Schoolteachers are known to be faced with various stresses in their work. A simple, less onerous, and effective intervention technique that can enhance the stress management skills, particularly, cognitive flexibility, of schoolteachers is needed.This study aimed to determine whether stress management training using a Web-based cognitive behavioral therapy (CBT) program is effective for enhancing the cognitive flexibility of schoolteachers and alleviating their subjective distress.This study was conducted in a random controlled design covering public elementary schoolteachers. Teachers allocated to the intervention group received 120 min of group education and completed homework using a Web-based CBT program that lasted for 3 months. The items of outcome evaluation were cognitive flexibility and subjective distress, and the efficacy of intervention was evaluated at 3 months after intervention.A total of 240 participants were randomly allocated to the intervention group  and the control group . On the basis of the principle of intention to treat, the intervention group and the control group were compared regarding the amount of change from before intervention to after intervention, using a general linear model. Scores of cognitive flexibility and subjective distress were significantly more improved in the intervention group than in the control group.The results of this study suggest that simple stress management training using a Web-based CBT program in elementary schoolteachers enhances cognitive flexibility and alleviates subjective distress. It is known that schoolteachers are faced with much stress. It is therefore important to seek measures to enhance the stress management skills of schoolteachers. Each schoolteacher in Japan bears the weight of various responsibilities besides lessons in class, including moral guidance, counseling parents, being an advisor to school clubs after class, participating in activities to enhance educational effects, and preparation of reports. Therefore, teachers often feel distress about various areas, and thus, the mental health of Japanese schoolteachers is lower than that of general workers ,2. In adA preceding study reported that cognitive behavioral therapy (CBT) is useful for enhancing stress management skills of workers . CBT enhLow-intensity CBT, a program to provide the essence of CBT using simple measures including group education, use of the Internet, and books, is now spreading to use CBT in a wide range of scenarios beyond clinical treatment. It is also reported that stress management education using CBT performed on the Internet (Web-based CBT) alleviated the distresses of general workers and enhanced their cognitive flexibility ,21. HoweIn this regard, this study provided schoolteachers with simple stress management training using a Web-based CBT program that allowed each of them to complete CBT homework independently, and investigated whether the training would contribute to the enhancement of cognitive flexibility and reduction of stress among teachers.This study included 241 schoolteachers serving in public elementary schools in Sagamihara City in Kanagawa, Japan, who were in the fifth year of their career and were prospective participants in a mental health–related training program in 2014. We obtained permission from the board of education of Sagamihara City for the mental health training in 2014 to be performed as part of this study to evaluate the efficacy of a stress management training program using CBT. The board of education recommended that potential participants receive stress management training using CBT; however, there were no exclusion criteria set for study participants.In a preceding study that used an intervention similar to ours in general workers , the effAll potential study participants were instructed orally or in writing by the investigator before the beginning of the study that they could discontinue participation at any time if problems were caused by the intervention, and that this study was to be conducted by an organization independent of the board of education and would have no influence on personnel evaluation. Only the persons who gave consent to this study after this explanation were included in this study. They were also instructed that participation in the study should be completely of their own volition and that not participating in the study would cause no disadvantages. The study protocol was approved by the Ethics Committee of the School of Allied Health Sciences at Kitasato University. Reporting of methods and results of this study are based on the Consolidated Standards of Reporting Trials of Electronic and Mobile HEalth Applications and onLine TeleHealth (CONSORT-EHEALTH) guidelines . This stThe participants in the study were randomly allocated to 2 groups, that is, the intervention group and control group. All participants in the intervention group were given 1 session of group education and a Web-based CBT program lasting for 3 months. The efficacy of the intervention was evaluated based on the results of a self-administered questionnaire survey performed at baseline and 3 months after the completion of the CBT program. For ethical reasons, participants in the control group (waiting-list control) were also given the same group education and Web-based CBT program after the end of the study.The intervention consisted of 1 session of group education about CBT , homework using the Web-based CBT program for the subsequent 3 months, and 6 emails sent during the self-learning period to stimulate the implementation of the Web-based CBT program .A specialist in CBT took charge of the group education. One session of group education consisted of part 1 and part 2, taking 120 min in total. In addition, there were 60 participants in one session, and with the therapist was 1 leader , 1 coleader , and 3 assistants.Part 1 was a seminar on the basic theory of CBT. Because the participants in this study were healthy, their awareness that CBT is useful for work and daily life was key to enhance motivation for education. Therefore, the purpose of including CBT in mental health education of teachers was clearly specified, such that CBT was not used as a treatment for mental illness but as a method of self-care to cope flexibly with various stress factors. The seminar was devised to use concrete examples and avoid technical jargon as far as possible to make the contents readily comprehensible.Part 2 comprised group training in cognitive restructuring, the core technique of CBT. Cognitive restructuring helps people identify negative thought patterns, understand that these thoughts are ineffective or disruptive, and learn how to think differently by replacing adverse and illogical thoughts with more rational and adaptive types of thinking. In this part, participants learned about cognitive restructuring by recording the following on a worksheet about a recently experienced familiar (benign) situation: context, mood, automatic thinking, evidence, contrary evidence, adaptive thinking, and change of mood. During practice, participants were divided into groups of 5-7 members. In each group, one member described a recently experienced stressful event (a mild one causing no privacy issues) to the other members and his or her mood and automatic thinking at that time. Then, all members of the group considered evidence, contrary evidence, adaptive thinking, etc to practice completing the columns of the worksheet. Finally, each group presented the contents of the worksheet to all participants to share patterns and to ask a CBT specialist questions that arose during the group work to deepen their understanding of cognitive restructuring. At the end of the group training, the Web-based CBT program was introduced to participants so that they could learn how to manipulate the program.Mind Skill Up Training [The homework using the Web-based CBT program lasted for 3 months after the end of the group education. The Web-based CBT program used Training . This weThe outcomes were cognitive flexibility and degree of subjective distress. Questions about these items were prepared, and evaluation was performed at baseline and 3 months after the end of the homework period, using self-administered questionnaires. Cognitive flexibility was evaluated in terms of the following 3 points proposed by Dennis and and Vander Wal: “I have a tendency to perceive difficult situations as controllable,” “I can perceive multiple alternative explanations for difficult situations,” and “I can generate multiple alternative solutions to difficult situations.” These items were rated according to 5 grades . Subjective distress was examined by the question “How much do you perceive stress at work?” and rated according to 10 grades .In addition, participants were examined for their base attributes, including depression, in terms of the Beck depression inventory, which is an index with established reliability and validity developed by Beck et al , and theAn independent researcher who had no direct contact with the participants used computer-generated randomization with a 1:1 ratio and block size of 6. No stratification was performed and evaluators were masked. Owing to the nature of the intervention, participants were informed of their allocation status.A generalized linear model was used for estimation, based on an intention-to-treat (ITT) analysis. To satisfy the ITT requirement that analyses be conducted for all participants, a multiple imputation (MI) method was used on the assumption that data could be considered missing at random. MI allows for uncertainty caused by missing data by generating several different plausible imputed datasets using a set of external covariates and appropriately combining results obtained from each ,27.The effect was calculated by subtracting the baseline outcome scores from those obtained after completion of 3 months of homework. Results are shown as changes in the raw scores for outcomes.P<.05. IBM SPSS 22 and IBM SPSS Missing Values 22  were used for statistical analyses.To analyze baseline characteristics of the study participants, a test was used for numerical variables and a chi-square test for categorical variables. Statistical significance was set at The flowchart of this study is shown in The 240 participants were randomly divided into the intervention group and control group, each comprising 120 individuals. Of the 120 participants in the intervention group, 117 received group education. The remaining 3 who did not receive group education did not respond to the follow-up survey performed after 3 months of intervention. Reasons for the lack of response were not obtained, and the number of implementations of the Web-based program was unknown. In the control group, 99 participants responded to the follow-up survey after the intervention, whereas 21 did not (for reasons unknown). This study did not exacerbate any existing psychological problems of any participants.The results of this study suggest that simple stress management training using CBT with elementary schoolteachers contributes to improvement of cognitive flexibility and reduction of subjective distress among these teachers.Teachers are surrounded by diverse stress factors. Teachers in Japan must cope with various tasks and strive to solve problems of students and their parents. In the context of these diverse issues, it is suggested that reducing the risk of burnout of teachers requires teachers to recognize problems correctly and respond appropriately to a situation. Namely, it is desirable to acquire realistic and adaptive stress-coping behaviors based on high cognitive flexibility -12. StatIn this study, greater importance was placed on provision of a feasible program for busy teachers. Regarding mental health measures in the occupational field, previous intervention studies using CBT for individuals or groups have shown beneficial effects such as alleviation of depression or anxiety, reduction of stress -32, and In addition, this study used some mechanisms to maintain motivation for training. Because CBT intervention in healthy subjects may be associated with low motivation for intervention, unlike patients who seek treatment, we emphasized to participants that training based on the principles of CBT in group education would be useful for coping with work stress and for improvement of productivity ,39. It hThis study had some limitations. First, evaluation indices were our original inquiry items. Although validated scales that evaluate psychological stress are present, and a limited number of scales for cognitive flexibility have been proposed, all these scales include many items. For this study, we chose to use simple questionnaire scales at the stage of study planning. Due to this, a 1-item scale was used for each outcome. Second, participants were limited to teachers in a city who were in the fifth year of their career. To increase the general validity of this study, this issue should be studied in a randomized controlled trial (RCT) design under wider conditions. Third, homework implementation status was not evaluated. This was aimed at reducing burden on the participants. However, because homework is considered to play an important part in CBT, it would have been desirable if we had analyzed in detail how often the participants performed the simplified CBT program and whether and how closely the number of implemented homework sessions was correlated with the effect of CBT. Fourth, evaluation of outcomes was completed only at 3 months after the completion of intervention. The decision to do this was made at the stage of study planning to reduce burden on the participants. However, longer follow-up would have been desirable, considering that the amount of work varies according to the time of year, and for the purpose of examining the long-term effect.This study was the first to examine whether an intervention using CBT in teachers would be effective for enhancement of the cognitive flexibility of teachers and alleviation of their subjective distress. The results of this study show that a simple intervention using Web-based CBT enhanced the cognitive flexibility of teachers and alleviated their subjective distress. Because the subjects of this study were busy schoolteachers, the methods of intervention and evaluation were simplified to the maximum possible extent. Therefore, this study had some limitations in its general validity, but it is of major significance that a useful means for stress management of teachers has been proposed. It is desirable that more useful programs using interventions based on CBT be developed and that a number of RCTs be performed to evaluate their effects appropriately.


Despite a global reduction in morbidity related to sub-optimal water, sanitation and hygiene, the incidence of such diseases remains a significant problem in sub-Saharan Africa. This study aimed to initially assess the potential effectiveness (primarily in terms of impact on morbidity) of a simple educational intervention delivered in Rwanda. Additionally, we sought to explore feasibility relating to the practicality of evaluating and implementing this type of intervention in a low- and middle-income country.Two districts in Northern Province were purposively selected; one was randomly allocated to receive the intervention, with the other acting as control. The intervention was based on an interactive DVD about basic hygiene. Baseline and follow-up data for incident cases of relevant morbidities were collected from health centre records. Changes were compared between the two districts using descriptive statistics and chi-squared tests. Qualitative data were obtained through observations, discussions and feedback and were analysed thematically.p < 0.001). Numbers of cases recorded as diarrhoea or dysentery, and changes between baseline and follow-up, were much lower . Qualitative data indicated a high level of acceptability for the intervention and also feasibility relating to the practicality of evaluation and implementation, whilst also highlighting problems encountered and possible solutions, in particular, the potential advantages of training local personnel to deliver this type of intervention.Cases of infection with intestinal worms and parasites were frequently recorded in both districts. For these morbidities, there was a 39% decrease in cases between baseline and follow-up in the intervention district (4995 reduced to 3069), compared to 13% (5002 reduced to 4356) in the control district (This small-scale study has a number of acknowledged limitations which would need to be addressed in a larger study in order to confidently confirm the effectiveness of the intervention. It nevertheless provides evidence suggesting that the educational intervention is promising in terms of a potential impact on health and feasible to deliver and evaluate. These findings indicate that further evaluation and possibly early implementation are warranted.researchregistry2180Research Registry,  In recent years, there has been a shift in the global burden of disease, with a reduction in morbidity related to sub-optimal water sources, sanitation and hygiene and an increase in chronic diseases linked to risk factors such as poor dietary practices and physical inactivity . There aMortality associated with sub-optimal water supply, sanitation and hygiene is not limited to diarrhoeal diseases. The WHO has suggested that, in 2004, 881,000 non-diarrhoeal deaths were attributable globally to poor quality water, sanitation and hygiene, including 15,000 deaths from the parasitic worm infection schistosomiasis and 12,000 from intestinal nematode infections .Low rates of handwashing on key occasions such as following defecation have been observed in low- and middle-income countries (LMICs) such as Ghana . A studyDespite these limitations regarding the evidence that educational interventions are effective, it appears that additional investigation is warranted, especially in relation to LMICs. A recently updated systematic review and meta-analysis of trials assessing the effectiveness of handwashing promotion interventions led to the conclusion that such promotion reduces episodes of diarrhoea. This included a reduction in incidence of around one quarter  identified from pooled results from community-based trials in LMICs . The autApproval was obtained from the Rwanda National Ethics Committee in January 2015. Data collection and delivery of the intervention were conducted between February and September 2015. This was a controlled pilot and feasibility study. The decision to make comparisons at the district rather than the village or community level was based on minimising the risk of between-site contamination. The sample size of two districts was based on practicality for a pilot-level study rather than using a power calculation. Randomisation was used to determine which of the two districts would receive the intervention, but blinding was not possible due to the nature of the intervention. A small-scale qualitative component was included; this was designed to explore feasibility and contribute to the evaluation of impact.The two districts selected were Gicumbi and Rulindo, Northern Province, Rwanda. To minimise any impact of confounding factors, these districts were purposively (rather than randomly) selected for comparability. This included similarity in terms of rural setting, population density, seasonal climate, occupational activities and income levels of people living in the villages. Comparability was determined using reported data  supplemeThe overall aims of the study were to explore the potential effectiveness of the intervention in terms of any impact on related morbidity and mortality and to assess the feasibility of evaluating and implementing this type of educational intervention in a LMIC such as Rwanda. The primary quantitative outcome measure was change in morbidity linked to sub-optimal hygiene, based on the number of recorded cases of diseases such as diarrhoea and worm infestation. We also sought to explore whether we could identify any changes in relevant morbidity. Assessment of feasibility was exploratory, including consideration of levels of difficulty associated with delivering the intervention.Health Center and Dispensary Monthly HMIS Report forms was used to finalise a standardised data collection form. This form is completed by health centres and returned manually and/or electronically to district offices. In order to focus on incident cases, we selected items of data included in the form which were categorised as ‘new’. We included categories considered to be most relevant to basic hygiene including water and sanitation  before the start of the intervention. The same data were collected for a follow-up period comprising the final 3 months during which the intervention was implemented (June to August 2015). Random samples of baseline and follow-up data for both districts were checked for accuracy, and further checks and corrections were made where indicated.At the end of the baseline data collection period, one district (Gicumbi) was randomly allocated (using Microsoft Excel RAND function) to receive the intervention, with the other (Rulindo) designated as the control. The intervention was delivered over a period of just over 6 months, beginning towards the end of February 2015 up to the end of August 2015. The intervention comprised education sessions using an interactive DVD developed by Thare Machi Education (TME), a small not-for-profit organisation based in the UK (registered charity no. 1080131) . TME’s sEducation sessions were delivered pragmatically, using a projector or a laptop computer with battery power, depending on the venue and electricity supply. Fieldworkers kept a record of the number of people who attended sessions, using close estimates for large numbers. After the sessions, health centres were provided with one or more copies of the DVD, which they could continue to use if they wished, but information regarding continued use was not formally collected.At the end of the study, qualitative feedback was collected from a small purposive sample of people who had contributed to the conduct of the study and from people involved in healthcare provision in Gicumbi Table . This stp value was determined as there was no expectation that the intervention would significantly increase the types of morbidity studied. We also determined the difference in difference [Changes in the number of incident cases recorded as diarrhoea and worm infection were calculated for the two districts, by comparing baseline and follow-up data. Percentages for (positive or negative) changes, as a proportion of the number of cases at baseline, were also calculated. A chi-squared test was used to compare the incidence of recorded cases in the intervention and control districts, for the combined age groups studied, for the two time periods. A one-tailed fference  for percDuring the intervention period, the Basic Hygiene DVD was viewed by over 47,000 people at sessions delivered by the research team. Those who attended included both men and women from low-income village communities generally reliant on small-scale agricultural activities. They were often accompanied by young children and babies. Initial review of the data identified very low numbers of cases recorded as food poisoning, so the analysis was restricted to impact on diarrhoea and dysentery and worms and parasites. At baseline, similar numbers of cases of infection with intestinal worms and parasites were identified in our two study districts, in the combined age groups for which data were collected . Much lower numbers of cases were recorded as diarrhoea and dysentery  . For worms and parasites, comparison of rates of change between baseline and follow-up revealed a much greater between-district difference in difference. In Rulindo, there was an overall reduction from 5002 to 4356 cases (13%), assumed to be due to factors unrelated to the intervention, such as seasonal variation between baseline (November to January) and follow-up (June to August) periods. In Gicumbi, the number of cases fell from 4995 to 3069 (39%). It was assumed that a reduction of 26% (39% less 13% due to other factors) is likely to be linked to the impact of the intervention. Comparison of results relating to worms and parasites in the two districts indicated statistical significance   in the intervention district (Gicumbi), but a difference of only 5 cases in the control district (Rulindo). Comparison of numbers of cases in the two districts in the two time periods indicated borderline non-significance , strengthening their capability for teaching people within their communities. This was confirmed by the community health workers who attended the training session at which feedback was invited. A question about whether they had found the DVD useful elicited an enthusiastic positive response, accompanied by broad smiles. They explained that the DVD had given them additional information about key messages that they needed to disseminate within their villages.Carrying out the research was described and observed as feasible, but reported challenges included problems with power supply and difficulties with travel and transport due to poor terrain and weather conditions. Fieldworkers described how visits to health centres had sometimes involved up to 4 h of travel each way. They also reported problems with power cuts or lack of a good electricity supply in some remote settings. Exploration of solutions to these problems during our interviews and discussions highlighted the potential benefits of using local personnel for evaluating and potentially implementing the type of intervention being investigated. It was suggested, for example, that Information, Education and Communication sessions could be used for showing DVDs at health centres or that community health workers could be provided with small battery-operated DVD players for showing DVDs within their villages.Our pilot-level study confirmed high levels of need in terms of reducing the morbidities studied. It also demonstrated the potential effectiveness of the intervention being tested. Our findings regarding high numbers of cases of intestinal worms and parasites in our study districts support previous observations regarding the high global burden of worm infestation, including particularly high rates in sub-Saharan Africa . The DVDWe used a controlled design that would help us to assess the extent to which changes were likely to be linked to the intervention or other factors such as seasonal variation. It is possible that there were unidentified confounding factors which influenced the difference in percentages relating to changes in the incidence of infection with worms and parasites in the two districts. These districts were, however, purposively selected for similarity, and we are not aware of any events or other interventions which are likely to have influenced the numbers of cases during the intervention period. Although we had been unable to obtain formal quantitative information about deaths related to intestinal worms, this issue was discussed as part of our feedback data collection from individuals involved in healthcare provision in Gicumbi. We were informed anecdotally that, in the year prior to the start of the study, there had been a small number of related deaths in young children. This suggests that there is potential for a reduction in mortality if morbidity can be reduced through education.Comparison of changes relating to the numbers of cases of diarrhoeal disease was non-significant, and inconsistencies made findings difficult to interpret. In Gicumbi, for example, a reduction in cases in adults was not matched by results for children and infants. Their findings may, however, be influenced by the types of cases recorded in these categories by health centres, including possible overlap between diarrhoea and worm infestation. Findings for diarrhoea may also be influenced by lack of statistical power due to lower numbers of recorded cases compared to infection with worms and parasites.Two previous studies had provided some evidence regarding the impact of the TME DVDs. An evaluation conducted in six countries indicated an increase in knowledge after watching a DVD-based lesson (unpublished report available on request from TME). Research in the UK demonstrated significant changes in understanding and attitudes amongst people of South Asian origin who viewed a DVD about insulin in type 2 diabetes, produced as a collaboration between TME and the University of Leicester . AlthougThere is some evidence that interventions with additional components alongside education may have greater impact. In a quasi-experimental study in Ethiopia, for example, tailored interventions including public-commitment with or without handwashing-station-promotion were more effective in terms of self-reported handwashing than education alone . In compOur qualitative findings indicated the practicality of carrying out the type of research investigated and also of potential implementation in a real-world setting. Feedback and observations suggested high levels of acceptability relating to the intervention, but also highlighted the importance of being aware of potential challenges. For practical reasons, the intervention was delivered by a team of fieldworkers who travelled to the health centres in the intervention district, but experiences and feedback suggested that it may be preferable to use local personnel. Training local providers to show the DVDs would provide a practical method of delivery that could lead to sustained impact.It is acknowledged that this small-scale study has some important limitations which would need to be addressed in a definitive evaluation. Using our data collection methods and working within time and budgetary restrictions, we were unable to collect numbers specifically for deaths from infections with worms and parasites, so it was not possible to quantitatively investigate any impact on mortality from these infections. From the data collected, we were also unable to compare cases of worms and parasites in children aged under 5 years, in whom these infections are particularly common. The health outcome information collected was restricted to recorded cases of relevant diseases in two defined periods, so we are unable to provide evidence related to other indicators such as longer term trends. Potential for statistical testing, to provide a robust assessment of effect size, was restricted by the data collected, including a lack of detailed information regarding the numbers of people in different age ranges served by the health centres. Our between-district comparisons using a chi-squared test were designed to provide an initial indication of effectiveness only but nevertheless suggested a significant impact regarding the incidence of infection with intestinal worms and parasites.It is further acknowledged that we cannot fully guarantee the accuracy of the data provided in health centre submissions to the district offices, although observations in one health centre prior to the start of the study suggested that information entered on report forms was derived from conscientious recording in paper records of clinic activity. Whilst recognising the small scale and informality of the qualitative aspect of our study, including stakeholder feedback, we consider that this made a useful contribution, particularly in terms of investigating feasibility. This emphasises the usefulness of including this type of component in evaluations both at the pilot and the full study level. It is acknowledged that qualitative data collection by one of the principal investigators could potentially have led to biased feedback, although care was taken not to deliberately influence responses. Furthermore, respondents were willing to share negative reflections relating to problems encountered as well as more positive feedback.It is clear that any shortcomings within a pilot study need to be taken into account when considering the strength of the evidence provided, and we fully acknowledge that our findings should be viewed bearing in mind the limitations described above. Our results relating to cases of infection with worms and parasites nevertheless raise the question of whether notable findings provided by a pilot study suggest that early implementation of the intervention may be justified in advance of more rigorous evaluation. This is particularly relevant where a high level of need has been confirmed. On this basis, training of community health workers in the use of the TME DVDs has been initiated in Rwanda, with encouragement and facilitation  from the Rwandan Ministry of Health. Over 5000 community health workers received training between June and November 2016, and this programme is currently ongoing . It is recognised, however, that sustainable financial support, such as government funding, is likely to be needed in order to cover the cost of full-scale implementation of any intervention. Justifiably, such funding is likely to be difficult to secure without confirmation of impact and an economic evaluation that provides strong evidence of cost-effectiveness. Economic evaluation was not within the scope of our pilot study.Our study has demonstrated the feasibility of evaluating and implementing a simple educational intervention on the topic of basic hygiene in a LMIC in sub-Saharan Africa. A larger, cluster randomised trial including estimation of sample size and adjustment for clustering would be required in order to confidently confirm the effectiveness of the intervention and to clarify the potential for reducing diarrhoeal disease. More comprehensive data collection would also be required, including health data from additional sources, information about how the educational messages were further disseminated by those who viewed the DVD and assessment of cost-effectiveness. Using local personnel was highlighted as a potentially effective and cost-effective method of delivering the intervention, but further formal evaluation or monitoring would be required to confirm the impact of the educational intervention using this method of delivery. Overall, it is considered that the results of our small-scale, low-budget study suggest that the intervention is promising in terms of a potential impact on health and that further evaluation and possibly early implementation are warranted.


This article describes, categorizes, and discusses the results of a rapid literature review aiming to provide an overview of the ethical issues and corresponding solutions surrounding pregnancies in epidemic outbreaks. The review was commissioned by the World Health Organization to inform responses to the Zika outbreak that began in 2015. Due to the urgency of the response efforts that needed to be informed by the literature search, a rapid qualitative review of the literature published in PubMed was conducted. The search and analysis were based on the operationalization of 3 key concepts: ethics, pregnancy, and epidemic outbreak. Ethical issues and solutions were interpreted within a principlist framework. The data were analyzed using qualitative content analysis. The search identified 259 publications, of which the full text of 23 papers was read. Of those, 20 papers contained a substantive part devoted to the topic of interest and were therefore analyzed further. We clustered the ethical issues and solutions around 4 themes: uncertainty, harms, autonomy/liberty, and effectiveness. Recognition of the identified ethical issues and corresponding solutions can inform and improve response efforts, public health planning, policies, and decision-making, as well as the activities of medical staff and counselors who practice before, during, or after an epidemic outbreak that affects pregnant women or those of reproductive age. The rapid review format proved to be useful despite its limited data basis and expedited review process. Aedes mosquitoes. Cases of perinatal and sexual transmission have been reported as well. Reports of transmission through blood transfusion are being investigated ’, ‘epidemic outbreak[s]’, and ‘pregnancy’ as defined above. Moreover, discussion of these topics had to make up a considerable part of the publication rather than being limited to quasi-incidental findings. If the topics were only mentioned or addressed in passing, the publication was excluded. In addition, only publications in English were included. PH screened the title and abstract of all identified articles. For papers identified as possibly relevant, we sought access via 3 university libraries. Authors were additionally contacted to gain access to publications where contact details were available. Data were analyzed and synthesized by means of an adapted version of qualitative content analysis . Our fraOur search strategy identified 259 publications. After screening the titles and abstracts, 36 publications were identified as relevant because they matched the inclusion and exclusion criteria. Unfortunately, 13 of these 36 publications were not available to us in full text, even after contacting the authors directly. The remaining 23 publications were read, summarized, and synthesized. These were published between 1975 and 2015; 13 of them between 2008 and 2015, 7 between 1975 and 1995, and 3 between 1996 and 2007. Nine publications were primarily concerned with human immunodeficiency virus, 6 with influenza, 2 with rubella, 1 with Ebola, 1 with cancer, and 4 were not focused on a specific disease. Three publications read in full-text fell short of addressing the research questions, and were excluded. The screening process is presented in We identified ethical issues and solutions mentioned in the publications, and clustered them around 4 themes that became salient during the summarizing and subsumption process: uncertainty, harm, autonomy/liberty, and effectiveness. An issue or solution was understood as relating to uncertainty if it concerned a lack of knowledge or guidance. It pertained to harm if it concerned any event or state of affairs that decreased the well-being of individuals, communities, or populations. The theme autonomy/liberty included issues and solutions speaking to the freedom and informedness of individual choice. Effectiveness covered issues and solutions relating to the proper functioning of interventions for controlling the outbreak or mitigating its effects. We provide examples of ethical issues in While the reviewed papers presented a significant number of issues relating to each theme, they mentioned relatively few solutions related to uncertainty and effectiveness. The number of solutions proposed for violations of autonomy was comparably high. Generally, a striking result was that the reviewed papers tended to discuss issues, particularly risks. The provision of solutions was much less common. Often these remained implicit.In the reviewed papers, uncertainty regarding clinical aspects was said to the endanger diagnosis, prevention, and treatment of pregnant women. For example, there is a risk of pregnant women being insufficiently included in the research agenda, such that knowledge is lacking for clinical decision-making on treatment options and the use of investigational drugs . Policy-The few suggested solutions related to uncertainty were mainly concerned with the implementation of adequate and timely procedures for formulating preemptive, formal preparedness plans . A rangeDue to the limited timeframe for this review, we could only conduct a rapid and not a full systematic review. This means we had to make concessions regarding the breadth and rigor of the analysis. First, we only searched PubMed for the relevant literature and therefore could only include scientific journal publications. Searching book publications via Google Books or the gray literature (including policy reports) might have provided us with additional insights. We were furthermore limited to the literature published in English. Nonetheless, no publications were excluded on this basis. Second, only 1 person (PH) conducted the screening and analysis process of individual papers, in which 2 or more people are normally involved. However, a second person (CK) was approached where uncertainties arose during screening and extraction. Furthermore, the process of synthesizing the data to obtain the final framework was done in a discursive process between PH and CK. Reviews of normative questions always involve a high level of interpretation because authors do not always clearly describe issues at hand, and there are various justifiable ways of synthesizing the data in a comprehensible format. We think that our approach of incorporating thorough discussions, especially during the most difficult phase of synthesizing, ensures the reliability and validity of our representation of the findings.A more general limitation that is not related to the rapid format of this review is our operationalization of the fundamental concepts on which the search was based, especially ‘ethical issues.’ We admit that other definitions might have given slightly different outcomes. However, we had good reasons for choosing a principlist understanding of ethical issues, primarily because it is the most commonly used framework in public health ethics. Moreover, other systematic reviews of normative information have already demonstrated the instrumental value of the principlist approach for a descriptive and stakeholder-oriented analysis.Moreover, ethical issues might arise that are not captured by this literature search because they are not discussed at all in the literature. It might very well be that certain issues are not on the radar of those with a scholarly interest in public health (ethics), but still cause severe trouble in the field. This review should therefore only be seen as a starting point and not as a full list of all potential issues and solutions. Further steps such as discussions with stakeholders are therefore suggested to get a full overview of ethical issues in this context.Epidemic outbreaks have the potential to affect a large number of individuals. Policy-makers need to ensure that responses are ethically sound and therefore acceptable to those affected. Since such outbreaks normally require relatively urgent responses, an informative yet time-efficient tool is needed to inform these efforts. The rapid review format is useful in new contexts such as epidemic outbreaks of unknown or rare epidemic diseases, outbreaks that are much larger in scale than previous ones, and emerging and pressing medical and public health phenomena in general. In each of these cases, one can expect that even if the target phenomenon exhibits a significant degree of novelty, some of the challenges that arise will be partly familiar from previous public health contexts. At the very least, it seems warranted to look for such similarities and take existing knowledge and evidence into account in order to ensure that lessons from past challenges are drawn and considered. The rapid review format is a time- and resource-efficient way to look back in order to plan ahead. Although the process of screening the existing literature in the target domain is expedited, the insights can contribute to the soundness and effectiveness of timely response efforts. In our case, fewer than 6 months passed from the initiation of the project to the submission of the final report. If the authors had been able to work full-time on the review, it would have been finalized even faster. This makes the rapid review format a useful tool for epidemic outbreaks where severe time constraints and urgency require decisions before a systematic review can be carried out. Despite the rapid execution and narrowed data base, the rapid review format likely offers a reasonable compromise between time-efficiency and the completeness of a full but more time-consuming systematic review. It remains an exciting question for further research exactly how attractive this trade-off is, and to what extent informativeness and completeness are inevitably compromised by the concessions.Furthermore, our review was descriptive, and did not evaluate the considerations that were identified. This means that only mentioning issues and solutions, not the quality or soundness thereof, was sufficient for inclusion. In contrast to systematic reviews that try to answer quantitative, empirical questions for which frameworks such as GRADE for evaluating the quality of evidence and strength of recommendations  exist, tWith these caveats in mind, we offer below some tentative remarks that go beyond mere statements of our findings, and concern the relationship between the identified issues and solutions and the Zika outbreak that prompted our review.Some of the issues that we identified have materialized in the Zika outbreak, such as the risk that there might be limited evidence on the effects of the epidemic on pregnant women and fetuses (in our review: ). In earMoreover, a paper noted that recommendations on reproductive choices during an outbreak could be too directive and infringe upon individuals’ autonomy (in our review: ). IndeedAs a final example, our review captured the concern that inconsistent access to contraceptives and reproductive health services (in our review: ) can renThe overlap between the risks identified in the review and those noticed in the Zika outbreak suggests at least 2 conclusions. Firstly, it validates the fit of our research questions, search strategy, and results with the real-world public health challenge. Secondly, it highlights aspects where Zika does not pose new and unique challenges, but exhibits characteristics that are familiar from other epidemics . BuildinIt is thus encouraging to see that just as some risks have materialized, some solutions from previous outbreaks have been recognized and implemented, too. For example, the Pan American Health Organization (PAHO) has made recommendations along the lines of the identified solutions. In view of the limited evidence on Zika, there is an urgent need to include pregnant women in research agendas. Otherwise, the scientific community will continue to face incomplete knowledge of the effects of Zika and a lack of diagnostics, vaccines, and/or treatment options (in our review: ). PregnaFurther overlap exists between the solutions identified in our review and those advanced in PAHO’s ethics guidelines on Zika, which recommend that pregnant women should be provided with up-to-date and understandable information on the disease and treatment options , providThis article describes, categorizes, and discusses the results of a rapid literature review on ethical issues and solutions surrounding pregnancies in epidemic outbreaks. Recognition of the identified ethical issues and corresponding solutions can inform and improve response efforts, public health planning, policies, and decision-making, as well as the activities of medical staff and counselors who practice before, during, or after an epidemic outbreak that affects pregnant women.


As of November 2011, the Korean government recalled and banned humidifier disinfectants (HDs) from the market, because four case-control studies and one retrospective epidemiological study proved the association between HDs and lung injury of unknown cause. The report reviewed the causal role of HDs in lung injury based on scientific evidences.A careful examination on the association between the HDs and lung injury was based on the criteria of causality inference by Hill and the US Surgeon General Expert Committee.We found that all the evidences on the causality fulfilled the criteria , which proved the unknown cause lung injury reported in 2011 was caused by the HDs. In particular, there was no single reported case of lung injury since the ban in selling HDs in November 2011 as well as before the HDs were sold in markets.Although only a few epidemiological studies in Korea have evaluated the association between lung injury and the use of HDs, those studies contributed to proving the strong association between the use of the HDs and lung injury, based on scientific evidence. The incident by humidifier disinfectants (HDs) in 2011 was a large-scale and unprecedented environmental catastrophic case. Since a notification by the infection control department at a university hospital in Seoul in April 2011 resulted in the epidemiological investigation by Korea Centers for Disease Control and Prevention (KCDC), studies on HD-induced lung injury have been performed. Evidence on the cause of these cases begun to be inferred from these study results. Based on the initial hospital-based case-control study and the preliminary result of inhalation toxicity test in mice, the government withdrew HDs from the market and banned its sale in order to prevent additional damages in November 2011. No similar incidence of lung injured patients was observed afterwards [However, despite the ban on the sale of HDs, there has been no progress in the treatment and compensation for victims affected by their use and it was failed even to grasp the problem magnitude, i.e., the number of victims. A lawsuit brought by some victims against the company and the government was dismissed. Fundamental investigation by the prosecution began in early 2016, and in the process, unethical behaviors by relevant companies and systemic problems have been discovered. Lately, with the establishment of a special investigation committee on HDs by the National Assembly, various systemic and political measures were being considered with respect to compensation for victims including recognition of the impact of the disease on other organs, as well as other respiratory diseases. Moreover, a legal resolution on the prosecution’s indictment, including the possibility of a causal role for HDs in health issues, was yet to be reached in court.Based on this situation, this report reviewed the causal role of HDs in lung injury based on scientific evidences, and discussed issues to be considered in establishing a possible causal association with other diseases other than lung injury.The counterfactual concept is often applied to prove that certain exposure can cause a specific disease in a population. It is assumed that whether a certain factor is the cause of the disease can be decided by comparing the prevalence of the disease under exposure (fact) with the prevalence of the disease without exposure (counter-fact) of the same subjects  in the same environment . HoweverAlthough recent models have been suggested, particularly to explain chronic disease related causality, this report was based on the criteria of causality inference by Hill  and the As of 2016, a total of six case series reports detailing the clinical, radiological and pathological patterns of lung injury and its prognosis have been published . Five epThere were four case-control studies: an epidemiologic study initially performed immediately after a report of lung injury from a university hospital to the KCDC in 2011 ; a case-Based on the results of epidemiological, clinical, toxicological and experimental studies, the causality of lung injury by HDs was summarized by applying Hill’s nine criteria and the US Surgeon General Expert Committee’s nine criteria as follows .First is the strength of association. According to the result of the above epidemiological study, the risk estimate between HD and lung injury was as low as 2.7 times, and as high as 116.0 times, showing a significantly strong association -14.Second is consistency. Although each epidemiological study had different populations (adults -14 vs. cThird is specificity. This lung injury could not be explained previously by other common types of lung diseases such as cases of infectious lung disease, those caused by other viruses or bacteria, or immunologic lung diseases, by clinical and pathological findings -9. And iFourth is temporality. Considering that these cases of lung injury had not been reported before HDs were on the market, and there have been no additional case reports since the ban of its sale in November 2011, temporality has been met.Fifth is the dose-response relationship. Three epidemiological studies have shown consistent results, that the risk of incidence, as well as mortality increased with larger doses, longer durations ,15, and Sixth is plausibility. The most common size of aerosol sprayed through humidifier was 30 nm to 50 nm. Particles of this size were found to have reached the bronchioles and precipitated , suggestSeventh is consistency with previous knowledge. Previously known lung lesions due to inhalation toxicity have characteristics of lobular, diffuse infiltration and peri-bronchial infiltration that are peculiar to lung injury ,9. As itEighth is experimental evidence. In a cellular toxicity test exposing normal pulmonary cells to the major components of HDs, dose-response toxicity was found. The result of the evaluation of reactive oxygen production also showed a dose-response relationship . In an iNinth is analogy. Ardystil syndrome, an interstitial lung disease developed in workers using spray paint in the western country in the 1990s, was similar to the lung disease caused by HDs . This waUnlike Hill’s criteria, the US Surgeon General Expert Committee suggested to consider alternative explanations as a causality criteria. First of all, the possibility of fungi as a cause of lung injury. Although there were no other significant risk factors than HDs in the studies of lung injury, the first epidemiological study showed significant association between fungi at room reported by questionnaire administration with lung injury, even after adjustment for various variables . AssociaIn addition, the US Surgeon General Expert Committee suggested that disease risk should decrease after cessation of exposure if it was a cause. The fact that there have been no new cases of this form of lung injury since HDs have been withdrawn and banned from the market in November 2011 meets the criteria of decrease in risk upon cessation of exposure.In summary, the unusual association between the HDs and lung injury met all nine Hill’s criteria and the nine criteria of US Surgeon General Expert Committee. Therefore, it could be inferred that there was a very strong scientific evidence of HDs as the cause of lung injury. However, the inhalation toxicity of HDs might not be limited to lung injury. As indicated in previously published reports, lung injury is considered as a disease developing in a high-risk group with a very high exposure level. There was a possibility that mild diseases could have developed in people exposed to a lower level. Moreover, damage of other organs than the lung was suspected. In fact, rhinitis or asthma was often reported in victims, as well as symptoms in other organs . MoreoveOn the other hand, most environmental diseases could be developed from multiple causes. It is more reasonable to infer various factors as a necessary cause or a sufficient cause working simultaneously and complexly. Also, environmental diseases develop under the influence of the complex and multi-dimensional interactions; from biochemical reactions at a microscopic level, individual behavioral factors and to the microscopic level such as the physical, chemical, social, and psychological environment . It was In conclusion, after reviewing the causal role of the HDs in lung injury based on the criteria of Hill and US Surgeon General Expert Committee, all criteria were satisfactorily met. It was found that the form of lung injury reported in 2011 was caused by exposure to HDs. Above all, since no lung injury of unknown cause was reported before the sale of HD, and not a single case of lung injury has developed after the ban on HDs in November 2011, there was a strong support for the view that the lung injury of unknown cause was caused by exposure to HDs.


Spastic quadriplegia has as an etiopathogenic substrate, a non-progressive brain lesion; however, the clinical manifestations of the disease evolve over time. Children diagnosed with spastic quadriplegia show a variety of symptoms in different areas: sensorimotor, emotional, cognitive, and social. The purpose of this study was to assess the functional status in patients diagnosed with spastic quadriplegia, who followed a complex medical rehabilitation program, during a year, and highlight the importance of using physical and kinetic techniques in improving their status. A total of 10 children diagnosed with spastic quadriplegia were included in the study and the Gross Motor Function Classification System (GMFCS) and manual ability classification system (MACS) were used to evaluate the functionality status of each patient. Every patient was evaluated initially (T1), after six months of program (T2), and after they completed the study. All the children were originally monitored daily, for 5 days per week for a period of one month, then two times a week for a year. A statistically significant difference regarding the modification of the GMFCS and MACS stage was found, which occurred between the first and the third evaluation. The inverse correlation of the statistical significance between the ages of patients and the decrease in GMFCS or MACS stage was highlighted; the younger the patient, the more the scale decreased. A direct link between the gross motor function and the manual ability was noticed. Applying a complex rehabilitation program has proven efficient by improving both the gross motor functionality and the manual ability. Cerebral palsy brings together a group of diseases that can cause significant changes in posture and motor skills, and can lead to loss of motor autonomy in varying proportions. It is considered that these shortcomings are due to changes made throughout fetal development or in the postpartum period [3].Depending on the nature of the disorder, three dominant forms of cerebral paralysis can be distinguished: spastic, dyskinetic and ataxic. Depending on the anatomical distribution of the deficit, they are classified in monoplegia, diplegia, hemiplegia, and quadriplegia [1-3].Quadriplegia affects all four limbs; the spastic form is the most common, generally, the deficit is higher in the upper limbs. Spasticity is present especially in the flexor muscles of the upper limb and lower limb extensor [4].Destructive damage to neurons in the pyramidal system determines conditioned reflex motor acts deficits. The voluntary conditional reflex movement is the most affected, especially if a high degree of complexity and finesse, such as the use of the hand, is required. The pyramidal system damage does not only permanently abolish the motor conditioned reflexes acts but also some innate reflex motor activities. Thus, cutaneous abdominal reflexes and cremasteric reflexes are affected to the abolition in the pyramidal system lesions [3].Spasticity is one of the dominants of the clinical picture in quadriplegia, and is due to an exaggeration of the tonic and phasic muscle stretch reflex. After a certain time, muscle stiffness may also occur amid this spasticity, seriously aggravating the pre-existing functional deficit. In turn, muscle contracture can be a preliminary stage and a cause that can lead to irreversible muscle retractions [5].The treatment of patients diagnosed with spastic quadriplegia is complex, requires the cooperation of a whole team of specialists, and is based on the full involvement of the family. The therapeutic methods used are medications , physical therapy, physiotherapy (electrotherapy and thermotherapy), orthopedic and surgical treatment . The upper limb ability classification manual (MACS) was used to assess functionality [7]. MACS is used to assess the child’s overall ability to handle objects from everyday life and does not take into account the functional differences between the two hands.Gross Motor Function Classification System (GMFCS) was used for the assessment of the motor function. With the help of GMFCS, the presence, amplitude, and force for active movements, particularly walking, were evaluated for each patient . Duration physiotherapy sessions averaged 45 minutes, with a break of 5-10 minutes, children not being able to follow and carry out a too long or too complicated kinetic program.The massage techniques used were the sedative massage for the limbs, and facial muscle massage that consisted in light smoothing with a low rhythm and intensity. Massage as a form of introducing kinesiotherapy was also used. Physical therapy was performed daily both individually and in groups , transfer favoring exercises, exercises of quadrupeds, the creeping from a seated position, crossing in orthostatic position, lifting exercises for balance and walking. Breathing exercises, such as deep thoracic-abdominal breathing, were associated to facilitate breathing.3. Therapeutic Exercises: Alternating isometric exercises, slow stretching, active relaxation-opposition movements and slow reversals with opposition within Kabat diagonals, concentric isotonic contractions, resistive exercises . The spastic form is found at a rate of 75-80% [3]. Impaired motor activity is the main feature in patients with cerebral palsy and is frequently accompanied by impaired sensory perception, cognition, communication, and behavior.Cerebral palsy is one of the most common causes of occurrence of disability in children, with a prevalence of 2-2.5 cases/ children . Patients often associated with spastic quadriplegia associate different types of pathologies, comorbidities and those are usually the ones that favor dysfunctionality in these children.Although in most cases, spastic quadriplegia’s etiopathogenic substrate is a non-progressive brain damage, clinical manifestations of the disease evolve over time [3].In addition to improving the physical, mental, and social areas, the maintaining and preserving of a good functionality is a goal in patients diagnosed with spastic quadriplegia. The most frequently encountered disabilities in these patients are self-care related and gross motor function motility .In order to determine the degree of the gross motor function, GMFCS classification system was used; for the motor function and the manual skills were evaluated by using the MACS classification system, both proving their effectiveness in a variety of studies and clinical trials  and then decreases gradually. Several studies have demonstrated that the damage to the functionality occurs mainly in children diagnosed with spastic quadriplegia, after 9 years of age [15-20].It was shown that a coarse motor function deteriorates with age in patients diagnosed with spastic quadriplegia. It is believed that the gross motor activity reaches a maximum around the age of 6-7 .Due to the difficulty in applying steady recovery programs, in some studies, patients from rural areas showed a significant long-term improvement in the functional status. Our study was not influenced during the course of the program because we benefited from the support and involvement of the families who have complied with the pace (5 sessions/ week) and daily duration of the proposed program [Nonparametric Friedman test was used to compare the parameter values observed for the gross motor function testing at the 3 evaluation points. A significant difference between T1 and the other two evaluation points was highlighted.22].The effectiveness of the complex rehabilitation program followed by the group of studied patients was demonstrated by parameter changes of the gross motor function classification system. Our data correlated with those reported in the literature .After applying a comprehensive rehabilitation program for patients diagnosed with spastic quadriplegia, there was a significant improvement in the coarse motility in those who had a better gross motor functionality score .Both classification systems, GMFCS and MACS, have proven useful in assessing functionality in patients diagnosed with spastic quadriplegia, being extremely useful in determining the value of applying rehabilitation programs .In patients older than 10 years with a lower original score for coarse functionality, regardless of the duration and intensity of the applied program, we did not obtain satisfactory results .The data contained in the literature showed that setting up a complex program rehabilitation as early as possible after diagnosis and continuing it for as long as possible is fundamental in recovering functionality in patients with spastic quadriplegia .The gross mobility classification system score was used as a predictor of the functional status in other studies, where it was noted that in patients with a better score, the rehabilitation methods led to a better recovery of the motor deficit [24]. Improving the gross motor function classified by using the gross motor functional score correlated with the ability evaluated by the manual classification system for manual ability in other studies [25]. The individualization of the rehabilitation program was one of the reasons for a favorable gross motor functionality and manual ability for patients in the studied group. In a study in which it was proposed to establish a relationship between the two types of functionality  in patients diagnosed with different types of cerebral palsy, significant statistical correlations have been demonstrated only in patients with spastic quadriplegia [Applying a complex rehabilitation program has proven its worth by improving the gross motor functionality and the manual ability, being a direct link between their development stages. The initiation of a rehabilitation program as early as possible after diagnosis is imperative, as it was highlighted by the inverse correlation of the statistical significance between the ages of patients and the improvement of the gross motor functionality and manual ability. The individualization of the rehabilitation program and the family involvement are essential in the functionality of the favorable development of the gross motor and the manual ability in children with spastic quadriplegia.Conflict of interestsThe authors declare that they have no conflict of interests.Contribution noteAll authors have contributed equally to this work.


The current literature suggests that load carriage can impact on a tactical officer’s mobility, and that survival in the field may rely on the officer’s mobility. The ability for humans to generate power and agility is critical for performance of the high-intensity movements required in the field of duty. The aims of this review were to critically examine the literature investigating the impacts of load carriage on measures of power and agility and to synthesize the findings. The authors completed a search of the literature using key search terms in four databases. After relevant studies were located using strict inclusion and exclusion criteria, the studies were critically appraised using the Downs and Black Checklist and relevant data were extracted and tabled. Fourteen studies were deemed relevant for this review, ranging in percentage quality scores from 42.85% to 71.43%. Outcome measures used in these studies to indicate levels of power and agility included short-distance sprints, vertical jumps, and agility runs, among others. Performance of both power and agility was shown to decrease when tactical load was added to the participants. This suggests that the increase in weight carried by tactical officers may put this population at risk of injury or fatality in the line of duty. Tactical personnel are defined as professionals whose sworn duty is to protect their community or country; that duty that can place them at risk of injury . These mTactical populations, by the nature of their occupations, are also required to wear and carry additional loads on a daily basis . Law enfIt has been well established that repeated or sustained high intensity bouts of physical activity negatively affect the ability to maintain power, speed, and agility performance among athletic populations ,17,18. TThe literature suggests that load carriage can impact on tactical task performance, most notably, in this case, mobility . The litA three-stage approach was used to identify and obtain studies that were potentially relevant to this critical review. The first stage consisted of a rapid literature review (conducted on 14 August 2017), which helped formulate the search strategy. Key search terms were identified and selected by extracting commonly used terms in the known research. Final research terms were then established by the researchers through joint collaboration. In the second stage, the aforementioned search terms were entered into the following databases: PUBMED, EMBASE, CINAHL and SPORTDiscus. These terms were modified as required to meet the individual search strategies within each database see . Where aOnce duplicates were removed, the articles were subjected to vigorous screening using carefully selected inclusion criteria. All articles were screened by title and abstract to meet the relevance of the aims of the review. Criteria for inclusion were as follows: (a) Study available in English or able to be translated into English; (b) study available in full text; (c) study used adult human participants only; (d) study involved participants carrying added load; and (e) study used a power and/or agility outcome measure.For the purposes of this review, power was defined as the product of force on a subject and the subject’s velocity in the direction in which the force was exerted . This diIn an effort to limit bias and accurately screen the studies derived from the literature search, two authors  again reviewed and screened the studies separately using the criteria above. Disagreements regarding the inclusion or exclusion of any article were discussed and mediated by a third author (R.O.) before continuing the process. Through this approach, search bias, inclusion and exclusion bias, and duplication bias were limited. Finally, as part of the third stage of the search strategy, additional relevant studies, as well as grey literature, were sourced from references found in the studies retrieved from the database search and from known researchers in this field identified through the references or known to the reviewers through previous collaborations.After subjecting the studies to all inclusion and exclusion criteria, the remaining studies were critically appraised using the Downs and Black checklist . The cheThe appraisal process described above was completed by two authors  individually, so as to limit bias. Using the calculation of a Cohen’s kappa coefficient (k), the level of interrater agreement of the raw scores was then determined by a third author (Robin Orr). This method followed previously published guidelines that are currently used in the literature . The CriOnce the critical appraisal of the studies was completed, pertinent data were extracted from the included studies and tabled. Information extracted included all authors, title of study, year of publication, aim of the study, participant details, and main findings that were relevant to the aims of this review.The PRISMA flow diagram  details In total, 14 studies were deemed eligible for review and were subject to critical review. Of these studies, seven were conducted in the USA ,29,30,31The final CAS percentage scores, indicating the methodological quality of each study, are presented in Common weaknesses were observed in the included studies in certain areas of the Downs and Black checklist . QuestioSix of the included studies measured power in the form of short distance sprints. Of the studies that measured 30-m sprints ,26,29,33Three studies included in this review measured power via a vertical jump test ,14,33. TNumerous studies used certain maneuverability tasks to measure the performance loss in agility with added load. These tasks included traversing obstacle courses that incorporated various agility measures ,29,33, fSprints from a prone starting position require a considerable amount of agility. This outcome measure was used to observe the performance of agility under load as opposed to power. Three studies used this measure ,32,33, aTwo of the included studies measured agility through the use of an agility or shuttle run ,31. BothThis critical review aimed to identify and critically appraise the methodological quality of studies investigating impacts of load carriage on measures of power and agility and to synthesize their findings. Four main areas of discussion were formed based off the results gathered: (1) the quality of the included studies; (2) the impact of added load on outcome measures of power; (3) the impact of added load on outcome measures of agility; and (4) implications of these findings to tactical population based on the volume of evidence reviewed and potential recommendations to mitigate these implications.The methodological quality of the included studies as a whole was deemed ‘moderate’ based on the grading system by Kennelly , with thBearing these considerations in mind, it should be noted that the quality of these studies was acceptable overall. Furthermore, based on the volume of research available, the findings of added load carriage on measures of power and agility can be considered with confidence.n = 6). This study did show an increase in time to complete the 10-m sprint when the 22.8 kg (±1.8 kg) load was added to the members of the specialist police unit, and it can be inferred that if more officers participated in this study, the results may have shown statistically significant decreases in performance. Overall, additional load was shown to have the most effect on short distance sprints in respect to completion time. This indicates that when under heavy load, the tactical officer will typically require a significantly greater amount of time to reach his or her destination safely. Power was shown to decrease across the included studies when additional tactical load was added to the participant. Both short-distance sprints and vertical jump tests were shown to have significantly lower results in the loaded conditions in the majority of the studies. Carlton et al.  did not The ability to generate power is necessary for explosive movements that the tactical officer performs in the field, such as sprinting to seek cover or jumping to negotiate a high fence. Increases in tactical load may come at the expense of the officer’s ability to successfully perform these movements quickly, and could mean risking the officer’s safety or the success of the mission. While this time period  may be considered very small it must be considered in context. For example, the cyclic rate of an AK 47 automatic assault rifle is around 600 rounds per minute and, on this basis, covering a distance one second slower could leave tactical personnel exposed to an additional 10 rounds while seeking cover from an armed offender or enemy combatant utilizing one of these weapons. This information should be taken into consideration when sending an officer into a situation in which explosive maneuvers may be required to survive.As was the case with power, agility was shown to suffer when the tactical officer was subjected to additional load. As a whole, the performance of all of the outcome measures used to observe agility decreased as load carriage increased. This was observed as many studies used tiers of weight in their experiments, and the heavier tiers typically showed increasingly significant differences from the lighter tiers. DeMaio et al.  observedIt should be taken into account, however, that while increases in times to complete obstacle courses were observed across the included studies, this may be due in part to the amount of space that the increased load occupied. For example, the increase in completion times for crawling underneath wires in the study by Holewijn and Lotens  could haApart from the agility to traverse or circumvent obstacles rapidly, which may give an opponent an advantage, it should be noted that reduction in agility may increase the tactical officer’s risk of a slip, trip, or fall. Research by Park et al.  identifiThese results are especially pertinent for the tactical population. Load carriage represented by the weight of additional equipment carried by tactical personnel significantly decreased their power and agility, and therefore their mobility. Although the equipment and armour that tactical populations are required to carry may offer additional protection or necessary supplies to the person, the load may reach a point to where mobility is suffering . This deConsidering this, it is critical that training procedures and policies for tactical personnel include physical conditioning to specifically increase and optimize the carrier’s ability to generate power and move with agility ,13. It iKey limitations of this review identified included a potential language bias and restriction to the majority of research to male participants. Given that only English databases were searched, in conjunction with English search terms, the potential for a language bias is present. Furthermore, while the quality of the studies was of good standard, many studies only used young male participants in their research. Considering that female personnel serve in tactical populations and perform the same operational tasks as male personnel, there was very little research into the effects of load carriage on female performance of power and agility. Given the relationship between fat mass and the ability to generate power  and thatIn conclusion, this review observed that added load may have significant impacts on the ability of tactical personnel to perform activities that require power and agility. This may in turn reduce their mobility and increase their risk of injury and potentially mortality and operational success. On this basis, measures that optimize the ability of tactical personnel to generate power and agility while carrying load, such as physical conditioning and load reduction, is of importance. More research is required to take measures to reduce the weight carried by tactical personnel without compromising the safety or utility the load may offer.