With the aging of the population and rising rates of chronic diseases, older adults need support if they are to adopt healthy lifestyles. Web-based interventions should be considered for this purpose, since they are easily accessed and can foster healthy lifestyles among older adults. However, the literature on such interventions discusses a variety of components and effects and provides only 2 syntheses of knowledge on web-based interventions with older adults. These studies focus on populations aged 50 years and older, whereas the components and effects of interventions for a population of older adults  may differ. In addition, these 2 syntheses examined only quantitative studies, although other types of studies  are available and could help advance knowledge in this field. A scoping review is therefore relevant in order to explore the extent of the literature on this subject.The purpose of the study described by this protocol is to explore the extent of the literature  on the components and effects of web-based interventions as a way to promote healthy lifestyles among older adults.The databases MEDLINE, CINAHL, PsycInfo, Web of Science, Cochrane Database of Systematic Review and Joanna Briggs Library will be searched, in addition to the grey literature using Google Scholar and OpenGrey. Studies will be selected for the review by 2 researchers, working independently. The data will be synthesized based on the conceptualization of web-based interventions . A thematic analysis will be performed to summarize the components of the interventions studied.The database search will begin in August 2020 and be completed in October 2020.This scoping review should highlight web-based interventions designed to promote healthy lifestyles, as well as their components and effects, among people aged 65 years and older. These results could provide important guidance for intervention developers and designers in identifying the components of web-based interventions relevant to older adults and lead to further studies on this topic.PRR1-10.2196/23207 The number of older adults worldwide  is expected to almost double over the next 30 years, from 12% to 22% . HoweverMoreover, with advances in health technologies, web-based is increasingly the preferred method of intervention, even among older adults, for whom internet use has been growing rapidly in recent years . Web-basHowever, although the literature documents numerous web-based interventions, their components and effects are diverse, making it difficult to draw conclusions about which components lead to optimal change outcomes for this population. In this regard, Webb et al  developeWhile some authors have published syntheses of the literature focused on web-based interventions designed to promote lifestyle changes in adults ,13,14, tFinally, these 2 syntheses of the literature ,16 focusTherefore, the purpose of this article is to present the protocol for a scoping review that will explore the extent of the available literature on web-based interventions aimed at promoting healthy lifestyles among people aged 65 years and older.This protocol describes the methodology that will be used to conduct a scoping review and the steps that will be followed to ensure its rigor. A scoping review will be conducted based on the framework proposed by Levac et al . This frThe research questions were identified following a brief review of the initial literature and discussions with the research team, composed of a doctoral student, a researcher, a research professional, and a librarian. This scoping review will seek to answer the following questions: (1) What web-based interventions are aimed at promoting healthy lifestyles among people aged 65 years and older? (2) What are the components of these interventions ? and (3) What have been the effects of these interventions as reported in the literature?The following databases will be searched: MEDLINE, CINAHL, PsycInfo, Web of Science, Cochrane Database of Systematic Review, and Joanna Briggs Library. These databases were selected for their focus on the field of social and health sciences, which is related to the topic of this study. Grey literature will be searched using the Google Scholar and OpenGrey databases. The reference lists of the identified articles will be checked to ensure that all relevant articles have been included. The authors of primary studies will be contacted if additional information is required.aged, elderly), lifestyle , and web-based interventions . The search strategy, established with a librarian’s assistance, will use keywords and descriptors related to the concepts of older persons . An initial selection will be made by reading the abstract and title of the article, and then the selected articles will be read in full to retain only those related to the purpose of the study, addressing the research questions, and eligible based on the inclusion and exclusion criteria. In case of disagreement concerning a selection, a third researcher  will be consulted. As suggested by Levac et al , researcData that include authors, year and location of publication, purpose, type of study, population and sample, method, type of intervention and comparison, and intervention components and effects will be extracted to a table. As suggested by Levac et al , data frData will be collected, synthesized, and reported according to the conceptualization of web-based intervention components proposed by Webb et al  . The main purpose of this focus group will be to present the preliminary results to these stakeholders and gather their impressions and any new ideas as a way to enrich the results and guide recommendations for future studies.We plan to begin the database search in August 2020 and complete the scoping review in October 2020. Upon completion, recommendations will be provided to facilitate integration of web-based interventions into practice to support older adults in healthy lifestyle habits and on the direction of future studies.In this paper, we have presented the protocol for a scoping review based on 6 steps . The proFinally, this scoping review will highlight the various web-based interventions aimed at helping older adults adopt healthy lifestyles, as well as the components and effects on people aged 65 years and older. The protocol for this scoping review proposes a novelty—to gather, synthesize and report the data from the literature reviewed according to a conceptualization of web-based interventions proposed by Webb et al . The goaThe studies will be selected systematically and independently by 2 researchers , and the second author will be consulted in case of disagreement, thus ensuring the reliability of the results. The search strategy involves consulting a large number of databases (n=7) as well as grey literature using Google Scholar, OpenGrey, and a manual search of the references of the articles identified, which reduces the risk of articles being omitted. In addition, the study identification process, including inclusion and exclusion criteria, has been explained in detail to ensure reproducibility. The PRISMA checklist specifically for scoping reviews will be used, which will contribute to the transparency and quality of this study .Although this is not the main objective or a necessary step in a scoping review, the quality of the literature will not be assessed in this review, which may raise concerns about the rigor of the literature and affect the generalizability of the results. We will take this limitation into consideration in our analysis of the results and will still critically analyze the literature reviewed. Otherwise, data will be extracted by 2 researchers only for the first 5 articles, whereas independent 2-researcher extraction of data for the entire sample of literature could have enhanced the reliability of the data by avoiding any misinterpretation or omission of information by the authors. Finally, a language restriction  will be imposed, which could affect the exhaustiveness of the set of articles identified.The purpose of this scoping review will be to explore the extent of the literature on web-based interventions to promote healthy lifestyles among people aged 65 years and older. Given advancements in the use of technologies in the field of health, web-based may be a preferred method for delivering interventions because of its accessibility, especially for a population of older adults, among whom internet use has been growing rapidly in recent years. Given that web-based interventions have the potential to encourage the adoption of healthy lifestyles and thus promote health, it is relevant to examine the components and effects of these interventions among older adults, whom we know are greatly affected by chronic diseases. The results of this scoping review will inform health professionals and interventions developers about the relevant components and effects of web-based interventions in a population of older adults. Knowing this, we can use web-based interventions to promote healthy lifestyles in this population.


To describe the impact of research, beyond the limits of the academic environment, Altmetric, a new social and traditional media metric was proposed. The aims of this study were to analyze the online activity related to orthodontic research via Altmetric and to assess if a correlation exists among citations, Mendeley reader count, and the AAS (Altmetric Attention Score).The Dimensions App was searched for articles published in the orthodontic journals listed in the Journal Citation Reports (JCR) throughout the years 2014 to 2018. The articles with a positive AAS were collected and screened for data related to publication and authorship. The articles with an AAS higher than 5 were screened for research topic and study design. Citation counts were harvested from Web of Science (WOS) and Scopus.r = 0.1463 and r = 0.1508, p < .05). The correlation between citations count and Mendeley reader  was moderate.The best performing journals were Progress in Orthodontics and the European Journal of Orthodontics with a mean AAS per published item of 1.455 and 1.351, respectively and the most prevalent sources were Tweets and Facebook mentions. The most prevalent topic was Oral Health-Related Quality of Life (OHRQOL) and the study design was systematic reviews. The correlation between the AAS and the citations in both WOS and Scopus was poor (Few journals displayed a high level of web activity. Journals and editors should enhance online dissemination of the scientific outputs. The authors should report the impact of the findings to the general public in a convenient way to facilitate online dissemination but to avoid an opportunistic use of the research outputs. Despite the lack of correlation, a combination of the citation count and the AAS can give a more comprehensive assessment of research impact. Citations metrics as the impact factor or the h-factor, among others, have been extensively used as a measure of quality of the published research items. The assumption behind this approach is that citations are a direct and reliable indicator of the scientific impact of a paper or a journal in its scientific field . CitatioAltmetrics or “alternative metrics or alternative metric measures.” The term Altmetrics was first introduced by Priem et al.in 2010 [Over the last decade, the ways of information interchange among the research stakeholders experienced a major change. With the advent of the so-called Social Web, the scholars discovered many novel options to back-up a published item through the web or by means of social media . All of .in 2010 .Altmetrics are measuring how much and what kind of online attention an item is attracting on the web. Altmetrics can measure different types of online activity, such as how often an article has been accessed or downloaded (in form of pdf or HTLM file); uploaded ; discussed ; bookmarked ; cited ; or recommended .In the actual scenario, few Altmetrics aggregators are available. An Altmetric aggregator is an online platform that provides an updated overview of the online activity surrounding a published item. The most popular are PlumX and Altmetric.PlumX is a fee-based web tool from Plum Analytics, a company owned by the Elsevier editorial. PlumX provides five categories of metrics: usage, captures, mentions, social media, and citations. It includes online activities and environments associated with both scholars and laypeople. The analysis of the provided data enables discovery if a published item is being informally and formally discussed and shared in a public or an academic circle . Altmetric  is a web screening program that aggregates information from three main sources: social media such as Twitter, Facebook, Google+, Pinterest, and blogs; traditional media, both mainstream  and science specific , and online reference managers such as Mendeley and CiteULike. Altmetric calculates an Altmetric Attention Score (AAS) for an article based on its mentions in those sources using a specific algorithm . The higAltmetric has been adopted by publishers like Wiley and Sons, Springer, and Nature Publishing Group among others. Altmetric, in summary, tracks and analyses the online activity around research outputs, it is a profit service and it provides both a commercial API for customers with all of the application services and a free tool that allows retrieving the AAS and other basic Altmetric data . In the dentistry, oral surgery, and medicine. The impact factor of the journals and the quartile rank were registered.Firstly, a search was done on the inCites JCR database to identify which journals were included in the JCR during the 5-year period from 2014 to 2018 in the category of https://app.dimensions.ai/discover/publication) in the Dimensions database.The online activity on orthodontic research was monitored by a search performed by means of the Dimensions Free App , The Angle Orthodontist, The European Journal of Orthodontics (EJO), Orthodontics & Craniofacial Research (OCR), Korean Journal of Orthodontics (KJO), Journal of Orofacial Orthopedics/Fortschritte der Kieferorthopädie, Progress in Orthodontics, the Australian Orthodontic Journal, and Seminars in Orthodontics.The search was performed by means of the Dimension Free App applying the following filters: publication year (2018 or 2017 or 2016 or 2015 or 2014); source title .The search was performed during December 2019 and was limited in time from January 2014 to December 2018. The search retrieved a total of 4301 items that were ordered by Altmetrics Attention Score highest first option.The Dimension Free App automatically generated a .csv file displaying the AAS of the selected items. Once downloaded, the data were exported to an excel datasheet (Microsoft Office for Mac 2011 package format).Three researchers cross-checked the number of retrieved items with the one reported in PubMed and items such as letters, replies, obituaries, table of contents, and adverts were excluded from the final sample that accounted for 3789 published items.The same researchers screened simultaneously, but not independently, the items with a positive AAS (AAS ≥ 1) and extracted by consensus information regarding the following: (1) article title; (2) journal title; (3) DOI; (4) time interval since publication; (5) Altmetric Attention Score; (6) number of authors and affiliations; (7) type of the affiliation of the corresponding author, i.e., university or other; and (8) country/region of origin as defined by the authors´ institutional affiliations, i.e., USA, Canada, Italy, China.The different Altmetric data resources contributing to an individual article AAS were recorded after accessing Altmetric through the Dimensions search engine. Additionally, citation counts were harvested from the science citation index expanded from the WOS  and from Scopus (registered trademark of Elsevier BV).For the articles with an AAS higher than five, the following information was also recorded: (a) article subject, i.e., oral health-related quality of life, (OHRQOL), clear aligners, or others; (b) study type, i.e., systematic review, randomized controlled clinical trials (RCTs), or others.The study subject categorization was based on the categories proposed by other bibliometric studies published in the field of orthodontics . If the r) < 0.3 was interpreted as poor, 0.3–0.5 as low, 0.5–0.7 as moderate, 0.7–0.9 as high, and > 0.9 as very high. p < 0.05 was considered statistically significant. All statistical analyses were conducted using IBM SPSS Statistics software version 25 .Descriptive statistics using counts and proportions were used to describe the articles and the journals included in the study. The Pearson’s correlation analysis was used to explore the relationship among citation counts for individual articles, the article AAS, and the total citation count in the analyzed databases. Pearson´s correlation coefficient . The correlation was poor also with Mendeley reader count . The correlation was high between WOS and Scopus citations  and was moderate among those citations database and Mendeley .When the items are stratified by topic Table , the higDespite the availability of two web tools, such as PlumX and Altmetric, we decided to use the latter for our investigation. Firstly, because despite Altmetric being a pay-per-use service, the Altmetric data are freely available through the Dimensions Free App, while PlumX data cannot be accessed freely. Moreover, most of the Altmetrics studied in medicine and dentistry relied on Altmetric data allowing a better discussion and analysis of the results. According to many authors , 16, AltTo our best knowledge, this is the second study to report on Altmetric in Orthodontics. Livas and Delli in 2017 analyzed the 200 articles in the Orthodontic literature which received the highest AAS . We did Progress in orthodontic, the journal that displays the better behavior in terms of AAS, offers Altmetric data of every published article but have not embedded the Altmetric badge to its website, while the EJO and OCR have already included the Altmetric badge to their articles and websites. Ortega in 2017 in an investigation about Twitter accounts and AAS, suggested that the presence and the activity of a journal or of the journal editor on social media is a key factor in contributing to the social dissemination of the journal production . In our data, Twitter activity represents the most frequent Altmetric data resource in all of the journals, while Facebook was the second one Table . The gloSince the AAS is mainly derived by Twitter and Facebook posts, there is a major concern about data manipulation that can be considered fairly easier than the one involving the classical citation counts. Social media is easily accessible, and in the web, it is operating many spam companies by selling votes or tweets from registered users. Altmetric claims to use a specific algorithm to limit the effect of such misconducts by tracking down artificial patterns of attention or detecting social media automation tools . The very low number of patents in the studied period could indicate a sort of disconnection between orthodontic research and the industry in contrast to the findings in periodontics, endodontics, and implant dentistry , 18, 23.We decided to limit the topic and study design analysis to the items with an AAS higher than five according to what suggested by Kolahi  in orderWhen the published items were stratified by study subject Table , OHRQOL The second article for AAS score in our sample was an article on erosion, one of the trending topics highlighted previously in paediatric dentistry .The highest AAS were reached by articles related to news outlets, which have a higher relative weight in the overall score calculation. The article of Lobre et al. was mentioned in 25 articles in online and traditional press that focused on the ability of Acceledent® to decrease the discomfort related to the orthodontic therapy . Also acThere can be therefore several factors behind a high AAS. In some cases, the article focuses on a subject that is appealing to the general public and can attract the media’s attention. In other cases, the topic can be sensitive for academics, patients, or laypersons involved or interested in a specific treatment or pathology and is disseminated in social media. Both social and classic media focus on laypeople, with a limited knowledge of medical topics, and different interests and sensitivity from the academic users that are the usual target of traditional metrics. Altmetric results interpretation must be done carefully due to the early stage of this metric.The online activity of research can provide a different, broader, and updated picture of an article’s impact. Altmetric data seem to be able to measure the broader impact of research, including the social impact, which in this case is the social improvements obtained from the transference of research results, and according to some authors can therefore play a major role in its assessment . Delivering access to orthodontic research to the general public can increase the social impact of our discipline and make the public aware of the benefits of the treatment on the global wellbeing and quality of life of an individual as well as the negative effects of a do-it-yourself approach that represent a present and a future threat of our profession. Due to the tremendous potential of dissemination at a global level of social media, it is pivotal to ensure that any knowledge transfer and public engagement is based on scientific rigor in order to maintain the credibility of our profession.The stratification of data by study design Table  displaysBoth systematic reviews and RCTs rest at the top of the evidence pyramid. It is indeed surprising how these high-quality articles are rarely used for evidence-based policy making as highlighted in the Altmetric data break-down. On the contrary, many studies performed only on citations count report that the most cited items are expert opinions and case-series with a low level of evidence . Altmetrr = 0,09; p = 42), while the correlation in WOS was not assessed by these authors [In our sample, the correlation between the citation count in the WOS and Scopus with the AAS was poor along the studied period. This result is in agreement with other authors in different fields of dentistry, who observed no correlation between the AAS and the citations count in Scopus or WOS , 19, 23. authors . In othe authors . FurtherFinally, we found a moderate correlation between Mendeley readers count and citations in our sample, both in WOS and Scopus. Our findings are in agreement with the ones of other authors , 30, 31.Our study presents some limitations in the literature search since we only analyzed the articles published in the orthodontic journals listed in the JCR and we did not include all those publications related to orthodontics which were published in non-specialty journals and those publications published in specialty journals not listed in the JCR such as the Journal of Orthodontics or the Journal of Clinical Orthodontics. The inclusion of these journals could have provided a broader insight into the impact of this new metric in the orthodontic field. The orthodontic specialty journals are more prone to publish highly focused and specialized papers, for example, comparison of two different cements and loss of strength of elastomers over time,, which are relevant for orthodontic clinicians and researchers, but may not be interesting for the general public and therefore disseminated via social media. Non-specialty journals, such as dental journals, may include articles of broader interest to the public, as they are not geared specifically toward orthodontists. The methodology of our search may therefore underestimate the online attention of orthodontic research. As a future development, we could consider if a study involving non orthodontic journal leads to different conclusions. Moreover, the correlation of the citation count in the WOS and Scopus was only performed on the article with a positive AAS and was not expanded to all the other articles. This aspect will need further investigation.Within the limitations of the present study, online attention to orthodontic research can be improved. Progress in Orthodontics and the European Journal of Orthodontics displayed the highest level of web activity. OHRQL studies appear to have significantly higher visibility on social and traditional media. Altmetric combined with traditional metrics could get a broader insight into research effects. No correlation exists between the citation count in WOS and Scopus and the AAS, while the Mendeley user count has a moderate correlation with citations. In order to facilitate the dissemination of the research output in non-scholar audiences, journal-related social media accounts should be implemented. When reporting the conclusions of their research, the authors should report not only the practical or clinical implications but also the impact of the findings on the general public in an easy to understand way, pointing out the limitations of the results in order to avoid an opportunistic use of the research outputs.


We provide a new protocol to connect how findings from field research on the local health care setting in resource-limited regions can inform researchers that are working toward developing a new point-of-care diagnostic test for neglected tropical diseases. A concept target product profile is an effective new tool that can aid researchers to develop a technology to match specific health care context more quickly than a conventional target product profile.The role of local volunteers and community health care workers is critically important for access to diagnostics in resource-limited settings.A noninvasive test-of-cure and a screening and confirmation test will significantly improve management of visceral leishmaniasis in endemic regions.Early during the research and development stage, researchers should consider who will administer the test  and for what purpose.Program managers should consider that the training level of staff and volunteers and the availability of the resources are the critical determinants for the use of a diagnostic test.  The rapid growth of point-of-care (POC) diagnostic tests necessitates a clear vision of when, where, and why a new POC diagnostic test needs to be developed and how it can be used in a way that matches a local health care context. Here, we present an innovative approach toward developing a concept target product profile (CTPP), which is a new mapping tool that helps researchers match a new diagnostic test to a specific local health care context early in the research and development process. As a case study, we focus on the diagnosis of visceral leishmaniasis (VL) in rural resource-limited regions of Kenya and Uganda. Our stepwise approach integrates elements of design thinking and uses a combination of literature reviews and field research for a context analysis of local health care systems and practices. We then use visual thinking in the form of Gigamaps and patient journeys to identify use case scenarios and to present our findings from the field research to key stakeholders. The use case scenarios describe the diagnostic scope of a new POC test based on the feasibility of the new test, the local need, and the contextual fit. For our case study of VL, we identify 2 valuable use case scenarios, namely test-of-cure and screening and confirmation, and we formulate a CTPP. We anticipate that a CTPP will enable researchers to match a new POC diagnostic test during the research and development process to the local health care context in which it will be used. Within the past decade, point-of-care (POC) diagnostic tests have received immense attention,It is crucial to ensure that new POC diagnostic tests meet the needs of the (multiple) end users and fit constraints within local health care contexts.affordable, sensitive, specific, user-friendly, rapid and robust, equipment-free, and deliverable to end users) to guide the development of new medical technologies and to encourage the adaptation of existing technologies to suit resource-limited settings better. However, the ASSURED criteria are rather general and broadly applicable.,Multiple guidelines are available that can be used to jointly guide the design of new POC diagnostic tests that address the needs of the end users and stakeholders in a local health care context. WHO developed the ASSURED criteria  as an intermediate guideline for developing a diagnostic test that addresses the needs of the end users in the local health care context. A CTPP does not replace a TPP, and it best serves as an intermediate guideline for researchers in the form of a mapping tool. Such a CTPP should preferably be developed at the onset of the research and development (R&D) of a new POC diagnostic test, aiding researchers in considering the context at an early stage while the POC diagnostic test is designed and developed. A CTPP would enable researchers to identify the minimum features for successful implementation of a POC diagnostic test in a local health care context, and it will cost considerably less time and resources than the development of a TPP. To illustrate, a recent TPP for dermal leishmaniases took approximately 4 years and 82 experts to reach a consensus,A concept target product profile best serves as an intermediate mapping tool for researchers to use to develop a diagnostic test that addresses the needs of end users in local health care contexts.For the development of a CTTP, we adopted a stepwise approach, using design-thinking principles . Design BOX.Design-Thinking PrinciplesDesign thinking refers to a strategic process in which design concepts are developed  before final product development. It is essentially an iterative method for problem solving. The use of design thinking encompasses the innovation of new products within social and business contexts. In this way, designers actively seek to understand the user and their experience before they try to solve the problem and move into the product development process. Therefore, design thinking involves methods such as context analysis, problem framing, creating thinking, prototyping, testing, and (re)evaluating.Core principles of design thinking are to empathize, define, ideate, prototype, and test. Design thinking aims to create a solution that is desirable (for the end user and stakeholders),  feasible, and  viable. Within the broad context of design thinking, tools such as visual thinking can be used to facilitate the design-thinking process. Visual thinking allows people from diverse backgrounds to share insights, synthesize existing information, and formulate superior ideas. Visual thinking tools enable designers to convey complex ideas to the stakeholders in a logical manner. To summarize, design thinking is an unconventional toolbox that within its visual thinking framework can facilitate the communication of complex problems and thereby aid in inventing/devising novel solutions to complex problems.–,In our case, the design-thinking principles were used to evaluate current diagnostic practices for a disease, identify the diagnostic need for a disease, and provide a diagnostic solution. The approach started with a comprehensive literature survey, followed by observations and semistructured interviews with the health care providers in the field and scientific researchers. In this step, the design principle empathize was integrated to gain an empathetic understanding of the problem at hand. Thereafter, the design-thinking principle define was utilized to combine the information gathered and identify the problem at hand. This step used a set of design tools known as “visual thinking.”The above methodology is expected to be broadly applicable in the field of diagnostics for use in endemic resource-limited settings, since context analysis is always essential to guide the design process during R&D. Developing a CTPP requires the following seven steps.A CTPP is expected to be broadly applicable for diagnostics in endemic resource-limited settings.A critical review of the existing literature on a disease and its relevant health care context is performed to gauge the disease endemicity, resource availability, and current diagnostic practices in the resource-constrained settings. Such critical analyses help in identifying the potential and the limitations of the existing diagnostic practices and in identifying stakeholders such as patients, health care staff, patient families, health care organizations, nongovernmental organizations, and government bodies, and thereby highlight the implementation needs for novel diagnostic solutions.Beyond mere literature study, it is important to direct field research for a case study. Selection criteria for a fitting case should include (i) an endemic region that bears a high burden of a disease; (ii) an area that has an urgent need for POC diagnostic tests; and (iii) a politically stable conflict-free zone for safety and logistic capacity (roads and access to remote endemic areas) for field research.Despite an extensive literature survey, many aspects of diagnoses in remote endemic regions often remain unclear, such as the clinical algorithm for disease identification, the patient’s journey from becoming infected to getting treatment, the availability of laboratory equipment, and the level of trained personnel at the lowest most constrained level of the health care system. To obtain observations from the field for filling the knowledge gaps in the literature, a field trip to the selected endemic regions was necessary. The objective of such a field trip is to gather direct observations at various health care levels in that region and to carry out semistructured interviews in the field to obtain expert input from key stakeholders as identified from the literature survey and from advice of the locals.To get a deeper understanding of the diagnostic practices for a disease, the assumptions made by the detailed literature survey (step 1) are analyzed in conjunction with the information that was obtained from semistructured interviews with the health care professionals (step 3). The observations are processed and organized to highlight the limitations of existing diagnostic practices. Since the health care context of a disease in resource-limited settings is complex with social and technical challenges and involves a wide range of stakeholders, understanding the corresponding diagnostic practices for a disease can be quite challenging. To deal with the complexity of such a multifaceted health care system, visual thinking tools are used to present the complex diagnostic problem at hand (define) and to identify the logical solution (ideate) in the form of use case scenarios. Visual Gigamaps are created to outline current diagnostic practices at various stages of the disease, and health care-seeking behaviors of patients from a health care provider’s point of view across different health care levels. Next, visual patient journeys are constructed within the selected disease endemic region. In our approach, these extended patient journeys represent a sequence of interactions between the patient, the health care system, and the stakeholders involved, and they consider both the technical, economic, and social factors.Next, we create various scenarios for the application of a diagnostic test within the selected region. Again, visual thinking is utilized to present every scenario to provide a clear understanding of the requisite diagnostic need and to suggest logical solutions.Visualizations of the scenarios from step 5 are used to facilitate discussions with different stakeholders with an objective to critically select and thus validate the most valuable scenario through which a diagnostic test can meet the local needs of the end users and stakeholders. Thus, detailed discussions are conducted with the stakeholders on each scenario to obtain the most pressing diagnostic need and to define the priorities from the perspective of health care providers.Finally, the stepwise approach collectively leads to the formulation of a CTPP for a diagnostic test that will be most effective for the selected disease-endemic region. The CTPP is formulated for the most urgent diagnostic need as viewed from the perspective of health care providers.For proof of principle, we selected the NTD visceral leishmaniasis (VL) as a case study to validate our CTPP design approach. Below we explicate the above 7 steps for this case study.Leishmania species, which are parasites that can be transmitted to humans and other animals by the bite of infected female phlebotomine sand flies.,,,,Leishmaniases are caused by more than 20 different VL is curable but remains a fatal disease because it is often left untreated, especially at early stages in low-resource settings.,,,,VL is currently diagnosed by using either one or a combination of the following: (1) empirical clinical observations,,,Leishmaniases remain endemic in more than 98 countries with the majority of VL cases in South Asia , South America (Brazil), and the horn of Africa  .31,38 SeConsidering the global spread of VL, our first challenge was to select a VL endemic region that was conducive for field research. Based on our selection criteria (see Methodology), we selected western Kenya and northeastern Uganda for our field research.During our field trip to western Kenya and northeastern Uganda, we visited several Pokot tribal communities, health care facilities, and local organizations over 2 weeks in November 2018 . Our intIn Kenya, VL testing and treatment can be accessed at the local health care facilities that are located in the Rift Valley region: the Kimalel health center and a newly constructed treatment facility at the Chemolingot subcounty hospital (both within the Baringo County), and the Kacheliba health center (within the West Pokot County). In Uganda, the Amudat hospital is the only VL treatment facility. VL testing can be accessed in Rupa subcounty and by a mobile CHW in the surrounding regions, and patients are referred to the Amudat hospital for further testing and treatment.A Gigamap of the health care system in western Kenya and northeastern Uganda was created based on the literature as well as on the insights obtained in the field. Seven phases were identified , from exSupplement. Possible factors and barriers encountered during the patient journeys were identified. Several factors determined the progress of a patient through these different phases resulting in the least efficient (story II) and the most efficient (story VIII) journey from infection to the treatment.Next, we created patient journeys . We relaAn important observation during our study was the key role of the CHV/CHW as the closest link to the people in rural communities. In Kenya, CHVs and CHWs are trained on a variety of health issues including case definition, prevention, and control of common ailments, as well as nutrition and family planning. They facilitate access to health services through advocacy, outreach, referral, community education, informal mentoring, and social support.In contrast, due to limited clinical trials and a subsequent lack of funding, we observed that CHVs in Kenya are involved in identification of patients and referring them to local health care facilities. CHVs are well-respected members of the communities, such as teachers and ministers, and are trusted by the locals. Furthermore, due to language barriers between the locals and researchers from abroad, CHWs and CHVs played a key role in most interactions with the locals, patients, and health professionals.The distance to a health care facility for diagnoses , phase 4The distance to a health care facility for diagnoses and treatment is the most significant barrier that patients face when seeking health care.Overlapping symptoms with other febrile illnesses often lead to misdiagnoses based on empirical clinical observations (signs and symptoms)  for diagnoses and treatment. Finally, the cost of traveling to a health care facility is a significant barrier, particularly when patients are asymptomatic and/or are simply not convinced that they are sick due to a lack of awareness. In general, a lack of financial resources contributes to poor health-seeking behavior , phase 2A significant lack of resources is apparent for the diagnosis and treatment of VL, particularly in terms of health care personnel, diagnostic testing, and financial resources.We learned that many VL patients know that they are sick , phase 2We observed that in general, VL patients also seek care from a traditional healer before considering visiting a health care facility because traditional healers are trusted, located closer to the homesteads, and often alleviate some of the initial symptoms. These deferrals worsen the patient’s health, thereby making the treatment more difficult. Unfortunately, critically ill patients often do not respond to the VL treatment, resulting in death. Such cases further strengthen the traditional beliefs and set a negative impression of health care facilities in the minds of health care seekers. Due to financial constraints and the cultural beliefs of the local population,We observed a traditional patriarchal society, in which males leave the homesteads for work, and females take care of the homes and the children. For males, the loss of income due to the time that is spent traveling to seek health care contributes to poor health-seeking behavior , phase 2Given all these factors, the total number of steps a patient takes to seek treatment can vary significantly. For example, seeking care in phase 3 requires many steps in complicated patient journeys, such as for patient stories I and II . This maPrompted by our extensive methodology, whereby we mapped the health care system in a specific endemic region and analyzed patient journeys, we sketched 6 use case scenarios based on the scope of application of a new POC diagnostic test . These dThe aforementioned 6 scenarios were discussed with experts in the field, including a Kenyan public health officer and VL specialists at Médecins Sans Frontières, to identify the most urgent need based on the perspective of health care providers. Thereafter, we chose a researcher-centric approach to obtain a context-specific diagnostic need that would facilitate researchers to outline the technological requirements of a new POC test. Interestingly, 2 scenarios—screening and confirmation and a test-of-cure—were consistently identified as a priority for developing a CTPP, and we did not obtain any discrepancies in the opinions of the experts. The selection of these 2 scenarios was based on the following criteria: how well the scenario represents a diagnostic setting in the current health care context of VL; how well the scenario meets a local need in terms of VL case management; and how feasible it would be to implement a new POC test in the scenario.Interestingly, 2 scenarios—screening and confirmation and a test-of-cure—were consistently identified as a priority for developing a CTPP.The first scenario selected, “screening and confirmation,” is beneficial for a number of reasons. Given the poor performance of the serological rK39 RDT in east African countries, a more specific and more sensitive POC diagnostic test that can be implemented by end users with minimal training at the lowest level of the health care system is clearly required. Furthermore, it is crucial to consider the end user(s) of a POC diagnostic test because the level of training and availability of resources will influence the diagnostic setting. Thus, a simple, noninvasive, yet effective VL POC diagnostic test that can be used for initial screening and confirmation (scenario 1) would significantly improve VL case management because it would replace the rK39 RDT for initial screening and invasive splenic aspirations for confirmation. The added value of an effective screening and confirmation test is that patients could be screened more reliably at the lowest level of the health care system, for example, by a CHV/CHW who is closer to the homesteads, which would prevent patients from traveling unnecessarily to regional health care facilities.The second scenario, “test-of-cure,” is useful because it would replace cumbersome procedures  that are currently used for test-of-cure. Serological tests cannot serve as test-of-cure owing to persisting antibodies after VL treatment. Thus, a POC diagnostic test that can serve as a test-of-cure (scenario 2) would significantly improve VL case management by replacing invasively obtained splenic aspirations. The added value of a test-of-cure is that relapse of the disease, which occurs in approximately 10% of VL patients, could be detected at an early stage after treatment. Therefore, the test-of-cure scenario fills a critical gap in VL case management.Scenarios 3 to 6 were excluded from further development of a CTPP. A screening day, as depicted in scenario 3, would be challenging to implement because one cannot ethically test everyone in a community, especially not asymptomatic patients, while symptomatic patients are covered in scenario 1. Additionally, it is difficult to get people to travel to a central location for a screening day because financial constraints or daily routines of herding cattle or taking care of the homesteads often restrict travel. Community testing, as depicted in scenario 4, is dependent on a multiplexed POC test that tests for multiple diseases simultaneously. Multiplexed tests are often more expensive and very few, if any, have been routinely used in the field.Similarly, integration with the malaria journey, as depicted in scenario 5, is also dependent on a multiplexed POC test for VL and malaria. A well-known multiplex test from DIAMED for VL and malaria is relatively expensive and not routinely used in Kenya and Uganda. By contrast, malaria RDTs are affordable and are routinely used in the field. A follow-up test, as depicted in scenario 6, would be challenging to implement due to the nomadic nature of the inhabitants that we encountered.A unidirectional problem-solving approach, instead of an interactive design-thinking approach that requires multiple iterations, would have yielded possibly 1 or 2 predictable scenarios instead of the detailed thorough 8 scenarios that were obtained in this study. Thus, after multiple iterations with a Kenyan public health officer and Médecins Sans Frontières, we concluded that scenarios 1 and 2, a test for screening and confirmation and a test-of-cure, are pivotal for VL management as they meet the local need and are feasible to implement. Furthermore, the CTPP developed for the 2 selected scenarios could be broadly applicable to the other 4 scenarios.The CTPP developed for screening and confirmation and a test-of-cure could be broadly applicable to other scenarios.Within each of these 2 selected scenarios, we identified variables that clarify how the diagnostic setting influences the features of the diagnostic test.A CTPP such as formulated in The approach presented here led to the development of a CTPP wherein the essential features of a POC diagnostic test for VL in Kenya and Uganda were quickly identified.The global diagnostic need for NTDs demands innovative solutions that are customized to the local health care context. To develop a technology that can be implemented in the relevant context, researchers must get access to a comprehensive, yet easily accessible overview of the status quo to understand the challenges and limitations of the existing health care system. Despite extensive literature reviews on VL diagnostics, treatment, and management, an evident knowledge gap persists, which prompted us to conduct field research in VL endemic regions and develop the notion of a CTPP.Although it is imperative to conduct a comprehensive context analysis before and during R&D of the technology, this is often done only at a much later stage by specialized teams, which may not include scientific researchers. The present study was conducted by scientific researchers who are developing a POC diagnostic test in collaboration with industrial-design experts to define scientifically feasible innovative solutions for VL diagnosis in a resource-limited setting. In contrast to a TPP that comprises a much larger group of experts such as social scientists and policymakers, a CTPP can be formulated effectively in a fast manner with a team that includes technical researchers, health care experts, and industrial designers.Initially, it appeared challenging to determine how to effectively engage with local stakeholders during a limited time in the field. From the very beginning of our approach, we overcame many logistical and cultural barriers by engaging with local stakeholders. Apart from engaging with medical professionals , we spent valuable time with the CHWs/CHVs and observed their crucial role in VL diagnosis in the field. We observed many similarities in the health care systems between Kenya and Uganda, which is unsurprising given the common border and a shared history; therefore, we created a combined Gigamap of their VL health care systems. We observed many challenges that are encountered by the locals: food and water insecurity, which causes malnutrition; remoteness; and a lack of infrastructure and poor health care systems, which collectively adversely affect access to adequate diagnoses and treatment. Furthermore, the lack of resources, both financial and in the availability of health care staff and RDTs for VL, and poor health-seeking behavior, which is exacerbated by the lack of education that is prevalent in the remote regions, impede effective VL management.Conducting field research provided rich sources of information for understanding how new POC diagnostic tests can fit into a specific health care context. We would like to highlight the importance of international cocreation through active collaborations between all stakeholders, including academia, industry, nonprofit, and governmental organizations.A CTPP is an effective new tool that can aid R&D researchers in matching the technology that they develop to a specific health care context more quickly than a conventional target product profile.The role of local volunteers and community health care workers is critically important for access to diagnostics in resource-limited settings. With improved yet simplified VL POC diagnostic tests, CHWs/CHVs could perform diagnosis of VL closer to the homesteads.A noninvasive test-of-cure and a screening and confirmation test will significantly improve the management of VL in the endemic regions. This would greatly benefit patients, particularly immunocompromised patients who are at a higher risk of relapse, as well as help pharmaceutical researchers and clinicians who are developing and testing new VL treatment regimens.The cost of the diagnostic test is an important factor to consider, especially in view of the fact diagnoses needs to be repeated, to screen the patient in the field initially, and again at the treatment facility to rule out any procedural error and to justify the toxicity and expense of VL treatment. Thus, the diagnostic test needs to be affordable.A number of key findings that were learned from the approach are as follows:Early during the R&D stage, researchers should consider who will administer the test  and for what purpose.Program managers should consider that the training level of staff and volunteers and the availability of the resources are the critical determinants for using a diagnostic test.Researchers should consider that introducing themselves to local communities and stakeholders early will improve the willingness of the communities to implement the new technology. Upon further development, testing prototype devices can be facilitated by the local East African partners, thus strengthening international cocreation, and increasing the probability of success of a new POC diagnostic test beyond a mere proof-of-principle.Key implications learned from the approach are:The plethora of information gathered in the field was comprehensively processed using our methodology, which includes design-thinking tools such as visual thinking, leading to the development of a Gigamap, patient journeys, and the consequent use case scenarios that are presented in this study. The visual thinking was used as a means to summarize, validate, and communicate key insights from the field research to the stakeholders, as well as to create an aligned vision within the team. The visualizations allowed us to identify where, when, and how a new POC diagnostic test can fit into the health care system within a resource-limited endemic region, in the form of a CTPP, which is an efficient mapping tool compared with a TPP. A CTPP approach was applied to sufficiently scope the problem of VL diagnostics, gather contextual information, and define the adequate features of a new POC diagnostic test.Disease eradication requires improved diagnostic tests, as well as an efficient system to successfully deliver and implement them in the appropriate settings.In this article, we presented an approach that included design-thinking principles to formulate a CTPP that consists of multiple steps. Our approach moved from identifying gaps in current VL diagnosis in endemic regions by critically reviewing the existing literature, to selecting an endemic region to validate the literature findings and conduct direct observations in the field. After that, we used visual thinking to create Gigamaps and patient journeys based on the combined insights that were obtained from the literature and the field research, which led to valuable use case scenarios that describe the ideal setting for a new POC diagnostic test. Finally, we used these collective data to formulate a CTPP for a new POC diagnostic test that is specific for VL diagnostics in resource-limited settings.In summary, we introduced the notion of a CTPP as an effective toolbox to match the development of a POC diagnostic test and the health care context for its application. More generally, we anticipate that a CTPP will be a useful new tool that enables researchers to match the development of new diagnostic tests or medical equipment, and the local health care context in which they will be used. We envision that a CTPP will enable researchers to ruminate on the new product and facilitate the iterative design process—and ultimately benefit global health.


COVID-19 is continuing to ravage the globe. In many Western Countries, the populous has not embraced public health advice which has resulted in a resurgence of the COVID-19 virus. In the United States, there is an absence of a coordinated Federal response. Instead, frontline workers and average citizens are having to cope with extensive mixed messaging regarding mask usage and social distancing from the highest levels of government. This has resulted in the United States not being able to achieve a low level of infection since the pandemic began. In addition, many citizens hold a profound belief that individual freedoms must be preserved, even at the expense of public health; and view the wearing of masks as renouncing this right. These engrained political beliefs can be traced back to the late 1800s. The response of the United States has also been hampered by a highly cost-efficient healthcare system, which does not provide universal care and has a just-in-time supply chain, with far too few supplies in reserve. This efficiency prevented a rapid scaling up of the healthcare response, which resulted in severe deficiencies in available personal protective equipment (PPE) and healthcare staff. To compound issues many healthcare staff are not provided an economic or healthcare safety net. Other frontline workers, such as those who work in transportation and food services, are working under even greater adversities. Many of these workers are from diverse backgrounds, who, along with their families, are at even greater risk for COVID-19. This vulnerable population of frontline workers are faced with a choice of going to work with inadequate PPE or placing food on their families’ table. In the United States, official recommendations seem to be ever changing, based more upon supply and test availability, than on science. We must rely on science and learn from the lessons of past pandemics or we will relive, even to a greater degree, the deaths and devastations experienced by our ancestors over 100 years ago. COVID-19 has devastated the World, affecting every country in its path. The 2020 COVID-19 Conference “Though the Eyes of the Front Line” had as its underlying goal, to educate nurses, health care professionals and the general populace about the challenges that this global pandemic has caused. Additionally, the conference focused on the consequences of the outcomes of COVID-19 which spread globally including the staggering loss of lives that continue to generate from the lack of leadership, transparency, and trust in the science to combat the disease.Much of the world has been surprised at the difficulties the United States is having containing this virus. Two major factors came into play. The first is a belief it could not happen in the United States; epidemics will happen only in underdeveloped countries with a rudimentary public healthcare system.Secondly, the view that individual freedoms and the rights of local governments over federal governments has provided an added barrier in controlling the spread of the COVID-19 across our nation. American Medical Association President Hunter Maguire , which hThe United States’ historical values and culture has been ideal for confronting almost insurmountable challenges in the past but for controlling a viral pandemic they are counterproductive. One only needs to look at the events that began in February, 1918 when what was thought to be “severe influenza” was initially identified at Camp Funston, in Haskell County Kansas. Barry , stated The belief in invincibility and that a pandemic could never reach the United States (U.S.) led to a depletion of personal protective equipment (PPE), including N-95 masks in the U.S. stockpile. The federal stockpile has been depleted for over a decade. Even though the original projected need for an epidemic response in the United States was 3.5 billion N-95 respirators, the stockpile was only designed to hold 85 million masks, with only 12 million actually present. The remainder were largely depleted during the N1H1 pandemic [The dysfunction of the United States’ Federal Emergency Management Agency (FEMA) became evident during Hurricane Katrina in 2005, and was exacerbated by the dismantling of the United States’ pandemic response team in the spring of 2018. All of these take-aways went largely unnoticed by the American people, leaving few protections and a lack of understanding and confusion about the role of leadership. Mixed messages, from leaders, seemingly driven by a willingness to not fully disclose the poor performance of our healthcare system and the early rapid spread of the virus. Public communications regarding the need for masks, along with the dangers of the virus were both conflicting and confusing,  with mesAccording to the Food and Drug Administration (FDA)  medical This is in contrast to Southeast Asian countries who learned from the past epidemics of MERS and SARS.Singapore was one of the hardest hit countries with SARS and prior to the SARS-CoV-2 pandemic had almost three N95 masks in their stockpile per citizen. A lesson can be learned from Singapore regarding the need for Universal Health Care for all residents. Singapore’s fourth wave of infections came from migrant workers who were housed up to 15 to 20 workers in each bedroom, and many of whom encountered barriers in healthcare access . The couA number of different strategies were used by other countries around the world to crush the pandemic curve. In the Netherlands,  there waSpain’s Government is similar to the United States in that it has strong local control. Initially, Spain did not have uniform or nationwide recommendations. However, on March 15th, as the pandemic started to progress, the central government took control of all measures and locked down the entire country . Unlike Unfortunately, learning from past mistakes and from others appears to be hard. In much of Europe, a second wave is occurring as a large portion of their populous has become weary of public health measures and appear to be adopting the laissez faire attitude and lifestyles of those denying the lethality of the coronavirus . In the In Massachusetts, healthcare facilities were the most common workplaces to receive complaints accounting for 30% of the total. Examples included reuse of N-95 masks and contaminated gowns, not having ready access to disinfectant wipes and minimal availability of PPE; and According to Jodi Sugarman-Brozan, Executive Director, Massachusetts Coalition for Occupational Safety and Health (MassCosh), “Most if not all of these complaints were closed by Occupational Safety and Health Administration (OSHA) without even an investigation.” .Sugarman-Brozan described the inadequacy of sick leave and workers’ compensation benefits. This lack of a healthcare and economic safety net for workers is a concern because it places a sick worker in the position of choosing between going back to work or paying for rent and placing food on one’s family’s table.In Massachusetts, the SARS-CoV-2 positivity rate for Black and Hispanic residents is three times that of white residents . They arFinally, no one is counting fallen and afflicted healthcare workers. The Centers for Disease Control and Prevention’s (CDC) COVID-19 Data tracker has data from over 5 million individuals, but healthcare personnel status was only available for 22.8%. The only data available was recovered versus death status which represent 73.5% of known healthcare workers . The CDCOne of the most important lessons this pandemic has taught us is that access to healthcare is needed for all. Infectious disease does not respect socioeconomic or geographic boundaries. It was evident that there were several different strategies which could be successful in controlling viral spread. However, the overriding factor in success was the widespread acceptance by the populous of public health control measures. The disparities that existed prior to the pandemic has become more evident and contributed to increased inequity among the nation’s most vulnerable population. The uninsured and homeless in the United States are potential foci for reinfection of our entire population.In addition, the United States needs to focus attention to all frontline workers. During the 2020 conference, there were stories of lack of appropriate PPE and changing recommendations. This was especially prevalent in the guidance for the type and need for masks. Recommendations appeared to be more based upon availability, rather than worker protections and public safety. With the recent revelations on the aerosolization of the virus,  all fronAccording to a report in the Morbidity and Mortality Weekly Report of the U.S. Centers for Disease Control and Prevention, (2020) , more thKaiser Healthcare News reported that between March and June 30th, 2020 there were over 4100 healthcare worker complaints in the United States regarding protective gear .During a webinar hosted by the Society of Critical Care Medicine, Anthony Fauci, MD, director of the National Institute of Allergy and Infectious Diseases, stated, “It is now clear that about 40–45% of infections are asymptomatic.” Asymptomatic carriers may be responsible for up to 50% of SARS-CoV-2 acquisitions .The response of the current public health officials and governmental leaders must now reflect the lessons that were learned but apparently forgotten following the 1918 pandemic. An allegiance to science is necessary in order to eradicate the destruction of COVID-19. If these lessons are not learned, we are destined to double the death and devastation experienced by our ancestors 100-years ago.


Aims and objectives: Lighting constitutes a critical issue in school design because of its importance as a strong enabler of performance, which is crucial for child development. However, data on light impacts on school performance are scarce. The main objective of this study was to assess the relationship between daylighting conditions in classrooms and mathematical and logical test scores. Methods: The population-based SINPHONIE (Schools Indoor Pollution and Heath: Observatory Network in Europe) study provides information on relationships between lighting conditions and school performance for 2670 elementary schoolchildren, aged 8–13 years from 155 classrooms in 53 schools across 12 European countries. These data were acquired through direct physical assessments and questionnaires completed by teachers, schoolchildren, and their parents, allowing for estimations of multiple objective daylight indicators, as well as subjective parameters such as the perception of lighting. Schoolchildren performed an attention/concentration exam that included simple mathematical exercises in addition to a logical ciphering test. The corresponding performance scores were compared against multiple daylighting parameters. Results: A positive relationship was found between performance scores and type of window shading, latitude, percentage of window facing south, and window glazing, with the highest impact due to the window-to-floor area ratio. Conclusion: Data collected in the SINPHONIE study across 12 European countries indicate that daylighting parameters are relevant to schoolchildren’s performance. As SINPHONIE was not designed specifically with lighting in mind, dedicated studies covering a wide range of classroom configurations would be enlightening. Light constitutes a critical issue in building design because of its importance as a strong enabler of performance. A recent review on lighting conditions in the work environment showed that specific illuminance conditions may promote better performance . This isFew studies have tried to establish a link between light and school performance in children in population-based studies, and results have shown the beneficial effect of daylight on performance ,10,11,12The primary objective of the present study was to investigate whether schoolchildren’s performance is affected by daylighting conditions in the classroom. This was attained by estimating schoolchildren’s exposure to light through the assessment of various classroom characteristics, as well as through personal perception of light, and by relating these characteristics to performance tests in the context of the European SINPHONIE study, which was conducted at the general population level using a standardized protocol. The study protocol allowed for the control of other known predictors of schoolchildren’s learning, including health, social status, and classroom and air quality.The SINPHONIE (Schools Indoor Pollution and Heath: Observatory Network in Europe), a population-based study conducted in Europe, was conducted over the period 2011–2012 to investigate the environmental impacts of schools and classrooms on the health and performance of schoolchildren . The proOut of the 23 participating countries, 12 conducted performance exams, for a total of 2670 schoolchildren, aged 8–13 years. Over half of the schoolchildren were Caucasian (65.54%), and there were approximately equal numbers of male and female schoolchildren. The countries were grouped into four geographical clusters sharing similar characteristics according to the World Health Organization (WHO): Cluster 1 (Northern Europe), Cluster 2 (Western Europe), Cluster 3 , and Cluster 4 (Southern Europe) .Data were acquired through both direct physical measurements as well as by the use of questionnaires. Teachers, schoolchildren, and parents were all given questionnaires to assess the conditions at the school, the health of the schoolchildren, and the perception of air quality. Parameters that could be objectively quantified, such as window and classroom size, were measured and recorded by an outside surveyor.2 measurements are also included as a confounding variable.Variables considered to have a possible influence on the amount of light inside the classroom included in the SINPHONIE study were the following: type of lighting , window size, presence of direct sunlight, type of window glazing, type of shading, latitude, percentage of windows facing south, and openable windows. Additional variables were created to enhance the capabilities of the data provided and were obtained by combining variables or including geographical information. The window-to-floor ratio is the ratio of measured window area to measured floor area and is used to understand how “big” the windows are compared to the size of the room. All variables relating to light are detailed in The Daylight Index was created as a relative measure of daylight hours and is intended to replace season or month as a measure of relative daylight . To calc2, as mentioned above. Window orientation is a binary variable indicating either a view from the classroom onto green space or urban space/other buildings.The average national latitudes and longitudes were taken from public online data  and usedThe perception of illumination variable is a subjective variable that estimates the overall illumination in the room and was asked of the teachers, schoolchildren, and parents individually. Thus, there are three measures of the same variable to be taken into account when considering any associations with schoolchildren performance test scores.Schoolchildren’s performance in the classroom was measured by means of a math and logic test given at the start of the school day. The first section tested basic arithmetic skills, while the second part of the exam focused on logic and memory skills. The second section consisted of 119 logical translation, or ciphering, elements, and children were given 120 s to complete as many as possible. Two slightly different versions of the test (Test 1 (basic arithmetic) and Test 2 ) were administered in different countries. Czech Republic, Italy, and Lithuania Portugal, and Serbia took the second variant of the test whereas other European countries took the first variant of the tests . Both ve2 concentrations.All light-related variables were initially considered equally as potential indicators of performance. The importance of each individual variable on the average score was determined by either a t-test or ANOVA for categorical variables  or by a univariate regression against the average test score. This enabled a better understanding of which indicators might be most relevant and allowed for verification that our data followed known patterns such as a significant dependence on indoor COp < 0.05) in the initial univariate screening process, while irrelevant variables were generally excluded in order to simplify the dataset and focus on variables that might truly impact performance levels. Multiple linear regression analysis was used to determine the overall model and to control for confounding influences.Variables were included in a multivariate analysis if they were significant . All statistical analyses were done using Stata 14 .Finally, window/floor area ratio, type of shading, latitude, percentage of windows facing south, daylight index, direct sunlight, window glazing, and open-able windows were analyzed using multiple linear regression analysis to determine the overall model and to control for confounding influences such as age, gender, race, and maternal education. COTo exclude any selection effects, no demographic bias was observed in the schoolchildren who participated in the performance exams  as compaA total of 1765 children completed Test 1, and 886 children completed Test 2. Each two-section exam was considered as single measure of performance. The average scores are 59.25%  and 58.39% (SE = 0.47) for female and male schoolchildren, respectively . These aNon-linear regression for the continuous variables did not yield any more detailed results than did linear regression. Several variables show a significant association with average performance test scores with the following exceptions. The window orientation was not significant, suggesting no difference in scores between classrooms facing urban settings and those facing green space. Similarly, the size of the floor area, type of wall covering or writing board, ceiling type or story number of the classroom showed no impact on performance. The percentages of window area facing north, east, or west were not significant; however, the percentage of the window area facing south was significant.The variables that individually showed a significant influence on the performance test scores are listed in Then, variables with significant association in the univariate analyses were analyzed further to understand the overall influence that these indicators have in schoolchildren’s performance.When all light indicators are included in a single model, the positive influence from the window-to-floor area ratio dominates, followed by the type of shading, the latitude, and finally the percentage of window area facing south. We found that other parameters namely daylight index, direct sunlight, and open-able windows were non-significantly inversely associated with average scores.2 concentrations; however, this result does not vary for differing values of the window-to-floor area ratio. When regressed separately for different quartiles of window-to-floor area ratio, there was no change to the effect on scores from CO2 concentrations (results not shown).A simple linear regression on the average score shows a slight significant negative impact on scores with increasing COScores were analyzed within geographic clusters to understand any difference between regions. The mean test scores for each cluster are provided in When the multivariate model was run for each cluster individually, results vary depending on the cluster. Only cluster 3, with the highest number of test takers, and cluster 1 show models similar to the overall multivariate model found for the study as a whole. These are also the only clusters where the window-to-floor area is a significant positive indicator of school performance.Other variables, such as the percentage of windows facing south, direct sunlight, the average national latitude, or the ability to open windows change their direction of impact depending on the cluster. Some variables have an impact in some clusters but not in others, such as the type of glazing (results not shown). In general, there is no consistent aspect of the models between clusters, and more information would be necessary to try to understand why the various indicators impact scores positively in one case but negatively in another.Models were also run separately for male and female schoolchildren. When the same multivariate regression is run for each gender separately, we see that window-to-floor area is not an important factor for females; however, the rest of the variables predict performance in much the same way for all schoolchildren. The coefficients for each indicator other than window-to-floor area are roughly the same for both males and females (results not shown).Test scores vary by season, with schoolchildren taking performance tests in the summer performing best (average score = 60.66%) and schoolchildren taking tests in the spring performing worse (54.76%). Schoolchildren performing the tests in winter have an average score of 58.77. Different results are obtained when the multivariate regression is performed by season. However, the regression failed when only scores from spring were included (Daylight Index was left out when regressing by season). In both autumn and winter, the window-to-floor area ratio still dominates; however, ceiling height, open-able windows, and the percent of windows facing south seem to have a positive impact in one season and a negative impact in the other. The only other indicator consistent between the two seasons is the average national latitude (results not shown).The main objective of our study was to investigate whether school performance is affected by lighting conditions inside classrooms in Europe. Our data is drawn from a population-based sample of primary schoolchildren in 53 schools from 12 European countries and shows a significant relationship between light-related variables and school performance. The window-to-floor area ratio is a highly significant indicator of school performance, indicating that a larger window area for a given room size has a positive impact on grades and achievement. This variable remains the strongest predictor when adjusting for confounders such as gender. However, it is not consistently important over the geographic region, and it does not seem to be as important for females as it is for males. In terms of gender, one can only speculate why window size might be more important for male students than for female students. This could be due to hormonal differences influencing cognition or in aptitudes between boys and girls. However, in terms of geography, we see that the window-to-floor area impacted schoolchildren in cluster 4 more than the others. These are the southernmost European countries, were there is more consistent sunlight, and schools may be more reliant on natural light vs. artificial light. In general, there is no consistent aspect of the models between clusters, and more information would be necessary to try to understand why the various indicators impact scores positively in one case but negatively in another.The type of window shading also appeared to be significant, and it does not seem to be correlated with direct sunlight. Classrooms with internal shading and south side shading had significantly higher average scores than did those with external or no shading, suggesting that it is advantageous to control the amount of sunlight entering the classroom, especially if glare is indeed a problem for some classrooms, as implied by the fact that we found a negative association with direct sunlight on exam performance. A similar negative association between direct sunlight was seen by , who fouOverall, schoolchildren performed better in the summer and winter. Lower scores in the spring may be a result of general burn-out over the course of the school year, although higher scores in the summer may contradict that theory. It is general knowledge that schoolchildren in Northern Europe perform better than Southern and Eastern Europe and indeed better than many countries around the world. The PISA ranking for 2018  supportsCeiling height was significant when regressed directly against the mean performance test scores with a univariate model, but it did not remain significant when other light indicators were included. We observed schoolchildren performing better in tests with triple glazed windows but did not see a significant difference in average scores between single- or double-glazed windows and double-glazed windows with filling. Triple glazed windows may also be a sign of affluent neighborhoods or colder, northern latitudes, rather than an effect due to the glazing itself, which could confound the results. There was no observable impact on performance from the orientation of the windows, suggesting no difference between a view toward green space or toward urban space. However, it should be noted that window height was not included in the data, and it is impossible to know if the schoolchildren were able to see out the windows from their seats.Perception of illumination was excluded from the multivariate analysis on the basis of subjectivity, as well as inconsistencies between the schoolchildren, parents, and teachers. However, it could be argued that the use of teachers’ perception of illumination, which was a significant predictor for performance, is justified, as their judgment should be based on a full day’s light from an adult with an understanding of differences between classrooms and various lighting conditions.Several potential mechanisms have been suggested concerning the impact of lighting conditions inside schools and offices and its effect on performance among building occupants ,20. Incl2 level, which could significantly affect the associations as currently observed, the effects of CO2 on mental performance being well documented.The major strength of the present study is that the data are drawn from the general population of primary schoolchildren, spanning more than 50 schools and 155 different classrooms in 12 countries across all regions of Europe. Compared to studies focused only on a handful of classrooms or schools, with a sample size of 2670 students, our study is able to observe daylighting effects that are more general and not specific to one location. We were also able to control for several confounding factors such as age, gender, maternal education, as well as for COA major limitation of our study is the fact that light was not originally considered as a stressor in the implementation of the SINPHONIE design protocol. As a consequence, no direct assessment of light was performed, and exposure misclassification cannot be excluded because light was not determined objectively. While this may limit the comparison between previous studies, there is still considerable data within the SINPHONIE study related to classroom lighting conditions to warrant an investigation. As a consequence of the fact that light was not one of the research questions of the study, bias toward light assessments is not expected, and classrooms were not selected based on lighting conditions. Similarly, the repertoire of cognitive tasks appears way too narrow for a reliable assessment of cognition. More specific tasks for attention and performance such as attention network test or more complex cognitive functions such as go/no go task would have provided with a better interpretation of the results, warranting cautious interpretation of the results. A further methodological limitation of the study is its cross-sectional design, which does not allow for inferring causality.Other limitations result from the differences in school systems for different countries. As a result of this heterogeneity, comparisons have to be made cautiously. Additionally, our analysis could not take all potential confounders of the relationship into account, such as air pollution, noise levels, and the use of screens can impact learning and impinge on the school performance. Socio-economic status, another confounder, was considered, but through the proxy of maternal education level. Another major confounder that we were unable to control for is the sleepiness levels; information on sleep-wake diaries could have provided a better picture of the effect of cognitive performance. However, to avoid sleepiness, most performance tests were performed in the morning.Exposure to indoor air pollution and other demographic factors have also been associated with the decrease in learning and performance in schoolchildren . In addiFor the first time in Europe, we related several parameters associated with daylighting to mathematics and logical test results in a large sample of schoolchildren. Overall, our findings suggest that classroom characteristics associated with daylighting do significantly impact the performance of the schoolchildren and may account for more than 20% of the variation between performance test scores. The window-to-floor area ratio in classroom appears to have the largest effect, indicating that larger window areas are advantageous. Having control over the shading of the windows is also important, most likely because it is indirectly related to sunlight. Scores are higher for tests taken during summer and winter months. Further studies are needed to confirm our findings.