We examine the psychosocial factors influencing community adoption of non-pharmaceutical interventions (NPI) to limit the spread of COVID-19. Using data from 990 respondents in communities across Nigeria, we examine the correlation of health behaviors and socioeconomic indicators. We conduct logistic regression to estimate the relationship between mask wearing as a health-seeking NPI with demographic and socioeconomic variables. We estimate separate models in the sensitivity robustness checks with other NPIs and control for differences across sex, age, education, number in household, and the presence of a student in the respondent’s household. A crucial finding is that health-seeking NPI behaviors are statistically significantly affected in different ways by the menu of socioeconomic indicators. The control for age, sex, education, and household size indicates that there is intersectionality of how these factors influence specific mitigation practices. We find that women are more likely to engage in mask wearing, hand washing, and use of hand sanitizers and tissues than men, and the provision of palliatives and access to family supplies significantly enhances community mitigation. Palliatives and access to family supplies enhance most health-seeking behaviors. The implication for pandemic mitigation policy is that minimizing incidence rates requires having responsive initiatives such as information updates on pandemic progression. At the peak of the coronavirus disease 2019 (COVID-19) pandemic, caused by severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2), in 2020–2021, public health measures were imposed in most countries to limit the spread of the virus, causing significant behavioral changes in human lives across the globe. These measures included non-pharmaceutical interventions (NPIs) that have been classified in four broad categories  by the World Health Organization  [Community mitigation refers to measures designed to be used by individuals, organizations, and governments to reduce the transmission of COVID-19 in the community. NPIs are central to community mitigation strategies, and they are critical in pandemic response plans given the considerable amount of time required to develop and deploy efficacious vaccines and drugs . Their pTo a large extent, the effectiveness of these NPIs involved partnerships that build on community strengths and limit inequities in accessibility . HoweverThe impact of the COVID-19 pandemic on lives and livelihoods in Nigeria led to a range of government responses, particularly in the campaign for NPIs. While vaccines may help the control of COVID-19, Nigeria, like other low- and middle-income countries is unlikely to reach the vaccination coverage rates necessary to combat the disease. Thus, NPIs will continue to play an important part in COVID-19 control, especially in the context of viral variants of concern and vaccine hesitancy. Since the first case of COVID-19 was reported in Nigeria in February 2020, the country, just like many countries around the world, encouraged the practice of NPIs such as regular hand washing, use of face masks, use of hand sanitizers, and physical distancing measures to limit the spread of the disease . The levA scan of the national COVID-19 measures and response structures in Nigeria ,21,22 shThe central hypothesis of this paper is underscored by seeking answers to three interrelated questions. First, what factors affect community adoption of NPIs? Second, what is the correlation between health-seeking behaviors and key socioeconomic indicators? Third, how do we inform pandemic mitigation policies? Understanding the drivers of NPI adoption can help inform strategies to improve the uptake and adherence to NPIs.This study is conducted in the context of an intervention to enhance Civil Society Organizations’ (CSOs) involvement in the COVID-19 response in Nigeria through improved coordination, capability, communication, and accountability. Thus, it is crucial to understand the factors that affect community adoption of NPIs. This understanding entails knowing the extent of the correlations between health-seeking behaviors and socioeconomic activities. This knowledge could be instrumental in the crafting of pandemic mitigation policies.This paper adopted a behavioral model of increasing vaccination to examine demographic and psychosocial factors that could influence the uptake of NPI. This adoption is based on the premise that behavioral interventions that are grounded on a cogent theory are more likely to be effective. The uptake of vaccines where available and affordable is often predicated on three general propositions: (i) the decision to receive vaccination may be motivated by thoughts and feelings; (ii) contemporary social processes such as free riding, i.e., taking advantage of the protection induced by herd immunity could influence vaccination uptake; (iii) facilitated interventions enhanced with reminders and prompts could increase responsiveness . Thus, tThus, considering the above, this paper is conducted in the context of By extension, receiving palliatives from the government builds trust in the government; (ii) social processes including awareness creation on NPIs, social norms, gender norms, information sharing, and rumors. For example, accessibility to health facilities implies that people may hear more, and believe more, about NPIs in clinics.The two propositions combine to motivate the community through increased readiness or higher willingness (or perhaps hesitancy) to use NPIs. It is in the nexus of the motivation and practical issues including crowding, availability of the NPIs, cost and convenience of practicing NPIs, incentives and palliatives, and the extent of intervention fatigue that combine to inform NPI adoption. We note that the motivations, propositions, and practical issues have different effects on different NPIs in the presence of other demographic differences and socioeconomic realities.This section describes the data collection process, the study areas and population, the variables, and the estimation method employed.The cross-sectional data set of observations was based on the survey of 990 respondents administered by the Coordinating and Mobilizing Civil Society Response in Nigeria (COMCiRIN) across communities in four states and the FCT in Nigeria between 3 November and 11 December 2020. The data collection was limited to the states in Nigeria in The community small sample survey was conducted in three selected local government areas (LGAs) and six communities in each of the five selected states—Cross River, Ebonyi, Gombe, Kano, and the FCT. The states were selected because of the COVID-19 high burden and to have a representation of the six geopolitical zones in the country. The LGAs and communities were randomly selected using Microsoft Excel and R software. To select the three LGAs per state, all the LGAs in each state were listed alphabetically and numbered, after which the three LGAs were selected using the random sample function in Microsoft Excel. The communities were also randomly selected using the probability proportional to sample size (PPS) methodology and the World Health Organization master list of communities in each of the states as sampling frame. The PPS methodology was selected because it ensures that every community in a selected LGA had an equal probability of being selected regardless of community size. This was important because the communities in the LGAs vary widely in size. Security-compromised communities were filtered out of the master list to avoid the risk of security challenges during data collection.The survey was conducted among community leaders and community members. In each community, ten adults and one community leader were surveyed. This yielded a sample of 66 respondents per LGA and a total sample size 990 for the five states. While community leaders were purposely selected for the survey, community members were randomly selected using the Lots Quality Assessment Survey (LQAS) field methodology. The study population was made up of 990 respondents with distributions as follows: 62% males and 38% females; 57% were aged 50 years and above; 21.7% were uneducated; occupations ranged from farmers, health workers, business owners, civil servants, engineers, and teachers to the retired.The dependent variables in this study are the NPIs with the primary one being the respondents’ mask wearing behavior. In the post hoc robustness test, other NPIs are examined. Mask wearing, like other NPIs, is a dichotomous variable with 1 indicating that the respondent engages in mask wearing as a health-seeking NPI behavior and zero otherwise. A recent World Bank study that tracked the socioeconomic impacts of the pandemic in Nigeria shows the prevalence of mask wearing and hand washing in the country from a national longitudinal telephone survey . Figure The independent variables are strictly variables that inform or inhibit the adoption of the health-seeking NPIs. These variables underline the core influential parameters that are in the socioeconomic and other macroeconomic interventions that were prescribed to limit the spread of the disease such as the restriction of movement. Awareness of COVID incidence is a dichotomous variable . We examined the presence of the awareness of pre-existing morbidity, specifically having someone with diabetes in the household, with aid of the variable diabetes in household . We conjecture that access to a health facility encourages NPIs and capture this variable as health access . In a similar manner, (i) access to palliatives = 1, otherwise = 0; (ii) access to food and essential supplies = 1, otherwise = 0. We controlled for the socioeconomic and demographic characteristics that may influence an individual’s health-seeking NPI adoption. The variable sex captures the acknowledged gender of the respondent . Age is a non-dichotomous variable just as the variable household size that captures the number of people living in the respondent’s household. We coded the respondent’s education  and the variable student in household . We conducted logistic regression to estimate the relationship between mask wearing as a health-seeking NPI and several demographic and socioeconomic variables. We estimated separate models in the sensitivity robustness checks with other NPIs. We controlled for differences across sex, age, education, number in household, and the presence of a student in the respondent’s household. These factors may influence the adoption of health-seeking NPIs. Our logistic regression model estimates a linear regression defined asi and 1 − πi, respectively [We note that the left-hand side is in the familiar probability scale, while the right-hand side is a non-linear function of the predictors. Thus, our dependent variable mask wearing, as with other NPIs, takes the values 1 or zero with probabilities πectively . We estiectively ,27. For ectively ,29 and wectively .This section provides details on the descriptive statistics of the variables and the results of the logistic regression estimations.Model 1 in The result shows that older people are less likely to wear masks with a relatively weak negative coefficient (β = −0.00037) that is not statistically significant. More interestingly, we observe that being educated (β = 0.547) and having students in the household (β = −0.569) are both positive coefficients and statistically significant at 5% level. Unexpectedly, we find that the larger the household size, the less likely they are to engage in mask wearing, though not statistically significant. In summary, the control variables indicate that females are more likely to wear masks than males, and being educated or having students in the household tend to promote mask wearing.Model 2 tests the effect of awareness of COVID incidence on mask wearing. We postulated that awareness promotes health-seeking behavior. The result shows that the coefficient for COVID incident (β = 1.396) is positive and significant, indicating that opinions about COVID-19, especially the perceived risk of infection, increase with the social process of awareness, thereby enhancing the motivation and willingness to engage in health-seeking behavior through the NPI of mask wearing.Model 3 tests the awareness of the presence of an existing medical condition, such as having a diabetic in their households, and the positive coefficient (β = 0.015) shows that it does promote mask wearing as expected, but the result is not significant. The absence of significance for both age and a pre-existing morbidity led to the interaction of both respondent age and awareness of any diabetic in their households in Model 4. The result of a negative coefficient (β = −0.0423) was further explored in an interaction graph. The take-away message that is instructive from this interaction is that older people living in households without diabetic people are more likely to wear masks than their counterparts who live in households with diabetic people. Perhaps the psychological science interpretation is that mask wearing is seen as a protection from contracting COVID-19 by younger people with diabetics in their household, while the older respondents with diabetics in their household are hesitant to engage in this health-seeking intervention. Model 5 with a positive coefficient (β = 0.480) that is statistically significant at 5% level for health access demonstrates that access to a health facility encourages mask wearing as a health-seeking NPI. The rationale for this is that health facilities generally tend to promote health-seeking behaviors. Thus, the more access to clinics that community members have, the more likely they are to engage in protective behaviors.Model 6 shows that the receipt of palliatives, independent of whether they were from the government or individuals or a non-governmental organization (NGO), has a strong and positive coefficient (β = 1.172) that is statistically significant at 1% level. This result is consistent with the value of aids that are provided in a pandemic, while providing some measures of relief also tends to enhance the adoption of protective behaviors. In sum, palliatives could be used as a mechanism to promote the adoption of NPIs.The result in Model 7 with a negative coefficient (β = −0.597) that is significant at 5% level implies that the more access to food and supplies households have, the less likely mask wearing is. The rationale for this behavior is that with the abundance of food and essential supplies, the need to be exposed to causative agents is reduced, especially at the peak of the lockdown in the community.The bottom data in A cursory look at the R-squared values shows that they are relatively low. However, it is not uncommon for such low values in logistic regression and models that predict behavior. The more important observation is, though, that the noise portrayed by the low R-squared values, indicating a high-variability data, still captures the significant trends. In other words, the trend indicates that the predictors offer sufficient information about the response variable. While the regression coefficients estimate the trends, the R-squared values reflect the scatter around the regression line . In esseWe estimated several robustness tests. We re-estimated the full Model 7 in The results are largely consistent with those in the main models where the constant term is a part of the predictors. However, we note here that not only do the prior results stand, but we also now have age and household size becoming significant at 5% and 1% levels, respectively. Though the values of the coefficients changed marginally, this only further reiterates that the properties of the logistic model imply that the magnitude of the effects may not be inferred from the coefficients, but only the sign and statistical significance of the variables ,37.We report a second and major test of robustness by repeating Model 7 from We graph this interaction in Our results indicate that there are variations in how these parameters influence specific mitigation practices. Specifically, we find that: (i) women are more likely to engage in mask wearing, hand washing, and use of hand sanitizers than men, (ii) the provision of palliatives and access to family supplies enhances the adoption of these community mitigation interventions. While these psychosocial factors influence the adoption of the COVID-19 NPI practices in different and often surprising ways, it is incisive to note there is a level of statistical coherence in the effects of these behaviors. For example, the outcome that younger respondents with diabetics in their households are more likely to engage in mask wearing or social distancing than their peers who do not have diabetics in their households underscores the relative manner in which these health-seeking behaviors are interpreted. Integrating these observations, we note that mask wearing, or any other NPI, has levels of discomfort, especially in humid weather, such that the notion of wearing a protective material over the nose and mouth may limit not just verbal but also nonverbal communication cues . NonetheThis study sheds light on the crafting of healthcare policies for pandemic mitigation in three ways. First, we note that awareness of COVID-19 incidence or death is a catalyst for community adoption of the NPIs. Thus, it is important for healthcare policy to be inclusive of information dissemination that is effective on updates of incidence or death rates because awareness as a psychosocial construct may provide inherent motivation to embrace community mitigation practices. The need for communication resilience is even stronger in the advent of a disaster or pandemic . This alSecond, the provision of economic palliative measures could serve as the invisible incentive to promote the adoption of NPIs. Combining these two implications for policy leads to a sweet spot, implying that it is not enough to merely broadcast community mitigation measures, it is also crucial to put in place responsive initiatives in the form of palliatives to support the community. Third, the overall community benefit of engaging in the adoption of NPIs is a derivative of the psychosocial parameters to limit the propagation media, i.e., air-borne or contaminated surfaces, by which the causative SARS-CoV-2 virus spreads. We draw a parallel between the achievement of herd immunity for vaccination and the more the community embraces the NPIs as prerequisites to eradicating the COVID-19. More importantly, for countries such as Nigeria still grappling with improving their vaccine supply chains ,41, the This paper makes three key contributions. First, enhancing community self-efficacy to predict the intention to adopt health-seeking behaviors through NPIs is influenced at different scales by a menu of socioeconomic indicators. Second, repeated public awareness of disease spread and progression during a pandemic in the community is a prerequisite to improve community mitigation practices. Third, these observations combine to inform healthcare policymaking in ways that are not always readily observable.Our study has several limitations that provide opportunities for future research. First, though our results are statistically significant in the context of a low- and middle-income country such as Nigeria, it is left to be seen to what extent these findings hold when examined in a developed country. Second, the study left it to be ascertained the impact of the time interval in which the data was collected. Perhaps a continuous data collection effort spanning a much longer time interval could further emphasize these observations. Third, the spread of the pandemic in Nigeria is not as pronounced as we have observed in countries such as Italy, India, or even the U.S. Consequently, it is an open question as to what extent these results are confirmed in countries with significant rates of infections.A crucial finding is that health-seeking NPI behaviors are statistically significantly affected in different ways by the menu of socioeconomic indicators. For example, the level of social awareness of the pandemic’s incidence and mortality rates influences the extent to which communities embrace health-seeking NPIs. The control for age, sex, education, and household size indicates that there is intersectionality of how these factors influence specific mitigation practices. We find that women are more likely to engage in mask wearing, hand washing, and the use of hand sanitizers and tissues than men, and the provision of palliatives and access to family supplies significantly enhances community mitigation. These findings help to reinforce the complexity behind the stipulation of the NPIs and some of the overarching unintended risk outcomes that have been reported to overshadow the interventions. This study underlines significant implications for pandemic mitigation policy, i.e., providing regular awareness to the community on the progress and intensity of the pandemic combined with the provision of economic palliative measures could serve as catalysts for enhancing the adoption of community mitigation practices that might, in turn, limit the spread of the pandemic. The prescription for the government of Nigeria (and other low- and middle-income countries) is that to minimize morbidity and mortality, as well as the social and economic impact of COVID-19, it is not enough to merely broadcast community mitigation measures, it is also crucial to put in place responsive initiatives such as routine information updates on disease progression and the provision of relief supplies. Theoretically, we contribute to the literature on pandemic mitigation policies by shedding light on the intricacies surrounding the impacts of psychosocial metrics on the adoption of mitigation initiatives.


Chronic constipation can be associated with a colonic motility disorder and/or obstructive defecation. An obstructive defecation disorder is suspected if the patient uses digital evacuation, performs excessive straining, and/or has a sensation of incomplete evacuation. A study using radiopaque shapes can reveal abnormal transit; colonic manometry can inform on abnormal colonic motor patterns or aberrant autonomic reflexes; anorectal manometry can reveal dyssynergia. Here, we discuss the physiological and clinical aspects of anal sphincter relaxation associated with continence, flatulence, and defecation, focussing on the rectoanal inhibitory reflex (RAIR) and the coloanal reflex.normal RAIR, can reveal the pathophysiology of obstructive defecation. Their methodology involved a detailed evaluation of the parameters of the RAIR, in a cohort of 58 patients. The patients reported a normal bowel movement frequency and stool form was normal, but most performed digital evacuation with excessive straining. The patients as a group had normal minimum and maximum anal sphincter pressures, the maximum tolerated volume was normal and so was the threshold for initiation of the RAIR. The authors concluded that the RAIR was impaired in these patients because the average internal anal sphincter (IAS) relaxation was 74% upon rectal distention by a 60 ml balloon compared to 92% in their control group of 20 subjects. Although the difference was statistically significant, it is not clinically relevant since 74% relaxation associated with the RAIR is normal, if not excellent, according to international standards  (prevents proper relaxation (The impetus for this opinion paper was to discuss the conclusion by Pucciani and Trafeli  that partandards . In addiex RAER) . The relThe relaxation that allows defecation and gas expulsion involves a proper sensation to initiate reflex relaxation, a sufficient relaxation of the IAS and the EAS, and the absence of counteracting contraction of the pelvic floor muscles and anal sphincters. It is the coloanal reflex that can produce full relaxation of both the IAS and the EAS, whereas the RAIR relaxes the IAS to allow sampling of content in the proximal anal canal.The RAIR test is executed to assess the response of the IAS to rapid and transient graded distentions of the rectum induced by a balloon. It is the classic test to discover Hirschsprung's disease: the inability of IAS relaxation in a newborn who does not pass stool suggests abnormal intrinsic inhibitory innervation of the anal canal, likely as the result of distal colon aganglionosis. In addition, nitrergic innervation of the IAS can be absent in children with Hirschsprung's disease . The RAIThe RAIR, in response to balloon distention is usually interpreted as absent or present, and a relaxation of 20% or more of baseline pressure is considered normal. In a characterization of the RAIR in healthy subjects by Rao and co-workers, a transient distention by a 70 ml balloon at a peak anal sphincter pressure of 70–80 mmHg for 30 s, caused a maximal relaxation of 47 mmHg, leaving a minimum pressure of 32 mmHg, proposed to be maintained by the EAS and puborectalis (Anal sphincter relaxation in response to the RAIR is primarily due to activation of enteric nitrergic nerves , 10 and The RAIR is sometimes called a defecation reflex, but it is more aptly called a sampling reflex; relaxation of the proximal IAS allows filling of the proximal anal canal which gives the central nervous system a chance to stop, or go ahead, with flatulence or defecation, hence it is involved in maintaining continence. The RAIR does not relax the EAS for expulsion. It is illustrative that patients with Hirschsprung's disease, after successful surgery, still do not have a RAIR but have normal defecation, indicating that the RAIR is not needed for defecation , 15.several tests provide evidence, since the reflexes evoked in the laboratory are often abnormal, even in healthy subjects, because of the unnatural testing conditions. With anorectal manometry, relaxation can be observed in response to rapid transient balloon distention. Relaxation can also be evaluated by asking the patient to bear down, simulating defecation during anorectal manometry or digital examination. With dyssynergia, tightening of the sphincters may occur, increasing pressure. A water filled balloon inserted in the rectum is normally expelled within a minute but with dyssynergia it may be delayed or absent. It should be noted that the patient will strain in response to bearing down or to expel the balloon, hence, these are tests of straining-assisted defecation, not necessarily a test of a normal defecation reflex. Of note, chronic excessive straining maybe a cause of dyssynergia (Dyssynergia involves the inability to relax the anal sphincters because of an autonomic dysfunction to prevent relaxation and/or the presence of counteracting contractions of the anal sphincters and/or pelvic floor muscles; hence reflex relaxation is prevented that may indicate abnormal sensory or motor innervation, or may indicate an acquired behavioral problem that can be rectified with biofeedback , 17. Dyssynergia . Dyssynesynergia .The coloanal reflex refers to the relaxation of the anal sphincters in response to a propulsive motor pattern of the colon , 19–23. The IAS relaxation as a consequence of the coloanal reflex , is mediThe relaxation of the EAS as a consequence of the coloanal reflex , is likeonscious experience of rectal distention that can also reveal dyssynergia. Low or high-resolution anorectal manometry can assess various aspects of rectoanal function such as the degree of IAS pressure inhibition, the slope of inhibition and recovery, any excitatory responses, etc. (Assessment of the coloanal reflex with high-resolution colonic manometry, can identify distal colon discoordination and dyssynergia, when the anal sphincters fail to relax in association with propulsive motor patterns or when excessive contraction of the anal sphincters and/or the sphincter of O'Beirne is observed . The sphes, etc. . High-rees, etc. , but lacThe RAIR in daily life is a sampling reflex that allows filling of the proximal anal canal to allow us to make a decision whether or not to accept expulsion of gas or stool; it is an integral part of our ability to maintain continence and can be the first step toward defecation or flatulence. The manometric parameters of a normal RAIR do not reveal the pathogenesis of obstructed defecation. The coloanal reflex is critical for complete defecation or gas expulsion as it involves relaxation of both the IAS and EAS, and absence will lead to distal colon dysmotility. An abnormal coloanal reflex is an autonomic nervous system dysfunction that can be the primary pathophysiology in outlet obstruction.This review was conceived and written by JH and J-HC. LL and AB made substantial contributions. All authors approved the final version.The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.All claims expressed in this article are solely those of the authors and do not necessarily represent those of their affiliated organizations, or those of the publisher, the editors and the reviewers. Any product that may be evaluated in this article, or claim that may be made by its manufacturer, is not guaranteed or endorsed by the publisher.


Human papilloma virus (HPV) is a viral agent whose transmission occurs mainly by sexual means. It causes different pathological conditions in both males and females, ranging from benign pathologies up to cancers. The introduction of vaccination has certainly had a major impact in terms of reducing the incidence of both HPV infections and diseases but in the European Union and the European Economic Area (EU/EEA) there are still about more than 13,000 deaths due to cervical cancer each year. To date in Europe and in Italy there are three vaccines available . The vaccination campaign started irregularly in Europe and Italy in 2007, with pre-adolescent girls as the primary target. Later, other cohorts were introduced such as 12-year-old boys, additional cohorts of >25-year-old women, women who already underwent cervical surgery and other subjects entitled to free vaccination. The COVID-19 pandemic has strongly impacted on public health services, particularly on vaccinations that, especially during the first pandemic phase, have been often delayed and/or canceled. The most affected vaccinations by the pandemic have been the non-mandatory ones, particularly those addressing the adolescent and adult population, such as immunization against papillomavirus. To date the achievement of the coverage target set by the Italian National Immunization Plan (NIP) has not yet been achieved. The aim of this work is to summarize the current situation in Italy and to discuss the strategies that have been implemented to increase overall vaccination coverage rates. Human papilloma virus (HPV) is an extremely widespread viral agent throughout the world; it includes more than 200 distinct genotypes and its human-to-human transmission occurs mainly by sexual means . HPV cauWorldwide, approximately 70% of cervical cancers and HPV-associated precancerous lesions are caused by the serotypes 16 and 18. Considering that this type of cancer is currently the fourth leading cause of death in the female world population, HPV is responsible for an important burden of disease .,39.4,39]As regards females, the average HPV vaccination coverage is well below the optimal threshold provided by the 2017–2019 NIP (95% in the 12th year of life) . Only onThe full-cycle coverage for 11-year-old girls (2008 cohort in 2020) has shown a decrease compared to the full-cycle coverage for 11-year-olds of the previous years   4,39]..39].For males, the average vaccination coverage rate is very far from the objectives set by the 2017–2019 NIP (95% in 2019) . Only twThe data on vaccination coverage (full cycle) 2020, for both females and males, show a significant decrease compared to those referring to 2019 . The decTargeted interventions would be necessary in specific geographical contexts bearing in mind that HPV vaccination, even not mandatory, is an Essential Level of Assistance and as such should be actively and free offered .The COVID-19 pandemic, with the temporary forced block of many health activities including vaccinations and the fear of contagion in attending healthcare environments , has certainly had a significant impact on vaccination coverage rates. In Italy, vaccination against HPV is recommended but not mandatory: according to the data collected by the Ministry of Health through a questionnaire administered to Local Health Units, the age group 13 months–18 years has been the one with the greatest reduction in vaccinations during the first lockdown period in 2020, consequently, HPV turns out to be the one that has suffered the greatest decrease in coverage. Given the significant impact that the pandemic has had on public health, the Ministry of Health has outlined some specific strategies for the catch-up of vaccination activities such as the hypothesis of making telephone contacts with the families, the preparation of a list of cohorts of subjects not yet vaccinated, the preparation of information and awareness activities on the importance of vaccinations, the strengthening of communication campaigns and the expansion of vaccination services to reach the unvaccinated more easily. With regard to HPV vaccination, a particularly important task is carried out by the school and by the teachers, who during their daily contact with adolescents and their families can have on a central role in communicating and disseminating information about the importance of vaccinations .Other useful tools for the catch-up and the maintenance of coverage rates are the involvement of general practitioners, pediatricians, gynecologists and midwives. A relevant role could be played by the active call of both sexes, the maintenance of the right to free vaccination at least up to 18 years of age and the right acquired based on the cohort of birth, the inclusion of subjects at risk in vaccine offer and the application of the previously listed multi-cohort strategies ,31,41.The role played by social media should also be considered central, especially in light of the infodemic period we are going through. Even before the pandemic, the important role of social media was highlighted as adolescents were the primary target of the HPV vaccination campaign .A recent systematic review has identified the perceived low efficacy of the vaccine, possible side effects, lack of trust in health authorities and inadequate and partial information as the main causes of vaccine hesitancy regarding HPV vaccination in Europe .Catch-up programs are essential to try to reach the coverage target set by the 2017–2019 NIP. According to a study published at the end of 2019, in Europe some of the countries that recorded the best vaccination coverage (>75%) in the period 2010–2017 had implemented mass catch-up strategies in a limited period of time, while in countries with low or very low vaccination coverage this strategy has not been implemented . The tarThe role of general practitioners and pediatricians is very important as they are the health professionals who first come into contact with adolescents and their families. Updated and continuous training on HPV vaccination are essential in order to keep these health professionals focused on this issue, so that they are constantly encouraged to talk and discuss with adolescents and their parents ,45.Vaccination coverage for HPV in Italy, according to updated data as of 31 December 2020, does not reach the 95% target set by the 2017–2019 NIP, both in male and female cohorts. Although over the years and until 2019 there has been an increase in coverage for female cohorts thanks to specific catch-up interventions and vaccination has also been recommended and made free for male cohorts, this has not been sufficient to guarantee the achievement of the target threshold. The use of additional cohorts and the implementation of multi-cohort strategies has certainly helped to increase the rate of citizens protected against HPV, but to date, not enough has been done to ensure effective coverage for the entire at-risk population. It is vital to continue pushing to ensure a gender-neutral approach to HPV vaccination. Providing adequate protection for all adolescents can lead to significant health gains for the general population, greater protection for the male population, especially for men who have sex with men who do not benefit from vaccination of the female population , and finBesides, a more homogeneous approach, both at European and national level, could help to reach the final target of 90% for 15-year-old girls set by the WHO for 2030. In European countries, in fact, a great variation of the HPV vaccination coverage is registered , which iLast data have shown the terrible impact that COVID-19 has had on HPV vaccinal coverage rate. In this historical moment in which vaccines are a topic of daily discussion, it is of fundamental importance to guarantee and disseminate information that is as clear, simple and reliable as possible and that is aimed at both adolescents and parents. Furthermore, given that when we talk about HPV vaccination it is inevitable to also talk about sexual health, there is the opportunity to deliver scientifically correct information on sexually transmitted diseases and sexual education in general.It is therefore essential, especially after the impact of COVID-19 pandemic, to try to implement even more expanded catch-up interventions and to continue with vaccination programs involving more and more professionals close to adolescents and to their families such as general practitioners, pediatricians, gynecologists, midwives, and teachers.


Background: The relationship between self-rated health and gender differs across countries and generations. The aim of this study is to analyze the effect of socioeconomic conditions on self-rated health from a generational perspective, its differential effect on gender, and its influence on the gender gap in order to explore health diversity using a multidisciplinary approach and considering policy implications in Eastern European countries. Methods: We used data drawn from the European Health Interview Survey for eight Eastern European countries and EUROSTAT from 2006 through to 2009. We conducted multilevel analyses to understand the individual and national health determinants of self-rated health by gender and to determine whether national differences remain after controlling for micro variables. In order to analyze the role of equity (Gini quartile) in gender differences, Oaxaca analyses were used. Results: The self-rated health gender gap increases with age. Individual characteristics, such as educational level or smoking, influence citizens’ perceived health, and have a stronger effect on women than on men. Knowing both the characteristics (endowment effects) and the effects of individual characteristics (coefficient effects) on health is important in order to understand gender gaps among people from the silent generation. Conclusions: Our research indicates that random effects are greater for men than for women. Moreover, random effects might be explained to a certain extent by economic equity (Gini index). The combined effects of gender, cohort, and geographical differences on self-rated health have to be taken into account to develop public health policies. Self-assessed health is an important indicator of people´s health status. It is a comprehensive assessment of an individual’s physical, mental, and social well-being . A negatSocial characteristics, such as socioeconomic status or educational level, influence the self-interpretation of health ,9,10,11.Additionally, it has been argued that disadvantaged groups will fail to perceive and report the presence of illness or health deficits, which may result in misleading assessments of population health, which is called “reporting heterogeneity”. On the one hand, advantaged populations tend to report higher levels of poor health than disadvantaged populations ,16. On tSocioeconomic macro conditions also have an important influence on self-assessed health. In this sense, the scientific literature has focused on the influence of the inequality index of the distribution of resources (Gini coefficient) . It seemCultural beliefs, attitudes, and values also play an important role in the self-perception of health . In thisThe relationship between gender differences and culture in self-rated health is not static. In this sense, it is important to differentiate between the effects of age and cohort . On the Regarding the dynamic variation in the educational gradient in health, Delaruelle et al. introduced two theoretical hypotheses: a diminishing health returns model and a cohort accretion hypothesis. The first predicts a decrease in educational disparities in health, while the second one affirms that the education–health gap will be bigger in younger cohorts . The treTherefore, further research on the direct effects of gender and culture on self-assessed health is needed . In thisWe focused on Eastern European countries for several reasons. In spite of the significant geographical size and population of Eastern European countries, we do not have enough knowledge about the evolution of inequities in regard to self-reported health and gender in these countries . EasternThus, the main objective of this study is to analyze the effect of socioeconomic conditions on self-rated health from a generational perspective, its differential effect on gender, and its influence on the gender gap in Eastern European countries.The data were drawn from the first wave of the European Health Interview Survey (EHIS 83/2014). The selection of countries that share important characteristics (welfare state and capacity to create richness) allowed us to identify how differences (equity) lead to different health statuses. The use of standard questionnaires and guidelines in all countries guaranteed the comparability of our findings .The final sample size was 79,487 individuals living in eight Eastern European countries . The sampling units used in Slovenia, the Czech Republic, Hungary, and Latvia were individuals. In Bulgaria, the sampling units were households, and in Romania, Poland, and Slovakia the sampling units were dwellings. Estonia was not included due to the lack of information about some of the key variables examined in this research.In this study, we considered people from the age of 15 years old. The variable age refers to the chronological age in the survey year, while the generational cohort was calculated according to birth year intervals. We repeated estimations by gender and generational cohort. Although there are slight international differences regarding the birth year of generation cohorts, we considered the following aggregation : the silWe selected primary questions related to whether people reported a low state of health . The original question was: How is your health in general? The answers were: it is very good (1), good (2), fair (3), bad (4), very bad (5), do not know (8), and refuse to answer (9). We recodified this variable into LowSelfRatedHealth so that answers were assigned a value of 1 if individuals reported answers from 3 to 5 and otherwise they were assigned a value of 0. Answers 8 and 9 were considered missing values.As an empirical strategy, we considered multilevel models (STATA: xtmelogit). Multilevel regression models are used when there is a hierarchical structure in the levels of data, with a single dependent variable measured at the lowest level and a set of explanatory variables on each of the levels. We followed the empirical strategy used by Pinilla et al. (2002) .In our case, our data were structured with j-countries, in each of which nj persons were interviewed. Our dependent variable was LowSelfRatedHealth ij, which summarizes if individual i of country j reports a low state of health . Thus, we represented this variable as:As explanatory variables, we controlled for socio-demographic characteristics  and lifestyles . Individual socioeconomic characteristics and lifestyles are traditionally included in a literature review to explain self-rated health with individual data. Nevertheless, their inclusion provides further empirical evidence about whether country differences are based on differences in individual, national, and contextual variables. In addition, the information provided by individual and national economic variables completes the whole picture. For example, self-perceived health depends on the family income level as well as on the national equity level and welfare regime.Older individuals reported a worse self-perceived state of health than younger ones, and women reported worse states of health than men. The gender gap increased with age. One potential reason for this is that life expectancy is higher for women; thus, living longer does not mean living better. In addition, another consequence is that the percentage of men who are married in the silent generation is much greater than the percentage of their female counterparts, among whom the percentage of widows is greater. Education levels improved among younger generation cohorts. We had to be careful with the case of the Y generation, because most of them were still enrolled in the education system (over 40%). For the silent generation and baby boomers, the education level was higher for men than for women, whereas this situation was reversed among younger generation cohorts. There were also important gender differences for working situation across the generations. The employment rate was greater for men than for women, and the other way around for the case of homemakers. One consequence of this is that the percentage of pensioners was greater among men than among women of the silent generation. Regarding lifestyles, men were more likely to be daily smokers than women, and the prevalence peak was reached in the X generation. Men were more likely to be overweight than women, and the prevalence peak was reached for baby boomers among men and for the silent generation among women. Lastly, women were found to be more sedentary than men. Gender gaps were flattened out for older cohorts.As expected, women considered their state of health to be worse than men for all generation cohorts. Self-rated health becomes worse with age, with remarkable gaps between men and women from the silent generation in comparison to baby boomers and for baby boomers in comparison to men and women from the X generation see .We drew macro data from EUROSTAT. The Gini coefficient was used to measure inequality. The results are provided in Looking at the national inequity levels, we observed that people living in countries in the second tertile of inequity showed the best perceived health, while people living in countries with the highest inequity or in the third tertile showed a worse self-perceived state of health see .As our dependent variable  is binary, we applied multilevel analysis with a logistic function. The multilevel analysis helped us to understand individual and national health determinants and whether national differences remained after controlling for micro variables. We repeated estimations using sub-samples of men and women. We also repeated estimation by generation cohorts.We were also interested in whether equity (Gini tertiles) plays an important role in health in general and in the corresponding gender gap in particular. We chose to focus on Gini and not on GDP pc because GDP pc is usually an alternative way of measuring average family income, so we prioritized equality versus a second measure of wealth. When classifying countries by Gini tertiles, the Gini values of the two countries included in T2 were close to the highest value of T1 (for the case of Hungary) and the lowest value of T3 (for the case of Bulgaria). Nevertheless, the tertiles, in addition to classifying countries by groups, order groups by values; thus, the comparisons between T1 and T3 remain valid. To that end, we carried out an Oaxaca analysis for LowSelfRatedHealth to address gender gaps, repeating estimations by sub-samples of countries distributed in Gini tertiles. The Blinder–Oaxaca decomposition showed that the differences in the means of LowSelfRatedHealth between men and women were due to differences in the mean values of the independent variables within them and/or group differences in the effects of the independent variables.Educational level has an important impact on the self-perceived state of health; thus, higher education levels improved the level of self-perceived health. The impact of education was the greatest for baby-boomers. In general, health perception was more sensitive to education among women than among men. Regarding employment situation, being unemployed versus being employed exerted a negative influence on the self-perceived state of health, with the impact being stronger for men and older generations. Being a pensioner and housekeeper also exerted a negative influence on the self-perceived state of health. Only being a student versus working had a positive influence for men from the Y generation.Smokers from younger generations perceive their health as worse than non-smokers. A special case is male smokers from the silent generation, who consider their health to be better than non-daily smokers. Being overweight and physically inactive is also negative for health. The negative impact of smoking and overweight on health perception is stronger for women than for men and for younger generations than for older generations. Nevertheless, the negative impact of sedentarism on health perception is, in general, stronger for men than for women from the oldest and the youngest generations.Random effects are relevant and statistically significant for both male and female sub-samples. Random effect models assist in controlling for unobserved heterogeneity; thus, unobserved heterogeneity plays a greater role in understanding self-perceived health. Random effects are stronger for older generations among women and for younger generations among men. As shown in Among the results obtained for a sample of Eastern European countries, we want to highlight that age is an important predictor of self-rated health, even among people who belong to the same generation. As in previous research, educational level is positively correlated with the self-perceived state of health, whereas unhealthy lifestyles and poor working conditions are negatively correlated. This research stresses that the impact of education on health perception is stronger for women than for men. Among generation cohorts, education has the greatest impact on baby boomers, as other research has pointed out .The impact of smoking and overweight is stronger for women than for men and for younger generations than for older generations. However, the opposite is true in the case of sedentarism. The European Commission (2013)  reports One of the main implications of this research, is the importance of to taking into account differences based on gender, generational cohorts, and national settings. It is significant that people who poorly assess their health are people living in the most unequal and the most equal countries. Regarding healthy aging, people from the silent generation show the widest gender gaps in relation to self-perceived health. In this case, characteristics and their impact on health explain the gender differences in equal countries, but in the case of the most unequal countries, gender differences based on characteristics (endowment effects) are not as important as gender differences based on characteristics’ impact (coefficient effects) . Gender The scientific analysis of these health inequalities at the national level is a complex topic because we need to isolate the effect of several indicators that are interrelated. In this paper, we selected Eastern European countries because they share a common welfare system, and there is an important linkage between equity and the capacity to create richness. However, in these Eastern economies, health care resources are limited and universal access, a feature of communism, has been lost . The traIn spite of the results, inequity could be studied as a mediating variable that also affects structural and cultural changes . How incAlthough self-reported health may not always be able to accurately capture variations in absolute health across countries, it can be especially useful for comparing national states of health among countries . In addiFor future research, the limitations of the use of self-perceived health assessment might be handled by including objective health indicators such as limitations in daily activities. Another research direction might be to analyze the impact of domestic health systems on the perception of health. In this sense, differences in coverage and access may be relevant in the assessment of citizens’ health. A longitudinal approach to these questions—for example, by a panel data strategy based on individuals, regions, and nations—would provide information on the impact of the economic crisis and its possible recovery according to wealth indicators.Lastly, a critical point when implementing the multilevel technique is related to the number of observations made at different levels. In this study, we compiled 79,487 observations of individuals living in eight countries. For studies such as this one, it is recommended to include around 20 countries. Nevertheless, the optimal number of groups also depends on the target of inference, because using a large sample of individuals (level 1) in a reduced number of countries (level 2) provides robust estimations of fixed effects, whereas estimated random effects might be biased . Under tDespite the important role of unobserved heterogeneity in determining self-perceived health, especially for men and older generations, our results show that in Eastern Europe, a gender gap in self-assessed health persists with relevant differences in health determinants among different generational cohorts, even when controlling for countries with the same welfare system. Historical, sociocultural, political, and economic context is therefore critical in attempts to understand the health trajectories of women and men, which are not uniform across cohorts . Family


This paper aimed to study the application value of Internet of Things (IoT) edge computing algorithm-based ultrasound-guided erector spinae plane block combined with edaravone anesthesia in thoracoscopic lobectomy. A total of 110 patients undergoing thoracoscopic resection were selected as subjects. The patients were anesthetized with erector spinae plane block combined with edaravone before surgery and underwent chest ultrasound scan. IoT edge computing algorithm was constructed and applied to ultrasound images of patients to enhance and denoise the images. It was found that, in different mixed noise mixtures , the edge computing algorithm can still maintain the edge information of the output image, showing better performance on edge information detection and denoising compared with the Prewitt and Canny operator. In addition, visual analog scale (VAS) scores decreased with postoperative time after edaravone anesthesia induction and erector spinae plane block lobectomy and reached the lowest level after five days. In short, erector spinae plane block combined with edaravone showed good sedative and analgesic effects on patients undergoing thoracoscopic lobectomy. Ultrasound images processed by IoT edge computing algorithm showed high accuracy in the identification of lung lesions, which was worth applying to clinical diagnosis. Lobectomy is mainly used for lobectomy of malignant tumors limited to the lung, pulmonary damage caused by tuberculosis, severe bullae, bronchiectasis, interstitial lesions, trauma, and dysplasia. Lobectomy is a kind of routine pulmonary resection . The humHowever, the postoperative pain of this type of surgery is relatively strong. Insufficient intraoperative anesthesia or insufficient postoperative analgesia will affect the patient's cough, sputum, and so on, which may easily lead to adverse events and affect the patient's recovery process. Edaravone is a new type of free radical scavenger, which can scavenge oxygen-free radicals, inhibit lipid peroxidation of cell membranes, and reduce tissue edema and damage. Studies have shown that edaravone can reduce the production of inflammatory factors in the human body and has a protective effect on the lungs of patients . In receWith the full integration and adoption of cutting-edge technologies such as big data, Internet+, AI, and Internet of Things (IoT), AI-assisted medicine has shown strong influence and vitality. It plays an important supporting role in deepening the reform of the medical and health system, accelerating the construction of “healthy China,” and promoting the development of the medical and health industry . At presIn the process of thoracoscopic lobectomy, some small pulmonary nodules cannot be accurately located during thoracoscopic surgery, and the boundary of pulmonary nodules is not easy to be identified. Ultrasonic guidance based on IoT edge detection algorithm was used to identify and locate hilar vessels and to surround small nodules in thoracoscopic lobotomy, to study the adoption value of the intelligent algorithm and ultrasound image in thoracoscopic lobectomy, aiming to provide more reference for the diagnosis and treatment of lobectomy and the sedation and analgesia methods of postoperative patients.In this study, 110 patients who received thoracoscopic lobotomy in hospital from September 2019 to September 2020 were collected as subjects, including 58 male patients and 52 female patients aged 25∼68 years (43.7 ± 5.2 years on average). This study had been approved by the Medical Ethics Committee. The patients and their families understood the content and methods of the study and agreed to sign the corresponding informed consent.Inclusion criteria were as follows: (i) patients who underwent lobectomy after prepathological and imaging diagnosis of lobectomy; (ii) patients aged between 45 and 65 years; (iii) patients with no pulmonary metastasis, mediastinal lymph node enlargement, or pleural hypertrophy; (iv) patients who had not received any other drugs or antibiotics recently; (v) patients with normal coagulation function and platelets.Exclusion criteria were as follows: (i) patients with other system or organ lesions; (ii) patients who did not cooperate with treatment due to personal or other factors; (iii) patients with incomplete clinical data and medical history.All patients were fasting and abstaining from drinking 6 h before anesthesia induction, and all vital signs were monitored before surgery, including heart rate, diastolic blood pressure, systolic blood pressure, pulse oxygen saturation, and mean arterial pressure. 0.5 mg/Kg edaravone was added to 100 mL normal saline, and the infusion was completed within 30 min. A conventional disinfection towel was taken from the surgical position, and an erector spinae plane block was performed under the guidance of ultrasound. The puncture was performed after local anesthesia with 1% lidocaine at the puncture site. Local anesthetic drugs were injected after a puncture to the designated location, and a two-point block was selected according to the intercostal incision. Each puncture site was injected with 10 mL of drugs, and 0.5 mg/Kg edaravone was used as an anesthetic. The results of nerve block were tested by alcohol cotton ball 10 minutes after injection.In lobotomy, an incision was made in the fifth intercostal area between the midaxillary line and the anterior axillary line, approaching the hilum at a small angle to facilitate the operation of hand instruments along the longitudinal axis. During the operation, the hemodynamic indexes of patients were monitored in real time, and the corresponding vasoactive drugs were timely corrected in case of intraoperative hemodynamic instability.All patients included in the study underwent lung ultrasound examination. The patient was placed in a lateral position, and a high-frequency linear array probe was used for sagittal scanning. After the T4 spinous process was positioned, the probe was moved 3–5 cm to the outside to show the T5 transverse process, pleura, and transverse costal ligament. The ultrasound images were interpreted by two attending physicians or imaging physicians with rich clinical experience. The specific location of pulmonary lesions, the maximum diameter of the lesion site, and hilar and mediastinal lymph node enlargement were mainly observed and analyzed by ultrasound.f,  is the position of the pixel, and f is the gray value at that point so that the image is regarded as a curved surface. The edge of the image is the most drastically changing position on the curved surface, and this position is also the position of the local extreme point of the curved surface. The basic idea of the image segmentation method based on edge detection is determining the edge pixels in the image first. Then, these pixels are connected together to form the required area boundary. The image edge generally refers to the position where the grayscale change rate of the image is the largest. Edge detection refers to the process of detecting edge points and edge segments from the image and describing the edge direction. The image is regarded as a binary function The brightness change of the image can be processed and enhanced by the difference between adjacent points. Differential processing of adjacent points in the horizontal direction can detect the brightness change in the vertical direction, that is, the horizontal edge detector . Differential processing of adjacent points in the vertical direction can detect the brightness change in the horizontal direction, that is, the vertical edge detector . The expressions are shown inEx represents the vertical edge and Ey represents the horizontal edge. The horizontal edge detection operator and the vertical edge detection operator are combined, and the vertical edge and the horizontal edge can be detected at the same time, as shown inAmong them, From the above equation, equation  is obtaiIf a pixel is inserted between two adjacent difference points to achieve this, it is equivalent to using two adjacent first-order differences as the new horizontal difference, as inExx represents the new level difference.Here, A gradient operator is defined by the method of first-order differentiation. The gradient is a vector, which indicates the direction of the most dramatic change in the gray level of the image.The gradient can be expressed asThe direction of the gradient is shown inIn actual image processing, the difference method is used for calculation. However, the use of the differential method for edge detection must make the direction of the difference perpendicular to the direction of the edge. Therefore, it is necessary to perform difference calculations in different directions of the image, which increases the amount of calculation. Generally, the edges are divided into horizontal edges, vertical edges, and diagonal edges.The Roberts gradient operator uses the difference between the values of two adjacent pixels in the diagonal direction as a measurement standard, and its calculation method is shown inEquation (11) is written in the form of convolution operation, and the convolution kernels are the following equations:The Prewitt operator combines the method of difference operation and neighborhood averaging, and its convolution template is shown inThe two Soble operators are for detecting horizontal edges and detecting vertical edges. It weighs the influence of the position of the pixel, which can reduce the degree of edge blur. Since the Soble operator is a form of filter operator, it is used to extract the edge and can use the fast convolution function, which is simple and effective. However, the Soble operator does not strictly distinguish the main body of the image from the background; that is, it is not based on image grayscale processing. If the weights of the center pixels of the two Prewitt template operators are doubled, the well-known Soble edge detection operator is obtained. It is composed of two masks that determine the edge in a vector manner. Soble has better performance than other edge detection operators in the same period as the Prewitt operator .Ultrasound uses the difference between echo and original sound waves to produce images. The ultrasonic wave will change after being reflected by the object. The change is related to the shape characteristics of the object, and the shape of the object is determined according to the reflected wave. Ultrasound is injected into the body through the organs and tissues with different acoustic impedance and different attenuation characteristics from the surface to the deep, resulting in different reflections and attenuations. However, the existing ultrasound imaging technology is susceptible to interference from image noise, and the detection effect of blur and discontinuous edges is not good. Therefore, the IoT edge detection algorithm processes the ultrasound image and then judges its blur and discontinuous edge detection effect on the ultrasound image by setting the direction of the edge detection and the edge gray threshold.VAS is used for pain assessment and is widely used in clinical practice. The basic method is to use a moving ruler about 10 cm long with 10 scales on one side, and the two ends are “0” and “10” points, respectively. 0 points mean no pain, and 10 points mean the most severe pain that is unbearable .s), and the count data were expressed by the percentage (%). Pairwise comparison used analysis of variance. P < 0.05 indicated that the difference was significant.The data processing in this study was analyzed by SPSS 19.0 version statistical software, some measurement data were expressed by the mean ± standard deviation .Edge detection of medical image is an important basis for image segmentation, object recognition, region shape extraction, and other image processing fields. In the process of image understanding and analysis, the first step is often edge detection to identify the points with obvious brightness changes in digital images . The so-P < 0.05). VAS scores decreased with postoperative time after edaravone anesthesia induction and erector spinae plane block lobectomy. After five days, the VAS score of the patients was reduced to a low level. The results of this study were in line with expectations. A number of previous studies have shown that erector spinal muscle plane block combined with edaravone has a positive sedative and analgesic effect on patients undergoing thoracoscopic lobectomy. Ultrasound images based on IoT edge computing algorithm are more accurate in the identification of lung lesions. This was similar to the results of Williams et al. [In this study, patients undergoing laparoscopic lobectomy were selected as subjects, and lung ultrasound examination was performed on the included patients. The ultrasonic image was filtered, enhanced, and denoised by IoT edge detection algorithm. Ultrasound images were processed and used in erector spinae plane block combined with edaravone anesthesia-induced lobectomy. It was found that, under different mixed noise conditions and SNR conditions, the edge detection algorithm can still maintain the edge information of the output image well and the image enhancement effect was good. The Soble operator had better edge detection performance than the Prewitt operator and Canny operator at the same period and had better edge information detection performance for ultrasonic images. Edge detection and filtering had a good effect on noise removal of ultrasonic images. The detection rate of the Soble operator for pulmonary nodules of different sizes was significantly higher than that of the Canny operator and Prewitt operator (s et al. , indicatIn this study, three edge detection algorithm models were constructed and applied in the ultrasound images of 110 patients with lung disease. The results found that the erector spinal muscle plane block combined with edaravone had a better sedative and analgesic effect on patients undergoing thoracoscopic lobectomy. The ultrasound image based on the IoT edge computing algorithm showed higher accuracy in identifying lung lesions, and it was worth applying to clinical diagnosis. The disadvantage was that it lacked comparison with other intelligent algorithms, and the representativeness was low. Therefore, in subsequent experiments, an improvement and optimization would be made in this area, and more in-depth exploration of this direction would be carried out. In summary, this study provided a reference for the application of intelligent algorithms such as edge detection in medical imaging.


Social distancing due to the COVID-19 pandemic represented a golden opportunity to implement telerehabilitation for clinical groups of children. The present study aims to show the impact that telerehabilitation had on the experience of well-being of children with special needs being treated at the Foundation IRCCS Neurological Institute ‘C. Besta’ in Milan ; it aims to do so by comparing it with experiences of those who did not undertake telerehabilitation despite the diagnosis during the pandemic, and with typically developing children. Results show that the three groups differed in the Support, Respect and Learning dimensions of well-being experience. Post hoc comparisons revealed that children with Specific Learning Disorders and Cerebral Palsy scored higher than normotypical children in Support and in Respect scales. Furthermore, children who experienced telerehabilitation showed the highest scores on the Learning scale in comparison with the other two groups. These results support the importance of reorganizing care and assistance by integrating telemedicine, which seems to have fostered a positive experience of well-being in people with special needs, particularly in the perception of a supportive environment that respects psychological needs. The COVID-19 pandemic crisis is causing concern for the health and well-being of the world as a whole. Social distancing, in response to the pandemic, has also implied social isolation which has exposed, especially children, to the risk of developing relational distress and particularly, in the clinical setting, in the case of those children who were following a rehabilitation program related to their diagnosis that they have, in many cases, interrupted. The COVID-19 pandemic has intensely affected Italy, in particular Lombardy and Milan, since March 2020; among the measures implemented at national and local level to reduce the contagion, there has been the reorganization of hospitals in general. In particular, the Foundation IRCCS Neurological Institute ‘C. Besta’ in Milan, which had initially been conceived as a hub for non-COVID patients with neurological pathologies, in order to ensure continuity of care for all patients already followed, has reorganized and converted its activities to remote  necessitIn Italy, child neuropsychiatric services were obliged to interrupt care assistance due to regulations provided by the government as measures for the containment of the virus . DistinThe attention provided by both clinicians and the world of research has also highlighted the risks of the pandemic emergency concerning the maintenance of human rights for children with disabilities and in poor socioeconomic conditions and disability . HoweverMoreover, at the Foundation IRCCS Neurological Institute ‘C. Besta’, the COVID-19 pandemic has provided new opportunities for rehabilitation of children with special needs, as children with Cerebral Palsy (CP) and children with Specific Learning Disorders (SLD) have benefited from the comprehensive integration of environment and family, in line with the International Classification of Functioning, Disability and Health (ICF) psychosocial model .The reorganization of rehabilitation was not intended as a simple transfer of remote therapeutic paths; instead, it required the redefinition of objectives and rehabilitation methods, with the maintenance of the same therapist. In order to revise the therapeutic protocols with respect to telemedicine, the specialists verified the possibility of a child telerehabilitation basing on an informative checklist, which includes: child’s characteristics ; family compliance . Then, together with the parents, a new care and rehabilitation plan is developed. Several clinical centres that experimented with telemedicine and telerehabilitation pathways during the COVID-19 lockdown (first phase) have carried out research on the perception and satisfaction of stakeholders in telerehabilitation ,13. DuriIf the above underlines the impact of the pandemic on rehabilitation and care institutions, at the level of the individual, the social distancing due the pandemic undoubtedly represented a challenge also for well-being and emotional experiences for children and adolescents. This scenario led to children’s perception of a feeling of isolation and lack of relational support with effect on the emotional and well-being experience, especially due to the absence of the scholastic environment . From a The impact that COVID-19 pandemic had on the well-being of typically developing children and adolescents was immediately a research object in the most affected countries, starting with China, and then in other countries. In particular, alarming levels of behavioral and emotional disturbances in children have been detected ,31. The The psychological consequences of the lockdown due to the pandemic were primarily studied on caregivers, who were stressed by the fear of contagion, the activation of smart working, job losses and consequently the effects this stress had on their children. Parental self-efficacy seems to play an important role in moderating the consequences of parental distress on children’s well-being . Anti-coWhat about children with special needs? Research on the impact caused by the pandemic on well-being and mental health in children with different types of special needs has been conducted through the administration of questionnaires aimed for parents, such as Child Behavior Checklist for ages 1.5–5 and for ages 4–18 , or quesThe present study aims to show the perceived experience of well-being of children with special needs that had been through telerehabilitation during the pandemic period by comparing it with experiences of those who did not undertake telerehabilitation during the pandemic, and with typically developing children. We proposed to ask both typically developing children, and children with special needs for their direct opinion on their wellbeing experience. The purpose of our research is to verify the hypothesis that those who had a rehabilitation path pre-COVID and had the possibility to continue the rehabilitation process and care remotely during the emergency period, may have experienced greater well-being compared to those who had not benefited from it. Comparison with a normotypical group gives us the opportunity to consider the pandemic variable and control it. The implemented contagion containment measures, have, in fact, required an enormous adaptive effort from the entire pediatric population, greatly limiting the possibility of social relationships, the possibility of learning through direct experiences, involvement and satisfaction in the learning process, trust in future and quality of life. The emotional costs paid by children have been extremely high: caregivers, educational facilities, schools and families, who were stressed and afraid, have struggled to understand and satisfy the development needs of each child. Therefore, we expect that participants with special needs who have had a presumably better response from the environment in terms of continuity in care, rehabilitation and relationships with specialists may have had a better experience of well-being than those who have not received it.In terms of participants, 56 children with different types of special needs were recruited from the clinical service of Developmental Neurology Unit of Foundation IRCCS Neurological Institute ‘C. Besta’ , and 30 normotypical children attending primary and secondary schools in Milan. All participants completed the online questionnaire, which was sent through an online survey (Google Forms) after collecting written consents by their parents, in the period from May to August 2020. All participants were native Italian speakers. The clinical study sample consisted of 36 children with Specific Learning Disorders (SLD) and 20 children with Cerebral Palsy (CP). From these two groups, children with SLD and CP who were telerehabilitation were selected for each group, respectively. These children were matched by gender, age and comorbidity in the SLD case and by age, gender and severity in the CP case with children who did not undergo telerehabilitation during the study period. More specifically, the SLD Telerehabilitation group (N = 8) had these clinical characteristics: 1 child with Dyscalculia, 2 with Dyslexia and Dysorthography, 5 with Dyslexia, Dysorthography and Dyscalculia. This group was matched with the children with SLD No telerehabilitation group (N = 8) that had the same clinical characteristics: 1 child with Dyscalculia, 2 with Dyslexia and Dysorthography, 5 with Dyslexia, Dysorthography and Dyscalculia.For children with CP, Telerehabilitation group (N = 9) had these clinical characteristics on the base of the Classification Systems for children with Cerebral Palsy, the Gross Motor Function Classification System , the MaAs for children with SLD, Telerehabilitation group , had the opportunity to have 2 online treatment sessions a week (45 min), focused on reading, writing and math skills whereas children in No telerehabilitation group  had finished their treatment before the pandemic period, after reaching the goals of their rehabilitation projects. More specifically they are involved in telerehabilitation with online dyslexia platform as RIDInet with Reading Trainer app and Rhythmic Reading Training RRT teleintervention . The telAs for children with CP, Telerehabilitation group  was supported by 1 online treatment sessions (45 min), for mean 13 weeks, tailored on their neuro-psychomotor needs, whereas children in the No telerehabilitation group  did not show, in that period, any specific need to be addressed through rehabilitation projects. Tele-treatment for children with CP consisted of real-time treatment for children with a neuropsychological and learning exercise program; sharing of either information with parents and with special need school teachers or an exercise program to be implemented by the parents or teachers. For these children with motor needs, video-tutorials were sent to parents twice a week, in which the exercises to be performed by the child were explained. The weekly supervised meeting with the therapist allowed parents to be correctly guided and above all, it allowed for subjects to maintain contact with the therapist; giving information and technical feedback about pharmacological treatment, checking the effects of the therapy on motor pattern and adaptive functions. Furthermore, two children continue the work about the study method that aimed to integrate compensatory tools in combination with the results of his CP .All children were tested to verify the efficacy of the treatment at the end of the rehabilitation cycle. In all, a benefit was found in their performances and instrumental skills. As for the normotypical children (N = 30), recruited from school in Milan, they had no diagnosis of special needs. They were matched to the clinical groups by gender and age  and age .In sum, in order to assess the impact of telerehabilitation on well-being in children with special needs, three groups were selected for both SLD and CP conditions: children with SLD or CP who made experience of telerehabilitation , children with SLD or CP who did not experience telerehabilitation , normotypical children . They were matched by gender   is a briAn invitation to participate in the research was sent to all families whose children were in charge of Developmental Neurology Unit, Foundation IRCCS Neurological Institute ‘C. Besta’ of Milan. The rate of positive responses was 92%. Parents who gave their consent communicated to the researchers the email address to be used to get in contact with their children. Each participant received, by email, a link to fill in the questionnaires on the online survey platform. Questionnaires were administered by researchers and were completed individually by children. Data collection lasted from May 2020 to August 2020.(1) In order to assess the differences in CIT-C scales between groups , a MANOVA was carried out on the CIT-C scales raw scores with Group  and Condition  as independent variables;(2) The effects of Group and Condition on SPANE scores (Positive and Negative) were considered as independent factors in two ANOVAs.Post hoc comparisons were applied to analyze significant differences in detail.First, it is worth noting that all three groups of children  showed mean scores on CIT-C scales within 1.5 SD from the normative mean .F24, 70 = 3.14, p < 001; 2η = 0.518), irrespective to the Condition, which did not reach significance level neither as main factor , nor in interaction with Group . One-way ANOVAs showed that the three groups differed on Support , Respect  and Learning  scales. In post hoc comparisons, Sidak adjusted  for children with CP is extensive, 2–3 times per week up to 6 years of age; for older aged children, depending on the objectives, the frequency of treatment is reduced (1–2 times per week), while extensive treatments are carried out in severe neuropsychological or learning disorders, and specific focus-intensive cycles, 2–3 times per year. The results of this study, even with limitations, contribute to the literature confirming that telemedicine reorganization provides a comfortable environment for young patients. Moreover, in our study, all children had already been diagnosed in our institute, although not all of them were undergoing rehabilitation. Previous research has investigated the experience of well-being in children and adolescents with special needs; indeed, the presence of neurodevelopmental disorders can be a risk factor for the development of emotional and behavioral problems, and not only has an impact on learning possibilities but also on well-being. However, some studies with students with learning difficulties show that having a diagnosis seems to have a protective role for their psychological well-being compared to those children who, despite presenting difficulties, have never received a diagnosis . RecentlThe result regarding the positive and negative experience measured by the Scale of Positive and Negative Experience (SPANE) did not reveal any significant difference neither by Group nor by Condition. This result can be explained by the same situations and the same feelings shared by all children. The impact of the restrictions due to the pandemic involved the whole world and led to shared feelings, regardless of condition. This has led to children answering questions such as “in the last 4 weeks I have felt sad” or “in the last 4 weeks I have felt happy” in the same way, regardless of whether they are in telerehabilitation or a typically developing child.In conclusion, our findings support the importance of having reorganized care and assistance by integrating telemedicine, which may have fostered a positive experience of well-being in people with special needs, particularly in the perception of a supportive environment that respects psychological needs. The aim was to ensure continuity of care, while remaining aware that this could not replace in-person interventions. Home-based rehabilitation is an emerging feature in the literature and the difficulty, which has not always been overcome, has been that of transferring the complex regimes based on motor learning principles and psychological consultation to the home setting. The possibility of maintaining remote rehabilitation also seems to have nurtured feelings of mastery and accomplishment in children with special needs. We would therefore like to see the maintenance of hybrid methods, integrating telemedicine into clinical practice, adapted to the needs of each individual and with attention to the psychological well-being of young patients.Although the results of our study give some insights about the opportunity for telerehabilitation to support students’ well-being, some limitations should be emphasized, concerning the size of the sample and the not entirely homogeneous nature of the types of treatments and clinical profiles. A larger sample size would have allowed us to consider the different types of treatment performed and also to analyze the relationships and comparisons between the different variables through more complex statistical techniques, which would allow for a greater generalization of results. This was also due to the period in which the data were collected, and the initial phase of the reorganization, which prompted an investigation into these issues, regardless. However, to the best of our knowledge, this is the first study to ask children with special needs how they were approaching this period of difficulty using a control group with typical development. Therefore, we hope that the present study might be considered a “small part” of the literature on the topic of telemedicine with a focus on its effects on the well-being of young patients.