The United Nations Convention on the Rights of Persons with Disabilities (UNCRPD), ratified in 2006, states that the achievement of equal rights, empowerment, and social inclusion of people with disabilities requires comprehensive rehabilitation services involving educational, social, economic, and medical interventions, all dimensions of the World Health Organization Community based rehabilitation (CBR) matrix. CBR programs aim at achieving those goals. In the present study, we investigated whether a large scale CBR program is improving access to multiple services  and providing satisfactions (by measuring the reduction in unmet needs) of Afghans with disabilities. We enrolled in the study 1861 newly recruited CBR participants with disabilities from 169 villages between July 2012 and December 2013, and 1132 controls screened with disabilities randomly selected with a two-stage process within 6000 households from 100 villages in the same provinces as the CBR but outside its catchment area. Using propensity score matching (PSM) and difference in difference analysis, we estimated the differences in accessing services. There were statistically significant differences between participants and controls on the access of available services between the baseline and endline. Using PSM we also found that needs were more often met among CBR participants compared to the controls. Our study indicates that a CBR program may be an effective way to provide services for persons with disabilities even in a conflict context such as Afghanistan. It contributes to addressing the longstanding question whether CBR can actually improve the rehabilitation of persons with disabilities. Persons with disabilities in Low- and Middle-Income Countries (LMICs) have been marginalised, enduring a level of multipronged difficulties in all spheres of life that no other social group has encountered . ExistinIn LMICs, resources to fight poverty, provide equal opportunities to persons with disabilities, promote their rights, and encourage full participation in society are limited. Community Based Rehabilitation (CBR) was introduced by the World Health Organization WHO) following the Declaration of Alma-Ata in 1978 on primary healthcare coverage as an effective strategy to overcome limited resources and poor access to existing ones for persons with disabilities by offering local rehabilitation initiatives in LMICs. Such initiatives aimed at implementing part or all of the five components of the CBR matrix—health, education, livelihood, and social and empowerment components depending on local needs and priorities ,22. The During an international consultation to review CBR program principles organised by the WHO and other Un agencies in 2003 , severalThe evaluation of CBR effectiveness remains scarce in LMICs, making the adoption of evidence-based practices problematic to achieve . Many stThe access to services can be considered as a key indicator of the performance of the CBR programs. Measuring satisfaction with services as part of access is essential as the literature has shown that persons with disabilities often are confronted to situations where inappropriate services, particularly healthcare services, are offered or they face attitudinal, financial, or physical barriers to access ,45,46. SThe present study seeks to contribute to the literature by investigating the effectiveness of a wide range of services delivery—physiotherapy, assistive devices, employment services, education services, and advocacy—for participants of a CBR program in rural Afghanistan with various types of disabilities, including their level of satisfaction with the services received over time compared to treatment as usual through the basic package of health services for a random control group of persons with disabilities. We conducted a large quasi-randomized field experiment of a CBR program that has been implemented in 13 provinces of northern and eastern Afghanistan since 2004. The CBR is implemented in 13 provinces with four regional project offices based in Ghazni, Jalalabad (Nangharar province), Mazar-e-Sharif , and Takhar  See . As of 2mahals where recruited CBR workers live and from where the program expands progressively to include nearby villages until covering extensively each district of the 13 included provinces.We included all new 1680 CBR participants included in the CBR program between July 2012 and December 2013 living in one of the 169 urban or rural catchment areas of the CBR program and identified using a locally developed, tested, and validated questionnaire based on the World Health Organization guidelines for grassroot disability program . CatchmeWe also included during the same period a group of controls living in 100 randomly selected villages and urban centres of the same provinces but outside of the program catchment areas. At the second stage, 60 households were randomly selected from the social centre (a mosque or an open square) of each village/urban centre yielding a total of 6000 households. From the social centre, a random direction was defined using a spinner, direction in which all households were numbered. The first household was identified using a random number selected between 1 and 60. And all other 59 households were selected using the nearest front door method. A household was defined as a unit that shared a kitchen, an income, and occupied the same flat, house, or compound. Children and adults with disabilities were identified using a locally validated disability-screening tool composed of 34 items for adults (DSQ-34) and 35 for children (DSQ-35) . All study participants were interviewed with a locally developed and validated questionnaire that inquired about demographic characteristics, socioeconomic status, access to various CBR services from among the five domains of the CBR matrix  , individThis study assessed self-reported measures of availability of CBR program services and service recipient satisfaction. We first measured if study participants received any of five types of services—namely physical therapy, assistive devices, employment support, education support, advocacy—and then we asked about quality-of-life improvement of the services received. A dummy variable was created for each set and for each outcome . For access to services, we considered the use of services as a relevant proxy ,55 and wPhysical TherapyPhysical therapy (PT) is provided in 12 existing physiotherapy centers and at home for both children and adults with disabilities diagnosed with a condition that can be improved through PT. Mobility and assistive devicesMobility and assistive devices are made available free of costs to participants with disabilities with mobility limitations. Prosthesis and orthotics are locally manufactured in four regional workshops by Swedish Committee for Afghanistan and provided to people wounded by ammunitions, landmines, or explosive ordnance. Orthotics have been provided in some cases to children presenting conditions such as poliomyelitis and cerebral palsy. In case of paralysis or other walking limitations, locally built wheelchairs or three wheels bicycles with a system of hand pedals have been used. Similarly, crutches, walking frames, and walking sticks all locally fabricated have been made available for different conditions of mobility problems. Finally, special chairs are fabricated for children with cerebral palsy who need some support while sitting. Employment and livelihood supportThe employment and livelihood support program has been offering increased services to persons with disabilities since the beginning of the present study. Such services include vocational training , business management training, small loans, in-kind support, establishing saving groups and producer groups engaged in sectors such as dairy, garments, and soap making to launch or support businesses. Education supportThe CBR program promotes early educational intervention through home-based education for children with disabilities. Following a period of home-based education, children are transferred to a Community Rehabilitation Development Centre, where they are introduced to formal literacy and numeracy for two to three years before transitioning to a mainstream school. Advocacy and community mobilizationShurah about the rights of people with disabilities aiming at fighting stigma and discrimination in the public sphere. Another important activity is awareness raising about the benefits of inclusion in education among school principals, teachers, and parents of both disabled and non-disabled children to promote open and welcoming schools. Similarly, targeted awareness towards employers to promote inclusion of persons with disabilities in employment is an important dimension of advocacy. Such definition was shared with CBR participants who were asked to acknowledge if any advocacy and community mobilizations activity has been conducted by the CBR program to address problems of discrimination they faced in their community.A variety of activities are included in the generic appellation of “advocacy and community mobilization” as we found through discussion with CBR workers and activity observation during the present study. In practice, advocacy and community mobilizations include a combination of disability sensitization and awareness raising interventions by CBR workers among community members. A major activity is general training and lecturing for families, village elders, and members of the local community called Service recipient satisfaction was measured with the following question: “What are the remaining needs you have that the program did not cover?”, from those who received a given service. Participants identified a list of nine possible needs: Education and training, housing, healthcare, income, job opportunity, disability pension, respect from family, respect from community, getting married. The present study measures exposure to CBR program services delivered to participants compared to a group of controls that received usual services offered by the State either directly or through the subcontracting to Non-Governmental Organizations (NGOs), in particular, the basic package of health services . We asseSeveral covariates were included in the calculation of the propensity score. We included study participants characteristics at baseline, including gender , age (continuous), disability type , cause of disability , ethnicity  education level , and level of wealth measured by a welfare index using polychoric principal component analysis based on a list of durable goods  owned by the household . We also included community-level variables such as availability of electricity (availability or not in the village), distance to the closest school (continuous), and to the closest healthcare facility (continuous). We did not include age and disability type in the calculation of the propensity score. The age range difference between participants and controls was very narrow. There was potential collinearity between cause and type of disability, therefore we used cause of disability for the calculation of the propensity score and for the adjustment of the model.t tests compare demographic and socioeconomic characteristics, and village characteristics and outcomes of interest (access to and satisfaction for CBR services) between CBR participants and non-participants.Descriptive statistics provide the distribution, and chi-squared tests and For obvious ethical reasons of NGO commitment to make the CBR program available to all persons with disabilities in its catchment area, we could not randomly select participants in the two arms of the study. In absence of meeting all the conditions for an experiment, and to reduce selection bias, we examined the change overtime on the outcomes of interest comparing CBR participants and non-participants using a difference in difference model after propensity score matching (PSM) . We usedWe estimated a propensity score for each individual representing their probability of receiving the mentioned five types of services, conditional on a set of observed covariates that are recognized to predict both treatment assignment and outcomes of interest (Models 1 to 5). Propensity score matching allows to reduce selection bias linked to the choice of a quasi-experimental study design by controlling for selection on observables that might influence the probability of being in the CBR program intervention or control group . SimilarIn both set of models (access to and satisfaction with services), we controlled in the analysis for personal characteristics that might have an effect on the impact of the programme  and because all those who are eligible within a catchment area are included in the programme we made the reasonable assumption that participant and control groups have similar characteristics overall ,65.ATE) and the average treatment effect on the treated (ATT) of the CBR program through its interventions can be estimated using the following formulas:E[Y0||D = 1] nor E[Y1||D = 0] can be observed, since we did not observe what would have happened to the controls had they received the program, or what would have happened to the treatments had they not received it. We estimated these two counterfactuals by matching each CRB participant with one or more controls that were similar in key characteristics. In mathematical terms, the average treatment effect (ATT) can be obtained by:To overcome the possible selection bias of non-random choice of participants and controls and the absence of independence between the effect variable and the treatment variable, we introduced an assumption of conditional independence. We assumed that we observed all the variables  we assumed the existence of common support, which implies that only CBR participants that have a probability of being treated also found in any of the controls were included in the analysis. Similarly, controls with an extremely low probability of being treated were not included either. This method has the advantage of not requiring any assumption on whether the program has homogeneous or heterogeneous effects on the model errors and by being non-parametric it can be combined with other methods in order to yield more precise impact measures .We combined PSM with the difference in difference (DD) approach in the case of access to services only when two points in time (bles (X) . We idenATT):We used a logistic regression of the likelihood to access the program based on baseline variables  of having unmet health needs and male while being a Pashto significantly increased the risk of having unmet educational and pension needs. Other minority ethnicities were more likely to have a remaining need to find a life partner than Pashto. Not surprisingly, unmet needs for income and pension increased with age, while educational and social (respect and marriage) needs were less likely to be unmet with aging. Conversely, people with intellectual and associated disabilities compared to persons with a physical disability as well as those disabled at birth compared to those disabled from a known cause such as war violence, a disease, or an accident, were more likely to lack family and community respect, a noticeable indication of the stigma associated to certain types and causes of disability. Uneducated people were also more at risk of unmet needs for respect. Finally, the poorest were more likely to have unmet needs in all domains. Our study offers several contributions to the literature on the impact of CBR programs in LMICs. First, we provide insights into the effectiveness of in the delivery of health and rehabilitation, employment support, access to school and advocacy, and community mobilization services of a CBR program in Afghanistan using a quasi-experiment approach. Our results revealed an overall significant impact of the CBR program on the access to physical therapy, assistive technology, employment, education and advocacy, and community mobilization, indicating that CBR programs can bring closer needed services to persons with disabilities in LMICs. Second, we established participants’ satisfaction with the program coverage by investigating the level of uncovered remaining needs—health, education, housing, employment, income, pension, family and community respect, and marriage—that belong to various components of the WHO CBR matrix . Third, The CBR program had a differential impact in terms of access to services. The highest positive effect was on the access to physical therapy services. After 3 years on average in the program, the estimated marginal effect is a considerable 105.8%. The large gap between treated and controls is the result of a long-standing offering of physical therapy services but also assistive technology devices, both at the origin of the CBR program in Afghanistan, a country where decades of conflict have generated a large number of people physically disabled by violence and in need of such services . These skismet), or black magic. The latter are designed by the use of a derogative term ‘mayub’ in Dari and Pashto, the two major languages in use [The improvement in access to services is not uniform across the sample of participants. In particular, the gap in the benefit of assistive technology between males and females is partially explained by the lower number of females who lost limbs or were injured due to the conflict. The program put an emphasis on intervening earlier in life and/or at the onset of disability to try and minimize the negative impact of the impairment explaining an early intervention for education. The program also aims at supporting those who are most stigmatized. This probably explains why people disabled due to the conflict were less likely to receive employment support compared to those disabled at birth. Literature has shown that in Afghanistan, persons who were disabled due to conflict are highly recognized in Afghan society and often benefit from socioeconomic advantages, in particular in terms of job opportunities. It is probably why the recipients of physical therapy and assistive technology are more likely to be found among the richest 20%. Conversely, persons who were disabled at birth or from an unknown cause, are stigmatized against and considered disabled as the consequence of a curse of God, spirits, jinn, fate  of program participants compared to the controls. We did not find such a gap in reducing unmet needs for disability pension. A possible explanation for the absence of a significant reduction in the need for a pension is the small amount of the existing disability pension scheme unlikely to cover basic capabilities, combined with the eligibility rules that favor persons wounded or killed at war (‘martyrs’), excluding de facto many persons with disabilities from its benefit. But the otherwise reduction in unmet needs is extremely important considering that a growing body of literature has demonstrated a higher level of deprivation of people with disabilities not only in terms of income and material wealth but also in terms of basic needs, compared to the rest of the population in LMICs ,82,83,84The impact of the CBR program on the level of respect from family and the community as well as access to marriage is an important finding with far-reaching consequences. First, building family and community respect has proven effective in reducing internalized stigma, low self-esteem , and menPashtunwali code that determines that men are the breadwinners while women should not participate in social and economic life and access public areas, including healthcare facilities, unless accompanied by a mahram, a male close relative, but instead fulfill a role of house wife and mother [There is notable variation in unmet needs according to people with disability characteristics. Poorer disabled people remained more likely to have unmet needs than wealthier disabled people. This finding is supported by the available evidence showing that the material deprivation of persons with disabilities is associated with the deprivation of other basic capabilities such as employment, healthcare, education, and social and political participation ,93,94 amd mother . It is od mother ,98. Liked mother .Our study presents some limitations. First, the quasi-experiment approach we had to adopt does not ensure random assignment to either the treatment or the control arm, presenting a risk of selection bias. Elderly people and people with associated disabilities were significantly less likely to participate in the program (53). Similarly, the program coverage area included villages that seemed less remote than the control villages when considering better electricity coverage and less distance to the closest school and healthcare facility. To reduce the risk of selection on non-observable variables, we included multiple control variables to calculate the propensity score. We also used a difference in difference model to increase the likelihood of unbiased estimates of the CBR program effect. Baseline information shows that CBR participants started worse off than their counterparts, reducing the chance that observed impacts were due to initial differences favoring CBR participants. Similarly, services sometimes started immediately, in particular for physical therapy, showing a high proportion of CBR participants already receiving services at baseline. Providing treatment and services came first, the study came second. Therefore, we observed a vast majority of people with mobility limitations who already started receiving physiotherapy from the program at the time of their first interview. There is also a risk of information bias as data collection was carried out by CBR workers for security reasons. This might have encouraged a social desirability bias as CBR workers might have been tempted to show a positive impact of their program. We conducted a close supervision of data collection, random re-interviews, and multiple consistency checks to reduce the risk of bias. This empirical study has shown that a CBR program could contribute to improve the livelihood of persons with disabilities, lessen the costs of living with a disability, promote their participation in family and community life, escape stigma and prejudice, and reduce the level of unmet needs by effectively ensuring access to various CBR services from among the five domains of the CBR matrix  in Afghanistan, a country characterized by over four decades of turmoil. A key message arising from this study is that CBR programs can effectively improve the social and economic life of persons with disabilities and their families, even in a crisis context. Consequently, CBR programs can also improve the mental wellbeing of persons with disabilities by reducing the impact of the multiple daily stressors they endure ,99. Thes


One of the most significant issues in the success of language students is communication skills. Due to the high importance of the willingness to communicate in foreign language learning, many researchers are looking for effective factors in raising the level of communication among language learners. Reviewing the literature, the researchers explored the role of language learners’ gender, major, age, and proficiency level in their willingness to communicate. To gather the necessary data, the researcher administered a willingness to communicate questionnaire among 860 Chinese english as a foreign language (EFL) students. The results of data analyses demonstrated that gender, major, and age played a significant role in determining language learners’ willingness to communicate. However, the findings showed that learners’ willingness to communicate could be different in all proficiency levels. The results showed that taking into account factors such as students’ gender, background, and age directly helps to improve the willingness to communicate among language learners. Finally, solutions to improve the willingness to communicate are provided. Human beings are social creators that making regular connections between members of society is one of the obvious needs. When people communicate, they do not take expressions out of their mouths for any specific purposes, but aim to communicate with and address others . We are The most important way to achieve positive results is to satisfy our needs and fulfill our desires in communication . Today’sStudents’ communication, whether in the school or outside the school environments, is not outside this framework, meaning that students’ interactions, verbal or non-verbal communication, affects their performance . CommuniOne of the important factors in learning a second or foreign language is learning motivation. The stronger the motivation to learn, the more diligent learners go through the grueling path of language learning and enjoy learning . In receWillingness to Communicate (WTC) is one of the important motivational variables that emphasizes the need to communicate through talking . It helpThe ability to communicate effectively is one of the most important fundamentals in the language teaching development . This abIn foreign language conversation classes, the goal is to persuade language learners to speak in public and participate in classroom activities, to develop language skills and to increase their desire to communicate.In this research, Bandura’s social learning theory has been used as a theoretical framework and central theory. Social learning theory is another interpretation of behaviorism . In thisTo avoid the dangers of trial and error, these behaviors are learned by observing, reading storybooks, or even listening to instructions. He calls this type of learning substitution learning in which the learner symbolically puts himself in the place of the model and at the same time learns his experience . Like SkThe first dimension, that is, language abilities are strengthened over time and according to the students’ reading rate . In thisIn today’s vast world, the desire to communicate is the major objective of language learning. The notion of WTC was first introduced in 1976 by In addition, many linguistic theories and hypotheses, such as the Interaction Hypothesis, the Socio-cultural Hypothesis, and the Output Hypothesis emphasize the need for interaction and communication in second language learning . The tenSince the introduction of this model, researchers have tried to examine the relationship between the desire to communicate with other environmental and psychological factors, to help teachers to increase or decrease the level of such variables, increase the level of desire to communicate among their learners , and ultOther factors, such as having a high level of emotional intelligence, which has a positive effect on the motivation for progress, reduce the anxiety of the language class . The scoMany studies explored WTC from different aspects: In another study, To solve the above-mentioned problem, the present study was conducted to investigate Chinese EFL learners’ WTC and answer the raised questions:RQ1: Are there any statistically significant differences in Chinese EFL learners’ WTC in terms of their gender?RQ2: Are there any statistically significant differences in Chinese EFL learners’ WTC in terms of their major?RQ3: Are there any statistically significant differences in Chinese EFL learners’ WTC in terms of their age?RQ4: Are there any statistically significant differences in Chinese EFL learners’ WTC in terms of their English level?A sample of 860 Chinese EFL students  was collected with a convenience sampling strategy in China from different universities and colleges across 10 provinces, one Autonomous Region, and two municipalities. The sample comprises 230 males (26.7%) and 630 females (73.3%), with their ages ranging from 16 to 22, 483 (56.2%) of them majoring in liberal arts and 377 (43.8%) in sciences. The EFL learning level of our participants ranges from undergraduates to postgraduates; the English level of the participants were based on the universities’ placement tests. Informed consent was given to all participants. The detailed demographic information is presented in The WTC questionnaire by The questionnaire containing 27 questions was designed by RQ1: Are there any statistically significant differences in Chinese EFL learners’ WTC in terms of their gender?T-Test. The results of this analysis are presented in To answer the first research question, the researcher ran an independent-samples The results of t-test to compare the WTC scores for males and females language learners. There were significant differences in scores for male learners and females t(361.846) = –2.979, p = 0.003, two-tailed. The extent of the differences in the mean scores were very small (eta squared = 0.01).The researcher conducted an independent-samples RQ2: Are there any statistically significant differences in EFL Chinese learners’ WTC in terms of their major?To answer the second research of the study, and the differences between two groups, the researcher conducted an independent-samples T-Test. The results of this analysis are presented in The results of t(858) = 3.164, p = 0.002, two-tailed. The amount of these differences in the means scores was very small (eta squared = 0.01).The researcher conducted an independent-samples t-test to compare the WTC scores for Liberal arts and Sciences learners. There were significant differences in the questionnaire scores for Liberal arts learners and Sciences RQ3: Are there any statistically significant differences in EFL Chinese learners’ WTC in terms of their age?To answer the third research question and find the differences among three groups, the researcher conducted ANOVA. The results of these analyses are presented in The results of p < 0.05 level in questionnaire scores for the three groups: F = 7.893, p = 0.000. Despite the statistical difference, the actual difference in mean scores between the groups was quite small. The effect size of the study calculated using eta squared was 0.01.The researcher conducted a one-way between-groups analysis of variance to discover the impact of age on WTC as measured by the WTC questionnaire. Participants were divided into three groups according to their age . There were statistically significant differences at the Post-hoc comparisons employing Scheffe test designated that the questionnaire mean score for 19–21  were significantly different from 22–24 .RQ4: Are there any statistically significant differences in EFL Chinese learners’ WTC in terms of their English level?To answer the fourth research question and find the differences among the three groups, the researcher conducted ANOVA. The results of these analyses are presented in The numbers of p < 0.05 level in questionnaire scores for the three groups: F = 2.278, p = 0.103.The researcher conducted a one-way between-groups analysis of variance was to discover the impact of learners’ proficiency level on WTC as measured by the WTC questionnaire. Participants were divided into three groups according to their English level . There was no statistically significant difference at the Numerous factors affect the way language learners perform and their WTC. The present study, considering the importance of this issue, sought to solve the problems of students in this field to some extent by examining factors such as gender, age, and proficiency level. The particular results of this study discovered that there were statistically significant differences between male and female language learners. The results showed that female language learners are more eager to participate in communication activities in language classrooms. The results were in consistent with what The results of this study also demonstrated that language learners’ background knowledge take parts in a key role in their WTC. The results showed that there was a significant difference between learners with different majors and language backgrounds. One of the important issues in the sociology of education is the discussion of academic success and educational experiences based on excellence, knowledge reserves and learning experiences according to the economic and cultural situation of families and students. Similar to The present study also investigated the impact of age on language learners’ WTC. The results discovered that there was a significant difference among the three groups with different age range. The results showed that those who were under 21 had a better performance than those that were under 18. Teachers always pay attention to this issue and try to recognize and differentiate the learners’ age in the classroom and to design and present the lesson in such a way that all students, despite their different abilities, achieve the maximum possible progress . AccordiLanguage proficiency and its relation with WTC was another factor that was investigated in the current study. The results demonstrated that there were no statistically significant differences among language learners with different proficiency levels. These findings demonstrated that language learners could have difficulty in communication in every proficiency level. These findings confirmed what Effective communication is one of the main pillars of social life. For many of us, communicating effectively requires learning some important skills. Learning these skills can deepen your relationship with others. This relationship also builds more trust and respect. Improve group work, problem-solving, and improve your overall social and emotional health. The present study investigated Chinese language learners’ WTC in terms of their gender, age, major, and proficiency level. The findings of the study demonstrated that the three factors play a crucial and considerable function in determining language learners’ WTC. However, the study found that learners in different proficiency levels have various levels of the tendency to communicate. In other words, WTC could be a problem for teachers at every language level.Language learners, foreign language teachers, and anyone involved in teaching or learning a foreign language can benefit from the findings of the present study to some extent. Learners need to be fully aware of the major role they play in their tortuous language-learning path. They need to know that by using the power of emotions and feelings, having passion and motivation, being actively involved, and taking full responsibility for their own learning; almost nothing will stop them from achieving their goals. Foreign language teachers should consider the factors that motivate and motivate learners and do not use traditional methods as in the past. They should also consider personal and environmental factors in their training. They can take into account the age and gender differences of students and by using activities and exercises that improve and enhance the level of emotional intelligence, independent functioning, self-centeredness, and having enthusiastic participation in discussions and conversations. These exercises subsequently lead to an increase in the level of students’ WTC. For example, give more freedom of action to learners and less control over them, providing them with opportunities and situations in which people feel safe and secure and lead to more speech and interaction. Awareness of the importance of emotions and feelings in the success and advancement of goals, or by skillfully and unconsciously using strategies to learn activities that lead to increased emotional intelligence, freedom in decision-making, and self-confidence. Curriculum designers in the field of language learning as creators of the learning environment should pay special attention to psychological factors and individual differences, especially emotional intelligence, learner independence, self-regulation and WTC. Individual differences are vital factors in teaching and learning a foreign language, and many researchers and scholars have paid special attention to these factors in learning and teaching English as a foreign language.Given the limitations as well as the lack of studies in this field, we make suggestions for future research. The same research can be done to evaluate the effect of emotional intelligence, self-regulation, and other skills such as listening, speaking, and writing skills. The learners’ proficiency level was indicated in the form of self-reported data, future studies can use more reliable procedure to check learners’ proficiency. Many individual differences such as self-esteem, self-efficacy beliefs, creativity, and critical thinking have not yet been studied in this area. In future studies, the relationship and effect of other motivational variables such as interest and the effect of different tasks and educational methods such as using the reverse educational method on motivation and WTC can be examined. In addition, qualitative methods such as observation and interviews, or longitudinal research can provide more comprehensible results.The original contributions presented in the study are included in the article/supplementary material, further inquiries can be directed to the corresponding author.The studies involving human participants were reviewed and approved by Ethics Committee of Anhui University of Chinese Medicine. The patients/participants provided their written informed consent to participate in this study.Both authors listed have made a substantial, direct, and intellectual contribution to the work, and approved it for publication.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.


Today, in response to consumer demand and market trends, the development of new packaging with better performance such as intelligent packaging has become more important. This packaging system is able to perform intelligent functions to increase shelf life, increase safety and improve product quality.Recently, various types of packaging systems are available for meat products, especially cooked, fresh and processed meats. But because meat products are very perishable, monitoring their quality and safety in the supply chain is very important. This systematic article briefly reviews some of the recent data about the application of intelligent packaging in meat products.The search was conducted in Google Scholar, Science Direct, Elsevier, Springer, Scopus, and PubMed, from April 1996 to April 2021 using a different combination of the following keyword: intelligent packaging, and meat.The results showed that the intelligent packaging presents several benefits compared to traditional packaging  at the industrial processing level. Thus, these systems have been applied to improve the shelf life and textural properties of meat and meat products.It is necessary to control the number of intelligent compounds that are included in the packaging as they clearly influence the quality and nutritional properties as well as the final cost of the food products. Today, in response to consumer demand and market trends, the development of new packaging with better performance such as intelligent packaging has become more important. In this review showed that the intelligent packaging presents several benefits compared to traditional packaging  at the industrial processing level. TTIs are usually small self‐adhesive labels that are affixed to shipping containers or single packages. These labels have visual indications of the temperature background during distribution and storage, which are especially useful for warning of unsuitable temperatures for refrigerated or frozen food products. These detectors are also used to estimate the remaining shelf life of perishable products. All of the commercially available TTIs have the potential to be used in meat products  and fat content. Spoilage of meat products can lead to quality loss such as colour change, off‐flavour, loss of crispness, and change in pH, which ultimately causes in consumer rejection and economic losses . The search equation used in Scopus and PubMed was: ‘intelligent’ AND, meat.2.2Articles were organised by the application of intelligent packaging in meat products. Three members of the team  extracted information about the characteristics of the articles. The information extracted from the articles included intelligent packaging applications in meat products such as red meat, poultry, chicken, fish and processed meat. After that, the quality evaluation and selection were performed by three authors  who independently worked according to the main criteria of PICO  Table .2.3The inclusion criteria for handling of studies were outlined according to PRISMA guidelines and used were the following: 1) intelligent packaging in meat products; (2) nanoparticles (NPs) in meat products and (3) studies with significant results collected via statistical analysis. The exclusion criteria used were as follows: (1) studies written in the English language; (2) the use of intelligent packaging, instead of intelligent; (3) studies without controls; and (4) the assessment of the efficiency of modern packaging in meat products. After removing duplicates, the title and abstract of each article were reviewed by one member of the team (H.E). After that, acceptability for inclusion was analysed based on the following: (1) reading the title and abstract by three authors ; and (2) reading the full text by three authors   detectors and radio frequency detection (RFID) systems] can be used in intelligent packaging  estimated lipid oxidation in cooked chicken and raw and cooked beef employing O2 sensors and showed that these sensors are suitable for the measurement of O2 in meat packages and predicting the quality of processed meats.Pundir et al.  developeIn recent years, several studies have been focused on the development of rapid methods to monitor microbial breakdown and real‐time freshness of fish and seafood products, using intelligent packaging. During spoilage, fish releases a variety of basic volatile metabolites, which are detected with sensors. Silva‐Pereira et al.  reportedSimilarly, several studies have been focused on the colourimetric indicators used in chicken. For example, Chen et al.  developeSome studies for monitoring pork and buffalo meat freshness were published (Choi et al., A much simpler sensor was developed by Pablos et al.  to detecSimilar findings have been reported in the literature in regards to monitoring raw and processed meat (Kerry et al., So far, various nanoparticles have been used in the intelligent packaging of meat and meat products. Many studies have been done on the antimicrobial effect of gold and silver nanoparticles on various microorganisms. Silver nanoparticles also reduced the microbial load of beef packaged under the modified atmosphere. Morsy et al.  reportedContinuous research seems to be needed to access the benefits and capabilities of intelligent packaging for meat and meat products. The scope of this research may be more appropriate in cases such as modelling of interactions between foods and microorganisms and their metabolites in different storage conditions, the relationship between the detection of spoilage and the sensory quality of food, suitable sensors and detectors, the behaviours and characteristics of tools used for intelligent packaging in different parts of the production, warehousing and distribution chain, as well as a more complete understanding of the sensitivities and reliability of intelligent packaging and their tools (Ahmed et al., The potential benefits of intelligent packaging for meat and muscle products are varied. Paying attention to the positive effects of this type of packaging on the quality, safety and health of food in different stages, we must also pay attention to its economic and marketing aspects (Panea et al., The increasing consumer information and awareness of consumers and their demands are among the factors that force manufacturers and researchers to innovate, develop and optimise modern packaging technologies (Ahmed et al., 5Food manufacturers should educate about food safety of intelligent packaging. Current regulations require that migration rate below from packaging materials to food. The acceptability of intelligent packaging techniques is considered from the point of view of migration. These techniques can be divided into two groups: Group 1, consists of external indicators fixed on the outer surface of a package, such as time‐temperature indicators and Group 2, consists of internal indicators intended to be placed in the main part of a package, such as oxygen and carbon dioxide indicators. The migration does not occur in group 1 indicators because there is no direct contact of the indicator with the food product. Group 2 indicators are not intended for direct contact with packaged foods. However, they are placed in the free space of a package or fixed on the inner surface (Han et al., It seems that extensive research is needed to access the advantages and capabilities of intelligent packaging. The fields of this research can be more appropriate in the modelling of the interactions between foods and microorganisms and their metabolites in different storage conditions, a better understanding of the relationships between spoilage detection and the sensory quality of food, finding suitable sensors and indicators, increasing information about the characteristics of the used tools for intelligent packaging, storage and distribution chain, understanding of the sensitivities and confidence levels related to intelligent packaging. The potential advantages of intelligent packaging are many and varied. Of course, in addition to the positive effects of intelligent packaging on the quality, safety and health of food should also be paid attention to its economic and marketing aspects. The awareness of consumers is force manufacturers and researchers to innovate and develop and optimise modern packaging technologies. Various forms of intelligent packaging, such as oxygen sensors, freshness and spoilage indicators and time‐temperature detectors, are answers that researchers and scientists have devised to meet the aforementioned demands. If the necessary coordination between efficiency and usefulness is established with the economic aspects of the use of intelligent packaging, it will be inevitable to use these technologies in the future.6In this article, the results of some research and articles related to new technologies and their applications for the packaging of meat and meat products are presented. Monitoring the quality and spoilage of fresh meat products is essential in order to reduce the incidence of foodborne illness and reduce the production of meat waste throughout the supply chain. However, traditional packaging systems are able to provide few services in the field of supply chain monitoring. But new intelligent packaging systems with the aim of monitoring the quality of packaged meat or its environment are advancing towards providing innovative solutions in the industry of production and supply of meat products. So, a variety of commercial freshness, temperature‐time, integrity and radio frequency detectors with intelligent concepts, in order to improve storage conditions and reduce waste of fresh and safer meat products, have been introduced to the food market. However, each of these methods has advantages and disadvantages, which affect the performance and efficiency of the system. Therefore, it is necessary to control the number of intelligent compounds that are included in the packaging as they clearly influence the quality and nutritional properties as well as the final cost of the food products.H. Eghbaljoo, S.M. Khodaei and Z. Esfandiari contribute in supervision, investigation, validation and methodology. I. Karimi assists in search and investigation. H. Eghbaljoo, Z. Esfandiari and M. Gholami‐Ahangaran contribute in methodology, analysis of data and writing the original draft manuscript and reviews.The authors declare no conflicts of interest.The authors did not receive any supportive finances.In this manuscript, all the ethical principles related to writing a review article, including maintaining trustworthiness and avoiding plagiarism, have been observed.https://publons.com/publon/10.1002/vms3.1017.The peer review history for this article is available at


Metabolic diseases are a global rising health burden, mainly due to the deleterious interaction of current lifestyles with the underlying biology of these diseases. Daily habits and behaviors, such as diet, sleep, and physical exercise impact the whole-body circadian system through the synchronization of the peripheral body clocks that contribute to metabolic homeostasis. The disruption of this system may promote the development of metabolic diseases, including obesity and diabetes, emphasizing the importance of assessing and monitoring variables that affect circadian rhythms. Advances in technology are generating innovative resources and tools for health care management and patient monitoring, particularly important for chronic conditions. The use of mobile health technologies, known as mHealth, is increasing and these approaches are contributing to aiding both patients and healthcare professionals in disease management and education. The mHealth solutions allow continuous monitoring of patients, sharing relevant information and data with physicians and other healthcare professionals and accessing education resources to support informed decisions. Thus, if properly used, these tools empower patients and help them to adopt healthier lifestyles. This article aims to give an overview of the influence of circadian rhythms disruption and lifestyle habits in the progression of metabolic diseases while also reviewing some of the mobile applications available to monitor lifestyle behaviors and individual chronobiology. Herein is also described the design and development of the NutriClock system, an mHealth solution developed by our team to monitor these variables. The prevalence of metabolic diseases, particularly obesity and type 2 diabetes mellitus (T2DM), continues to rise globally. Obesity has grown to epidemic proportions, with over 4 million annual deaths attributed to overweight in 2017 , heightened an additional need for valid and reliable technology in health care. This includes the development and improvement of digital platforms dedicated to assisting professionals in providing health care to patients whenever face-to-face interactions are not viable . The proSeveral mHealth apps have been developed to assist patients in managing chronic diseases, such as metabolic diseases. Through education, diet, activity tracking, and personalized health advice, these apps have the potential to guide behavior change. Dietary changes combined with healthy lifestyle adjustments should be the first approach since they have been identified as one of the most effective interventions for preventing, managing, and reversing chronic conditions. mHealth apps designed to support these actions may have a central role in health promotion and care .The relevance of circadian rhythms in the regulation of energy metabolism, as well as the role of circadian disruption in poor health outcomes, is well-documented in the literature, both in clinical and non-clinical experimental settings . These rThe present article aims to provide an overview of the current clinical evidence regarding the impact of circadian rhythms on the development of metabolic diseases and summarize the mobile applications available to monitor lifestyle behaviors and individual chronobiology, highlighting the innovative aspects brought by the NutriClock mHealth solution.Metabolic homeostasis is a critical component that regulates energy metabolism. In recent years, several studies enlightened the relationship between human physiology, the circadian rhythm and a cluster of metabolic diseases, including T2DM and obesity , 9.The circadian rhythm, also known as the biological clock, refers to the physiological, molecular and behavioral changes that occur during a cycle of approximately 24 h. In humans, these rhythms are synchronized by a hierarchical system: the central clock in the suprachiasmatic nucleus (SCN) of the hypothalamus and the peripheral clocks, located in several organs and tissues throughout the body . While tDaily eating patterns are affected by several factors, including, hunger and satiety, social habits and food availability. Nonetheless, when eating occurs at a consistent and expected schedule, the circadian clock system initiates nutrient-sensing pathways to uphold nutrient homeostasis . When eaThese findings highlight the importance of measuring variables related to circadian behavior, such as eating schedules, physical activity and circadian biomarkers, to potentiate the effects of current nutritional and medical approaches in the management and prevention of chronic metabolic diseases.my Circadian Clock (mCC) application was developed as part of a chrononutrition-related study to assess the influence that the timing of caloric intake has on metabolic homeostasis and subsequent prognosis of pathology. The 156 participants were asked to record all the meals they ingested. They received app notifications once or twice a day, at random times, to check if they had eaten in the last 30 min and forgotten to record the event. The false-negative rate was estimated to be 10.34%. The results showed that more than half of the participants had an erratic eating pattern. According to the data inserted in the mCC application, the participants spent most of the day consuming calories, with only a brief period of fasting. Furthermore, a higher caloric intake was observed in the afternoon and evening, which could have several consequences, including a negative impact on sleep quality  mHealth platform is a deliverable of the NutriClock study, whose primary goal is to serve as a data collection, monitoring, and analysis support tool. The NutriClock app collects data related to lifestyle behaviors including sleep, physical activity, dietary patterns, and circadian rhythm biomarkers. The multidisciplinary team behind the design and development of this platform included computer engineers, nutritionists, physiologists, and psychologists.The platform was built using agile methodologies, which enable iterative, incremental, and adaptable system implementation in response to changing requirements, as well as continuous feedback on potential improvements.http://nutriclock.herokuapp.com/api/documentation, and are protected by authentication mechanisms. Furthermore, middlewares are used to parse and filter client requests to increase security. To store images, send emails, and manage user notifications, the backend communicates with external services.The backend module is a REST API that writes and reads data from the database to provide the information requested by client applications. The available resources are documented at The backoffice is a single-page web application designed to provide a platform for administrators, healthcare professionals, and researchers to manage and analyse data from participants. To protect and limit access to participants' data, each user role has different management and access permissions. As an example, healthcare professionals can only access the data of the participants registered in their healthcare institution.The following are some of the main features available in the backoffice:1 Authentication and user profile management;2 Management of the participants' data , including:3 Create and manage personalized meal plans by a registered nutritionist/dietitian;4 Monitor and analyse the data from the sleep, food, and physical activity diaries;5 Manage the list of participants ;6 Communicate with the participants via chat . This can be a motivational feature for the participants;7 Select the participant to the control or experimental arm of the study ;8 Check if the participant has entered the information necessary for the study through a color system . The system will automatically send reminders if there is information missing;9 Create, update, or delete information, including the professional categories, institutions, pathologies, food database, physical activity database, biomarkers, and terms of acceptance (available for the administrators only). These features were included to help the administrators manage the information available in the app and will be used strictly following the Good Clinical Practice.10 View the NutriClock mobile app ratings (available for the administrators only).The mobile application provides an interface for participants to enter the data and communicate with healthcare professionals via NutriClock's chat. Besides, the application will notify them when data is missing in their meal, sleep, or physical activity diaries, and when saliva and urine samples should be collected. The following are some of the features available:1 Create a new account and authentication related functionalities;2 Sleep diary to assess quantity and quality of sleep;3 Physical activity diary ;4 Food diary ;5 Chat where the participant can message the healthcare professional;6 Access to contacts, meal plans, reports and biomarker information ;7 Manage the notifications settings (turn on/off);8 Option to delete the account and data according to the right to be forgotten;9 Rating of the NutriClock application using a 5-points Likert scale.The design and development of mobile applications with an easy-to-use interface is a crucial step for their successful adoption in long term . UsabiliTesting the usability of mobile applications is constrained by several factors, including small screen size and limited technological performance compared to other devices. Apps' ease of use and acceptance is linked with users' perception of time consumed when performing tasks, easy-to-learn functions, and user-friendly features , charactIn the case of the backoffice application, the development process focused mainly on functionality. However, usability tests conducted on this web application are also important to identify usability related issues that were improved, for example, providing feedback regarding actions taken by users , 30.The NutriClock system was tested using manual, automated, and usability tests. Manual tests were primarily used to validate features and identify changes and improvements to be made to meet the platform requirements. Automated tests helped in the discovery of bugs that were missed during manual testing. Usability tests were useful to improve the user interface and to solve usability problems identified by test users, for example, knowing how to access some sections of the mobile application.To participate in the usability tests, people had to be over 18 years old, provide their informed consent and not have any prior contact with the NutriClock system . No exclusion criteria were applied.To conduct the usability tests, the researchers created three scripts which included two scripts to test the mobile application with a patient account covering different sets of features of the NutriClock app (seven tasks in each script) and one script with 6 tasks to test the backoffice using administrator and healthcare professional accounts. The three scripts with the complete tasks are detailed in the p-value < 0.05.Statistical analysis was performed using SPSS 27.0 to assess the differences in execution time between participants with equal or <30 years (subgroup A) and participants with more than 30 years (subgroup B) for the seven tasks of test no. 1, 7 tasks of test no. 2 and 6 tasks of test no. 3. The age cut-off point for the subgroups was selected according to the distribution of age ranges of the total sample. Statistical significance was set at Following the Zhang and Adipat  methodolScript no.1 for the NutriClock app, was conducted on 11 people and took, on average, 6 min per participant to complete the seven tasks. Participants took longer to complete tasks 1 and 3 , which wA = 6, nB = 5, p = 0.045 two-tailed). Although execution time might be an indicator of the difficulties the participants experienced, in this task, participants could take longer because they had to add more information. For example, a participant who answered that they woke up during the night had to fill in more information than a participant who answered no to this first question.In this test, there was only a statistical difference in median execution time for task 2 (add an entry in the sleep diary) for subgroups A (38 s) and B (80 s)  . This waA = 6, nB = 6, p = 0.037 two-tailed). This difference was due to a participant from subgroup B that took 120 s to complete this task, while all the other participants took <55 s. There were also significant differences in median execution times for task 5 (consult notifications settings): subgroup A = 6 s and subgroup B = 22.5 s . In this task, the participants that took more than 15 s to complete it were from subgroup B which may explain the difference found in the median execution times. The last statically significant difference was found on median execution times for task 7 (logout application): subgroup A = 2.5 s and subgroup B = 6 s . All of the participants took <10 s to complete this task, except one participant in subgroup B that took 30 s.A statistically significant difference was found in the median execution times for task 2 (edit information entered in the food diary): subgroup A = 24 s and subgroup B = 48 s  was the one that participants had more difficulty completing. This was the one with a longer execution time , a lowerIn general, the expected path for executing a task was followed, on average, by 87 and 18% of participants needed assistance.No significant differences were found in the execution time between subgroups A and B.Some limitations were identified that should be considered in future studies, the main one being the small sample size. Also, the usability testing in this controlled setting may not represent how the end-user will interact with the mobile application in their daily routines. The participants were not all representative of the real end-users (patients with metabolic diseases) and the age range of the participants included should have been broader to represent all the potential end-users of the NutriClock application. This will be taken into consideration in the next phase of usability tests as well as in the tests to evaluate the perceived quality of the system. In future work, and after improving the issues identified, the app usability will be re-tested based on a validated model and in real-end users. Also, future tests will be performed in the field to assess how people use the app in a real and not controlled environment.The potential of mHealth applications to improve access to healthcare resources and real-time monitoring is already recognized –33. MediHowever, these solutions may also present some issues, particularly concerning data privacy and the protection of sensitive information shared by patients . AnotherTo circumvent some of these challenges, when designing a mobile application to address behavior change, it is important to have a comprehensive concept, essential to achieve an ongoing impact , 43. McCIn the future, evidence-based mHealth solutions may be integrated into traditional clinical treatment approaches to improve health results and access to primary care prevention. This could be particularly important in the context of chronic diseases, such as metabolic diseases since they frequently need to be managed from their onset with few options for a full recovery and these solutions could help patients achieve better results , 46. PatThis perspective is aligned with the future of the NutriClock app and backoffice, as it is expected that this system can be implemented in clinical settings to help healthcare professionals monitor lifestyle behaviors and individual circadian rhythms and empower patients by giving them an active role in their healthcare monitoring and management process. Besides, this system will also help researchers in the field design clinical studies on chrononutrition and chronobiology, with larger samples since participants can be monitored remotely.The evidence arising from the use of mHealth solutions appears promising. However, the current published evidence of improvements in patients' health outcomes using these tools is still restricted to a limited number of clinical situations . More reThe results of chrononutrition studies are encouraging but more clinical studies with larger samples and longer periods of intervention are necessary before translating the current knowledge to clinical practice. So tools that support these interventions and studies, such as the NutriClock system, are relevant. Currently, there are still improvements to implement in the NutriClock system, including adding reference pictures for the portions, according to the meal or food item entered by the user in the food diary. Another feature that could be important to add would be a time setter and reminders to show the optimum eating window according to the individual chronotype to attempt to control erratic eating patterns. To circumvent the shortcomings of the currently available mHealth applications, especially, the lower engagement of patients, we added the chat function to have a fast direct contact point with the healthcare professionals. Motivational strategies to integrate into the NutriClock app, to lower the dropout rates and increase patients' engagement with this technology, are also being studied. The next steps will include a usability test to assess these new features, followed by a feasibility and acceptability study before starting the clinical validation of the NutriClock system.Lifestyle interventions to treat and prevent chronic metabolic diseases need to consider the daily circadian rhythms since aligning those behaviors with the individual biological rhythm potentiates the health benefits. The use of mHealth is increasing and these solutions represent an interesting opportunity to monitor and measure health variables and lifestyle habits in normal living conditions, helping patients and healthcare professionals in disease management. The NutriClock mHealth system collects data related to lifestyle behaviors and will serve as a basis to elaborate meal plans tailored to the individual circadian characteristics, making this an innovative and differentiating solution. In the future, it is expected that this platform becomes a clinically validated therapeutic tool used to integrate individual biological rhythms in the treatment and prevention of metabolic diseases supporting interventions directed to lifestyle changes.The raw data supporting the conclusions of this article will be made available by the authors, without undue reservation.Ethical review and approval was not required for the study on human participants in accordance with the local legislation and institutional requirements. The patients/participants provided their written informed consent to participate in this study.ML, MG, and RB led the design of the study with the contributions of IR and CG. ML and IR drafted the manuscript, with the contributions of MG and CG. All authors contributed to the manuscript, revised it critically for intellectual content and approved the final manuscript submitted.This work was supported by Portuguese National Funds provided by Fundação para a Ciência e Tecnologia (UIDB/05704/2020 and UIDP/05704/2020). ML was supported by a PhD Scholarship from Fundação para a Ciência e Tecnologia (2021.07673.BD).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. The reviewer RC declared a shared affiliation with the author RB to the handling editor at the time of review.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.


Triclosan (TCS) is a widely used chemical whose effects on human health remains elusive. TCS may play a role in a variety of health issues, including endocrine dysfunction, irregular embryonic development, and immune suppression. It is possible that TCS’s penetrative abilities across all body barriers, including the blood–brain barrier, may make bioaccumulation the primary driver of these issues. In addition, chronic overuse of this chemical in everyday life may further contribute to the already increasing problem of antibiotic resistance. TCS research has steadily increased since its transition from medical to commercial use over the last 50 years. However, there are some clear gaps in the depth of this research as the safety of this agent is not fully agreed upon. The Food and Drug Administration recently issued regulatory rules regarding TCS in some commercial products; however, it is still found in a variety of goods marketed as “antimicrobial” or “antibacterial”. The purpose of this bibliometric study is to analyze research trends in this field and determine the amount of global attention TCS has received as to its relevancy in human health. Documenting and determining research concentration trends related to this field may outline where additional research is most necessary, as well as demonstrate the most valuable research produced and its relation to the advancement of our understanding of TCS. We found there to be a shift in research from TCS and its role in medical environments, to research based on the indirect effects of TCS through environmental contaminations, such as the propagation of antibiotic resistance. This shift was coupled with an increase in global research related to this field and identified China as a significant contributor. Although TCS has received notice, the simple fact of its continued use in so many common products, as well as the unclear understanding of its direct health impacts, reinforces the need for additional and more conclusive research before it has possible irreversible effects on our environment and health. Triclosan (TCS), or 5-chloro-2- phenol, is an antimicrobial agent, registered pesticide, and known toxicant, which is a frequent and common ingredient in household products, such as deodorant, liquid soaps, cosmetics, and furniture . TCS wasTCS targets the phospholipid membrane through its detergent-like property that affects the stability of lipid structures . Some baResearch on the effectiveness of TCS remains inconclusive. TCS has been reported to be especially useful in the prevention of the spread of disease in healthcare settings, effectively performing as an antimicrobial agent. Most notably, the use of TCS-coated sutures proves especially efficient in the prevention of surgical site infections post closure, when used in decontaminated surgical environments . HoweverAntibiotic and antimicrobial overuse seeps into every form of our daily life and continually puts us at higher risk of bacteria that we do not have the ability to fight when resistance emerges . AlthougTCS was also detected in neonatal cord blood. A study in New York City showed that 100% of urine samples from 181 expectant mothers and 51% of cord blood samples from their infants contained TCS ,20. PeriIn the 2016 ruling on the safety of TCS, the FDA determined that although TCS has been shown to cause significant endocrine disruption in rat models, because of the physiological differences between humans and rats, TCS should pose no risk to human health . They thAltogether, TCS is a potential risk to human health in development, neuropsychology, immunity, the emergence of AR, and others; however, it remains prevalent throughout our everyday use of common commercial products. The status and trends of research on the effect of TCS on human health have not been systematically analyzed in recent years. Therefore, the purpose of this bibliometric study is to analyze research trends in this field and determine the amount of global attention it has received regarding its effects, thus identifying a potential gap in global research trends for the suggestion of future research endeavors.®, which broadly encompasses research from multiple scientific fields. A search of the data was performed on 8 November 2021. All data were imported into Microsoft Excel and VOSviewer for analysis [The workflow demonstrates the data collection process used in this analysis . All datanalysis . The sea® Excel. This includes growth trends, citations per year, main researchers, and most prominent journals that published TCS research. Further visual analysis was then carried out in VOSviewer 1.6.17. VOSviewer is a software tool for constructing visuals related to bibliographic information [This study involves the analysis of research related to the TCS and its effect on human health in a broad range of concentrations. TCS dates back to its original patent in 1966 filed by the company Ciba-Geigy and was then introduced into medical settings in 1973 [ormation . This inA total of 3278 documents that fit the search criteria were analyzed. Research growth was analyzed between the dates of 1 January 1973, and 11 February 2021. Although TCS was patented in 1966 for use in medical procedures and environments, research related to TCS on human health did not emerge until 1973 . In addiAnalyzing the subject and concentration of TCS-related research in three main phases can outline a more detailed research trend and make clear what areas may need more focus . These pA total of 3278 publications related to TCS and health led to a total of 123,534 citations . The treScience of the Total Environment and Chemosphere lead in publication number by almost two-fold in comparison to other journals of this type  was eliminated from hand soaps in 2016 by the FDA but remains in a variety of everyday items, yet the effect on human health remain elusive. So, we have attempted to identify the research trends of TCS to determine whether research resources have been adequately spent to resolve the issue of uncertainty. TCS research has substantially increased over the last 50 years, but we determined that there are definitive gaps that remain in certain areas of focus. Although a large number of publications and citations have been produced, the vast majority are in relation only to the environmental impacts of TCS or its use in specific products, such as dentifrices and surgical devices. We found a significant lack of research in relation directly to TCS and human health in comparison with that related to its environmental impact. This, in conjunction with the FDA’s acknowledgment of a lack of definitive understanding of the role TCS could play in dermal carcinogenicity, endocrine dysfunction, and antibiotic resistance, proves the need for additional research in these fields. Since the current study is based on bibliometric analysis, it is focused on identifying overall trends, so we plan to provide a fuller picture of the collective understanding of TCS research in review paper format.


There is a close relationship between food and nutrition policies and oral health. The relationship between nutrition and dental problems has been widely discussed, including the major dental problem in children: early childhood caries (ECC). Health-oriented national policies are the main principles of public health welfare. This article is a policy brief that provide a review of the food and nutrition policies in Indonesia that may have a relationship with ECC. It is concluded that some policies support the efforts to prevent ECC however, other technical explanations are still needed for health workers and especially parents regarding its simple implementation in everyday life. Multisectoral approaches that includes health, nutrition and education are needed to address ECC. Early childhood caries (ECC) is the most common chronic infectious disease in children aged <71 months. The World Health Organization (WHO) has represented the ECC as a global problem since the prevalence is increasing rapidly in low and middle-income countries and particularly frequent or severe among children living in deprived communities . There wEvidence suggests that food and nutrition which play a role in the growth and development of children also have impacts on the occurrence of ECC eventually . Thus, tIndonesia is the largest archipelagic country in the world and the most populous nation in Southeast Asia . IndonesThe Nutritional Supplementation Policy aims to achieve nutritional adequacy for infants, toddlers, school-age children, women of childbearing age, pregnant women, and postpartum mothers as a vulnerable group . NutritiThis Regulation has a potential role in ECC prevention since several nutrients, including calcium, fluorine, phosphorus, vitamin A and vitamin D, have a significant function in the formation of tooth morphology, chemical composition, and tooth eruption pattern . A lack This policy aims to reduce the risk of non-communicable diseases, such as hypertension, stroke, diabetes, and heart attacks caused by excessive sugar, salt, and fat intake in processed or ready-to-eat foods . The sugThis policy is intended to provide guidelines for daily food consumption and healthy behavior, including for children . This poa. Consumption of various foods in a balanced proportion and sufficient (not excessive) quantities that are carried out regularly.b. Physical activity to balance the expenditure and intake of nutrients, which are the main body's energy resource.c. Getting used to clean living behavior refers to maintaining cleanliness to avoid infectious diseases.d. Monitoring indicators of the balance of nutrients in the body, known as body mass index (BMI).These balanced nutrition guidelines are presented as a visual picture of a balanced nutrition pyramid that serves as a guide for daily consumption. Sugar, salt, and fat are found in the highest position on the pyramid, indicating that consumption of these foods should be limited to small quantities. For each food group, the recommended number of servings is written.Concerning ECC, this Regulation can be a guide to keeping children's BMI at normal status. Research shows that a BMI above or below normal is associated with caries . ConsumpThe nutritional adequacy rate or recommended dietary allowance (RDA) is a value that indicates the average need for specific nutrients that must be met every day to maintain a healthy life for all people according to age group, gender, level of physical activity, and physiological conditions. RDA is used at the level of consumption, which includes adequate calories, protein, fat, carbohydrates, fiber, water, vitamins, and minerals. The average consumption level is 2,100 kcal daily to achieve optimal health status . The RDAThe central government and local governments are responsible for the implementation of countermeasures to nutritional problems for children due to disease in an integrated and sustainable manner. Diseases, as referred to in this Regulation, include diseases that cause children to be at risk of failure to grow, like malnutrition or congenital metabolic disorders . HandlinThe implementation of strategic food and nutrition policies aims to improve the nutritional status of Indonesians . EffortsStudies have found a link between a child's malnutrition AL status and ECC. The stunting and underweight rate in Indonesia is 24.4 and 17.0% for children under the age of five mostly come from low-income families; moreover, the prevalence of obesity is found in 3.8 % of children and is more common in children from wealthy families . This coOne challenging condition is the Indonesian people's diet pattern, which is high in carbohydrates . CarbohyThe food and nutrition policies implemented in Indonesia are expected to impact ECC prevention positively. One important nutrient responsible for the increasing prevalence of ECC is excessive consumption (quantity or frequency) of sugar (sucrose) . Thus, iMinisterial Regulation on Health No. 41 of 2014 concerning Guidelines for Balanced Nutrition provides recommendations for the number of servings according to adequate caloric intake levels for various age groups. Unfortunately, there is not enough information about the right amount (units in grams) of food  that children should consume on a daily basis. The explanation of the measured weight is very important, especially for a child's mother/caregiver, because the recommended amount of sugar consumed by children every day (in grams) will impact the incidence of ECC . Thus, tMoreover, the policies implemented in Indonesia are currently limited to only providing information on the sugar content in foods and beverages sold commercially, not directly regulating restrictions on consumption. Many people find it challenging to decrease their sugar intake on a voluntary basis. Restricting the sugar added to food and beverages sold commercially should become the efforts enacted to prevent caries in children . ResearcMinisterial Regulation on Health No. 28 of 2019 concerning the recommended nutritional adequacy rate for Indonesians must be presented in a simple and easy-to-understand way to meet the children's daily nutritional adequacy rate. It will be very useful for mothers or caregivers and help them identify the right foods and beverages that are good for their children. It is not wise to just let parents focus on how to meet the nutritional needs of children by only informing them about the standards of nutritional adequacy while ignoring the skills they need to choose enjoyable and healthy foods. Combining carbohydrate intake with the consumption of vegetables and fruits is crucial since studies showed that increasing the intake of fibrous foods can produce saliva, which has protective properties against ECC .The Presidential Regulation of the Republic of Indonesia Number 83 of 2017 concerning Strategic Food and Nutrition Policy and Ministerial Regulation on Health No. 29 of 2019 concerning the management of nutrition problems for children due to disease may become the ultimate Regulation on strengthening community empowerment in the field of food and nutrition for having a significant role in preventing ECC. Since health promotion programs and early childhood education have become important strategies, health workers must actively provide consultation on nutrition and good feeding practices for children in the community to prevent ECC. This kind of intervention has significantly reduced the incidence and severity of caries in 4-year-olds in low-income communities . AnotherIt is concluded that since national health programs vary widely in mission, policies related to ECC are not specifically mentioned or discussed in those documents. However, some potential contents of the existing regulations may encourage efforts to prevent ECC.1. A more detailed explanation regarding sugar intake restrictions for children in Indonesia is needed. For instance, in the Regulation concerning Guidelines for Balanced Nutrition, there is no detailed explanation on how much the right amount of sugar for a group of children (units in grams) in 1 day. The content contained in the Regulation only describes the size of the number of servings. It is important to set rules for limiting sugar intake based on age to become a guide for parents when choosing safe and healthy foods for children and, further, may control the incidence of Early Childhood Caries (ECC).2. Guidelines for child feeding practice need to be emphasized more on information related to nutritional adequacy rates in each age group. A guideline is needed for parents to implement good eating patterns for their children, which can avoid the risk of Early Childhood Caries (ECC).3. Includes Healthy Diet education to prevent ECC, particularly for pre-schoolers' parents/caregivers. Thus, it is hoped that parents or caregivers have more skills in implementing healthy eating parenting patterns for children. Parents also can teach their children to choose healthy snacks and have an impact on reducing the prevalence of ECC.4. Since high sugar consumption and obesity is the crucial risk factor for ECC, there must be strict supervision and sanctions for the company that sells food and beverage exceeding the maximum standard amounts of sugar, salt, and fat. In addition, there should be coordination in the trade sector, food system, and agricultural policy to protect children's health.5. Professionals Training for dental health workers to improve skills in providing nutrition education in a dental clinic setting or the community is needed. Dental health workers should provide accurate information about nutrition's influence on ECC occurrence and information related to current nutritional regulations. However, multisectoral approaches that includes health, nutrition and education are needed to address ECC.It is hoped that the above recommendation efforts to implement policies related to food and nutrition in Indonesia will complement efforts to improve children's dental health, namely to reduce the prevalence of ECC.RA came up with the initial concept for the manuscript, produced the preliminary draft, and revised it. According to their areas of competence, FS, MA, and LA added materials. All authors gave the manuscript a close reading to assess its intellectual quality. All authors contributed to the article and approved the submitted version.The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.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.