Elaeis guineensis Jacq.) is typically propagated in vitro by indirect somatic embryogenesis, a process in which somatic cells of an explant of choice are, via an intermediate phase of callus growth, induced to differentiate into somatic embryos. The architecture of the oil palm, lacking axillary shoots, does not allow for vegetative propagation. Therefore, somatic embryogenesis is the only alternative to seed propagation, which is hampered by long germination times and low germination rates, for the production of planting material. The current oil palm somatic embryogenesis procedure is associated with several difficulties, which are described in this review. The limited availability of explants, combined with low somatic embryo initiation and regeneration rates, necessitate the proliferation of embryogenic structures, increasing the risk for somaclonal variants such as the mantled phenotype. Several ways to improve the efficiency of the tissue culture method and to reduce the risk of somaclonal variation are described. These include the use of alternative explants and propagation techniques, the introduction of specific embryo maturation treatments and the detection of the mantled abnormality in an early stage. These methods have not yet been fully explored and provide interesting research field for the future. The development of an efficient oil palm micropropagation protocol is needed to keep up with the increasing demand for palm oil in a sustainable way. Mass production of selected, high-yielding palms by tissue culture could raise yields on existing plantations, reducing the need for further expansion of the cultivated area, which is often associated with negative environmental impacts.The oil palm ( Elaeis guineensis Jacq.) is a tropical plantation crop cultivated for its production of two types of vegetable oil: palm oil and palm kernel oil. It is a monocotyledonous species belonging to the family of Arecaceae, which includes more than 2,000 palm species. The genus Elaeis contains two species: E. guineensis or African oil palm and E. oleifera or American oil palm. The African oil palm is native to West Africa, but nowadays 84% of palm oil production takes place in Indonesia and MalaysiaE. oleifera × E. guineensis is mainly cultivated in South America . In this process somatic cells of a plant tissue of choice differentiate, via an intermediate callus phase, into bipolar structures resembling zygotic embryos  and growth conditions. Although the potential of SE has been shown for many different plant species, only a few species are propagated at large-scale by SE   medium  is added at a concentration around 2.5 g L−1. In a few cases agar is used. On top of AC and putrescine, some other additives are frequently added to the culture medium. These include hydrolyzed casein  the initiation of SEs out of EC cultures, and (2) the conversion of SEs in fully developed plantlets.Depending on the genotype used, between 1 and 52% of immature leaf explants form callus  predicts normal fruit set, while hypomethylation , which might arise during stressful tissue culture procedures, leads to alternative splicing of EgDEF1 and the formation of an incomplete protein. This truncated protein is involved in the establishment of the typical homeotic transformation present in mantled palms  they are highly responsive to culture conditions; (2) they are almost free of microorganisms; and (3) they can easily be harvested in large amounts without damaging the ortet  those aiming to limit the incidence of somaclonal variation, and (2) those aiming to detect mantled palms in an early stage, as to avoid they are sold to plantation holders. The former includes interventions such as an increased efficiency of SE, the use of alternative micropropagation methods not based on SE or the use of alternative explant types with higher availability. The latter includes the development of a rapid and affordable detection technique for early detection of mantled palms. Both types of interventions are discussed below.In this review several ways to increase the efficiency of the oil palm micropropagation protocol have been put forward, including the use of alternative explant types, the development of a micropropagation method not based on indirect SE or the increase of SE initiation and regeneration rates. As shown in Another way to limit the impact of the mantled abnormality on oil palm tissue culture, is the detection of affected plantlets before they are being planted in the field. In this way, no labor, plantation area and resources are spilled to mutated plantlets and a yield reduction is avoided. By incorporating a detection step in the propagation protocol, the delivery of high-quality, mantled-free planting material can be assured.Karma (see above), that a detection test was developed by Orion Biosains, a subsidiary of Orion Genomics. The so-called SureSawit™ KARMA test allows for the detection of mantled palms at the nursery stage. With the use of a collection kit, a leaf punch is taken and sent to the laboratory for analysisKARMA can be easily detected with a PCR assay  Plantation holders would possibly like to see the performance of the test with their own eyes, before implementing it to large scale. This might take several years, namely until the first tested palms are flowering and it can be visually confirmed that they do not exhibit the mantled phenotype; (3) The test might not perform as well as expected, for example due to large genotype-dependent variation, with lots of false negatives popping out. More research is needed to validate the SureSawit™ KARMA test.A fast increase in production of tissue culture plant material was expected to be associated with the development of this test, but, as far as we know, the production is still on a low level. Several hypotheses for this can be put forward: (1) The cost of the SureSawit™ Karma in the establishment of the mantled phenotype could deliver important information for optimization of a detection test.An efficient detection technique for early identification of mantled plants, seems inevitable to increase the demand of tissue culture plant material. Therefore, the possibilities to optimize current detection technique should be examined. Also, the efficiency of other methylation detection techniques, not based on bisulfite treatment, on the early detection of the mantled abnormality can be tested. Bisulfite treatment is the most common technique for studying DNA methylation but has several drawbacks, including the inclusion of a costly and time-consuming sample preparation step, and the risk for DNA degradation by the harsh reaction conditions applied (Flusberg et al., To date, the large-scale production of oil palm plantlets by tissue culture is limited because of several difficulties associated with the propagation procedure, which is based on indirect SE starting from immature leaf explants. In this review, several research directions have been put forward, that aim to allow mass production of tissue culture planting material while limiting the risk for somaclonal variation. Some of the proposed techniques, e.g., direct SE and floral reversion, might be more challenging and less likely to be successful than others, but the most challenging techniques could also provide the most progress toward a more efficient and reliable oil palm micropropagation protocol. To allow mass propagation of oil palm by tissue culture, most likely a combination of several different adaptations to the protocol will be needed, indicating the importance of the investigation of several of the proposed research topics instead of focusing on one technique. For example, an increase in SE induction and/or regeneration efficiency alone could increase the number of plantlets produced from a single isolation of immature leaves and could thus reduce the need for a proliferation phase but it will never allow the elimination of callus or embryoid proliferation completely. Somaclonal variation will thus still be present to a certain amount. On the other hand, if an increase in SE induction and/or regeneration efficiency could be combined with a performant new detection technique, mass propagation of reliable oil palm tissue culture plantlets could be achieved. Tissue culture planting material provides many advantages over hybrid seeds in increasing oil yield on the current cultivated area. Since the demand for sustainable palm oil keeps growing, it is important to keep investing in the optimization of oil palm tissue culture procedures.The manuscript was prepared by SW and reviewed by DI and LM.SW and LM were employed by the company Deroose Plants NV. The remaining author declares 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 ESR International Forum at the ECR 2019 discussed strategies for engaging the young generation. The future of radiology is a crucial topic that goes hand in hand with tomorrow’s radiologists. The European Society of Radiology (ESR) established the ESR International Forum in order to discuss hot topics in the profession of radiology with non-European radiological partner societies. At the ESR International Forum 2019, different strategies, initiatives and ideas were presented by the different societies with regard to engaging young doctors into radiology. It is important to understand the characteristics of the younger generation and develop a new approachYounger generation needs to be guided, mentored and delegated more responsibilitiesNew and innovative forms of engagement through technology need to be adoptedRadiologists’ role is changing, and the image of a radiologist’s job accordingly needs to be re-envisionedIncreased use of social media and technology is the crucial element for engaging the younger generationThe ESR International Forum was established by the European Society of Radiology (ESR) with the aim of discussing pivotal themes in the field of radiology with international societies from outside Europe. The ESR International Forum is held every year at the European Congress of Radiology (ECR) and participation is by invitation only. Previous topics discussed are the relation between radiology and nuclear medicine, the position of ultrasound in radiology, the relation of general radiology and subspecialty radiology, the implementation of clinical decision support and imaging referral guidelines in the clinical routine, the position of interventional radiology within radiology, and value-based radiology.The following societies were invited to deliver a presentation and to present the point of view of their respective country or region: The American College of Radiology (ACR), the Asian Oceanian Society of Radiology (AOSR), the Brazilian College of Radiology (CBR), the Canadian Association of Radiologists (CAR), the Chinese Society of Radiology (CSR), the Colombian Association of Radiology (ACR), the Egyptian Society of Radiology and Nuclear Medicine (ESRNM), the Indian Radiological and Imaging Association (IRIA), the Inter-American College of Radiology (CIR), the International Society of Radiology (ISR), the Japan Radiological Society (JRS), the Korean Society of Radiology (KSR), the Mexican Federation of Radiology and Imaging (FMRI), the Mexican Society of Radiology and Imaging (SMRI), the Radiological Society of North America (RSNA), the Radiological Society of Saudi Arabia (RSSA), the Radiological Society of Thailand (RST), the Royal Australian and New Zealand College of Radiologists (RANZCR), the Royal College of Radiologists of Thailand (RCRT), and the Radiological and Diagnostic Imaging Society of Sao Paulo (SPR). The host presented the situation in Europe. In addition, representatives of non-European past “ESR meets” countries of the last five years were invited to the meeting.Canadian Association of Radiologists (CAR). Placing special emphasis on engagement as the main task of any association, E. Lee pointed out that in a landscape that is increasingly competitive, it is important to demonstrate value and appeal to current and future members. Historically, radiology has been considered one of the most competitive specialties in the Canadian Resident Matching Service (CaRMS). In recent years there has been widespread speculation that applications are decreasing as the number of radiology positions has increased while number of applicants has not grown commensurately. The situation has, however, mostly corrected itself. Currently around 80% of Canadian radiologists are members of the CAR. Seeing how the constant increase of membership is vital for the healthy functioning of the association, the CAR has set a goal of 2% increase in membership per year, with the increase in 2018 being 10%. In order to achieve this goal CAR is strongly focusing on residents, while maintaining relationships with reciprocal provinces and developing new partnerships with non-reciprocal provinces. In order to tackle the challenge of motivating resident members the CAR has implemented a strategy targeted specifically at them, such as a dedicated resident section on the CAR website, discounted membership and conference registration, and a Membership Working Group, among others. E. Lee explained that the idea behind the strategy is that the chances of retention are significantly increased if members can be recruited before they enter the workforce. The CAR emphasises word of mouth and testimonials as one of the most important communication techniques. According to E. Lee, having ambassadors spread the word will be the single most effective method in reaching the association’s recruitment and retention goals. Vital elements of this approach are identifying key opinion leaders that can speak the key messages, liaising with non-members, providing a visibility platform and empowering ambassadors with tools and resources. Finally, E. Lee outlined significant opportunities for internationals. The CAR can help bridge the connection and provide information on placements and jobs for new graduates as well as offer a discounted rate for international members as an excellent way of getting Canadian specific information.E. Lee presented on behalf of the Radiological Society of North America (RSNA), explained that encouraging young people to join and become members is a high priority. The societies are competing for members’ time and money. That is why it is important to understand what young people want and need, as opposed to what the societies think they need. In order to tackle this issue, the RSNA has developed a variety of tools, including free membership , volunteer committee service opportunities, a specialised Resident and Fellow Committee, introduction to Research programme, R&E Foundation grants, as well as the RSNA Diagnosis Live gaming tool that is free for residency programs worldwide. The RSNA gives special attention to early-career practitioners. They do not pay full dues during the early years of membership but nevertheless have full access to the RSNA Annual Meeting and journals, volunteer service opportunities, education for all aspects of any type of career as well as R&E Foundation grants.American College of Radiology (ACR), emphasised the incredibly vibrant resident and fellow section of the ACR. The ACR provides free membership to residents and fellows and offers representative governance to both trainees and young practicing physicians including a seat on the ACR board for this latter group. This representation allows residents and fellows to bring policy resolutions to the ACR Council floor, thus effectively highlighting topics that are pertinent to this community. An important activity mentioned by G. McGinty is the ACR community’s active engagement on social media as well as its internal networking platform called Engage. This online conversation helps identify concerns among the trainee and young physician groups and helps set priorities for the organisation as a whole.G. McGinty, on behalf of the V. P. Jackson, presenting on behalf of the Mexican Federation of Radiology and Imaging (FMRI), presented the current situation in Mexico. Due to the fact that only around 50% of the 164 medical schools and faculties in Mexico include radiology in their curriculum, the students have little knowledge and interest in radiology. That is why the FMRI strives to generate interest among medical students. In order to achieve their goals, the FMRI has asked the Secretariat of Public Education to include radiology in all their programmes. The FMRI also provides teaching tools and the newest technologies to faculties and schools and actively involves students in the learning process. M. Hernandez Cruz further provided an example of a successful case study from the Universidad Autonoma de Nuevo Leon. This university includes radiology in its program and offers students with the best results the opportunity to become instructors after successfully finishing a course, thus giving the students an active role in the teaching-learning process. This approach has resulted in an increased interest in radiology and its role in patient care. Additionally, 118 students have so far took part in the radiology course as instructors, more than 50 applicants per year have registered for the program and the overall success of the students in the medical school has increased. Finally, M. Hernandez Cruz summarised the strategy for demonstrating medical students the importance of radiology. He emphasised the need for image in patient care, leadership in healthcare and innovation and technology, pointing out that radiologists must see new technologies as an opportunity. In conclusion, M. Hernandez Cruz expressed positivity regarding the future of radiology saying that radiology will continue to be an important part of medicine.M. Hernandez Cruz, on behalf of the Mexican Society of Radiology and Imaging (SMRI), spoke about the importance of understanding millennials as the new generation. According to M. Palacios Montesinos, regardless of their nationality millennials have some common traits, such as being digital natives and multitasking among others. The societies need to adopt new programmes, motivate and encourage millennials, and develop specialised plans tailored to each generation. M. Palacios Montesinos presented three main strategies of the SMRI. Firstly, it is important to spread enthusiasm, with a dose of reality, to better understand technological processes and to encourage and guide young people. Furthermore, activities aimed at the younger generation need to be posed as challenges or goals and it is crucial to dedicate time and effort to obtain positive results. Finally, investments in communication technologies and the promotion of virtual training tools, technological advances and the A.I. are crucial. M. Palacios Montesinos concluded that the historical, political, social, cultural and technological changes have marked and moulded the millennials in different ways and that their role and generational importance will depend on their way of engaging with the world.M. Palacios Montesinos on behalf of the Colombian Association of Radiology (ACR), presented the context of radiology education in Colombia. The country operates 18 radiology post-graduate programmes, with 265 residents currently in the ACR. Since 2017 the ACR established quality standards programme for radiologist in training. The programme serves as a reference for universities’ self-assessment of training programmes and allows them to develop new education curricula. M. E. Oyuela pointed out that in order to engage new generations it is crucial to identify radiologists’ mental barriers. Having those barriers in mind, the ACR has developed a strategy proposal divided into two aspects: technological/academic and humanistic. From the technological and academic point of view, M. E. Oyuela emphasised the importance of training with a systematic approach, allocating time and resources for research and greater involvement of mentors. Online radiological networks, web-based learning, social media as well as delegating residents responsibilities in accordance with their competences present important aspects of the ACR strategy. From the humanistic point of view, important elements include person centred care, communication skills, work in interdisciplinary groups, professional and ethical competence, greater work-life integration, equality of opportunity regardless of gender, emotional support, empathy and respect. Finally, M. E. Oyuela stressed the importance of minimally invasive procedures, promotion of accredited services, adapting to change and participation in the society’s activities. M. E. Oyuela concluded that these strategies will contribute to the engagement of new generations of young radiologists, and ultimately lead to better professionals and better human beings.M. E. Oyuela representing the Brazilian College of Radiology (CBR), presented the background information on the society as the official national entity representing the radiologist in Brazil. The society currently has more than 12,000 radiologists, with around 40% younger than 40 years. There are currently 212 centres for training in radiology in Brazil with 2,212 residents in training. A. Sarmet Santos pointed out the importance of understanding what young people expect form the societies - learning and professional formation, protection of their interest and opportunities other than just a job. In that sense the CBR organises the annual Brazilian Congress of Radiology, continuous medical educational courses, annual ESOR courses as well as hands-on courses. A. Sarmet Santos further pointed out that the CBR publishes formal job opportunities in every communication outlet of the CBR and offers special awards to residents. The CBR highlights opportunities for clinical and research fellowships for young professionals, within and outside the country, by consulting a network of established academic radiologists. Furthermore, the CBR has an agreement with the Brazilian Ministry of Education aimed at supervising and preforming regular evaluation of every residence program in the country. The CBR also acts in cooperation with the Brazilian Medical Association and Federal Council of Medicine to ensure a reliable radiology practice for all professionals, especially the new ones, and offers general legal counselling to every member of the CBR. A. Sarmet Santos emphasised the importance of mobile learning initiatives and other educational initiatives such as Radiologia Brasiliera journal, open access journal, hands-on training and face-to-face training series. Finally, A. Sarmet Santos presented the CBR goals for the 2019-2020 period, primarily the launch of the CBR’s Virtual Learning environment, that will offer distance courses and performance evaluation.A. Sarmet Santos, on behalf of the Radiological and Diagnostic Imaging Society of Sao Paulo (SPR). The SPR is a society of more than 7,000 members, with around 50% younger than 34 years. The SPR offers these young professionals several benefits that provide a high level of educational content and opportunities for professional improvement. C. Homsi pointed out the online course for residents that is free of charge for members of the SPR and content-wise provides all the information that a resident should know at the end of the 3-year programme of residency. Another important tool of the SPR is the Feres Secaf course, a 4-day event with 180 lecturers and more than 1,800 participants. The course serves as the annual residents meeting and its scientific program offers themes regarding daily routine of diagnostic imaging, professionalism courses as well as case review discussions. C. Homsi further mentioned the activities of the Roentgen Club and the Manoel de Abreu Club that offer lecture presentations and case-based review discussions with cases being prepared and presented by the residents. The SPR maintains 15 subspecialist study groups with more than 4,000 participants in 2018, as well as subspecialist advanced courses. The SPR also invests in the hybrid teaching model, a program that starts with an online theoretical phase and then develops the practical module. C. Homsi pointed out that all the members of the SPR have free access to the STATdx platform, the world's largest digital radiology database and that the SPR offers opportunities for residents to participate in international fellowships programs, international congresses and international courses. He concluded that the SPR is very successful in attracting young radiologists and that their main concerns currently are the specialist over 46 years of age that are losing their interest in radiology.C. Homsi, represented the Interamerican College of Radiology (CIR), gave an overview of the CIR that was founded in 1943. He pointed out the importance of defining the generations properly, making a distinction between millennials, born between 1981 and 1996, who are now residents and radiologists, and post-millennials, born from 1997 onward, who are currently students. As each generation has its own characteristics H. Carrete Junior presented the key factors that in his view differentiate these two groups and suggested adopting a special approach towards the Gen Z as they are the first truly digitally native generation that is accustomed to having information at their fingertips. H. Carrete Junior therefore suggests adopting new strategies for teaching the Generation Z focusing on short lectures with graphical and digestible content, maintaining relevance by explain upfront why a lesson is needed and how it can be applied in the real world as well as establishing student alliances. When it comes to residents and young radiologists H. Carrete stressed the importance of implementing a variety of teaching methods focused on innovation and the issue rather than the organisation. Ultimately, it is important to promote competitions or challenges and demonstrate social responsibility.H. Carrete Junior, representing the Egyptian Society of Radiology and Nuclear Medicine (ESRNM), spoke about the situation in Egypt. He presented the main problems faced as well as the strategies implemented by the ESRNM to overcome them. Lack of an applicable plan for continued education leads to the young generation not being aware of how the learning process is going to continue. The ESRNM thus proposes setting up a plan with clear methods of application, instructing the young generation and setting up orientation meetings to be done by the training committees all over Egypt. One of the problems faced by the younger generations is that professional training using advanced tools is very localised and limited to certain hospitals due to a relatively low number of such tools in comparison to the number of radiologists. The ESRNM proposed designing a clear clinical training programme that facilitates rotation of the junior radiologists in well-equipped hospitals. T. El-Diasty also spoke about the difficulties faced by the younger generation regarding external training. Very few opportunities for joining western radiology fellowship programmes are available to Egyptian radiologists. The ESRNM therefore advocates for a more active involvement of sponsors and cooperation with international societies/organisations. An important issue is that research is not widely well implemented in universities, teaching hospitals and governmental hospitals. As much as 70% of radiologists in Egypt have not been engaged in any research activity due to limited capacity or lack of mentoring and motivation. The proposed solutions aim to create research teams that offer research courses, provide a research plan to each group of hospitals based on their needs and location and to engage radiologists. Additionally, the ESRNM offers lectures, courses and workshops on scientific writing at different radiology departments and annual conferences and promotes publications through international journals including the Egyptian Journal of Radiology and Nuclear Medicine (EJRNM). Finally, T. El-Diasty pointed out that most of the young generation is not aware of membership benefits. He concluded that the younger generation should be offered free membership, free/reduced registration for training courses/national and international meetings, educational materials, and membership in other societies.T. El-Diasty, on behalf of the Radiological Society of Saudi Arabia (RSSA), presented the demographic background of the country emphasising the strength of a very young, well-educated population. L. G. Jamjoom explained that leaders from every area of the society have created an action plan to be completed by 2030 with three fundamental objectives being a vibrant society, a thriving economy and an ambitious nation. In the context of education, and in particular medical education, L. G. Jamjoom pointed out that radiology is integrated in every module throughout the 3rd year of medical school education with medical students additionally attending an intensive 2 week radiology course during the 4th and the 6th year, with lectures in all radiology subspecialties, practical rounds and students’ presentations. Radiology department at the King Abdulaziz University Hospital (KAUH) hosts approximately 10 to 12 interns every month, and the interns get the chance to shadow the residents and attend lectures and departmental meetings. When it comes to residents, there are currently 40 residency programs with a total of 547 residents. Approximately 20 years ago, the government has created a very successful scholarship programme; 90% of Saudi board-certified radiologists complete the fellowship training, with 70% of them doing the fellowship training abroad. The country operates 7 body imaging and non-vascular intervention fellowship programmes and 8 interventional radiology fellowship programmes. In conclusion, L. G. Jamjoom stated that the RSSA plays an active role in education through providing visiting professors for different regions as well as through international collaborations.L. G. Jamjoom, on behalf of the Indian Radiological and Imaging Association (IRIA), presented the situation in India. Radiology is one of the most sought-after specialties in India for more than a decade. More than 50% of radiologists in India are younger than 42. In order to identify the main needs of the younger generation, the IRIA conducted a survey, resulting in a list of priorities and consequently appropriate actions and solutions. Some of the needs expressed by the younger generation include, inter alia, learning for everyone, the use of technological advances such as 3D printing and molecular imaging, increased use of web and social media, as well as more financial support for innovative ideas. In order to tackle these issues, the IRIA has developed a variety of tools aimed at helping the younger generations and meeting their needs. The IRIA organises CMEs at various state and district levels so that radiology teaching can reach every corner of the country, with this year’s primary focus on Interventional Radiology and Breast Imaging. Due to a large interest of the younger generation in sonography, H. Patel pointed out that the IRIA also organises a SonoSummit, the largest conference focused on sonography in India that has workshops and live demos at the forefront. One of the most important initiatives launched by the IRIA is the Youth Wing of Radiology (YUWA), working exclusively on the welfare of postgraduate residents and young radiologists. As part of its activities in 2019, YUWA celebrated international women’s day in 100 cities in India, organising meetings exclusively for women radiologists and dealing with topics such as women's imaging, finance management and health tips. H. Patel concluded that the YUWA initiative helps understand and address the problems faced by radiology residents and young radiologists, serves as a platform to showcase talent of the younger generation and helps radiology residents by preparing them for future challenges.H. Patel, on behalf of the Royal College of Radiologists of Thailand (RCRT) and the Radiological Society of Thailand (RST), provided background information regarding radiology training in Thailand. A. Churojana explaining that there are currently 8 institutes that provide training in diagnostical radiology, radiation oncology and nuclear medicine. The quotas for training in diagnostic radiology in 2019 have been filled, indicating interest of the younger generation in this field. However, as it is important to engage the younger generation even further, A. Churojana presented a three-fold approach for achieving that goal, namely undergraduate promotion, postgraduate promotion and public promotion. Undergraduate promotion aims to convey main principles of radiology and image interpretation, provide positive attitude towards radiology and introduce advanced tools. Postgraduate promotion entails a roadshow regarding radiology training, “open house” activities of each institute, radiology outreach meetings/programmes, team building activities in radiology and establishing connection and collaboration between all related radiological societies. Finally, A. Churojana explained the importance of public promotion in Thailand. Public promotion is done through a specialised website aimed at undergraduates that promotes radiology and related fields, explains treatment of diseases and fosters interest in new technologies and tools. A. Churojana concluded that an important part of public promotion is inviting medical students and young radiologists to be part of public promotion teams as well as organising Corporate Social Responsibility (CSR) events.A. Churojana, presenting on behalf of the Chinese Society of Radiology (CSR), spoke about the situation in China. China currently has around 16,000 radiologists, 30% of which are young radiologists. Z. Y. Jin stressed the importance of understanding the character of the young generation for developing a correct approach. Younger generation is independent, creative, self-confident and energetic. Accordingly, the approach must be flexible and must not involve over-management of the younger generation. Z. Y. Jin pointed out that it is important to create an environment with best modalities, best technologies and best mentors for the young generation and to develop personalised pathways in order to find the right person for the right position. In that sense the CSR provides a lot of opportunities for younger people including standardisation of the fundamental training programmes and diverse training programmes/chances from the academic societies and institutions.Z. Y. Jin, on behalf of the Korean Society of Radiology (KSR). The action plan of the KSR for engaging the younger generation includes a membership committee, webpage with a member lounge, as well as a specific Korean Congress of Radiology (KCR) event. The webpage provides younger generation with the opportunity to anonymously upload any comment or question that is replied by a KSR officer. Two keywords of the KSR strategy aimed at the younger generation are communication and share of information. A vital aspect of communication is the opportunity to discuss any topic or idea and make inquiries via the website. W. Lee explained that this in turn allows the KSR to identify problems by collecting and categorising data and provide improved service to the young generation based on the collected data. When it comes to the share of information, the KSR makes sure to collect basic member information, develop databases or distribution charts and help the young generation find the information easily. Finally, it is important to engage young generation even more in events such as the KCR. During the KCR, the KSR provides a young radiologists lounge, organises photo contests and movie clips/user-created content (UCC) contests where participants capture the moments of the KCR and have a chance to win awards and prizes.W. Lee presented on behalf of the Japan Radiological Society (JRS), talked about the situation in Japan. Y. Imai initially presented the strategies for research work pointing out that the JRS offers several awards to young researches, including academic awards, JRS related awards as well JRS related research grants. The Japan Radiological Society also focuses on strategies for medical training abroad fostering exchange programmes such as the Japanese-German Radiological Affiliation and the French Society of Radiology – Japan Radiological Society (SFR-JRS) Fellowship Program Exchange. Furthermore, Y. Imai explained that the most expected development happening in the next generation would be the application of A.I. to radiology with multiple effects. Y. Imai, however, pointed out that recently there has been a false rumour that radiology specialists are one of the jobs to be replaced by the A.I. Consequently, the number of young people who aspire to become radiology specialists is decreasing and there is a fear that people in general will pay less attention to the radiologists’ job. That is why it is of paramount importance to have open lectures and events in order to spread the idea of the importance of the radiologists’ job that includes not only diagnosing the disease, but also selecting an appropriate treatment for each patient. The A.I. is a useful tool for radiologist but ultimately only a radiologist can check whether the A.I. made an error. Accordingly, the JSR is preparing a special corner for the public, including children, at the General Assembly of the Japanese Association of Medical Sciences (JAMS) in order to demonstrate the most recent advancements in radiology.Y. Imai, on behalf of the Asian Oceanian Society of Radiology (AOSR), presented some background information on the AOSR. As the AOSR assembles different national societies it cannot deal with individual country-specific issues only. That is why the AOSR established the Asian Oceanian School of Radiology (AOSOR). The three major projects of the AOSOR include the AOSOR Conjoint Session, the AOSOR Youth Club and international visiting professors. D. Varma put special emphasis on the AOSOR Youth Club as an important initiative to engage the young generation. The AOSOR Youth Club was established in 2015 with the main aims of providing intensive basic leadership skills, fostering engagement of future AOSR leaders, strengthening inter-society relationship and establishing AOSOR-YC alumni. The Youth Club organises 3-day leadership training courses for around 15 trainees from member societies with tutors sponsored by AOSOR and the host society. D. Varma concluded that this approach provides a different solution for engaging the young generation and will hopefully result in a network of young radiologist who have attended the Youth Club. The 2019 AOSOR Youth Club is taking place October 16-19 in Nagoya, Japan.D. Varma, on behalf of the Royal Australian and New Zealand College of Radiologists (RANZCR). A large part of the RANZCR responsibilities is to set the curriculum and administer training programmes for admission into radiology professions, accreditation for overseas-trained specialists, and a continuing professional development programme for the members. Speaking about the numbers, L. Lawler pointed out that the RANZCR currently has a 1:4 ratio between students and practicing radiologists. Apart from the training programme itself, the RANZCR connects with trainees at every level through elected representative trainee committees as well as by having trainee representative on the Council and most decision-making committees. A Trainee Learning Day for clinical radiology and radiation oncology forms part of the College’s Annual Scientific Meeting (ASM). The Day’s program is determined by the Trainee Committees and usually includes teaching sessions, trainee scientific presentations, a discussion forum and dedicated topical sessions. An important element is the RANZCR Branch of Origin, established to support the training research requirements of Clinical Radiology. Participating Branches hold an annual trainee presentation evening with the most outstanding presentation from each Branch being presented at the College’s ASM in the ‘Branch of Origin’ session. The winner is announced at the Gala Dinner. Finally, L. Lawler pointed out that a big focus of the College staff is to maintain a social media presence as well.L. Lawler presented on behalf of the European Society of Radiology (ESR). The main objectives of the ESR are to engage medical students early and throughout their medical school curricula as well as to emphasise the intellectual, imaging and procedural components of radiology. The ESR has produced the undergraduate curriculum, that is being updated every year, and has defined several aspects that need to be considered regarding the needs of the undergraduates. C. Catalano pointed out that the ESR pays a lot of attention to teachers, stressing the importance of providing adequate teaching materials. It was further stated that the AI is an enormous resource for radiology, but that it is also important to introduce the need for patient-centred radiology with A.I.’s active and increasing role in precision medicine. Over the last 16 years, the ESR has invited more than 8,000 young residents in radiology and radiographers in training to the European Congress of Radiology and continued developing its flagship youth project. Successful applicants for the Invest in the Youth programme were offered free registration for ECR and an accommodation voucher. C. Catalano mentioned other important ESR initiatives including “Coffee and talk” sessions dedicated to residents and trainees, as well as “Present my thesis in 3 minutes” aimed at further engaging young people who visit the conference. C. Catalano concluded that a bright future for radiology can only be ensured by recruiting those individuals that have the greatest likelihood of achieving job satisfaction in radiology.C. Catalano presented on behalf of the International Society of Radiology (ISR), presented the ISR findings regarding undergraduate radiology teaching from the student’s perspective. Radiology teaching should be represented in all pre-clinical and clinical undergraduate years. Medical students rate interactive case-based teaching sessions as very effective and there is a call for reliable, up-to-date open access electronic resources for medical students. L. Donoso also pointed out the importance of the “radiologist’s image”. Radiologists are no longer relegated to the back room where they interpret studies in a vacuum. Frequently clinician colleagues come to the reading room for radiologist’s opinions, and residents are an integral part of that process. Residents are often on the front lines, rendering opinions and discussing with clinicians how to manage particular patients. L. Donoso explained that the cross-generational teamwork in radiology can be easily fostered by involving millennials on tumour boards and in multidisciplinary conferences, especially those that emphasise the importance of imaging and image-guided procedures as part of the patient’s clinical care. When thinking about radiologists’ collective reputation patients’ opinion, referring physicians’ opinion and the opinion of the hospital need to be considered. L. Donoso further explained the need for the activities of the ISR stating that radiology needs a unified voice in dealing with global issues affecting radiology and the patients served. The World Health Organisation (WHO) and the International Atomic Energy Agency (IAEA) exert tremendous influence through regional and international initiatives on the appropriate use of medical radiation to improve population health. The ISR, in turn, serves as a primary advisor to the WHO and the IAEA in dealing with global issues affecting radiology. The main goals of the ISR are to promote global radiological quality and safety and bring high quality radiological education to underserved areas, acting as a convener and facilitator of content rather than the creator. Finally, L. Donoso mentioned specialised ISR programmes, Global Outreach: Education for Radiology (GOED) and Global Outreach Radiology (GORAD), that aggregate and disseminate high quality educational material from major journals and organisations to resource challenged areas.L. Donoso, on behalf of the The current young generation is different than any generation that preceded them. Accordingly, the societies need to adapt their approach and adopt new strategies tailored specifically for the new generation in order to engage young doctors into radiology and ensure an increase in their membership base.The societies understand that, in order to achieve these goals, it is important to first fully comprehend the character of the younger generation. In that sense, the CIR and the SMRI emphasise the importance of properly defining the millennials while the RSNA has developed a variety of tools aimed at understanding what young people want and need and what their expectations are. In Thailand, the societies developed unique approaches towards undergraduates and postgraduates, as it is important to understand the different needs these two groups might have. China is striving to create the best possible environment for the young generation and to develop personalised pathways to find a best possible match between an open position and an individual.The ISR points out that, in order to engage the younger generation, it is also important to adapt the current image of a radiologist, and, in a similar vein, Colombia is focusing on mental barriers the radiologists themselves might have and is looking for ways of overcoming them.A very important tool for understanding the younger generation as well as adapting the current image of the radiologist is the use of technology and social media and many societies are increasingly involving their current and future members in this way. The ACR has developed an internal networking platform called Engage. In Korea, the KSR is carefully listening to the needs expressed by the young radiologists and is using data analysis to develop the best approach based on the expressed needs. For Japan, understanding the technology and the A.I. is crucial for the engagement of the younger generation. The A.I. must be seen as an opportunity for radiology rather than a threat and public promotion is very important in that regard.Delegating responsibilities and motivating residents are important aspects of strategies implemented by many societies. The CAR has accordingly implemented a strategy targeted specifically at residents and the RSNA gives special attention to early-career practitioners.Perhaps the most important tool for further engaging the young generation is the use of innovative teaching solutions and increased participation in clubs, activities and other youth-oriented programmes. The IRIA has developed a specialised youth-oriented program (YUWA) working exclusively on the welfare of postgraduate residents and young radiologists. As it is important to engage younger generation in the actives early on, the AOSR is maintaining different clubs such as the AOSOR Youth Club, while the RANZCR has trainee representatives on the Council and most decision-making committees and organises events on topics decided by the trainees themselves. The FMRI is actively involving students in the learning process by including radiology in the University programmes and offering students with the best results the opportunity to become instructors after successfully finishing a course, thus giving the students an active role in the teaching-learning process. The SPR also uses innovative teaching solutions as well as increased participations in clubs and activities. Egypt is developing strategies to tackle concrete issues and create an approach that will benefit young generations in the entire country, while the CBR offers mobile learning initiatives and other educational activities. In Europe, the ESR is further developing its flagship youth project and has, over the last 16 years, invited more than 8,000 young residents in radiology and radiographers in training to participate in the European Congress of Radiology and its various events. The ESR has produced the undergraduate curriculum and is paying attention to the education of teachers as well.Finally, many societies stress the importance of trainings abroad and appropriate fellowship programmes. In that sense, Saudi Arabia is placing great emphasis on fellowship trainings, especially those abroad, and the RSSA is playing an active role in education of younger generation of radiologists while the JRS is fostering exchange programmes such as the Japanese-German Radiological Affiliation and the French Society of Radiology – Japan Radiological Society (SFR-JRS) Fellowship Program Exchange.Radiology is changing; in parallel to these changes a new approach towards the younger generation needs to be adopted. The technology plays a key role in this process and will serve as a bridge between already established and future radiologists, thus ensuring a bright future for radiology as a whole.


Reducing maternal mortality remains a significant challenge in Indonesia, especially for achieving the country's Sustainable Development Goals (SDGs) by 2030. One of the challenges is increasing delivery at healthcare facilities to ensure safe and healthy births. In Indonesia, research on factors affecting women's use of facility-based childbirth services is scarce. This study was conducted to identify the determinants of facility-based deliveries in Indonesia. This study used data from the Indonesia Demographic and Health Survey of 2012, with a cross-sectional design. An odds ratio with 95% confidence intervals (CI) was employed to outline the independent variables for the determinants, including maternal age and education, place of residence, involvement in decision-making, employment status, economic status, and number of antenatal care visits. The dependent variable in this study was the place of delivery: whether it took place in healthcare or nonhealthcare facilities. The statistical significance was set at p<0.05 using bivariate analysis and binary logistic regression. This study showed that a high level of education , high economic status , urban residence , working status , involvement in decision-making , and having more than four visits to antenatal care centers  were significant determinants of delivery at healthcare facilities. Efforts to improve facility-based childbirth in Indonesia must strengthen initiatives that promote women's education, women's autonomy, opportunities for wealth creation, and increased uptake of antenatal care, among others. Any barriers related to maternal healthcare services and cultural factors on the use of health facilities for childbirth in Indonesia require further monitoring and evaluation. Maternal and infant mortality remains a significant global health concern. From 1990 to 2015, the global maternal mortality ratio (MMR) decreased by about 44%, from an estimated 385 to 216 deaths per 100,000 live births. In Southeast Asia, as of 2015, the MMR stands at 164 deaths per 100,000 live births [Indonesia has made good progress in the area of maternal healthcare services by the increased percentage of deliveries at health facilities from 20.9% in 1991 to 46.6% in 2007 . The latThe World Health Organization (WHO) reported that the use of healthcare facilities to deliver babies significantly decreases maternal mortality . NonetheThe next section of this paper is a method that delineates the research data sources, the analytical methods used, and the variables in the study. The section following this outlines and discusses the results of the research. The final part of this paper is a conclusion that contains policy recommendations for related parties.This study employs secondary data from the 2012 Indonesian Demographic Data Survey (IDHS). Even though the 2017 IDHS has finished, the final data is not yet available, so the 2012 IDHS is the best choice at this time. The IDHS is part of the international Demographic and Health Survey (DHS) program conducted by the Inner City Fund (ICF). The 2012 IDHS was carried out by the Central Statistics Agency (BPS), in collaboration with the National Population and Family Planning Board (BKKBN) and the Ministry of Health.The 2012 IDHS sample selection was performed using stratification and multistage random sampling and carried out in 33 provinces in Indonesia from May to August 2012. Each province was divided into districts and then villages. The sample used in this study was married women of reproductive age (ages 15–49). The 2012 IDHS successfully interviewed 43,852 households.The 2012 IDHS obtained ethical approval from the National Institute for Health Research and Development of the Indonesian Ministry of Health. All respondents' identities were deleted from the data, and the respondents gave written approval for their involvement in the research. Permission to use the 2012 IDHS in this study was obtained from ICF International through its website: https://dhsprogram.com/data/new-user-registration.cfm.This study employs three stages of analysis: the first is univariate analysis, which is conducted to come to a description of each variable studied; the second is bivariate analysis, done to examine a significant relationship between the independent and dependent variables using the chi-square test; and the last is a logistic regression analysis, performed to identify the significant factors involved in choosing the place of delivery. All data were analyzed using IBM SPSS version 22.0 for Windows.The dependent variable in this study was the place of delivery, whether or not it took place in a healthcare facility, such as a hospital, clinic, health center, village health post, delivery post, or maternity hospital. The nonhealthcare facilities included the respondent's home or another's home. The reference category of this variable was delivery that took place in a healthcare facility. The analysis unit in this study was all births in the five years before the survey.The independent variables in this study were maternal age, maternal education, place of residence, women's involvement in household decision-making, working status, economic status, and number of antenatal care visits. The mother's age was divided into seven age groups of five years to see changes in the behavior of each birth cohort of mothers in choosing the place of delivery. The reference category of this variable was the youngest age group (15–19 years). Likewise, the distribution of education levels intended to determine the differences in the behavior of women with the lowest level of education (no education) up to the highest education (university) in the selection of places of delivery. The division of residential areas can be divided into urban and rural areas, where the determination of an area is urban or rural based on the criteria of access and facilities owned. Women's autonomy was measured by the involvement of women in making decisions about respondent's healthcare, divided into two categories, namely, yes and no. Although the availability of data related to employment status is very limited in the IDHS, we sought to cover women's participation in the labor market as measured by working status, based on the question of whether women had worked at least one hour without interruption in the previous week (yes/no). The variable economic status was measured by ownership of durable goods in households divided into five groups, ranging from the poorest to the richest, with reference categories being the poorest. The last explanatory variable is the frequency of examinations during pregnancy, divided into two categories, namely, less than four visits and four or more than four visits.The logistic regression is applied in this paper, since the dependent variable is categorical. The Omnibus test and the Hosmer-Lemeshow test are used to assess the model significance and the model goodness of fit, respectively . The nulIn this study, of the 17,401 births during the five years before the survey, 55.2% took place in healthcare facilities and 44.8% took place in nonhealthcare facilities . More thThe results from the bivariate analysis revealed that age, education level, residence area, economic status, number of ANC visits, employment status, and involvement in decision-making were significantly associated with the use of facilities for childbirth p<0.05; . FurtherThe logistic regression model used yielded p value of 0.001 for the Omnibus test and p value of 0.056 for the Hosmer Lemeshow test, which means that our model is a satisfactory fit for the data. After adjustment for all other variables included, the age of the women no longer had a significant effect on the use of facilities for childbirth . The regThe results of this study indicate that women who have achieved higher levels of education are more likely to deliver babies in healthcare facilities than those of lower education backgrounds. This is consistent with previous studies in which mothers with higher education were more likely to deliver in healthcare facilities , 21. EduWomen who live in urban areas prefer to deliver babies in healthcare facilities. An earlier study by Kenea and Jisha  in 2017 Mothers' working status is also a significant determinant in the decision to choose the place for delivery. This study found that Indonesian women who were working were less likely to give birth in healthcare facilities when compared with their peers who were not working. This is in contrast with previous studies that identified that working mothers were associated with giving birth in health facilities , 27. ThiWomen with a higher economic status were more likely to choose to deliver babies in healthcare facilities than their poorer counterparts, which is a similar finding to previous studies –30. WomeInvolvement in decision-making is significantly associated with the decision to use a healthcare facility . HoweverThe number of ANC visits is also associated with facility-based childbirth. Mothers who visited ANC units more than four times during their pregnancy were more likely to choose to deliver in healthcare facilities than their counterparts who did not. This is similar to earlier studies by Anastasi, Borchert , and DahThis research has some limitations. Due to the nature of cross-sectional surveys, the researchers were able to identify associations but not causal effects. Additionally, our study was based on secondary data analysis of the 2012 DHS ARH survey, which may not be able to explore other determinants of the use of healthcare facilities for delivery such as psychological issues and other social aspects. Furthermore, we did not test any interactions between variables in this study.This study revealed that Indonesian women's institutional delivery service utilization needs to be improved. Level of education, economic status, residential location, working status, decision making on mother's healthcare, and number of ANC visits were associated with facility-based childbirth in Indonesia. Taking these findings into consideration, it is recommended that maternal healthcare programs should be expanded and promoted toward uneducated and poor women, especially in rural areas, and culturally appropriate campaigns should be considered. Strategies with a focus on increasing recommended antenatal care visit uptakes would benefit the success of delivery in institutional healthcare facilities. Scaling up facility-based childbirth in Indonesia in terms of the numbers, utilization, and quality remains an inevitable issue in maternal healthcare programs. Promoting intersectoral actions to address all associated factors is recommended and would be a benefit for improving health facility-based delivery in Indonesia. Future research on decision-making processes among individuals and at the family level regarding the choice of institutional-based deliveries may provide detailed information.


The goal of this article is to present and demonstrate the applicability of an original method to assess the economic and health impacts of compliance with food-based recommendations. The method takes account of consumers’ preferences and the associated adoption cost in the assessment of various recommendations.We combine an economic model of diet choice with an epidemiological model to compute the health impacts of dietary changes. To demonstrate the use of the method, we analyse the impacts of a 5% variation in the consumption of seven food groups taken separately: a 5% increase in consumption of fruits and vegetables (F&V) and milk products; and a 5% decrease in consumption of red meat, all meats, salty/sweet products, ready meals and butter/cream/cheese.A recommendation, when adopted by consumers, generates important changes in the whole diet due to substitutions and complementarities among foods. All simulated recommendations have a positive impact on health. The F&V recommendation has the largest impact on the number of DALYs averted, but the highest adoption cost for consumers, especially for low-income consumers. Alone, the change in energy intake explains from 71% to 98% of the DALYs averted induced by a recommendation.Small increases in recommended foods have the potential of generating relatively significant health gains. Preference-driven substitutions among foods have a major effect on simulated health outcomes and should be included in the assessment of dietary recommendations, together with the adoption cost borne by consumers. The adoption of healthier diets is not easy for consumers , 2, as hMoreover, the adoption of a dietary recommendation affects the entire diet through complex product substitutions between- and within-food categories. For instance, a rise in fruits and vegetables (F&V) consumption may lead consumers to modify their consumption of meat or milk products, either because these products are substitutes or because of an indirect effect due to an income constraint. A popular way to construct diets that meet nutritional guidelines is to use linear programming models that provide optimized diets resulting from compliance with nutritional guidelines , 8. HoweThe goal of this article is to demonstrate the applicability of an original method to assess the potential health and well-being effects of compliance with dietary recommendations while taking into account consumers’ preferences and their effect on product substitutions within the diet. We use the economic theory of rational consumer choice, which allows the evaluation of the dietary changes compatible with revealed consumer preferences as well as the associated welfare cost of adoption of a recommendation. This model of diet choice is then combined with an epidemiological model in order to compute health impacts.First, we use an economic model to predict the dietary adjustments that a rational consumer would make to satisfy a given recommendation . Our appIn line with microeconomic theory, consumers are assumed to choose the goods (including foods) that they consume and their quantities so as to maximize their well-being, or utility, subject to a budget constraint reflecting prices and available income. Combining the theoretical solution to this ‘nutritionally unconstrained problem’ with data on actual consumption permits the estimation of price elasticities of demand for foods, which characterize consumers’ preferences. For instance, a low price elasticity of demand for a specific food group means that, even in the case of strong price increases, consumption does not change: this might be explained by taste preferences or cultural attachment to the product. Price elasticities provide information on the reaction of consumers facing a change in the relative prices of goods and are often used to compute the effects of fiscal policies  , 14. In Within this framework, compliance with a dietary recommendation, such as that to consume five portions of F&V daily, is conceptualized as the addition of a constraint in the unconstrained programme, which gives the ‘nutritionally constrained problem’. The new constraint forces the consumer to adjust her choices, both in terms of which goods are consumed and their quantities, in order to satisfy that constraint. The two problems, constrained and unconstrained, are linked by ‘shadow prices’, which are defined as the set of prices that would have to prevail for the nutritionally unconstrained consumer to make the exact same choices as his/her nutritionally constrained equivalent. Thus, by definition, if shadow and market prices coincide, the consumer spontaneously satisfies the nutritional constraint. Using empirically estimated price elasticities, shadow prices can be calculated, from which follows the adjustment in consumption for each good so as to comply with the new constraint (i.e. a food-based recommendation).The cost of adoption of a recommendation  is then measured by a ‘compensating variation’ (CV), defined as the additional income necessary to bring back the consumer to his initial level of well-being after he has adopted the recommendation. This CV is empirically estimable and quantifies the short-term loss of utility of the consumer who adopts a recommendation. Thus, the CV measures the difficulty of adopting a recommendation.In this article, we used recent estimates of price elasticity of food demand available in France . They arSecond, the epidemiological model PRIMEtime estimates the health effects of compliance with a recommendation by translating the dietary changes computed with the economic model into variations in the incidence of chronic diseases and mortality . The PRIThe effect of dietary changes on population health is measured relative to a simulated baseline scenario, which describes a situation where current trends in incidence and case fatality from diseases continue into the future. Then, for each food-based recommendation the model is simulated reflecting the impact of the adoption of the recommendation by the whole population. The difference between the baseline and a simulated scenario is expressed through the number of averted disability-adjusted life years (DALYs). A DALY is a summary health outcome measure capturing both morbidity and mortality effects .The PRIMEtime model is parametrized by using French data concerning the age structure of the population, the incidence of chronic diseases and mortality.2In general, the cost effectiveness of a public health measure is defined as the ratio of its total cost and associated health effect. Measures are then judged to represent ‘good value for money’ if that ratio falls under a threshold , 24. In In line with recent dietary guidelines updated by the French national agency (Anses)To illustrate the dietary changes induced by the adoption of a recommendation and the mechanisms that explain the changes, we first present the impact of a 5% increase in F&V consumption. Table As shown in Table The adoption cost associated with the adoption of the recommendation is very different for the different consumer groups Table . Thus, tIf we now turn to the health impact of the seven tested recommendations, it appears that they all improve health as the number of DALYs averted is always positive Fig. . The topAlone, the change in energy intake explains from 71% (recommendation on F&V) to 98% (recommendation on milk products) of the DALYs averted due to the adoption of a recommendation. The changes in intakes of F&V and red/processed meats have on average similar relative health impacts but, in some cases, those impacts can be negative. This is when a recommendation leads to a decrease in intake of F&V  or an increase in red and processed meats . The health impact of changes in intakes of salt and dietary fats is generally small but positive.The adoption of the simulated recommendations reduce the number of incident cases of the different diseases considered in the analysis . However, the largest impact is on type 2 diabetes  choices. However, depending on the recommendation, the cost of change, interpreted as a adoption cost, can be high or low Table . For exaThe adoption cost per DALY ranges from around €2000  to about €17,000 (F&V), meaning that it is less costly for consumers to avert one DALY by reducing consumption of ready meal and red meat, or by increasing consumption of milk products rather than by increasing consumption of F&V.In this article, we proposed an original approach to assess the compatibility of dietary guidelines, regularly published by public health authorities , 26, witSubstitutions among foods have a major effect on estimated health outcomes, which confirms the need to introduce realistic preferences and consider whole diets in the analysis of nutritional health policies. In particular, the results establish that a large share of the health gains are due to changes in dietary calories rather than improvements in diet quality, although that type of adjustments are usually ignored by assumption in studies of dietary recommendations through the imposition of iso-energy constraints . The stuThe decrease in consumers’ short-term well-being that we measure as the adoption cost with recommendations can be large when measured at population level . In many cases, such large private costs are likely to exceed direct policy costs and should therefore be included in cost-effectiveness analyses although, to the best of our knowledge, that has never been done when assessing nutritional health interventions. The significance of the adoption costs also explains the non-adoption of recommendations, and provides a measure of the relative difficulty of compliance with different recommendations. In any case, the adoption cost per DALY is substantial and should be therefore integrated in the evaluation of the cost effectiveness of nutritional and dietary recommendations.Overall, recommendations to increase consumption of F&V or decrease consumption of salty/sweet products and butter/cream/cheese have the largest health impact as measured by the number of DALYs averted, but they also generate the largest adoption cost for consumers. Conversely, other recommendations, such as those seeking to raise consumption of milk products or decrease consumption of ready meals, have lower health impacts but impose small adjustment costs on consumers.Because the dietary adjustments to recommendations depend on consumers’ preferences, they are expected to vary within a population. Our method permits quantification of the relative difficulty of adoption of recommendations and could be used to estimate how this difficulty varies across types of consumers, which should help policymakers select appropriate nutritional health campaigns depending on the target group of interest. Another relevant application of the method would be to develop comparative analyses across countries.We must also acknowledge some limitations. The method only allows for marginal dietary changes , as it is based on elasticities estimated from observation on current consumption patterns. Thus, our approach should be seen as a complement to usual approaches based on linear programming to optimize diets . While t


Orthodontic treatment aims at oral health and restoration of function as main objectives, however, psychological and social effects end up being the main reason for the demand for treatment. To determine the association between the oral health-related quality of life (OHRQoL), the need for orthodontic treatment and bullying among Brazilian teenagers. This was a cross-sectional epidemiological study. To assess the malocclusion, the Dental Aesthetic Index was used. And the Oral Health Impact Profile-14 was used to analyze the OHRQoL. The Kidscape questionnaire was used to investigate cases of bullying. The following variables were also included: previous orthodontic treatment and a desire to fix the teeth to improve one’s appearance. Multivariate analysis was performed using logistic regression considering the poor OHRQoL as a response variable. p= 0.0270), desire to fix the teeth (p< 0.0001), sex (p= 0.0309), history of being a victim of bullying (p< 0.0001), frequency of bullying episodes (p= 0.0170), and consequences of bullying (p< 0.0001). The following were considered as risk factors for poor OHRQoL: lack of previous orthodontic treatment (OR = 2.191) and negative consequences of bullying (OR = 3.042). 815 teenagers participated in the study. There was a statistically significant association between oral health-related quality of life and the variables: previous orthodontic treatment (The need for orthodontic treatment was not associated with the OHRQoL; however, bullying and previous orthodontic treatment had a statistically significant association with this variable.  Untreated people who have this disorder, in comparison to those who have already received orthodontic treatment, usually have a worse OHRQoL,Although orthodontists traditionally consider oral health and function reestablishment as the main objectives of clinical intervention, psychological and social effects can be the main reasons leading patients to seek for treatment.,,In this context, it is known that the expression of body image has great importance during adolescence. Dissatisfaction with the body at this stage can be quite prevalent, because physical changes and the significant biopsychosocial transformations inherent to this period of life can be potentially negative when individuals are morbidly concerned about how they are seen by the others.Bullying among adolescents at school has been widely studied. This phenomenon is a subtype of violence, and it is characterized by negative actions of one or more students in an unequal power relationship.However, there are few reports of studies that evaluated the impact of bullying on OHRQoL of Brazilian adolescents. Furthermore, most of the studies investigating the effect of orthodontic treatment on OHRQoL in adolescents were conducted in a clinical setting, by evaluating adolescents who seek treatment for either aesthetic or functional reasons. In this context, the objective of this study was to determine the association between the OHRQoL, the need for orthodontic treatment and a history of bullying, among Brazilian adolescents enrolled in the public education system. th, 8th, and 9th grades of elementary school). This age group was chosen because they had the minimum education required to answer the self-administered questionnaire. All adolescents enrolled in these grades were invited to participate in the study; however, were excluded: adolescents whose parents did not allow the examinations; adolescents who were allowed but did not want to participate; and adolescents who were not present on the three dates scheduled for the examinations.This was a cross-sectional epidemiological study with adolescents of both sexes enrolled in public schools of a medium-size city in northwest São Paulo, Brazil, from August to December 2014. The city had 20 elementary schools in the urban area, and nineteen schools were selected to be part of this study, because one of them did not consent in time for data collection (n = 4.283). The students participating in the study belonged to the 11-to-16-year-old age group . Considering an error margin of 5% and reliability of 95%, the minimum sample size was determined to be 384 individuals. Due to the number of schools in the city, the sample collection was performed considering both the number of schools and the number of students. It was established that the effect of the sampling design was two-fold (corresponding to the two collection stages), and, in this case, the sample size should be at least 768 individuals.The final sample consisted of 815 adolescents; therefore, it showed adequate statistical power. Moreover, the bullying sample was estimated to be 48.22%, which is close to the prevalence established and within the error margin considered.Initially, participants were separated into groups of 10 students and asked to answer to the self-administered questionnaire  and the Oral Health Impact Profile (OHIP-14) and Kidscape indices. The OHIP-14 index measures the impact of dental problems on the subject’s quality of life. Its first version was developed by Slade and Spencer Oliveira and NadanovkyIn order to evaluate bullying among students, we used the Kidscape model, a questionnaire developed by the British institution KIDSCAPE, which is engaged in preventing bullying and child sexual abuse.Subsequently, oral examinations were performed following the diagnostic criteria recommended by the World Health Organization (WHO). Biosecurity precautions were taken to protect the participants and the examiner. The Dental Aesthetic Index (DAI) was used, an instrument proposed by Cons et alThe oral examination and the questionnaire analysis were carried out in the educational institution itself by a single previously calibrated researcher. The pilot study and the pre-test preceded the study.Data were analyzed using the statistical program SAS for Windows, version 9.3. The chi-square test or Fisher’s exact test at a 5% level of significance was applied to verify the association between OHRQoL and the independent variables . Multivariate analysis was performed using logistic regression considering poor quality of life as a response variable, and the others as explanatory variables. Variables that showed statistical significance were included in the model and the results were expressed as an odds ratio (OR), in association with bad OHRQoL and its confidence interval of 95% (CI).Universidade Estadual Paulista Júlio de Mesquita Filho. The adolescents were examined only when parents or guardians had signed the Informed Consent form. Data collection began after the approval of the regional director of education and the direction of the schools involved.The study was approved by the Ethics Committee in Research with Human Subjects of A total of 815 adolescents aged between 11 and 16 years, and enrolled in municipal elementary schools participated in the study. p< 0.05). Analysis of the association between OHRQoL and other independent variables  shows a After the association analysis, the variables sex, skin color, desire to fix teeth, previous orthodontic treatment, frequency and consequences of bullying were assessed in the logistic regression model. Multivariate analysis considering the outcome OHRQoL showed that adolescents who reported consequences resulting from episodes of bullying had three times greater chance of having a bad OHRQoL. Another important fact was the protective effect of previous orthodontic treatment, since adolescents who had undergone treatment were two times less likely to have a bad OHRQoL .The results of this research are of great importance, since no previous study examined the influence of bullying on the OHRQOL of Brazilian adolescents. Students who reported negative consequences of episodes of bullying were three times more likely to have a bad OHRQoL. Only one study in JordanAssessments of OHRQoL are important for subjective evaluations of the population,,Bullying can have devastating consequences on the emotional state of adolescents. Low self-esteem, impaired school performance, depression, loneliness, insecurity, and shyness are commonly reported in the literature as sequelae of such situations.,A notable finding in this study is that the factors subsequent to bullying had a greater influence on the OHRQoL than the actual event itself, because the need for orthodontic treatment had no statistically significant association with OHRQoL. This result differs from most studies that evaluated this condition and found an association between malocclusion and bad OHRQoL.,,-As previously reported in other studies,Some limiting factors should be considered, such as the fact that the results of this study cannot be generalized to other locations; however, it is important to emphasize the need to compare the results of this study with those of other studies with similar goals conducted in Brazil and other countries. It should also be considered the low adhesion of the target population. Although the sample was representative, it was obtained a low rate of returns of parents/guardians’ authorizations. We cannot state whether the authorizations were given to those responsible for the students; according to a report of the coordination of participating schools, the age range of the group studied does not show great interest in extra-curricular subjects. Moreover, unlike other countries, culturally, Brazilians do not have the habit of participating in scientific research; the government does not encourage this practice, which is important for both the scientific environment and the community. However, it is of great importance for the population to highlight and measure the problem related to collaboration in directing targeted strategies for preventive action. Both the school and the family environment play an important role in supporting these adolescents.There was an association between the OHRQoL and bullying variables. Adolescents who reported negative consequences after bullying episodes were three times more likely to have bad OHRQoL. There was no statistically significant association between the need for orthodontic treatment and OHRQoL, but adolescents who have a history of orthodontic treatment prior to the research showed a protective effect against bad OHRQoL.


Data have become an essential factor in driving health research and are key to the development of personalized and precision medicine. Primary and secondary use of personal data holds significant potential for research; however, it also introduces a new set of challenges around consent processes, privacy, and data sharing. Research institutions have issued ethical guidelines to address challenges and ensure responsible data processing and data sharing. However, ethical guidelines directed at researchers and medical professionals are often complex; require readers who are familiar with specific terminology; and can be hard to understand for people without sufficient background knowledge in legislation, research, and data processing practices.This study aimed to visually represent an ethics framework to make its content more accessible to its stakeholders. More generally, we wanted to explore the potential of visualizing policy documents to combat and prevent research misconduct by improving the capacity of actors in health research to handle data responsibly.We used a mixed methods approach based on knowledge visualization with 3 sequential steps: qualitative content analysis ; visualizing the knowledge structure, which resulted from the previous step; and adding interactive functionality to access information using rapid prototyping.Through our iterative methodology, we developed a tool that allows users to explore an ethics framework for data sharing through an interactive visualization. Our results represent an approach that can make policy documents easier to understand and, therefore, more applicable in practice.Meaningful communication and understanding each other remain a challenge in various areas of health care and medicine. We contribute to advancing communication practices through the introduction of knowledge visualization to bioethics to offer a novel way to tackle this relevant issue. Traditional health data sources such as medical records and clinical trial data are nowadays complemented by an ever-increasing amount of behavioral and lifestyle data, which we create by interacting with everyday technologies such as our smartphones. Although data collection remains important, data sharing is fundamental to modern scientific practice and is of great value to the health sciences. First, this is because data are crucial to the confirmation of research findings and the replication of results [We live in an era where data are omnipresent and seemingly omnipotent. Data constitute one of the forces, if not  results . Second, results . Third,  results . Fourth, results . In the  results .However, although the quantity and types of data available for research are rapidly expanding, the handling of such data is a complex process that involves and impacts several stakeholder groups such as patients and research institutions. In recognition of precision medicine’s reliance on big data, the Swiss Personalized Health Network (SPHN) produced the Ethical Framework for the Responsible Usage of Personal Data in Health Research . The fraEthical and policy guidance is only as effective as its application. To combat and prevent research misconduct and to foster data sharing practices, stakeholders involved need to understand available guidance and apply it in practice. Some researchers have questioned the efficacy of policy documents as communication tools . ResearcSo how can we ensure that policy documents actually fulfill their purpose? Extensive research exists on how to communicate complex information to stakeholders. One promising approach is knowledge visualization. Knowledge visualization “examines the use of complementary visual representations to improve the transfer and creation of knowledge between at least two persons” . EvidencOur approach to transforming a complex framework into an interactive visualization involved 3 steps, as shown in Our first step was to identify the knowledge and knowledge structure manifested in the framework. To do this, we analyzed the framework using a qualitative content analysis approach that combined inductive and deductive category development -20. MoreWe conducted an inductive analysis to identify (1) the key elements in the ethical framework, (2) stakeholders, (3) the knowledge types present in the SPHN framework, and (4) the connections between the elements and stakeholders. We started with open coding, with the restriction that codes had to be mutually exclusive to ensure that the resulting knowledge structure remains unambiguous .withdraw and revoking consent into withdrawal process just as we merged communication and information into participant information. These categories form the lowest layer of abstraction in the knowledge structure of the framework, that is, the subthemes. This task was conducted iteratively, where we revised, refined, and checked the subthemes to ensure that they remained mutually exclusive.We then grouped codes that concerned the same subject matter and merged them into categories. To give an example, we merged the codes further use and withdrawal process both belong to the theme consent process. These groups can overlap as a subtheme can belong to multiple groups. For example, further use is part of both the consent process and the data and samples themes.In the next step, we formed overarching themes out of the subthemes, adding another layer of abstraction. As an example, the 2 subthemes We then determined the primary stakeholders from the frequency of their occurrences in the text and used axial coding to identify and map out the relationships between the stakeholders, themes, and subthemes . AlthougFinally, we used deductive analysis to assign the stakeholders, themes, subthemes, and their relationships with 1 or more of the 4 normative ethical principles of the SPHN framework: respect for persons, data fairness, privacy, and accountability. The resulting 4 groups are not mutually exclusive as a stakeholder, theme, and subtheme can be affected by several ethical principles. This fact contributed to the complexity of the original SPHN framework document.A total of 3 content experts from the fields of bioethics (EV and AB) and public health (FG) reviewed the coding and the knowledge structure. We selected the experts through purposive sampling. Moreover, 2 of the 3 experts (EV and AB) contributed to the development of the original SPHN framework and made sure that the result reflects the entirety of the framework’s content.To visualize the previously derived knowledge structure in a simple yet comprehensive way, we tested different graphics and visualization methods: alluvial diagrams, graphics such as symbols, concept maps, and systems maps. The 4 methods were chosen based on Burkhard’s model of visualization types for knowledge visualization . The folAlluvial diagram is a type of flow diagram, or branch-based diagram, that represents weighted correlations between categorical dimensions, visually linking the number of elements to shared categories . As abstSketches, drawings, symbols, and icons are nonverbal representational forms used for knowledge transfer and communication. The making of meaning from visual representations is a very different undertaking than that of language . SketcheConcept mapping, also referred to as structured conceptualization, is an established method for the organization and representation of knowledge. The method produces a map that consists of nodes and lines—the nodes indicating concepts and the connecting lines denoting relationships between them . What diSystems mapping is the process of visually representing and describing an entire system, including the elements and actors involved as well as their relationships, links, and interconnections. This method makes clear how things such as information or materials flow through a system. Other types of systems maps are causal loop diagrams, actor-network maps, and value chain maps. Reasons for using this method are as follows: (1) systems maps make sense of complexity, (2) they engage stakeholders by highlighting their position in the system, and (3) they enable both issues and opportunities to be easily identified . We chosWe invited 2 experts (EV and AB) to assess which visualization method was most appropriate for the SPHN framework content. Both experts were selected because they had contributed to the revision of the original SPHN framework in 2018 and the underlying analysis of existing policies . We condAttention: Is the visualization attractive and engaging?Context: Does the visualization convey why the knowledge is needed and is of value?Overview: Does the visualization give an overview of the complexity of the framework?Options to act: Does the visualization provide options to act, to use, and to apply the knowledge.Details: Is the amount of detail appropriate?The experts’ review showed that although many of the visualization methods were engaging, they oversimplified the content, making important details inaccessible. For example, the concept maps were determined to be effective at showing the actors and elements inherent to each ethical principle, but neither did they explain how the principles related to each other nor did they provide definitions. Only the system map was successful in providing both an overview and adequate detail of the ethical framework. However, according to the experts, the systems map failed to make the underlying ethical principles visible. Despite some shortcomings, we identified the systems map to be the most appropriate method.To address the shortcomings of the systems map and make the SPHN ethical framework content accessible in its entirety, we developed an interactive visualization using rapid prototyping . We wantTo assess the design and usability of the prototype, we conducted 3 expert reviews  at different stages of the prototyping process with a different reviewer for each stage. We used convenience sampling to find experts for user experience (UX) research, design, and storytelling. For this purpose, we presented reviewers with the prototype and asked them to provide feedback. A UX researcher, with a background in media studies and economics, participated in the first expert review. A UX designer with a Masters in Design and over 15 years of experience in product development undertook the second review. This expert was familiar with the topic of data processing, yet had no experience in the health sector. A UX copywriter completed the final review. This reviewer has a background in nanotechnology design and is also familiar with data processing and data sharing practices. These experts judged the prototypes according to usability requirements and according to the previously introduced questions by Burkhard . We systTo prototype an interactive systems map, we used a data visualization platform called Kumu . We firsExpert reviewers noted some limitations with Kumu; thus, to overcome these, we developed a website with a customized interactive visualization of the nodes with additional functionality and information. In addition, we implemented custom views that present content based on the different stakeholders’ perspectives on the systems map. Each perspective was composed of 11 views that highlight the themes and explain their importance according to the respective stakeholder’s responsibilities and interests. Furthermore, we integrated the 4 ethical principles by allowing the user to highlight the affiliation of the nodes to the activated principle.In this section, we present the final interactive visualization prototype of the SPHN ethical framework and its features. In total, we identified 4 primary stakeholders, 3 general themes, 8 research process themes, 2 effect themes, and 30 subthemes. The inductive analysis further revealed that the SPHN ethical framework comprises multiple knowledge types. These included the following: declarative knowledge (know-about), experiential knowledge , individual knowledge (know-who), orientational knowledge (know-where), and procedural knowledge (know-how) . MultimeThe focal point of the prototype is the interactive systems map visualizing the SPHN ethical framework. It shows the stakeholders, themes, subthemes, and their relations to each other. The map is made up of edges and nodes. The large-sized nodes correspond to the stakeholders, whereas the medium-sized nodes represent the themes and the small-sized nodes indicate the subthemes. In addition to the map itself, there are complementary functionalities, which we describe along with the other interaction techniques in the following paragraphs.First, users can hover to highlight a node and its connections see . This fuSecond, the select function is used to activate the display of a node’s information and metadata. In other words, by clicking on a node, users can access the information based on the SPHN ethical framework see . Each noResearcher and Part 1, the nodes corresponding to the subperspective are highlighted in the map, and additional information for the selection is displayed (see data governance is less detailed than the institution viewpoint for the same topic.Third, to enable navigation of the content according to the stakeholder categorizations, stakeholder perspectives were defined and can be activated through buttons above the map. Each stakeholder’s perspective is divided into 11 subperspectives, titled parts, reflecting the 11 themes of the respective perspective. By clicking on a perspective and subperspective button, for example, ayed see . These pFourth, to incorporate the SPHN ethical framework’s 4 ethical principles, we used a color legend. As such, we assigned each ethical principle a color and tagged the nodes accordingly. By clicking an ethical principle in the legend, users can then highlight the relevant nodes see . In thisIn this study, we developed an interactive visualization to navigate the content of the SPHN ethical framework. Our mixed methods approach consisted of qualitative analysis, visualization techniques, and rapid prototyping. In contrast to the ethical framework’s original form as a text document, our interactive visualization offers users an overview of the ethical framework content and provides access to detailed descriptions and definitions enriched with multimedia content. Another unique function of our interactive visualization is that it allows users to examine the relationships between elements and themes.Our method finds application beyond the specific type of policy document we used in our case study. Specifically, the individual parts of the method can be applied independent of context to transform a defined text scope. Only the choice of visualization type based on the expert review was specific to bioethics. This dependency can be resolved by calling in experts from other respective fields. The method presented in this study, therefore, holds great potential for a variety of text contents beyond policy documents and bioethics.Future research is needed to unlock the potential of this visualization approach. To begin with, this study does not assess the interactive visualization’s educational powers compared with the original policy document. Further research is, thus, required to measure the effectiveness of the knowledge transfer. In addition, systematic user testing is needed to resolve functional shortcomings. The combination of these 2 assessments would optimize the tool’s efficacy and, therefore, improve the impact of data sharing policies on the stakeholders’ actions.Another limitation is that the visualization does not assist the stakeholders’ understanding of the dependencies between different elements of the framework. In the words of Tufte, understanding “... is to know what cause provokes what effect, by what means, at what rate” . To resoThis study sheds light on how to develop an interactive visualization from a policy document and lays the foundation to innovate ethical framework dissemination practices on the Web. In practice, this method to translate ethical frameworks gives bioethicists and health care policy makers a tool to communicate complex information to diverse audiences. More broadly, the results offer guidance to researchers, practitioners, and designers who create dynamic visualization for scientific and scholarly communication.Meaningful communication and understanding each other remain a challenge in various areas of health care and medicine. We contribute to advancing communication practices through the introduction of knowledge visualization to bioethics to offer a novel way to tackle this relevant issue. Our work bears value for every person involved in modern health research: from policy makers who give guidance, to researchers who process data, to the patients who use their smartphones throughout the day and generate data.