This study aims to examine the impacts of community gardening on the daily life of residents and the management organisation of pandemic prevention in the context of the COVID-19 pandemic, a major public health scourge in 2020. The research team applied a participatory action research approach to work with residents to design and implement the Seeding Plan, a contactless community gardening program. The authors carried out a study to compare the everyday conditions reflecting residents’ mental health of the three subject groups during the pandemic: the participants of the Seeding Plan (Group A), the non-participants living in the same communities that had implemented the Seeding Plan (Group B), and the non-participants in other communities (Group C). According to the results, group A showed the best mental health among the three; Group B, positively influenced by seeding activities, was better than Group C. The interview results also confirmed that the community connections established through gardening activities have a significant impact on maintaining a positive social mentality under extraordinary circumstances. From this, the study concluded that gardening activities can improve people’s mental health, effectively resist negative impacts, and it is a convenient tool with spreading influence on the entire community, so as to support the collective response to public health emergencies in a bottom-up direction by the community. Exposure to natural environments contributes to the improvement of human health, which has been proven by a variety of theories and experiments since the 1980s, such as stress recovery theory and attention restoration theory ,3,4,5. FCommunity gardening is shown to be the type of activity which enable ordinary people to get close to nature in their daily life and promote the health of individuals and the environments ,11,12,13In China, the physical environment of most residential neighbourhoods in cities, including those central garden and green space scattering around the houses and buildings are managed by property management companies . ResidenThe research team launched the Community Garden Initiative in China in 2014, aiming to create a green and healthy environment through collaborative horticultural activities by public participation. The initiative contains five stages: first, researchers took the lead in guiding residents’ involvement in gardening step by step; second, to engage enterprises and NGOs in community garden building with residents; third, to foster community leaders as pioneers to guide residents’ gardening; fourth, to encourage communities to carry out gardening activities independently, and; fifth, to develop the Initiatives to a community-oriented gardening program called the Seeding Plan. The ultimate goal of the initiative is to develop community gardening into a public campaign incorporating the whole society with the assistance of researchers. It is a progressive process with decreasing interventions from the outside and increasing autonomous governing within the community. It has integrated nearly 70 community gardens, going beyond the city of Shanghai to a number of cities across the country till 2019 when we conducted surveys on the effects of community gardens. The results confirmed a reinforcement on community cohesion and also demonstrated the greater influence of community gardening on mental health. The outcomes of the research have already been published .The implementation of the Community Gardening Initiative was badly affected by the outbreak of coronavirus in early 2020. Most cities in China launched a first-level response to major health emergencies at the end of January 2020. Almost all the public places were shut down, including subways, buses, shopping malls, restaurants, bars, scenic spots, parks, museums, auditoriums, community centres, etc. The duration of the national holiday around the Spring Festival (24–31 January 2020) was extended to make sure people stay in place put for the prevention and control of the disease. Benefitting from gated and enclosed neighbourhoods design, the community became the frontline for epidemic prevention, with strict regulations on the entry and exit of neighbourhoods. Some neighbourhoods also imposed a period for daily shopping. Residents were encouraged to stay at home and cut down on outdoor activities. The peak weeks of the coronavirus outbreak vary from city to city, with about three months of strict social distancing in general. Even after the lockdown ended, people had to become accustomed to a new normal when living with the COVID virus and preventive measures of various degrees have become a part of daily life. The Seeding Plan, on the one hand, as the late stage of the entire Community Garden Initiative, was inevitably affected by the pandemic; but on the other hand, its contribution to the capacity building and mental health of the community was also highlighted. Therefore, the research and implementation of community gardening had to adapt to the situation for pandemic prevention.The research team employs a participatory action research (PAR) framework, a type of applied social research aiming to pursue practical solutions to the situation; meanwhile, to advance scientific knowledge when the researcher and the researched acting together . The PARThe research team restarted the Seeding Plan in mid-February 2020. This paper aims to investigate the impacts of community gardening on the daily life of residents and the organisation of community disease prevention in the context of the COVID-19 pandemic. Questionnaire surveys and comparative analyses were conducted in August 2020 to examine the daily situation of residents during the program. Detailed interviews were carried out to evaluate how the implementation of the Seeding Plan influenced the organisation of the community prevention of the disease. The research results show that gardening activities are a good way that enables access to nature and social interactions that can soothe people’s psychological stress during a major public health emergency. With easy implementation and dissemination through the community network, gardening contributes to improved mental health for the community to respond to health emergencies in a bottom-up process.PAR is not a method at the micro level but rather a guide to creating the circumstance of accumulating knowledge and tracking change ,32. RobiThe six years of experience in the Community Garden Initiative laid a solid research and personnel foundation for the Seeding Plan, which had already started before the pandemic outbreak. In the initial stage of Shanghai’s lockdown, a research team comprising a core group of 11 researchers and 30 gardening activists from the communities held online meetings to identify the problems and needs of the residents, then laid out the objectives and action plans. Pertinent problems became relevant in the following two features: the depressive moods accumulated among the residents directly caused by the lockdown had no proper way to be released; social distancing led to distrust among neighbours. Therefore, the team focused on the two topics of ‘how to resume gardening activities during lockdown’ and ‘how to restore human interactions through gardening’. People being isolated for such a long time acquired a cave mentality, tending to take a long time to sociability. The idea of a contactless seeding action then came out pursuing ‘building of trust and seeding of hope’. The plan was set to restore communication between neighbourhoods through a non-contact form of seed sharing and planting and bring vitality into daily life.The research team designed various contactless ways to distribute seeds and planting schemes, thus establishing an implementation plan involving collaborations among the researchers and participants, with the engagement of the active members from the neighbourhoods. Within two weeks, more than 400 participants joined the online social networking of the Seeding Plan for requesting technical support.In the beginning phase, the team encouraged residents who already had seeds or those with access to seeds to start planting on their balconies, hallways, or vacant lots around their houses. The research team provided a few tips on gardening indoors, plant conservation, and other information through online guidance and Q&A sessions. At the same time, the team launched the Seed Moving Ark action to distribute seeds and provide year-round planting guidance to the participants who had already mobilised at least 10 households to join the action.The team designed a device called ‘seed relay station’, a simple wooden shelf to place seeds, envelopes and post-it notes, etc. Participants shared seeds from the shelf in a contactless way during the epidemic and thus established a new way to social interact . The firThe Seeding Plan also established a loop of feedback, adjustment, and promotion. Online salons met constantly to exchange planting experience and discuss technical issues. For example, the construction of the first batch of relay stations from paper boards for cost reduction meant they could only be placed indoors. Through discussion, upgrading the stations for long-term and outdoor use proved more effective. The research team also organised other online activities, such as a ‘cloud reading club’ to enhance social cohesion among the community residents.As experience accumulated, the participants gradually grew into independent organisers and contributed to the expansion of their influence. Ms. Zhang, a retiree and member of the team, set up a seed relay station in her courtyard, organised garden tours and a neighbourhood market. Several households in her community have joined her. Mr. Zhu, a club owner, organised his employees to start planting activities and set up a seed relay station in front of his shop while also mobilising other shops along his street to participate in the Seeding Plan .Seeding incorporates the meaning of ‘growing’, which indicates the nurturing of positive actors to spread the idea of actions and expanding the ranks of participants. In this process, the Seeding Plan had received support from horticultural, woodworking, landscape design, and short-video companies, official and folk media, community building groups, etc. They offered seeds, seedlings, timbers, video recording, and publicising ideas. Through six months of operation, the league of Seeding Plan had been formed with its branches in a dozen provinces and municipalities including Beijing, Tianjin, Guangdong, etc.After running for six months and undergoing an expansion nationwide, the research team conducted surveys to see how the Seeding Plan affected people during the outbreak of coronavirus.The questionnaire survey employed means to obtain the data of the residents’ daily status during the lockdown. The influence of seeding activities can be learned by a comparison of the distinction between the Seeding Plan’s participants and non-participants. The team designed a questionnaire that asked eight questions to cover the changes to three aspects of individual status, social status, and environmental conditions . A scaleThe research team distributed online questionnaires to three respondent groups: those who participated in the Seeding Plan (Group A), those who do not participate but live in the same communities where the Seeding Plan is implemented (Group B), and those who live in other communities without implementing the Seeding Plan (Group C). Investigating participants and non-participants in the same neighbourhoods that have implemented the Seeding Plan could avoid the bias caused by the difference in region and neighbourhoods, while other neighbourhoods which do not participate in the plan could be perceived as randomised control group without being influenced by the Seeding Plan’s activities. https://www.wjx.cn/, accessed on 8 June 2021). The questionnaire was distributed online and could not be submitted unless it was completed. Consequently, 10 days after the questionnaires were sent out, 1154 valid responses were collected, including 552 from Group A, 396 from Group B, and 206 from Group C. More than 30 communities that have implemented the Seeding Plan across the country participated in the survey. Compared with the whole amount of about 5000 participants and 300 communities that implemented the Seeding Plan, around 10% of the participants were involved in the questionnaire survey. As the questionnaire was distributed online through the sharing among social media groups, it is impossible to calculate the total number of questionnaires issued. The concept of response rate does not apply to this survey context.Questionnaires to group A were distributed in the Seeding Plan group in WeChat . Participants were encouraged to spread the questionnaires to those participants who were not in the WeChat group. The research team also asked participants to forward the questionnaires to their neighbours who did not participate in seeding activities (Group B). Questionnaires to group C were distributed online to the public via Questionnaire Star, which is a professional online questionnaire platform for surveying, evaluation, and voting , followed by residential environment (2.35/1.28/0.61), with a minimum change in the improvement of entertainment (2.17/0.91/−0.11); while the statistics of other indicators were relatively close. It can be inferred that social distancing contributed to the improvement of family relationships and the residential environment. Although leisure time increased, the forms of leisure and entertainment were limited by the travel restrictions and social distancing, and consequently, it was the only negative factor in this questionnaire . The difference between group A and group B reflected the extent to which the seeding activity influenced the participants’ rating of their daily life. Many comparative assessments did not change that much according to the difference in ‘Seeding helped many of our families to reconnect and return to nature by farming during the pandemic, unease the stress from the outbreak and bring us new understanding and hope of life. Staying at home for a few months, every day I share with other seeding participants in the WeChat group the process of the seed growth, and I sensed sincerity and kindness flowing among people. I kept thinking about the seed relay station all the time and can’t wait to go there to share with others as soon as I obtained new seeds. I have started to talk to my neighbours that I didn’t know about before. Now every time we meet, I would say hello to them.’The indicator difference between Group B and Group C was about the same. This comparably slight difference in the family indicator was ascribed to the interactive nature of the activity with which people with extroverted personalities tend to be more comfortable. A comparably larger difference could be observed in the entertainment indicator. A possible explanation was that although Group B did not participate directly in seeding activities, the lack of entertainment during this isolation period increased people’s mental sensitivity, thus the perception of the activity seemed more obvious. One of the members of group B wrote:‘Seeding is a meaningful thing, I was meant to join in your activities but I couldn’t because of my job. I feel lucky to be aware of the existence of such kind of public activities and are moved by the efforts and dedication people have invested in it. I hope everyone will keep their dreams, and make the Seeding Plan better!’The interviews with active participants, general participants, and social workers in the communities have generally confirmed the positive impact of seeding activities on the COVID-19 prevention measures and other community activities. Regarding the impact on pandemic prevention work, 15 out of the 18 respondents believed that seeding activities provided exchange opportunities for people in the same neighbourhoods to understand each other better, which, in turn, facilitated the management organisation of pandemic prevention work within the community. They gave examples of participants spontaneously donating masks and disinfectants to the community and sharing other pandemic prevention reserves. Two other respondents deemed there were neither positive nor negative impacts of seeding activities. However, the other respondent held a negative view towards the seeding activity, accusing it of producing more garbage. Regarding the impact on other activities in the community, 14 respondents believed that due to the foundation of seeding activities, more residents joined the online or offline activities in the neighbourhoods, therefore making it easier to organise other community activities. They also listed a few other activities such as cloud picnics, float production, parent–child activities, garbage sorting, and other activities. The other four respondents said they were not aware of other activities. It can be inferred that seeding activities can eliminate the anxiety of home isolation, increase trust between people, and help individuals to be more engaged in public affairs. Therefore, it has accumulated experience for community responding to major public emergencies in the future. When people use their balconies, doorways plus other private and semi-private spaces for sharing activities, the space boundary between private and public areas breaks down, which activates individuals’ concern about public affairs, thus promoting the establishment of community identity.There are three characteristics of community gardening that make it prominent in public health emergencies: (1) community gardening and its easy access as a ubiquitous natural element in daily life match people’s increasing needs and longing for nature as a means to release pressures; (2) gardening as both a group and individual activity effectively adapts to spatial limitations imposed by lockdown and social distancing; (3) the technical issues involved in gardening provides a good medium for communication between neighbourhoods.The study confirmed the positive role of community gardening activities to promote mental health and provided a viable strategy for the community to respond properly to public health emergencies. This is demonstrated in three aspects:First, gardening activities have direct or indirect impacts on people’s mental health, which becomes particularly relevant in the context of public health emergencies. The data on the changes in the quality of daily life, whether in personal, social, or environmental dimensions, were collected by the descriptions of subjective feelings, not by quantitative measurements of objective factors. Therefore, they were results from the subjective perception of the respondents, which belongs to mental status.Second, neighbourhood connections established through gardening activities benefit the organisation of virus spread prevention measures within the community, and its bottom-up way helps the community to respond properly to public health emergencies. With the least restrictions on space and distance, the Seeding Plan can quickly spread among individuals to the whole community, as reflected by the contrast between Group B and Group C. The interview surveys also confirmed its flexibility in organisation and implementation forms and its adaptability to the ways of human interactions under the lockdown period, which improved residents’ sense of belonging and the capacity building of the community. Third, organisation and participation in horticultural activities is an effective way to relieve negative emotions in the context of public health emergencies since gardening is an activity that enables close contact with nature to release pressure, as well as having flexible application in space and acting as a convenient medium of communication. The comparison of data from the questionnaire and interview surveys confirmed this conclusion. p-value analysis of the samples, we can infer no population with characteristics of group A and B; (2) the social and interactive nature of the Seeding Plan means the activity tends to attract the participation of those who innately have a more positive and optimistic personality, leading to a possible biased high baseline value of the survey data in seeding communities. However, it does not affect the general conduction of comparative research. Instead, it supports the idea of community gardening as a public health strategy, as it can rally optimistic people to develop a positive driving force to promote personal, familial, and community health as well as the overall neighbourhoods’ environment. This also matches the ultimate goal of the Seeding Plan: to make gardening activities a collective action initiate from bottom to up by the community and to have fun.The limitation of the study exists in two aspects: (1) questionnaires of group C were randomly distributed online; therefore, they did not evenly cover the populations of all provinces and cities in China; the respondents with the characteristics of groups A and B could not be excluded from group C, but from the


Electric shocks may have neurological consequences for the victims. Although the literature on the neurological consequences of electric shocks is limited by retrospective designs, case studies and studies of selected patient groups, previous research provides some evidence of a link between electric shocks, and diseases and symptoms of the central nervous system (CNS) and the peripheral nervous system (PNS). This study aims to employ a register-based, matched cohort study, to investigate whether individuals demonstrate a greater risk of neurological diseases and symptoms of the CNS or PNS in the years following an electrical injury.We identified 14,112 electrical injuries over a period of 19 years in two Danish registries, and matched these with three different groups of persons in a prospective matched cohort study: (1) patients with dislocation/sprain injuries, (2) patients with eye injuries and (3) persons employed in the same occupation. Year of injury, sex and age were used as matching variables. The outcomes we identified comprised neurological disorders and central or peripheral nervous system symptoms that covered a range of diagnoses in the Danish National Patient Register. The associations were analysed using conditional logistic regression for a range of time periods (six months to five years) and conditional Cox regression for analyses of the complete follow-up period (up to 20 years).epilepsy, convulsions, abnormal involuntary movements, headache, migraine and vertigo. We also identified an uncertain, increased risk of spinal muscular atrophy and dystonia, whereas we identified no increased risk of Parkinson’s disease, essential tremor, multiple sclerosis or other degenerative diseases of the nervous system. For victims of electric shock, the PNS sequelae we identified included an increased risk of disturbances of skin sensation, mononeuropathy in the arm or leg and nerve root and plexus disorders. We also identified an uncertain, increased risk of facial nerve disorders, other mononeuropathy, and polyneuropathy.For victims of electric shock, the CNS sequelae we identified included an increased risk of Our results confirm that electrical injuries increase the risk of several neurological diseases and symptoms of the CNS or PNS in the years following the injury. Most often the diseases and symptoms are diagnosed within the first six months of the injury, but delayed onset of up to 5 years cannot be ruled out for some symptoms and diagnoses. Some of the conditions were rare in our population, which limited our ability to identify associations, and this warrants cautious interpretation. Therefore, further studies are needed to confirm our findings, as are studies that examine the mechanisms underlying these associations. Electric shocks may have both serious immediate consequences, such as burns or cardiac arrest caused by the current, and serious secondary physical injuries, for example, those caused by falling or being thrown back by the shock. These serious, immediate consequences may be the most notable and well-known, but electric shocks may also have both immediate and delayed neurological consequences , 2. ThisPrevious research has yielded mixed evidence of a link between electric shocks and diseases and symptoms of the CNS. For instance, a review of the literature based primarily on case studies and patient groups from burn units reported an association of electric shocks and an increased risk of epilepsy, Parkinson’s disease and Amyotrophic Lateral Sclerosis (ALS), first manifesting a significant time after the electric shock . HoweverResearch has also indicated a link between electric shocks and conditions and symptoms of the PNS, although the aetiology behind this possible association is debated , 6. The Generally, the literature on the neurological consequences of electric shocks is limited by retrospective designs, case studies and studies of selected patient groups, which are prone to recall and/or selection bias. Furthermore, there is a lack of comparison groups, so casuistic and descriptive cohort studies dominate the field, which is also reflected in reviews , 2.This study aims to employ a register-based, matched cohort study, to investigate whether individuals demonstrate a greater risk of neurological diseases and symptoms of the central or PNSs in the years following an electrical injury.This study was a matched cohort study based on injuries registered in two population-based registers: The Danish National Patient Register (DNPR) and the register of work injuries reported to The Danish Working Environment Authority (DWEA). Furthermore, it included data from other population-based registers in Statistics Denmark, described in detail in the following sections.The DNPR covers all hospital contacts in Denmark, including information regarding diagnoses and procedures carried out during in- and outpatient, and casualty department visits , 17. ManThe DWEA register lists work injuries reported by employers, employees, unions and healthcare workers. In Denmark, it is mandatory for employers to report any work injury that results in sick leave lasting at least the day following the day of the injury. The DWEA register exists to support compensation claims, but the reporting system is also designed to provide an overview of work injuries . StatistThe period studied covered registered Danish electrical injuries from 1994 to 2016, and we included electrical injuries from 1996 to 2014 in our analysis, to allow for at least two years prior to the injury, with no evidence of the sequelae of interest, and at least two years following the injury for the sequelae to develop.Statistics Denmark is the central Danish registries and statistics authority. The range of topics covered includes the population register, which includes movement within and to/from Denmark, and nationality , 20. StaParticipants’ occupation was determined from the register-based labour-force statistics (RAS) register at Statistics Denmark by means of DISCO codes. DISCO is the official Danish version of International Standard Classification of Occupations (ISCO), prepared by the International Labour Organisation (ILO) . CurrentThe DNPR enabled us to identify patients with electrical injury (ICD10) diagnoses , related to contact with a hospital. The DT754 code was used throughout the period studied, whereas the two accident codes (EU*) have been used only since 2000, when a separate injury register was established and subsequently included in the DNPR. Both hospitalisations and outpatient visits were included.In the DWEA register, persons with electrical injuries were identified by information regarding cause of injury. Two different codes defined exposure: ‘Acute/short exposure to welding arc or electrical arc’ and ‘Acute/short exposure to electricity or reception of electric charge in the body’.If an injury was registered in both registers (+/− 7 days), only the first registration was used, regardless of the register in which it appeared.Sex, age and occupation at time of being matched for this study were derived from Statistics Denmark, as was the date of emigration or death, if applicable. We registered whether the patient was part of the workforce at the time of the injury. If the injury was identified in the DNPR, it was not necessarily work-related, whereas all injuries in the DWEA register were occupational injuries.For sensitivity analyses we calculated the total length of hospitalisation, including time in the casualty department, and derived the diagnoses of concussion (S06.0) and diabetes (E10-E14) from the DNPR. Not all injuries from the DWEA register could be assigned a length of hospitalisation, if we could not identify any hospital contact at the time of the injury (+/− 7 days).Each patient was matched in three different ways with persons from the same data source (DNPR or DWEA).Match 1 –dislocation/sprain. Electrical injury patients were matched with up to ten other patients with a dislocation/sprain (DS93 in the DNPR and ‘sprains’ in the DWEA register)Match 2 –eye injury. Electrical injury patients were matched with up to ten other patients with an eye injury (DT15 in the DNPR). We could not identify eye injuries in the DWEA register.The matching variables were sex, year of injury and age. For all matches, the match-persons were randomly chosen, if more than ten were available per patient. This randomisation made it possible for the same person to act as a match-person for more than one electrical injury, but only in that particular year, as only the first event was used. If a person had both an electrical injury and a dislocation/sprain within the same year, the person could not be matched to him/herself. If it was impossible to match the exact age, the algorithm identified the closest person in age within the same 5 years’ age group, but of the same sex and injury-year.The diagnoses of dislocation/sprain and eye injury were chosen since they are frequent, and are not suspected of causing the types of outcomes being studied.Match 3 –Occupation. Electrical injury patients were matched with up to ten other persons from the working population, of the same occupation-group, sex and age. The patient and the match-persons were working at the time of the match. However, the electrical injury registered in the DNPR could have happened outside work. Match-persons were assigned a fictive injury date, based on their match-person’s injury, to be able to identify outcomes before and after a specific point in time. The purpose of this match was to determine whether persons with certain occupations presented a higher risk of the outcomes we were studying, due to socioeconomic factors or other occupational exposures than electrical shocks.If a person had experienced more than one electrical injury during the period studied, only the first injury was included in this study. A person that had experienced an electrical injury was eligible as a match-person before and after the observation period (two years before and after the injury). Thus, one individual could be part of the data set more than once, if the time periods were separate. Persons with an injury that could not be matched with at least one match-person were excluded.In the occupation match, all persons with an injury registered with the DWEA were defined as part of the working population, as their injury had occurred while working. However, not all were defined as part of the workforce by Statistics Denmark, probably because some had experienced their electrical injury while working a part-time job . Thus, 175 persons with an injury registered with the DWEA could not be matched in the occupation match, but only in the two injury matches with dislocation/sprain as controls.We preselected a wide range of possible sequelae as outcomes, based on the literature, including reviews, original studies and case reports, and experience from clinical praxis at our department of occupational medicine. These outcomes were examined one by one. The outcomes related to the CNS with an ICD-10 diagnosis were: Spinal muscular atrophy and related syndromes , Parkinson’s disease , Dystonia (G24), Essential tremor (G25.0), Other degenerative diseases of nervous system , Multiple sclerosis (G35), Epilepsy , Migraine (G43), Headache , Vertigo , Convulsions, not elsewhere classified (R56) and Abnormal involuntary movements (R25).Outcomes related to the PNS were: Facial nerve disorders , Nerve root and plexus disorders , Mononeuropathy, arm (G56), Mononeuropathy, leg (G57), Other mononeuropathy , Polyneuropathy  and Disturbances of skin sensation (R20).We compared the matched groups using conditional logistic regression for a range of time periods (six months to five years). We also did a conditional Cox regression for analyses of the complete follow-up period, including a subgroup analysis for matches 1 and 2, with persons who were part of the workforce at the time of the injury. We tested the proportional hazard assumption with Schoenfeld’s residuals test. To simplify data analyses and maximise statistical power we analysed each diagnosis individually and did not look at differences in patterns in diagnoses for individuals or follow the course of diagnoses for individual patients or groups of patients. If persons  were registered with the outcome of interest before the matching day, they were excluded. This was done separately for each outcome, to keep the persons in the data set to examine the other outcomes. If an electrical injury patient was excluded, all their matching controls were also excluded, whereas match-persons were excluded individually, keeping the remaining match-persons and the exposed person in the data set. This means that for each analysis of a specific outcome, the study sample was different. These numbers are presented in Electrical injury patients and match-persons who emigrated or died during follow-up were excluded from the date of this occurrence.Epilepsy after an electrical injury had been diagnosed with Convulsions (R56) before the injury, given the probability that convulsions could have caused the electrical injury, and indicate that the person already suffered from (undiagnosed) epilepsy at the time of the injury. Finally, to investigate possible late onset effects of the electrical injury, we carried out a supplementary analysis for the most frequent outcomes, where we excluded individuals who reported the outcome before each follow-up period. All sensitivity analyses were carried out in match 1 only.In sensitivity analyses, we used length of hospitalisation as a proxy for severity, given the probability that the most severe accidents would result in longer hospital stays. Therefore, we excluded patients who were hospitalised for less than one day, to determine whether the more severe injuries would reveal stronger associations with outcomes. As several authors have described traumatic brain injuries related to electrical injury , 25, we We identified 20,155 electrical injuries in the DNPR and 1,810 in the DWEA register. After excluding persons under 18 years, persons without a valid CPR number and persons who died within the first 2 days of their accident, there was an overlap of 817 persons from the two registers. Invalid CPR numbers may reflect entries for tourists or migrant workers in the DNPR and DWEA registers, or possible mistyping in the DWEA register. When the overlap was eliminated and only the first electrical injury for each person kept, we had 14,112 injures . These were used for match 1 (distorsion). For match 2 (eye) we identified 13,387 DNPR injuries. For match 3 (occupation) we excluded 2,646 persons who were not in the workforce. Here, we had 10,764 injuries from the DNPR and 702 from the DWEA register available for the occupation match. A match with 10 match-persons was possible for almost all electrical injuries, before the exclusions. A full flowchart of the study has been published previously in .Most of the injuries happened to men (85.4% in DWEA and 76.4% in DNPR), and younger persons (<40 years) were overrepresented (60.3% in DWEA and 74.7% in DNPR). The occupations with most injuries were craft workers (50.1% in DWEA and 36.9% in DNPR), but service and sales workers were also overrepresented (8.8% in DWEA and 11.3% in DNPR), even when comparing to the distribution of occupations in Denmark. Only 1/5 of the injuries led to hospitalisation for one day or more (19.4% in DWEA and 21.9% in DNPR). More details on the study population can be found in .migraine, headache, vertigo and mononeuropathy in the arm were common, whereas others were rare  than among matched persons 17.1%[15.2–19.0%]).Restricting the time-to-event analyses to patients in the workforce did not significantly change most of the estimates . When we the CNS . For patAbnormal involuntary movements with an odds ratio of 3.45, while there was no increased risk in the later time intervals. There was no increased risk for Convulsions in any time intervals, although the odds ratio was highest in the first 6 months.We were able to estimate possible late onset effects for the seven most frequent outcomes . For theWe were only able to estimate late onset effects for one diagnosis related to the PNS, and here we found and increased risk for Mononeuropathy in the arm within the first six months, whereafter the risk stabilised at a lower level (about 1.3–1.4) in the following time intervals.To the best of our knowledge, this study is the first to examine the association between electrical injuries and conditions related to the CNS and PNS, through a register-based, prospective cohort study that uses a matched design. We studied 14,112 electrical injuries identified over a period of 19 years, and found an increased risk of conditions related to both the CNS and PNS in the years following an electrical injury, when compared with three different matched control groups.epilepsy, convulsions, abnormal involuntary movements, headache, migraine and vertigo. We also identified an uncertain, increased risk of spinal muscular atrophy and dystonia, whereas no increased risk was identified for Parkinson’s disease, essential tremor, multiple sclerosis or other degenerative diseases in the nervous system.For the CNS, we identified an increased risk of disturbances of skin sensation, mononeuropathy in the arm or leg and nerve root and plexus disorders. We also identified an uncertain, increased risk of facial nerve disorders, other mononeuropathy and polyneuropathy.For the PNS, we identified an increased risk of Our sensitivity analyses revealed that the risk estimates increased when we restricted our analyses to injuries that required hospitalisation of longer than one day as a proxy for severity, whereas other sensitivity analyses did not affect the estimates.Because this is a register study, there are some inherent risks of bias that should be addressed. Registration in the DNPR is probably incomplete and thus only a proportion of the electrical injuries were registered. This may indicate underreporting, especially during the first years of the period studied. If the types of electrical injuries registered differ in type, severity or duration from those not registered, this may cause bias in an unknown direction. Even today, underreporting may be a problem, since detailed registration in the casualty departments may be deprioritised in acute situations. If the electrical injuries not reported in the DNPR were the most severe, where the consequence of the injury, such as a burn, was registered, and not the code for the electrical injury itself, we may have overlooked the most severe injuries, and thus underestimated the associations between the injuries and our outcomes. In the part of the cohort derived from the DWEA register, we have no reason to think that there is any difference in reporting due to exposure, although the number of injuries decreased over time, which is also the case in other types of work injuries .The severity and other characteristics of the electrical injuries were not registered, since the definition of an electrical injury was based on the ICD-10 code in the DNPR, and type of injury, in the DWEA register. Previous studies have distinguished between high- and low-voltage injuries as a measure of severity. We tried to accommodate this by restricting our analysis to patients who were hospitalised for longer than one day as a proxy for severity, and found that most estimates of association with outcomes increased. This indicates that the severity of an injury is positively related to the risk of developing a CNS or PNS disorder in the years following the injury. In most cases, hospitalisation was very brief, and a large proportion of electrical injuries registered with the DWEA did not involve hospitalisation, or involved only an outpatient visit. The definition of an occupational accident that should be registered with the DWEA is an accident that has led to at least one day of sick leave in addition to the day of the accident, and thus of a certain severity.The outcomes used in the study are diagnoses from the DNPR register which covers all hospital contacts. However, some of the symptoms and diagnoses used in the study would probably not require a hospital contact but could instead be handled in the primary care sector. So, it is possible that some patients were seen by their general practitioners during follow-up, and thus not registered in the DNPR. A previous study in the same population confirms this, as persons with an electrical injury had an increased risk of many contacts with general practitioners in the five years following the injury compared to matched controls . ConsequA further potential issue with the outcomes is that some of the persons may have been diagnosed with the outcomes of interest prior to 1994, and thus should have been excluded from the study, However, this is only an issue if persons diagnosed prior to 1994, were not seen at a hospital due to their disease/disorder in the time period after 1994 and before their injury (a period ranging from 2–20 years). Several of the diagnoses under study, such as epilepsy, require regular hospital contacts and we would therefore be able to identify and exclude them. If there is an issue, it would be non-differential between persons with electrical injuries and match persons. Thus, if present, the bias would cause us to overlook associations.An important further limitation was the choice of matched persons. We found it difficult to identify the perfect type of injury to match with an electrical injury. Since the electrical injuries are heterogeneous in severity, ideally, the match group would be similarly heterogeneous, and at the same time, it would have a rather frequently-occurring type of injury, to enable us to find a sufficient number of suitable matched persons. Our solution was to use three different types of matching: patients with a dislocation/sprain, patients with eye injuries and persons from the same occupation group as those with electrical injuries. The first two matches had the disadvantage that the injuries themselves were not life-threatening or disabling, as an electrical injury may be. Match 3, persons with the same type of job, had the disadvantage that the matched persons had no injury, and thus were probably not using the healthcare system at the time of the match. This means that the estimates based on match 3  are probably overestimated, if patients with electrical injuries had other healthcare seeking habits. In this case, we could not accommodate the possible bias by restricting the analyses based on length of hospitalisation, as this was not applicable to the matched control group. This same approach was used in a Danish cohort study on cardiac disease and mortality after electrical injuries which matched injured persons with randomly selected controls from the general population based on age and gender . We aimeMisclassification also presents a risk of bias in this study. A range of the chosen diagnoses were symptoms, such as essential tremor, headache and vertigo. The diagnoses were based on the patients’ subjective complaints, and although they were real ailments and problems for the patients, they may not indicate specific diseases, and thus may be misclassified. Although the risk of misclassification may be highest when it comes to common symptoms, the impact on our results and conclusions would potentially be larger when it comes to rare diagnoses, where (lack of) association may be due to there being only a few cases, and thus being more vulnerable to random misclassification of one or two cases. Related to this issue, we retrieved outcome data from DNPR and the validity of these data are critical for our results. Previous studies have found a positive predictive value (PPV) of 81% of diagnoses related to the medical speciality in general  and specFinally, the size of this study was the largest possible using Danish data, but it still raises concerns about statistical power, with respect to some outcomes. Even though the DNPR was established in 1977, information about electrical injuries was insufficiently registered until the introduction of ICD-10 codes in 1994. Since we chose to include two years of observation time preceding the reported accidents to exclude persons with the outcome of interest, and at least two years of observation time following the injury, we were limited to 19 years, from 1996 to 2014. Despite the length of this period and the considerable number of injuries registered, we still had limited power in some analyses, especially with rare diagnoses and when the sequelae of interest had occurred prior to the injury. The latter could cause bias if a previously unregistered electrical injury was related to the outcome. However, since the matching included the year in which the injury occurred, the risk of missing previous injuries was the same for persons with electrical injuries and matched persons, and thus the risk of bias is unlikely. The statistical power, as well as lack of available information, also limited our possibilities to adjust for additional potential confounders, such as life style or personality factors.vertigo and migraine, which was previously identified in a Danish register study [headache, which has also been seen in previous research [Our results regarding conditions related to the CNS both confirm and conflict with previous research. First, our results confirm the increased risk of er study  that is research , 8, and research .epilepsy following an electrical injury, which is consistent with previous studies [convulsions before the electrical injury, as this may be an indication of epilepsy. However, our results showed no difference in the incidence of convulsions before the electrical injury in the group that suffered electrical injuries and matched persons. At the same time, we also found an increased risk of convulsions following an electrical injury. The same goes for the somewhat related diagnoses, abnormal involuntary movements, which also includes convulsive movements. So, it seems reasonable to assume that electrical injuries indeed may increase the risk of epilepsy, although a complex relationship may be at work, and further studies are needed to determine the mechanisms underlying the association.Secondly, we found a greater risk of  studies , 4. If e studies . Thus, r studies . Hence, spinal muscular atrophy and related syndromes, which includes ALS, where we identify an uncertain association, due to a very small number of cases. However, previous reports have highlighted the delay of onset [Thirdly, our study did not specifically address the previously suggested association between electrical injury and ALS , 34, as of onset , which iof onset , 36 wherof onset . Our datParkinson’s disease, essential tremor or other degenerative diseases of the nervous system. With regard to Parkinson’s disease, our results were consistent with a previous Danish register study [Dystonia, in the time-to-event analysis, indicating that it may develop over time, but again, this diagnosis was rare in our population. Multiple Sclerosis was the last diagnosis for which we found no association with electrical injuries, which confirms the results of the previous Danish register study [The remaining diagnoses related to the CNS also had the issue of few available cases in our population, which limited our ability to identify associations. Thus, we did not find an increased risk of er study  and a caer study . Howeverer study , we did er study .Mononeuropathy was the most frequent peripheral neuropathy we found, and was primarily seen in the arms or legs, probably due to these extremities often being the entry and/or exit points of the current. This is similar to what other studies with similar methodologies [polyneuropathy and disturbances of skin sensations, were relatively rare in our population, our results indicated either an association with electrical injuries or a possible association. Thus, we were unable to disconfirm an association for any of our selected diagnoses related to the PNS. Together with the conclusions of previous research, the link between electrical injuries and peripheral nerve disorders seems to be well-established, and further research should focus on understanding the causal mechanisms, where different explanatory models are debated [When we looked at the results related to conditions of the PNS, we found a rather clear pattern that showed that peripheral nerve disorders are common sequelae of electrical injuries. dologies , and revdologies , 2, haveSeveral studies emphasise the possible delayed onset of neurological symptoms following electrical injuries, where months and years may pass after an electric shock, before the consequences become evident . HoweverOur results confirm that electrical injuries increase the risk of several neurological diseases and symptoms of the CNS or PNS in the years following the injury. Most often the diseases and symptoms are diagnosed within the first six months of the injury, but delayed onset of up to 5 years cannot be ruled out for some symptoms and diagnoses.Some of the diagnoses were rare in our population, which limited our ability to identify associations, and this warrants cautious interpretation. Further studies are needed to confirm our findings, as are studies that examine the underlying mechanisms driving the associations.The findings of this study may probably be generalised to other populations, especially in countries where access to healthcare is similar to Denmark’s, and where the habits and culture of diagnosing is similar.


The acceptance or practical application of the do-not-resuscitate order is substantially dependent on internal or personal factors; in a way that decision-making about this issue can be specific to each person. Moreover, most nurses feel morally and emotionally stressed and confused during the process decision-making regarding DNR order. Therefore, the purpose of the present study was to evaluate nurses’ attitudes towards DNR order in a systematic review.This critical survey was conducted using a systematic review protocol. To this end, the most relevant articles published in domestic and foreign databases with no time limits until October 2018 were searched. The inclusion and exclusion criteria were articles on DNR order, studies about nurses’ attitudes, descriptive and analytical research papers, as well as those with download links and full texts. The given articles were also assessed in terms of their quality and their main results were extracted.Of the total number of 1663 articles searched in the process of systematic review to investigate nurses’ attitudes towards DNR order, 88 articles were included in the full-text review step and finally 10 articles, meeting the inclusion criteria, were found. Assessing the quality of articles included in this review showed that 8 articles, in general, were of good quality and 2 studies were characterized with moderate quality. The main factors associated with nurses’ attitudes towards DNR order were grouped into three categories of (1) nurses’ attitudes towards DNR order, (2) guidelines for DNR order, and (3) decision-making by patients and their families about DNR order. In most of the studies examined, nurses’ attitudes towards DNR order were reported positive.It seemed that nurses were willing to get involved in DNR order and each hospital was recommended to develop a written DNR policy directing individuals and avoiding their confusion in this respect. Today, with the increase in the quality of medical care and the improvement of the welfare of society, the number of patients in the final stages of chronic diseases is increasing day by day. Therefore, providing care for such patients can bring about numerous challenges including doing or not doing cardiopulmonary resuscitation (CPR). It should be noted that CPR contains all primary and advanced therapeutic actions in the conditions of cardiac arrest due to various clinical reasons , 2. MoreSometimes, medical teams do not consider CPR as a useful activity due to patients’ general conditions, their age, functional status in cardiac arrest, distance between cardiac arrest and onset of CPR, as well as underlying illnesses and their prognosis  In majorGiven the emergency of providing care services in this situation as well as lack of patient clinical capacity to make informed decisions, occurrence of emotionally anxious reactions by patients’ companions and absence of specified clinical guidelines in such cases, physicians might feel confused in the process of decision-making about doing or not doing CPR. This confusion sometimes results in inappropriate decisions and patients who could benefit from CPR may be deprived of this care service and those willing to receive it might have a short life in intensive care unit (ICU) accompanied by major physical problems and mental stresses .Dealing with this issue is not the same in various societies considering the diversity of religious beliefs, rituals and customs, cultures, and as well as socioeconomic status . In thisDespite unprecedented advances in technologies associated with care services, nurses are still engaged in taking care of patients with DNR order, so there is the possibility of involvement or non-involvement of nurses in the process of DNR order . ConsideOnce decisions are made in this domain, nurses left alone with the consequences caused by decision-making about patient and family care. Lack of clear descriptions for patient care can be mostly influenced by nurses’ DNR order and also question the suitability of this decision as well as the benefit of providing specific services for patients with this order –22. ThesProblems that occur in the face of DNR order can fall into intrapersonal and interpersonal ones. In this regard, intrapersonal difference is caused by a conflict between individual values in encounters with DNR order and quick interruption of care services considering long-term sufferings in patients. Interpersonal controversies also take place when nurses’ attitudes are different from those involved in the process of DNR , 25, 26.Considering religious values and beliefs, this issue needs to be delineated all over the world in order to reduce confusion in medical teams at the bedside. Therefore, the purpose of the present study was to investigate nurses’ attitudes towards DNR order in Iran and across the world in a systematic review.This critical survey was conducted using a systematic review protocol. The statistical population included all the articles on DNR order among nurses in Iran and around the world. The search strategy was also fulfilled based on proper combination of Persian and English keywords  and the studies and scientific documents were searched according to the features of search engines or databases. To conduct the given search; the databases of ScienceDirect, Web of Science, Cochrane, ProQuest, Scopus, PubMed, SID, Irandoc, Magiran, and Iranmedex were explored with no time limits to find the related articles. Moreover, the search was carried out in Google Scholar and the website of American Nurses Association (ANA). Furthermore, the references of the selected studies were reviewed to find articles missed in the search process. The search continued on articles published without any time limits until September 2018. Using the notification systems of online databases and Google Scholar, the search for articles was updated until October 2018. The inclusion and exclusion criteria in this study were articles related to DNR order, nurses’ attitudes, descriptive and analytical studies, and those with download links and full texts. Following the search and based on the specified keywords, the duplicates were initially removed and the remaining articles were selected through screen-outs based on titles, abstracts and full texts, considering the inclusion and exclusion criteria. Then, the full texts of the articles were retrieved from the databases upon their open access; and if not so, such articles were crossed out from the study. To assess the quality of the articles, they were reviewed by two individuals and comments by a third person were further used in case of disagreements. To validate and assess the quality of the given articles , critical tools matched with the type of study were employed. To review quantitative and qualitative studies, the Strengthening the Reporting of Observational Studies in Epidemiology (STROBE) and the Standards for Reporting Qualitative Research (SRQR) were also used, respectively. The selected articles were divided into three categories of good, medium, and weak ones in terms of quality. After removing duplicated and non-relevant articles, according to the article extraction form, the remaining ones were analyzed using thematic analysis. The findings were also reported in the form of descriptive tables containing author’s name, year and country of origin, summarized findings, and conclusions of each of the articles. The process of selecting articles and the number of searched, excluded, and included ones were illustrated in Fig. Of the 1663 articles retrieved from the online databases, a total number of 88 articles were examined. Considering the inclusion and exclusion criteria, 10 relevant articles were finally included in the systematic review and the remaining articles were excluded. Of the reviewed articles, 8 cases (80%) were of good quality and 2 articles (20%) were characterized with moderate quality. With regard to study location i.e. the country of origin in which the articles had been conducted, there was one relevant article in each country including Iran, Sweden, Poland, Belgium, Jordan, Australia, Japan, Canada, South Korea, and Rwanda examining nurses’ attitudes towards DNR order.As presented in Table The results of investigating quantitative articles in this systematic review showed that nurses had different attitudes towards DNR order.In the study in Jordan, Al Khalaileh examined nurses’ attitudes and experiences concerning DNR order. In this study, 111 nurses working in three state-run hospitals were investigated. The findings revealed that 21% of the nurses had stated that they had the experience of involvement in decision-making regarding this procedure. Ultimately, it was concluded that such nurses were willing to play a part in DNR order .In Belgium, De Gendt et al. explored nurses’ attitudes towards making decisions about DNR order in geriatrics departments and found that 74% of the nurses had been involved in the process of DNR order. Therefore, these participants acknowledged that they had the choice of DNR order and had also adopted positive attitudes towards this procedure .In one other study by Moghadesian et al. conducted at two universities in the cities of Tabriz and Kurdistan, Iran, a total number of 186 nursing students were investigated and it was reported that nursing students had negative attitudes towards DNR order. However, these students stated that they needed to learn much more about this procedure. It seemed that teaching students about DNR order could change their attitudes in this regard .The study conducted by Manias in Australia also showed that nurses had positive attitudes towards DNR order. Moreover, they put emphasis on involvement of patients’ families, patients, and nurses in decision-making concerning DNR order, since physicians were mostly responsible for such decisions. Finally, they reiterated that it was essential to have standard guidelines for decision-making about DNA order .The results of quantitative studies included in this systematic review indicated that lack of guidelines for DNR order was one of the biggest barriers to implementing this procedure. For example, Goniewics et al. found that 67% of the respondents had assumed the existence of declarations or guidelines for DNR order as a necessary and obligatory issue . Other mMoreover, two qualitative studies investigating nurses’ attitudes and experiences towards DNR order were identified. These investigations had been conducted in Sweden and Rwanda in hospital environments between 2014 and 2017.The main themes of the qualitative studies in this systematic review were role of guidelines in DNR order implementation, lack of a document registration and development system for DNR order, involvement of patients and their families in implementation of DNR order, ethical issues, as well as barriers to provision of proper care services  Table 11.The purpose of this systematic review was to evaluate nurses’ attitudes towards DNR order in Iran and across the world in a systematic review. After half a century, DNR order has been welcomed in many Central and Western European and North American countries and most of healthcare centers in these countries have developed specific policies for this procedure . StudiesMoreover, in the Islamic culture in which life and human life have certain values and life moments are respected with high values, development of guidelines that have transparently elaborated the procedure to make decisions about DNR order and to reduce the interference of personal, impractical, and non-professional factors is of utmost importance. According to the related literature and despite the fact that DNR orders are implemented in some Muslim countries, it is not still legalized to do them. There are currently controversies regarding the legality of this decision in Iran and there is no definitive outcome; however, evidence has suggested that Iran’s legal system has the potential to regulate DNR order and its related issues .The results of the analysis of the selected articles on nurses’ attitudes towards DNR order implied that such attitudes and perspectives could be different in terms of race, religion, country of origin, and other factors. But, in the end, the findings revealed that nurses in most articles had positive attitudes towards DNR order. In the study by Moghadesian et al. 2014) conducted at Tabriz and Kurdistan Universities of Medical Sciences in Iran, nursing students had a negative attitude towards DNR order. Furthermore, such students had stated that they needed to learn much more about this procedure. It seemed that teaching students about DNR order could change their attitudes in this regard  As well, conducteAs well, almost all the studies indicated that it was necessary to implement DNR orders. Instructions or permits as well as legal guidelines for DNR order were also of great importance. Moreover, the nurses participating in the analyzed studies stated that they needed to have the right to make decisions about DNR order given their involvement in such situations. The study conducted by Pettersson et al. (2014) in Sweden similarly showed that it was necessary to develop guidelines and to document DNR orders .In another study by Nankundwa et al. in Rwanda examining a total number of 6 ICU nurses’ experiences concerning patients with DNR order through interviews, it was noted that only physicians had made decisions about DNR cases. Nurses participating in this study also believed that they needed to be allowed to decide about DNR orders. Additionally, existence of guidelines for such a procedure for the nursing group was necessary .Furthermore, the study by Rye Park et al. (1997) on ICU nurses’ perceptions and attitudes towards DNR order in South Korea revealed that 76.6% of the nurses had agreed with the decisions to implement DNR orders based on guidelines and only 22.2% of them considered physicians’ votes as the basis for implementing the given procedure .In other investigations, nurses also considered the existence of instructions or legal guidelines for DNR orders as an essential issue. Given the involvement of nurses in the process of DNR orders, presence of guidelines for DNR orders could prevent confusion and other factors such as psychosocial issues in nurses, legal issues, etc.It should be noted that deciding about DNR orders is a difficult process that can be affected by various factors. The results of the studies in this domain indicated that making decisions regarding the implementation of DNR order should not be based solely on the wishes of a particular person. In the mentioned studies, most of the nurses had stated that nurses, patients, and patients’ families were required to play roles in deciding about DNR orders, and thus their willingness and desires needed to be taken into account. For example, the findings of the study by Goniewicz et al. . In PolaThe results of the study by Manias (1998) on Australian nurses’ experiences and attitudes towards decisions about DNR order also revealed that nurses believed that patients’ families, patients, and nurses needed to get involved in making decisions about DNR orders, since physicians were only responsible for deciding about such orders in current circumstances . In addiThe results of this study showed that, nurses were willing to implement DNR orders in the last moments of patients’ life. It was also suggested to develop a DNR order policy in each hospital to avoid any confusion in this regard. Moreover, it was required to pay attention to nurses’ roles and their encounters at the bedside in such conditions and take necessary measures in policy-making in this domain.


Fringe benefits are an important social support in the work scenario, but empirical research on their effect on the mental health of employees is lacking. This study aims to analyse the relationship between different fringe benefits and depression in urban and rural areas.Chi-square analysis was used to describe the distribution differences of individual characteristics between urban and rural areas in depression groups. Logistic regression was used to further estimate the relationship between fringe benefits and depression between urban and rural areas.People with free lunch in urban areas are less likely to suffer from depression. People with food subsidies in rural areas are also less likely to suffer from depression. The abnormal result is people with housing subsidies in rural areas are more likely to be depressed. The effects of job type and contract on depression were different between urban and rural areas.Employers in urban areas should focus on providing free lunch and the quality of lunch, whereas in rural areas, catering subsidies may be a more appropriate way to improve the mental health of employees. The psychological status of rural workers who receive housing subsidies and have contracts also needs attention. Depression is very common worldwide and is a growing public health concern. More than 260 million people are affected, resulting in 43.1 million full age disability adjusted life years (DALY)  analyse the distribution of specific fringe benefits between urban and rural depression groups; and (2) analyse the differences in the relationship between specific fringe benefits and depression in urban and rural areas. This study fills the gap in research on the relationship between social support-fringe benefits and depression in the employed population.This study contributes to the precise intervention of depression. Firstly, the research on the relationship between fringe benefits and depression is conducive to the rational allocation of work welfare resources and to the alleviation of fatigue and burnout caused by work, thereby improving the happiness of employees. Secondly, the research on China's urban and rural areas has implications for other developing countries and regions to effectively adjust their employee welfare policies.The data used in this study were obtained from China Health and Retirement Longitudinal Study (CHARLS) targeting the middle-aged and older population (45+ years) in China. The data used in the study came from the China Health and Retirement Longitudinal Survey (CHARLS), a large-scale survey conducted by the National Development Research Institute of Peking University and jointly implemented by the Chinese Social Science Survey Center of Peking University and the Youth League Committee of Peking University. Interdisciplinary survey project. The national baseline survey was carried out in 2011. Survey visits were carried out in 150 counties and 450 communities (villages) in 28 provinces  across the country in 2011, 2013, 2015, and 2018. Due to the large number of samples lost in the longitudinal study (withdraw from the survey). The study used data from the most recent survey in 2018, and a total of 1,891 samples entered our analysis.The 10-item  Center for Epidemiologic Studies Depression Scale (CES-D10) was used to describe the depression symptoms. The responses for CES-D10-based questionnaire were coded on a four-point scale from 0 to 3. Therefore, the individual's depression score range is 0–30; 0 means perfect mental state, whereas 30 reflects the most serious depression symptoms. A CES-D10 score ≥12 the mental health of employees indicates depression , 19. Thevia questionnaire whether they have the following nine fringe benefits . To examine the relationship between the diversity of fringe benefits and depression, these variables were assigned values according to the respondent's “Yes” and “No,” and a binary variable was used to represent the individual's status in each fringe benefit.Individuals with stable employment were asked The SES variables analyzed in this study included gender, age, marital status, education, income, living arrangement and lifestyle. Age was divided into three subgroups, namely, 45–50, 51–60, and 61 years old or older. Education in this study was divided into four levels, namely, primary school or below, junior middle school and senior high school and above. Marital status is defined as a binary variable, which means that married couples who live with or temporarily do not live with their spouse have a spouse, whereas other marital statuses indicate having no spouse. Family income was used to measure the economic status of the respondent, and quintile was used to show their economical level. Based on whether the respondents lived in the same town or city as their children, the respondents' living arrangements were divided into two groups. Smoking and drinking were included in the study and classified by lifestyle of smoking or drinking in the year before the survey.The state of physical health was represented by chronic disease, disability and self-rated health (SRH). Chronic disease variable was divided into three groups, namely, no chronic disease, only one chronic disease and two or more chronic diseases. Self-perceived health is divided into four groups, namely, very good, good, fair, poor or very poor. Disabilities were divided into two groups based on whether or not they answered “yes” in the ADL  survey. Based on whether the respondents lived in the same town or city as their children, the respondents' living arrangements were divided into two groups.To control the confounding effects of job-related variables, the study also included the type of work unit, the position of the employee, the professional and technical level of the employee, the presence or absence of contract, the form of wage payment and job satisfaction as the control variables. The type of work unit is divided into four groups, as follows: government, public institutions or NGO; Firm; Individual firm; and Individual household. According to whether the employee has leadership position and professional skill level, occupation type and professional skill are divided into dichotomous variables. Salary payment method was divided into two categories, namely, monthly salary and other. Job satisfaction is divided into three categories, as follows: completely satisfied and very satisfied; relatively satisfied; not very satisfied; and not at all satisfied.Chi-square analysis was used to test the differences in respondents' characteristics among depression groups within urban and rural areas. Then, logistic regression on urban and rural areas with depression as the outcome variable was performed to explore the association between fringe benefits and depression.p < 0.05.STATA software 13 was used to execute the Chi-square analysis and logistic regression with statistical significance at Ethical approval for data collection in CHARLS was obtained from the Biomedical Ethics Review Committee of Peking University (IRB00001052–11015). All interviewees gave written informed consent before recruitment.We also found that in urban areas, people who are employed in individual households are more likely to be depressed, but there was no significant association in rural areas. People with employment contracts in rural areas are more likely to be depressed. These results suggest that there are differences in the factors affecting depression between urban and rural areas, which is worthy of further discussion.We found that people with free lunch in urban areas were less likely to be depressed. People with food allowance in rural areas were also less likely to be depressed. People with housing allowance in rural areas are more likely to be depressed. The effects of job type and contract on depression were different between urban and rural areas.Urban and rural economic development and working conditions are different. Compared with rural employees, urban employees may enjoy a higher-quality lunch, which also reduces the mental pressure brought about by the economic burden of life to a certain extent. The quality and value of free lunch in rural areas is limited, so it may not significantly improve the mental state of employees. One study indicates that the satisfaction degree of working meal is related to food quality and service level . And theUrban and rural housing system and social environment may be the potential explanatory factors of the relationship between housing allowance and depression in rural areas. Housing subsidy is given by employers to employees who do not have their own housing. China's rural housing system is the homestead system, which means that farmers can build their own houses on their own on collective land . On one The lack of formal support, such as social welfare, may be responsible for the relationship between work unit type and depression. Individual households are different from individual industrial and commercial households in terms of the types of employers. Individual households comprise informal employers that rely on social relations and rules for governance. They lack formal business registration. Therefore, formal social welfare, such as industrial, commercial and unemployment insurance, cannot be handled for employees. Compared with the social welfare support provided by a large number of formal enterprises in urban areas, this relative mental deprivation will be more intense, thereby aggravating the symptoms of depression. In rural areas, small and medium-sized and small and micro enterprises are the main employment agencies . The hetConflict governance mechanism of social relations may be the potential reason for the relationship between contract and depression. Social relations in rural areas in China are social networks composed of acquaintances, such as relatives and neighbors . The govFirstly, the types of fringe benefits in the study include basic life support. In fact, the types of extra benefits may include life support and recreational activities  and holiday gifts. However, no relevant items are found in the questionnaire. Thus, more research on non-life support is needed. In addition, more samples with more balanced characteristics need to be further analyzed when future data becomes available.Secondly, this is a cross-sectional study that did not consider the effects of time and longitudinal changes. Although the survey of the data source is a longitudinal survey, a sample with fringe benefits information is missing too much from the longitudinal survey. Moreover, the study only used samples over 45 years old due to the age limit of the survey respondents.Moreover, the study includes family surveys and excluded high-risk groups, such as those who could not recover from hospitalization for major mental illness. However, this situation also shows that the results are relatively robust.The relationship between fringe benefits and depression in urban and rural areas differs. Employees in urban areas who have free lunches are less likely to be depressed. Employees in rural areas who have subsidized meals are less likely to be depressed. People with housing allowance in rural areas are more prone to developing depression. Employers in urban areas need to pay attention to the free provision and quality of lunch, whereas in rural areas, providing catering allowance may be a more appropriate way to improve the mental health of employees. In addition, the mental state of employees who have received housing allowance and have contracts in rural areas needs to become a focus of research.The original contributions presented in the study are included in the article/supplementary material, further inquiries can be directed to the corresponding authors.All procedures performed in this study involving human participants comply with the Ethical Standards of Institutions and/or National Research Committees, as well as the 1964 Helsinki Declaration and its subsequent amendments or similar ethical standards. Ethical approval for data collection in CHARLS was obtained from the Biomedical Ethics Review Committee of Peking University (IRB00001052–11015). All interviewees gave written informed consent before recruitment. The management agency of Peking University's public data approved our data use application.TL wrote the manuscript. CY conceived the idea and provided suggestions for the discussion of the manuscript. XZ critically revised the paper. All authors read and approved the final manuscript.This research was funded by National Science Foundation of China (Grant Number: 72074084). The funding body only provided financial support for the research, and did not participate in any part of the research, such as research design, data analysis, manuscript writing, etc.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.