Although rare, the rates of diagnosis of male breast cancer (MBC) have been increasing over the years, and it can be quite aggressive in the male organism. Some strategies such as health education disseminating knowledge about MBC can be essential for early discovery and finding better prognosis.Protocol to map the available evidence of health education approaches on MBC.A scoping review on health education on MBC will be carried out in Latin American and Caribbean Literature on Health Sciences (LILACS), Web of Science, Scopus, Scielo, Online System of Literature Search and Analysis Medical (MEDLINE), Embase, Virtual Health Library (VHL). Two independent reviewers will perform screening, data extraction, and risk of bias assessment through the Joanna Briggs Institute (JBI) Critical Assessment Checklist. For the quality of evidence, the Grading of Recommendations, Assessment, Development and Evaluation (GRADE) Analysis will be used.The results of this review will be published in a peer-reviewed journal.This scoping review will provide evidence of how health education on MBC is being addressed in health systems. Evidence can help healthcare professionals and patients recognize the most effective educational inventions in disseminating knowledge and preventing MBC. The risk of developing this type of cancer increases with advancing age, it is currently known that, throughout their lives, about 1:1000 men can be diagnosed with this problem, while the prevalence in women is more around 1:8.,4Over the years, the incidence of MBC has been on the rise on all continents, worldwide, newly diagnosed cases have increased from 8500 in 1990 to 23,100 in 2017, and these figures may be even higher due to the invisibility of the topic. Some risk factors related to these numbers include increased longevity, obesity, diseases, testicular tumors, and gene mutations such as BRCA2.,6The presentation of MBC is usually the presence of a painless volume in the breast and armpit region, wrinkled skin, nipple retraction and increase in the size of the axillary lymph nodes. Despite the small risk for males to develop the disease, when diagnosed, this cancer is more aggressive and is in an advanced stage, contributing to a worse prognosis and lower survival when compared to cases in women. The treatment is similar to that for women and may involve surgery, radiotherapy and/or chemotherapy.,8Health promotion and specific prevention strategies such as mammography are effective in the early screening of female breast cancer. In the case of men, there is no recommendation for screening at detection due to the low general prevalence of the disease, this recommendation is extended even to men with known risk. In men’s health care, this topic is not commonly addressed, being absent in health actions and services.Knowledge of MBC is essential for early diagnosis as well as for structuring of prevention and health promotion strategies. Despite this urgent need, since cases are increasing every year, research carried out with male college students shows that only one-third knew about the existence of MBC and even smaller proportions were aware of risk factors and the main signs and symptoms. Evidence from this study suggests that undergraduate students have limited knowledge about breast cancer in men.Health education actions for health professionals and the target population are necessary for better prevention of MBC, since there are prejudices, stigmas and lack of prior knowledge that hinder early diagnosis actions. These must happen mainly at the primary level, for the main means of prevention to be included in the health systems. In this context, this review is justified by the need to understand how interventions are carried out at the level of health education on MBC.A preliminary search was conducted at PROSPERO and no current or ongoing scoping reviews or systematic reviews on the topic were found. In this context, the objective of this protocol was to map the available evidence on health education actions on MBC.What are the main methods, instruments or strategies used in health education actions on male breast cancer?Studies with participants over 18 years of age without age or sex restrictions, who may be users of the health system or health professionals, will be included.This review will consider studies that explore health education actions and describe their educational strategies for approaching the topic of MBC. It will also describe the positive impacts on prevention and early diagnosis of MBC.The present review will mainly consider studies focusing on the male and elderly population and health education interventions, not limited to these aspects, as well as any geographic region.This scoping review will consider studies with quantitative, qualitative, and mixed methods designs for inclusion. In addition, systematic reviews and text and opinion articles will be considered for inclusion in the scope review proposal. proposed by the Joanna Briggs Institute. The protocol of this study was registered in the Open Science Framework (https://osf.io/5qs9k/).This is a research protocol for a scoping review following the recommendations of the Reviews extension for Scoping Reviews (PRISMA-ScR)http://links.lww.com/MD/H455), where the search strategies in the Web Of Science research database conducted in March 2022 are presented. The search strategy, including all the identified keywords and indexing terms, will be adapted for each information source included. Reference lists of articles selected for full-text review included in the review will be selected as additional articles.The search strategy will aim to locate published and unpublished primary studies, reviews and text, and opinion articles. A limited initial search in the Web of Science was performed to identify articles on the topic. The text words contained in the titles and abstracts of relevant articles and the indexing terms used to describe the articles were used to develop a comprehensive search strategy as can be seen in the supplemental digital content ;MEDLINE (Ovid Online - www.ovid.com);EMBASE (Ovid Online - www.ncbi.nlm.nih.gov/pubmed/);PubMed ;www.scielo.org/php/index.php);SCIELO (www.ebscohost.com);CINAHL ;WEB OF SCIENCE ;www.ovid.com);EMBASE .Sources of unpublished studies and gray literature to be searched include Catalog of Theses and Dissertations from Brazil;Open Access Scientific Repository of Portugal;Gray Literature Information System in Europe (Open Grey). This online platform was developed by the Qatar Computing Research Institute, available for free, offers a wide range of resources, including uploading citations in different formats, navigations, automatic extractions to exclude duplicate citations. For this study, the Rayyan QCRI will be used for exclusion of duplicated articles and it will be required for title and abstract analysis. After a pilot test, titles and abstracts will be selected by 2 independent reviewers for evaluation according to the inclusion criteria for the review.After the search, all identified records will be grouped and loaded into all data and will be exported from databases in EndNote, Export, Refman/RIS or Text format and included in the Rayyan QCRI platform. as can be seen in the supplemental digital content  that presents the PRISMA 2020 flow diagram for new systematic reviews which included searches of databases and registers only.The full text of selected citations will be evaluated in detail according to the inclusion criteria by 2 independent reviewers. The reasons for excluding full-text articles that do not meet the inclusion criteria will be recorded and reported in the scoping review. Any disagreements that may eventually arise between reviewers at each stage of the selection process will be resolved by discussion or with a third reviewer. The research results will be reported in full in the final scoping review and presented in a PRISMA flow diagramData will be extracted from articles included in the scoping review by two independent reviewers using a data extraction tool developed by the reviewers in Excel spreadsheet format. The extracted data will include specific details about the identification of the publication containing the author/year information; country of study, language; journal; study design; participants; type of intervention; educational strategies; intervention and conclusion site. This extraction will be performed by the two reviewers and then compared, if no agreement is reached, the third reviewer will be called. The draft data extraction tool will be modified and revised as necessary during the data extraction process for each article included. Modifications will be detailed in the full scoping review.http://links.lww.com/MD/H457) this extraction box contains the key information to be extracted from the included studies.A draft extraction tool is provided in the supplemental digital content (Appendix III, Supplemental Digital Content, Data will be descriptively mapped and presented through tables and figures with the distribution of articles by publication period, country, and main variables found. A narrative summary of the overall results will accompany tables and figures that describe key health education strategies in MBC.For the development of this study, approval of ethics and consent is not necessary because it is a systematic review that will use secondary studies.The adequate inclusion of health education actions should be priority for an early diagnosis of various types of cancer. In the case of MBC, this should be addressed within the context of men’s health. As it is a subject usually discussed among the female audience, more assertive guidance is necessary in order to reach men with risk factors as well as health professionals.,17A low adherence and search for health care is known to happen among men, which may be explained by reasons of gender, time incompatibility, fear of detecting serious illnesses, insufficient number of consultations in public health services and professionals, and lack of specialists. These data may be even lower when the male body is affected with a pathological process common in females, leading to a process of rejection of the sick body. Men have difficulty accepting MBC, leading to serious mental illness.,19Personal and environmental aspects must be considered when health care is linked to cancer. Psychological aspects are usually affected, placing the individual in a vulnerable situation, further increasing the chances of illness and death. Greater knowledge, management, and preparation of the professionals who assist these patients and their relatives are necessary, especially where male patients with breast cancer have worse survival rates compared to female patients.It is expected that by concluding this review, the main findings may contribute to improvements in health education processes for professionals and users of health services, aiming at enhancing the knowledge and dissemination of the existence of MBC and providing subsidies on how to approach this topic in the daily practice.Conceptualization: José Felipe Costa da Silva.Methodology: Vilani Medeiros De Araújo Nunes, Gilson de Vasconcelos Torres.Project administration: Gilson de Vasconcelos Torres.Supervision: Luciana Araújo dos Reis, Julliane Tamara Araújo de Melo Campos.Writing – original draft: José Felipe Costa da Silva, Thaiza Teixeira Xavier Nobre, Jéssyca Camila Carvalho Santos, Thalia Natasha Silva Barbalho.Writing – review & editing: Julliane Tamara Araújo de Melo Campos.


The number of studies with information at multiple biological levels of granularity, such as genomics, proteomics, and metabolomics, is increasing each year, and a biomedical questaion is how to systematically integrate these data to discover new biological mechanisms that have the potential to elucidate the processes of health and disease. Causal frameworks, such as Mendelian randomization (MR), provide a foundation to begin integrating data for new biological discoveries. Despite the growing number of MR applications in a wide variety of biomedical studies, there are few approaches for the systematic analysis of omic data. The large number and diverse types of molecular components involved in complex diseases interact through complex networks, and classical MR approaches targeting individual components do not consider the underlying relationships. In contrast, causal network models established in the principles of MR offer significant improvements to the classical MR framework for understanding omic data. Integration of these mostly distinct branches of statistics is a recent development, and we here review the current progress. To set the stage for causal network models, we review some recent progress in the classical MR framework. We then explain how to transition from the classical MR framework to causal networks. We discuss the identification of causal networks and evaluate the underlying assumptions. We also introduce some tests for sensitivity analysis and stability assessment of causal networks. We then review practical details to perform real data analysis and identify causal networks and highlight some of the utility of causal networks. The utilities with validated novel findings reveal the full potential of causal networks as a systems approach that will become necessary to integrate large-scale omic data. Due to recent technological advances, data acquisition of molecular components on large scales and in multiple omics capacities has been realized. Yet, advanced analytic methods are desperately needed to systematically integrate these data to facilitate discoveries and improved understanding of the biological process that impacts omics health and disease. Systematic analysis refers to the simultaneous analysis of all data in the study while considering their interconnectivity/dependency. Identifying the underlying relationships among molecular entities as a network provides insights into complex processes that would not be revealed by focusing on individual entities in isolation . Such anCausal networks, as a systematic analysis of data, are ideally suited for analyzing multi-omics and heterogeneous data sets to reveal the role of entities individually or as a module in a system . Using the principles of MR on a genome-wide scale and integrating genetics with other omic data allow researchers to relate information at different levels of omic data in a cohesive analytic framework and possibly uncover the underlying relationships that represent molecular networks . Causal Identifying causality through classical MR has received attention in biomedical research. The characteristic of this framework is hypothesis-driven with a focus on a small set of entities with known underlying relationships  . In modeWe here review the integration of classical MR and causal networks which seem mostly as two distinct branches of statistics. Here, we first briefly review some recent developments in the classical MR framework then, we discuss the identification of causal networks, evaluation of the underlying assumptions, and introduce some tests to assess the stability of the networks. We also review practical steps to identify causal networks on real data and review some utilities of causal networks, such as the identification of molecular regulatory sub-networks and the identification of molecules with an essential role in the system under study.1. IV is associated with an explanatory variable conditional on other covariates in the model.2. IV is not associated with unmeasured confounders.3. IV is not associated with response conditional on the explanatory variable and unmeasured confounders.To estimate causal relationships when experiments cannot be controlled or randomized, which is often the case for biomedical studies, statistical regression models are frequently used by regressing a response variable on an explanatory variable. However, regression models can give biased results when an explanatory variable is correlated with the regression model’s error term. To overcome this limitation, instrumental variables (IV) can be used, but with strong assumptions. A valid IV induces changes in the explanatory variable but not the response of interest other than through the explanatory variable, hence allowing identification of the causal effect of the explanatory variable on the response variable. The basis of MR is the use of IVs, as discussed extensively in the literature . In biomIn MR applications, when a genetic variant affects response via a different biological pathway from the explanatory variable,  effect) . In the  effect) : If thertruments . Some restimates . For modstimates , MR mixtstimates , and MR-stimates . In addistimates .One of the recent MR developments in the classical MR framework includes applications with several explanatory variables, called multivariable MR. Multivariable MR enables estimating the effects of multiple individual explanatory variables (primary and secondary explanatory variables) on one response to avoid violation of MR assumptions due to secondary explanatory variables being the confounders of the primary explanatory variable and response relationship , Figure n is the number of explanatory variables in the multivariable MR.In The application of multiple uncorrelated Since the instruments are uncorrelated, the variation explained by each of the instruments is independent from the other.In mediation analysis, the interest is in the contribution of variables that lie on the causal pathway from an explanatory variable to a response, k stands for the number of uncorrelated IVs, Due to high measurement costs or lack of appropriate biospecimens, data on e, e.g., . The algThis approach can also be applied to summary statistics of both samples without having the individual levels . In thisThe application of summary statistics and two-sample studies are common for wide association studies, such as transcriptomic/phenotypic wide association studies, where the association of the predicted-explanatory variable and the response of interest is tested. Two-sample studies based on summary statistics are also used in colocalization, where we estimate the probability of the same signal for GWAS and the study of quantitative trait loci (QTL), such as expression or metabolite QTL. However, in these studies, the MR assumptions, especially the lack of pleiotropic effect, are not assessed. Otherwise, these studies will be the same as MR studies, see .a priori in a small set of variables, and the interest is finding an individual cause of a specific response. Even in multivariable MR when multiple explanatory variables are considered, the interest is in finding the individual causes of a response and not revealing the underlying relationships among the entities in the study. Therefore, the classical MR framework is hypothesis-driven  are essential to the conclusions. In this framework, each entity can be an explanatory variable, mediator, confounder, as well as a response at the same time. The key feature of causal networks is being discovery-based, and suitable for handling large-scale data, where we have limited knowledge about the underlying interconnectivity. There are different applications of systematic analysis of omics including causal networks . For insCausal networks can be based on Bayesian networks augmented with the principles of MR . For detIVs . Otherwis  isIf this property is not satisfied, the variable used as As reviewed above, the validity of networks . Using Hnetworks .We here introduce some tests to assess the stability of an identified causal network. Understanding the tests requires some background in basic concepts for causal network exploration, such as the “graphically” identification of cofounders using the “back-door” criterion, see Supplementary or . Due to Confounding-equivalent Test. Assume we are interested in the effect of This equality guarantees that, adjusting for either set The confounding equivalent property was introduced previously in . Here, wVariable-Reduction Test. In an identified causal network, consider a node that has only a role as a response/receptor. The property of this node is no arrows out but arrows in, such as node To quantify this in practice, we can use the receiver operating characteristic (ROC) curve for a different number of nodes having only a role as a response/receptor in the network . If thisVariable-Increment test. Assume we are interested in the effect of Considering Permutation Test. Permutation analysis can be performed to examine the stability of an identified causal network. Since the implementation of the permutation test for causal networks is not straightforward, here, we review how to perform a permutation test to assess the stability of a causal network ( network : the setFirst, we adjusted metabolites for the set of covariates in the study, such as age, sex, and body mass index. Second, we selected a set of third step, we assessed conditional independence properties among metabolites using a constraint-based Bayesian algorithm. Note that this step can be carried out using a score-based algorithm too. Fourth, for each of the conditional dependence properties from step 3, we assessed the exclusive effect of the In this section, we review an application to identify a causal network in real data. We review a study of systematic integration of genetics and metabolomics to identify the metabolomic-causal network . Metabollgorithm , and theDistance , Figure A close-up of the network is depicted in We may not be able to identify causal relationships between metabolites with no, however, having them in the analysis provides us with an opportunity to reveal the relationship with other modules or metabolites in the network . ExtractThe utilities of causal networks are multiple and flourishing, such as revealing principles governing omics under study and understanding them as a system, understanding functional links, explaining the results of perturbations, as well as facilitating efficient experimental/clinical designs. We here review the utilities by exploring the metabolomic-causal network identified in the previous section as well as using the network for downstream analysis.In addition to effect size and significance level for each entity, using causal networks, we can reveal the role of entities in the system under study. Through exploring the network, we can identify modules/sub-networks, a set of entities that interact with each other to control a specific function . The borThe causal networks do not only lead to a deeper understanding of how the metabolites affect each other, but also serve as the basis for downstream analyses. We explain this utility with the systematic integration of the metabolomic-causal network with triglycerides, a known risk factor for cardiovascular disease : In totaKIAA1755 with an unknown function is identified with a strong relationship with metabolite eicosapentaenoate which affects essential hypertension with no known cause (The other utility of causal networks is improving biological understanding of the GWAS pathways leading to disease . The genwn cause . Mappingwn cause . The relwn cause . These fThe last utility of causal networks that we will review here is assessing GWAS findings hypothesized with pleiotropy. Causal networks reveal the underlying relationships, therefore, providing an opportunity to satisfy the assumptions of structural equation modeling and assess if a GWAS finding affects two entities independently or if it is just an indirect effect .A key challenge for elucidating disease mechanisms in the 21st Century is understanding the topology and dynamics of molecules . SystemaIdentification of causal networks, as a systematic analysis of data, is established in the recognition of the hierarchical structure of the biological systems and reflects the underlying patterns . The appMR techniques can be modulated for systematic analysis of large-scale omics and identification of molecular networks. Some recent discussions toward this goal can be found in . Opposit


In recent years, a possible association of lifestyle factors with rheumatoid arthritis (RA) has attracted increasing public interest. The aim of this review is to provide an overview of the extent and the limitations of current evidence regarding lifestyle factors and RA. The PubMed medical database was screened for epidemiological and prospective studies investigating the contribution of lifestyle factors to the development and the course of the disease. Large epidemiological studies have identified smoking, unhealthy diet and adiposity, as well as a low educational level and low socioeconomic status, as factors that increase the incidence of RA. In addition, several lifestyle habits influence the response of RA to antirheumatic drugs. Among others, smoking, obesity and poor physical activity are associated with a worse treatment outcome. Methodological problems often impair firm conclusions with respect to the causal role of these factors in the risk and the course of RA. However, current evidence is sufficient to recommend a healthy diet, the prevention of obesity, the cessation of smoking and the maintenance of a high level of physical activity to support the effectivity of modern antirheumatic medication. Patients with inflammatory rheumatic diseases (IRDs) often express their desire to ensure the success of medical treatment or to replace antirheumatic drugs, at least partially, by changing lifestyle factors. This desire is fostered by the plethora of media reports that describe the influence of nutrition, body weight, physical fitness and stress level on health and life expectancy . In addiHowever, under the scrutiny of evidence-based medicine, only a handful of lifestyle factors are of proven influence for patients with IRD. Most data in this respect are provided for rheumatoid arthritis (RA), clearly showing that lifestyle is important with respect to the risk of this disease. Recently, the Nurses Health Study (NHS) cohorts were analyzed with respect to the impact of modifiable lifestyle factors  on the risk of RA. A healthy lifestyle index score (HLIS) was developed to quantify these five factors . In geneThe aim of this review is to provide an overview of the extent and the limitations of current evidence regarding lifestyle factors and RA.The question as to whether nutritional factors contribute to the pathogenesis of RA is difficult to answer. Human food consists of variegated components. Its origin, preparation and quality is highly variable and changing with time. However, it is now well-established that food can influence the inflammatory milieu of the human body  via seveHowever, it takes large databases to demonstrate that these factors are of real importance with respect to the risk of IRD. One such database is the Sister Study Cohort of the National Institute of Environmental Health Sciences (NIEHS) . By analBy correlating the intake of 39 predefined food items with the levels of inflammatory markers measured in the NHS, the Empirical Dietary Inflammatory Index (EDII) was developed in a non-RA cohort to identify a dietary pattern most predictive of increased values of interleukin 6, C-reactive protein (CRP) and tumor necrosis factor alpha receptor 2 . ComponeThe NHS data could not demonstrate a connection between the adherence to a Mediterranean diet (MD) and the risk of developing RA . The MedPolyunsaturated oils such as fish oil and various plant oils exert anti-inflammatory and antiarteriosclerotic effects. Several studies have reported a trend towards a protective role of fish, especially oily fish species, although the observed effects did not achieve statistical significance ,17,18. TThe effect of a high EDII on RA risk mentioned above was attenuated after adjusting for BMI . In addiIt was hypothesized that central adiposity may be of prominent importance for an elevated RA risk. A British cohort analysis revealed that central adiposity, assessed by waist circumference, was associated with an elevated odds ratio for the prevalence of RA and psoriatic arthritis. This association was stable, even after adjustment for confounders and BMI . HoweverIt is now well accepted that low-to-moderate alcohol consumption is a protective factor with respect to RA (review in ). AccordNutritional studies to investigate the impact of food on the activity of IRD are difficult to perform. A blinding of treatment arms is not possible, and the risk of selection bias is high. In 2009, a Cochrane analysis of 14 clinical trials including 837 patients concluded, “The effects of dietary manipulation… on rheumatoid arthritis are still uncertain due to the included studies being small, single trials with moderate to high risk of bias” In general, dietary interventions are not suitable to replace effective disease-modifying antirheumatic drugs (DMARDs). In addition, no data demonstrate the ability of diet to either prevent structural damage or to be effective against highly active disease. Significantly, a far-reaching interference into accustomed dietary habits may be difficult to tolerate for patients and may lead to early discontinuation of clinical studies . TherefoOne of the earliest studies that investigated the role of nutrition in RA was a randomized controlled trial that combined a fasting period of approximately one week with three to five months of a vegan diet, followed by lactovegetarian nutrition. The study demonstrated small but significant improvements in swollen joint count and patient global assessment, which were mainly achieved during the fasting and maintained thereafter. However, 40 of 53 participants in the study did not receive DMARD treatment. Therefore, the disease activity of the sample was probably very low .In 2003, a randomized controlled trial investigated the impact of an MD on RA disease activity over 12 weeks. The intervention resulted in a small albeit significant improvement in the Disease Activity Score (DAS28) . The effTaking these studies together, it can only be speculated whether the association of inflammatory markers with nutrition observed healthy subjects ,11 transBesides the study mentioned above that included a fasting period , a meta-In recent decades, the possibility of food allergens contributing to the pathogenesis of RA was discussed intensely. However, a study eliminating milk allergens and azo dyes in a double-blinded fashion did not convincingly demonstrate a clinical effect in RA , althougA retrospective analysis of RA patients who underwent bariatric surgery demonstrated a marked reduction in inflammatory markers, as well as reduced RA disease activity after the surgical intervention . In a raReports arguing for beneficial effects of nutritional supplements for IRD have been published in large numbers. In a broader sense, some components of daily food may be considered a supplement, namely spices such as curcumin, cinnamon, garlic and saffron. These food ingredients possess multiple anti-inflammatory and antioxidative features in vitro and in experimental models ,53. HoweProbiotics contain living microorganisms such as lactobacilli or yeast. Several smaller studies have claimed a symptom-modifying effect of probiotics in IRD . HoweverOf all nutritional supplements, omega-3 PUFAs have been studied most extensively in RA patients . In a CoExperimental studies argue for a pathogenetic role of trace elements such as zinc and cadmium in RA , and defVitamin E was formerly regarded as an antioxidant with anti-inflammatory potential. However, vitamin E supplementation was not associated with a reduced risk of RA development in the Women’s Health Study , and an It is common sense that a relevant deficiency of vitamin D and iron has to be treated in RA patients. Beyond that, however, an over-supplementation is of no use and should be avoided .A brief overview of studies on the influence of nutrition is provided in With respect to the literature presented in this review, it would be beyond the scope of the article to derive firm recommendations for patients with established RA or for persons at risk of developing this disease. However, recent efforts have been made to develop nutritional recommendations for RA patients on the basis of the current scientific evidence. The European League Against Rheumatism (EULAR) recommends a healthy balanced diet and a healthy weight for patients with rheumatic and musculoskeletal disease . RecentlExposure to tobacco smoke is the major known environmental risk factor for developing RA  and seemA deeper insight into the apparent interaction of genetic factors and smoking in the development of RA is provided by a Swedish case–control study of 858 incident RA cases and 1048 controls. This study showed a strong association between shared epitope (SE), smoking and the development of seropositive RA . The SE Smoking leads to lung disease and periodontitis and thus to chronically increased inflammatory activity. Furthermore, nicotine can drive autoimmunity via multiple pathways. Smoking activates peptidyl-arginine deaminase in lung tissue, leading to increased citrullination of proteins ,76. SubsThe evaluation of a large cohort of 6239 Japanese RA patients showed a clear positive correlation between nicotine consumption and the occurrence of ACPA and RF . MoreoveIn patients with RA, smoking is associated with a poorer prognosis of the disease. A poorer response to conventional synthetic DMARDs and TNF alpha inhibitors has been demonstrated in smokers ,80. HoweSmoking is also of relevance with respect to the comorbidities associated with RA. Among them, interstitial lung disease (ILD) is found in up to 10% of patients with RA ,85. BothAnother environmental factor that fosters the development of both ILD and RA is exposure to particulate matter. There are numerous reports of an increased risk of RA due to inhalation exposure to silica among coal miners. The simultaneous occurrence of pulmonary fibrosis and rheumatoid arthritis in miners has become known as Caplan’s syndrome . In the In summary, the data presented on smoking, silica dust and fine particulate matter exposure suggest an association between inflammatory processes in lung tissue and the development of ACPA-positive RA.A correlation between socioeconomic status and health is common knowledge. In general, high socioeconomic status seems to be associated with better health and vice versa . SocioecAn English cohort study of 869 consecutive RA patients showed a correlation between lower socioeconomic status and lower level of education and a higher disease activity at baseline and during the course of the disease. Increased disease activity was mainly shown with respect to functional parameters such as the HAQ, grip strength or joint score but was not reflected in the radiological course or the erythrocyte sedimentation rate (ESR) . The forWhereas a dependence of the course of the disease on socioeconomic factors seems to be well established, data regarding social status as a risk factor for the development of RA are scarce. In the Swedish case–control study EIRA, the association of the development of RA with socioeconomic status, as measured by education and occupation, was investigated in 930 incipient RA cases and 1126 controls. After adjustment for age, residential area and smoking, there was still an increased relative risk of 1.4 for the occurrence of RA in the group without a university degree. This effect was pronounced for RF-positive RA (RR 1.6). Similar effects were observed after the stratification by occupation; high-ranking, non-manual employees showed a 20% lower risk of developing RA compared to other non-manual employees .Chronic psychosocial stress is discussed as another possible factor influencing the development of chronic diseases, and patients often suspect psychological stress as the trigger of their disorder. Psychoneuroendocrinological theories postulate that chronic psychosocial stress influences the immune system via the corticotropic axis and can lead to chronic diseases ,101,102.Data from the Swedish EIRA study were examined for the influence of psychosocial stress at work on the development of RA . RA caseThe prognosis of established RA also seems to be influenced by psychosocial stress. In the randomized controlled CareRA-trial, patients with early arthritis were more likely to lose the state of remission if they were assigned to a group with a high psychosocial burden .Patients with RA are no more often divorced than comparable persons . SignifiSexual dysfunction occurs more frequently in RA patients compared with the healthy population, although this factor is rarely discussed with the treating rheumatologist . The proThere are currently no data available with respect to the influence of parenthood on RA disease activity or outcome. In contrast, a recent investigation of 23,981 parent–child pairs in whom at least one of the parents had RA reported an increased rate of mental disorders in children born to a mother with RA. There was a higher risk for autism spectrum disorders, attention-deficit/hyperactivity disorder, bipolar and major depressive disorder .There is little doubt about the beneficial effects of regular physical activity on factors such as quality of life, cardiovascular fitness and muscle strength in patients with RA . AccordiA single study described damage progression of large joints in patients with pre-existing extensive damage as a result of high-intensity weight-bearing exercise . HoweverData on the possible protective effect of physical activity on the development of RA are inconsistent. In the prospective observational Nurses’ Health Study II of 113,366 women with 506 incident RA cases, recreational physical activity was dose-dependently associated with a reduced risk of developing RA. Recreational physical activity of 4 < 7 h/week and ≥7 h/week was associated with a reduced risk of developing RA (RR 0.84 and RR 0.67) compared to <1 h/week . The SweDifficulties in adjusting for confounding risk factors are a weakness of studies on the influence of physical activity on the development of RA. A healthy lifestyle in terms of diet, smoking and body mass index can be assumed in participants with increased physical activity. An independent evaluation of the effect of physical activity on the development of RA does not seem feasible with the observational analyses conducted to date.Environmental factors influence the development and the course of rheumatoid arthritis. Many environmental factors interact directly with predisposing genetic risk factors. Such a relationship has been described, for example, for the interaction between smoking and SE in the development of ACPA ,74,78. SThe extent to which a single factor contributes to the development of the disease is often difficult to assess. Many risk factors occur in clusters. This holds true for dietary habits, nicotine consumption, physical activity and socioeconomic status—factors that all depend on educational status. Estimating their individual effects requires large sample sizes and demanding stratification procedures. Furthermore, the onset of rheumatoid arthritis itself may influence the lifestyle and socioeconomic status of patients. These reciprocal effects have to be taken into account as well.The identification of lifestyle factors connected to the origin and course of RA relies on the retrospective analysis of large cohorts, although in some of these epidemiological studies, the data were gathered prospectively. Therefore, a causal influence of individual environmental factors on RA is difficult to prove. Nevertheless, the evidence for the influence of smoking on the development and an unfavorable course of RA is convincing. For other environmental factors, the evidence is not as strong. It can be assumed with confidence, that a healthy diet, as described above, frequent physical activity and a high socioeconomic status are associated with a more favorable course of the disease. To some extent, these factors also protect from the development of RA. However, the magnitude of influence and the relationship between the individual factors should be defined more precisely in future investigations.


The outbreak of COVID-19 and the uncertainty it brings have created enormous pressure on governments to control the global pandemic and restore economic growth. It is an inevitable choice for governments of various countries to seek to control the pandemic and to provide support such as subsidies to people who lose their jobs or cannot work. However, governments should evaluate their pandemic policies to determine their effectiveness. To maintain social stability and help vulnerable groups, governments also must determine when subsidies are needed and when these support policies should be withdrawn. This research demonstrates that the administration of vaccines and the wearing of masks have a relatively limited impact on preventing the spread of the COVID-19 virus. By contrast, strict school closure policies combined with personal movement restrictions are more helpful in mitigating the spread of the virus. Compared with vaccine policies and wearing masks, controlling internal movement is the most effective way to manage the pandemic in schools. Additionally, economic support such as subsidies for the unemployed and underemployed is not only conducive to prevention of the virus' spread but also to economic recovery and social stability. When the pandemic is brought under control, economic support for vulnerable groups can be gradually reduced or even withdrawn. Governments all over the world have responded to the COVID-19 outbreak. Many countries have chosen to develop and inject vaccines, require people to wear masks, restrict activities in public places, and close schools to control the spread of the virus. The World Health Organization (WHO) recommends immediate vaccinations, physical distancing of at least 6 feet from others, mask-wearing, and frequent hand-washing with alcohol-based hand sanitizer or soap and water to keep oneself and others safe during the pandemic. However, Johns Hopkins University's global pandemic map indicates that the prevention of new cases in various countries remains highly difficult. On February 15, 2022, the daily new cases of COVID-19 in the United States reached 163,525; although that figure represented a sharp drop from the peak of 900,000 daily cases, the situation is still not optimistic. Although the total number of vaccine doses administered has reached 10.3 billion globally, the emergence of the COVID omicron variant has resulted in 1,630,848 new cases per day, and the cumulative number of confirmed cases has reached 415 million. Dense urban areas were affected more severely in the early stages of the pandemic. However, in late 2021, COVID-19 spread to less densely populated areas of some countries as vaccinations became common in cities. There is growing evidence that poorer communities have higher mortality rates. Without adequate protection during the pandemic, many low-income workers were forced to continue working to survive, exacerbating the spread of the disease in low-income countries. The continuation of the pandemic has a lasting impact not only on people's health, lives, work, and even psychology, it also has a greater impact on vulnerable groups such as people who have lost their jobs or cannot work.COVID-19 has directly affected people's health and has damaged human capital. Additionally, the pandemic has triggered the worst economic crisis since World War II. The continued spread of the virus has resulted in the unemployment of workers in sectors such as tourism, hotels, restaurants, and aviation. Moreover, flight bans and strict entry restrictions have created worker shortages in some countries that rely on foreign workers. Furthermore, containment and quarantine measures are damaging global supply chains and causing sharp declines in trade and foreign investment. Measures to curb the spread of the virus have hit small and medium-sized enterprises and entrepreneurs particularly hard. Some industries or businesses that can adopt remote working styles have been relatively unaffected by the pandemic, while the digital divide has exacerbated its impact in rural areas or in countries with low levels of digitalization. Face with this crisis, to support vulnerable groups such as people who have lost their jobs or cannot work, governments around the world have adopted supportive policies such as loan concessions, subsidies, and transfer payments, and have increased spending on healthcare. These measures could lead to greater government debt. To fill the fiscal gap, some governments have been forced to postpone or cancel some investment projects to save money. The decline in capital and infrastructure investments will, in turn, lead to more job losses. Therefore, controlling the pandemic and restoring economic growth are the way to break out of this vicious circle.Political and scientific leaders are wrestling with many questions. Can vaccines alone prevent the spread of the virus? Would other measures be more effective in alleviating the pandemic's impact on the global economy, especially on vulnerable groups? How much support is needed to provide cash and other subsidies to unemployed people? When can these support policies be withdrawn? To explore these challenges and to answer these questions, we have used daily pandemic data released by WHO, government response tracking data released by Oxford University, and travel data provided by Google. Our research found that restricting people's movements is the most direct and effective means of pandemic prevention, and the use of vaccines and mask requirements is a reliable policy combination. In terms of economic support policies, countries are using measures including loans and subsidies to assist vulnerable groups, and this support can gradually be withdrawn as control over the pandemic grows.Some scholars have used WHO data to predict the trends of the pandemic or to provide reference for the formulation of strategies. Riverol  used WHOAdditional literature has examined the role of Oxford University's COVID-19 Government Response Tracker in outbreak tracking research. Hale et al.  describeSaha et al.  used GooThe COVID-19 government response tracker we used is from the University of Oxford.In our panel regression model, the dependent variable is the number of new cases per day. The independent variables are relevant pandemic data from Oxford University, WHO, and Google. The panel regression using the above data see  indicateThe calculation results in columns (3) and (4) reveal that in the control policy, the “school” and “move” variables are significantly negative, indicating that the stricter the policy of closing schools and restricting the movement of people, the better the control over the spread of the virus. However, it can be found from column (4) that if the variable controlling internal mobility is added, the school policy is not significant; that is, the improvement effect of closing schools is ultimately brought about by reducing internal mobility. From the structure of columns (5) and (6), compared with vaccine policies and wearing masks, controlling internal flow is the most effective way to limit the growth in new cases.In response to the impact of the pandemic, governments around the world need to increase support policies such as subsidies for vulnerable groups to maintain social stability. OECD defined vulnerable and disadvantaged groups as: young people; people with a disability; minorities; migrants; aboriginals; and early school leavers. Due to the availability of data, we used the unemployed to represent vulnerable groups. The dependent variable in Using data from Oxford University, WHO, and Google, this paper studies the effectiveness of government pandemic control policies and economic support policies for vulnerable groups. The results of the study reveal that, overall, the pandemic prevention policies of various countries have effectively reduced the number of new cases. The policy combination of vaccine popularization and mask-wearing can better control the spread of the virus alongside strict policies regarding school closure and the restriction of people's movements. The positive impact of school closures is attributed to reductions in mobility. When compared with policies regarding vaccines and mask-wearing, controlling people's movements is the most effective way to limit new cases. As new cases increase, so should financial support for vulnerable groups. When the pandemic is gradually brought under control, government support policies such as subsidies for vulnerable groups should be slowly reduced until they are withdrawn.Based on the above research conclusions, we believe that, to more effectively control the spread of the COVID-19 pandemic, multiple policy combinations are needed. Chief among them are that the entire population be vaccinated, that people continue to wear masks and socially distance, and that people who test positive for COVID-19 be quarantined in time to stop the spread of the virus. These policy combinations are more effective than a single policy. After new cases are found in a specific area, the use of isolation measures to restrict people's movements is an effective means of blocking the spread of the virus. For example, when outbreaks are detected in schools and workplaces, timely closure of these sites can help curb the spread of the virus and reduce new cases. Additionally, public awareness campaigns urging vigilance against COVID-19 are effective, highlighting the importance of communication and dissemination of scientific knowledge on disease prevention among various stakeholders in social groups during a pandemic.During a pandemic, it is necessary to adopt a subsidy policy for vulnerable groups such as people who lose their jobs or cannot work. This is invaluable for these groups to ensure basic living security, alleviate the impact of the pandemic on society, and maintain social stability. However, once the pandemic is under control, these support policies can be reduced gradually, allowing funds to be diverted to driving the economic recovery, thereby providing more employment opportunities for vulnerable groups.https://ceicdata.com/.Publicly available datasets were analyzed in this study. This data can be found at: XL: writing—original draft. YF: literature. GC: investigation and design. ZL: draft writing. All authors contributed to the article and approved the submitted version.The authors thank for the support by Philosophy and Social Sciences Planning Project of Zhejiang Province (18NDJC215YB); National Natural Science Foundation of China (71874160); Fundamental Research Funds for the Provincial Universities of Zhejiang ; the Major Humanities and Social Sciences Research Projects in Zhejiang Province (2021QN050), Zhejiang Soft Science Research Program (2022C25015).The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.All claims expressed in this article are solely those of the authors and do not necessarily represent those of their affiliated organizations, or those of the publisher, the editors and the reviewers. Any product that may be evaluated in this article, or claim that may be made by its manufacturer, is not guaranteed or endorsed by the publisher.


Diverse measures have been carried out worldwide to establish Alternative Care Facilities (ACFs) for different ends, such as receiving, curing or isolating patients, aiming to cope with tremendous shock in the urban medical system during the early passage of the COVID-19 epidemic. Healthcare workers always felt anxious and stressed during multiple major public health emergencies in medical facilities. Some active measures to improve healthcare workers' perceptions, such as temporary training, workflow improvement, and supplementary facilities, were proved insufficient in several past public health emergencies. Therefore, this study aims to analyze the contributing factors of the healthcare workers' perceptions of the ACFs in this pandemic, which can help find an innovative path to ensure their health, well-being and work efficiency.This paper conducted semi-structured in-depth interviews with the world's first batch of healthcare workers who have worked in ACFs through a qualitative study based on Grounded Theory. The healthcare workers interviewed from Heilongjiang, Shandong, Fujian, and Hubei provinces, have worked in one of the four different ACFs built in Wuhan. The results are obtained through the three-level codes and analyses of the interview recordings.The factors affecting the perception of healthcare workers in ACFs during the epidemic situation can be summarized into five major categories: individual characteristics, organization management, facilities and equipment, space design, and internal environment. The five major categories affecting the composition of perception can be further divided into endogenous and exogenous factors, which jointly affect the perception of healthcare workers in ACFs. Among them, individual characteristics belong to endogenous factors, which are the primary conditions, while other categories belong to exogenous factors, which are the decisive conditions.This paper clarifies factors affecting the perception of healthcare workers in ACFs and analyzes the mechanism of each factor. It is posited that the passive strategies are a promising solution to protect healthcare workers' health, improve their work efficiency, and help reduce the operation stress of ACFs. We should train multidisciplinary professionals for future healthcare and enhance collaborations between healthcare workers and engineers. To sum up, this paper broadens new horizons for future research on the optimization of ACFs and finds new paths for alleviating healthcare workers' adverse perceptions of ACFs. The scarcity of medical resources is ubiquitous worldwide, resulting from the large number of patients caused by the COVID-19 pandemic . AlternaPerception is the human body's organization, identification, and interpretation of acquired information through the sensory system to present the information or environment . RelevanHealthcare workers' perception of ACFs is the overall presentation of information generated in the working process through a series of their sensory systems. Traditionally, the point of view of medical staff has been measured by using questionnaires that monitor the satisfaction with the care received. However, the exclusive use of surveys to study overall health care quality has some weaknesses, including framing the protagonists' subjective experiences into rigid categories imposed by the researchers based on preconceived ideas . Thus, Gvia concept extraction, induction, and summary in a bottom-up way based on data collected and the relationship between various categories is further explored to establish a theoretical model to solve the research questions. Specifically speaking, research processes of the Grounded Theory can be divided into four steps: research question–data collection–data analysis–theoretical construction, among which data analysis, as the core link, is usually categorized by the three-level codes, namely open coding–axial coding–selective coding , Heilongjiang (3 participants), Shandong (2 participants), and Fujian Provinces (1 participant) in China with an average age of 38.9 , including four men and four women. These participants included five nurses and three doctors with an average working seniority of 15.6  with bachelor's degree . To ensuInformed consent was obtained from all participants before the interview began. Participants were informed about the goals and contents of the study, privacy, and data protection and that their participation in the study was voluntary. Biological samples were not collected.This study draws up an outline for the interview as follows. There are four parts of the interview, which are not conducted in a fixed order to avoid interrupting the interviewees.Basic information: the name of ACF, the stationed time of the healthcare workers, the number of patients, etc.;(1) Work contents: the respondents' work division, organization and process, as well as the problems they encountered in ACFs, etc.;(2) Perception: recognition of the respondents in different positions and at other times in ACFs from the beginning to the end;(3) Improvement suggestions: the management, operation and layout design of the ideal ACFs from respondents' perspectives.(4) This study has conducted interviews either online or offline because, on the one hand, interviewees are from various medical care teams in different provinces; on the other hand, it can avoid the interactions between respondents. The critical information was recorded during the 1h to 1.5h interview. Furthermore, the respondents' personal information was not mentioned so that they could tell their actual perceptions. After the interview, the interviewers analyzed the recordings.According to the Grounded Theory, researchers will not be able to obtain new information from the research data when the research results reach saturation . After an”)—conceptualization –categorization (classify the conception and categorize as “An”)—open coding. In all, there are 406 labels, 53 concepts, and 27 categories after the process of open coding  and exogenous factors . As endogenous factors are composed of individual characteristics, it is regarded as the basis of the workers' perceptions and the exogenous ones play rather critical roles. Both of them are merged together by the sensory system of the healthcare workers and then the primary perception is produced. The improvement measures that counter healthcare workers' adverse perceptions can be further classified into two parts: active and passive strategies .via promoting the design of space and environment of the buildings. ACFs are some of the most promising solutions to the pressing health care needs under disaster situations. During the COVID-19 epidemic, previous studies show that the environment of the ACFs not only has adverse impacts on the patients but requires healthcare workers to adjust themselves to the new surroundings (The passive design strategy improves the performance of the building through the optimization of the building design, like the appearance and space design of the building and the selection of building materials. The active strategy aims to enhance building performance by artificial supplementary measures, such as air-conditioners and the operations of the buildings. The design of a hospital is usually improved by analyzing the workflow and needs of healthcare workers, by which the designer can ensure better user perception for the healthcare workers oundings . To improundings , 60–62. oundings –66. Althoundings –69. Someoundings , 71. Alsoundings . Passiveoundings .Because healthcare environments are one of the most complex and demanding fields of work, an interdisciplinary solution is needed to achieve the goal of passively improving the healthcare environment. Giuliano K. K. and other researchers proposed that a nurse-engineer partnership is one of the most promising solutions to health care issues. Although the nurse-engineer partnership is faced with many barriers, it is encouraging to empower both nurses and engineers to create collaborations. According to Giuliano, finding a way for engineers to be trained in nursing and nurses to enter engineering are strategies helpful to developing infrastructure for health care innovation . For exaThe above discussions show that building characteristics affect personal perceptions during the pandemic, and the optimization of the built facilities can improve healthcare workers' health and well-being. Therefore, it is necessary to strengthen the emerging multidisciplinary education, which can develop the nurse-engineer partnership, to excavate passive improvement strategies for seeking more optimization measures for the building design of the ACFs. Specifically, such passive measures include the number of beds in each care unit in the bed area, the layout of healthcare workers passage and patient passage, the openness and accessibility of nurse stations, and the position of medical apparatus and instruments. The optimization of the building design and environment of the ACFs can be realized by the passive strategies, reducing the healthcare workers' adverse perceptions and the operating costs and active measures.The research aims to analyze the contributing factors to the healthcare workers' perceptions of the ACFs in this pandemic. Analyzing the actual narration of healthcare workers can avoid presupposition by the researchers through a qualitative study based on Grounded Theory. Eventually, there are five factors affecting the healthcare workers' perceptions which can be further divided into endogenous factors and exogenous factors. By interpreting the interactions among the factors and perception of healthcare workers, the passive strategies are realized to protect people's health and well-being in ACFs. In all, the research broadens new horizons for future research on the optimization of ACFs. It is also suggested that the emerging multidisciplinary education should be strengthened, especially the nurse-engineer partnership. Furthermore, exploring the measures of the rebuilding facilities as many as possible can help improve healthcare workers' perceptions and protect the health and well-being of people in ACFs.Although this paper proposed a way to optimize the healthcare workers' perception of ACFs based on passive design, it did not explore specific measures which need further research. In addition, the healthcare workers interviewed are all from China. As mentioned above, the ACFs have played various roles in different countries during the epidemic –16, whicThe raw data supporting the conclusions of this article will be made available by the authors, without undue reservation.Ethical review and approval was not required for the study on human participants in accordance with the local legislation and institutional requirements. Written informed consent for participation was not required for this study in accordance with the national legislation and the institutional requirements.HW is responsible for interview data collection, article writing, and post revision. PL is responsible for interview design and article content inspection. YW is responsible for interview data collection and post revision. XZ is responsible for post revision. All authors contributed to the article and approved the submitted version.This research was funded by the National Natural Science Foundation of China, grant number 52078156.The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.All claims expressed in this article are solely those of the authors and do not necessarily represent those of their affiliated organizations, or those of the publisher, the editors and the reviewers. Any product that may be evaluated in this article, or claim that may be made by its manufacturer, is not guaranteed or endorsed by the publisher.


The emergence of the coronavirus disease 2019 (COVID-19) pandemic has resulted in communication being heightened as one of the critical aspects in the implementation of interventions. Delays in the relaying of vital information by policymakers have the potential to be detrimental, especially for the hearing impaired.This study aims to conduct a scoping review on the application of artificial intelligence (AI) for real-time speech-to-text to sign language translation and consequently propose an AI-based real-time translation solution for South African languages from speech-to-text to sign language.Electronic bibliographic databases including ScienceDirect, PubMed, Scopus, MEDLINE and ProQuest were searched to identify peer-reviewed publications published in English between 2019 and 2021 that provided evidence on AI-based real-time speech-to-text to sign language translation as a solution for the hearing impaired. This review was done as a precursor to the proposed real-time South African translator.The review revealed a dearth of evidence on the adoption and/or maximisation of AI and machine learning (ML) as possible solutions for the hearing impaired. There is a clear lag in clinical utilisation and investigation of these technological advances, particularly in the African continent.Assistive technology that caters specifically for the South African community is essential to ensuring a two-way communication between individuals who can hear clearly and individuals with hearing impairments, thus the proposed solution presented in this article. The World Health Organization (WHO) projected that approximately 2.5 billion people globally will have some degree of hearing loss by 2050, and rehabilitation will be required for 700 million individuals WHO, . CurrentBasic functional auditory abilities are significant for navigating daily activities at home, work, business and in social contexts , an infectious disease caused by the novel coronavirus  like South Africa need to explore advances in technology that is currently available in HICs that cater for the hearing impaired. Considering the current paradigm shift in South Africa and the transition towards the Fourth Industrial Revolution (4IR), it is imperative that current technologies being developed in South Africa include AI and ML concepts in their design of solutions that are targeted towards bridging communication between the normally hearing and the hearing impaired. Alexander  reportedHearing assistive technologies  have been developed to assist individuals who are hard of hearing  were included. The search consisted of the following terms: AI, speech-to-text to sign language, communication with hearing impaired, translation for hearing impaired.Initially, a total of 84 publications were identified for potential inclusion in this study. During data collation and organisation, seven studies were deleted as they were duplicates; therefore, only 77 studies were then considered. Of the 77, 37 were removed based on the titles and/or abstracts that were deemed as not meeting the focus of the study. Subsequently, 40 studies were evaluated for eligibility, and from these, 28 studies were excluded as they did not meet the study’s inclusion criteria. During the full-text review, a further six manuscripts were excluded, thus leaving six manuscripts for analysis see .This article followed all ethical standards for research without direct contact with human or animal subjects.As depicted in Granular analysis of articles included in this review revealed that four studies were at conceptualisation stages – sign language recognition (continuous sign language recognition and isolated sign language recognition) or sign language representation  (Ezhumalai et al., Current review findings exposed the noticeable lack of urgency in developing effective AI technology for communication that includes people who are hard of hearing. Furthermore, these findings indicate a significant dearth of evidence focusing on the real-time speech-to-text to sign language translation for hearing-impaired individuals. Such a lacuna in evidence is an indictment on those involved in ensuring access to communication by everyone, including those with barriers to communication. The dearth of studies indicates the lack of aligning clinical research with emerging technologies, as well as missed opportunities in maximising innovations that AI and ML have introduced – systems that can be trained to develop ASR to convert speech-to-text to sign language for people with communication difficulties (Agarwalla & Sarma, Evidence suggests that in relation to sign language and AI, there is a plethora of studies conducted for sign language users in different parts of the world; however, currently there is limited research on the application of AI and ML in Africa. A systematic review conducted by Adeyanju et al.  on sign The results of the review also indicate that there are currently very limited documented studies conducted in South Africa that utilise AI and ML techniques in the translation of South African languages from speech-to-text to sign language, thus highlighting the gap that exists. In the development of a translation tool for South African languages, this current research work will firstly consider the real-time translation of South African languages from speech to text using AI, which may be used, for instance, in creating real-time closed captions that can be used by individuals who have hearing impairments that require assistive technology.South Africa currently has 11 official languages, excluding South African Sign Language, which has recently attained official language status as the twelfth. In South Africa, English is spoken with various accents and is usually mixed with words from Afrikaans and African languages Lanham, . IsiZuluTo translate speech to text for South African languages using ML, huge data sets are required to be used in training the ML model. Therefore, several sources of data sets that could be used in this research work were identified. Firstly, there exist a few corpora for South African languages, including the African Speech Technology Project (Roux, Louw, & Niesler, The last step of ASR in !’ is input as a speech signal and the corresponding text representing the audio signal is outputted.To implement the South African speech-to-text translator using ML, the authors of this work propose the use of the NCHLT speech corpus for training as it is a sufficiently large data set, containing approximately 50 h of speech per South African language. The NCHLT contains monolingual speech that allows for the training of the algorithm for each language independently. The data set contains speech prompts in the form of short phrases that will be used to train the ML models. In addition, another data set will be collected from volunteering individuals which will be used for testing the trained models. Three ML architectures will be explored, namely, CNN, RNN and ANN. The models will be trained to recognise the phrases in one of 11 South African languages. The speech signal will be used as input, while the corresponding text will be used as the expected output. Each speech file is annotated with the corresponding text. The data will be split into two, 80% of which will be used for training and 20% for testing. This work has only proposed the approach that will be used to conduct the translation from speech to text, without practically demonstrating its application using collected data. The next publication will demonstrate it using real data, the translation from speech to text for South African languages.The work has also not demonstrated how the translation from speech-to-text to sign language and from speech to sign language will be conducted. This will be covered in the publications to follow, as this work forms part of a series.This article highlights that there is a dearth of evidence in the use of AI and ML applications in Africa, with very limited or no tools for speech-to-text to sign language translations for South African languages using AI and ML. This lagging became heightened during COVID-19 and prompted the current researchers to engage in this study. An implementation plan of speech to text using ML for South African languages has thus been presented. Currently, it is viewed that South Africa and Africa as whole seldom apply AI in the development of their systems, especially systems used for the improvement of the social lives of their citizens (Shezi & Ade-Ibijola,


In conclusion, we found the SDSC to be a useful tool for measuring sleep disorders in ASD children. Our findings offer concrete inputs to achieve adequate pathways for taking care of children with ASDs and their parents.Sleep disorders in children with autism spectrum disorders (ASDs) are well-described. However, there is a lack of specific assessment tools to investigate sleep disturbance in this target population. The present investigation reports the Italian validation of the Sleep Disturbance Scale for Children (SDSC) in the ASD population, also investigating the correlation between sleep disorders In both children and parents. Internal consistency and test–retest reliability were investigated using Cronbach’s alpha and intraclass correlation coefficient (ICC), respectively. Concurrent validity was analyzed by comparing the score of the SDSC with the Pittsburgh Sleep Quality Index (PSQI), while the correlation between the SDCS score and the General Sleep Disturbance Scale (GSDS) was used to analyze the correlation between sleep disorders in children and sleep disorders in their parents. In total, 99 children with a diagnosis of ASD participated in the study. Cronbach’s alpha revealed satisfactory value (0.853), as well as reliability (ICC 0.972) and concurrent validity (0.745). Our results also revealed a significant linear correlation between children’s and parents’ sleep disorders ( Sleep is a physiological process in which the reduction in consciousness and metabolism occurs; it affects mental and physical health and is essential for the normal functioning of all human body systems, including the immune system . Sleep qInsomnia is one of the most common health problems in clinical practice, and among all sleep disorders, it is certainly the most prevalent, as it is estimated to occasionally affect more than half the population and afflicts at least 9 million Italians . It is aThe use of structured and semi-structured clinical interviews to assess the nature, history, and severity of sleep difficulties is increasing in clinical practice . The ChiAutism spectrum disorder (ASD) is a condition characterized by abnormalities in behavior, deficits in communication, language, and social interactions; restricted and repetitive interests are also reported . Sleep dConsidering there is no validation of a specific tool for the ASD population in Italy, our primary objective was to analyze the psychometric properties of the SDSC in a population of children with a diagnosis of ASD. As a secondary objective, we also explored the relationship between the sleep quality of children with ASDs and that of their parents.The present study was conducted by a research group from the Sapienza University of Rome together with the Rehabilitation and Outcome Measures Assessment (R.O.M.A.) Association. In the last few years, this research group has dealt with different studies related to ASDs and the validation of different outcome measures ,27,28,29Parents or caregivers of children with a diagnosis of ASD between 3 and 16 years old were recruited for the study throughout different health centers in Italy, namely Istituto Leonarda Vaccari of Rome, Casa di Cura INI- Villa Dante in Guidonia, Anffas in Rome, the Logos Center in Taranto, and within the Department of Human Neurosciences at the Sapienza University of Rome. Diagnoses of both ASD and insomnia were evaluated by medical doctors specialized in child neurology and psychiatry according to the International Classification of Sleep Disorder and the DSM-V . ChildreSleep Disturbance Scale for Children (SDSC)  is a ratThe Pittsburgh Sleep Quality Index (PSQI) ,32 is a The General Sleep Disturbance Scale (GSDS-IT)  is a selAll statistical analyses were performed with the Statistical Package for Social Science (SPSS) software. Internal consistency was examined with Cronbach’s α to assess the interrelatedness of the items and the homogeneity of the scale. A value of α ≥ 0.7 is commonly considered an acceptable indicator . To asseFor the present study, 102 children with diagnoses of ASD were recruited from different rehabilitation centers. Of these, 99 agreed to participate and were included in the study. The demographic characteristics of the population are summarized in The SDSC demonstrated good internal consistency, with a Cronbach’s α of 0.853. The SDSC showed good test–retest reliability, with an ICC of 0.972 for the total score, ranging from 0.916 and 0.991. Values for each SDSC subscale are reported in p < 0.01. The results are summarized in The Italian version of the PSQI was administered to the whole population. Pearson’s correlation coefficient showed statistically significant values and a positive correlation between the subscales and the total scores, indicating a very good correlation between the total score of the SDSC and that of the PSQI, with a value of 0.745 and a In the present study, the first specific validation of the SDSC for children with ASDs was reported, which revealed good internal consistency, reliability, and concurrent validity.Measuring sleep disorders in ASD patients is a compelling challenge. Although sleep disturbances are not inherent to the ASD condition, they are clearly more prevalent in children with ASDs than in typically developed children . Sleep dAt the outset of our investigation, we intended to validate the SDSC for ASD children. With regard to internal consistency, as measured with Cronbach’s alpha, our results are in line with those of the original , French Interesting topics emerge from the analysis of the correlation between sleep disorders in both children and their parents. Our results revealed a linear positive correlation between sleep disorders in parents, as measured with the GSDS, and sleep disorders in children with ASDs, as measured with the SDSC. In fact, when sleep problems are present in children with ASDs, they have a greater effect on parents’ sleep than when similar sleep problems are present in typically developing children . The carDespite these encouraging results, our study has some limitations that need to be addressed. We did not investigate the differences in sleep disorders in parents across gender. The sample was likely limited, but further research should investigate the different manifestations of sleep disorders between mothers and fathers. Second, we did not use objective measures for detecting sleep disorders, but diagnoses were performed from a clinical perspective. However, it is also worth noting that polysomnography and/or actigraphy should be considered to provide more precise and accurate estimates of sleep disturbances and to reduce measurement errors related to these problems. These objective measures can also allow researchers to estimate the discriminant validity of the SDSC in the target population. Third, we did not investigate differences in sleep disorders across different age groups; however, sleep quality, as well as sleep disturbance manifestations, can differ between children and adolescents. Thus, further studies should investigate these aspects and verify the cross-cultural validity of the SDSC for the target population.The present research revealed the SDSC as a valid and reliable tool for measuring sleep disturbance in children with ASDs. As a result, healthcare professionals can use it more often, and with more confidence, to better understand the sleep-related problems of the target population. This can help clinicians to improve the quality of care in both clinical and community settings, also supporting parents in the management of symptoms and behavioral issues. Furthermore, the present study highlights the need of caring for parents of children with ASDs.