study.The search yielded 755 studies of which 30 studies met the inclusion criteria. As shown in We identified 7 common themes to the barriers reported in the included studies . We discFear of consequences is the most reported factor for underreporting ME. 19 out of the 30 studies reported that fear is a significant barrier to report ME –40, 42.Fear of being blamed for the error is by far the most reported fear. But additionally, providers reported fear of losing one's job, fear of patient's or family's response to the ME, fear of being recognized as incompetent, fear of legal consequences, fear of punishment, and fear of losing respect by coworkers were also commonly reported –40, 42.Not only is “fear of consequences” the most reported factor for underreporting, it also happens to be the most significant factor for underreporting in most of the included studies –40, 42. It is important to highlight that some of the included studies did not find “fear of consequences” as a significant factor for underreporting . FindingBoth lack of feedback by administration and/or negative feedback have been associated with underreporting. While some studies reported the negative impact of improper feedback, some reported the positive impact of appropriate feedback. Specifically, it was evident that feedback to the reporting person about the error supports the provider who committed the error and communication openness regarding errors all improved reporting of ME , 40–42.The administration's attitude toward ME and the work environment are important factors that influence ME reporting , 40, 42.A number of studies reported poor understanding by providers as to what constitute a medical error as a barrier to reporting. Providers in a number of studies reported the lack of clear definition of medical errors and the lack of a clear protocol on what incidents need to be reported, as a significant barrier to reporting ME. Additionally, poor understanding of the importance of reporting ME is a significant barrier to reporting as well , 41, 44.Busy work schedule and high workload have been reported as significant factors for underreporting. Additionally, reporting itself is time consuming and cumbersome. Both forms of reporting systems (paper and electronic) are time consuming , 41, 44.It is no surprise that the lack of a reporting system is a barrier. Many studies, mostly international, reported the lack of a reporting system as a barrier to reporting , 29, 35.A number of personal factors influence the reporting of ME. Younger and/or less experienced nurses are less likely to report ME. The longer the employment period is, the more likely it is for an employee to report ME. Additionally, personal experience with ME affected the rates of reporting medical errors , 40, 42.In this systematic review of literature, we present reported barriers to ME reporting in hospital setting. We identified and presented common themes to the reported barriers. We also highlighted the variation in perceived barriers between different centers and countries.The healthcare system and healthcare delivery vary from one country to the other. Thus, it is no surprise that perceived barriers to reporting were also variable between different countries. For example, “fear of consequences” is more prevalent in East Asia and Middle East compared to the United States. On the other hand, work climate/culture is more reported as barrier in centers across the United States. Reported barriers also varied from one center to the other within the same country. These differences are probably secondary to different management strategies, reporting systems, different work place culture, and whether patient safety is a focus of the hospital administration or not.Nurses, physicians, and pharmacists are the most studied groups of providers regarding ME and the reporting of ME. Unfortunately, none of the studies directly compared the barriers perceived by these different groups. It is logical to anticipate different perception of barriers between these groups of the provider. Additionally, current studies failed to include other groups of clinical providers such as respiratory therapists, physical/occupational therapists, and laboratory and radiology technicians, despite their significant role in hospital medicine.Fear of consequences is reported in most of the studies we reviewed as one of the important barriers to reporting ME. Some of the sources for fear are modifiable, for example, fear of being blamed for the error or fear of losing one's job. Changing workplace culture and strategies in addressing reporting ME is an imperative step to overcome this barrier. A work culture that promotes patient safety, encourages error reporting, and implements system changes is essential. On the other hand, fear secondary to concern over patients' and their families' reactions to medical error is not modifiable or predictable. Educating the providers on the importance of ME disclosure to the patients/families and providing them with the necessary tools to better communicate ME and adverse events can help overcome some of these nonmodifiable fears.The most challenging and probably most effective change to overcome barriers to reporting medical errors is the adoption of patient safety culture. Under patient safety culture, employees are rewarded and feel empowered to report and act on medical errors. This safety culture helps overcome the employee's fear of consequences and provides a work environment that is supportive of error recognition and reporting.The reviewed studies showed that a significant number of healthcare providers lack proper understanding of what constitutes a medical error. Poor understanding of medical errors and the importance of reporting both lead to underreporting. Educating healthcare providers on what constitutes medical errors, the benefit of reporting medical errors even in the absence of apparent harm, and that medical error reports are used to identify system deficiencies rather than individual faults, can help improve ME reporting and eventually decrease ME.As hospitals across the world are adopting changes in their management and care delivery to improve patient's safety, the barriers to reporting medical errors may change. Periodic evaluation of this matter is needed to continue the improvement process.Healthcare institutions are encouraged to evaluate their ME reporting rates, perform root cause analysis for underreporting at the local level, and finally implement changes to improve reporting. The common themes we identified in this study can guide healthcare institutions in their local root cause analysis. Causes of ME and factors for underreporting ME may change with time as we implement changes to our healthcare delivery. Thus, continuous tracking of ME and periodic evaluation of the root causes is needed to continue the improvement process. In some institutions, deep changes in the hospital's management strategy to align with and encourage patient safety culture might be needed.Our study has several limitations. The first limitation is inherent to the nature of survey and interview studies. All published reports on this matter used either self-administered questionnaires or interviews. The second limitation is inherent to the nature of systematic review of the literature. The variability of study methodology and study population makes it challenging to draw an objective conclusion. Due to the variability in the methodology and study population in the selected studies, a meta-analysis is not feasible and only a subjective conclusion can be presented.We identified and presented 7 common themes of barriers to report medical errors. Fear of consequences is the most reported barrier worldwide, while work climate/culture is the most reported barrier in the United States. Barriers to reporting can vary from one center to the other. Each healthcare institution should identify local barriers to reporting and implement potential solutions. Overcoming the barriers may require changes in the hospital's management strategy to align with and encourage a patient safety culture. Further studies are needed to investigate whether an anonymous reporting system can help overcome the fear barrier and to compare perceived barriers to report ME between different healthcare providers.


For active-contour-based surgery systems, the success of skin cancer boundary segmentation depends on the initialization point of the snake model, which is a task originally performed by skillful experts, and on the parameters set for the algorithms of active contour. This paper proposes initial geometrical templates and parameter sets for the active contour on skin cancer boundary segmentation. To establish initial geometrical templates and parameter sets for the active contour, first, template candidates, which are geometrically designed by users in advance, are simply calculated based on similarity with a skin cancer boundary, and the candidate with the least difference is selected as an initial template. Initially, all candidate templates are performed before the test with some selected skin cancer samples by randomly varying needed parameters to determine parameter sets for each template. The parameter set is therefore implicitly selected as the suitable set with the selected initial template. Experiments with 227 skin cancer samples were performed based on our proposed initial templates and parameter sets, and the results show 99.46% accuracy, 97.43% sensitivity, and 99.87% specificity approximately in which accuracy, sensitivity, and specificity were improved by 0.26%, 0.36%, and 0.26%, respectively, compared with the conventional method. According to a WHO's  report in 2016 ), where s ∈ ), and it is adjusted to minimize the energy (E) in the following equation:α and β are weighting parameters corresponding to elasticity and stiffness of the snake, respectively, and they are assumed to be uniform for all. X′(s) and X″(s) are 1st and 2nd order derivative of X(s) with respect to s.Based on , the actEext representing image features. At that time, the total energy (E) should reach minima or even none, and the image boundary is regarded to be obtained. Since, normally, a shape of a skin cancer boundary is arbitrary, the snake operation sometimes cannot be performed accurately to segment the boundary due to some local minimum even logically reaching no total energy.In operation, the snake curve represented by the first and second terms in , which eAs the research theme of this paper mentioned earlier, the authors of this paper try to find a simple way to automatically initialize for practical snake operation for practical applications. Mathematically, geometric shapes can be approximated as candidates of the initialization, and the criteria of geometric shape selection should be an issue to discuss.Ti) are conceptually approximated in terms of template as initialization, a geometric shape (TP), which is selected based on the most similarity to the skin cancer image (W) from a group of candidate geometric shapes including circle, ellipse, triangle, rectangle, pentagon, hexagon, possibly differed the least compared with the skin cancer image, as shown in n is the number of template candidates.If some geometrical shapes (Ti), in which their scale is determined based on the maximum skeleton (lmax) of the rough skin cancer boundary and their posture is varied by all angles (θj) starting from an initial angle, can be expressed as follows:t and j are initial angle and angles around a point , respectively.The geometrical template candidates  is added to the rough contour of skin cancer for ensuring to cover the whole skin cancer, and centroid and the longest radius (lmax) of the workpiece are determined. Consequentially, mapping between the skin cancer image and candidate templates retrieved from the database is performed based on centroid and the longest radius and offset for template (Tt) is added to ensure the template will cover the workpiece. Differences between templates and workpiece are obtained while the candidate templates are rotated around the centroid in all angles, and the best candidate template and the best rotation angle with the smallest difference between the candidate template and offset skin cancer boundary (C) are selected as initialization and will be applied for active contour. Simultaneously, a parameter set, which was fixed in the training state and stored in the database, would be retrieved determined by template. The algorithm is illustrated in th line, and template mapping and selection are performed from the 7th line.In the testing state, when a skin cancer image is input, a geometrical template and parameter set will be selected, as shown on the right side of Currently, there exist many kinds of active contours such as normal gradient vector flow , convoluIt is well known that a couple of important keys for applying an active contour for image segmentation are initialization and parameters. In general, these are manually determined by experts based on the trial-and-error concept. The experts, who are going to tune up parameters to find the ones that are best matched with the images for segmentation, should well understand parameter characteristics for tuning suitably. These determined appropriate initialization and parameter set may contribute to energy minimization of active contour, especially for a local minimum.This paper proposes initial geometrical templates for the automatic initialization of active contour. The geometrical template is first selected as the best matched with the skin cancer boundary image from a group of geometrical template candidates, and the selected template then performed mapping with the skin cancer boundary image in terms of scale and rotation. In addition, the parameter set, which was initially trained for each geometrical template, will be set with the initialization for active contour operation. To start running the operation of active contour, the mentioned geometrical template and parameter set are set in the program of active contour, as shown by an example in nd column of rd column of th and 5th columns of th column. Evaluation of our proposed method using geometrical shapes with parameter sets for automatic initialization can be concluded as 99.46% accuracy approximately with 13.61 sec per skin cancer image as computational time, while conventional methods [This paper concentrates on the research problem of initial templates and parameter sets for initializing the active contour for skin cancer boundary segmentation and proposes a method for initial template and parameters setup. Since most of the medical image samples are sensitive and confidential, it is normally difficult to find samples for experiments and evaluation. To verify the effectiveness and evaluate the performance of the proposed method, the GVF snake algorithm was selected as active contour, and 227 images of skin cancer, as shown in the 2 methods  achieved methods  can be c methods  and conc methods .Sensitivity:Specificity:Accuracy:Jaccard index:This paper proposes initial geometrical templates and parameter sets as automatic initialization for the active contour on skin cancer boundary segmentation. The initial templates, which are geometrical shapes, such as circle, rectangle, ellipse, pentagon, are initially trained with some skin cancer image samples for template candidate determination. The parameter sets are accordingly established by varying all parameters and selecting the best parameter groups for each template.In testing, candidate geometric shapes are compared with the input skin cancer image. The initial template is then determined by the least difference with the candidate initial templates, and the parameter set is used to initialize and run the active contour for the skin cancer boundary segmentation. Since normally medical image samples are not open in public due to personal information, it is difficult to collect a lot of samples. Moreover, the samples for evaluation based on conventional methods are not open in public, it is impossible to directly compare performance on the same samples. Therefore, the authors of this paper attempted to collect skin cancer image samples in a number, in which evaluation results can be relied on, to compare with the conventional methods. Experiments were performed based on our proposed method, and the performance of the proposed method achieves as high as 99.46% accuracy approximately, which is similar and slightly better than the conventional method . HoweverFurthermore, since our basic concept is to approximate a similar geometrical shape as the initial template applied in the initialization of active contour, our initialization is originally apart from the skin cancer boundary. Mathematically, any shaped template which is close to the skin cancer boundary is the most suitable, but the algorithm may be complicate and time-consuming. The idea of using geometrical shape as a template for initialization is considered as a solution for implementation. As seen in the experimental results in For skin cancer boundary segmentation, our proposed method achieves 99.46% accuracy which includes both concave and convex results. As observed, most of the results are convex. However, some are partially included in concave, and most of them are tiny. In medical practice, miss-segmentation in convex is better than concave because all skin cancer cells are removed. The concave segmented boundaries are recovered by offset as a final boundary.Automatic skin cancer image segmentation using active contour, which originally depended on skillful initialization done by experts, required practical automatic initialization with appropriate parameter sets. This paper proposed a method of initial geometrical templates with parameter sets for active contour on skin cancer boundary segmentation. Some skin cancer images were initially trained to evaluate and select geometrical shapes as candidate templates by mapping the geometrical shapes with skin cancer image samples based on the centroid and the longest radius and finding shapes with the least differences as candidate templates. These candidate templates were then used to perform active contour by possible parameters and then find a parameter set which performed the best active contour segmentation as a parameter set for each candidate template. In testing, these candidate templates performed mapping with a skin cancer image and rotating around the centroid in the same manner with training, and a geometrical template with the least difference with the skin cancer image was determined as the initial template for active contour. The determined geometrical template with the trained parameter set then was initialized for the active contour segment. Finally, the effectiveness of the proposed method has been evaluated by experiments with 227 skin cancer images.


Sternalis/rectus sterni is a rare muscle found in the anterior chest wall, it occurs in 35% of humans. The early detection of its presence is critical in regular mammogram screening in order to avoid possible differential diagnostic dilemma.We report here a case of the sternalis muscle observed bilaterally, it was found during routine dissection session of an elderly male cadaver in the dissection room, Faculty of Medicine, University of Khartoum.Sternalis muscle is a familiar entity to anatomists, but can pose a diagnostic and surgical dilemma to some clinicians. Presence of the muscle can be confusing in regular mammogram screening and CT and MRI should be utilized to clear the dilemma, and further evidence needs to be explored and studied. •Sternalis/rectus sterni is a rare muscle found in the anterior chest wall, it occurs in 3-5% of humans.•We report here a case of the sternalis muscle observed bilaterally, it was found during a routine dissection session of an elderly male cadaver in the dissection room, Faculty of Medicine, University of Khartoum.•Presence of the muscle can be confusing in regular mammogram screening and CT and MRI should be utilized to clear the dilemma, and further evidence needs to be explored and studied.•Considering its insignificant function, it could be used as a muscle flap in surgical reconstructions of the head, neck, chest wall and breast. SMSternalis MuscleCTComputed TomographyMRIMagnetic Resonance Imaging1Sternalis muscle is a rare anatomic variant of the chest wall musculature, it is found in front of the sternal end of the pectoralis major parallel to the margin of the sternum. It is supplied by the anterior thoracic nerves and is probably a misplaced part of the pectoralis Bartolemen Cabrolio first noticed this muscle in the year 1604 and a proper description was first made by Du Puy in 1726, The occasional presence of the Sternalis muscle in human has always been a subject of great interest to anatomists This muscle occurs in 3–5% of humans, found slightly more frequently in females than males This variant muscle is a dilemma for surgeons and radiologists whereas a matter of interest for anatomists. The literature of the subject provides constantly varying assessments of the morphological presentation of this muscle, especially in its nerve supply, origin, and its tendency to present bilaterally or unilaterally The early detection of its presence is critical in regular mammogram screening in order to avoid possible differential diagnostic dilemma. Additionally, there are potential surgical benefits, as it can be used as a flap in reconstruction surgery of the head and neck, anterior chest wall, and breast This case report has been reported using SCARE guidelines for surgical case reports 2Sternalis muscle was found during routine dissection session of an elderly male cadaver in the dissection room, Faculty of Medicine, University of Khartoum.Two muscles were bilaterally positioned, distinct, 9 cm long in the left hemithorax, and 14 cm long in the right hemithorax. They were covered by superficial fascia and located anteriorly and obliquely to the pectoralis major muscle .Fig. 1ShOn the right side, the muscle attached to the lower end of the fifth costal cartilage. Its cranial end blended with the sternal head of the right sternocleidomastoid muscle. The right one was broader than the left and had two anterior cutaneous nerves seen crossing in front , Fig. 2.On the left side the muscle attached to the upper part of the fifth costal cartilage and terminates cranially in the pectoral fascia, approximately at the sternal angle. It was slender than the right one , Fig. 2.The two muscles were easily separable from the underlying pectoralis major muscle. Pectoralis major and minor muscles were normally placed.3The sternalis muscle is an unusual normal variant that is familiar to anatomists, but can represent a diagnostic dilemma to clinicians in terms of differentiation from pathology Incidence of the sternalis muscle varies among populations, ranging from 4 to 7% among the white population, 8.4% among Africans, and 11.5% among Asians Regarding the nerve supply, two sets of nerves are closely related to the sternalis muscle: the pectoral nerves No clinical symptoms were found to be associated with the existence of the sternalis muscle, but it may present alterations in the ECG 4The sternalis muscle is an anatomical chest wall variant, with uncertain origin and function. It is a familiar entity to anatomists, but can pose a diagnostic and surgical dilemma to some clinicians. Presence of the muscle can be confusing in regular mammogram screening and CT and MRI should be utilized to clear the dilemma, and further evidence needs to be explored and studied.The Cadaver was an unclaimed body, was taken for educational purposes with permission and agreement between Forensic unit – Federal ministry of Health and Anatomy Department – Faculty of Medicine, University of Khartoum. During educational dissection, Cadavers were treated according to the ethical guidelines of University of Khartoum, and during the preparations we discovered the existence of the rare Sternalis muscle and decided to report it. The anatomy department can be considered the legal guardian.No funding was received for the work involved in this article.KA: Supervisor, assistant professor of Anatomy, has supervised, written and revised this case report and managed the dissection of the cadaver.GA, QA, HA: Participated in manuscript writing and revision.All authors read and approved the final manuscript.Not commissioned, externally peer-reviewed.The authors report no conflicts of interests.


While the prevalence of childhood diseases and related mortality have been decreasing over the past decades, progress has been unequally distributed. The poorest households often carry the highest disease burden. As morbidity and mortality also decline most slowly among children of the poorest households, socioeconomic status may become a more relevant risk factor for childhood diseases.We analysed the association between socioeconomic status and highly prevalent childhood diseases, specifically diarrhoea, acute respiratory infections (ARI), and malaria, and how this association changed over time. For this observational study, we used repeated cross-sectional data, namely all available Demographic and Health Surveys as well as Multi-Indicator Cluster Surveys from Western and Central Africa between 1995 and 2017. We estimated the predicted prevalence of each disease for the entire region in three time periods. We repeated the analysis separately for each country to highlight heterogeneity between countries.A notable wealth gradient can be seen in the prevalence rates of diarrhoea, ARI, and malaria in Western and Central Africa. Children in the poorest quartile have a much higher morbidity than children in the richest quartile and have experienced a considerably slower decline in prevalence rates. In the period 2010-2017, predicted prevalence of diarrhoea was 17.5% for children in the poorest quartile and 12.5% for children in the richest quartile. Similarly, the predicted prevalence was 11.1% and 8.6% for ARI, and 54.1% and 24.4% for malaria in endemic countries. The pattern does not differ between boys and girls. While exact prevalence rates vary between countries, only few countries have seen a decline in the wealth gradient for childhood diseases.The increasing wealth gradient in health raises concerns of increasing inequality that goes beyond wealth. It suggests a need to further improve targeting of health programmes. Moreover, these programmes should be adapted to address the interlinked challenges which burden the poorest households. National as well as global programmes such as the WHO Global Malaria Programme (GMP) and The Global Action Plan for the Prevention of Pneumonia and Diarrhoea (GAPPD) strive towards a reduction in morbidity and mortality due to preventable childhood diseases ,2. Over However, progress is unequally distributed and slowing down -4,10. ThEvidence from single countries suggests that children in poorer households are at higher risk of being infected with childhood diseases. Kahabuka et al. found a positive association between risk of severe pneumonia and diarrhoea and lower socioeconomic status in Tanzania . SimilarWe contribute to this evidence by analysing the association of socioeconomic status with highly prevalent childhood diseases, namely diarrhoea, acute respiratory infections (ARI), and malaria, over time. We present the change of the wealth gradient in disease prevalence. Due to limited data on malaria, we also look at fever as a proxy of malaria. Our regional focus is on Western and Central Africa, given that several of the countries with the highest burden of diarrhoea and pneumonia are located in Western and Central Africa, including Nigeria, the Democratic Republic of the Congo, Chad, Niger, and Côte d’Ivoire . SimilarFor this observational study, we used repeated cross-sectional, nationally representative survey data from Western and Central Africa. We combined two data sources, the DHS and MICS. The DHS is administered by ICF International. In seven rounds since 1984, the DHS Program has collected nationally representative data in low- and middle-income countries. MICS is a data collection initiative by UNICEF and has collected data on women and children in low- and middle-income countries since 1995. In both survey programmes, women in reproductive age, typically between 15 and 49, were asked for information on all children ever born to them. The surveys apply a multistage stratified sampling design for the within-country selection of households. For each country, regions were defined, within which the population was stratified into urban and rural. For each stratified area, enumeration areas were randomly drawn and denoted as primary sampling units (PSUs). Selection of PSUs was based on a probability proportional to size, in this case the number of households. Within each PSU, all households were listed from the most recent population census. Applying an equal probability systematic sampling, a fixed number of households in each PSU was selected for an interview. Weights for the calculation of nationally representative statistics are provided with the survey data. For the analysis across countries, we re-scaled weights using each country’s female population aged 15 to 49 years in the last year of the considered time period. This ensures that small countries do not excessively influence the estimation of overall disease prevalence.In this analysis, we included data from 1995 to 2017 for all countries in Western and Central Africa for which data for outcomes, exposure, and covariates was available. Observations with missing information in any of these variables had to be dropped. We analysed the association of socioeconomic status with three childhood diseases, namely diarrhoea, acute respiratory infections (ARI), and malaria, as well as fever as a proxy for malaria. All diseases were coded as dummy variables that equal one if the child has the disease. A child was defined as having diarrhoea or fever if his/her guardian responded that the child suffered from diarrhoea or fever in the past 24 hours. Malaria was identified by a positive result of the rapid diagnostic test. A child was defined as having ARI if he/she had cough in the past 24 hours and experienced short, rapid breathing. A stricter definition would identify the disease as ARI only if the breathing difficulties were related to a problem in the chest. However, only more recent surveys included the question whether the child’s difficulty in breathing was due to a problem in the chest or a blocked nose, which would not allow for an analysis of the change in the association. We looked at ARI as proxy for pneumonia, despite evidence that it is not a very accurate indicator ,20. UnfoTo capture the socioeconomic status of a child’s household, we created an asset index of observed household assets. While many of the included surveys provided an asset index or a variable identifying the wealth quintile of a household, we preferred to calculate an asset index comparable across countries for as many surveys as possible. Our asset index was calculated using principal-component analysis to define asset-based survey-specific wealth quartiles based on the same list of assets for each survey. Included assets were radio, television, bicycle, car, motorcycle, refrigerator, phone, electricity, piped drinking water, flush toilet, floor material, wall material, and roof material. Households with information on less than 88% of underlying assets were excluded. This cut-off was chosen to include the maximum information about assets while retaining as many country-years as possible. Due to low variation in asset ownership in earlier years for some surveys, few wealth quartiles contain no actual observations.Covariates used in the analysis for the prediction of disease prevalence, included the child’s gender and age in years, the mother’s age at birth of the child and her educational level , as well as the location of the household .In order to assess the change over time in the association between socioeconomic status and disease prevalence, we split the data into three time periods. Time periods were defined such that each country had at least one survey in each time period, as far as possible. This resulted in the earliest period containing surveys between 1995 and 2001, the middle period containing surveys between 2002 and 2009, and the most recent time period containing surveys between 2010 and 2017. Since rapid tests for identifying malaria were only conducted in more recent surveys, associations with malaria prevalence could only be shown for the recent time period.We estimated the predicted prevalence of each disease for the whole sample in the three time periods, and repeated the analysis separately for each country to highlight heterogeneity between countries.The predictions were based on regressions of the disease on the set of covariates mentioned above. Furthermore, we added survey year- and country-fixed effects as country level factors have been shown to influence childhood diseases such as diarrhoea . No furtEthical approval was not obtained for this study due to the use of secondary data. Both DHS and MICS obtain ethical approval for data collection.In the most recent period 2010-2017 the predicted prevalence of diarrhoea decreases with each wealth quartile (The predicted prevalence of ARI is depicted in For fever, the differences of the predicted prevalence between the wealth quartiles are smaller (Data on malaria is only available from more recent surveys and for selected countries. We therefore present the predicted prevalence for malaria in the most recent period (We also analysed whether wealth has a different association with childhood diseases for boys and girls. Figure S1, Panels A-D in the For the most recent survey, the predicted prevalence rate of diarrhoea among children from the poorest quartile ranges from 8.7% in Sierra Leone to 26.2% in Cameroon. For children from the richest quartile it ranges from 5.6% in Nigeria to 23.8% in the Central African Republic. From the first to the most recent survey, the prevalence of diarrhoea increased by about 10 percentage points in the poorest wealth quartile in Cameroon and declined by about 18 percentage points for all quartiles in Sierra Leone.The predicted prevalence rate of ARI in the most recent period ranges from 4.4% in Burkina Faso to 31.4% in the Central African Republic for the first quartile and from 1.8% in Nigeria to 27.7% also in the Central African Republic for children from the fourth quartile. The prevalence increased over time by 9.6 percentage points in the third quartile in Sao Tome and Principe and decreased by 14.2 percentage points for children of the richest quartile in Sierra Leone.The highest prevalence of fever is observed in the Central African Republic with 33.5% for the poorest and 32.3% for the richest quartile, the lowest in Gambia with 11.9% and Nigeria with 7.8% for children from the poorest and the richest quartile respectively. The change in the prevalence over time ranges from a just above 5 percentage point increase in the richest quartile in Cameroon to around 27 percentage point decrease for all quartiles in Sierra Leone.The broadest range is observed for the prevalence of malaria from 0.9% in Gambia to 35.5% in Burkina Faso for children from the first quartile and 0 to 24.3% for children from the fourth quartile in the same countries.We express the wealth gradient with two different indicators shown in For diarrhoea, the gradient in the recent period is largest in Nigeria with a percentage point difference of 9.5 and a ratio of 2.7. Guinea-Bissau, Burkina Faso and the Democratic Republic of Congo show a negative gradient. Nigeria also has the biggest ratio for the prevalence of ARI, with children from poorer households being almost 3 times more likely to suffer from acute respiratory disease than children from the richest quartile. The Central African Republic has the largest percentage point difference with 3.8 percentage points. Similarly, Nigeria has the largest gradient for the prevalence of fever with a ratio of almost 2. In Togo, the percentage point difference is largest with children from the poorest quartile having a 11 percentage point higher likelihood of suffering from fever compared to children from the richest wealth quartile. Ghana has the biggest gradient for malaria with a difference of 26 percentage points and a ratio of 34, an extreme case of a wealth gradient., Panels A-C. The difference between the poorest and the richest quartile in the earliest survey is plotted on the horizontal axis and the difference in the most recent survey on the vertical axis. For countries located above the 45-degree line, the difference between the riches and the poorest quartile increased over time, for those below it decreased. The distance to the line indicates the magnitude of the change. The percentage point differences between the predicted prevalence of the poorest and the richest quartile in different countries and their change from the first to the last survey are illustrated in In most countries, the wealth gradient of diarrhoea prevalence increased over time. The largest increase in terms of difference in percentage points occurred in Cameroon, Nigeria and Togo, and in terms of the ratio in Nigeria, Ghana and Togo. While some countries show a decline in the gradient of ARI, for the majority of countries it has grown over the years. The largest increase in the difference occurred in Nigeria, the largest decrease in Senegal and Gambia. The wealth gradient for the prevalence of fever amplified for most countries over time. Nigeria and Togo show a very large rise both in the difference as well as in the ratio. For Ghana with low overall prevalence of fever, the difference has not increased largely but the ratio did. All countries with a decreasing gap show only smaller changes.In this study, we analysed the change over time in the association between wealth status and childhood diseases for Western and Central African countries between 1995 and 2017. The predicted prevalence of each disease can be compared with the mean prevalence for the region .Our results suggest a notable wealth gradient in the prevalence rates of diarrhoea, ARI, malaria, and fever. Children in the poorest 25 percent of households are much more often sick with diarrhoea, ARI, or malaria than children in the richest 25 percent. This is consistent with the findings of Kahabuka et al. in Tanzania . While iProgrammes that have driven down disease prevalence are insufficiently capable of reaching the poorest, most vulnerable households. This may be because those households are the ones most difficult to reach or the ones with multiple interlinked challenges that were not yet addressed in their entirety by previous programmes. Efforts should be increased to adapt programmes to target the poorest households. Insufficient resources and inappropriate allocation are major impediments to the delivery of effective health care that reaches the poor. Most obviously, economic resources are often insufficient to support the provision of essential services. Public expenditures on health care have to be further scaled up substantially to address this concern.A strong focus on financing primary health care as well as preventive measures seems warranted. Diarrhoea, pneumonia as well as malaria are all easily preventable diseases. For example, effective basic sanitation and drinking water infrastructure together with initiatives promoting healthy behaviour in the communities can substantially reduce the prevalence of diarrhoea. One of the key programmes of UNICEF West and Central Africa focuses on eliminating open defecation through community behaviour change and adequate sanitation systems .This study contributes to the literature by providing insights about a particularly interesting region, containing some of the countries with the highest burden of the diarrhoea, ARI, and malaria. While predicting disease prevalence for the whole region, this study adds comparable analyses for each country separately. In addition, it expands the literature with the analysis of the change in the wealth gap over time.There are some important limitations to this study. While we create an asset index that is comparable across countries and time to capture the wealth status of households, this asset index might not be the best suited for each individual country. Ensuring comparability at the same time means reducing the adaptation to each country context. In addition, as fewer assets were recorded in earlier surveys, the asset index is less accurate for the earlier time period than for the more recent periods. Data availability therefore limits the robustness of our analysis.Moreover, surveys that did not record information on outcomes, assets and covariates had to be dropped. This restricts the generalisability of the results to the countries and years included in this analysis. Additionally, within included surveys, observations with missing information could not be used in the estimations, potentially limiting the representativeness of the sample.Another limitation is that our analysis does not include all possible risk factors that might be associated with the prevalence of each disease. Our set of covariates in the prediction of disease prevalence is the same for each disease. This increases comparability between the estimations. However, we might miss out on disease specific risk factors such as nutrition for diarrhoea or housing characteristics for malaria. Our focus is on wealth and its association with childhood diseases. Analysing the effect size of any particular factor in isolation from the role of others, however, might lead to an overestimation of the true effect size .This study illustrates the strong association of wealth with the prevalence of childhood diseases in Western and Central African countries. It also highlights that the wealth gradient in health tends to increase rather than decrease over time, which raises concerns of increasing inequality that goes beyond wealth.While increasing people’s wealth may impact several factors that in turn affect the prevalence of childhood diseases, this strategy is rather difficult and costly. Trying to reduce the link between wealth and childhood diseases, as well as directly aiming at reducing the prevalence of childhood diseases may be a more effective approach. In addition, households in the lowest wealth quartile might be burdened by several interlinked challenges at the same time that cannot be addressed by programmes focusing solely on disease prevention. This requires further efforts in implementing programmes that aim at improving health practices at the household and community level as well as programmes to improve housing, sanitation, and access to health services. The considerable wealth gradient suggests that targeting the poorest households and developing programmes that are adapted to their specific needs is necessary for achieving the goal of further reducing the high prevalence of childhood diseases and diminishing the stark health disparities across wealth.


Learn from yesterday, live for today, hope for tomorrow.Albert EinsteinI am writing this on the 30th of January 2021. Exactly one year ago the World Health Organization (WHO) declared the coronavirus outbreak a public health emergency of international concern, the highest level of alarm under international law. To date, there have been more than 100 million confirmed cases of coronavirus disease 2019 (COVID-19) including over 2 million deaths [Yet here we are amidst the greatest health care crisis of our generation. Clinicians all over the world take care for and cure the patients infected by COVID-19. Health care professionals are facing huge emotional stressors including grief from seeing patients die, fears of getting infected by the virus and infecting their close ones. Many non-clinician experts, epidemiologists, virologists, and immunologists have provided a surge of information to lead us through this catastrophe. The pace at which the clinicians have adapted to this new knowledge is astonishing. Digital communication platforms have helped us to keep a distance from each other, but these new types of software may also turn out to be additional sources of stress.On top of this all, primary health care has to face the physical, mental and socioeconomic consequences of the pandemic, which certainly will affect peoplés needs and access to care in the years to come.In the light of all this, it seems correct and reasonable that WHO has designated 2021 the International Year of Health and Care Workers ‘in recognition of their dedication to providing care during and despite the COVID-19 pandemic’ , and a sWe all should pay more attention to our work well-being and supporting our colleagues. GPs too often feel that physical and emotional exhaustion is part of the job. We too often share the ethos that vulnerability is a sign of weakness. This is especially strenuous for the young physicians. In Finland, participation in a Balint group is nowadays recommended during the specialty training in general practice. Clinicians tend to accept support from colleagues who understand the stressors of the occupation . Thus, wmust be the turning point of the COVID-19 pandemic, it restores all hope and faith for the good times to return. Hopefully year 2021 can promise even more; faith for true science, and better well-being for health care workers.Year 2021


Background: As more and more countries enter the low-transmission phase, maintaining prevention awareness among the population is critical to prevent a secondary outbreak. With large-scale interpersonal communication, whether Chinese residents can maintain a high awareness of prevention and control and adhere to the use of masks during the Chinese New Year of 2021 is worth studying.Methods: A cross-sectional survey was conducted in China from February 4 to 26, 2021. A convenient sampling strategy was adopted to recruit participators. Participants were asked to fill out the questions that assessed the questionnaire on face mask use. Descriptive statistics were used to assess the mask-wearing behaviors of the public. A binary logistic regression analysis was performed to identify the risk factors affecting mask-wearing behaviors.Results: A total of 2,361 residents filled out the questionnaire. In the mixed-effect logistic regression analysis, Chinese residents who were older , employed , had a chronic disease , reused face masks  and have read the face mask instructions  were more likely to use face masks in interpersonal communication during the Spring Festival; while people who have breathing discomfort caused by face masks  and considered that using masks repeatedly is wasteful  were more unlikely to use face masks.Conclusions: Our results revealed that 83.86% of people wore face masks during the Chinese New Year; however, some aspects require further promotion. By investigating the use of masks by Chinese residents during the Spring Festival and its influencing factors, we can reflect the prevention awareness of the residents during the low transmission period of COVID-19, which can provide a reference for Chinese and global public health policymakers. The origin of the outbreak of COVID-19 was initially detected in Wuhan, China in December 2019 .It can live on surfaces for up to 72 h  and contA growing number of places recommend wearing masks in community settings. The WHO and the U.S. Centers for Disease Control and Prevention  stronglyThe Chinese New Year holiday, which coincides with the COVID-19 outbreak, is one of the most festive times of the year in China, with a lot of human interaction . The ChiCurrently, the COVID-19 epidemic has been controlled and China has entered a period of low transmission . At thisThis study scheme was approved by the Institutional Review Committee of Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China. All the methods are performed in accordance with relevant guidelines and regulations. The respondents were informed that their participation was voluntary and implied consent on the completion of the questionnaire.A cross-sectional survey was conducted in China from February 4 to 26, 2021. We stratified the respondents mainly according to the eastern, central, and western regions of China. We selected residents from eastern , central , and western  China to complete the survey. A convenient sampling strategy was adopted to recruit the participants; the research team used WeChat, the most popular social media platform in China, to publicize and distribute the survey links to their network members. The network members were asked to distribute the survey invitations to all of their contacts. The participants were informed that their participation was voluntary and their consent was implied by their completion of the questionnaire. The applicants should be Chinese citizens aged 18 or above and are able to understand and read Chinese.The questionnaire was compiled according to the guidelines issued by the National Health Commission of China , 18. Thewww.wjx.cn), a survey platform widely used in China. Online posters with access codes or links to the questionnaires were distributed in one of these two ways:(1) posted on our WeChat; (2) distribution was made through the WeChat group, and each person was to be compensated 1–2 ¥ on average. To avoid duplicate submissions, each person can only participate one time for each WeChat account.The electronic (e)-questionnaires were compiled using Wenjuanxing . We dichotomized the answers of the residents regarding their willingness to use face masks as “Yes” and “No.” The descriptive statistics were presented as the percentage (%) of the number of observations, and we analyzed the differences in the demographic statistics using a Chi-square (χ2) test. Due to the disparities in the socioeconomic status in the different regions, the data has a typical hierarchical structure. We performed a mixed-effect logistic regression model with a random cluster effect (geographic regions) to investigate the adjusted odds ratio (OR) (95% CI) of the influencing factors of the willingness of residents to use face masks. Further, we explored the factors influencing the willingness of the participants to use face masks in Eastern, Central, and Western China, respectively, through multivariable logistic regression analysis. The significance level was accepted as P < 0.05 (two-sided).The data were analyzed using A total of 2,453 residents received the questionnaire, of which 21 did not reply and 71 did not accomplish the questionnaire. The response rate was 96.24%. The results were analyzed using the 2,361 complete questionnaires. P < 0.05)  have used face masks in their interpersonal communication during the Spring Festival. The results of the univariate analysis suggested that the gender, age, place of residence, region, employment status, “have a chronic disease,” “main sources of face masks,” “reuse face masks,” “have read the face mask instructions,” “face masks cause breathing discomfort,” and “consider that using masks repeatedly is wasteful” were statistically significant influencing factors for “using face masks in interpersonal communication during the Spring Festival”( < 0.05) .Univariate analysis of the participants from Eastern, Central, and Western China was conducted, taking the sampling differences across the geographical regions into account . In the In addition, we stratified the study samples by region and performed multivariate logistic regression analysis. The results showed that the “main source of purchase of face masks”  was also a related factor for the increase in the willingness to use face masks among residents in Central China .Our study, based on a cross-sectional survey, determined the willingness to use face masks in interpersonal communication and its influencing factors during the Spring Festival among Chinese residents. We found that 83.86% of the citizens have used the face masks, and this rate is lower than that in another study about the rate of face masks usage among Chinese citizens (99%) by Tan et al.  during tAge can be a factor in mask-wearing behavior. Consistent with previous studies that examined the changes in public behavior during influenza outbreaks , 20, theWe also observed that different situations affect the behavior of people. Compliance is much better in patients with chronic diseases. This may be due to their concerns about the high risk of COVID-19 transmission in these settings and the association between the perception of high risk and good compliance with mask use . SimilarAmong the factors influencing mask-wearing behaviors, we found that people exposed to the instructions on how to use masks showed better compliance than people who are not. Interestingly, there was no significant relationship between educational background and compliance. Thus, good mask-wearing habits seem to depend on how much education is received about mask use, rather than on the level of education. This finding also supported the hypothesis proposed by Greenhalgh et al.  that, inEconomic factors are crucial. The participants who considered that using masks repeatedly is wasteful are more likely to refuse using face masks. Similarly, reusing face masks also increases compliance. Whether or not people will reduce their health protection to save money has not been reported, but it is still an important Research Topic during periods of low transmission. Notably, the residents who bought masks out of their own pocket also demonstrated low compliance, but this phenomenon was only seen in central China, thus the effect of this factor needs further investigation.Wearing masks in large-scale interpersonal interactions can reflect the awareness of residents regarding the prevention of COVID-19. This is the first study to investigate the mask-wearing behaviors of the general public in the period of low COVID-19 transmission. We used a nationwide sample of the Chinese population. The findings provide evidence about the way the public uses masks and the factors that influence their behavior, which is of great significance to China and other countries. First of all, this research takes social media as the main communication survey method. Participants who do not have Internet access may not be included. Therefore, the strategy of simultaneous online and offline development should be adopted in future research. Online surveys rely on social software, while offline surveys rely on community or rural health service institutions, medical personnel, and primary management personnel. This method of the survey will include a wider range of residents and reduce the bias caused by online surveys. Second, the study participants were unevenly distributed in different regions . Therefore, the subgroups of the variables may not be representative of the population. Third, the study was unable to determine how many participants have seen the online posters or surveys but decided not to complete them, therefore, the existence of the non-response bias cannot be evaluated. Finally, since these behaviors are self-reported, reporting bias is possible. In general, the generalization of the results should be viewed with caution.Because of the highly infectious nature of COVID-19 and the ongoing severity of the global epidemic, wearing masks has become a part of daily life. Although more and more countries are entering the low-infection period, face masks can still play an important role in preventing a second outbreak. Therefore, understanding how the public uses masks and what factors are associated with good compliance will help determine ways to promote proper mask-wearing behaviors.Our results show that 83.86% of the Chinese residents wore masks during the Spring Festival. However, there are still some areas that need further promotion. In future evidence dissemination or behavior change interventions, particular emphasis should be placed on wearing masks among young people, employed persons, and healthy residents. In addition, the reusing of masks and the instructions for the use of masks should not be ignored. In the period of low transmission, it is important to take as many publicity measures as possible to promote the wearing of masks by the public. Therefore, different influencing factors should be considered in the dissemination of evidence to reach different populations. Methods should be adopted for the clear and ubiquitous dissemination of government warnings and alerts. Social media is the most powerful way to reach an audience and facilitate data collection. However, further research on how social media can promote public behavior change is needed.The raw data supporting the conclusions of this article will be made available by the authors, without undue reservation.This study protocol was approved by the Institutional Review Board of the Tongji Medical College of Huazhong University of Science and Technology, Wuhan, China.XS, SY, and YG conceived and designed the study. JF and ZL participated in the acquisition of data. XS and SY analyzed the data and drafted the manuscript. HC, YZ, and ZN provided advice for the methodology. YG, CL, and XH revised the manuscript. YG is the guarantor of this work and had full access to all the data in the study and takes responsibility for its integrity and the accuracy of the data analysis. All authors contributed to the article and approved the submitted version.This work was supported by the Fundamental Research Funds for the Central Universities (2020kfyXJJS059).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.All claims expressed in this article are solely those of the authors and do not necessarily represent those of their affiliated organizations, or those of the publisher, the editors and the reviewers. Any product that may be evaluated in this article, or claim that may be made by its manufacturer, is not guaranteed or endorsed by the publisher.