While public health campaigns disseminated through Twitter have multiple theoretical advantages over other strategies , the effectiveness of social networks as facilitators of attitudinal and behavioral changes in the population seems to remain weakly supported. Therefore, this systematic review was aimed to analyze the degree of impact of healthy behavior-related campaigns as documented in scientific literature.Strictly following the PRISMA methodology, a total of 109 indexed articles were obtained, of which only 18 articles met the inclusion criteria. In addition to accessing the literature available on WOS, Scopus, BVS, Medline, Cochrane Library and PubMed, the quality of the existing studies was assessed through the Critical Appraisal Skills Programme (CASP) protocol.The results of this systematic review revealed a small number of evaluations of the effectiveness of social campaigns disseminated on Twitter, although the quality of these studies was considerably good. Most of the research used statistics and metrics for evaluation, with residual use of other measurement methodologies. However, their effectiveness and impact on public health-related behaviors remain arguable, in view of the existence of marked tendencies to: (i) not evaluate these campaigns; (ii) evaluate them through excessively brief, ambiguous, or potentially biased indicators; and (iii) not carry out systematic follow-ups over time.Although there is no strong evidence of the suitability of Twitter as a suitable medium for raising public health awareness on behavioral health affairs, the actual limitations identified in this review would help to optimize this paradigm and enhance the quality, reach, and effectiveness of such communication strategies. Typically, social marketing strategies tend to use very generic marketing practices  in the attempt to raise public awareness of a wide range of issues , partly Like any other publicity campaign, cost-effectiveness becomes a critical factor in determining the effectiveness of campaigns in raising awareness among the audience . In thisIn the same line, some other applied researches have shown that, while product advertising usually achieves the expected effectiveness, social campaigns through traditional media fail to modify behaviors in favor of healthier behaviors and lifestyle habits . HoweverThe good results obtained by digital media in many terms have contributed to “open the door” to a new line  for developing public health campaigns. During recent years, social networks have been a way to raise awareness of different issues . In partThe latest official data indicate that worldwide 500 million tweets are posted every day . These fThe core aim of this systematic review was to analyze the reported impact and effectiveness of behaviorally-based public health campaigns broadcast on Twitter. Additionally, we applied assessment tools commonly used for this type of campaign, in order to detect the possible methodological limitations of the methodologies used to assess such issues on communication campaigns.Overall, systematic literature reviews consist of a comprehensive mapping of scientific evidence based on a protocol and a transparent and systematic methodology to find and explain in detail a research question . The preFive steps were followed in the development of the systematic review:(1) Identifying the research question.(2) Finding relevant studies.(3) Selecting the studies.(4) Charting and collating the data.(5) Summarizing, analyzing and reporting the results.The aim of this systematic review was to determine the degree to which healthy behavior-targeted campaigns broadcast on Twitter are reported as effective in their evaluation studies. Consequently, this study seeks to identify the number and category of scientific studies that have evaluated the efficacy of a health campaign carried out through this social network.In this sense, articles that analyze the opinion of Twitter users regarding social or health issues were discarded. Neither there were be taken into account those investigations that collect reactions to campaigns issued through other media or any other type of study in which the objectives are not to evaluate the effectiveness or impact of a campaign published using Twitter. No comparisons were made between the studies. The results include a summary and a thematic analysis of all the selected articles.The present investigation was conducted following the PRISMA 2020 guidelines for reporting systematic reviews . In the Subsequently, six databases were used for the preliminary literature search, which were selected because of their recognition as reliable quality indicators valued by the scientific community. The selected databases were Web of Science, Scopus, Virtual Health Library, Medline, Cochrane Library and PubMed. We also reviewed other reference lists of different primary research scoping reviews, potentially eligible and not captured by our search strategies.The search was conducted in the first week of August 2022. It did not have exclusion criteria related to the year of publication. Therefore, all literature published from the beginning of the database until the search date was taken into account for the present review.The search strategy was carried out taking into account that the review covered research published in both English and Spanish. Therefore, the same Boolean search operator “ AND twitter AND  AND (campaign OR campaña)” was used in all databases. The terms selected and the search operator were agreed upon by the authors following the information acquired during the scoping review.During this step, articles that did not address our research objective  were excluded. Given their substantial differences in terms of targets, dynamics and population quotas, no other potential social networks were considered as suitable channels for the campaigns analyzed. Therefore, all studies assessing campaigns broadcast on e.g., Instagram, Facebook and TikTok, or overlapping Twitter with other platforms were automatically excluded. Although it clearly reduces the scope of the review, it also prevents the data analysis to get affected by many biases and virtually uncontrollable effects. All authors initially, and independently, evaluated a subset of titles and abstracts and then met to discuss and resolve any discrepancies.Only scientific articles were included, avoiding the inclusion of gray literature. Therefore, we did not select publications in the form of letters, doctoral dissertations, conferences/abstracts, editorials, case reports, protocols, or case series. We also restricted our eligibility criteria to articles published in English and Spanish to which we could obtain access to the full paper, either because they were available due to their open access status, or because they could be requested through the library system used.The data sources (papers) meeting the inclusion criteria were critically reported and analyzed using the Arksey and O'Malley's  descriptThe data extraction is recorded in tabular form, in order to help readers to identify the key sections, features and contents of these sources. Once their relevant features and main findings were summarized, the quality of the papers included in the systematic review process were assessed through the Critical Appraisal Skills Programme (CASP) tool, whose core utility is performing a quality assessment of the studies analyzed, in order to ensure that the results are not significantly altered or biased by potential technical shortcomings present in these sources.By means of the search strategy, a total of 109 possible articles were obtained for analysis, after discarding all duplicate documents. After reading the title and abstract and being preliminarily assessed by reviewers, 79 articles were discarded because they did not respond to the objectives of the review. Subsequently, a new manual screening was performed after reading the full text of the remaining articles. After this process, 18 eligible articles were obtained and included in the study. n = 5), Canada (n = 4), Ghana (n = 2), United Kingdom (n = 2), Australia (n = 1), Spain (n = 1), Korea (n = 1) and China (n = 1). In addition, one of the studies was conducted worldwide without restricting the data geographically.Although the search was conducted for articles published in both Spanish and English, the 18 eligible articles were all published in English. The selected papers were published between 2014 and 2021, which is in accordance with the recentness and novelty of the subject matter of the study. In addition, the studies were conducted in geographically different countries . In thisn = 14) than mental health campaigns (n = 4). Specifically, the issues that have been most emphasized are cancer prevention (n = 3), each of which deals with a different type of cancer, reduction of tobacco consumption (n = 3) and breastfeeding recommendations (n = 3). On the other hand, most of the health campaigns are of a preventive nature (n = 16), with very few referring to the treatment of diseases that are already present or manifest (n = 2). This is the case of the campaign on dementia and on Hirsch-Sprung's Disease, in which its broadcast via Twitter was not only aimed at information and awareness of the disease, but also intended to facilitate contact between people or families who were living the same situation for the formation of support groups in the distance.The evaluated health campaigns broadcast on Twitter cover a wide range of issues. n = 16; 88.9%). Therefore, these articles generally conclude that the campaign was useful in raising user awareness.The record of findings on the effectiveness evidenced by the campaigns indicates that the conversation on Twitter about the issue addressed increased substantially during their broadcast period , 40, 43.n = 6; 33.3%). In some of these cases, the results of this qualitative analysis evidence that part of the users' messages was not linked to the promotion of healthy behaviors or attitudes  quality assessment tool was applied. This instrument makes it possible to assess the level of rigor, credibility and relevance of a study by means of ten questions . The resThe core aim of this systematic review was to explore and analyze existing scientific studies evaluating the effectiveness of behavioral-based public health communication campaigns broadcast on Twitter. Social networks offer multiple advantages for the promotion of awareness campaigns . HoweverHowever, evaluations of the impact of this type of awareness campaigns are not usually carried out. Only 18 articles were found that met the inclusion criteria. Thus, given the large number of campaigns that are based on Twitter sharing, or that use this social network as a complement to other broadcasting channels, it is surprising that there is so little research aimed at evaluating the impact of these campaigns . DespiteThe scarcity of analysis of the impact of campaigns is a common problem in social marketing, regardless of the subject matter and the media used to disseminate them . Cost-efThere are other factors that may be influencing this situation. For example, the scientific literature evidences certain limitations in measuring the effectiveness of social campaigns . The maiThese limitations are exacerbated in campaigns broadcast through social networks . Our revAdded to the aforementioned, one of the main problems in resolving the issue is to identify variables to be considered to evaluate the effectiveness of a public health campaign . From a However, the factors are inevitably different for the evaluation of social advertising . Thus, iSecond, most of the research reviewed assesses impact solely using Twitter metrics , 31, 40.Additionally, from a social advertising perspective, a campaign is considered effective when it manages to raise awareness among the audience about a certain issue, promoting a change in their attitudes and behaviors. Therefore, qualitative evaluation tools could be applied, such as semi-structured interviews, focus groups or anonymous mass surveys, which would allow knowing the real change achieved through communication strategies , 62. TheThe current evidence is insufficient to support the effectiveness of Twitter as a broadcasting platform for public health campaigns in general. However, some advantages make it worthy of consideration and further studies, especially having in mind its cost-effectiveness and the broad audience they can reach, especially if compared with traditional programs or interventions based on “aged” communication sources, such as TV, radio and paper-based media , 18. TheThis systematic review was carried out following the PRISMA procedure to avoid possible biases in the selection and/or recording of data. In addition, the inclusion/exclusion criterion was that the eligible articles should form part of relevant indexes and databases worldwide to guarantee, as far as possible, the quality of the research.Despite all this, the present systematic review is not exempt from the limitations characteristic of this type of study. Thus, the review may present publication bias. This bias occurs when research with negative” or non-significant results is either published in journals of lower impact or not published at all. Therefore, they may not have been included in the review .Moreover, the final low number of original research papers that met the eligibility criteria makes it remarkable the high number of technical shortcomings and potential quality flaws found in these papers. This indeed is one of the conclusions of the conducted review, i.e., that the scientific literature on the evaluation of health campaigns issued through Twitter is really scarce. However, this circumstance could limit the breadth and scope of the research findings. Furthermore, it is possible that the non-indexed literature could have provided more interesting information on this subject . Also, it is worth mentioning that none of the sources found corresponded to longitudinal or time-based research, something that might be of great use to measure the successfulness and stability of the effects produced by these actions/program over time .The present study has provided some guidelines for the improvement of public health campaigns. However, future studies could try to address this aspect and develop a standard and accessible tool to evaluate the impact of social communication campaigns carried out through Twitter. In this way, it could be easier to measure the effectiveness of awareness campaigns, and data of interest for the development of future communication strategies could be obtained.Contrary to what was initially hypothesized on the basis of the study background, the results of the studies analyzed in this systematic review do not provide clear evidence on the suitability of Twitter as an effective communication channel for the promotion of healthy behaviors.On the other hand, it is noteworthy that the evaluation of the quality of the studies analyzed gave considerably positive results endorsing their key features and scientific rigor in many terms, but the adequacy of both research methods and researcher-object relationship represent frequent constraints among these scientific studies.In addition, the scarcity of research that performs post-campaign follow-up, as well as the lack of measurement on the degree of awareness and behavioral change, are manifested. These factors limit the findings of the studies, since they do not take into account the real effectiveness of the campaign, but only its digital impact.The usefulness of this review is fundamentally practical since it offers information of interest for the development of communication strategies on Twitter. Thus, the limitations of current evaluation tools are discussed, and more complete evaluation methodologies are proposed to measure the impact of public health campaigns on social networks.The original contributions presented in the study are included in the article/supplementary material, further inquiries can be directed to the corresponding author/s.MF and FA conceived and designed the research and contributed with reagents, materials, and analysis tools. MF, SU, and AJ analyzed the data and wrote and revised the paper. All authors contributed to the article and approved the submitted version.This work was supported by the Research Grant ACIF/2020/035 (MF) from Generalitat Valenciana. Funding entities did not contribute to the study design or data collection, analysis and interpretation or writing of 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.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 purpose of this study was to compare previously identified demographic risk factors for injury in agility dogs, and explore other potential associations with demographic risk factors in new populations, and across different levels of injury severity.via backward selection.An internet-based survey of agility handlers was conducted. The primary outcome was if the dog had ever had an injury that kept from agility for over a week. Demographic information about the dog and handler were recorded. Logistic regression was used to quantify associations between variables of interest with injury history and all models were adjusted for age. Analyses were stratified by geographic location. Final model building was done The sample included 2,962 dogs from North America and 1,235 dogs from elsewhere. In the North American sample, 8 variables were associated with injury history; dog breed, height and weight, handler age, gender, agility experience, competing at the national level, age dog was acquired, and taking radiographs to assess growth plate closure. In the non-North American sample, 4 variables were associated with injury history; breed, handler age, occupation (dog trainer or not), and handler medical training. In both samples, Border Collies showed a marked increase in injury risk (ORs 1.89 and 2.34) and handler age >65 was associated with lower risk (ORs 0.62 and 0.77). Consistent with previous studies, greater handler experience was associated with reduced risk in the North American sample, but the other sample did not show this pattern, even in unadjusted models. Dog spay/neuter status was not associated with injury risk in either sample.Dogs with radiographs assessing growth plate closure may have increased injury risk as this population of owners may plan to train their dog harder, and at an earlier age. This finding also poses the question of whether or not growth plate closure is a good indicator of safety for increasing training intensity. Knowledge of what risk factors exist for injury in agility dogs is imperative in determining direction for future prospective studies, as well as creating recommendations to help prevent injury in this population of dogs. Canine agility is a sport where a handler directs their dog through a course of pre-set obstacles, such as jumps, weave poles, tunnels, A-frames, teeters, etc., which need be completed within a specific time limit. Entries into events sponsored by the American Kennel Club have increased 38%  from 2009 and 2019, indicating a dramatic increase in the sport's popularity.Despite the increase in popularity and numerous changes that have occurred in canine agility in the past decade, there has been little updated information in regards to risk factors for injuries sustained by agility dogs. A previous study evaluating demographic risk factors for injury in agility dogs, published in 2013, by Cullen et al., reported that the Border Collie breed and <4 years of agility experience for dogs were associated with an increased risk of injury  samples, raising the issue of whether or not risk factors for injuries might be different for dogs competing in agility in different geographic regions. Differences in injury type and injury frequency among agility dogs in different geographic regions have been previously reported , making The purpose of this study was to investigate risk factors for injury in dogs competing in agility, focusing on handler and dog demographics, comparing previously identified risk factors and exploring potential associations with demographic factors in new populations and with different levels of injury severity. We hypothesized that less experienced handlers, competing at a higher level, and early spay/neuter would increase the risk of developing an injury. Based on differences observed in injury type and frequency by geographic region , we alsoAn internet-based survey  was conducted during a 6-week period in the fall of 2019. The details of this survey have been previously published , medical training , and handler agility experience.The primary outcome was history of any injury, defined as an injury that kept the dog from participating in agility for over a week, as reported by the owner. A secondary outcome, history of “severe injury” was defined as any injury where the dog was out of agility for more than 3 months.Descriptive statistics (means and proportions) were first calculated for all variables. Separate logistic regression models were used to quantify associations between variables with the binary injury status outcome variables. All models were age adjusted to account for the differences in lifetime exposure for different aged dogs. For categorical variables, a multivariate Wald test was used to test for the overall association between that variable and injury history. In some cases, categories of responses were collapsed in order to avoid small cell sizes and facilitate interpretation; such adjustments were made prior to final model building and without respect to the association between the variable and the outcome of interest.Risk factors were identified through backward stepwise selection in all models. The primary model used all available data and the outcome of any injury history for comparison with previous studies. To evaluate potential differences in risk factors between North American and non-North American agility dogs, models for risk of any injury were also constructed separately in the North American and non-North American subsamples. A final model evaluated risk factors for severe injury using all available data but with the outcome of severe injury (out of agility for longer than 3 months).p-value until all variables in the model had p < 0.05. Data were analyzed using Stata 15.1 .For all models, variables that were significant at p < 0.20 in models adjusted only for age of the dog were retained for variable selection. All variables retained from the initial selection process were included in the first adjusted model and then stepwise backward selection was used to eliminate the variable with the highest The sample included data from 4,197 dogs, including 2,962 from North American and 1,235 from the rest of the world . Injury Among the entire sample, the final model for injury history included nine predictor variables in addition to dog age . As prevOther variables associated with injury history have not been previously reported. Dogs whose handlers were over the age of 65 had the lowest odds of injury history, with the highest odds observed among handlers 25–34 and 35–44 years old. Dogs of handlers who reported having ever competed at the national level in agility had higher risk of injury, while dogs of handlers who are veterinarians or licensed veterinary technicians had lower odds of injury compared to other categories of occupation . Dogs thIn the North American sample, most of the same patterns were observed, with the final model including all the same variables except handler medical training and whether agility was the main sport focus of the dog . In the In the non-North American sample, only four variables (in addition to dog age) were retained in the final model . Border Severe injury keeping the dog out for 4–6 months or longer (>3 months) was reported for 629 dogs, representing 15.0% of all dogs in the survey and 36.2% of the 1,739 dogs reporting any injury history. After model building, four variables (in addition to dog age) remained in the model with severe injury as the outcome: breed, history of radiographs to assess growth plate closure, handler age, and handler medical training . As in tSeveral variables associated with either increased or decreased odds of injury in agility dogs were identified in this study. Some risk factors that were identified in previous North American surveys were also consistent in our North American survey sample. However, patterns were not entirely consistent between geographic regions.The most consistent finding is that the Border Collie breed had the highest odds of injury, in both North American and non-North American samples when considering only severe injuries. This result is consistent with previous studies , 6. BordHandler age above 65 was associated with lower risk of injury in the overall sample, and both the North American and non-North American samples, although it has not been noted in previous studies. Additionally, handlers over the age of 65 had the lowest risk of reporting a severe injury. There was a somewhat elevated risk for middle aged (25–44) aged handlers relative to the youngest category (18–24). It is possible that younger handlers are choosing faster dogs, and training at a higher intensity in order to keep up with the increased competitiveness and faster course times that have arisen over the last decade. Further studies are needed to assess training and handling styles of different age groups and how that might be associated with injury development and severity of injury.Handler medical experience was correlated with injury risk, though correlation varied between geographic regions. Dogs with handlers that had medical training, especially those that were veterinarians or veterinary technicians, had a decreased risk of injury, with the exception of veterinary assistants. This held true in the overall sample as well as the non-North American sample, but was not true for handlers with medical experience in the North American sample. Veterinarians in particular, were also at the lowest risk of reporting a severe injury to their dogs. Those with a more advanced veterinary background may be able to detect subtle lameness or changes to gait more easily, and take appropriate measures to prevent further injury, thereby also decreasing the risk of severe injury. They may also be more aware of injury risk in general and take additional proactive approaches to injury prevention. It is unknown why there was a difference in risk between the non-North American and North American samples.The North American sample, in this study, showed the same previous association with handler experience where dogs of handlers with greater agility experience were found to have a decreased risk for injury . HoweverDogs of handlers who had a history of competing at a national level had an increased risk of injury. This risk factor was present in the overall sample and North American sample, but not in the non-North American sample. There was no association found between competing at a national level and severity of injury. It is likely that handlers with a history of competing at the national level are selecting dogs for agility specifically, which was also an identified injury risk factor. They may also be training more frequently, for more repetitions and pushing their dogs harder during training and competitions, which could potentially increase injury risk. Overuse and repetitive stress injuries are common among human athletes and often related to high training frequency, intensity, and repetitive movements –14. WithThis study also found that, in the overall sample and North American sample, dogs acquired after 12 months of age were found to have decreased odds of injury. In the overall sample, those dogs for which agility was not the main focus also had a decreased risk of injury. Handlers and their dogs who are competing recreationally in agility likely do not train as hard, nor as often as those competing at a national level. It is also possible that, like in human athletics, early sport specialization increases the risk of injury, particularly risk of overuse injuries –17.In the North American sample, for dogs of the same height, the odds of injury were higher for dogs that were heavier. This correlation was only identified in the North American sample and not in the non-North American sample. There was also no association with severity of injury. Unfortunately, given the nature of using a survey we were unable to accurately assess body condition score of dogs, and therefore cannot make conclusions regarding relation of body condition score and injury risk. Without accurate body condition scoring, it is impossible to determine whether the heavier dogs had an increased body condition score and were obese, or whether the increased weight was due to increased muscle mass. It is possible that those dogs that are heavier, in relation to their height, are less physically fit, and therefore are more likely to sustain an injury. This correlation has been described in human sports medicine , and mayAn interesting finding in the overall and North American samples was a correlation between having had radiographs taken to confirm growth plate closure and increased odds of injury risk. These dogs were also more prone to a severe injury, keeping them out of competition or training for an extended period of time. The correlation between having radiographs taken to confirm growth plate closure and injury risk was not retained in the final model in the non-North American sample. Radiographs for assessment of growth plate closure were more commonly performed in the North American sample vs. the non-North American sample . Therefore, it is possible that the correlation with injury risk is similar in both geographic regions, but that the smaller sample size in the non-North American sample limited the statistical significance.It is thought that high impact training before growth plate closure may cause injury to the growth plates or contribute to developmental musculoskeletal disorders . In humaThere are anecdotal guidelines among agility trainers and competitors on general ages to start various training techniques, jump heights, and obstacle training. Growth plate closure is often used in the agility community to determine when to progress the intensity of training, increase the height of jumps, and start weave training, although there are no studies available to support the use of growth plate closure as a guideline in determining training progression. It is possible that the population of agility handlers that choose to have radiographs of their dogs made to assess growth plate closure do so in order to train harder, and at a younger age, which may be contributing to the increased injury risk. It is also possible that radiographic growth plate closure is not a good indicator of safety for increasing training intensity as it does not necessarily correlate with development and strength of the surrounding soft tissue structures, such as ligaments, tendons, and muscles, nor cartilage development , 26. StuOne can also consider that those handlers who had radiographs taken to assess growth plate closure may also represent a population that is more aware of potential injuries, and/or have more access to veterinary practitioners with sports medicine expertise, which may make them more likely to diagnose an injury. However, this would not explain why these dogs were also at a higher risk of severe injury, as one would think that earlier recognition would lead to a less severe injury and/or more rapid return to training and competition. Further studies specifically focusing on growth plate closure, canine sports readiness, effect of training intensity on musculoskeletal development and injuries are warranted.One surprising finding was that, in the non-North American sample, dogs owned by handlers who were professional trainers had a significantly increased risk of injury. This association was not observed in the North American sample. It could be hypothesized that handlers who are professional trainers are more likely to push their dogs harder in both training and competition in order to achieve success at high levels of competition, as this could affect their reputation and client demand. However, if this hypothesis were generally true, it would be expected that the association with increased injury risk would be found in the overall sample, as well as the different geographic samples, which was not the case. It is unknown why dogs of North American professional trainers did not have an increased injury risk, but those of non-North American trainers did. It is likely that there are training and competition differences between the North American and non-North American professional trainers that could result in injury risk differences. Prospective studies are needed to evaluate differences in training and competing among professional agility trainers between different geographic regions, and how that may influence development of injury.Counter to our hypothesis, early (<12 months of age) spay/neuter was not associated with injury risk in the North American, non-North American or combined samples. Early spay and neuter practices have been associated with increased risk of joint disorders in certain breeds . One preIn a study by Sellon et al. removal of dewclaws was associated with increased risk of digit injury . As suchKinematic studies in dogs have demonstrated the importance of tail movement in maintaining balance during treadmill locomotion . This mavia survey. These data were also reported by handlers and were unable to be verified by a veterinarian, which could result in inaccuracies in injury data. Selection bias may also be present, so our findings may not be representative of the entire agility dog population. Data on severity of injury was based on time off from agility, which may not be an accurate depiction of the true severity of an injury due to other extenuating variables. Many of the observed associations in the North American sample that did not persist in the non-North American sample are likely sample size issues .Limitations of this study include potential recall bias due to retrospectively collected data Overall, this study confirmed previously reported increased risk for injury for Border Collies, and decreased risk for injury with greater handler experience. This study also identified new variables affecting risk for injury such as dog weight in relation to height, age at which the dog was acquired, agility as main sport focus, radiographic assessment for growth plate closure, handler medical training, handler occupation, and handler history of competition at a national level. Furthermore, this study identified differences in demographic risk factors between the North American population of handlers and the non-North American population of handlers. The results of the current study provide insight on risk factors for injury, as well as a basis to guide further research. More research is needed to evaluate the increased injury risk in Border Collies, how weight and body condition affect injury risk in canine athletes, how canine musculoskeletal development is impacted by training, and how handling factors impact injury risk. Knowledge of what risk factors exist for injury in agility dogs will aid in creating recommendations for training and veterinary care in order to help decrease injury in this population of dogs.The raw data supporting the conclusions of this article will be made available by the authors, without undue reservation.Ethical review and approval was not required for the animal study because the Ohio State University Office of Responsible Research Practices determined the project was exempt from IRB review because it was an owner-based internet survey and the information was recorded without direct or indirect identifiers. The patients/participants provided their written informed consent to participate in this study.ASu participated in data evaluation and writing the manuscript. AP and NK assisted in study design, data collection, data evaluation, and writing the manuscript. ASh participated in study design, statistical analysis, and writing the manuscript. All authors contributed to the article and approved the submitted version.The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.All claims expressed in this article are solely those of the authors and do not necessarily represent those of their affiliated organizations, or those of the publisher, the editors and the reviewers. Any product that may be evaluated in this article, or claim that may be made by its manufacturer, is not guaranteed or endorsed by the publisher.


BackgroundPneumonia is a common respiratory infection that affects all ages, with a higher rate anticipated as age increases. It is a disease that impacts patient health and the economy of the healthcare institution. Therefore, machine learning methods have been used to guide clinical judgment in disease conditions and can recognize patterns based on patient data. This study aims to develop a prediction model for the readmission risk within 30 days of patient discharge after the management of community-acquired pneumonia (CAP).MethodologyUnivariate and multivariate logistic regression were used to identify the statistically significant factors that are associated with the readmission of patients with CAP. Multiple machine learning models were used to predict the readmission of CAP patients within 30 days by conducting a retrospective observational study on patient data. The dataset was obtained from the Hospital Information System of a tertiary healthcare organization across Saudi Arabia. The study included all patients diagnosed with CAP from 2016 until the end of 2018.ResultsThe collected data included 8,690 admission records related to CAP for 5,776 patients . The results of the analysis showed that patient age, heart rate, respiratory rate, medication count, and the number of comorbidities were significantly associated with the odds of being readmitted. All other variables showed no significant effect. We ran four algorithms to create the model on our data. The decision tree gave high accuracy of 83%, while support vector machine (SVM), random forest (RF), and logistic regression provided better accuracy of 90%. However, because the dataset was unbalanced, the precision and recall for readmission were zero for all models except the decision tree with 16% and 18%, respectively. By applying the Synthetic Minority Oversampling TEchnique technique to balance the training dataset, the results did not change significantly; the highest precision achieved was 16% in the SVM model. RF achieved the highest recall with 45%, but without any advantage to this model because the accuracy was reduced to 65%.ConclusionsPneumonia is an infectious disease with major health and economic complications. We identified that less than 10% of patients were readmitted for CAP after discharge; in addition, we identified significant predictors. However, our study did not have enough data to develop a proper machine learning prediction model for the risk of readmission. The Centers for Disease Control and Prevention (CDC) has defined pneumonia as “a lung infection that can cause mild to severe illnesses in people of all ages.” As a worldwide infectious disease, pneumonia is the leading cause of death in children less than five years of age . In the The impact of readmission has raised the awareness to investigate its causes and risk factors. Many studies have been conducted to investigate these factors. Hebert et al. found that the risk factors identified can vary from pneumonia-related 35.8%) to comorbidity-related reasons 5.8% to c. A systeMachine learning methods have been used to guide clinical judgment in gray areas as they can predict a pattern based on data and help decision-making. In 1959, machine learning was defined as a “Field of study that gives computers the ability to learn without being explicitly programmed.” Many prediction algorithms have been proposed and successfully used in healthcare, such as support vector machine (SVM), decision tree (DT), and logistic regression, and have been tested in many medical conditions such as diabetes among other conditions .The importance of creating prediction models for readmission is to overcome all previously mentioned complications. Due to the difficulties in predicting readmission, the model can guide healthcare providers (HCPs) in improving/supporting clinical decision-making during healthcare episodes while considering the risk of readmission . As a reIn 2016, a systematic review identified all used models and described their performances. The study concluded that only a few validated models predict the risk of readmission of pneumonia patients, the published models were moderately acceptable, and that any future model should have additional parameters to improve the prediction accuracy, or as suggested by O'Brien et al. to include all available patient care information if possible ,14.Another study aimed at predicting readmissions in general not specifically to pneumonia at King Abdulaziz Medical City (KAMC) in Riyadh, Saudi Arabia, used neural network (NN), SVM, rules-based techniques, and C4.5 DT and concluded that the models achieved higher accuracy levels when the prediction was designed for readmission within 15 days only. Furthermore, the study suggested that SVM was the best model. Of all the variables used in the training set, the visit history, lab tests, and patient age had more weight in the prediction than other variables in addition to the length of stay before discharge [Furthermore, other researchers have developed logistic regression models with stepwise removal for the prediction that showed better prediction models . Other sData collectionMultiple machine learning models were used to predict readmission of CAP patients within 30 days of diagnosis by conducting a retrospective observational study on patient data. The dataset was obtained from multiple tertiary healthcare organizations in Saudi Arabia. All patients diagnosed with CAP from 2016 until the end of 2018 were included. We excluded pediatric patients who were less than 18 years old or patients who died within 30 days of discharge. Ethical approval was obtained from the Internal Review Board (IRB) of King Abdullah International Medical Research Center because the acquired data were de-identified.Data pre-processingThe raw data were segregated into multiple datasets. The datasets obtained contained different attributes, including the history of pneumonia admissions, vital signs, radiology, laboratory, medication list, and comorbidities. For modeling, different data transformation and cleaning processes were conducted on the dataset. The length of stay (LOS) attribute was changed for patients discharged in less than a day to 1. The age attribute was derived from the date of birth and the admission date. All comorbidities, medications, radiology examinations, and lab results were transformed to dummy attributes with the values 1 and 0 for each admission. Attributes with missing values were filled with the median. Lastly, a new attribute was also derived to represent the class labels (readmission within 30 days of discharge and no readmission) as 0 and 1. Python coding language and Scikit-learn machine learning package were used for dataset cleaning and modeling .Data analysisUnivariate analyses were deployed using logistic regression to study the significance of the relationship between each factor and the readmission. All significant variables with a p-value of less than 0.05 were then passed to multivariate logistic regression, and the odds ratios were calculated to determine the magnitude of the relationship. Furthermore, various classic and modern machine learning models have been reported in the literature. In this study, to predict readmission within 30 days, we experimented with several algorithms using predictive analytics. The first model was developed using RF with a maximum depth of two levels and 100 estimators . Second,Model evaluation and validationA cross-validation technique was used by splitting the dataset into 70% of the dataset for training and 30% for testing. To measure the performance of the model, precision, recall, f1-score, and accuracy metrics were used to measure both results, readmitted and not readmitted. These results were calculated for both labels in Python using the Scikit-learn library .The collected data included 8,057 admission records related to pneumonia for 5,776 patients, including 2,965 males and 2,811 females. Patients were located at six different hospitals under the Ministry of National Guard Health Affairs. Of these admissions, only 791 admissions were followed by a readmission within 30 days, with a percentage of 9.1% of the total number of admissions included in the dataset. The minimum age was 18, and the maximum age was 119, but more than 60% of the patients were older than 66 years old with a median of 70 years  to balance the training dataset, the results did not change considerably, and the highest precision achieved was 16% in the SVM model . The higFactors that affect patients’ readmission have been studied extensively in the past two decades. In this study, we studied clinical factors that can be linked to the risk of readmission for patients with CAP. The results of the analysis showed that patient age, heart rate, respiratory rate, medication count, and the number of comorbidities that the patient had were significantly associated with the odds of being readmitted. All other variables showed no significant effect. The significant variables from our analysis are all factors that could indicate the severity of the patient’s condition in general and during the initial admission.However, when examining the magnitude of the relationship using odds ratios, we can observe two controversial themes. The first is that the worse patients have higher odds of readmission than their counterparts, which can be drawn from the odds of the temperature and number of comorbidities. The second theme is that worse patients have lower odds of being readmitted than their counterparts, which can be drawn from the odds of the age of the patient, heart rate, respiratory rate, and the number of medications prescribed. These two themes can be explained by the behavior of clinicians when dealing with admitted patients.The researchers’ hypothesis is that factors such as age, heart rate, and respiratory rate are directly related to the condition of patients with CAP, whereas temperature and the number of comorbidities are not related. This implies that patients who are worse according to their age, heart rate, and respiratory rate should be given more attention and prescribed more medications, which subsequently results in lower odds of being readmitted. This explanation is consistent with another study conducted at the same hospital for studying seven-day readmission for emergency department patients . NeverthTo build a prediction model, multiple algorithms and techniques were available for use in this study. However, we selected the ones that can easily be interpreted by HCPs where each rule can be translated into if/then rules. Moreover, we included other models that have been showing promising results per our literature review. After extensive testing of the final clean dataset and multiple trials of creating the prediction model, although the accuracy of the model reached 90%, we did not find any appropriate prediction for readmission. This can be explained by the nature of our dataset because the data for readmitted patients within 30 days of discharge was only 9.1% of the dataset and not enough to create an appropriate prediction.Looking at the results of the model, the SVM performed poorly, which contradicts the findings reported in the literature. In this study, SVM showed zero recall by predicting that all patients will not require readmission. Moreover, as part of the models’ training exercise, we tried to add and drop some of the predictors while using precision and recall to observe the effect on the performance of the models. This exercise resulted in a slight improvement in the RF model after decreasing the number of dummy attributes. On the other hand, better performance of the DT model was noticed after removing the continuous attributes of vital signs. Even with the best version of each model, we conclude that none of these models would qualify to serve as a reliable or valid model to predict readmissions of patients with CAP.This poor performance of the models is in part due to the low quality of the dataset that was available for this analysis. For example, the laboratory results were provided as free text instead of structured numeric values, which required sophisticated and advanced text-mining efforts to extract the relevant values for our study. Unfortunately, this led to only including the number of labs that were ordered for each patient instead of the results of the labs. Conducting more natural language processing could have a real contribution in creating a model with better performance than our models.Furthermore, in comorbidities, there were several entries for the same comorbidity for each patient. Therefore, the frequency of those comorbidities was not easily derived from the data. In addition, the same comorbidity had multiple descriptions which made it harder to calculate. For example, diabetes mellitus, type II diabetes, and type II diabetes mellitus can be found simultaneously, and they might have been documented differently for the same patient. Moreover, we used the International Statistical Classification of Diseases and Related Health Problems, Tenth Revision, Australian Modification codes of pneumonia for applying the inclusion criteria that only include patients who had CAP as a primary diagnosis. However, we noticed that different codes of pneumonia were used interchangeably in the HIS documentation even during the same visit, which affected the accuracy of including only CAP patients.Dealing with such data requires a careful process to ensure that the cleaning process was done appropriately and did not result in faulty data or missing data from the original dataset. Furthermore, the decisions to choose how to transform the data should be discussed before each action with an expert in the field not only be taken by the data scientist. For example, because we had multiple readings of vital signs, we needed to transform it to get only one value for each visit; the data scientist might use the median value to give an overall view of the entire admission status, but the physician would rather take the last reading before discharge because it will better reveal how the patient was discharged, which will affect the readmission possibility. Another would rather use the worst reading during the admission to reflect how bad the patient’s condition was, which would affect the possibility of being readmitted.The main limitation of this study was the structure of the original dataset, which limited the number of features that could be engineered and used for prediction. Another limitation was the lack of data outside the hospital that could strongly impact the readmission of patients. For example, if the hospital collected how well patients are adhering to their medications or their diet, we hypothesize that the prediction could have gained more accuracy. This kind of data could be collected as part of future studies from patients’ smartphones through dedicated applications. Future nationwide studies can be conducted to compare different populations based on different societal factors, such as lifestyle and diet, to determine their impact on readmission.Pneumonia is an infectious disease with major health and economic complications. Predicting CAP readmission using machine learning is an essential area of further research. Based on our study findings, the model accuracy reached 90%, but we did not find an appropriate prediction for readmission because the number of readmissions within 30 days was only 9.1% of the entire dataset received. We propose that machine learning can be used for predicting CAP readmission, but appropriate data sources and a suitable modeling technique are required to improve the accuracy of the model.During the development of our machine learning and statistical analysis models, we identified factors that are associated with the readmission of patients with CAP. These factors should be used and closely monitored by HCPs to minimize the rate of readmissions of patients with CAP. In our study, we identified that less than 10% of the patients were readmitted for CAP after discharge within the dates included in our study. Furthermore, our results indicated that age, heart rate, respiratory rate, medication count, and the number of comorbidities that a patient had were significantly associated with the odds of being readmitted. However, the prediction performance of the models in our study was not adequate to predict the risk of readmission.


The declaration of COVID-19 as a pandemic on March 11 2020, by the World Health Organisation prompted the need for a sustained and a rapid international response. In a swift response, the Government of Ghana, in partnership with Zipline company, launched the use of Unmanned Automated Vehicles (UAV) to transport suspected samples from selected districts to two foremost testing centres in the country. Here, we present the experiences of employing this technology and its impact on the transport time to the second largest testing centre, the Kumasi Centre for Collaborative Research in Tropical Medicine (KCCR) in Kumasi, Ghana.Swab samples collected from suspected COVID-19 patients were transported to the Zipline office by health workers. Information on the samples were sent to laboratory personnel located at KCCR through a WhatsApp platform to get them ready to receive the suspected COVID-19 samples while Zipline repackaged samples and transported them via drone. Time of take-off was reported as well as time of drop-off.A total of 2537 COVID-19 suspected samples were received via drone transport from 10 districts between April 2020 to June 2021 in 440 deliveries. Ejura-Sekyedumase District Health Directorate delivered the highest number of samples . The farthest district to use the drone was Pru East, located 270 km away from KCCR in Kumasi and 173 km to the Zipline office in Mampong. Here, significantly, it took on the average 39 minutes for drones to deliver samples compared to 117 minutes spent in transporting samples by road (p<0.001).The use of drones for sample transport during the COVID-19 pandemic significantly reduced the travel time taken for samples to be transported by road to the testing site. This has enhanced innovative measures to fight the pandemic using technology. This acth February 2020  KCCR’ was created on WhatsApp  on 16Fig 2A).The WhatsApp group was used to inform the KCCR team when samples were sent. Only messages related to suspected COVID-19 samples sent were posted on the WhatsApp page. Each message sent contained the number of samples and the name of the sending district. Notification on the order identification (ID), and the estimated time of arrival were provided. An additional message was sent when the package was 5 minutes away from delivery. The final message was sent when the package dropped in the drop zone. The group was administered by Zipline representatives  and analysed. Proportions were generated using Excel. Comparison of the distances covered, and time taken for sample delivery using roads and drones was done using the student T-test on GraphPad Prism version 5.0 . Alpha values < 0.05 were considered statistically significant.Upon receipt, sample numbers and their means of identification were cross-checked with the list provided and the information logged into the sample reception system at KCCR. All districts whose samples were tested by the laboratory were assigned codes for easy identification, as shown in Ethical approval for this study was obtained from the Committee on Human Research, Publication and Ethics (CHRPE) of the School of Medicine and Dentistry, Kwame Nkrumah University of Science and Technology (KNUST) (CHPRE/AP/566/21) and the Ethical Review Committee of the Ghana Health Service (GHS-ERC087/03/20).From April 2020 to June 2021, a total of 2537 suspected COVID-19 samples were received via Zipline drones . These sFig 3).Overall, the number of samples received corresponded with the rising number of cases during the two main waves that hit the country. Samples peaked in July 2020 (708) and February 2021(438) in 91 and 50 deliveries, respectively  tested positive for SARS-CoV-2 . Of the Table 3 shows a comparison between the distances from the districts to the laboratory and the drone zone. There was no statistically significant difference between the distances covered by the districts to KCCR and to the Zipline office (p = 0.1085). On the contrary, there was a significant difference between the estimated times of arrival (ETA) to KCCR and to the Zipline Office when the ETA to KCCR was compared to the ETA to Zipline (p = 0.0237). Averagely, it takes 96 minutes to travel from the Zipline office to the KCCR by road covering a distance of 63 km.During the period, the farthest district to transport samples to KCCR via Zipline drones was Pru East. The distance from the Pru East district to KCCR in Kumasi was 270 Km and to the Zipline office at Mpanya was 173 km. The hallmark of effective disease control is early diagnosis, and the outcome of Africa’s recent outbreaks before COVID-19, especially Ebola virus and Lassa fever, largely depended on this. In the case of COVID-19, early diagnosis is even more important, considering the dire transmission risks potentially posed by asymptomatic individuals . Therefoth of April, 2020, KCCR received its first test sample from the Sekyere Central District, and subsequently, other districts followed. Ghana, like most African countries, is bedevilled with poor road network [In a swift response to the pandemic containment and the call for more testing, Ghana became the first country to introduce the drone technology in sample transport to some testing sites , 27. On  network . ConsideProximity to the Zipline office may have also influenced the number of samples received from a district as is reflective of the Asante Mampong Municipal Assembly, where the Zipline office is located, transporting a total of 560 samples . Other districts including Sekyere Central and Sekyere South which are located less than 30km from the Zipline office also transported 352 (14%) and 400 (16%) samples, respectively. On the contrary, the farthest districts, Pru East and Atebubu Amantin, transported less than 100 samples forming less than 2% of total samples received via drone transport. The distance to the drone office may still be a reason for some districts to accumulate samples to transport in order to avoid several trips times to the drone office. A possible suggestion will be that there is the need for more drone offices to be situated in the districts particularly those that are at the periphery and far off from the major cities where the drone sites and offices are located.The high numbers received from some districts may also reflect the infection rate and the high positivity rates in those districts as compared to other districts. The use of drones to transport the samples has saved a lot of resources and time that potentially could be used for other activities such as contact tracing and for effective and rapid response to management protocols. The use of the drones during the pandemic has also increased the visibility and the ability of Ghana to employ among other technologies , 26, 29,Globally, the role of drones during this pandemic has been limited to the transport and delivery of essential supplies including medical supplies, mostly personal protective equipment as reported in China and India as well as the USA , 31, disThere were however, a few challenges that were identified, most importantly with the weather. Even though there are drones designed specifically for weather and other climate studies , 43, theAt the peak of the pandemic in the country was the rainy season and its associated weather conditions which affected the operations of the drones a couple of times. Results of these unfavorable weather conditions impacted the activities of the Zipline company by either delaying the sample delivery by a day or a few hours, otherwise, samples were hand-delivered via land transport. In such a situation, notification was made on the WhatsApp platform. In spite of these challenges, the use of drones for the delivery of samples was very effective and considered a great technological breakthrough in the pandemic.The importance of this technological innovation is reflected in the travel time it saves health workers in transporting samples and resources to be used. To this end, some health workers have expressed satisfaction in the drone services and are relieved to know that sample transport, which would have taken about one-third of their time, had been reduced . It alsoThe SARS-CoV-2 pandemic has reiterated the need for technological advancements to combat it and many individuals, corporate organisations and governments responded appropriately including the use of drones. Instead of waiting several days for a batch of samples to be transported, coupled with numerous challenges such as bad roads, a single test from a rural area can be delivered for analysis in less than an hour. Especially for districts close to the drone centre, using contactless drone delivery to transport COVID-19 test samples made it possible for tests to be run in time, allowing the government to respond to the pandemic and enhanced potential to save lives.S1 TableA list of all the health facilities under each district that transported samples via drone.(DOCX)Click here for additional data file.


The application of mulch films for preserving soil moisture and preventing weed growth has been a part of agricultural practice for decades. Different materials have been used as mulch films, but polyethylene plastic has been considered most effective due to its excellent mechanical strength, low cost and ability to act as a barrier for sunlight and water. However, its use carries a risk of plastic pollution and health hazards, hence new laws have been passed to replace it completely with other materials over the next few years. Research to find out about new biodegradable polymers for this purpose has gained impetus in the past few years, driven by regulations and the United Nations Organization’s Sustainable Development Goals. The primary requisite for these polymers is biodegradability under natural climatic conditions without the production of any toxic residual compounds. Therefore, biodegradable polymers developed from fossil fuels, microorganisms, animals and plants are viable options for using as mulching material. However, the solution is not as simple since each polymer has different mechanical properties and a compromise has to be made in terms of strength, cost and biodegradability of the polymer for its use as mulch film. This review discusses the history of mulching materials, the gradual evolution in the choice of materials, the process of biodegradation of mulch films, the regulations passed regarding material to be used, types of polymers that can be explored as potential mulch films and the future prospects in the area. The technique of mulching has been a part of agricultural practice for a long time. In simple terms, mulches are defined as materials that are applied directly onto the surface of soil for various purposes such as the protection of seedlings and young shoots through insulation, reduction of evaporation, control of weed growth and prevention of soil erosion . They spThe history of using mulching to enhance crop production dates back to around 500 BCE, as shown in Various anthropogenic activities over the years have led to the production of greenhouse gases, which, in turn, have resulted in climate change. The emission and accumulation of these gases in the atmosphere has led to global warming, i.e., an increase in average temperatures and fluctuations that contribute to extreme weather conditions, as well as alterations in precipitation patterns throughout the world. Such changes in agricultural regions have an adverse impact on crop production, thus creating problems when providing adequate food supply for an increasing population in an efficient and sustainable manner . The limIn 2015, under the banner of the United Nations Organization, the international community developed a series of Sustainable Development Goals, known as SDGs, which include ensuring access to food for all, increasing agricultural productivity and achieving zero hunger by 2030 . These gBiodegradable polymers may be one solution, and have the potential to replace plastics for many applications. However, these polymers have certain limitations which are restricting their use on a commercial scale for the purpose of mulching. Factors that need to be considered before a polymer can be used include not only its physical and chemical properties but also the source and method of production. These polymers have different mechanical properties, which, in turn, affect their biodegradation in the environment . MoreoveThis review discusses the practice of mulching in agriculture, its benefits, the materials used as mulch films, and the alternate options that can be explored for sustainable agricultural practices. It also includes an overview of the biodegradation process that occurs in the soil for the breakdown of mulching materials, factors affecting this process, and a list of different commercially available mulches, highlighting the direction of further research in this area.The increasing food demand of a growing world population has driven the need to increase agricultural crop yields. Protected cultivation is one way to help optimize the yield of crops. This involves controlling the microclimate around the growing plant to protect it from harsh climatic conditions . MulchinThe use of mulch films in agriculture has several benefits when compared to non-mulched crop production. These may be categorized as improvements in the soil microenvironment or economic advantages a. Soil mIt is important to control the temperature of soil, since temperature fluctuations adversely affect the development of roots . Since tThe presence of heavy metals in soil affects the growth of plants. Mulches can be used as a remediation strategy for the removal of these heavy metals from soil. Organic and plant-based mulch material forms complexes with heavy metals and converts them into a form that renders them non-toxic for plants . MulchesGenerally, mulching decreases the stress level on plants, leading to better growth. This leads to enhanced crop yield and improved product quality. The crop may also be harvested earlier and tends to be more profitable . All theThe use of mulch films dates back to ancient civilizations. The earliest mulch material comprised by-products from the agricultural and forestry industries, and included the trimmings of trees and shrubs, animal waste, stubble and residues of crop plants . With tiThe type of mulch used is governed by many factors, including the plant species, soil type and characteristics, the cost and availability of mulching material, as well as the regulations and law governing the region . For insOrganic mulches mainly comprise animal or plant residues such as compost, manures, straws, husks, saw dust, grass and paper clippings, and wood/bark chips A–F. The Other organic materials that can be used include straw and husks. These materials have a long life span when used for mulching and are effective for vegetables grown in winter months . They arSawdust is readily available and has exhibited potential as a mulching material specifically for acid loving plants. It is very efficient in minimizing water runoff and soil erosion . StudiesGrass clippings are very effective as a mulching material when applied as an appropriately thick layer. If the layer is too thick, it prevents air from penetrating, resulting in rotten and odorous clippings. If the layer is thin, the grass clippings decompose quickly, and need to be replenished frequently to maintain efficacy of the mulching material . Fresh gPaper mulches are made up of cellulose fibres which can be decomposed naturally by most soil-borne microorganisms. Sheets of paper, mainly newspapers with black ink, can be used as mulch, as a part of a recycling strategy. The colour of paper used for mulching has an impact on the control of weed growth. Black paper mulching has shown promising results for decreasing the growth of weeds in lettuce and cantaloupe farming . HoweverWood and bark chips are preferred as mulching materials since these are very effective in retaining moisture in the soil. They also allow proper aeration and contribute to the organic content of the soil. Pine bark makes an attractive, usually dark-coloured mulch and may be used for ornamental plants. However, bark chips and pine needles have been reported to reduce the soil pH upon application and cause phytotoxicity . The decThe main factors that limit the use of organic mulches are that they may not be available in adequate amounts throughout the year, have an inconsistent quality and are extremely labour intensive .Inorganic or synthetic mulches are made up of materials such as glass, rubber sheets and plastic . Glass mRubber mulches are frequently made by shredding worn out tyres as a strategy of recycling. These shredded tyres include very fine particulate matter that can be inhaled, ingested or taken up transdermally, increasing health risks. The use of rubber mulches is also associated with the hazard of ignition since rubber catches fire quickly and is very difficult to extinguish . MoreovePlastic mulch films G–I have However, there are several problems associated with the use of plastic mulch films, including laborious and costly removal from the fields after use, lack of sustainable end-of-life management options and the addition of plastic waste to the environment . At the Most countries in the world are now opting for sustainable practices and have banned single-use plastics to overcome plastic waste generation and pollution. This has necessitated the need to look for sustainable and eco-friendly alternatives that can be used as mulch films . As a soHowever, these mulch films have low strength and can break down prematurely while being spread onto the field. This fragility and their lightweight nature makes the application very difficult. Moreover, the absence of UV light reduces degradation of these plastics once they are incorporated into the soil. Even if there is breakdown in the soil, it is never fully biodegraded. The mulch pieces persist in soil and watersheds, and form micro plastics that have the ability to adsorb toxic pesticides, insecticides and herbicides, and carry them into the food chain . ResearcIn recent years a lot of research has been carried out to produce mulch material that is both sustainable and eco-friendly. The material for a mulch film should ideally be bio-based and very prone to biodegradation . To replThe use of biodegradable material imparts the main advantage of being tilled into soil once used, so that it can be degraded by the action of soil microbiota, reducing the costs of labour and disposal . To replThe term biodegradation refers to the breakdown of macromolecules by the action of microorganisms. Molecular level studies have shown that it is a two-step process . In the Polymers may constitute aliphatic chains or aromatic groups. Generally aliphatic polymers are easily hydrolysable while aromatic polymers require harsh conditions for breakdown, such as extremely acidic environments at high temperatures. Most biodegradable polymers are therefore aliphatic, but some aliphatic-aromatic polymers that have a limited number of aromatic units may also be included in this category .Many factors affect the biodegradation of a polymer, including environmental conditions and the characteristics of the polymer, as shown in It is interesting to note that the biodegradability of a polymer is not linked to its source but is dependent on its physiochemical properties such as molar mass, cross-linking, functional groups, crystallinity, flexibility and the presence of co-polymers, additives or cross-linkers . As a geBiodegradable polymers may be derived from fossil fuels or renewable resources, or even a blend of both . They usBiodegradable material made from synthetic polymers or derived from fossil fuels that have been used as mulch films includes polyurethanes such as polybutylene adipate terephthalate or PBAT, poly ε-caprolactone or PCL, and polybutylene succinate PBS . The chePolybutylene adipate terephthalate (PBAT) is a derivative of common petrochemicals and is considered to be fossil fuel based. It is a co-polymer of 1,4-butanediol, adipic acid and terephthalic acid. Therefore, it is an example of an aromatic–aliphatic polymer, with properties that are partially attributed to the aromatic group and partially to the aliphatic chain. It has a higher elongation break than most other polymers and is flexible . PBAT alThe degradability of these films may not be same in all types of soil. Studies have shown that the type of microorganisms present in the soil and the composition of soil structure influenced the extent of biodegradability of PBAT-based mulch films in field experiments , while mPoly ε-caprolactone (PCL) is an aliphatic, synthetic, and thermoplastic polyester derived from petrochemical feedstocks. It is produced by ring-opening polymerization of ε-caprolactone, which is obtained from crude oil. It has ester linkages and can be easily broken down by microorganisms that produce the enzymes lipase or esterase . The cheHowever, results of the field trials have indicated that these mulch films degrade in a shorter time if certain fungi and actinomycetes are present in the soil. In some conditions, these films degrade within a short span of 60 days, reducing their practical value and importance in agricultural practices . With thPoly Butylene Succinate (PBS) is a thermoplastic polyester which has physico-chemical properties such as conventional non-biodegradable plastic. It is made up of 1,4-butanediol and succinic acid . PBS is PBS is synthesized through various processes including co-polycondensation and reactive and physical blending, all of which impart different physical characteristics to the product formed. The higher the degree of crystallinity in the polymer, the lower its potential to be degraded by enzymes or microorganisms . To overPBS and its blends are broken down by microorganisms that produce esterases. It has been found that the degradation rate of a PBS-based mulch film is influenced by the presence of certain fungi in the soil, as well as the availability of nitrogen and carbon sources to these microorganisms . This maBio-based polymers are defined as materials formed naturally by living organisms over many growth cycles. These include lipids, proteins, and carbohydrates. Lipids are hydrocarbons, chemically, and may exist as esters, acid polyesters or free acids. They include hydrogenated fats, oils, fatty acids, and waxes . AlthougProteins may be produced by microbial cells or extracted from plants and animals. These can be easily degraded in the environment by indigenous bacteria and fungi. Films made from soy protein, zein protein, wheat gluten, collagen and gelatine have been tried for mulching applications but have not been successful. The main problem associated with the use of protein-based mulches is their high-water sensitivity, which reduces the efficiency of these films .The most abundant among these polymers are carbohydrates; mainly polysaccharides. These may be produced by the bacteria or exist naturally in plants and animals. Naturally occurring polysaccharides include chitin, alginate, starch, and cellulose . ChemicaPolylactic acid (PLA) was discovered in the 1930s and is produced by lactic acid forming microorganisms. It can be manufactured using renewable resources as the substrate for the microorganisms, such as corn, sugar beet starch and other agricultural products . As suggTo counter the problems of high cost and brittleness, blends of PLA are made with other polymers. A common blend is to mix PLA with starch, which has been shown to enhance the mechanical properties of PLA. Formulation of PLA-starch blend also reduces the cost of the mulch films, making it more economical for use . StudiesHowever, the formation of these blends is challenging and difficult. The non-compatibility of composites is an area that is still under research. It has been found that formation of unstable bubbles in the film may occur after blending, leading to wrinkles and tears in the sheet. Similarly, electrostatic attraction may result in adhesion between these films, reducing the efficacy in agricultural applications ,137. To Polyhydroxy alkanoates (PHA) are a class of aliphatic polyesters that are produced by many bacterial species as distinct granules. Discovered in 1925, the polyesters are synthesized intracellularly and used as storage polymers for carbon sources in many prokaryotes . PHA graGenerally, the mechanical properties of PHAs do not support their use as mulch films. However, blending different PHAs together or with other polymers improves their mechanical strength. The main feature of PHAs that imparts an advantage is their ability to function as controlled release systems for agricultural chemicals. Studies have shown that PHB blends are particularly effective as mulch films for the slow and controlled release of pesticides and fungicides ,147. BleThe desirable characteristics such as structural variability, raw material availability, and biodegradability of PHB polymers make them an ideal candidate for replacing plastic as mulch films. Yet, despite the microbial source and versatility, the large-scale production of PHAs is restricted by the high cost of the manufacturing process . DiffereChitin is found naturally in the cell walls of fungi and yeast, and in the exoskeleton of arthropods. The most abundant crystalline form of the polymer is α-chitin, which may be obtained from seafood waste in large quantities . It is mWhen used for mulching, chitosan has exhibited the potential to control weed growth much better compared to some herbicides . It can Alginate is an aliphatic, water-soluble polymer found in the cell wall of brown algae. It is chemically made up of β-d-mannuronic acid (monomer M), and α-l-guluronic acid (Monomer G). The sequential arrangement and proportions of these two monomers in the alginate chain impart its different properties . It can However, the main problem with the use of alginate-based mulch films is their dependency of synthesis on the presence of calcium ions in the soil, since the films cannot be produced in the absence of these ions. Furthermore, the stiff structure of sodium alginate and the rigidity of the resulting cross-linked film leads to rips and tears in the mulch film, which paves way for the growth of weeds . A methoStarch is the main storage polysaccharide found in plants and is made up of the chains of amylose and amylopectin. Amylose is linear and consists of glucose units linked by α-1, 4 glycosidic linkages, while amylopectin has branches that stem out of the main chain. The main chain is made up of glucose units joined by α-1, 4 glycosidic linkages while the branch points have α-1, 6 glycosidic linkages . Starch Starch is one of the most abundant and cheap polymers that can be used to replace plastic. It can be easily processed without any stringent requirements and can be produced commercially using already installed plastic processing machinery/equipment . ConsideCellulose is the main structural component of plant cell walls and is the most abundant polysaccharide in nature. It is a linear homopolymer made up of D-glucose units joined through β- 1, 4 glycosidic bonds . CelluloThe main challenge for the production of cellulose on a commercial scale is the higher cost of this process. Scientists are investigating the use of cheap waste material as a substrate for the bacteria to produce cellulose to decrease the cost of production ,183. OthA comparison of the advantages and disadvantages of biodegradable polymers and their degradation times is given in Despite the challenges and problems related to production of biodegradable mulch films, consistent research efforts over a number of years have resulted in the development of some commercial mulching materials. All these mulch films are polysaccharide-based and are manufactured by blending two or more polymers .®, which was produced by Novamont, an Italian company. The mulch film is made of a blend of poly ε-caprolactone and thermoplastic starch and possesses reasonable biodegradability and mechanical strength [® TPS, Biopar®, Bionelle, Biosafe™, Ingeo®, and WeedGuardPlus [The first biodegradable mulch film used in agriculture was Mater-Bistrength . Its appstrength . Other cuardPlus ,191,192.Results obtained from field experiments have indicated that biodegradable mulch films are as effective as polyethylene mulch in controlling weed infestation and promoting plant growth. However, the increasing demand for food and cash crops has led to a continuous rise in the global consumption of plastic mulch film. Although there is a wide range of biodegradable material available on the market, the quantity is still not sufficient to completely replace non-degradable plastic mulch films . The maiDespite extensive research in the development of biodegradable mulch films commercially, the large-scale use of these materials is still limited. The biodegradable mulching material needs to be cost effective and easily accessible to the farmers for complete replacement of polyethylene in the field. Commercially available biodegradable mulch films are not preferred by most farmers because these are expensive, difficult to manage and require specialized equipment for application . This meThere is a need to develop polymers suitable for mulching in different climatic zones, with a wide range of temperatures and soil types, so that these can be utilized for the production of different crops . It is cAmong all polymers that may be used, cellulose offers potential for further research since the only problem associated with it is the cost of production. New processing methodologies such as 3D printing and electrospinning are also being considered for production of mulch material and can be used for lowering the cost of cellulose . HoweverThis review provides a detailed account of the history of mulching, the concerns about the use of plastic mulch films and their impact on the environment. It also discusses the alternative biodegradable polymers with the potential to be used for mulching, including those produced naturally by microorganisms, animals and plants as well as some derived from fossil fuels, alongside their advantages and limitations. Most of the biodegradable polymers have characteristics that are a compromise in terms of parameters that need to be met for agricultural use in terms of maintaining the optimum microclimate for plant growth for the whole growth cycle and sufficient high tensile strength. For example, materials that exhibit good biodegradation often lack mechanical strength, and vice versa. The formation of blends or use of co-polymers appears to be a promising solution but presents a limitation of increasing the cost of production significantly. The future outlook for the development of biodegradable mulch films is nonetheless favourable. The cost of production can be reduced by adopting waste valorisation strategies wherever possible, and advanced scientific techniques can be used to improve the quality of the polymer produced so that it can meet the required standards. The discussion reflects the potential for research and development in the design of biodegradable mulch films. Further research in all domains of production, design, characterization, biodegradation analysis and commercialization needs to be carried out to encourage the use of biodegradable polymers for mulching to promote sustainable practices.