The global burden attributed to Neglected Tropical Diseases (NTDs) is 47.9 million Disability-Adjusted Life Years (DALYs). These diseases predominantly affect disadvantaged populations. Priority for NTDs has grown in recent years, which is observed by their inclusion in the sustainable development goals (SDGs). This study analyzed the process that allowed these diseases to be included on the global health policy agenda. This global policy analysis used the Shiffman and Smith framework to understand the determinants of global health political priority for NTDs. The framework comprises four categories: actor power, ideas, political contexts, and issue characteristics. Global documents and World Health Assembly (WHA) resolutions were examined, key-informant interviews were conducted, and academic publications were reviewed to understand the four categories that comprise the framework. A total of 37 global policy documents, 15 WHA resolutions, and 38 academic publications were examined. Twelve semi-structured interviews were conducted with individuals representing different sectors within the NTD community who have been involved in raising the priority of these diseases. This study found that several factors helped better position NTDs in the global health agenda. These include the leadership of actors that mobilized the global health community, the creation of a label combining these diseases as a group to represent a larger disease burden, the presence of mechanisms aligning the NTD community, and the agreement on ways to present the NTD burden and potential solutions. The process of building the priority of NTDs in the global health agenda shows that several determinants led to positive outcomes, but these diseases continue to have low priority at the global level which requires the implementation of actions to increase their global priority. These include sustaining the commitment of current actors and engaging new ones; increasing the attention given to diseases formerly categorized as “tool-deficient”, including zoonotic NTDs; continue leveraging on policy windows and creating favorable policy moments to sustain commitment, as well as setting realistic targets. Findings from this study can help develop strategies to build the momentum and drive actions to implement the goals of the new Roadmap for NTDs in the pathway to universal health coverage (UHC) and sustainable development. Neglected tropical diseases (NTDs) affect vulnerable populations living mostly in tropical and subtropical settings, and disproportionately affect women and children. Historically, the priority given to NTDs in global health policies has been lower than that of HIV, malaria and TB, but in recent years it has increased. To understand the processes that helped raise the positioning of NTDs in global policies, this study used a framework by Shiffman and Smith that assembles determinants of political priority under four categories: actor power, ideas, political contexts, and issue characteristics. A total of 37 global policy documents, 15 WHA resolutions, 38 academic publications, and findings from 12 semi-structured interviews with individuals representing different sectors within the NTD community, were analyzed using a policy framework proposed by Shiffman and Smith. This study found that elements that helped increase the priority of NTDs in global policies included the presence of leaders, institutions and guiding documents to mobilize the community, the creation of the NTD label, and the way the burden and solutions were presented. To continue raising the profile of NTDs at the global level, the study presents suggestions that are in line with UHC and SDG targets. Neglected tropical diseases (NTDs) are diseases of poverty that affect disadvantaged populations living predominantly but not exclusively, in tropical and subtropical environments . The estHowever, the global political priority of NTDs has grown in recent years. Overlooked in the Millennium Development Goals (MDGs) where they were categorized as “other diseases” ,9, NTDs Prioritization of issues on the global health agenda is often political ,16. AccoThe Shiffman and Smith framework  has beenTo understand the four categories of determinants of global health political priority, we examined key global documents and World Health Assembly (WHA) resolutions, undertook key-informant interviews, and reviewed academic publications see . A similA qualitative analysis of key global policy documents and WHA resolutions was conducted from July to December 2016. The London Declaration on NTDs  was seleTwo reviewers analyzed the documents . One reviewer extracted data for a document, and the other reviewer cross-checked for accuracy and to ensure reliability. A codebook guided the data extraction process. Reports were produced on an ongoing basis, and preliminary findings as well as data extraction process were discussed in meetings with the co-authors of this paper. As a result of this analysis, a list of stakeholders and a timeline with key milestones in the history of NTD prioritization were developed. Both the timeline and the list of stakeholders informed the key informant interviews.The second component of this study took place between June 2017 and February 2018 and consisted of interviewing individuals from organizations identified during the analysis of documents. This process was carried out by one of the researchers who participated in the document analysis (NAP). Confidential semi-structured interviews with individuals representing the diversity of actors of the NTD community were conducted. The interview was organized along five themes: 1) an introduction to build rapport and contextualize the interview which included identifying the role of the interviewee in influencing health policies for NTDs, 2) questions to understand the process of policy development, 3) questions to identify key actors and their roles, 4) questions inquiring about expectations on the future of the NTD policy agenda, and 5) suggestions of other individuals to contact which facilitated snowball sampling. Examples of questions used during the interviews are available in Interviews were conducted in person, by phone, or by Skype, were audio-recorded and transcribed verbatim. To ensure the anonymity of participants, a code was used to name the interview transcriptions. Analysis of the data was done deductively using the Shiffman and Smith framework of factors determining political priority which comprises four categories: actor power, ideas, political contexts, and issue characteristics . InductiWhile a literature review informed this study design and conduct, the study included the identification of academic publications through search engines to prepare for the interviews, with a focus on publications by the interviewees and the organizations they represented. In addition, articles shared by some of the interviewees before or after their interviews were included. All publications were screened to identify if they provided additional information that could help in understanding the NTD prioritization processes, more specific information related to any of the following were searched for: mentions of key documents, actors or moments in raising the priority of NTDs at the policy level. These publications helped fill in gaps from the document review and interviews, and to complement the timeline.This study was carried out as part of a research for development project, COHESION Project , addressA total of 37 global policy documents and 15 WHA resolutions were analyzed. Thirty-eight academic publications were examined. The list of documents and academic publications analyzed is provided in Twelve semi-structured interviews were conducted, 11 by the lead author of this paper (NAP) and one by another researcher mentioned in the acknowledgments, ten were carried out in English and two in Spanish. Of the 12 interviewees, four were women and eight were men. Interviewees were employed at academic institutions (n = 5), non-governmental organizations (NGOs) (n = 2), non-profit organizations (NPOs) (n = 1), philanthropic foundations (n = 1), multilateral organizations (n = 1), and pharmaceutical companies (n = 2). Some of these interviewees were based in endemic countries (n = 2), others had travelled extensively or lived in those settings (n = 5), and most had previous or ongoing NTD projects with stakeholders based in LMICs (n = 10), which allowed them to bring the perspectives from the Global South. All interviewees had participated in multi-partner NTD initiatives at a global level, and some had collaborated with the WHO NTD Department (n = 6). On average, the interviews lasted one hour.The first category of the Shiffman and Smith framework  is actorData triangulated from the three sources used in this study revealed that at the global level, the NTD community comprises eight types of actors see . (1) MulDisease groups are in the form of partnerships and coalitions that comprise individuals from the other seven groups of actors. Disease groups are subcategorized in disease-specific groups and cross-disease groups. Disease-specific groups focus on a single disease . Cross-disease groups work on several diseases, some groups focus on diseases that have similarities in terms of their characteristics or types of interventions (e.g. Schistosomiasis Control Initiative—schistosomiasis and soil-transmitted helminthiasis), while other groups focus on a broader variety of NTDs . These groups allow for actors from different sectors to converge for research, collaboration, and advocacy. One interviewee  mentioned that the purpose of cross-disease groupings varies. Some focus on making sure the targets are met, some on advocacy at the government level, and others on reporting research to influence funding priorities.The role of actors within the community varies. One of the core functions of the WHO is “providing leadership on matters critical to health and engaging in partnerships where joint action is needed” , as wellDonor governments and philanthropic foundations  provide funding, for example, for medicines, R&D, and programming. Research outputs from academics and their recommendations help inform how money could be spent . AcademiInternational NGOs have played an important role in obtaining and providing data on the disease burden in endemic countries , as wellPharmaceutical companies are involved in drug donations but also in providing knowledge and building capacity in endemic countries to facilitate having a more significant impact with donated drugs, said one interviewee from the industry . Other interviewees mentioned benefits pharmaceutical companies obtain from donating; first, they are able to enter new markets and second, they improve their public reputation. Other companies from different sectors within the “private sector” category of actors, also collaborate but to a lesser extent expressed an interviewee .The diversity of areas of expertise and focus of actors in the NTD community is one of the reasons for which partnerships are particularly valued. This community engages in public-private partnerships, product development partnerships, and private-private partnerships ,34,35. T“…there is some sort of sense of belonging among the NTD community. People like the hashtag NTDs, it’s been quite effective to bring together people who have an appetite for tropical medicine. I think it’s been successful in that sense…” The second category of the framework is ideas and focuses on how the actors involved with the issue understand and position it. The internal and external frames are the two factors included in this element . SeveralThe NTD concept focuses on two things, the idea of neglect and the emphasis on diseases with similar characteristics and their impact on poverty and development ,48–50. SWhile several lists of NTDs exist, the WHO priority list  is the ost WHO NTD report, namely: anthroponotic leishmaniasis, anthrax, brucellosis, and Japanese encephalitis. From 2010 until early 2017 the WHO prioritized 17 NTDs. The current priority list includes 20 diseases, four that were not part of the Global Plan: foodborne trematode infections, mycetoma, scabies and other ectoparasites, and snakebite envenoming. The Global Plan listed 20 priority diseases, but the number and types of diseases included in the WHO priority list has varied. Four diseases were removed from global priorities and were not included in the 1The Global Plan originally classified NTDs in two groups of “tool-ready” or “tool-deficient” diseases. The former focused on diseases having low-cost and available strategies (e.g. preventive chemotherapy), and the latter on diseases with strategies more difficult and expensive to implement (e.g. innovative and intensified disease management). Two of the interviewees mentioned that this initial grouping of NTDs created an imbalance in the allocation of resources and funds that focused predominantly on “tool-ready” diseases, especially on those controlled by preventive chemotherapy . One of them stated that for this reason, the tool-ready and tool-deficient terminology was abandoned, although its effects persist today .rd WHO report on NTDs  guiding the global policy, it turns out that it is the interactions we have with the countries, the money at which the countries are using, the technologies that we are working on, that ends up guiding global policy, which should be the other way around” The final category is issue characteristics, which denotes the problem’s attributes in relation to three factors: the presence of credible indicators, the severity or size of the burden, and the existence of effective interventions . In the Linkages between the burden and the resources allocated to NTDs have been described. For example, a commonly cited reference made in the reviewed articles was that of a study by Liese and Schubert  who founThe documents and articles reviewed also show that the NTD burden has been described in terms of the populations affected  ,8,13,28,Concerning how NTDs have been presented and by whom, one interviewee mentioned that the arguments used to drive resources to NTDs have been aligned by the interests of specific groups with the power to influence policymaking. They stated:“The organizations with power are related to the North…and they are who say what problems are important to our countries, regrettably…There is a group of North American and European experts who say what tropical diseases are important. Something that you can imagine that exacerbates my spirit as a [nationality] and there are a bunch of diseases that they want to include because they are working on them and want to prioritize them, because they know that the money goes that way and not in other diseases.” When describing the NTD problem, two other areas emerged from the documents and articles reviewed. The first one related to gender and the second one to non-communicable diseases (NCDs). About gender, some of the documents mentioned that gender differences in exposure to risk factors, the burden of care, access to health-care, and other social consequences (e.g. stigma) exist ,10,44,69The determinants under issue characteristics also include effective interventions and the availability of indicators to monitor progress. Based on the literature, the rapid-impact package to simultaneously control seven NTDs  with four medicines  at a cost of about US$0.40 per person per year ,46 was ust WHO report presented a group of interventions to address these conditions. These interventions have since been promoted and were included in the NTD Roadmap. The five interventions also referred as public health strategies, are: preventive chemotherapy and transmission control (PCT), innovative and intensified disease management (IDM), vector ecology and management (VEM), veterinary public health measures, and the provision of safe water, sanitation and hygiene (WASH). The names of these interventions have had minor changes over the years  that resonated with the perspectives and arguments of different groups has shown to be successful in attracting attention and funding. The creation of a label that clearly and explicitly denotes the characteristics of the diseases, and that results in a higher disease burden than having these as individual diseases, has shown to be one of the key elements for success in gaining external recognition.Regarding political context, the NTD community has used policy windows present in the environment, but has also created favorable policy moments such as meetings of global partners to generate or sustain commitment from global actors. A governance structure lead by the WHO with strong participation of actors from multiple sectors has been favorable in gaining recognition for these diseases. With respect to issue characteristics, the NTD community has consistently presented the severity of the problem and the interventions needed to address them, backed up with scientific evidence. The existence of clear common goals to drive collective action and monitor progress has also been beneficial.Challenges revealed in this study include making a case for diseases that were once described as “tool-deficient”, lacking simple and cost-effective tools and treatment. So far, diseases that were previously categorized as “tool-ready” received greater attention, and so has the main intervention used to address them, specifically preventive chemotherapy and transmission control (PCT). Although the importance of PCT is undeniable and should be maintained, other priority interventions are necessary. Likewise, diseases prevented, controlled, or managed with other priority strategies have not been prioritized to the same extent as diseases using PCT, even though they are included in the WHO list of priority NTDs; of these diseases zoonotic NTDs are notedly sidelined. Diseases not included in the WHO priority list are even more neglected. A possible way to make a case for diseases and needs of the NTDs community that are not currently prioritized would be to involve more actors from the Global South in determining global priorities.Identifying differences and similarities with the experiences of other health issues using the Shiffman and Smith framework  is also Sustaining and embracing new partnerships should continue to be a priority for the NTD community. While involving actors from multiple sectors differentiates NTDs from other health issues ,35,74, iThe 2030 Agenda for Sustainable Development calls for integrated responses . BecauseIn the pathway to achieving the SDGs, the WHO launched a global consultation in 2019 to help determine the priorities of the new Roadmap for NTDs (2021–2030). Discussions on the new NTD Roadmap should make a stronger case of how addressing NTDs contributes to attaining UHC priorities, ensuring the new agenda prioritizes strengthening health systems and integrates NTD policies with those of other intersecting issues such as gender and NCDs. The new NTD Roadmap should provide a platform for intersectoral and inter-programmatic collaborations  that are currently challenging to implement. Based on findings from this study, other areas requiring the attention of the NTD community include implementing measures to increase the engagement of other actors such as the G20, BRICs, endemic countries, and civil society in endemic countries.Findings from this study should be seen in the light of some strengths and limitations. Strengths include the innovation in using the Shiffman and Smith policy framework  for the The determinants of political priority help understand the processes that have led to the current position of NTDs in the global policy agenda. The presence of individuals and institutions leading collective action, the involvement of actors representing different sectors, the creation of the NTD label as well as the framing of the problem and possible solutions, and the use of key environmental moments, have influenced in building the priority of these diseases once excluded from global health and development priorities. Despite the successes reached to date, NTDs remain neglected. Continuing to leverage policy windows and create moments to sustain commitment, along with greater involvement of governments and civil society of endemic countries are of paramount. Further, more attention should be placed on former “tool-deficient” diseases and to neglected NTDs, such as zoonoses or those not currently prioritized by the WHO. Involving more actors from endemic countries in determining global NTD priorities could help in setting responses that are relevant to the needs of health systems and affected populations. The findings from this study can help develop strategies to drive actions to implement the goals of the new Roadmap for NTDs, in the pathway to UHC and sustainable development.S1 Text(DOCX)Click here for additional data file.S2 Text(DOCX)Click here for additional data file.


This paper describes the development of the Irie Homes Toolbox, a violence prevention program targeting parents of children aged two to six years. The intervention was designed to complement an existing, teacher-training, violence prevention program, the Irie Classroom Toolbox, thus promoting an integrated approach across home and school settings. The Irie Homes Toolbox was developed through a four-stage process by integrating data from theory, formative research, and practice to ensure the intervention is acceptable, feasible, relevant, and effective in the context. The perspectives of Jamaican preschool teachers and parents of preschool children, who are the end users, were integrated into the design of the intervention throughout the development process. Stage one involved integrating theory and formative research to inform the initial intervention design. Stages two and three involved iterative cycles of design, implementation and evaluation of the intervention content, process of delivery, structure and materials. Stage four involved a further cycle of learning through a process evaluation conducted as part of a cluster-randomized controlled trial. Data from each of these four stages was used to inform the design and ongoing revisions of the toolbox with the aim of developing a low-cost, scalable and sustainable intervention for the Jamaican context. The resulting program is theory-informed and uses empirically derived content and behavior change principles operationalized for the context in which it will be delivered. The Irie Homes Toolbox is suitable for integration into the existing preschool provision in Jamaica, thus utilizing an existing service and existing staff and increasing the likelihood for wide-scale dissemination. Globally, violence against children exists in almost all countries with the violence often being committed by caregivers . This viParenting interventions are a key strategy used to prevent violence against children . A meta-Jamaican parents regularly use verbal aggression and physical punishment to discipline their children . In a stIntegrating such programs into existing services would promote parent participation and program sustainability. The most common services accessed by parents of young children are the health and education sector. For example, a parenting program for parents of two to six year old children, implemented in child health clinics in Iran decreased dysfunctional parenting practices and child physical and emotional abuse  and a trJamaican preschools cater to children aged three to six years and over 98% of young Jamaican children attend preschool. Training Jamaican preschool teachers in appropriate discipline techniques has shown benefits to teachers' child behavior management practices . We haveDeveloping a complementary parent-training program to be implemented in preschools is a logical next step and has the potential for near universal coverage. Integrating the Irie Homes Toolbox into the services offered to parents through community preschools maximizes on this training of preschool teachers as (1) teachers trained in the Irie Classroom Toolbox can deliver the intervention with the parents, and (2) it promotes an integrated approach across home and school settings. In addition, integrating training in violence prevention into early childhood educational services will promote a high quality caregiving environment for young children that is safe, secure, and nurturing, in addition to providing cognitive stimulation. Provision of integrated violence prevention and early childhood development interventions thus promote child development across multiple domains, address multiple risk factors, and help children develop to their full potential , 25. EarThis paper describes the development of the Irie Homes Toolbox, a violence prevention parenting program for parents of children aged two to six years. The main aims of the Irie Homes Toolbox are: (1) to prevent violence against children by parents/caregivers of young children, (2) to promote positive parenting practices including positive discipline, and (3) to prevent the early development of antisocial behavior in young children. The Irie Homes Toolbox was developed as a complementary program to the Irie Classroom Toolbox to promote an integrated approach to child behavior management across home and school settings. It was developed to be integrated into the existing preschool network and to be suitable for implementation by preschool teachers. Preschool teachers have regular contact with parents and are ideally placed to engage parents in a parent-training program being conducted at school. “Irie” is a Jamaican word that describes feeling at peace and in harmony with oneself and with others.The Irie Homes Toolbox was developed over fifteen months using the framework of the UK Medical Research Council Guidance on Developing and Evaluating Complex Interventions . The devIn stage one, conducted in December 2017 and January 2018, we integrated evidence from theory, empirical research studies and the perspectives of Jamaican parents. The first step involved identifying the core components of evidence-based parenting programs related to both the content and methods of implementation . The focThe common core components of evidence-based parenting interventions and the components of the Irie Classroom Toolbox relevant to parents are shown in The aim of stage two was to undertake preliminary piloting of the intervention content and methods of implementation to produce a first draft of the intervention. The activities for stage two were conducted in February and March 2018. We continued to work within the same four community preschools that participated in stage one and convenience samples of five to twelve parents were invited to participate in sessions. The majority of participants were mothers although four fathers and one grandfather were included in the sample. Sessions were conducted at the beginning of the school day. Each individual session was piloted twice with different groups of parents, with ongoing revisions based on lessons learnt during each session. During these sessions one member of the team delivered the content while another team member made notes on: (1) parents' engagement, level of understanding, ability to use the strategies, and what content resonated within the group, (2) ideas for materials and visual aids that would help to promote parents' understanding and engagement, (3) session logistics including session structure, duration and optimal group size. Throughout the process of piloting the sessions, we used the following guidelines to inform our decision making and note taking:Be reflective: constantly think of ways to improve the acceptability, feasibility, relevance, and effectiveness of the program.Evaluate whether parents understand and are able to use the concepts introduced and plan how their knowledge and skills can be improved.If something does not work, or does not work well, problem solve in real-time. Try a different approach and document what happens.Pay close attention to the group vibe; if it's flat then something is wrong. Identify ways to maximize participation, fun, and interest.Pay attention to individuals in the group, ensure all are participating.Make note of scenarios that resonate with the group.Note parents' strengths and needs throughout the session.Note examples that parents give and use their comments and ideas to revise the content and delivery of the program.After each session, the notes were discussed among the research team and decisions made to increase the acceptability, feasibility, relevance, and effectiveness of the intervention. These decisions were incorporated into the relevant session prior to piloting the session with a different group of parents.A core component of the intervention is to encourage parents to engage in daily child-led play or Irie Time. To ensure parents had the resources available to do this, we decided to include a toy or book in the materials given to parents after each session. We choose toys that facilitated free-play such as blocks, cars, animals and a pretend play set, rather than structured toys such as puzzles, and matching games. We also included three wordless picture books. Two of these books were adapted from the Reach Up and Learn parenting intervention, additional details, and extra pictures were added to make them more suitable for the older child age range targeted in this intervention . One booBy the end of stage two, we had developed an initial draft of the content and process of delivery of the intervention and designed the intervention materials  to be tested in stage three.The first draft of the Irie Homes Toolbox produced through stage two activities consisted of eight 90-min sessions. The full program was then piloted in five new community preschools from April-June 2018. The ultimate goal is for the Irie Homes Toolbox to be delivered by preschool teachers who have been trained in the Irie Classroom Toolbox, hence it was important to include the perspectives of preschool teachers in the development of this parenting intervention. We invited preschools whose teachers had participated in the Irie Classroom Toolbox training to assist us . Harsh pThe most effective recruitment strategies involved working through the teachers and/or school principal rather than the research team recruiting parents directly. Three of the parents recruited directly by the research team decided they no longer wanted to participate before the program commenced and four parents attended only the first session. These parents were replaced by parents recruited through their child's teacher and/or the school principal. The average attendance of the participating parents was 81% (range 50–100%). We also found that the collaborating teachers would rarely attend the entire session and would leave the sessions frequently to attend to other duties. To promote teacher engagement, we therefore included a structured and scripted co-facilitator role for the teacher in the revised intervention as shown in The intervention was tested in a cluster-randomized trial in eighteen community preschools that had not participated in stages one to three. The parenting sessions were implemented during the period September 2018 to April 2019. Preschools were selected to participate in the trial based on the following criteria: (1) had participated in the Irie Classroom Toolbox training and had two or more Irie trained teachers still working at the school, (2) were interested in participating in the program, (3) had parents who consistently dropped children and/or picked up children from school rather than a driver, (4) had no other structured parenting program currently operating, and (5) the principal and all teachers in the school consented to participate in the study. Nine preschools were randomized to participate in the parenting intervention and an ongoing process evaluation was conducted. Parents were recruited at the school by the research team with the help of the teachers and principal. A minimum of six parents were recruited from each school in the Autumn term and an additional six recruited in the Spring term resulting in a minimum total of 12 parents per school. The inclusion criteria for parents were: (1) interested in participating in the program, (2) able to stay back for 90 min either in the morning after dropping off their child or in the afternoon when they came for pick-up one day a week, and (3) parent gave consent for him/herself and his/her child to participate in the study. The quantitative results from the trial will be reported separately. In this paper we are focusing on the process of developing the intervention. One hundred and fifteen parent-child dyads participated in the intervention. The children were aged two to six years old with a mean age of four years; 52.2 % of the sample were boys. Caregivers had mean age of 31 years, 104 (90.4%) were mothers, two (1.7%) were fathers, and nine (7.8%) were other relatives. Less than half the parents completed high school (46%) and 43% were in paid employment. The ultimate aim is for the preschool teachers to implement the intervention. However, in this small-scale efficacy trial we wanted to assess the effectiveness of the program when delivered consistently and with high fidelity; when the intervention is delivered by teachers the quality of implementation may be more variable. Hence, a member of the research team delivered the intervention. Each school principal allocated one preschool teacher to assist the research team by co-facilitating the parenting session. This ensured that we were able to continue integrating the perspectives of the preschool teachers, into the program design. Parenting sessions were held on the school compound (in the school yard or any available room), once a week for eight weeks and lasted 90 min.The ongoing process evaluation included a quantitative and qualitative component. The quantitative component included recording parent and teacher attendance. For the qualitative component, after each session the facilitators (including the preschool teacher) discussed the session together and then the main facilitator completed a record form that documented enablers and barriers related to: (1) the content of the session , (2) the process of delivery , (3) the context in which the session was delivered , (4) the involvement of the children, (5) teachers' co-facilitation of the sessions, and (6) facilitators' skills in delivering the session. Notes were also made on individual parents' engagement, understanding, strengths, and needs. Facilitators noted their perceptions of which strategies were most acceptable, feasible, relevant, and effective and suggested solutions to any problems encountered in implementing the intervention. The information from the facilitator record forms was used to further refine the Irie Homes Toolbox.n = 28) and with one teacher from each preschool who co-facilitated the sessions (n = 9). A section of the interview focussed on participants' perspectives of the main benefits of the program and is reported here. One or two parents from each school who had attended a minimum of four sessions were randomly selected for interview. Eighty three (79%) parents had attended four or more sessions and fourteen parents were randomly selected from participants in round one (Autumn term) and a further fourteen parents were randomly selected from participants in round two (Spring term). In-depth interviews with parents were conducted over two phases, within one month after the end of the sessions. Teacher interviews were conducted at the end of round two. Interviews were conducted in a quiet place in each preschool by a female research assistant who had not been involved in implementing the sessions. All interviews were recorded and transcribed. The analysis was conducted using the framework approach which is particularly appropriate for applied research with specific objectives  and 67.1% in round two (Spring term). 61.8% parents attended six or more sessions with 28.7% all eight sessions. We documented the reasons for parent non-attendance and 79% of the absences were rated as legitimate. Legitimate absences were absences that were deemed unavoidable such as: clinic/doctor visit, called in to work unexpectedly, child being sick, unchangeable appointments, and meeting at older children's school. Teachers co-facilitated a mean of 7.1 (SD 0.9) sessions in round one (the Autumn term) and 3.4 (SD 2.8) sessions in round two (the Spring term). In the Spring term, teachers had many competing activities and responsibilities and attendance was more challenging. In addition, teachers were confident that the facilitator would continue to conduct the sessions if they were absent and this also led to reduced attendance, especially in the face of competing activities.Facilitators made notes of multiple instances that supported the fact that the intervention developed was acceptable, feasible, relevant, and effective to the participants. In terms of acceptability it was noted that parents would consistently laugh and have fun with the games, role-plays, and visual aids presented. Parents were eager and willing to participate in the different activities during the sessions and they would incorporate their own personality and flair to the activities further confirming their acceptability. The feasibility of the strategies was shown through the parents' reports on how they used the strategies at home in different situations. The relevance of the intervention was illustrated through the discussions in which parents shared instances of issues they were experiencing with their child and would provide examples of how the strategies helped them at home. Throughout the sessions, facilitators documented evidence of effectiveness including parents being able to use strategies with little to no prompting and becoming more confident and skilled in using the strategies as the weeks progressed.The intervention developed through the four stages of this study is a violence prevention program for parents of children aged two to six years called the Irie Homes Toolbox. The main goals of the program are to prevent and/or reduce parents' use of violence against children, increase positive parent-child interaction, and prevent and/or reduce child externalizing behavior problems. The Irie Homes Toolbox is a group-based parenting program consisting of eight sessions, each lasting 90 min, delivered once a week for eight weeks. Each of these eight sessions follows a set structure that includes (1) a game or song, (2) feedback from the previous week including a discussion of the home assignment, (3) introduction of a new topic consisting of discussions, role plays, demonstrations, rehearsal, and practice, (4) introduction of a child-led play or picture book reading activity with demonstration, rehearsal, and practice, (5) practicing the child-led play or book activity with their child with supportive feedback, and (6) review, goal setting, and allocating homework assignment. The toolbox consists of content divided into five modules (1) promoting positive behavior, (2) preventing misbehavior, (3) understanding emotions, (4) managing misbehavior, and (5) supporting homework . In eachThe development of the Irie Homes Toolbox was guided by theory, evidence, and practice. Through a series of four stages, the intervention content, materials, structure, and process of delivery was tested through an iterative and cyclical process of design, implementation and evaluation with the aim of producing a parenting intervention that was acceptable, feasible, relevant, and effective in the context. The resulting intervention: (1) is theory-informed and incorporates evidence-based content and evidence-based behavior change principles, (2) was developed with participation of Jamaican parents and teachers who are the end users, and (3) was designed to be low-cost and integrated into the existing preschool network thus promoting wider dissemination and sustainability. Evidence from stage four showed that parent attendance and retention in the intervention was good indicating that the intervention was acceptable to parents. Parents and teachers reported benefits to parenting and child behaviors that were targeted through the intervention. Specifically, this included: (1) parents using less violence against children and spending more time building a positive relationship with their child, and (2) children displaying more positive behaviors and fewer behavior difficulties at home and at school. These perceived benefits indicate that parents understood and were willing and able to use the strategies taught through the program, providing evidence for feasibility, relevance, and the perceived effectiveness of the intervention. Parents reported greater confidence in their parenting skills which is likely due to the positive, supportive, and non-critical nature of the program in combination with the changes that they perceived in their own and their children's behavior. The advantages of integrating the intervention into the preschool network were evident as teachers reported benefits to their relationship with the parents and to parents' interest and engagement in school activities. There was also evidence that teachers' involvement in delivering the Irie Homes Toolbox reinforced and enhanced their previous training in the Irie Classroom Toolbox as they reported increased use of appropriate child behavior management strategies in the classroom, in addition to with their own child(ren). The fact that teachers reported benefits to their own personal and professional life is promising as interventions are most likely to be sustained when there are clear benefits to the persons delivering an intervention, in addition to the intended beneficiaries . In prevThere are three broad categories in the literature for the development of behavior change interventions that involve: (1) transporting an existing evidence-based program for use in a new cultural and/or economic context , (2) deThe Irie Homes Toolbox incorporates the use of evidence-based behavior principles with a particular emphasis on behavior change principles that have been shown to be most valued by Jamaican preschool teachers in a complementary teacher-traning program. These behavior change principles include rehearsal and practice, positive feedback, group support, provision of materials, and ensuring sessions are fun and interactive . These mThe development and/or adaptation of interventions for use in LMICs often entail formative research , 57–60. Following this development process, we now have an intervention that can be tested in a larger scale effectiveness trial. In the next phase of implementation, the program will be implemented by preschool teachers and supervised by government supervisors from the Early Childhood Commission. There will be a continued need for ongoing learning cycles to identify the strengths and needs of preschool teachers and government supervisors to implement the program and to identify the optimal levels of training and support to ensure the intervention maintains its effectiveness at scale. From a public health stand point, scaling up effective programs is critical to achieving population-level benefits in terms of reduced violence against children and reduced child externalizing behavior problems . HoweverThe methods used in the development of the Irie Homes Toolbox are relevant for use in developing or adapting other educational and public health programs. We recommend an approach that integrates formative research, theory, empirically derived content and behavior change principles, with extensive piloting in the context. Throughout this process, ongoing attention should be given to ensuring the content, process of delivery, and materials used in the intervention meet the four key principles of acceptability, feasibility, relevance, and effectiveness. h.henningham@bangor.ac.uk.The datasets generated for this article are not readily available because the data is mostly formative data and is not suitable for sharing as it is difficult to anonymise. Requests about datasets should be directed to The studies involving human participants were reviewed and approved by University of the West Indies, Ethics Committee and School of Psychology, Bangor University Ethics Committee. Written informed consent to participate in the study was provided by participating parents and teachers.HB-H and TF contributed to the conceptualization of the study, funding acquisition, project administration, investigation, data curation, data analysis, writing the original draft, and reviewing and editing the manuscript.The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.


The global outbreak of coronavirus disease (COVID-19) in 2020 has significantly affected the information environment as well as the daily life of individuals across the world, with information about COVID-19 dominating all media channels. The information provided at the time of a health crisis like COVID-19 is critical in helping people learn about the disease and the recommendations to prevent infection. However, studies have shown that when people are overwhelmed by too much information (referred to as ‘information overload’), this leads to adverse effects. This study examined the antecedents and consequences of information overload in the context of COVID-19. A survey was conducted among 627 residents in Seoul, South Korea, one of the earliest affected countries in the global outbreak. The results showed that cognitive capacity and the frequency of online news use and interpersonal communication were significant predictors of information overload. Information overload influenced how information is processed; it was associated with the tendency toward greater heuristic processing and less systematic processing. In addition, people were more likely to enact prevention behaviors when the information was processed systematically, as opposed to heuristically. The results are discussed considering both the theoretical and practical implications. In the past few decades, no issue has received greater global attention than coronavirus (COVID-19 hereafter). Since its first outbreak in December 2019, COVID-19 has affected and is still affecting significant numbers of people across the world. As of October 2020, over 37 million cases were confirmed with about one million deaths globally according to the World Health Organization (WHO) )In addition, those who engaged more in interpersonal communication about COVID-19 also tended to perceive greater information overload. One possible reason is that personal communications with others have increased the amount of information that requires cognitive effort to process. In the same vein, Kim et al.  also demAs such, one of the major issues in this line of research is the complexity between information overload and information-related behavior  because one can affect the other and vice versa. In other words, frequent media use is likely to increase the amount of information to process, which makes the probability of information overload higher . At the same time, however, overloaded people intentionally avoid information by not using media . It seems that the forces in the two directions may have balanced out in the current study. All of these conjectures deserve deeper investigations by examining the influence of other individual attributes  and information characteristics .Unlike the consistent relationships found in previous studies, there was no direct impact between information overload and intentions to take prevention behaviors in the current study. For example, this finding does not concur with that from Chon and Park’s  study shM = 4.44; SD = 0.612), which hinders statistical significance. As mentioned earlier, the survey was conducted in the middle of intensive public and media attention to COVID-19, and a strong third variable or variables about individuals  or the environment  might have affected the respondents’ strong tendency to engage in prevention behaviors. In this regard, it is important to take the ‘context’ into account in examining the phenomenon of information overload, as Kim et al. [The non-significant impact on behavioral intention as found in this study seems to result at least partially from the highly skewed distribution and low variance for the behavioral intention variable Although it was beyond the scope of current study, it is worth noting that scholars  and autThe current study bears a few limitations that merit future studies. First, while focusing on selected predictors, the influence of other confounders was not explored in this study. For example, as shown in Hsu et al. , pre-exiSecond, the sample in this study was limited to residents of Seoul, which is inhabited by younger and more educated individuals. Accordingly, those who were more educated were over-represented in the sample as compared to the entire South Korean population. This seems to largely result from the method of data collection  and the greater sample size for the group aged 20 to 49 years than the group of those aged 50 years or over. These sample characteristics suggest caution in the interpretation of the results. The results might have differed if the survey was conducted in another area of South Korea, which has a different socio-demographic composition.Regarding data collection, this study was conducted in South Korea at the very beginning of the COVID-19 pandemic. This was before COVID-19 severely affected the Western countries of Europe and America. These factors may have created a unique study context, indicating the need for cautious interpretation of the findings and further investigations because they may not be applicable to other contexts. Therefore, it is expected that future studies will be conducted in different contexts, for example, in terms of the phase of the pandemic, nation-wide impacts of COVID-19 and the government’s handling of it.Lastly, the media use variable deserves further elaboration. Even within a single media outlet, different types of content and information are provided to users and require a varying degree of activeness. For example, even though social media is known as an interactive media platform, people are often exposed incidentally to news in social media . Such paIn fighting COVID-19 over the past several months, many people have become tired of performing prevention behaviors such as social distancing and wearing a mask, and they are becoming insensitive to the recommendations against COVID-19, claiming fatigue from too much information. However, as an inverted U-shape indicates , it woulBased on the results of the current study, we expect special attention now to be paid to the information overload phenomenon. First, it would be important for health communicators and professionals to examine the current information environment, particularly online news platforms. To reduce information overload and the negative consequences associated with it, they should be guided to present succinct content and not over-repeat information. In addition, as many scholars have already pointed out, public education programs would be pertinent in improving an individual’s ability in handling information in this information-overloaded environment.


Neck pain is a prevalent health problem, largely reported in adult patients. However, very recent data show that new technologies are inducing a shift in the prevalence of this relevant issue from adulthood to all of the pediatric ages. In fact, the precocious and inappropriate use of personal computers and especially cell phones might be related to the development of a complex cluster of clinical symptoms commonly defined as “text neck syndrome”. The purpose of this article is to analyze the new phenomenon of the “text neck syndrome”, the underlying causes and risk factors of musculoskeletal pain, that can be modified by changes in routine life, in different cultures and habits, and on the “text neck syndrome” as increased stresses on the cervical spine, that can lead to cervical degeneration along with other developmental, medical, psychological, and social complications. Findings support the contention that an appropriate approach for an early diagnosis and treatment is crucial to properly evaluate this emerging issue worldwide in children and adolescents who spend a lot of time watching smartphones and computers; additional research with more rigorous study designs and objective measures of musculoskeletal pain are needed to confirm significant relationships. Existing evidence is limited by non-objective measures and the subjective nature of musculoskeletal pain. A 16-year-old girl was admitted to a pediatric unit for a medical history of headache, dizziness, and acute neck pain. The referred symptomatology was headache, subjective vertigo, and ataxia. No fever or trauma were referred. Blood exams  resulted in the normality range. Ophthalmologist examination resulted negative. Otorhinolaryngology’s examination excluded vestibular pathology. Medullary syndrome was considered by the neurologist.An MRI (Magnetic resonance imaging) of the cervical spine was obtained. This exam showed an inversion of physiological cervical lordosis and posterior disc protrusion at C4–C5 level.The hypothesis of text-neck syndrome was made. The girl was a high-school student, she described a daily routine of almost 6 h/day committed to study. The patient was re-evaluated by the orthopedic consultant and the physiatrist, who underlined the importance of primary prevention of musculoskeletal pain, avoiding excessive forward bending of the neck, thus maintaining ergonomic postures during study hours, and also limiting the use of mobile devices.She was discharged with the indication not to watch touch-screen devices over 2 h/day and to help herself to study in a better position, paying attention to posture angles. This case highlights the importance of the new phenomenon of the text neck syndrome.During the last few years, a growing reporting of data is showing that the “text neck syndrome” might be considered as an emerging 21st-century syndrome. This clinical condition refers to the onset of cervical spinal degeneration that results from the repeated stress of frequent forward head flexion while we look down at the screens of mobile devices and while we “text” for long periods of time . It is eNeck pain is a very complex and important public health problem in our modern societies ,6,7. AnyIn epidemiology studies evaluating the general population, the 1-year incidence of neck pain can be as high as 40% . Among aIn adults, there are extensive data about the epidemiology, burden and treatment of musculoskeletal pain, but contrasting and not universally accepted results are reported in children and adolescents. In fact, the lack of clinical research in children and adolescents has been emphasized by several studies ,15,16,17As we know that the prevalence of musculoskeletal conditions in childhood and adolescence is always increasing, it may be important to investigate the condition early in life and to understand the main aspects and risk factors of the onset of the symptoms, in the way to provide and to develop the best and the most efficacious treatments . In addiThe weight of the head on the spine is dramatically increased when it is flexed forward, and the effects and amount of weight are strongly and progressively enhanced by varying the degrees . In factIt is estimated that children and adolescents spend a medium of 5 to 7 h a day on their smartphones and handheld devices with their heads flexed forward to read and text. It has been reported that the cumulative effects of this exposure reach alarming results of an excess stress on the cervical spine area, ranging from an average of 1825 to 2555 h a year [There are several complications of text-neck syndrome. They can involve the eyes, the heart and lungs, the head, and the psychological field. An elevated number of studies all over the world have analyzed musculoskeletal pain in children and adolescents. There is now enough evidence to support the association between flexing toward the neck and symptoms referred to the cervical spine.Children and adolescents do not take the long-term damage to the body seriously or do not know about it, probably because the short-term effects are not so noticeable. Only in adulthood can the effects of forward flexion of the neck seriously affect the quality of life. This fact must put the attention on younger people, the most frequent users of smartphones and tablets: this increase the fear that young people could face a future of pain and disability, or even worse taking years off of their life expectancy .Some authors conducted a study in which they examined a sample of 207 children and adolescents with nonspecific neck pain . In all Another study evaluated upper quadrant musculoskeletal pain (UQMP) in children and adolescents as a common health problem, due to the increased sedentary lifestyles and the growing use of screen-based activities ,23. The In other studies, a significant association between sitting and UQMP in children and adolescents has been highlighted ,33,36,37Straker et al. studied also the postural differences between adolescent computer and non-computer users and found that computer users had increased neck flexion and increased pelvic tilt . The samIn an Australian study, 33 adolescents aged from 12 to 15 years were evaluated to verify the correlation between information and communication technology (ICT) use and musculoskeletal discomfort. The participants were eligible if they used ICT at least once per week, for almost 15 min at a time, in their normal activities; adolescents with a pre-existing diagnosis of musculoskeletal disorder were excluded. This study clearly showed an increase of prevalence of low-level discomfort, more frequently in the legs, head/neck, back and shoulders in those using ICT. The types of ICT most used were TV, desktop and laptop computers, mobile telephones, and portable hand-held gaming devices. The specific areas involved with ICT use, such as head, neck, shoulders, and upper back and arms/hand were significantly associated with the amount of ICT use and discomfort described at the end of the day. No significant correlation was found between the amount of ICT use and the discomfort in the areas of the body commonly affected by ICT use  .A study in Hong Kong examined the ergonomic issues involved in computer workstations: the study was conducted in the home environment of students at primary school age. The authors considered different factors, such as anthropometric, postural, and ergonomic considerations, to show the effect of computer use in the home environment on the children. A sample of 15 participants, 6 males and 9 females, aged from 8 to 11 years old, all attending the primary school levels 3–6 were collected. This sample did not highlight discomfort symptoms related to computer use, maybe because they were not intensive users or because they do not suffer serious musculoskeletal symptoms related to computer use. Only 4 out of 15 highlighted a discomfort directly related to computer use, while in other studies with a larger sample the discomfort was more frequently evaluated. This study aimed to investigate how computer use in primary school students in the home environment can influence musculoskeletal symptoms. It was identified that the computer furniture is not ideal for users; this contributes to have constrained and awkward postures during computer use. It is possible that these mal-adaptive postures may become habitual and extended into adolescence or adulthood. About 20–30% of the children reported musculoskeletal discomfort related to computer use. It becomes very important to understand the ergonomic issues in more extensive research studies, maybe using motion analysis and electromyography measurements to better understand children’s postural control and variability during computer use in the home environment .Another study examined the adolescent upper quadrant musculoskeletal pain (UQMP), as a significant health concern with a worldwide prevalence of 30% ,44,45. AA large number of studies report a significant association in high school students between neck pain and weekly computer use of nine or more hours . The aimIn addition, a study performed in Thailand investigated the common complaint of non-specific symptoms of musculoskeletal pain that can have a sudden onset in adolescent age and can have long-lasting symptoms ,58. The A cross-sectional questionnaire was used in primary and secondary Thailand schools, in Khon Kaen and Phitsanulok Provinces, from November 2009 to June 2011, recruiting 2750 participants. Thai school-age adolescents reported a high prevalence of neck and shoulder pain, as European adolescents (from 15% to 28%) ,62 and CThe prevalence of musculoskeletal pain symptoms in school-age adolescents is different among age, groups, and sex. Headache was the most common musculoskeletal pain symptom referred with the highest prevalence in Thai school-age adolescents. Additionally, it was found that headache and musculoskeletal pain symptoms were more prevalent in girls than in boys and these rates tend to be higher in older adolescents. Ankle or foot pain was a common musculoskeletal pain among younger boys and girls playing sports. Neck and shoulder pain were a common musculoskeletal pain among older boys and girls and were associated with computer use and school bag carrying.Chronic pain in the neck and shoulders can be referred to the head, causing headache, especially tension-type headache, which is quite common in adolescents. Trigger points in the head, neck, and shoulders shared similar pain patterns with chronic tension type of headache in children , so we cThe effects of texting with the neck in forward flexion can cause nearsightedness, eye strain, or dry eyes, because the focus on the object is nearby . In a reAnother complication of texting is electromagnetic radiation: according to a recent study, cell phones, computers, wireless internet, and televisions generate an extremely low-frequency electromagnetic field . ElectroChanges in the behavior of children and adolescents in daily habits and usual social interactions, noticed by parents, have also been reported; these symptoms have been reported in 147 young participants (82%). Parents described them as more irritable and alienated, and parents of 115 participants (64%) reported a decline of the school grades of their sons [The psychological sphere is strongly involved: pediatricians must pay attention to what parents are worried about. In a study by Emre et al., parents report that most of the children/adolescents who participated in the study reported a high grade of isolation and easy irritability . Their gSome new studies have suggested that forward postures, like we have while studying, emailing, texting, surfing the web, and playing video games, are related to hyper-kyphosis, which is associated to cardiovascular problems and pulmonary disease. In fact, when someone looks at a smartphone or a tablet, he drops his head and rounds his shoulders while looking down, so there is a restriction of the muscles of the ribs and impeachment in movement that make it harder to take a full breath .There is also an important relation between increased neck flexion and increased weight, probably due to the decreased physical activity .The prevalence of headaches, especially migraines, has been studied among school-age children and adolescents, and it varies according to age and sex . A SwediA study conducted by the Commonsense Census analyzed the mobile media and the use in children and adolescents. It demonstrated that mobile media have become an essential part of the children’s media landscape, across all levels of society.Nearly the totality of children (98%) (aged 8 or less) have some type of mobile device and a TV in their home. Ninety-five percent of families with children have a smartphone, with a trending up from 41% in 2011 to 63% in 2013, and 78% of families have a tablet (from 8% in 2011 up to 40% in 2013). Indeed, 42% of children have their own tablet device, from less than 1% in 2011 up to 7% in 2013. The main activities of children on mobile devices are watching TV and playing video games. It is estimated that around 7 out of 10 children under the age of 8 (around 70%) have watched videos on YouTube in their lifetime and played video games on a mobile device, while only 59% of children have watched TV shows or movies on a mobile device. Only 28% of children have read a book on a smartphone or tablet .Musculoskeletal neck pain is a multifactorial disease that has become common in children and adolescents. Numerous risk factors are known to contribute to the development of this pathology. Movements such as bending the head, neck, and shoulders on cell phones and portable devices, and distorting the neck position while sitting, studying, or watching television, can progressively increase stress in the cervical spine. This stress can result in various complications, such as premature wear, lacerations, degeneration, possible surgery, developmental, medical, psychological, and social complications. While it is very difficult to avoid habits in bad postures and avoid overuse of modern technologies, today’s young people should strive to perform their daily activities while keeping their spine in a neutral position as much as possible, avoiding excessive neck flexion for several hours every day ,77,78,79Various indicators of psycho-physical well-being in children have been negatively associated with insufficient physical activity ,81, and According to data recently published by the WHO, overweight and obesity are among the most serious public health problems of the 21st century. The increasing prevalence of excessive weight in childhood can consequently cause an increase in the problems of suboptimal posture in children and adolescents . The incIt has been shown that the prevalence of neck pain is higher in older adolescents and that physical inactivity and professional activities can be a risk factor for the onset of back pain .In fact, in a three-year longitudinal study by Wedderkopp et al., physically active adolescents were less likely to develop back pain . PhysicaMany information campaigns have aimed to raise awareness of the problems related to musculoskeletal pain (neck pain in particular), with particular regard to the possible medical, psychological, and social consequences and the methods of prevention and treatment .Avoid excessive usage and take frequent breaks.Avoid prolonged static postures.Position the device such that it reduces stresses both on the head/neck and the upper extremities.Avoid high repetitions of movements such as prolonged typing or swiping.Avoid holding large or heavy devices in one hand for long duration.Prevention is the key when it comes to text-neck. The following suggestions should be kept in mind while using smartphones or other handheld devices :Avoid exChildren < 2 years: recommended no time watching TV or using other electronic media .Children 2–5 years: no more than 1 h/day sitting and watching television and other electronic media .Infants, toddlers, and preschoolers should not be sedentary, restrained or kept inactive for more than 1 h at a time, with the exception of sleeping.The Australian Department of Health (2012) published guidelines for children about the recommended time to pass on mobile devices or electronic media ,94:ChildTop 5 recommendations of Italian Society of Pediatrics (2019)” [Even the Italian Society of Pediatrics released their top-5 rules for families with children in 2019. These are the “ (2019)” :1. Talk with your son—It is important to encourage open communication between parents and adolescents, explaining to children what a positive and intelligent use of media devices means, paying attention to the contents that are published and read and reminding them that it is essential to protect online privacy to protect themselves and your family.2. Understand, learn and control—Parents should monitor the time their child spends on tablets, smartphones, and PCs, first learning the available technologies to be able to understand them as much as possible, and playing with them and sharing activities on media devices as much as possible.3. Set clear limits and rules—It is necessary to limit the time of use of smartphones, tablets and PCs during the day or on weekends, by establishing precise times of prohibition, for example during meals, homework, and family gatherings. Consider media an opportunity for the whole family to watch movies together or share social content or use chat and video messages.4. Give a good example—The parent’s example is essential, so fathers and mothers should be the first to limit the use of smartphones when they are with the family and during meals. It is also important that the parents choose appropriate content and languages on social networks.5. Do network—Collaboration between parents, pediatricians, and health professionals is essential to protect and support children through information campaigns that provide greater awareness of the positive aspects but also of the risks of excessive use of media devices.The aim of this article was to examine the problem of musculoskeletal pain in children and adolescents, since it is a common multifactorial disease. It is known that there are numerous potentially modifiable risk factors contributing to its development. The increased stress on the cervical spine is due to the continuous flexion movements of the head and neck on mobile devices used daily.Childhood and adolescence are characterized by periods of rapid growth and many physical problems can occur due to prolonged and excessive use of smartphones or computers, although it is often thought that this type of problem is more common in adults. Recently, the literature has focused attention on issues that can become a serious health problem, such as the increase in sedentary living and the excessive use of electronic devices among young people.All of the studies carried out on musculoskeletal pain in the pediatric age show the same characteristics: the specific symptoms  are expressed more in females than in males, and these rates are higher in adolescents than in children. Joint pains, especially in the lower limbs (ankle or foot), are more common among younger boys and girls who play sports. On the other hand, musculoskeletal pain referred to the cervical spine is more frequent among older boys and girls, often associated with carrying a backpack and using a computer for study purposes.Symptoms of chronic pain to the cervical spine and shoulders can sometimes also be referred to the head, causing headache and muscle tension, frequently encountered in adolescents. In fact, the trigger points of the nociceptive signal in the head, neck and shoulders share the same pathways as chronic tension headache in children, so this may justify why neck and shoulder pain can begin in childhood and early adolescence and persist into adulthood with chronic musculoskeletal problems. Thus, maintaining incorrect sitting postures for a long time could cause the appearance and persistence of musculoskeletal disorders related to the head, neck, shoulders, and dorsal-lumbo-sacral spine.Currently, studies on musculoskeletal pain in children and adolescents are still limited, so there is a lack of validated tools to have an objective measure of musculoskeletal cervical pain and to evaluate the direct consequences. Therefore, it is difficult to draw conclusions based only on self-administered tools, such as questionnaires. Furthermore, there is the difficulty of comparing different samples, populations and cultures to consider. Future studies should therefore aim to validate a unified tool for measuring musculoskeletal pain in the neck and make it comparable in different cultures. It is known that pain experienced in childhood is related to pain reported in adulthood, although the pathophysiological mechanisms are still unknown; several studies have hypothesized that in cases of psychological triggers in childhood (such as a particular painful experience), in genetically predisposed subjects, there is also a predisposition to develop chronic pain in adulthood. Further studies would be needed in the future to explore and investigate the mechanisms responsible for these associations.In addition, further research is needed to improve school furniture in classrooms , and about postural hygiene , to help improving the head flexion (HF) posture.Although it is very difficult not to use modern technologies or to avoid incorrect postural habits, the cause of musculoskeletal problems, information policies should be implemented for young people to be aware of the most correct postures. For their part, young people should strive to perform their activities by keeping the spine neutral and avoiding excessive neck flexion for hours on end every day.What is Already Known on This Subject?➢Musculoskeletal pain is a predominant problem during childhood and adolescence.➢Low back and neck pain are exacerbated by the augmentation on forward flexion on mobile devices used daily.➢Recently, the literature has focused attention on the increase in sedentary living and the excessive use of electronic devices among young people that can become a serious health problem.➢Studies on musculoskeletal pain in children and adolescents are limited, because of the lack of validated tools to have an objective measure of musculoskeletal cervical pain and to evaluate the direct consequences. Therefore, it is difficult to draw conclusions based only on self-administered tools such as questionnaires. Furthermore, there is the difficulty of comparing different samples, populations, and cultures to consider.What Does This Study Add?➢This study examined current literature focusing on musculoskeletal pain in children and adolescents and to evaluate the direct consequences.➢It presents a comparison among different cultures and highlights the physio-pathological base of the pain experienced in childhood; probably in cases of psychological triggers in childhood (such as a particular painful experience), in genetically predisposed subjects, there is also a predisposition to develop chronic pain in adulthood.➢The study highlights the need for future studies to therefore aim to validate a unified tool for measuring musculoskeletal pain in the neck and make it comparable in different cultures and to investigate the mechanisms responsible for the associations in genetically predisposed subjects to develop chronic pain in adulthood.➢This study concludes that further research is needed to improve school furniture in the classrooms  and about postural hygiene , to help improving the head flexion (HF) posture.➢The COVID-19 pandemic will probably exacerbate the problem.The problem will probably worsen in the near future and will be even more relevant, in light of the COVID-19 pandemic; in fact, distance learning made inevitable forces an entire generations of children and adolescents to spend even more time at home on books and inevitably on mobile devices.


In the dentistry field, the analysis of dental plaque is vital because it is the main etiological factor in the 2 most prevalent oral diseases: caries and periodontitis. In most of the papers published in the dental literature, the quantification of dental plaque is carried out using traditional, non-automated, and time-consuming indices. Therefore, the development of an automated plaque quantification tool would be of great value to clinicians and researchers.This study aimed to develop a web-based tool called DenTiUS and various clinical indices to evaluate dental plaque levels using image analysis techniques.The tool was executed as a web-based application to facilitate its use by researchers. Expert users are free to define experiments, including images from either a single patient  or several patients (to perform a group characterization) at a particular moment or over time. A novel approach for detecting visible plaque has been developed as well as a new concept known as nonvisible plaque. This new term implies the classification of the remaining dental area into 3 subregions according to the risk of accumulating plaque in the near future. New metrics have also been created to describe visible and nonvisible plaque levels.The system generates results tables of the quantitative analysis with absolute averages obtained in each image (indices about visible plaque) and relative measurements (indices about visible and nonvisible plaque) relating to the reference moment. The clinical indices that can be calculated are the following: plaque index of an area per intensity , area growth index , and area time index . Images and graphics can be obtained for a moment from a patient in addition to a full report presenting all the processing data. Dentistry experts evaluated the DenTiUS Plaque software through a usability test, with the best-scoring questions those related to the workflow efficiency, value of the online help, attractiveness of the user interface, and overall satisfaction.The DenTiUS Plaque software allows automatic, reliable, and repeatable quantification of dental plaque levels, providing information about area, intensity, and growth pattern. Dentistry experts recognized that this software is suitable for quantification of dental plaque levels. Consequently, its application in the analysis of plaque evolution patterns associated with different oral conditions, as well as to evaluate the effectiveness of various oral hygiene measures, can represent an improvement in the clinical setting and the methodological quality of research studies. Dental plaque is a diverse community of microorganisms located on dental surfaces in the form of a biofilm embedded in an extracellular matrix of polymers from both the host and microbiota ,2. It isThe planimetric method  was an iIt was only in the 21st century that experts began to rely on techniques that employ analyses of digital images to quantify dental plaque. The main approach involved the planimetric method, with an imaging tool used to detect the dental plaque and tooth areas individually and calculate the ratio between them. An expert operator could outline both regions manually using a graphical interface ,15. AlsoSome researchers used image-processing software ,17,21-23The computer vision techniques used previously vary from rudimentary to extremely complex. One of the simplest methods was image thresholding, which made it possible to isolate two or more different areas according to their color or light intensities. This technique was able to distinguish between disclosed plaque and nonplaque ,28; teetThe different methods available today produce promising results, with many studies reporting the suitability of automatic or semiautomatic techniques for assessing dental plaque and, as a result, oral hygiene levels ,27,29,32Following this trend of digital development , we presThe rest of the paper is structured as follows. The Methods section first describes the entire platform, including its main features and software architecture, and also contains a brief description of the patient database. Then, it explains DenTiUS Plaque, describing the kinds of images it can process, the experiment's design, and the processing algorithms. In the Results section, the different parameters of the quantitative analysis of dental plaque offered by the tool are presented, as well as several graphics, through a real case. Subsequently, the results of a questionnaire to individuals working in the field of dentistry on the usability of software are presented to evaluate the ease of use of the instrument and its usefulness. Finally, the paper closes with a discussion and some closing remarks and identifies possible future improvements.The DenTiUS platform emerged naturally as a way to manage users, images, and patients in dentistry research. It was initially developed as a standalone application for the quantification of dental plaque, with modules for managing the patients and experiments of a unique user, but not the different profiles and interactions of multiple users. As our research group is also working in other dentistry fields, all of which employ a shared patient and user database, the decision was made to develop an entire web-based system, DenTiUS Lab, for dental assessment experiments. DenTiUS Lab integrates DenTiUS Plaque's structure into a modular platform that isolates the user interface and the patient and user database from the main DenTiUS Plaque module. DenTiUS was designed as a global platform to support clinical dental research through the inclusion of different modules that enable users to obtain a set of measures, graphs, and images with which to easily reach conclusions about their experiments. It was developed as a web application for several reasons: (1) most personal computers come with a pre-installed web browser, meaning that an installation process that could be complicated for nonspecialist users is avoided; (2) platform updates  are deployed in a process that is completely transparent, but also unintrusive, which also ensures that all users are employing the most up-to-date application, removing any requirement to support old versions or manage compatibility issues between them; and (3) as having a web browser is the application's only requirement, it can be used on both computers and mobile devices.The platform was implemented as a client-server application, which runs on a central server where all the data are stored . All theThe Java programming language was employed when developing the platform because of its popularity, power, verbosity, and ease of maintenance . The ModIn summary, DenTiUS was developed with maintainability and extensibility as the main objectives. In this way, the application was implemented by following a modular structure, where the visual, logic, and data layers were isolated. The functionality in each layer was divided into classes, with many abstractions available to improve the extensibility. Consequently, the only elements requiring implementation (if necessary) to develop a new module related to dental research are the data definition , description of a new kind of experiment and its processing algorithms, and a customized report format . Access to other utilities is also possible through the common interface bar at the top of the screen see . These iA “Patient” database interface C allows DenTiUS Plaque was the main objective behind our development of the DenTiUS platform. The goal was to enable DenTiUS Plaque to perform as an automated decision support system to help experts analyze and quantify the macroscopically observable dental plaque deposited on teeth. In the first step, the software requires reproducible images of the fluorescein-dyed plaque taken under ultraviolet light. Fluorescein is a well-known fluorochrome in the field of dentistry, and a patent for its use as a dental plaque marker was filed in the USA in 1967 by Herbert Brilliant . In these images, the bright blue region corresponds to the tooth area unaffected by plaque, while the green region matches plaque deposits over both the tooth surfaces and gingiva.To enable the assessment of dental plaque levels at different times, an entity called a “plaque moment” was defined for a single plaque image  or a set of images  captured from a patient at a particular time. The possibility of including lateral views is a novelty of the system, as these provide a better view of the posterior teeth, where more plaque is usually accumulated.Plaque moments can be attached to a patient's file via the Patients section C, which The plaque experiment design module see  enables The configuration of the experiment is decided by the user according to the specific circumstances  or objectives . The system performs the experiments defined by the user by processing the data of all the patients and all the patient moments included in the experiment. When the experiment involves multiple moments for the same patient, the images with the selected tooth areas are subjected to a process of normalization in the number of pixels.DenTiUS Plaque does not permit comparisons between groups, as this was not the objective of the system, but users can export all the computed parameters to manage and prepare their own statistics with no limitations.After an exhaustive analysis of the color characteristics of each region of interest, a process is defined to segment the dental area, excluding the gingiva region: Initially, the blue and red channels are added together, and the result is thresholded according to a parameter fixed by the user . The isolated pixels are then removed, and a connected component analysis is performed to identify objects from that binary image. Thereafter, a set of conditions related to region size  and solidity  are applied to remove nondental regions. Other specific rules, which were defined to eliminate bright artifacts, are included to make the process fully automatic. All these parameters can be changed in the “Process” tab  plaque by analyzing the differences between the green and blue channels (Equation 1). The rest of the dental region is considered to be a first approximation of the nonvisible plaque area (Equation 2).visibleP is the visible plaque, nonvisibleP is the initial approximation of the nonvisible plaque, and G and B are the green and blue channels of the dental area, respectively.where G-B dental area histograms are included to assess how levels of dental plaque increase over time when oral hygiene stops, with the positive and negative sides corresponding to the visible (G>B) and first approximation of the nonvisible plaque (G<B), respectively. δ and l, the blue/green differences are thresholded to produce 3 different region masks in the negative part of the graph, namely level 1 nonvisible plaque (risk of being plaque in the following hours), level 2 nonvisible plaque (risk of being plaque in the following days), and no plaque (no risk of being plaque in the medium term):According to 2 different parameters, l parameter is automatically calculated from nonvisible plaque histograms of current and reference images . The image collection was performed following the ethical standards of our institution's research committee and the 1964 Declaration of Helsinki and its later amendments .When the processing finishes, the user can view the results by clicking on the appropriate notification or the “Processings” submenu. The processing results are divided into 4 tabbed subsections : “Data aThe clinical indices defined in this research provide information on the bacterial plaque on dental surfaces, specifically the area where it is present, its intensity, a combined value between the area and intensity, and different growth parameters. The system can produce dental plaque clinical indices in a computerized form, including in relation to the plaque index of an area per intensity , area growth index (growth rate of plaque per unit of time in hours: percentage area/hour), and area time index .In the example in The measurement tables can be customized and downloaded in CSV and spreadsheet formats via the “Measurements download” tab, where users can also select specific parameters within the absolute and relative measurements.Pie and bar charts comparing the levels of visible plaque and nonvisible plaque, as well as the nonplaque areas, are also presented. Finally, 2 histograms are presented that compare the intensity distribution of the plaque in the selected image moment to the corresponding image of the reference moment and the intensity distributions of the plaque through all the moments. A vertical line at 0 can be seen in both histograms, separating values corresponding to visible plaque (Equation 1) from those relating to nonvisible plaque and nonplaque . Finally, a full report presenting all the tables and graphs can be generated in PDF format via the main “Processings” menu. This will contain all the processing data, including all the information described previously for each processing tab.As with most web applications, DenTiUS has a graphical user interface (GUI) that is designed to be friendly, simple, and intuitive, as well as adaptable to the various screen sizes on mobile phones, tablets, and computers. A usability test, based on the Computer System Usability Questionnaire , was proThe questionnaire was sent to 34 dentists doing research in the field of dentistry, including mainly PhD researchers , undergraduate research fellows in their final year of career , and senior researchers . The testers were given instructions about how to enter DenTiUS Lab and proceed with a test case based on a patient with plaque growth over several days. In particular, they performed the following steps: signing up to the application, registering some patients and plaque moments, defining an experiment, continuing with the processing, and searching for various results.Access to the DenTiUS Lab web platform is available free of charge for non-commercial use for researchers and clinicians .The importance of dental plaque in the etiopathogenesis of important oral diseases, such as caries and periodontitis, is well-known ,46; on tThis paper introduces DenTiUS Plaque. This is a tool for the quantification of bacterial plaque integrated into a general web-based platform with a common management process for users and patients.DenTiUS is the first dental research system to enable image collections and patient data to be managed, experiments to be designed, and images with customized configuration to be automatically processed. The developed tool produces accurate and repeatable results for the assessment of clinical indices of bacterial plaque levels relating to a patient or group of patients over time, ensuring the sustainability of the process in terms of the time and effort required by users of the system. Clinical users with no technical background can process the images in batches and obtain a table of measurements  and explanatory graphs that can be exported in various formats . Although a more complex final report could be designed, these different outputs were a requirement identified by dental researchers to enable them to have access to all the values needed to produce their own statistics.Specifically, a novel algorithm was developed in DenTiUS Plaque to detect and quantify dental plaque levels from ultraviolet images. This approach first detects the dental region and then segments and quantifies visible plaque by analyzing the difference between green and blue channels. Initially, DenTiUS Plaque could represent a tool that offers the following advantages over the QFL-D system -35. The Regarding the usability test conducted with people working in the dental field, overall, the users stated that they were likely to use the application in the future, with the results revealing that DenTiUS Plaque was suitable for its ultimate purpose.Biological coherence between conventional clinical indices and new indices derived from image analysis is a study to be carried out to test the validity of the latter ,47,48. IFurther work will be conducted to improve the platform. Additional help will be included in the software based on the results of a GUI validation exercise.The image cropping system will be improved to automatically exclude unwanted artifacts in the image. More research tools will be fully integrated into the DenTiUS platform. An example is DenTiUS Biofilm, which will enable the quantification of microscopic dental plaque as well as comparisons of the plaque growth pattern at the microscopic (biofilm) and macroscopic levels (plaque), taking advantage of the shared management of patients and users.The DenTiUS Plaque software allows automatic, reliable, and repeatable quantification of dental plaque levels, providing information about area, intensity, and growth pattern. Dentistry experts recognized that this software is suitable for quantification of dental plaque levels. Consequently, its application in the analysis of plaque evolution patterns associated with different oral conditions as well as the evaluation of the effectiveness of various oral hygiene measures can represent an improvement in the clinical setting and methodological quality of research studies.