Schizophrenia is among the world’s top 10 causes of long-term disability with symptoms that lead to major problems in social and occupational functioning, and in self-care. Therefore, it is important to investigate the efficacy of complementary treatment options for conventionally used antipsychotic medication, such as physical training, and psychosocial interventions.To combine aerobic and strength training with cognitive, emotional and social stimulation in one intervention for people with schizophrenia and test the feasibility and effects of this intervention.The study is a mixed-method randomized controlled trial to evaluate the effects of a 12-week intervention for adults with schizophrenia. The treatment group (30 participants) will receive the intervention in addition to standard care and the control group (30 participants) only standard care. The intervention consists of 24 biweekly sessions with a duration of 60 min. The pre-test (weeks from 4 to 2 prior to the intervention) and post-test (week 12) include clinical measure (PANSS), quality of life, social performance, movement quantity, brain function and eye tracking measures. In addition, a treatment subgroup of 12–15 participants and their family member or other next of kin will complete a qualitative interview as a part of their post-test. Two follow-up tests, including clinical, quality of life, brain function and eye tracking will be made at 6 and 12 months from the completion of the intervention to both study groups. The primary outcome is change in negative symptoms. Secondary outcome measures include general and positive symptoms, quality of life, social performance, movement quantity, brain function and eye tracking. Explorative outcome includes patient and family member or other next of kin interview.Pilot data was collected by June 2023 and the main data collection will begin in September 2023. The final follow-up is anticipated to be completed by 2026.The InMotion study will provide new knowledge on the feasibility, efficacy, and experiences of a novel intervention for adults with schizophrenia. The hypothesis is that regular participation in the intervention will reduce clinical symptoms, normalize physiological measures such as brain activation, and contribute to new active habits for the participants.ClinicalTrials.gov, identifier NCT05673941. Schizophrenia is among the world’s top ten causes of long-term disability . The majPeople with schizophrenia have a substantially lowered life expectancy, reduced cardiorespiratory and muscular fitness and increased risk of cardiovascular disease and metabolic syndrome in comparison to the general population . They alMixed exercise program that combines aerobic, flexibility and resistance training is suggested to be effective in decreasing the symptoms of schizophrenia and increasing cardiorespiratory fitness and muscular strength . HoweverExpressive therapies, through dance, music or drama, emphasize the human body as the primary means of communication and expression . Dance mMirroring movement is a core technique of the Chacian approach on dance movement therapy in which the therapist creates empathic movement reflections in an interaction with the patient to connect deeply and authentically . Chace bMany people with schizophrenia suffer from symptoms of disembodiment, body image disturbances and deficits in the feeling of being an agent in their own bodies and lives . Body imWorking with and enhancing body awareness, movement and agency for own body and action are the core elements dance movement therapy . In dancFor people with schizophrenia, a qualitative study on dance movement therapy suggested that group exercises through dance may transfer to their daily life . In geneResearch on dance movement therapy for people with schizophrenia suggests enhanced attention and self-regulation  whereas Taken together, recent results suggest that dance-movement therapy and body psychotherapy may be effective in reducing both negative and psychotic symptoms in individuals with schizophrenia, as well as improve psychosocial functioning and ability to control anger e.g., . In addiBehavioral and brain imaging studies may help to explain the bodily disconnection people with schizophrenia display. A disturbed implicit sense of the bodily self in people with schizophrenia is traced partly to deficits in the motor representation in the brain related to their bodily self . The braSeveral empirical studies suggest that disturbances in self-experience and self-monitoring could be closely associated with anomalies in the self-other relationship . BecauseLow tolerance for stress and stimuli is a common symptom within people with schizophrenia . ResultsConventional occupational or physical therapy in people with schizophrenia does not include emotional expression. On the other hand, dance-movement therapy and body psychotherapy focus on emotional, social, cognitive, and physical integration of the individual. They do not primarily aim for the physical benefits that aerobic training, conducted at a moderate to intense level around 60% and higher of the maximum heartrate, is known to have. Nor do they aim primarily for gaining muscle strength, the training of which utilizes body weight with repetitions and progression in load and complexity over time.There is a growing interest in the mechanics through which motor-related brain processes influence in emotional and cognitive processes. Several studies show how creative movement, such as dance, shapes the brain structure and function in both the general population and trained dancers  and modiPositive influence of regular dance training is shown to go beyond the improvement of physical abilities to the alleviation or prevention of symptoms in clinical populations. Different dance trainings in people with stroke, Parkinson or dementia are shown to increase physical abilities such as balance, muscle strength and smoothness of movement sometimes even more efficiently than conventional physiotherapy. Such dance trainings are also shown to improve quality of life, mood, emotional expression, and other behavioral measures  general and positive symptoms of schizophrenia, (b) quality of life, depression and social performance (c) levels of physical activity, physical function and general health indicators, and cortical aspects of (d) error detection and conflict resolution on the prefrontal cortex, (e) emotional induction and regulation on specific emotions on the frontal cortex, (f) full-body movement quantity and rigidity, (g) cognitive function such as memory and fluency of speak, and (h) to explore the participants experiences of taking part in the intervention and any experienced change from it. Similarly, experiences from their related parties  will be collected regarding the influence of the intervention in the participants . Our hypClinicalTrials.gov (No. NCT05673941). Any protocol modifications will be communicated to relevant parties.The study was approved by the Swedish Ethical Review Board in Uppsala, Sweden (No. 2022-03980) and is registered on This study, called InMotion, will be conducted in two phases: pilot study and main study.In the pilot study, which finished in June 2023, two people with schizophrenia participated in the intervention of mixed exercise program with creative movement (InMotion intervention) with 2–3 instructors. Participants did not need so many instructors, but the pilot study was a good chance also for the instructors to practice guiding the intervention. Hence, three instructors participated in some of the pilot sessions. A family member or other next of kin could attend the movement sessions if the patient wished so. The intervention lasted 12 weeks including 60-min sessions twice a week, similar to the following main study. The following pre- and post-intervention data was collected: PANSS, CGI-S, CGI-I, PSP, CDSS, BAQ, EQ5D, blood pressure, resting heartrate, breathing frequency, waistline, BMI, postural stability, leg strength and accelerometer/everyday activity. Cognitive and brain imaging data were not collected at this phase due to logistical issues with the EEG-fNIRS equipment. However, the brain imaging measurement will be piloted separately with a person with schizophrenia.The main study will be a prospective randomized controlled trial (RCT) with 2 parallel groups: an intervention group (30 participants) and a control group (30 participants) of adults with schizophrenia or disorders with symptoms similar to schizophrenia, as described in section “2.3.1. Inclusion criteria.” The intervention consists of sessions on mixed exercise program with creative movement two times a week for 12 weeks in addition to standard medical care as described in section “2.9 Standard care.” Each group will include 4–6 participants under the guidance of two instructors. The control group receives standard medical care and gets access to the video-links after the 12-month follow-up. Most outcomes are measured at baseline, after 6 and 12 weeks, 6 and 12 months see . The stuN = 60) includes adults diagnosed with schizophrenia or schizophrenia-like disorders according to the criteria presented below.According to national guidelines , schizopPeople aged 18–65 years with schizophrenia diagnosis or schizophrenia-like disorders, performing moderate to vigorous physical activity less than 150 min/week based on self-report, are included in the study. Outpatients with schizophrenia (F20), schizoaffective disorder (F25), and acute schizophrenia-like psychotic disorder (F23.2) with at least mild symptom severity (>21 on 7 negative items of PANSS) will be included.People with current or recent history of substance abuse, bipolar disorder, severe autism, suicidal, severe physical illness, inability to read and understand the Swedish language, inability to participate in a group setting or patients who reported more than 150 min of physical activity at moderate to high level per week are excluded from the study. Patients with less than 21-point score on PANSS negative scale will be excluded.Recruitment is planned to take place at an outpatient psychiatry center, where clinicians, such as psychiatrists, nurses, occupational therapists, social workers, physical therapists and assistants are asked to inform patients about the study and recruit them during their regular check-ups. Written and informed consent will be obtained from all participants. After written consent is received, the diagnosis according to the inclusion criteria will be verified in the medical records or by examination by a psychiatrist.Schizophrenia patients and their legal guardians, who consent to the study and are eligible for the study according to the inclusion criteria, will be offered to proceed with the baseline measurement.The intervention covers various themes through three different parts (4 weeks per part) with the aim to improve clinical symptoms, physical fitness, cognitive skills and emotion regulations. The intervention was developed by a team consisting of a neuroscientist, a psychiatrist, dance teachers and physiotherapists with previous experience in designing dance and movement interventions for different target groups with internalizing problems , functioThe participants will be randomly divided into two groups, 30 patients who will receive the mixed exercise program with creative movement intervention in addition to continuing their conventional treatment plan and 30 patients who will only receive their usual treatment. Randomization in the main RCT study will be carried out in sealed envelopes after the baseline measurements. An external statistician will prepare the envelopes that will be delivered to the participants by the research team. Thus, the randomization will be blinded to the research team, meaning the research team will not know the group or identify of the participants when analyzing the data. Due to the nature of intervention studies, blinding toward the participants is not possible. Physical activity cannot be blinded, meaning that the patients know whether they are receiving the treatment or not.N = 60 (30 intervention + 30 control participants), including a 25% dropout rate.The sample size is calculated according to the primary outcome PANSS. For the primary outcome (improved negative symptoms according to PANSS after 12 weeks), the total number of required study participants was calculated . CalculaThe intervention is called “InMotion” to highlight physical activity as a natural part of positive lifestyle habits for adults with schizophrenia. Essential elements of the intervention will include a focus on physical exercise, enjoyment, socialization, and playful creativity in a safe environment. Physical activity is central in the intervention since previous result showed decreased BMI and increased condition , increasThe InMotion intervention shares some similarities with dance movement therapy. Our intervention has similar components especially with the approach by Chace . For exaThe group setting of our intervention is similar to the one used in dance movement therapy for people with schizophrenia . In addiStandard care is based on the national guidelines includes regular outpatient visit at a minimum of once a year, treatment with an antipsychotic agent (>80% of those with standard care on one or the other antipsychotic agent), a once-a-year general check-up with blood samples including metabolic markers, among other things. This varies, however, according to individual patient need.The instructors are healthcare professionals such as counselors, physiotherapists or nurses with experience in physical interventions, and/or dance teachers (bachelor’s in dance pedagogy) with experience of meeting patients with mental health issues. Before starting the intervention in the main study, the instructors will attend a 1-day course regarding the target-group as well as the intervention administered by the research team. During this course, the instructors will receive practical instructions about the movement sessions according to the standardized program design and how to work with the target-group safely, supportively and ethically. The course will also cover shortly the theoretical background of schizophrenia and the mechanisms through which the intervention aims to improve the clinical, physiological and emotional condition of the target group. Written and digital informational material will be distributed by the research team. The material will be distributed not only with documents but also with informational videos made by the research team. The intervention coordinators will provide information regarding the practical components, choreography, and modifications as well as recorded movement exercises.When a patient at the psychiatry clinic is interested in participating in the main study, contact information will be transferred from responsible clinician to doctoral student, who will call the participant, give further information, answer questions if needed, and check inclusion/exclusion criteria. A meeting at the movement laboratory at the hospital will be set up with participant and psychiatrist who will do the PANSS, CGI-S, CDSS, and PSP as well as the doctoral student who will conduct physical tests and measures and test cognitive function combined with functional brain imaging and eye tracking. The baseline measures will take about 2.5 h with a break in between. Data on gender, age, years of education, way of living, years with schizophrenia diagnosis, medication, and smoking will be collected but no other sociodemographic information. The baseline measurements will be conducted 4 to 2 weeks prior to the beginning of the intervention. It may take a few weeks to form a group, and therefore, a 2-week window for the baseline data collection is needed. The participant will be instructed about the accelerometer, which is to be worn for 7 days to evaluate everyday activity. After baseline measures are finished, sealed envelopes will be given to the participants to randomize whether they will be part of the control or intervention group. The participants in the intervention group will be shown videos of the instructors and the training studio, to enable recognition and feeling of safety.At session 2, 12, and 23 motion capture will be recorded. Those sessions will take place at the movement laboratory. Participants and one instructor will wear small reflex balls on six points: hands, elbows and knees, while doing the training session. Setting up will be done by an engineer at the movement laboratory or the doctoral student. On week 6 of the intervention the same procedure of tests, apart from the accelerometer, cognitive tests and functional brain imaging, will be repeated. After the last session, about two participants and their family members or other next of kin from each group will be purposefully selected for interview. The get a heterogenic group, we will strive for a variation regarding age, gender, participation rate and severity of disease. The participants and their family member or other next of kin will receive written and oral information about the qualitative study , before signing a written consent. After finishing the intervention at week 12 all tests from baseline will be repeated in 1–2 weeks. This will also be done after 6 and 12 months, excluding the accelerometer.The pilot study was conducted in the same way, except there was no control group or randomization procedure nor cognitive or brain imaging measures, nor will there be any follow-up tests in 6 or 12 months.The intervention will most often take place in a training studio at the psychiatric clinic, an environment well known and safe to the participants. In detail, this applies to session 1, 3–11, 13–22, and 24. Sessions 2, 12, and 23 are conducted in the Laboratory of Motion Analysis at the Örebro University Hospital which is equipped with the EEG-fNIRS and Motion Capture devices. The same locations were used for the pilot study.The duration of the biweekly movement intervention will be 60 min, the order and content of which is described in detail in After the pilot study, which was conducted in spring 2023, the intervention is modified if needed, to suit the needs of the participants based on the remarks made during the pilot study. To address individual differences and to give easy-access modifications when needed, the components will be introduced in steps with sensitivity to the group needs with a central aim to make the participants feel included regardless of previous experience. For those who need extra instruction and support, one of the instructors will be able to assist.Intervention adherence will be noted by the instructors during both pilot study and main study. To stimulate high adherence to the intervention throughout all the intervention time period, we will work in close collaboration with the clinic, both for reminding about the importance of intervention participation during the 12 weeks and in practical issues regarding getting to the studio in time. To keep the creative physical exercise sessions motivating and interesting, the focus will be on enjoyment, social inclusion and increasing body movement in harmony with music. In addition, the fact that the intervention consists of three different parts with separate themes will hopefully stimulate adherence motivation. To retain as many participants as possible, reminder text-messages and emails will be sent to participants. Notes about participants who discontinue or deviate from the study will be made.Randomization will minimize bias, but we will assess any change in the treatment plan of the participants including medication, if they stop taking their medication and become ill, or if they change to a better medication and improve because of the intervention.This study includes neuroscientific and physiological measures, questionnaires (for the patients in the study and their family member or other next of kin), and qualitative interviews  before, after the intervention and at follow ups. The patients’ psychiatrist and a person who knows the patients, such as a family member, will evaluate the state of the patient before and after the intervention, and then, the family member will also be asked about their experience on burden of care. The Personal Social Performance scale  cognitive tests with region of interest (ROI) on the prefrontal cortex: Stroop task  during the movement intervention on sessions 2 on week 1, 12 on week 6 and 23 on week 12. Each participant and the facilitators will have reflective markers attached to the skin on their hands, knees and elbows  which they will wear throughout the movement session. The markers are small and light and will not influence movement.Patients will also fill in Body Awareness Questionnaire BAQ;  before, Physical function and status will be measured at baseline, half-time through the intervention, after the intervention and at follow up 6 and 12 months. The measures are the following: (1) Postural stability test  with parTo capture the participants’ experiences of taking part of the intervention, individual semi structured interviews on the topic will be conducted with 15–20 participants in the intervention groups . The sam1EEG data will be analyzed with EEGLAB  for MATLMotion Capture data will be analyzed with the MoCap toolbox  which isU-test or unpaired t-test for continuous outcomes. A P-value of < 0.05 for the two-tailed test will be considered statistically significant for all outcomes. When deemed necessary, correction for multiple significance will be performed.The InMotion study follows the intention-to-treat paradigm. Complementary analyses will be performed per protocol according to the number of sessions the participant attends. For baseline statistics between the groups, descriptions will be constructed using frequencies and proportions for categorical data and means and standard deviations for continuous variables. Baseline characteristics will be compared using the Fisher exact test for dichotomous outcomes, the Mantel-Haenszel chi-square test for ordered categorical outcomes, and the Mann-Whitney The primary outcome analysis will initially be performed using a Fisher exact test to evaluate differences between groups. To analyze the change in scores from baseline between groups for approximately normally distributed variables, a repeated-measures covariance pattern mixed model will be used, adjusting for significant differences at baseline. To identify predictive factors at baseline that might be associated with the primary outcome, a univariable logistic regression analysis followed by a stepwise multiple logistic regression analysis will be performed.The distribution of continuous variables will be described using the mean and standard deviation or median and interquartile range. Categorical variables will be described with numbers and percentages.The interviews will be analyzed by qualitative content analysis, to this day planned to be according to The study is conducted in accordance with the standards of Good Clinical Practice and in agreement with the Declaration of Helsinki. Written informed consent will be provided by the research team. The information letter includes written information about the study, the purpose and procedures, the voluntary nature of participation, and the option to withdraw at any time. If needed, clinicians will help to clarify the written information. The participants are guaranteed confidentiality and that their data are stored on a secured server except the brain imaging data, which will be made anonymously public. It is impossible to identify the participants from the brain imaging data, and at the same time, open science is supported by publishing the data. The participants will be informed about the public data sharing on a group level without any personal information in their information letter and asked for their consent for it. In addition, the participants in the study were invited to an information meeting before the start of the study, where verbal explanations of all the procedures were given. Any adverse events or harm arising from study participation will be reported and managed by the instructors and the research team in accordance with ordinary healthcare routines.Data are collected in both pen-and-paper and digital formats and securely stored at the University Health Care Research Center. The questionnaires and tests will be pretested on a conditions-appropriate group during the pilot study to determine whether the wording and length of the questionnaire and tests were appropriate for the study’s target group. The pilot study investigated different aspects of intervention fidelity. No unauthorized persons have access to the collected data, during the study, apart from the brain imaging data as mentioned above. All the data collected are coded to protect the study participants’ identification. All data and the code list are stored securely and separately to prevent unauthorized persons from having access to them.Instructors in the study will regularly ask participants in the intervention how they felt after the previous session. Any adverse events related to the participation in intervention will be recorded and assessed in terms of severity which will be reported to the principal investigator, serious adverse events will be recorded in the patient’s medical chart.The pilot study, which was conducted in spring 2023, evaluated the acceptability and feasibility of different perspectives of the intervention, the data collection timeline, and the logistics of the study. This gives the research team valuable lessons to learn and if needed, enable adjustments before entering the main study. Due to the small sample size in the pilot study, we do not evaluate the feasibility in terms of recruitment, measurement completion, attendance rate nor drop-out. We will include the adjustments in the intervention design, data collection and logistics which will be made based on the pilot study and advance to the main RCT study in autumn 2023. We expect to publish the first results of the pilot study in spring 2024.We expect to publish the first results of the main study in 2026 with the primary, secondary and exploratory results described in detail in section “3. Outcomes.”Schizophrenia is prevalent in the adult population worldwide. Considering that the pharmaceutical treatment of the illness is far from optimal, cost-effective and easy-access interventions, which can be added on the conventional treatment, are needed. Physical, creative and social activities form an effective strategy, but intervention studies are needed to better understand if and how such activities improve the clinical symptoms, quality of life, physical skills, cognitive and emotional capacities, and facilitate regular participation for this target group.Our study will investigate several aspects of the ways that mixed exercise program with creative movement may improve symptoms, physical health and quality of life of adults with schizophrenia or schizophrenia-like symptoms. As primary results, we expect to find differences related to the negative symptoms of schizophrenia. As secondary results, we expect to find differences in several variables on general and positive symptoms, physical health, cognitive and emotional capacity and quality of life. To our knowledge, this is the first study to investigate the influence of regular physical exercise with focus on creative, emotional and social activity in people with schizophrenia with a broad spectrum of measures from clinical symptoms to physical health and brain imaging.Several studies report improved physical and emotional state in people with schizophrenia after regular practice of physical and body-awareness training, respectively . Howevercombination of all these subcomponents together. Methodologically, we follow the highest standards for clinical studies including the randomized controlled design, one-year follow-up and the combination of quantitative and qualitative measures related to clinical symptoms, physical abilities, and cognitive, emotional and cerebral functions.The challenge in a holistic intervention combining physical, creative and social components is that we cannot know which individual components contribute to the changed clinical and health outcomes. The influential subcomponents in a positive outcome could be the supportive group setting, instructors, music, or specific parts of movement exercises. However, we hypothesize that the core of the intervention is the Several aspects of our trial design are worth noting as potential limitations. Since the sample size is calculated according to the primary outcome PANSS, the results of the secondary outcomes should be considered cautiously, and the results replicated in future studies. If the sample size was calculated according to the amount of all the measurements, the sample size would be so high that it would be beyond realistic possibilities, and this study would very likely never be completed. Some of the measures, such as PANSS, are subjective whereas other measures, such as brain imaging, are objective. Although it is difficult to blind the assessor during the assessment of the objective measures, the person performing the analysis will be blinded. Since this is the first time we use such intervention of creative physical exercise, we cannot know whether the design will be robust enough to capture changes with the content  and dosage we defined (twice a week for 60 min per session). However, the content and dosage are based on previous literature on creative movement interventions in schizophrenia .In the pilot study, we tested the feasibility of biweekly attendance, which might be challenging for the participants with schizophrenia. However, in the pilot study, there was a high attendance rate and no dropouts. Nonetheless, we are aware that biweekly commitment implies a behavioral change that can be hard to achieve for this target group. Thus, it is interesting to investigate if the format of this intervention can influence motivation, retention, and interest to participate regularly.The results from this study will broaden the knowledge of the ways non-pharmacological interventions can be valuable for reducing the burden of schizophrenia for patients themselves, their families, and the healthcare system. Mixed physical exercise with creative movement could be an example of an easy-access joyful intervention as a complementary treatment.To conclude, this randomized controlled study with 60 participants will investigate the effects of combined physical, creative and social training in adults with schizophrenia. The primary aim is to study the effects of the intervention on negative symptoms of schizophrenia, but several other aspects, such as physical skills and health-status, cognitive and emotional capacity and brain functions related to them as well as movement quantity and mimicry, will also be studied. The results from this intervention study may provide useful information and potentially a complementary treatment to use for caregivers in primary healthcare and psychiatric in- and outpatient clinics.The studies involving human participants were reviewed and approved by the Swedish Ethical Review Board in Uppsala, Sweden (No. 2022-03980). The patients/participants provided their written informed consent to participate in this study.HP, AD, ML, and MMs designed the creative movement intervention. HP wrote the original manuscript. All authors commented and edited the manuscript.


A global survey among dentists was used to identify the various impacts of the COVID-19 pandemic on this professional group. Special attention was given to perception and assessment of infection risk. From May to August 2020, the questionnaire was delivered in 36 countries by respective research groups and was completed by 52,491 dental professionals. The survey was designed as a cross-sectional survey based on a previously standardized questionnaire. This study focuses on the part of the questionnaire that deals with the perception of the infection risk of COVID-19 by dentists and their patients. A logistic regression model was used, which consisted of four Likert items as response options and the additional self-reported routine or emergency treatment as the dependent variable. Analysis by continent found that European and Asian dentists were particularly likely to be infected at work , while it was likely that Australian dentists did not feel particularly at risk due to low infection rates. Three quarters of Americans treated only emergencies during this survey period, while Europeans (64.71%) and Asians (66.67%) provided mostly routine care. This could affect the Europeans’ confidence that they would not be able to protect themselves from infections in the long-term. The COVID-19 pandemic and its impact on dental professionals’ infection risk perception is determined by the geographical origin of dentists. This study shows that, especially in high-incidence countries, infection risk perception was higher when dentists tried to provide routine dental procedures to their patients. Dental professionals can offer themselves and their patients good protection by maintaining high standards of hygiene. However, their concerns should be taken seriously and the dental professionals’ group that is of great importance for oral health care and prevention, should not be neglected in the future, even in the event of emerging pandemics. It has been just over 3 years since SARS-CoV-2 (severe acute respiratory syndrome from coronavirus type 2) plunged the world into a pandemic. As of 15 September 2023, 695,289,957 cases of virus infection and more than 6.9 million deaths have been reported worldwide .Due to the high rate of virus transmission through the respiratory system, dentists and dental clinics have received close attention in the past three years ,6,7. DenA global survey among dental professionals has been developed and performed with the aim of evaluating the impact of the SARS-CoV-2/COVID-19 pandemic in different countries around the world through a large multicenter study . Due to The international survey was created, as previously described, with a modified Delphi method during the first wave of the SARS-CoV-2/COVID-19 pandemic between April and August 2020 ,15. UsinTo proceed with the study, the number of active dental professionals in each country that participated was collected. To reach the target of 5% participants, invitations to participate were requested at a proportion of 5–20% in each country. Each country team was able to use the strategies and modalities best suited to their country to reach the largest number of dentists in both public and private health care systems. Direct mailings to individual dental professionals were used, as well as invitations to participate through national dental associations and other related organizations and social media outreach .www.project-redcap.org; accessed on 23 October 2023).The platform that conducted the survey and collected the data was designed to avoid duplicate responses. The project protocol and the consent were approved by the local Ethics Committee in some countries, if required. If the online informed consent was not accepted/signed by a participant, the questionnaire was not evaluated and excluded. Each applicant was able to review their answers, also, all participants received a unique identification number, based on their IP address. A Research Electronic Data Capture  account provided a secure repository, where all data were stored . REDCap As independent variables, there were several data entered and updated by the national research teams, i.e., limited clinical activities to emergency only, the gross national income (GNI) per capita 2019 and purchasing power parity , and the community positive rate (CPR) during the survey period. This has been described in a previously published article .The variables analyzed in the present paper related to the dental professionals’ perception that COVID-19 infection represented a risk both for themselves during work and for the patients treated. Both items were completed with a Likert scale with four possible options .All data collected were entered into an Microsoft Excel spreadsheet  and quality-checked for correctness. STATA16™  was used for statistical analysis. The analysis was performed by the management team  at the central level. No demographic data were missing and absolute as well as relative frequencies were calculated for each item.Countries were grouped according to continents . If a cell had a value of less than five, differences in proportions were evaluated with the Chi-square test or the Fisher exact test. Multiple testing for post-hoc estimation, such as the number of observed frequencies, expected frequencies, percentage, and contribution to the Chi-square were run. Estimation of a nonparametric test for trends across the areas with different prevalence of COVID-19 self-reported rates and questionnaire items were also calculated. The effect size was calculated using the Cramer’s V, as a measure of the strength of association among the levels of the row and column variables. Logistic regression analysis was run using dental professionals’ perception that COVID-19 is a risk for both dentists and patients; dentists’ awareness of avoiding COVID-19 infection at work as a dependent variable.A total of 52,491 dental professionals from 36 countries completed the questionnaires. Participating countries are shown in In Europe and Asia, dentists considered the COVID-19 infection risk for both themselves and their patients very likely . AmericaDescriptive analysis of This paper deals with awareness and perception of risk infection of dental professionals during the COVID-19 pandemic worldwide. Since dentists are considered front-line workers in the health care system and are exposed to infection through aerosols and close patient contact, it is important to place this professional group and to take their concerns and fears seriously. The results of this paper show that dentists around the world consider COVID-19 infection risk to be high both for themselves and their patients, especially among those who continued to provide routine dental treatment during the first wave of the infection. However, it was difficult to make a comparison between the different countries and continents, as the study took place at different times of the respective infectious events within each country. Therefore, the study is certainly only a snapshot of the time ,18,19. IA central aspect regarding the limitations of this research project is the composition of the present sample. Despite the high number of respondents, it is not possible to generalize the results as, for example, Europe is represented by many more countries than Africa, where only Egypt, Nigeria and Tunisia answered, and Oceania is represented only from Australia. Previous studies show that among health care workers, the fear of infection was very high (71%) and the fear of infecting others was much higher (85%) . The resThe period of data collection was not homogeneous across the different countries and especially with different phases of the pandemic and this could explain the high variability of results. When dental offices are closed or routine treatments are canceled, dentists can also experience depression and fear of failure; because business viability is at risk due to a lack of patients ,26. FurtEven though the present study was conducted early in the pandemic, it is currently possible that new variants of the virus and new waves of infection will be unleashed, but with milder symptoms and provision of better protection through vaccination. Nevertheless, the dental practice and clinic remains a place where the risk of infection is always possible, and dentists must therefore adhere to national and international guidelines for infection prevention. For this reason, protective measures such as eye protection, FFP2/N95 masks, and regular ventilation of rooms and use of rinsing solutions before treating patients remain essential precautions, according to international documents, that dentists should be aware of. In addition, there are already informative international brochures and papers for the dental profession to read and utilize ,31,32. PThe COVID-19 pandemic and its impact on dentists in terms of perception and infection risk are different worldwide and are mainly determined by the geographical origin of dentists. In countries where the incidence was high, risk assessment and perception of potential infection were higher when dentists tried to maintain regular practice and offered routine treatments to their patients, as shown by results from Europe and Asia. Dentists in countries such as Australia where infection rates were low at the time of the survey, also had a lower perception of the risk of infection.Our aim was to assess the impact of the COVID-19 pandemic in different countries worldwide, in a comprehensive multicenter study. The differences between continents and regions may have been influenced by the chronology of regional outbreaks and the rapidity of response to COVID-19. The results reflect socioeconomic and cultural differences and inequalities in different countries that are also reflected in the dental care system. The perception of infection risk also increases psychological distress, and this can lead to subjective overload, which can have many consequences in the healthcare system and its workers.


Trypanosoma cruzi infection in Latin America and globally, contributing significantly to the burden of Chagas disease. The interruption of transmission from mother to child has recently become a focus issue. However, the research landscape on congenital Chagas disease remains largely unexplored. The purpose of this scoping review is to assess the production of knowledge on congenital Chagas disease (CCD), aiming to identify research trends and potential gaps. Our initial hypothesis was that the CCD literature overly represents the medical sciences and that there is a need for socio-cultural research on the subject. We conducted a systematic search of publications focusing on congenital Chagas disease in six languages . This comprehensive literature search identified 876 studies that met the inclusion criteria, out of a total of 8893 sources. The relevant literature was analyzed by language, year of publication, discipline, source type and research location. The main outcome of this study has been to prove our hypothesis that there is a scarcity of knowledge produced within the non-biomedical sciences on CCD. This underscores the need for further exploration into the social and structural issues surrounding this disease. Visually clear data concerning congenital Chagas disease produced by this study can contribute to hone in future research efforts and support funding applications. Additionally, this article provides a reference list that other researchers can consult for their own studies. Congenital transmission is a key route of  Trypanosoma cruzi that affects approximately 6 to 7 million people worldwide [T. cruzi primarily occurs as humans or other mammals come into contact with the feces or urine of infected blood-sucking triatomine insects. Other forms of transmission include blood transfusion from infected donors, the consumption of food or drinks contaminated with T. cruzi, organ transplants and congenital transmission during pregnancy or birth [Chagas Disease (CD) is a neglected tropical disease transmitted by the parasite orldwide . The vecorldwide . Argentior birth . “In vecor birth .T. cruzi. Among these cases, there is an incidence of 8668 congenital infections per year [According to the World Health Organization , it is eper year . Concernper year  and 200,per year , Japan, per year  or urbanper year , Italy [per year , Switzerper year , France per year , Sweden per year  and Irelper year . In 2011per year , where hper year . Congenital infection occurs, on average, in 5 percent of children born from chronically infected mothers . The majTherefore, the diagnosis of infection in pregnant women and their newborns has become the standard of care, integrated into the Pan American Health Organization guidelines for the elimination of mother-to-child transmitted diseases (EMTCT Plus or ETMI-Plus for the Spanish acronym) for Syphilis, Hepatitis B and HIV.Antiparasitic treatment is contraindicated during pregnancy due to the unknown risks it may pose to the fetus. However, new data have shown that the diagnosis and treatment of women of childbearing age before pregnancy provide not only benefits for the woman but also play a crucial role in preventing future congenital transmission ,20. TherGiven this paradigm shift, research on congenital Chagas disease (CCD) is fundamental in supporting the goals laid out by international health institutions and provides insights on how to develop adapted healthcare implementation. Medical practice and knowledge production are closely linked, and it is now widely recognized that effective health strategies should rely on global and comprehensive approaches that encompass not only biomedical sciences but also diverse disciplines and key actors. Therefore, to elaborate effective and sustainable health interventions, the research landscape should incorporate various dimensions, including social, economic, cultural and environmental factors, and rely on collaborative efforts with diverse stakeholders, including concerned communities, civil society organizations, policymakers and healthcare providers.An increase in focus on CCD demands a more in-depth understanding of the research landscape, language predominance, global distribution of research disciplines, source types and research locations. This is a fundamental contribution to knowledge intended to improve maternal and child health, by identifying gaps and foci of the current approaches. This enables the identification of the predominant centers of research in order to encourage collaborations and serves as an advocacy statement in the creation of awareness about this form of transmission and the importance of early detection as an effective public health campaign. It is not the purpose of this article to analyze the content of the literature reviewed, which will be the focus of forthcoming publications. We argue, however, that understanding the geographical, language and disciplinary context of the literature on CCD is a valuable contribution to the knowledge landscape on Chagas disease in general. By highlighting approaches that require reinforcement for designing effective and tailored health interventions, this research supports the consideration that effective and appropriate health strategies must address the root causes of health disparities and promote health equity, particularly for neglected diseases that have long faced deficiencies in research and public health implementation. Scientific knowledge production on Chagas has been the focus of several studies ,26,27,28There are other reviews with a more specific focus, such as Chagas cardiomyopathy ; health The contribution of our review is a much broader scope in terms of the type of literature, time frame, study focus and language coverage . Within the large—and growing—corpus of the Chagas-related literature, there has been notably little attention paid to congenital Chagas. The purpose of this article is to review the academic literature on CCD in order to highlight the foci and gaps within CCD research. Our initial hypothesis was that the literature on CCD was notably scarce but increasingly necessary in order to support the progressive attention given to CCD within public health and global health initiatives. Furthermore, within the limited corpus on CCD, we also hypothesized that social, cultural and political issues surrounding CCD are largely overlooked within most academic approaches.The aim of a scoping review is to map the literature on a specific topic or research area and to establish key concepts, gaps, types and sources of evidence that inform practice, policymaking and research . As compThis article presents partial results from an extensive scoping review project conducted on the CCD literature, aiming at better understanding the current state of the art on CCD knowledge production. This paper assesses the current state of research on CCD, considering the disciplinary approaches, places where research is conducted, types of populations studied, languages and years of publication in order to identify gaps and areas for future research and knowledge dissemination. Additionally, part of the scoping review has been the creation of a comprehensive database of publications on CCD and making a reference list available for other researchers’ consultation.This scoping review was developed using the methodological framework proposed by Arksey and O’Malley , the furHow is the current literature on CCD distributed geographically, thematically and by discipline?What are the gaps within the scientific literature on CCD?The main research questions guiding this scoping review have been the following:What is the geopolitical configuration of the research teams?What is the geopolitical configuration of the research sites and which population/countries are most studied?What changes can be observed through time in terms of the volume of research, themes and political geographical distribution?In which journals is Chagas-related research being published?Who are the most prolific authors?How do research domains co-create knowledge ?What problems emerge through the classification of countries and areas as endemic/non-endemic?How is “congenital Chagas” defined?These questions provided the framework for the choice of keywords that determined our research . After duplicates were removed using both Mendeley’s electronic tools for deduplicating and manual deduplication methods, all the remaining citations were reported in a spreadsheet in Microsoft Excel. The two authors independently examined titles and abstracts for potential inclusion. After applying exclusion criteria, a total of 1289 references remained. At this stage, the list of articles that we could not obtain online or through institutional funds available to the authors (University of Zurich and University of Applied Sciences and Arts Western Switzerland) were sent to colleagues, along with a request for support in obtaining full texts. Our corpus includes all articles . The full texts (when available), or abstracts, were examined independently. An important point was to analyze whether the CCD subject was a main focus of the publication. For this, we compiled a list of articles that we identified as not focusing solely on CCD but including other topics . We then independently screened this list to identify publications with a significant focus on CCD. We included publications in which CCD is at least an important part of the article or provides significant or new information on the topic. Any doubt about the inclusion of an article was discussed by both authors. As our aim is to explore the extent of available literature, we did not assess the methodological quality of the articles included, which is consistent with the guidelines on scoping review methods . During the coding process, we realized that some duplicates were not previously identified because they had different titles in multiple languages. Particularly, non-accessible articles may lack sufficient information or abstracts, making it challenging to determine their potential duplication. Electronic methods of deduplicating search results have limited effectiveness , and, deTitles and abstracts were screened independently by the 2 authors using the following inclusion/exclusion criteria:The two authors divided the articles according to language and coded them individually in an online shared Microsoft Excel spreadsheet. To ascertain congruence, a “standardized data extraction form”  was deveThe following data were extracted from the selected sources: the year of publication, language of publication, disciplines, place of research (for articles that are not knowledge syntheses), endemic/non-endemic categorization, studied population and types of literature. While the year and language were straightforward categories, we encountered some categorical issues in most other codes. Upon deliberation, and based on our research interest, we determined the following definitions:Discipline: As our aim was above all to explore the knowledge produced and the disciplinary field for which the research is intended, we decided to code the disciplinary fields rather than to perform a bibliometric analysis of the authors’ location and the disciplines in which they are registered. Some sources were classified as involving more than one disciplinary approach. Place of research: This category encompasses publications with primary data generation and excludes knowledge synthesis and commentaries. Place of research with original data production include laboratory research, clinical research, clinical cases, case studies , field research (veterinary research), mathematical modelization and data analysis . Where mentioned, we collected the research locations .We identified the country and city where the research was conducted in a column called “research location”;We identified whether the country is endemic or non-endemic;We then subclassified endemic countries into whether the area of research is endemic or not (NEA—non-endemic area);We considered whether the endemicity status has changed through time.Endemic versus non-endemic: We encountered epistemic questions in attempting to distinguish research places according to the evolving spatial and temporal reality of endemicity. What terms should we use to identify research conducted in non-endemic areas but in so-called “endemic” countries? How should countries that are no longer endemic but located in the southern part of the American continent be referred to? . In an effort to highlight the complexities of the distinction between endemic and non-endemic, and observing the discrepancies between the terms used and the multiple socio-medical realities of different Latin American countries, we proceeded in the following manner:The comparison of the latter two columns allows us to analyze the discrepancy between the terms used and the multiple socio-medical realities of different Latin American countries. A more thorough analysis of this issue will be the focus of a future paper. Studied Population: This refers to the subjects of study. The larger distinction was between animals and humans, as much of the research was laboratory trials on rats and mice. But within the human cohort there were subclassifications when the research was conducted in the laboratory on body organs, cell tissue, blood samples and other body products separate from identifiable clinical patients.The characteristics of the sources were graphically mapped using Microsoft Excel. Depending on the needs of the analysis, the unavailable articles are included or not. For each result and graph, we indicate the data included in our analysis (fully available or limited corpus).n = 3409 sources after removing 5484 duplicates. After examining the title of the remaining sources, 1462 studies were excluded, leaving 1947 sources that were selected based on their abstracts for further reading. Of these, 1302 sources (1289 from database searches and 13 from hand searches) were sought for full-text retrieval. All 1302 sources (full text or only with the abstract or title available) were further examined according to the inclusion criteria of CCD being at least an important part of the publication or that the publication provides significant or new information on the topic. At this stage, an external review identified 23 duplicates that had not been previously identified because their titles were in different languages. A total of 876 relevant publications fit the categorizations above  were published before the year 2000. Of these inaccessible sources, 126 had available abstracts, which enabled the collection of information. A total of 85 sources were not available online and had no abstract. In some cases, the title was informative enough to extract some basic data. The systematic literature search yielded 8893 sources from databases and 22 sources from other methods (Google Scholar and the pearl growing strategy). The corpus was reduced to ns above . Among tThe process of article selection is presented in the PRISMA flow diagram .n = 504, 57.5%), even while Chagas affects mostly Spanish-speaking countries. The languages of the publications, in order of prominence, are as follows: English = 504, Spanish = 259, Portuguese = 74, French = 11, German = 9 and Italian = 3 . Of thesThe first publication appears in 1927 , with a n = 876) because some of the sources were classified as involving more than one disciplinary approach. Upon analyzing the publications by discipline, it becomes evident that a significant proportion of approaches belong to the biomedical and microbiological fields, while a smaller proportion are from epidemiology and public health. Disciplines such as mathematics, economics, veterinary science and social sciences are comparatively underrepresented, as clearly seen in The classification of the literature by research discipline has been outlined in more detail in our Excel database. In order to facilitate the representation of research by disciplinary field, different types of disciplines have been grouped together into broader sets. For example, the term “biomedical” includes disciplines such as gynecology, ophthalmology, clinical cases, pediatrics, etc.; “microbiology” includes parasitology and genetic research; “epidemiology” includes serological prevalence studies; and “public health” includes studies that often focuses on implementation and policy. “Mathematics” includes different modeling techniques based on available data, such as modeling the transition from vector transmission to vertical transmission in Chile  or the dn = 275) of the total. This includes research conducted in hospitals, which represents 18.7% (n = 164) of the literature, and clinical cases, which contribute 12.6% (n = 111). These figures are represented by different tones of green in n = 208) of the overall distribution. It is noteworthy that serological surveys , which represent epidemiological data collection, constitute an important part of the publications from clinical fields as well as from outside hospitals (defined here as case studies). We can observe that the literature referred to as “general knowledge production”, including literature synthesis and commentary, represents a substantial proportion of total publications . Those publications aim primarily to synthesize and disseminate knowledge.The distribution of literature types shows a predominant contribution from the healthcare sector accounting for 31.4%  and Brazil  are the two most represented countries, followed by Bolivia , Spain  and Chile  . The mapn = 641): laboratory research, clinical research, clinical cases, case studies , field research (veterinary research), mathematical modelization, data analysis and original protocols. The same publications written in two different languages were counted for one source. The sum of the countries (n = 674) appears greater than the total number of primary research studies (n = 641) because some of the research was conducted in more than one country.This Table takes into account the data set among primary research publications based on original data (n = 6 0.7%) specifically involve healthcare professionals. A significant portion of the research  focuses on the placenta  rather than the human/animal as a whole. The vast majority of them focus on the immune system of the placenta in order to better understand the mechanisms of parasite invasion. To illustrate the significant effort research devoted to the placenta, in The vast majority of studies  focus on humans, while  examine animals,  of studies specifically target the placenta, and  are dedicated to the T. cruzi parasite. These last three categories are predominantly studied in laboratories. Among research focused on humans, the majority comprises pregnant women and/or children and a very small percentage of studies , this paper explores the knowledge production landscape on CCD. Through an analysis of geographical, language, field of research and disciplinary aspects, it examines the scope of the literature dedicated to CCD. More specifically, this study examines the hypothesis that the literature on CCD is mainly produced within the biomedical sciences, highlighting the need of adopting a global perspective in health strategies and recognizing the complex interaction of social, economic, cultural and environmental factors. This research/publication is part of a broader project exploring the current worldwide state of the art on CCD knowledge production. A negative correlation between the availability of articles and the amount of time that has passed since their publication can be observed , suggestInterestingly, while the healthcare sector is an important contributor to literature production, our review reveals that a very restricted proportion of studies focuses on healthcare providers themselves. Yet, these studies would be particularly important for identifying aspects  that contribute to the difficulties encountered in clinical practice. This is particularly relevant in non-endemic areas, where barriers to access and care often fall within the lack of knowledge and experience of health professionals with Chagas disease generally. Despite the growing interest in CCD, there are still many gaps in knowledge that need to be filled, particularly in the domain of social science. Indeed, saliently, the review shows that the literature stemming from the social sciences is very limited. Yet, Chagas disease (and its consequences) extends far beyond the medical sphere, encompassing social, economic, cultural and political dimensions that need to be more thoroughly understood and documented. In fact, there are a growing number of publications focusing on the social and cultural elements of Chagas disease, as mentioned in the introduction. Furthermore, within interdisciplinary teams, social science, as well as other less prominent sciences, such as veterinary sciences, are often represented, yet mostly within projects framed by a biomedical perspective. Additionally, these do not focus specifically on the issues pertaining to the congenital aspect of CD. Such research is clinically oriented and focuses on how to increase access to care. The perspective of affected people is often absent and the multiple social determinants of health remain unexplored. A comprehensive approach to tackling Chagas disease requires considering the perspectives and experiences of affected individuals and exploring Chagas disease more broadly as a social phenomenon embedded in complex contexts. For better understanding the dynamics surrounding CD, social sciences are crucial to develop interventions tailored to the specific needs and realities of the people and communities affected. In this sense, social science approaches have much to offer. Other key actors notably absent from the corpus are patient associations. Yet, to date, thirty associations of people affected by CD have been reported on five continents . PatientSome authors raise concerns about the practical use of knowledge gained from the growing number of international publications stemming mainly from a biomolecular perspective . QuestioChagas should be considered from four interrelated dimensions : biomediThe gap between the biomedical vision for patients and the actual lack of acceptability for screening and treatment call for more research on understanding the socio-cultural aspects surrounding the disease. Social sciences provide a systematic and rigorous approach to studying human behavior and society, gathering data on the experiences, attitudes and behaviors of different populations. This helps to identify patterns and trends that shape people’s lives. Furthermore, social sciences provide insights into the ways in which structural and cultural factors influence people’s experiences and perspectives, to understand complex issues from multiple perspectives and to develop nuanced understandings of the experiences of different populations.Some issues related to Chagas disease are very specific to the context of pregnancy. For example, the risk factors that determine the transmission of the parasite to the fetus are not well-known. There is also no scientific certainty regarding the risk of disease transmission during breastfeeding, although the risk of transmission of the disease to breastfed babies is believed to be negligible. Maternal Chagas disease is generally not considered a contraindication to breastfeeding, except for women in the acute phase of the infection or those with bleeding nipples . In thisSimilarly, the scarcity of economic studies on the cost-effectiveness of treating pregnant women and their children is a gap that must be redressed  as it isThe research location predominance corresponds mostly to the endemicity of the countries see , with ArAs Chagas disease is a neglected tropical disease, it is particularly important to understand how knowledge is produced. Firstly, it helps to identify areas where further research is needed. In this case, we have seen that research in areas such as the social sciences or economics sciences is scarce and that supplementary efforts are needed in those domains. Understanding how research is produced (which disciplines and types of literature are predominant and which are overlooked) is essential to addressing this neglected disease. The lack of knowledge about the systemic challenges faced by at-risk populations hinders effective action at the socio-political level. Secondly, understanding knowledge production can also help to identify areas where current knowledge is limited or contradictory, which may have important implications for clinical practice or public policy. This can inform future research projects and funding decisions and help prioritize research efforts and allocate resources more efficiently. Finally, by providing a comprehensive list of publications on CCD for future research purposes , the aimWe provided a comprehensive review of the published literature with the aim of being as thorough as possible. This exhaustive search required significant time from both authors, and the results do not include the analysis of article content, which is currently underway. Practical constraints were encountered, such as not accessible resources, limiting the depth and accuracy of our analysis. However, by considering the titles and abstracts of the unavailable articles, in many cases we could incorporate relevant information and insights into our analysis. Nonetheless, by combining the bibliographic access rights of our institution, we had access to a wide range of literature. Thus, this research provides a strong overview of the available knowledge that researchers and other stakeholders rely on to contemplate potential solutions. Through the inclusion of publications in six languages using peer-reviewed journals and other sources, this review provides a comprehensive overview of the literature landscape and the research on congenital Chagas disease in all major geographical regions of the world. In this article, we analyzed the extent, scope and nature of research activity related to CCD and discussed gaps in research approaches and disciplines. We have discussed the crucial need of further exploration in the fields of social science, specifically focusing on the experiences of pregnant and breastfeeding women and women of childbearing age living with Chagas disease, as well as the medical and systemic challenges they may encounter.Two important themes have been left underexplored in this paper and will be the focus of future publications: the complexity of the issue of endemicity and the content and tendencies in the production of knowledge. A future publication will focus on the content produced by the literature, specifically on the socio-cultural aspects of CCD. Through the inclusion of publications in six languages using peer-reviewed journals and other sources, this review provides a comprehensive overview of the literature landscape and the research on congenital Chagas disease in all major geographical regions of the world. In this article, we analyzed the extent, scope and nature of research activity related to CCD and discussed gaps in research approaches and disciplines. It should be noted, however, that we did not assess the methodological quality of the articles included, which is consistent with the guidelines on scoping review methods  We have In a forthcoming article, we will focus on the research results from the published literature, providing a summary of the knowledge produced and identifying major tendencies around the diagnosis, treatment and management of congenital Chagas disease.


To evaluate parental perspectives of accessing eye care for children aged under seven years.The survey was conducted during September 2020 to March 2021 using online applications and distributed to parents whose children were between the ages of three and seven years. The survey included parents' background, their knowledge of the provision of eye-care services, and the possible barriers that existed to access eye-care services. The relationship between parents' knowledge, barrier scores, level of parental education, and demographic or socioeconomic status was assessed using nonparametric tests.n = 564). Further, 47% had not taken their children for vision screening at reception/year one (n = 467). In addition, 65% of them were not aware of the mandatory screening program at reception/year 1; whereas, only 20% (n = 207) knew how to access eye-care services; and only 39% of the children had undergone any kind of eye or vision test. The pathways to eye care and the cost of eye services/glasses were the main limitations. The parents' responses were significantly influenced by their demographic and socioeconomic characteristics (Kruskal Wallis, P  In total, 1037 questionnaires were completed. The respondents were from 50 cities across Saudi regions. The participants' age was 39  There was a need for enhancing parent information on how to access eye care for young children and the currently available vision screening programs. Finally, a national protocol to cover the cost of the eye exam as well as spectacle prescription shall be proposed as a mean of incentive. Specifically, several studies have stated the importance of vision screening in children under seven years old.,20,24 These children are at risk of functionally low vision.,26A great number of population-based studies have indicated that the main visual disorders in children are refractive errors, amblyopia, and strabismus. The American Academy of Pediatrics, the American Association for Pediatric Ophthalmology and Strabismus, and the American Academy of Ophthalmology have also set a joint policy statement on child vision screening. Preschool vision screening policies vary due to differences in the policies that exist in countries.,16,17,26 In Saudi Arabia (SA), according to government laws, the Ministry of Education requires an obligatory medical examination, which includes an assessment of visual acuity for all school entrants. However, it is observed that examination facilities may be inadequate.In the agenda of VISION 2020 (The Right to Sight), the World Health Organization set the management of childhood visual disability as a priority.,29,30,31 A study conducted in England reported that approximately 30% of children did not attend follow-up visits after failing screening tests at schools' entry year. Several studies have emphasized the importance of parents' awareness in combating children's visual problems.,30,31,32 The parents' knowledge of the potential visual disorders at younger age and receiving the screening outcome of children who failed visual screening could be essential for seeking health counseling.,29,32 Specifically, parents as caregivers play the fundamental role in seeking eye-care services for their children to avoid experiencing visual disorders that may go untreated. Parents' socioeconomic status could also pose as an important factor when accessing eye-care services.,34,35Interested individuals involved in preschool vision screenings include parents, school teachers, and health professionals . The perception, awareness, and level of accepted responsibilities of these individuals could play a crucial role in the efficacy of child vision screening programs and the development of policies for school and preschool-age children.,36,37,38 Therefore, this study evaluated parents' knowledge of how to access eye care and what barriers might disable them from accessing eye care for their children.To date, very few studies have been done on accessibility and barriers to eye care for children in SA, and generally in the Middle East region. The problems outlined through this research is of critical importance toward understanding the extent and complexity of the challenges facing policy makers and eye-care professionals. This knowledge gap provided an opportunity to establish a point of reference as compared to other studies conducted in other worldwide countries.The study protocol was reviewed and approved by the IRB ethical committee of King Saud University, Saudi Arabia, and the approval number is E-22-7412. In addition, the protocol of the study complied with the guidelines for human studies and the World Medical Association Declaration of Helsinki, and parental consent was electronically obtained before filling out the questionnaires. In order to ensure transparency and to receive honest responses from participants, information and aims of the survey were absolutely and clearly described to the parents at the beginning of the survey. The survey involved parents' demographic data, general medical and ocular history, and their knowledge and barriers regarding accessing eye-care services.This study is cross-sectional in design and targeted toward the parents of children under seven years of age in different regions of SA. The survey used in this study was adapted from a previously published study. Furthermore, in the calculation, 95% confidence intervals, an expected frequency of 50%, a design effect of 2, and the number of clusters of five regions  were included. The overall sample size was estimated to be 760 parents. The sample was expected to be unequal in each cluster but proportionate to the number of inhabitants in each region as they differed to a large extent . The survey was promoted for about six months (from September 2020 to March 2021) in order to recruit sufficient participants representing the Saudi population.To compute the required sample size, we used Epi Info, version 7 , and the number of children under seven years in SA were approximately 6 million.The survey used an online questionnaire, which was accessible without any restrictions. Emails were sent to the members of the Saudi Optometry Society to promote the survey in their areas using all accessible legal means, and the survey was distributed using all available social media applications . To avoid duplicate responses, at the beginning of the survey, a note was placed stating that responding to the survey more than once is prohibited. Lastly, the raw responses were properly reviewed and checked for duplication and to detect the parents who did not have children under seven years old, and eventually, 125 responses out of the 1162 initial ones were excluded.Data were explored for normality using the Kolmogorov–Smirnov test, which indicated that the data was not normally distributed. Therefore, the nonparametric Kruskal–Wallis test was performed to consider any possible relationship among the factors of parents' knowledge, barrier scores, level of parental education, and demographic or socioeconomic status. Data were collected in Excel  and analyzed using the Statistical Package for the Social Sciences .n = 861) being mothers. Most participants were married , and the rest were either divorced or widowed (2% for each category). The participants were recruited from across five regions, involving 50 cities.The number of participants was 1037, with 83% (n = 187) had a general medical history . Lastly, approximately 33% of the participants reported some form of ocular disorder .The participants' mean age was 39 Interestingly, about half of the parents  responded that they had not taken their children to a vision screening at the entry of reception/year one. When asked if they were aware of the mandatory vision exam at the entry of reception/year one, 65% of the parents' responded with “NO” and another 13% with “maybe”. The parents' responses to questions directed toward the current visual status are summarized in Table 1. Regarding children who refused an eye test, only seven parents reported that they were given a reason for not being provided the service [Table 1]. Reasons included poor cooperation, young age, cost of service, waiting time, and presence of autism in a child.The survey also checked to understand the reasons why parents would consider seeking eye care for their children. Their responses varied across different reasons as listed in Table 2. Some participants reported other reasons for intentionally seeking eye care, including excessive use of electronic devices, dry eyes, juvenile diabetes, eye redness, itching, and excessive blinking. In addition, the parents were surveyed based on their preexisting knowledge related to child vision and vision screening [Table 3].The parents were asked about the barriers that might prevent them from taking their children for an eye test [Table 4]. Some parents mentioned additional barriers including their beliefs that the vision of their children was normal, the child being uncooperative, and personally not seeing a reason for an eye test and challenges with time management.An investigation was conducted to determine whether the responses were influenced by the parents' background or other related factors that included gender, marital status, age, income, working status, level of education, and family history of eye problems. After the investigation, it was ascertained that those characteristics influenced some of the parents' responses listed in Table 5.This study showed that half of the parents had not taken their children for vision screening at reception/year one. The majority of them were not even aware of the mandatory screening program. Further, only one-fifth of them knew of the pathways to access eye-care services. About 60% of the children had not undergone any kind of eye or vision test. Barriers and misconceptions related to eye-care services, which needed intensive and in-depth strategies to deal with, were detected. Participants' backgrounds and socioeconomic characteristics also played a major role in some of the parents' responses.,40 Understanding the barriers to and knowledge of accessing eye-care services for children from a parental perspective is fundamental in determining strategies and programs that enrich the parents' awareness and provide methods to direct them for the best possible access to checking the vision of their children. Parental knowledge of risk factors related to not checking children's vision could contribute to early detection and management of various visual disorders, such as amblyopia and strabismus.,35,41 This would also require the cooperation of eye-care professionals. In 2019, Cassetti et al suggested that it is imperative to consider parents' lack of eye health education as well as the importance of enhancing specialists' experience when treating children, and how to tackle parents' negative attitudes toward diagnosis and treatment.Accessibility to vision screening is important for the well-being of children. In comparison to another study, our findings were better than those found in Swaziland children, where 60% of their participants had never taken their children for an eye test. Furthermore, concerns were raised about the efficacy of mandatory assessments at school reception/year one in light of poor awareness of the screening program, supported by the findings of Donaldson et al who reported that only 15% of the parents whose children go to a school with a screening program knew of its existence. Moreover, only a few participants had been given a reason for not being provided the service, and not allowing a child to undergo vision screening could cause major consequences on the child's well-being and quality of life.,42 The reasons given by healthcare workers for not providing vision screening were mainly due to a lack of cooperation by the underaged subjects, a lack of financial resources by the parents, or the patients' ailments that would require more intricate testing and evaluation. Providing more professional training, giving out vouchers for eye examinations in schools, and easing the access to eye-care services provided by governmental hospitals may be very helpful in alleviating the lack of eye care for young children.,32 In agreement with previous research, parents may also need more health education and more effective and accessible eye-care services.,43,44In this study, the percentage of parents whose children had received any kind of eye or vision test was closely similar to a report of a study in English children .,45,46Parental misconceptions about eye examinations for children and their vision were the main barriers to taking children for a vision test. Similar to previous research, not knowing how and where to access eye-care services and not being able to afford the cost of service/glasses were other observed barriers. In addition, it is important to advise parents that vision screening is not a comprehensive examination and it is only the first step as certain other conditions may be missed if complete examinations are not performed.Effective efforts to correct those misconceptions, explaining the methods for accessing eye-care services and making these services free of charge are expected to increase the number of children taken to an eye test, exceeding the current 45% observed in this study. Potential strategies for enhancing parents' knowledge include distributing leaﬂets, providing online links to vision screening information, and giving out references to pathways for accessing eye-care services. Based on the results reported in this study, educating new parents, easing accessibility to vision screening, making them free of charge, and increasing parental awareness across all working fields, including unemployed parents could increase the number of children being evaluated for vision.,32 Although based on our findings, teachers could be important mediums to refer children for vision screening. Nevertheless, less educated parents and those with or without medical/ocular history should be properly educated about the importance of vision screening for children; education should focus more on providing fathers with more information about the vision of children and informing parents generally about patients' right to avoid/handle potential test refusal.,37,38,47The demographic and socioeconomic factors of the parents significantly influenced their responses, and this has also been supported in previous research. Moreover, studies have suggested that the most common reason for not undergoing comprehensive eye care after the child fails the initial vision screening was the parents' lack of knowledge about the outcome of the primary screening and/or what it means.,47 Finally, Hartmann et al proposed developing a national integrated data system that would include child-level vision screening data, referral records, and follow-up diagnosis and treatment; following such a route can be very efficient.Currently, no efficient national guidelines were applied to suggest pathways for vision screening, although the Ministry of Health and Education has recently agreed on a newer pathway for vision screening at school reception/year one and another at grade 4. However, the method in which the program would handle the referral for comprehensive eye examinations for children who fail the initial eye test is unclear, which may vary depending on local arrangements in different regions of SA as it was previously suggested in other countries.,33,45 however, the method in this study avoided possible bias that existed in other studies due to sample selection from a clinically based population. This could be because younger children may not have visited the eye clinic; alternatively, researchers might not have been able to distribute the questionnaires nationwide to have a sample representing the targeted population. That being said, the online survey may have some biases, like including the responses of parents who do not have any children under the age of seven, or parents who may ask for someone's help in responding to these inquiries, so it does not reflect their own thoughts and feelings about the topic. Although, we implanted a question in the survey to verify whether the respondents had children under seven years and excluded some of the collected data as stated in the method section, the responses of some parents who had no children under seven years of age might still have been included. Unfortunately, the second possible bias could not be verified, we were only able to trust the respondents' integrity and voluntary participation stated in their consent.This study enrolled 1037 parents, most of whom were mothers (83%). The unbalanced gender recruitment could be a limitation of this study, although mothers may be more attached and closer to children than fathers. The recruited parents were diverse in terms of where they lived, their age, income, education, and the number of children. Furthermore, approximately one-third of the participants did experience some ocular disorders, indicating that they were aware of the importance of vision screening in children. This diversity in response could provide the representation required to reflect the assessment of the targeted population in different regions of the country. The recruitment method used in this study was not typical or similar to other studies that have distributed the questionnaires in hard copies in schools;In summary, this study showed that the majority of parents lack the knowledge about the importance of vision screening and the existing pathways to accessing eye care for young children. It is recommended that parents' awareness of eye-care services be enhanced, and improved communication is needed to educate parents about the importance of vision screening for children, how to access eye-care services, and share knowledge of the existence of any national/mandatory screening programs. A second recommendation would be developing well-structured protocols to inform parents about their children's vision screening results and provide referral pathways to avoid any dropouts after failing school vision screening. And finally, a national protocol to cover the cost of eye services/glasses may be needed to address those parents who are unable to pay for the cost of eye services.None.The author has no conflicts of interest to declare.


Pelvic floor disorders (PFDs) include urinary incontinence (UI), overactive bladder (OAB), fecal incontinence (FI) and pelvic organ prolapse (POP).The pregnancy period demands several modifications in the woman's body in order to allow fetal development and childbirth. These physiological, anatomical, biomechanical and hormonal changes alter the functioning of the pelvic floor, mainly by increasing the elasticity of structures.Despite the impact of pregnancy on the pelvic floor, the main factor associated with pelvic floor injuries and PFDs is childbirth, even though no consensus on the impact of the delivery route and PFDs is available in the literature.In our service, we evaluated a cohort of primiparous women 12-24 months after delivery and found no difference between the prevalence of UI and the delivery route.Some studies followed postpartum women for longer periods, one of which showed that the peak risk for stress urinary incontinence (SUI) was five years after delivery, while the peak for POP was 20 years after childbirth.Handa et al.This same cohort of women was monitored for up to nine years, resulting in a publication in 2018Regarding the effect of cesarean section on PFDs, 12-year follow-up studies from the United Kingdom and New Zealand have shown an association between cesarean section and lower risk for urinary incontinence, and that POP is less frequent in women who have had cesarean section.The pathophysiology that explains the effect of childbirth on PFDs involves several aspects such as decreased support of pelvic organs, damage to the levator ani muscle and pudendal nerve. In relation to perineal musculature, women's pelvic floor was evaluated with a perineometer in a study. It was found that women with reduced muscle strength and at least one vaginal delivery were associated with a shorter interval for presenting PFD, compared to women who had cesarean sections. In addition, the decrease in muscle strength was associated with a higher risk for SUI, 16%; OAB, 27%: and POP, 43%.DeLanceyInjuries to the levator ani are also associated with the appearance of POP, but some injuries are not so evident immediately after delivery. Studies with 3D ultrasound show there may be injury to the levator muscle in 13% of women after a vaginal delivery,Bladder neck hypermobility is also associated with PFDs, specifically SUI. However, our review article showed no difference between bladder neck hypermobility and delivery route.PFDs seem to be closely related to vaginal delivery, especially cases of instrumental delivery. Cesarean section is associated with a reduction in the risk for PFDs, although the routine performance of this procedure does not eliminate the risk for dysfunctions because the pathophysiology is multifactorial. The pelvic floor undergoes several changes during pregnancy and, especially, postpartum. Some injuries, such as injuries to the levator ani, are not routinely diagnosed. Knowledge of the pathophysiology and diagnosis of pelvic floor injuries are crucial for actions that can recover this musculature and reduce the impact of childbirth and PFDs.