Municipal home-healthcare services are becoming increasingly important as growing numbers of people are receiving healthcare services in their home. The COVID-19 pandemic represented a challenge for this group, both in terms of care providers being restricted in performing their duties and care receivers declining services for fear of being infected. Furthermore, preparedness plans were not always in place. The purpose of this study is to investigate the consequences for recipients of home healthcare in Norway of the actual level of COVID-19 infection spread in the local population, as observed by licensed nurses working in home-healthcare services. Approximately 2100 nurses answered the survey. The most common adverse consequences for home-healthcare recipients were increased isolation and loneliness, increased health concerns, and the loss of respite care services. An increased burden for relatives/next of kin and fewer physical meetings with service providers were frequently observed and reported as well. This study shows that there were more adverse consequences for service users in municipalities with higher levels of contagion than in those with lower levels of contagion. This indicates that the municipalities adapted measures to the local rate of contagion, in line with local municipal preparedness strategies. When the COVID-19 pandemic struck in the winter of 2020, the world was facing a situation of great uncertainty. There was little knowledge about how the pandemic would develop and what the consequences would be for both individuals and society at large. What was known was that most countries had a limited capacity to handle a situation with many patients with extensive healthcare needs. To reduce the spread of COVID-19 and to prevent a collapse of healthcare services, many countries around the world implemented lockdowns and took strict infection control measures. Such measures impacted all parts of healthcare services, affecting both staff and patients. Much attention was paid to patients in hospitals; particular attention was paid to the follow up of COVID-19 patients, but also to non-COVID patients who experienced restrictions on visitations and strict infection control measures. Persons living at home and receiving home-healthcare services were also affected, but appeared to be less visible in the public debate. In this paper, we draw attention to the consequences of the first phase of the pandemic for home-care recipients, defined as home-dwelling persons receiving home-healthcare services.Due to a growing ageing population with increasing needs for healthcare services, a lack of capacity in hospitals, and incentives for the early discharge of patients from hospitals, the use of home-healthcare services has increased over the past decade . This trTo summarise, home healthcare is becoming an increasingly important service, attending to medical, practical, and organisational tasks . In timeProblem framing: narrowing down a social phenomenon to a “problem” and making assumptions about its severity;The relations between government and experts: navigating when knowledge about the virus is uncertain and when experts’ advice is sometimes conflicting. How much trust can be placed in experts?The public sector’s preparedness for crisis: lacking or insufficient crisis management plans and the need for the adaptation to and the improvisation of pandemic plans;One-size-does not-fit-all solutions: variations in policies and responses across nations and regions; variations in the flow of power during crises, sometimes favouring centralised approaches, other times favouring decentralised ones;Pluralism in response to crises: societies are always pluralistic, and this does not disappear during crisis; consensus vs. pluralism in opinions on the crisis and its management;Social inequality and vulnerability during a crisis: both the crisis itself and the response measures affect people differently.Handling a pandemic is a prime example of crisis management, and emergencies such as the pandemic must be handled on both the national level and at the local, municipal level . Within There is no definitive benchmark for crisis management success , and theCrisis management is built on predefined emergency plans and, during the pandemic, a national  emergency plan and local plans in the municipalities co-existed in Norway. However, from the early onset of the pandemic, it was clear that these plans were not specifically developed for handling a situation such as the COVID-19 pandemic. Particularly relevant for understanding how home-healthcare services were affected is the fact that the Infection Control Act places infectious disease expertise at the local government level . This imWhen the pandemic broke out, the Norwegian central government implemented a lockdown in March 2020. Several measures were taken to flatten the infection curve and keep the healthcare services at a sustainable level. Central government recommendations were issued regarding hand hygiene and cough etiquette, working from home, if possible, that public transport should be avoided, that domestic travel should be limited, and that there should be no visits to members of vulnerable groups in health institutions . To secuInternational studies indicate that persons receiving home-healthcare services experienced negative consequences from the pandemic crisis measures. Home-healthcare recipients had their services postponed, reduced, or removed to both prevent the spread of infection and to ensure preparedness ,16,17,18In addition to consequences for care recipients, healthcare workers were also negatively affected by the pandemic. As a consequence of working with limited resources and knowledge of the virus, nurses experienced emotional exhaustion, depressive symptoms, and reduced personal accomplishments ,26.In Norway, it has been discussed in hindsight whether the authorities overreacted to the situation in the first phase of the pandemic through stages of building up negative emotions and the propagation of fear and isomorphic decision-making, leading to an intractable crisis . If centThe purpose of this study is thus to investigate how the COVID-19 infection level in Norwegian municipalities correlated with the extent of the reported consequences for home-healthcare recipients.To study whether the severeness of the pandemic (measured by confirmed COVID-19 cases relative to population size) was in line with the degree of reported negative consequences for home-healthcare recipients (reported by the licensed nurses working in the services), we tested whether high levels of contagion were found in municipalities with more reported consequences; that is, if the reported negative consequences vary according to the actual local levels of contagion.We used a cross-sectional approach with a questionnaire administered between September 2020 and October 2020. Licensed nurses reported on 23 adverse consequences for home-healthcare services users in whichever of the 356 municipalities they were employed in. The date of survey completion was automatically registered, and the date of completion and municipality information were used to link the number of accumulated, confirmed COVID-19 cases.This study was set across locations of local home-healthcare services in Norway, and the target provider group was licenced nurses. In 2020, when the data for this study were collected, 160,673 persons received home-healthcare services, according to Statistics Norway. Staff in home healthcare worked in an ambulatory setting in which they visited persons in need of healthcare services in their homes.We searched the literature but did not find any questionnaires that measured nurses’ experiences of the consequences of the COVID-19 pandemic for patients and their next of kin. Therefore, we developed a questionnaire in several phases. First, the researchers outlined the main themes that we wanted to investigate. Second, we organised an expert group with nurses from the professional groups of the Norwegian Nurses Organisation (NNO). These nurses had clinical experience, and some of them had research skills. Some of the nurses provided written feedback relating to the themes that had been sent to them via e-mail. Thereafter, two of the researchers met with the expert group in a Teams meeting to further discuss the questions. Third, we organised a group of persons which represented patient and next of kin associations to gain input on the themes and questions which they considered important. The group consisted of persons from five associations representing persons that are frequently among recipients of home healthcare service. The following groups were represented: persons with chronic diseases, persons with mental illnesses, and persons with disabilities. At this point in time, the associations had received a good deal of input from their members about their experiences with the pandemic, and this information was valuable for the design of the questionnaire. The meeting with the patient and next-of-kin association was held digitally, via Teams. Two of the researchers and persons from the NNO took part.The next phase consisted of the questionnaire development. The questionnaire was developed based on input from the aforementioned meetings. It was thereafter pilot-tested by the expert group and licensed nurses who worked in healthcare services. It was then revised. These steps provided significant and valuable information for what became the final version. The final version of the questionnaire contained 23 items and included information about the municipalities in which the nurses worked.The questionnaire items were rated on a five-point Likert scale as follows: (1) strongly disagree, (2) disagree, (3) neither agree nor disagree, (4) agree, and (5) strongly agree. In addition, free-form answers were used to gain more information from the respondents. A total of 58 respondents commented in free text. The Questionnaire containing 23 items can be found in the N = 26,915). From this sample, we established a sub-sample of 2860 licenced nurses working with adults or elderly service users in home care services. Between 2072 and 2116 nurses (72–74%) responded to the 23 questions regarding consequences for service users.All nurses who were members of the Norwegian Nurses Organisation and had registered an e-mail address in the member database were invited to participate. The inclusion criterion was that they should have been employed in the period that commenced with beginning of the pandemic (March 2020). An exclusion criterion was not being employed in the healthcare sector. Among those who were employed in the healthcare sector, 35% responded (The data collection period covered 28 days (22 September to 19 October 2020). In addition to the 23 questions about consequences for service users, we collected information about the municipalities in which the workplaces of the responding nurses were located. Based on this information, we linked information about the reported number of accumulated COVID-19 cases in each municipality from the Norwegian Surveillance System for Communicable Diseases (MSIS) on each of the 28 days. Thus, we had information about the consequences for the adult service users in the view of the nurses working in home care services as well as the actual dissemination of disease in the municipality in which the workplace of each nurse was located. The MSIS data were provided by the Norwegian Institute on Public Health, and the municipality data were extracted from Github on each date and subsequently linked to the answers from the survey using municipality numbers, which entailed a four-digit code assigned to each of the 356 municipalities.We treated each of the 23 consequences for the service users as different dependent variables. The dependent variables were ordinal in nature; that is, they had a natural ordering with values from “To a very large extent” to “To a very small extent”, so we estimated ordinal regressions for which the only explanatory variable was the accumulated number of confirmed COVID-19 cases per 1000 inhabitants on the response date in the municipality where the workplace was located. The ordered probit model provided an appropriate fit to these data, preserving the ordering of response options while making no assumptions on the interval distances between the response options. To test whether the level of contagion in the municipality where the responding nurse worked was correlated with the extent of the reported consequences for the service users, we used a standard chi-squared test for each of the 23 consequences separately, in which the null hypothesis was that the regression coefficients in the model were equal to zero. Pairwise correlation coefficients between the consequences (C1–C23) are shown in the Graphical representations of the results of the linear predictions of each of the 23 consequences are displayed with 95% confidence intervals around the mean.The nurses who were invited to answer the questionnaire received written information explaining that their participation was anonymous and that returning the questionnaire meant that they agreed to participate in the study. For the questionnaire, a secure sockets layer (SSL) was used to provide security to the data when transferred between the web browser and the server. All data were securely stored and protected using approved solutions. This was a prerequisite for study approval. The methods for the data collection and the handling of interviews, as well as the questionnaire, were approved by the Norwegian Centre for Research Data (registration number 580244) and the Research Ombudsman in SINTEF.The most frequently reported negative consequence for persons receiving home care services, as reported by the nurses, was increased isolation and loneliness. A total of 79.2% reported that this was experienced to a very large or large extent; see Answers to the open-ended questions support these findings. One nurse wrote: ‘It has been–and is–very difficult for many patients and next of kins, that day care and respite care were closed or reduced. Several patients have had a reduced quality of life, become physically poorer, and have struggled with anxiety and depression. More use of drugs in vulnerable patients. Several patients had to be admitted to hospitals because they could not eat and drink enough, when they did not sit with others around the meals at the day care centre. During the summer, their state of health was so reduced that they were admitted. Also observed that there was more focus on pain and discomfort in some, and thus higher consumption of medication than when they were more active’.Few respondents reported that the service users to a very large/large extent stopped taking medication because they the medications were immunosuppressive (0.7%). However, as can be seen in the fifth column of As can be seen from the correlation matrix provided as As can be seen from the chi-squared test in the last column of Consequences that did not seem to depend on the level of contagion in the first part of the pandemic included an increased contact with services, ceasing to take medications because they were immunosuppressive, and problems with access to medication. The results imply that these consequences happened independently from the actual level of contagion and that these consequences were perhaps more national in nature than the other consequences included.As is shown in An element of uncertainty in the response categories of the survey is the response ‘not relevant’. This could mean that the consequence was not observed at all or that none of the home care service users could have experienced this consequence. In the data and analyses presented in In this study, we have investigated the consequences of the COVID-19 pandemic situation on home-healthcare recipients in Norway. We were interested in finding out if the municipalities’ actual level of COVID-19 infection was reflected in the frequency of adverse consequences for home-healthcare recipients. Regardless of the infection level in the municipality, the most common adverse consequences observed were increased isolation and loneliness as well as increased health concerns. This is in line with previous studies that found such experiences to be consequences of both the elimination of formal services and a reduction in informal caregiving ,20. Additionally, among the most frequently observed consequences in our study was a loss of respite care services. Furthermore, increased burdens on relatives/next-of-kin and fewer physical meetings with home services were frequently occurring consequences. A reduction in and the termination of home care and respite services were direct consequences of the municipalities’ efforts to reduce the spread of the SARS-CoV-2 virus. In turn, this had second-order consequences for both home-care recipients and informal carers. In their study, Vislapuu et al.  found siBy linking information about observed consequences and the actual level of contagion in the municipality where each nurse worked, we find that more adverse consequences for care recipients were observed in municipalities with higher levels of contagion. Only for three of the mapped consequences do we not find a systematic correlation with the actual level of contagion; these include needing more contact with the services than before the corona situation, ceasing to take medications because the medications are immunosuppressive, and having problems with access to medication. These findings indicate that scepticism towards taking immunosuppressive medication and access to medication are consequences stemming from national-level policies rather than consequences due to local restrictions and levels of contagion.Home-healthcare services were important services during the pandemic, both for the early recognition of COVID-19 cases and for the continuity of care and prevention ,30. The Our study was not designed to show in detail how the various municipalities responded to the crisis that the pandemic led to. However, we have shown that municipalities seem to have adapted their measures to the level of contagion they faced. Relating to the crisis-management literature, it is clear that the municipalities, as other governmental bodies, have been forced to compromise and make trade-offs in their approach to the COVID-19 pandemic. The “problem framing” of the pandemic —that is,An important factor in handling a crisis such as a pandemic at the municipal level is the existence of local pandemic-preparedness plans ,10. SuchResponding to the COVID-19 pandemic was not easy for authorities on any level; nor was it easy for the home-care service managers, given that there was a lack of evidence-based knowledge and much uncertainty regarding the efficacy of measures used to fight the pandemic. Overall, the main decision-making style and handling of the pandemic outbreak might be said to be based on a pragmatic collaborative approach combining argumentation and feedback, flexibility, and compromise . Such anAdverse consequences for adult home-healthcare service users in the first phase of the COVID-19 pandemic were observed by licenced nurses working in home-healthcare services. Most of the observed consequences for service recipients were correlated with the actual level of contagion in the municipality where the responding nurse worked. This indicates that the local authorities took measures to try to slow the spread of the virus and protect the health and safety of their citizens according to the local infection situation; therefore, more adverse consequences are observed in municipalities with high levels of contagion than in municipalities with lower levels of contagion.


Recently, there has been an increase in interest in the nocebo effect, with a subsequent rise in the number of publications on the subject .A survey of university students and staff showed that a stronger belief of being infected with COVID-19, and potentially over-reporting of symptoms was linked to conscientiousness and health anxiety . The responders were aware of the existence of the nocebo effect, and only 18.6% said that it was “rarely,” and 1.4% that it was “never” present in their practice. They recognized the importance of the treatment provider and reported that they actively try to minimize the nocebo effect by managing patients' negative expectations.The need for more extensive education on the subject of nocebo and its management was also emphasized in a survey of physiotherapists . Anxiety and fear learning after verbal suggestion are stronger in delusion-prone people .A series of experiments by Meeuwis et al.). Once generated, treatment-related expectations are difficult to modify and may persist—even when proven not to be supported by evidence .The effect between the verbal suggestions and the reported negative symptoms, e.g., itch, is mediated by expectations .A study in patients under general anesthesia undergoing a surgical procedure has shown that verbal suggestions given to sedated patients may reduce post-operative nausea and vomiting (There are two very positive aspects of this Research Topic that are worth highlighting. Firstly, the included articles demonstrated the ubiquitous and heterogeneous nature of nocebo—not just as a negative response to a placebo but also as adverse effects of treatment and common symptoms misattributed to treatment or disease. For example, the publications were concerned with the nocebo effects in various contexts: from experimental studies with an inert placebo, through side effects of treatment, to COVID-19 symptoms. These studies investigated the associations between nocebo effects and suggestions, expectations, health anxiety, personality factors, and racial/ethnic differences. Secondly, unlike most of the existing literature on the subject, which is dominated by reviews and opinion papers, most of the included studies were primary data-based articles. For example, two-thirds of the articles reported the results of experimental studies, including one, which used neuroimaging to explain further the mechanisms linking fear learning with the nocebo effect. There were also two surveys, one of the healthcare providers and one of the public. There is an urgent need for more good quality mechanistic research studies designed to investigate factors responsible for nocebo effects.post-hoc and secondary analyses of studies rather than primary analyses—emphasizing the lack of experimental studies in clinical populations specifically designed to investigate the nocebo effect as the primary outcome rather than as an afterthought. Secondly, many purposefully designed studies were often in healthy controls and attempted to generalize findings from healthy controls to clinical populations. Finally, there is a need for a standardized definition of the nocebo effect. Defining the nocebo effect in the context of placebo obscures the fact that it is a separate problem with far more serious consequences for clinical practice and research. Furthermore, referring to the same phenomenon by many different names hinders the development of a standard definition of nocebo and a consolidated analysis of the research on the subject.However, this Research Topic also reflects some of the problems with the existing research on the nocebo effects. Firstly, many of the experimental studies reported In summary, this Research Topic has demonstrated an increasing recognition of the complex nature of nocebo and the current gaps in both clinical practice and research.KW drafted the manuscript. KW, MA, and LC edited the manuscript and revised it for important intellectual content. All authors contributed to the article and approved the submitted version.


Objectives: This paper examines the gender gap in unhealthy life expectancy across education levels and age in Spain to understand the extent to which the gender paradox exists over education and across ages.Methods: Death registrations and vital status were taken from the Spanish Statistical Office, while the three health measures  from the 2019 European Health Interview Survey. We used Sullivan’s method to compute unhealthy life expectancy by education level. We computed the gender and the education ratios of the proportion of unhealthy life years in each health measure by education and age.Results: At almost all ages and all education levels, women significantly lived longer but in poorer health than men. Marked gender differences are seen across most age-groups, particularly among the low educated. We detected greater health inequalities by education level for women (confirming the gender paradox) and a health gradient due to aging and across the health measures charting the disablement process.Conclusion: The new education distribution might improve the unhealthy life expectancy and might reduce the gender gap in the number of years spent in poor health. Women’s life expectancy is higher than men’s at all ages in all countries of the world. Yet, while it is universally observed that male mortality exceeds that of females, studies examining gender differentials in morbidity generally find that women are in poorer health ; howeverThis work examines gender differences in UHLE based on diagnosed and self-reported health indicators by education level in Spain. Disparities in health measures by sex and education over the life course confirm the relevance of this approach.We consider education as a social determinant of health. In general, those with higher levels of education present longer life expectancies, lower mortality rates, and lower burdens of disease –10. TherSocioeconomic differences in mortality levels in Europe have historically been lowest in Spain , 17, yetOverall, our study aims to examine in depth female-male differences in UHLE by education status in Spain for middle-aged and older people. Interestingly, we used three health indicators that allow us to provide a more complete view of the appearance of several health outcomes while aging. This is of considerable relevance to the aging process and ties in closely with the study reported here as we also seek to highlight the need for a full understanding of health deterioration over the life-course by measures that generally follow on consecutively over the process. Thus, we studied the variation of the gender gap in health expectancy using three health measures and two levels of education in an effort to identify the main inequalities in the age-range considered.We drew on three data sources provided by the Spanish Statistical Office  for individuals aged 45+. First, mortality data come from the 2019 Spanish National Registry of deaths by sex, age group, and level of educational attainment. We chose to use the 2019 figures because it is the year previous to the COVID-19 pandemic [We used three health status indicators to compute gender differences in UHLE based on the EHIS questionnaire. The importance of studying these indicators is key for understanding the appearance and the duration in life of different health measures while aging. First, we used self-perceived health over the previous 12 months, the original question being: “How is your health in general? Is it very good, good, regular, bad or very bad?“. We grouped these five responses into two categories: good (very good and good) (coded as 0) and poor health  (coded as 1). Second, we analyzed the presence or absence of chronic conditions and risk factors. In line with Zueras and Renteria’s  study ofInternational Standard Classification of Education: First, “Low Education,” corresponding to those with compulsory education or lower, which includes the first stage of secondary education, primary credentials, as well as illiterate individuals ; and, second, “High Education,” corresponding to those with upper secondary, higher secondary credentials, vocational training, and university degrees at all levels, BA graduates, masters’ and PhDs (codes 5–9) (INE). To compute the life tables, we used data from EHIS to calculate the weighted proportion of the presence of the three morbidity health measures considered, within the two education levels and ten-year age groups, and for men and women separately.Here, education serves as our indicator of socioeconomic status on the grounds that, first, it is more likely to remain constant during an adult lifespan and is easily measured for all individuals, even the economically inactive; second, it has been relatively well reported in questionnaires and survey data; and, third, the likelihood of reverse causation between education and health at older ages is lower than that between income/occupation and health . We clasFirst, we estimated life expectancy by each level of education and gender for the year 2019. As our abridged life table terminates in a large group at ages 85+, we calculated life expectancy at age 45 by computing the average number of years lived over this age. We chose 45 as it is safe to assume that for the majority of the population their education level will not change and, moreover, the question concerning cognitive impairment was only put to individuals of this age and above. Death registries presented missing data on the level of education in 2% of the cases that were distributed proportionally by the education levels in each age group. When comparing our estimated life expectancy by level of education with the ones published by INE [We used Sullivan’s method to estimate Spanish UHLE , 23. ThiDescriptive findings are reported in Regarding gender gaps, women spend more years in bad health (UHLE) than men for all measures and educational levels through all age groups, and these differences are significant when comparing 95% confidence intervals . Regarding educational differences, those with low levels of education live more years in poor health. Both of these patterns apply at all ages with few exceptions at advanced ages 85+. On one hand, gender differences in UHLE at the oldest age group with higher education are not significantly different for all the health measures considered. On the other hand, UHLE differences between primary and secondary education are not significant at ages 85+ for chronic diseases among men and women, and for men with bad self-reported health.Our findings show the persistence of marked gender differences in health across most ages 45+ and among those with low educational attainment. In particular, we found (1) longer life for women at all ages and at all levels of education, but with longer periods subject to health problems compared to men; (2) greater health inequalities by education level for women (except for the years lived with cognitive impairment); and (3) a health gradient associated with aging as well as across the health measures. Thus, we can confirm the gender paradox for all health measures, both educational levels, and across all ages. Regardless of age, and for both levels of education, women spend a higher proportion of their lives with chronic morbidity, worse self-rated health and cognitive impairment. Our results are consistent with previous evidence from a comparative study including more than a dozen countries from Europe, Asia and America that confirmed that at present women live longer than men and have more disabling chronic conditions while men have more lethal conditions . HoweverThe socioeconomic differences observed here go in the expected direction. Those with low education levels spend more years in worse health than those with high education, a finding that holds across all ages. When comparing each health measure, the education ratios are lower when measuring the presence of chronic diseases. This might be attributable to the lower frequency of use of medical/health services by individuals with low education levels , 30, makHere, for the first time in Spain, we have estimated life expectancy with cognitive impairment , a growiOur most relevant contribution is the comparison of gender and educational ratios of UHLE for different health measures and age groups among adults aged 45-plus. In sensitivity analysis, we performed the same analysis for years spent with activity limitation, measured from the Global Activity Limitation Index (GALI), and results were very similar to those from the more general measure of self-rated health (results upon request). As we have seen, the selected health measures used here present a gradient by age which, despite the cross-sectional nature of our study, reflects the aging (disabilty) process —startingThree potential limitations that might affect our results should be mentioned. First, our study employs cross-sectional data and draws on different data sources. The latter leaves our results open to the possible risks associated with the distribution of deaths by level of education, which might be slightly different to the method used by INE , althougDespite these limitations, this study highlights the important role played by education in subjective well-being and complements previous findings reported for Spain . SpecifiTo conclude, our results support the argument that the changing distribution of education should improve the healthy life expectancy of the total population and reduce the gender gap in the number of years spent in poor health. However, while we await the arrival of more educated cohorts, reducing poor health for all, but especially women with primary or less education, should be a priority in contributing to active aging and delaying the disablement process. In line with our results, we recommend addressing age-specific prevalence of diseases by promoting effective health measures with a focus on their impact on the genders to enhance independent living for future generations of older men and women.


Thoroughbred horses have been bred exclusively for racing in England for a long time. Additionally, because horse racing is a global sport, a healthy leisure activity for ordinary citizens, and a high-value business, systematic racehorse breeding at the population level is a requirement for continuous industrial development. Therefore, we established genomic evaluation system (using prize money as horse racing traits) to produce spirited, agile, and strong racing horse populationWe used phenotypic data from 25,061 Thoroughbred horses  that competed in races between 1994 and 2019 at the Korea Racing Authority and constructed pedigree structures. We quantified the improvement in racehorse breeding output by year in Korea, and this aided in the establishment of a high-level horse-fill industry.We found that pedigree-based best linear unbiased prediction method improved the racing performance of the Thoroughbred population with high accuracy, making it possible to construct an excellent Thoroughbred racehorse population in Korea.This study could be used to develop an efficient breeding program at the population level for Korean Thoroughbred racehorse populations as well as others. In Korea, the domestic horse racing industry was gradually popularized under the leadership of the Korea Racing Authority (KRA) and grew into a large industry scaling billions of dollars with total prize money of approximately 188 million dollars, and average prize money per race was close to 100,000 dollars in 2018, according to the IFHA report. It is also recognized as a healthy leisure activity for ordinary citizens and an important resource for the Korean Government. In Korea, the domestic horse racing industry have been trying to secure global competitiveness in terms of quality and scale. In order to achieve this goal, it was important to build and maintain an excellent racehorse population. Therefore, the scientific goal of the Korea Racing Authority is to establish breeding system that can produce racehorses, which can compete internationally with excellent racing ability [Thoroughbred horses had been bred exclusively for racing in17th and 18thcentury England, when native mares were crossbred with imported Oriental stallions of Arabian, Barb, and Turkoman breeding [In this study, based on previous research that race ability is inherited, we tried to build genomic evaluation system that could select excellent individuals and utilizes them as genetic resources for the next generation . Traits In this study, we analyzed the genetic capacity of Thor oughbred racehorses and quantified the improvement in racehorse breeding output by year in Korea, which was the basis for a high-level horseracing industry and continues to be crucial for further development. To establish breeding system that can produce racehorses, which can compete internationally with excellent racing ability, we applied BLUP, which is a reliable model of the best fit to hundreds of thousands of observed race records. In this genomic evaluation, we used the adjusted prize money as a phenotype instead of the race records to measure the racing ability of each Thoroughbred. Our results indicated that this pedigree-based BLUP method improved racing performance in Thoroughbred populations with high accuracy, and the breeding system based on this evaluation method facilitated the selection and production of excellent stallions and racehorses in Korea. Additionally, this racehorse study contained diverse information related to Thoroughbred racehorses breeding at the population level .All racehorses registered under the KRA are accommodated and trained within the confines of KRA racing facilities. KRA is a quasi-market-type public corporation established for promoting horse racing and the development of horse livestock through efficient implementation of plans and fair distribution of horse racing resources. All animals were cared for according to the appropriate animal health and welfare guidelines approved by the Animal Care and Use Committee of the KRA, Korea. The phenotypic data of 25,061 Thoroughbred racehorses  born between 1994 and 2019 was sourced from the KRA and employed in this study. This Thoroughbred racehorse population was composed mostly of individuals aged 2 years and older, with an average inbreeding coefficient of 0.02. Pedigree structures and inbreeding coefficients were obtained using BLUPF90 software . The totAll the data used belonged to domestic races that took place on dirt tracks. There was diversity in the country of origin of the horses. Racing time, finishing rank, and prizes earned were recorded for all the racing . Before We performed traditional BLUP analysis with a pedigree-based relationship matrix to estimate breeding values using the entire race record data. The animals were then split into training and validation datasets according to the race start year, and phenotypes in the validation dataset were used to compute the accuracy of the predictions. For traditional pedigree-based genomic evaluations, the following single-trait and repeated-record animal models were fit:where Y is a vector of observations (log-transformed prize money index); X is the vector of fixed effects ; Z is the vector of random effects, which is an additive genetic effect following a normal distribution We evaluated the predictive ability of the BLUP for Thoroughbred racehorse performance using validation tests. For these tests, we split the racehorse records into training and validation datasets and created five validation datasets. Each validation dataset predicted the Thoroughbred racing performance for 2014 through 2019, respectively. The validation data included animals that started racing after the cut-off date, while the training dataset was composed of animals that started racing before the cut-off date. For example, in the validation dataset for 2014, the validation set included animals that started racing between January 1, 2015, and December 31, 2015, while the training set was composed of animals that started racing before January 1, 2015.When we performed genomic evaluation using the training dataset, we assumed that the phenotypes of animals in the validation set were unknown and only pedigree information was available. Based on the BLUP result, the accuracy of genomic prediction was evaluated by the correlation of the estimated breeding value (EBV) from the validation and the corresponding phenotypes (average of a racing prize index) divided by the square root of the heritability of the trait.Before the genomic evaluation of Thoroughbred racehorses, we estimated the genetic parameters for the racing prize money index of Thoroughbred, the jockey effect, the permanent environmental effect, and the genetic effect, and the errors found were 0.02, 0.17, 0.14, and 0.67 . Although the racing prize money trait’s heritability was small, this trait was an important phenotype for predicting Thoroughbred racing ability because the repeatability was 0.3118. Based on these parameters, the breeding value of Thoroughbred racehorses was estimated.In 25,061 Thoroughbred racehorses in Korea (from 1994 to 2019), there were 3,364 Thoroughbred sires and approximately 130 sires per year based on the racing start year of the progeny . More ThFor 25 years, KRA has applied a breeding program (mainly sire-centered improvement) consisting of selection and mating of Thoroughbred racehorse populations in Korea to improve race performance. A detailed description of the racehorse breeding program is shown in We showed the reliability of the prediction by calculating the accuracy of the Thoroughbred racehorse genomic evaluation. The accuracies of genomic evaluation per year (2014 through 2018) for the racing prize money index using pedigree-based BLUP are presented in For a long time, most sires of Thoroughbred populations in Korea were selected and used based only on the race records outside Korea or on pedigree information. If the environment of data generation is different from the actual racing environment, the breeding efficiency may be reduced regardless of how well the genetic ability analysis is performed. To overcome this limitation, KRA built a system that produces excellent thoroughbred sires using Korean race records in racehorse breeding programs for over 10 years. In this study, we evaluated sires selected from a retired Korean racehorse population, which had racing experience, based on race records in the Korean racecourse. We found that there were only 70 of 3,364 sires (1994 through 2019) in the Korean Thoroughbred population and their progeny started the race in Korea in 2007. We compared the EBV of these sires to the overall sire EBVs between 2007 and 2018 . From thIn this study, we performed the genomic evaluation of a Korean Thoroughbred population containing sires and racehorses based on race records between 1994 and 2019. For 26 years, there were 25,061 racehorses and 430,106 racing records in KRA. As the number of horse racecourses increased, the number of race records and racehorses increased after 2006 . Since the system in all racecourses was the same, we used racecourse information as a constant factor, and data from all racecourse were used in racehorse genomics evaluation. Although several previous studies have reported that using the individual best racing finish time is important for genomic evaluation ,19, it sFrom the genomic evaluation of the Korean Thoroughbred racehorse population, it was found that the average sire breeding value gradually and slightly increased from 1994 to 2019 . This meIt is crucial to evaluate and predict the racing performance of racehorses before the actual race, as well as to construct a good sire population for breeding programs. Therefore, we intended to show the reliability of the prediction by calculating the accuracy of the Thoroughbred genomics evaluation using five validation datasets. The average accuracy using pedigree-based BLUP in the last five years was 0.699 . HoweverOriginally, Thoroughbred racehorses were bred exclusively for racing in England, and because of the lack of opportunities to build up sufficient know-how and the limitation of group size, many countries around the world that held horse races did not have superior sire or racehorse production and advanced breeding systems. This is because establishing a sire or racehorse production and the breeding system is different from holding horse racing. Therefore, we selected sires from a foreign population to improve the racing performance of the Thoroughbred racehorse population in Korea for approximately 20 years. However, the racing environment is very diverse, and if the sires or racehorses have to be imported, the host has to rely on a race record from a different environment. Since traits for measuring racing performance may differ with the racing environment, breeding systems using imported sires or horses may be less efficient in population management. From a genetic point of view, sire selection is the most important decision by livestock breeder, as the level of a stallion determines the average ability of the next generation. Most of the genetic improvements in domestic animal populations, including horses, have been a direct result of sire selection, so it is very important to maintain an excellent and suitable sire. This is why KRA has been carrying out a strong breeding strategy centered on sires. Although the Korean population was not originally a horse racing population, KRA built a system that could produce sires based on large-scale Korean race record data and was able to select sires with better-than-average breeding value. However, since it was still only a small proportion, it was necessary to continuously select sires from the Korean Thoroughbred racehorse population and analyze the race patterns of their descendants.In this study, we could have collected enormous horse racing data from 1994 to recently and we thought that such near-perfect race and pedigree data of thoroughbred were very rare in the world. Nevertheless, there had been no systematic genomic evaluation for breeding program in Korea. So, we aimed to establish genomic evaluation system based on large-scale Korean racing records (using the prize money index as a novel phenotype) and performed this method for many years to test whether it was suitable to construct and improve the Thoroughbred racehorse population. Our results indicated that this evaluation method was judged to be very useful in measuring the racing characteristics of horses and suggested the possibility of producing superior sires selected from a retired Korean racehorse population. We hope that this study will be used to design and construct efficient breeding programs at the population level for Korean and other Thoroughbred racehorse populations. Additionally, we plan to study various methods  containing single nucleotide polymorphism data or using other phenotype or other genomic evaluation model contacting different effects) using large-scale genome data in the future starting from this study.


These four patterns showed significant differences in terms of the caloric and nutritional contents (p < 0.001). Energy sources in the identified patterns were primarily sugars (15.8–40%). No association was found between the anthropometric and metabolic parameters of children and the dietary patterns. No dietary pattern obtained from the school lunch could be considered as healthy, since all of them had high energy content, and a high percentage of the energy was from sugars from ultra-processed foods and beverages.The identification and characterization of dietary patterns are tools that are used to assess associations between diet and health or disease conditions. In Mexico, studies have examined dietary patterns in children for breakfast or for the whole day, but not specifically for their school lunch. The aim was to describe dietary patterns identified in school lunch and their association with the nutritional status and metabolic parameters of schoolchildren. In this cross-sectional study on schoolchildren from four elementary schools of Mexico City, we recorded anthropometry measurements, a fasting blood sample was collected, and metabolic parameters were determined. We obtained information on the foods and beverages that children brought for their school lunch; estimated the caloric and nutritional content; and created food groups to obtain dietary patterns from the energy provided by those groups. Among the 350 schoolchildren  included, 24.9% and 21.7% presented having overweight and obesity, respectively. A total of 89.4% of schoolchildren brought the school lunch from home. Using the K-means method, the following four dietary patterns were identified: (1) sandwiches,  Overweight and obesity are public health problems that affect children and adults worldwide. These conditions are risk factors for the development of metabolic disorders and chronic noncommunicable diseases from an early age . In MexiThe diet of the Mexican population, both in children and in adults, is characterized by low consumption of vegetables, fruits, and wholegrain cereals, and by high consumption of foods high in energy density from added sugars and saturated fats. This is based on the consumption of ultra-processed foods, which are mainly refined flours, sweetened dairy, and non-dairy beverages, among others. The 2018 ENSANUT survey showed that 76.1% of schoolchildren consume snacks and appetizers ; 85.7% of them consume sweetened non-dairy beverages; 44.3% consume fruit; and 43.2% consume legumes on a regular basis . These results are consistent with the information reported by other studies conducted in Mexico [The recommended percentage of energy that each meal should provide are 25% for breakfast, 30% for lunch, 15% for dinner, and two light meals  as this meal time has been considered as a collation ,9,10. Ho kcal as n Mexico ,50. In tn Mexico . Taking The dietary patterns from the school lunch identified in this study, show the intake of a high percentage of calories from sweetened foods as sweetened milk, sugar beverages, cereals, and cookies. The quality of those dietary patterns could be improved by omitting sweetened foods and reducing portion sizes of foods consumed. Because overweight and obesity represent health problems in Mexican schoolchildren, actions to prevent and control these problems are required; they should go beyond the individual level and involve the household environment, for example, implement community interventions that help children and parents to select and prepare food for school lunch in advance. It is necessary that the nutritional recommendations and guidelines given by health and education authorities be guided by knowledge of the population’s eating habits, so that the recommendations are culturally acceptable to enable a change in the quality of school lunch. Improved school food policies and appropriate, nutritionally adequate guidance for planning school lunch menus are needed. In addition, legislation on the quality of foods provided by the food industry is required. The limitation of this study is that the evaluation was of only one meal, which may or may not be representative of the consumption through the rest of the day, future studies are needed to evaluate the diet of one or more days of schoolchildren to know the energy distribution of each meal time. This information could be useful to give more culturally acceptable nutritional recommendations on the distribution of total energy from the different meals in this population. In addition, in this study foods bought from inside or outside the school were not taken into account; these foods could increase the energy consumption. Likewise, the children’s level of physical activity was not included; this information could explain the lack of association between anthropometric and biochemical data and the identified dietary patterns. No dietary pattern obtained from the school lunch that was brought from home was identified as healthy; all of them had a high energy content, with a higher percentage of energy from sugars, which came mostly from ultra-processed foods and drinks. Identifying, describing, and understanding dietary patterns that schoolchildren consume from the school lunch that comes from home acquires great relevance for implementing future strategies where nutritional guidance will be designed for parents and children so that they can make adequate choices and preparation of foods.


Breast cancer is a major public health concern in both developing and developed countries. The mortality rate of breast cancer is high in India due to late detection, and lack of knowledge about the screening mammography. The objective of this study was to develop and establish the psychometric properties of the tool.A qualitative method was used to carry out the development and validation of a tool to assess the knowledge, attitude, and perception of women towards screening mammography using a cross-sectional study design. Data analyzed using the SPSS 16 were descriptive, and Cronbach's alpha coefficient was used to standardize the tool.The pilot test, content validity, and internal consistency reliability of the final 25 items were found to be highly adequate. Intra- class correlations of this questionnaire were considered acceptable. Cronbach's alpha score was 0.825.A valid scale has been developed to evaluate the knowledge, attitude, and perception of women toward screening mammography. The scale is adequately responsive to test the knowledge and possesses strong internal consistency. Lack of knowledge among the general population about the screening mammography. It is recommended to conduct an educational program to enhance knowledge about screening mammography. The questionnaires can be used for evaluating the knowledge, attitude, and perception of women toward screening mammography. Broadening the concept for further questionnaires tool development of knowledge, attitude, and perception of women towards screening mammography in other geographical areas. Breast cancer is the most common cancer in females worldwide. During the year 2018, around 2.1 million women were newly diagnosed with breast cancer, i.e. about one in 4 of all new cancer cases among women, and the cancer is the most common in 154 of the 185 countries included in GLOBOCAN .In light of the increasing risk of breast cancer worldwide, understanding women's attitudes and perceptions regarding screening mammography is essential. Primary screening of women for breast cancer is the first step toward preventing the disease. Developed countries have recognized these many years back. With limited resources available in developing countries it's difficult to access breast cancer affecting women.Our study aimed to develop and validate a tool to access the knowledge, attitude, and perception of women towards screening mammography. Most of the previous studies were done to estimate the knowledge, attitude, and perception toward the screening mammography and breast cancer –12, howeDemographic data included age, level of education, and occupation of the participants. Questions about their knowledge, attitudes, and practices regarding breast cancer were also asked. In the present study, all the participants were employed irrespective of their educational qualifications. Working status determines participants' interest in healthcare needs by checking other factors we can assess the acceptance of medical services. The tool used for this study was a self-administrated, pre-tested, structured questionnaire validated by the experts. Whereas other similar studies have used either a standard questionnaire or conducted a structured interview for their studies. The study populations in the previous studies were women from rural and urban areas and one study done in morocco was conducted on general practitioners .This study primarily focuses on the general population in the rural and urban areas in the south coastal region. Phase I of our study was a qualitative analysis of data where a total of fifteen subjects were interviewed and recorded by audio tape to ensure a more data collecting process. In this study, most of the participants have less information about the risk factors, signs, and symptoms of breast cancer. Most of the participants identified breast self-examination and mammography as used for primary diagnosis of breast cancer. More than 50% of the women are not practicing self-breast examinations. Results showed that participants have less knowledge about breast cancer and screening methods. These results corresponded with a similar study done by Nitin Gangane et al  in a rurThe validated questionnaire was suitable for surveys of knowledge, attitude, and perception of screening mammography of women. A similar study conducted by Louise Linsell et al  in LondoWe recommend further study to conduct an educational program to enhance knowledge about screening mammography and these questionnaires can be used for evaluating the knowledge, attitude, and perception of women towards screening mammography. Broadening the concept for further questionnaires tool development of knowledge, attitude, and perception of women towards screening mammography in other geographical areas should also be done.Therefore, a valid scale had been developed to evaluate the knowledge, attitude, and perception of women toward screening mammography. The scale was adequately responsive to test the knowledge and possess strong internal consistency and we concluded that there was a lack of knowledge among the general population about the screening mammography, which may be one of the prime reasons for the higher mortality rate due to breast cancer in India.


By adopting game theory, this study analyses electricity carbon life cycle in leading EV countries. Results show that although the spread of EVs in Europe and the USA can mitigate carbon emissions, the production and use of electric vehicles in some countries, such as China and India, become a new source of such emissions. This reverse effect is due to the emission of greenhouse gases from electricity sources in these countries. Game theory also suggests that countries with unclean electricity sources should reconsider their plans to produce and use EVs. This study confirms that although carbon emission and global warming are global problems, regional and local policies can be substituted with a single comprehensive approach for an effective means of CO2 emission reduction.Universal environmental policies adopt strategies that enhance and encourage the production and usage of electric vehicles (EVs). Universal cooperation is evident in the framework of agreements or protocols so as to successfully lead countries towards the predetermined goals. The question is whether this trend can reduce global warming or CO The transition from petroleum as an energy source in the transportation sector and concerns over the climate change issues result in increasing numbers of electric vehicles (EVs) being included in many transport plans of governments around the world  programme. The ZEV programme is a set of regulations which push carmakers to sell EVs in California, Colorado, Connecticut, Maine, Maryland, Massachusetts, New Jersey, New York, Oregon, Rhode Island and Vermont , Financial Support Scheme for New Energy Vehicle Promotion 2016–2020, Double Quota Programme  has 130 g CO2e/km. However, a hybrid Toyota Corolla  has only 101 g CO2e/km  produces 157 g CO producesy Stuart  confirms2 emission per 1 kWh of generated electricity in Canada, Japan, Australia and South Africa are 220, 505, 752 and 949 g CO2/kWh, respectively  and plug-in hybrid electric vehicles (PHEVs) show that China, the USA and Norway are on the top of the list in 2019. China ranked first by selling more than 3,367,000 cars in 2019, whereas the USA sold 1,448,000 cars. Norway, as the top European country, sold more than 384,000 new cars which are more than those sold in Germany and France Irle .In 2008, China, as the most populated country, started providing various incentives, including subsidies, cash payments, no-license driving and tax exemptions  for common energy sources, including fossil or renewable energy sources.Sovacool  collecte2 emission per kWh of generated electricity, researchers need to have a primary energy use for electricity generation in selected countries and the total electricity usage for selected areas from secondary data then calculate produced CO2 based on primary electricity shares for each country or region.To find the average CO2 emitted from electric cars has decreased to 1922 in California, decreased to 972 in Idaho and decreased to 8106 pounds of CO2 equivalent  in the world, numbered N represent this world, so thatThere are Authors assume that each country is rational and targets to maximise its utility. The countries have common knowledge of the game and choose their strategies simultaneously. The strategies in this game structure refer to a matrix of two decisions – using resources (clean/unclean electricity sources) for producing EVs and using EVs.Let Let A country Let Let The electricity carbon life cycle utility function of each country isThe participation constraint of each country ensures that they are better off playing in the EV market. That is,Each country targets to maximise its electricity carbon life cycle utility by choosing strategy The Nash equilibrium for country The electricity carbon life cycle utility-maximising analysis indicates two behaviours. Firstly, all countries prefer the electricity sources that can offer the lowest total electricity cost in production and consumption of EVs. Secondly, the countries with comparative lower electricity cost  in EV production will reduce the total electricity cost of the countries with comparatively higher electricity cost in EV production. Alternatively, it indicates a possibility that the countries with unclean electricity sources have cost leadership in the EV market and become the large EV exporters.2 emission worldwide. In other words, social optimisation targets to minimise the total electricity cost of production and use EVs, subject to the condition that this EV market project can reduce global warming or CO2 emission worldwide. That is,2 emission function.The social optimisation  aims to maximise all countries’ utility and reduce CO2 emission target in this social optimisation problem, clean electricity sources are required in the production and consumption of EVs used by all the players in this game. The players (countries) are suggested to improve the capacity of generating electricity with clean sources, that is, to reduce To achieve the reduced COThe welfare-maximising mechanism finds that the individual utility-maximising behaviour deviates from social optimisation. Countries using unclean electricity sources with a lower total electricity generating cost may have cost leadership in the EV market and become the large exporters. Moving the Nash equilibrium to social optimisation, the authors suggest the universal agreement of minimising the number of countries using unclean electricity sources in the production and consumption of EVs. The purpose of this proposal is not to exempt or demotivate some countries engaged in the EV market. Instead, it encourages the countries to invest in infrastructures so as to improve the capacity of electricity generating using clean sources. Welfare maximisation can then be achieved dynamically.Considering that the electricity market is not based on production cost, if electricity is generated from renewable and clean sources, then it becomes more expensive than usual. People will naturally lose interest in EVs, considering that fossil fuel is a cheap energy resource. This condition holds true, given that having cheap clean energy in many countries remains impossible. In addition, the instabilities of oil prices and oil supply are other reasons countries are generally interested in accelerating the EV market. The instabilities in the Middle East and Ukraine make these countries be concerned about the future of the oil and gas market EFA . All uniChina, the USA and India are the top coal producers in the world , then we should encourage governors to develop EV usage; otherwise, the main policy should focus on decreasing electricity CO2 emission. For producing EVs in factory, countries must have low electricity emission because producing electric cars causes more pollution than producing other cars (approximately 600 g CO2/kWh). Considering electricity drop in grid connection can reduce this amount.Accordingly, if a country or state is generating electricity with an average pollution less than petrol or diesel (less than 700 g COThis study highlights the issues that the level of carbon dioxide production of electric cars is not limited to daily electricity consumption and that it is not the same in all part of the world. In the calculations and policies, extra produced carbon in EV production should be considered, too. After all, the goal of universal declarations and policies should be reducing the level of carbon dioxide and not increasing the production of electric cars. In this regard, paying attention to the resources of the generated electricity in each country and region can be the main discussion of any declaration’s draft.Nash equilibrium in game theory confirms a possibility that the countries using unclean electricity sources with a lower total electricity generating cost have cost leadership in the EV market and become the large exporters. The application of game theory in this study also shows that the significant EV producers and markets have incentives to use the electricity sources that can provide the lowest electricity cost in production.2/kWh, should prioritise the maintenance of energy sources rather than the production and development of EVs.Accordingly, in universal declarations, the priority must be given to primary electricity sources. Developing EV production with the current primary sources in China, India and some developing countries generates more pollution than current fossil cars. Although carbon emission and global warming are universal problems, the regional policies following by local approaches, in the case of EVs, can sometimes be more efficient than universal policies. This study proposes that the first target of universal declarations and agreements must aim for the infrastructure of each country instead of sectorial planning. That is, a country, which is still generating electricity with pollution higher than 550 g COIn answer to the question of this study; naturally, all countries in the world are interested in a better place to live in, and governments agree that a better environment can be realised by producing fewer pollutants. However, fluctuating oil prices owing to political tensions and economic competitions on the one hand and the high price of renewable energies on the other hand have made it very difficult for countries to entirely and suddenly stop consuming coal, which is too cheap for them. Moreover, many jobs and local economic growth and development in these countries continue to depend on coal mining. The non-production of environmental pollutants is not related to EV production but the change of economic infrastructure and generation of clean energy.2 is much higher than the given figures. Factors such as lack of wind or reduced sunny days in European countries also force some of these countries to use fossil fuels temporarily to address electricity shortages.A notable limitation of this study is the carbon emission data in power plants. Usually, these figures are an estimation based on energy usage and capacities in each country. By contrast, in the pick of electricity usage, the emitted COAnother limitation of this study is the lack of accurate statistics on carbon emissions during EV production. Despite the possibility of calculating this figure, owing to the highly competitive condition of the car production market, the exact carbon figures are not published by the manufacturers. The publishing of these statistics can be considered a negative point by manufacturers and can even disrupt the production of electric cars. Therefore, the statistics provided in this regard are not accurate statistics by automakers but a variety of estimates provided by researchers. In many cases, the material of the engine, body and battery are secrets of the manufacturers, which makes even the estimates impossible. In addition, the rapid change in the industry in terms of engine and body and the rapid evolution of batteries have made accessing accurate data on pollutants in the EV production challenging.Electric cars are one of the main components of reducing carbon emissions. The policies of international organisations to reduce emissions through the development of electric vehicles globally have shown their effectiveness in European countries. As the world’s largest economies with a significant share in the production of pollutants, China and India have written their plans and announced them to the world. These countries and even other developing countries only need time to invest in producing low-emission energy to join the fight to reduce carbon emissions and global warming. Countries must accelerate EV production with low-emission energy production to help the universal movement in this battle.Western countries, along with China and India, have started comprehensive and codified programmes for the development of EVs. However, the study indicates that some countries producing EVs have not yet reached the ideal limit for low-carbon electricity generation.The proposed regulation suggests countries not to be involved in the economic competition in the EV sector as they must prioritise electricity as the largest source of emissions. Otherwise, the current approach by universal declarations is shunting investments towards final production instead of investing in infrastructures, such as renewable energy or clean resources for power plants.2/kWh, should prioritise the maintenance of energy sources rather than the production and development of EVs.In some cases, developing EV production with the current primary sources in China, India and some developing countries generates more pollution than current fossil cars. Although carbon emission and global warming are universal problems, the regional policies following by local approaches, in the case of EVs, can sometimes be more efficient than universal policies. This study proposes that the first target of universal declarations and agreements must aim for the infrastructure of each country instead of sectorial planning. That is, a country, which is still generating electricity with pollution higher than 550 g CO


To evaluate changes in the retail food environment profile in a Brazilian metropolis over a 10-year period.An ecological study was conducted in the city of Belo Horizonte, Minas Gerais, Brazil. The addresses of formal food establishments were geocoded and classified according to their sold-food profile. Density changes were analysed according to neighbourhood, population size, income level and geospatial distribution.Totally, 468 neighbourhoods in the city of Belo Horizonte, Minas Gerais, Brazil.Totally, 83 752 formal food establishments registered for operation in any one or more of those years: 2008, 2011, 2015 and 2018.There was an increase in unhealthy establishments (154 %), followed by mixed (51 %) and healthy establishments (32 %), during the period evaluated, in addition to an increase in density according to income categories. There was a higher proportion of unhealthy establishments in relation to healthy establishments, indicating worsening of the community food environment over time.Over the course of 10 years, changes in the neighbourhood’s food environment were unfavourable for adequate access to healthy foods in lower-income neighbourhoods. The findings reinforce the need for interventions aimed at increasing the availability of businesses that offer healthy food in the city. Widely explored aspects of the food environment include the distribution, type and access to commercial food establishments as well as the price, quality and variety of available food–8.In recent years, researchers have become increasingly interested in investigating the influence of the food environment on health outcomes. Many have sought to elucidate the relationship between the food environment and obesity, chronic non-communicable diseases, dietary patterns and other health-related factors. In most countries, there has been a significant increase in the availability of foods, especially ultra-processed foods, which are often offered in larger portions and at low prices–10. The consumption of these foods is associated with several non-communicable diseases and overweight status–13.The environment in which individuals live has undergone numerous changes in recent years, highlighting those related to the nutritional transition, whose main features are reduced physical activity, changing aspects of eating and dietary patterns. Several studies have indicated that greater availability of supermarkets and establishments specialising in the sale of fruits and vegetables can contribute to the consumption of healthy foods–18. On the other hand, greater availability of snack bars, fast food and convenience stores facilitates access to food with lower nutritional quality, particularly ultra-processed foods–21.Among the various factors associated with food choices, the unequal availability of food outlets in different regions of cities is known to potentially influence the food consumption of individuals, particularly in socio-economically vulnerable neighbourhoods.When food stores close and are replaced by other establishments with the same marketing profile, residents are chronically exposed to certain types of food, whether healthy or not. On the other hand, variations that occur in the emergence of different types of food stores modify the characteristics of the food environment, which can promote changes in food consumption and, consequently, in the health of individuals,7,23. Understanding the dynamics of this environment can contribute to the formulation and implementation of health policies that reduce the inequalities that exist among communities over time, particularly in relation to access to and availability of food. Moreover, research on the community food environment is an important aspect of building healthier food environments.It is important to emphasise that the characteristics of the community food environment and the socio-economic context influence an individual’s diet as they constitute opportunities and/or barriers that impact the supply and consumption of healthy or unhealthy foods.In the Latin American context, most studies are focused on different dimensions of the food environment and their impacts on diet, obesity and chronic diseases. The main works analyse food retail/provision, but there is still a gap in knowledge about the longitudinal evaluation of this dimension–28, but to date, no study has focused on changes in the characteristics of this environment over time. Our objective was to assess the change in the retail food environment profile in a Brazilian metropolis over a 10-year period. The specific research questions were as follows: (1) Did the distribution of food stores in the city bring about changes in the profile of the food environment over the study period? (2) How does the profile of food stores differ by time period? (3) How are food establishments distributed throughout the city? And (4) Does the profile of food establishments differ by population density and neighbourhood income?In Brazil, some studies have assessed the retail food environment of different cities.This ecological study was carried out in the city of Belo Horizonte, Minas Gerais, using secondary data obtained from a government database. Belo Horizonte is the sixth largest city in Brazil and the eighth largest in Latin America, with an estimated population of 2 512 070 inhabitants and 486 neighbourhoods grouped into 9 administrative regions. The CNAE is an instrument to support the national standardisation of economic activity codes and classification criteria used by the various bodies of the Brazilian Tax Administration (IBGE) and organises establishments into different types according to their main activity .The database was developed using information on formal food establishments in Belo Horizonte registered to operate in any one or more of those years , for a total evaluation period covering 10 years. The analysed period and its time interval were determined considering the potential for evaluating the data over the period of a decade. The establishments’ addresses and main activity codes were collected according to the National Classification of Economic Activities (CNAE), which categorises foods into: (a) fresh and/or minimally processed foods; (b) culinary ingredients; (c) processed foods and (d) ultra-processed foods.Based on the evaluation of each establishment, they were classified into categories. The CNAE description was used to classify these establishments according to the main activity and the predominantly commercialised foods, considering the extent and purpose of food processing and its classification as proposed by NOVA. Based on this, food outlets were classified as healthy, mixed and unhealthy . Data were collected in the WGS 84 Geographical Coordinate System configuration and later transformed into the Projected Coordinate System, Universal Transverse Mercator System (UTM), spindle 23S, and datum SIRGAS 2000, using the QGis 2.14.4 software.The geographic coordinates (latitude and longitude) of the food outlets were obtained from the addresses registered with the CNAE using the Google Maps online search service  in addition to the population estimate by the year of study evaluation. The density of food outlets was also analysed according to the per capita income of the neighbourhoods, calculated as the total income of the neighbourhood divided by the number of residents in the neighbourhood. and from the website of the Brazilian Institute of Geography and Statistics (https://www.ibge.gov.br/pt/inicio.html).Precise and estimated data were extracted from the 2010 Demographic Census, three to assess relative density (proportion of establishments), three to assess density per population and one to assess the disadvantage of the availability of unhealthy establishments in relation to the availability of healthy establishments in the municipality , the average population per neighbourhood (Mean = 5000 residents) and the estimated population of the municipality per year of assessment as units of analysis. An average population of 5000 residents was adopted, as this is the approximate value of the average population per neighbourhood. The estimated average population was used to assess the density of establishments by neighbourhood.The analysis of the indicators for evaluating the food environment included the neighbourhoods (n 101). Density results are presented in the form of tables.The density of food outlets was also analysed according to the per capita income of the neighbourhoods, calculated as the total income of the neighborhood divided by the number of residents in the neighbourhood. The 10th and 90th percentiles were considered, corresponding to the lowest and highest income neighbourhoods, respectively , version 14.2.To characterise the food environment of the neighbourhood in the four periods analysed, bivariate analyses were performed, including frequency, mean and standard deviation. The variation in the number of food outlets among the analysed periods (absolute and percentage) and between the final (2018) and initial (2008) periods was quantified. Generalised linear models were used to analyse the trend in the number of food outlets. The level of significance was set at 2) during the analysed periods. Kernel analysis allows for the detection of clusters based on the distribution pattern of points, generating a density surface of the areas with the highest occurrence of an event. Spatial analyses were performed using the QGis 2.14.4 software.The analysis of the spatial distribution was performed using kernel maps for each category of establishments per area (kmP < 0·05) in the municipality, except for hypermarkets, for which there was a reduction (P < 0·001), and supermarkets (P = 0·738), grocery stores (P = 0·147), and butchers (P = 0·316), for which there was no significant variation. Convenience stores , bars , street vendors  and delivery services  showed the greatest variation  over the 10-year period. Mixed establishments, in turn, presented a percentage reduction over the same period from 33·2 % to 24·3 %; on the other hand, the number of establishments in this category grew over the years (4829 to 7305). The number of establishments that were considered unhealthy increased from 56·0 % in 2008 to 68·8 % in 2018, a variation of 154·3 % over the analysed period  to about 42 points per neighbourhood in 2018 (sd = 68·0)  Table .From 2008 to 2018, the average size of the population residing in the municipality increased slightly (3 %), while the density of food establishments continued to increase. In 2008, there were about 3 healthy establishments for every 5000 inhabitants per district in the municipality. In 2018, there were about four establishments for the same average population of residents. On the other hand, the density of unhealthy establishments more than doubled during the same period, going from about seventeen establishments to forty-one over a 10-year period, considering the same population average per neighbourhood.The analysis of the density ratio indicator suggests a disadvantage in the availability of healthy establishments in relation to the availability of unhealthy establishments in the municipality, with this difference accentuated over the years. In 2008, there were five unhealthy establishments for every one healthy establishment. In 2018, there were ten unhealthy establishments for every one healthy establishment.When analysing whether the density of commercial food establishments in the city differed between the neighbourhoods at the extremes of income level, it was observed that residents of neighbourhoods where the per capita income was less than $89·27  had no access to establishments that sold healthy foods, while residents of neighbourhoods where the per capita income was greater than $630·43  had access to approximately seven establishments in the same category. Similarly, in higher-income neighbourhoods, there was a greater density of establishments with mixed and unhealthy commercialisation patterns, illustrating the inequalities of access to commercial food establishments according to income , followed by mixed (51 %) and healthy foods (32 %), demonstrating that the retail food environment among formal commerce in Belo Horizonte’s food sector has changed significantly over the years, primarily in relation to the restricted availability of establishments that predominantly sell healthy foods.,34,35. It is noteworthy that Belo Horizonte is known as the ‘bar capital’, and these establishments are part of the city’s food culture, moving even the gastronomic tourism sector; this can influence and justify the growth of this type of trade.The results of the present study showed a trend towards a higher density of unhealthy food establishments. There was greater growth in these establishments between 2015 and 2018, with an increase of about 60 % in the number of establishments during this period. There was greater growth in bars (571 %), street vendors (1304 %) and food delivery (7089 %). In this study, delivery refers to places that provide ready-to-eat or frozen meals for consumption at home, such as pizzerias, snack bars and restaurants. In Brazil, part of this group of establishments is characterised by providing ultra-processed food quickly and at discounted prices, similar to fast-food outlets in other countries, where the increase in this category is also notable, the average number of unhealthy establishments in the census tracts increased from three in 1990 to about six in 2010, with an emphasis on the increase in grocery stores, convenience stores, fast-food restaurants and bakeries. The increase in the density of establishments also occurred with an increase in income and population density in the census tracts evaluated.The increasing density of unhealthy establishments found in this study is also consistent with surveys conducted in high-income countries. In a study carried out in New YorkSimilarly, the results of the present study indicate that the density of commercial food establishments in Belo Horizonte is related to population growth in the municipality, albeit disproportionately. The results show that, considering the same average population size in all periods, the density of unhealthy establishments more than doubled, with a greater availability of these foods being maintained. Over a period of 10 years, the population in Belo Horizonte grew by 2·7 %. The total number of food establishments grew by 107 %..In a similar, researchers from Melbourne, Australia, found that the density of food establishments grew at a greater and more advanced proportional rate than the residential population, particularly the density of those classified as unhealthy. As observed in Belo Horizonte, the proportion of unhealthy establishments in relation to healthy establishments was higher, indicating a retail food environment with unfavourable characteristics for healthy eatingThe results of the present study also indicate that, regardless of the per capita income range, the density of establishments that predominantly sell unhealthy foods is considerably higher than the density of establishments that sell healthy foods. In this sense, there is evidence of inequalities in relation to the availability of food in lower-income neighbourhoods, where residents have proportionally greater availability of establishments that sell unhealthy foods, with this difference being accentuated over the period analysed..Also considering the availability of establishments, the spatial analysis maps show a pattern of agglomeration of mixed and unhealthy establishments in the central area of the city. Another study conducted in the same location also observed a tendency for food establishments to cluster in this region, characterised by having greater purchasing power. These results indicate the importance of public policies that seek to promote food supply to prioritise the most vulnerable areas, where access and availability of food becomes more difficult, especially healthy ones. To date, no Brazilian or international study has analysed the density, type or proportion of food outlets in a Brazilian city over time. In addition, the use of spatial analysis resources associated with statistical analysis allowed us to assess changes in the food environment in a longitudinal way, providing a more comprehensive understanding of the availability of food in the assessed city. Moreover, by including several categories of establishments that sell food, as opposed to evaluating only large establishments, the present study provides information on the trend of food commercialisation, especially for places similar to the one studied.Thus far, few studies have sought to assess disparities in access linked to the food environment over time, especially in low- and middle-income countries,38. As noted, the density of these establishments in Belo Horizonte grew substantially over the 10-year period, which may favour the availability of unhealthy foods.Another differential is the analysis of establishments categorised as delivery. Currently, there is a dynamic relationship among the dimensions of the food environment through Internet access and exposure to a wide variety of foods. The main attraction for the use of delivery services and their applications is based on practicality and convenience, allowing you to purchase food without leaving home. However, these characteristics increase individuals’ exposure to marketing strategies that encourage the consumption of ultra-processed foods, which correspond to most foods offered by this type of service–18, as well as the current food system in which these foods are more widely produced and marketed. Given this, we believe that changes in the food supplied and also in the profile of these establishments may have occurred, but further studies are needed to confirm this hypothesis, especially those that seek to evaluate the consumer’s food environment, where other food characteristics such as quality, variety and price are analysed, and also of the digital food environment.Still on the increase of delivery establishments and due to the data used, we point out that it is not possible to evaluate the difference in the type of food offered over the period in this category, but it is important to consider the increasing availability of ultra-processed foods in various types of establishments and locationsThe main limitation of this study is the secondary data used in the evaluation. In some categories of establishments, such as street vendors, the variation in the absolute number between the years of assessment is not linear, with a considerable drop in 2015 compared to 2011 (from 534 to 11) and a subsequent increase in 2018 (to 1587). It is believed that this variation is due to the fact that existing establishments may not be registered and establishments that existed may have ended their activities without the regulatory bodies being aware, highlighting a possible effect of the economic crisis. Furthermore, with this type of data, it is not possible to assess the informal food trade, which is characteristic of low- and middle-income countries such as Brazil.This study provides evidence of the disproportionate growth in the sale of unhealthy foods relative to the sale of healthy foods in a Brazilian metropolis, generating changes in the profile of the food environment. Moreover, the distribution of categories of establishments across the city is not homogeneous, especially in low-income areas, which are more exposed to unhealthy foods. Understanding the food and environmental context in which individuals are inserted is relevant to the development of long-term processes that provide better food choices. From this perspective, public nutrition policies that aim to promote availability and access to places that offer healthy foods, such as subsidies for stores selling fruits and vegetables, are important for the promotion of healthier eating environments, particularly in neighbourhoods of lower socio-economic status.