The Indonesia government has succeeded in achieving national health development targets and has invested heavily in public health. Many positive results have been achieved, which indicate an increasing number of school-aged children free of caries and a decrease in caries experience scores. However, result of previous studies on early childhood caries (ECC) in pre-school children showed high prevalence and severity. Understanding the link between the epidemiology of the ECC and components of health development is critical for formulating appropriate actions. The purpose of this study is to provide a comprehensive review of the epidemiology of ECC in Indonesia based on the results of the national basic health surveys. The complementary data describes access, utilization and profile of oral health personnel in Indonesia. Dental caries affects people of all ages and remains the major problem of dental health among children worldwide . For preECC is also highly prevalence in preschool children living in developing countries like Indonesia . Every 5However, a comparison of the data could not be conducted because of inconsistencies in the measures of the oral variables used for the surveillances. ECC severity using the dmft index, was only conducted in 2018. Also, the data on the dmft was not disaggregated. Data on the proportion of preschoolers who brush their teeth properly was only available in 2018. Despite this limitation, the table highlights a few important issues. First, it suggests that prevalence of ECC is increasing over the study period, and second, it suggests that children age 3–4 years contribute significantly to the high prevalence of ECC in the country. Caries severity also appears to increase by almost a third between the ages 3–4 and 5 years.Publications on ECC in Indonesia has been limited in scope. Most of them were conducted in cities with few participants. In 1992, a study on preschool-aged children in the Jakarta area showed an ECC prevalence of 85.17% . Other r2, while the width of its sea is about 3,257,483 km2. Indonesia is a country with the fourth largest population worldwide  and two oceans (Indian and Pacific). The width of land area in Indonesia is around 1,916,862.2 kmorldwide . Indonesorldwide .It is evident that variations in caries prevalence among children are associated with multiple factors, including ethnicity and culture. Results of national basic health surveys in Indonesia also show that prevalence and severity of oral disease varies across ethnic groups. Yearly, the highest average caries index is found on the island of Borneo, followed by Java and Sulawesi. Factors like socioeconomic status, natural fluoride content in the water, and the culture of sweet food consumption have been suggested as causes of the high caries prevalence. unfortunately the data is presented in general for all ages, while specific data about ECC in children is not available. Interestingly, since the causes of caries are the same at all ages, it can be hypothesized that the variation in the prevalence of ECC across ethnic groups will not be much different.Indonesia is classified as a country with lower-middle income population with increasing rate of national income per capita , 21. DesRecently, Ministry of Health developed the oral health provision grand design for 2015–2030 with the goal of having a healthy Indonesia free of caries by 2030. The Healthy Indonesia Free Caries campaign roadmap is revised every 5 years. The Road map started with the issuance of the National Act Plan of Oral Health Service which focused on strengthening policy, resources, and oral health service delivery. Targets were set for caries control in 12 years old children, oral health program at Community Health Centers (CHCs) were standardized, and the role of school-based dental programs and community-based health efforts were strengthened . The graIt is worthy to note that recently, the government of Indonesia has implemented the decentralization policy in the health sector, under Law No. 23/2014 on Local Government, stated that local government has a responsibility to focus on the delivery of defined essential services  while the central government has the responsibility to determine the expected standard for the provision of services. Decentralization plays a part, with each authority having an important role in setting policy in its region; every region has a unique approach depending on its individual needs. Unfortunately, reports about the success of ECC prevention program that take advantage of the opportunity for decentralization have not been published.The number of community health centers and health workers in Indonesia has increased rapidly in the last few decades. Oral health personnel and CHCs have important role in the implementation of oral health policy regulations. Dental care has been offered to school children via the national school-based dental program (SBDP) for years. As part of the national school health strategy, SBDP are organized by community health centers located throughout Indonesia, and these aim to promote health by preventing oral disease and developing healthy behaviors. Community Health Centers also have responsibility to manage community-based dental programme where mothers and toddlers are the target of health programs including oral health. The issue of unsufficient number and unequal distribution of oral health personnel in Indonesia are quite worrying because the driving force for the dental public health program in CHC is expected to be the oral health personnel. It is evident that areas that have sufficient numbers of oral health personnel have been shown to have a school-based dental program that runs well and has a high rate of dental treatment to treat children's caries, and vice versa .It is evident that the number of ECC studies carried out in Indonesia over the last 20 years is limited, yet in general the data generated consistently shows high prevalence. Methodological differences and confounding factors, especially socio-demographic influences, limit national comparisons of data on caries prevalence.The increasing number of oral health personnel, along with the increase in the per-capita expenditure toward health services, does not seem to have had a significant impact. However, the decision maker  need to realize that the chosen strategic model to tackle ECC cannot be separated from the socio-economic context. For instance, since economic growth is a rapid process in Indonesia, consequently the consumption of sugar will be augmented. Therefore, dental caries in preschoolers can be expected to increase in coming years. In this case, successful cases of sugar restrictions policy in other countries could serve as examples of the importance of continuous oral health promotion .Nevertheless, this approach is not without challenges. Sociodemographic variations can be a significant barrier, especially in low-income and low-education populations, and can have an impact on low awareness of the importance of oral health for children. This lack of awareness can be seen in the low rate of tooth brushing. This condition must be an alarm for policy makers because the current best practices for reducing the risk of ECC include twice-daily brushing with fluoridated tooth paste. Fortunately, due to policies in Indonesia, toothpaste is relatively affordable and must contain fluoride, so this should be an advantage in caries-prevention strategies. Following this, the role of parents is very important. This should be a concern because children's health development is very dependent on the health and well-being of their parents. The study concluded that some important health behaviors in parents, such as tooth brushing habits are important determinants of these behaviors in their young children. So promoting parent knowledge and attitude could affect their children oral health behavior and status .Indonesia has had a series of policies regarding caries prevention strategies for children. The strength of this program is the direct involvement of parents for children under 6 years old, with parents at the center of counseling on how to maintain children's dental health. This program is community-based, with mothers as the targets. For children 6 years and older, the programs are directly applied and school-based. However, it is worth considering whether school-based dental programs that only focus on elementary education actually have a weakness, because children, at an early age , receive only limited information about good oral hygiene practices directly from oral health personnel. It is also important for oral health personnel to manage the ECC strategy for early childhood/kindergarten children conducted in schools, including conducting ECC risk assessments, teaching daily tooth brushing, and introducing the importance of regular dental visits.Related to policy development at the regional level , the role of the District Health Office is very important. Detailed directions or guidelines can be given to program implementers in the field regarding what should be conveyed to parents to prevent ECC, including the importance of avoiding sticky and sugary foods, not prolonging the use of bottles, and proper practice of oral hygiene. Decision-makers in each region will better understand the various approaches that can be attempted, depending on the specific conditions in each region. A policy of implementing a homogeneous strategy would not bring optimal results due to, for example, the presence of language and literacy barriers in remote and underdeveloped areas. Providing information using local languages or adapting modifiable procedures to cultures can help to overcome obstacles to understanding how to implement healthy behavior.Despite limitations, there is a strength in the national policy implemented in Indonesia. NHI can be a guarantee of access to health services, reaching even families with low socio-economic status and children with special needs. It is important to note that dental health services at NHI also include preventive services, such as early detection, and preventive restoration, such as fissure sealants. However, parents often do not know that such services exist; they only know about services like restoration and tooth extraction . This unIt is important for oral health personnel to consistently and continuously conduct policy-maker advocacy regarding the consequences and preventive strategies for ECC. The national road map of the caries prevention strategy cannot only be targeted at school children, but must also be aimed at preschool children. The national target that considers only school children has even resulted in a lack of attention to ECC among oral health personnel themselves. This is such a concern because, nationally, there is no ECC program, and oral health personnel are not spread evenly. The high numbers of other health workers should be a resource that can be used to deal with dental diseases that occur in children.Taken together, the results of analysis on epidemiological data and oral health policy suggest following recommendations:National preventive program toward ECC should be prioritized including activity of prevention program in kindergarten or early childhood education. However, oral health programs for young children cannot rely solely on school-based and the decision maker must consider a reasonable range of alternatives to expand the provision of the program.Expanding the program via maternal care should be considered as a potential alternative. Integrating immunization programs with dental check-ups also could be another option, since this program is widely spread and accepted among citizen.Oral health training can be provided for other health workers, like midwives, to help them identify, and refer high-risk patients for subsequent care management in a dental clinic. Such programs should be actively delivered via early childhood education programs by involving teachers and health cadres via integrated healthcare posts.Under the NHI system, there is a potential scheme in implementing early screening for ECC for pre-schoolers. Children referred upon screening will be treated free of charge in CHCs.National data on caries should illustrate the prevalence for each of the provinces to indicate regional differences. If the decision maker seeks to develop an efficient and sustainable oral health system, the successes, and failures of the existing service model must be identified. The decision maker needs to realize that the chosen strategic model to tackle ECC cannot be separated from the socio-economic context.There is a necessity to review dental public health policies and develop effective strategies to prevent the epidemic of ECC in Indonesia. The key to success in the prevention and curative management of ECC lies not only in the availability of oral health personnel but also in a joint commitment with other parties. Further, advocacy to prevent healthcare problems among children is critical because this will have consequences for general health. In particular, policies that promote children's oral health as part of public health initiatives can help attract people's attention.RA initiated the idea for the manuscript, wrote the initial framework, and edited the manuscript. FC, MA, and AS added materials according to their expertise. Each author critically reviewed the manuscript for its intellectual content.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.


Connected health has created opportunities for leveraging health data to deliver preventive and personalized health care services. The increasing number of personal devices and advances in measurement technologies contribute to an exponential growth in digital health data. The practices for sharing data across the health ecosystem are evolving as there are more opportunities for using such data to deliver responsive health services.The objective of this study was to explore user attitudes toward sharing personal health data (PHD). The study was executed within the first year after the implementation of the new General Data Protection Regulation (GDPR) legal framework.The authors analyzed the results of an online questionnaire survey to explore the willingness of 8004 people using connected health services across four European countries to share their PHD and the conditions under which they would be willing to do so.Our findings indicate that the majority of users are willing to share their personal PHD for scientific research . Age, education level, and occupation of the participants, in addition to the level of digitalization in their country were found to be associated with data sharing attitudes.Positive attitudes toward data sharing for scientific research can be perceived as an indication of trust established between users and academia. Nevertheless, the interpretation of data sharing attitudes is a complex process, related to and influenced by various factors. The evolution of information and communication technologies in health care holds promise for the reformation of health care services. The development of novel technologies and their acceptance by health care providers has an impact on the design and delivery of services, resulting not only in a greater number but also better quality of services . SimilarThe use of personal health data (PHD) can be essential to the evolution of health care systems in general  and connThe literature that examines user behavior in terms of technology adoption and use draws on various theoretical perspectives—for example, the technology acceptance model or theory of reasoned action . These tDigital technology user attitudes toward sharing different types of personal data have been examined in previous studies . A studyWillingness to share PHD has been found to be dependent on various other parameters. For example, users are motivated to share their PHD in exchange for care improvements, better public health , or healApart from control over data sharing preferences, knowledge and trust have been found to contribute to more positive attitudes. Previous findings support the argument that it is unimportant for participants to fully comprehend different types of consent; nevertheless an opt-in model of informed consent is valued as a more trusted data sharing practice ,51. The Over the years, researchers have been paying attention to people’s willingness to share their PHD. As technology and legal frameworks evolve, user attitudes are also undergoing a shift. This study explores and discusses current attitudes across four European countries and addresses the following research questions (RQs):RQ1: Are connected health users willing to share their PHD?RQ2: Under what conditions are they are willing to share their PHD?In order to interpret the results of the study, the RQs will be discussed along the following parameters: participant age, area of residence, country of residence, education, and occupational group.The purpose of this study was to investigate user willingness and conditions for sharing their PHD. This paper presents findings from a household questionnaire survey designed by Sitra Innovation Fund and distributed by Kantar TNS Oy, a global market research and information group, in December 2018. Sitra is a Finnish Innovation Fund that through its research aims to influence European policy makers toward more sustainable well-being on social, financial, and ecological levels. The data used in this study are a subset of data from large-scale research conducted within the framework of Sitra’s IHAN project . The aimIn regard to the research design of the survey, author MI has been actively involved in its development as a scientific advisor. The content of the survey was designed by Sitra through collaborative team processes to get an overall understanding of the data-driven attitudes after the implementation of the new GDPR. The website survey design was developed by Kantar TNS Oy in collaboration with Sitra. Quantitative surveys have been used by prior studies to explore and discuss user perspectives -66. A suThe original online survey comprised 27 questions, both open- and close-ended, to collect data relevant to background characteristics of respondents, attitudes toward services, and trust toward services and data management. For the purpose of this paper, none of the open-ended questions were used, and we only considered two of the closed-ended questions. The questions we chose to include were close-ended, as the goal was to get a quantitative overview of attitudes. The two questions measured user willingness to share and conditions of sharing their PHD.RQ1: Are connected health users willing to share their PHD?RQ2: Under what conditions are they are willing to share their PHD?Data sharing in this context was pertinent to various purposes such as scientific research, public interest, and in exchange for services or financial benefits. Additionally, several sociodemographic background questions were administered to the participants to capture factors that might influence user willingness. The questionnaire was translated by professional translators from Finnish to the official language of each country. For the purpose of analysis and reporting, the questions and related responses were translated back to Finnish and English to ensure a common understanding. The survey was conducted anonymously in compliance with the EU GDPR legal framework.Four European countries were chosen, as GDPR is an EU regulation, even though it has global implications. Data collection was carried out from December 6 to 18, 2018, in Finland, the Netherlands, Germany, and France. The inclusion criteria were consent for participation in the survey and a self-declaration of being at least 18 years of age. Random sampling was performed by Kantar TNC Oy and was representative of the age, gender, and locality. Participants were invited to participate in the survey via phone or email communication. The questionnaire was delivered in the official language of each country. All participants were given financial compensation upon the completion of the online survey . The aveAnalysis of the raw dataset was performed by Kantar TNS Oy using SPSS Statistics (IBM Corp) software. In this study, we used the descriptive statistics that we were given by Sitra and Kantar TNS Oy to generate visualizations. The data visualizations were used for the interpretation of the results.The online survey included a total of 8004 respondents: 2000 from Finland, 2004 from Germany, 2000 from the Netherlands, and 2000 from France. The sample was representative in terms of gender, age, and locality. The completion rates were 84.32% (2000/2372) in Finland, 53.27% (2004/3762) in Germany, 48.77% (2000/4101) in the Netherlands, and 54.10% (2000/3697) in France.The majority of respondents were willing to share their PHD under specific conditions as shown in The aim of this study was to explore user willingness to share their digital PHD across four European countries. The four countries were chosen to represent countries in the EU that have a medium or high level of digitalization and availability of digital health data. Our findings show that the majority of users are willing to share their health data (RQ1), most often preferring to share it for scientific research . User willingness was not strongly gender-related; however, our findings suggest that age, education, and occupation were prevalent factors affecting user attitudes.In line with previous literature, our findings indicate that users are willing to share their PHD for research purposes ,69. ThisCurrent user trends in the four European countries were also informative about the impact of digitalization of health care services. The four countries that participated in the online survey belong to different groups in relation to the use of internet services. Finland and the Netherlands have the most advanced digital economies, while Germany and France belong to the medium performing group, with France ranking in the lowest position . As for In regard to the conditions under which users would be willing to share their PHD, scientific research and financial incentives were prevalent. This is consistent with previous findings ,72,77. FWhile sharing for research purposes was the most prevalent condition, a disregard of public entities may be perceived as an indicator of trust issues. Incidents of data breaches in public health care are numerous , which mWillingness toward sharing PHD is related with privacy and security considerations. The privacy calculus theory suggests that risk factors, such as the purpose for which the shared information will be used, are related to user willingness . AccordiThe interpretation of data sharing attitudes is a complex process related to and influenced by various factors  includinOur findings reinforce the idea that the majority of connected health users are willing to share their PHD and prefer to do so for scientific research. Furthermore, this study highlights that age, education, and occupation as well as the level of digitalization in the country are significant factors affecting user data sharing attitudes. Positive attitudes toward scientific research highlighted by our results can be perceived as an indication of trusted relations between users and academia.Our results have both theoretical and practical implications. The enforcement of the new GDPR in Europe demands more active participation of users in the management of their personal data. Nevertheless, this requires users to be knowledgeable and fully comprehend their rights and options over privacy settings. Educating users on the benefits and safety of data sharing could facilitate fair handling of data and increase trust. From the perspective of service providers, future efforts need to be directed toward simplification of privacy statements and reconsideration of systems design. The provision of user-friendly interfaces to enable faster and seamless screening of privacy settings could be another practical implication for technology developers. From the standpoint of policy makers, this study can facilitate shifts in policies toward accommodating user needs more effectively. Educating users, information technology professionals, and service providers on the importance of implementing public policy that supports responsibility of user-mediators while identifying gaps in policy frameworks are some of the steps that stakeholders should consider in the creation of future health care systems.


Service-Learning (SL) has become a teaching methodology that promotes social and personal skills while helping groups in need and at risk of social exclusion. This paper is a systematic review of the literature on SL experiences and research on college subjects in the area of health-care promotion in settings for older adults. After an exhaustive search, 43 peer-reviewed publications were classified according to frequency and geographical distribution, sample and duration of the programs, research methodologies, data collection instruments used, and main outcomes investigated. The results indicate that the research methodologies used tended to be qualitative and mixed, while the variety of samples and duration of interventions was very broad. The instruments used were mainly interviews and questionnaires, and the programs were developed specially in the United States of America. The groups receiving most SL were healthy older adults and older adult populations with aging disabilities and illnesses. The articles in the present review highlight that SL can have a positive effect on older adults’ health promotion and can enhance their community participation. The World Population Ageing report  concludeThis might be alleviated with the increase of general knowledge related to gerontology, as well as supporting issues related with well-being, active aging, and physical and mental health in aged people . IntergeSL is a pedagogical methodology that establishes a genuinely operational relationship between theory and practice and provides students with the opportunity to learn while contributing to the community. SL combines learning and community service, based on the application of skills and reflective understanding of curriculum content in real contexts, experientially, and with the aim of improving students’ critical skills while offering a social benefit .The increase in SL has roused great interest in educators at all levels and academic disciplines. Consequently, a multitude of studies examining its impact have been implemented, particularly in higher education . Due to SL requires great deal of effort and attention in the specific field of health-care promotion and community participation. It is important to note that the American College of Sports Medicine highlights the need to have some basic knowledge in working with different collectives while focusing on health promotion and community participation . For thiThis study presents a systematic review of the literature focused on higher education SL aimed at achieving benefits associated with health promotion and community participation among older adults. There is substantial literature on the beneficial impact of volunteering on older adults, much of which helps older adults . HoweverConcerning the conjunction of work among older adults and SL, Roodin et al.  have preThe present review is therefore structured around the following descriptive categories: Frequency with which SL articles on older adult populations are published, geographical distribution of papers, sample and duration of the programs, research methodologies employed, data collection instruments used, and the main outcomes investigated. Knowing the main advantages and disadvantages involved in these dimensions before starting a program can be critical for SL success.Because there have been some critiques of previous reviews that have not adopted a transparent and reproducible search protocol , we wereAfter identifying the problem, two main search strategies were used. The first step consisted of a search in two of the most respected databases in the field of social sciences and education: (ISI)-Thomson Reuters and Scopus-Elsevier. From these, we considered all peer-reviewed publications from the 21st century, that is, between 2001 and July 2019. Due to the variety of the terminology used in the literature, we sought to identify multiple terms to capture the intersection of ideas for our review. All of the publications therefore had to contain at least one term related to the following concepts: ‘Service-learning’ ; ‘health’ ; ‘higher education’ ; and ‘older adults’ . The search strings consisted of a combination of the terms for each concept, which were scanned for in titles, keywords, and abstracts.Finally, as a second step, the reference lists of all retrieved articles were reviewed to identify the possible existence of other interesting publications on the subject of SL in the field of health and higher education with older adults. The reason for choosing articles from the last 19 years was to highlight selected existing studies and trends from the current century.The selection of the literature to be reviewed was based on four general criteria: Quality, relevance, educational level, and topicality. Papers that did not meet these criteria were excluded from further consideration. Regarding quality and relevance, the first filter was the academic nature of the database where the articles were found and the accomplishment of the PRISMA literature search procedure. The format of each item also had to meet the standardized scientific criteria by being empirical, narrative, or reasoned, with well-defined objectives, methodologies, and designs containing valid and recognized studies. Regarding educational level and topicality, the search was directed solely at SL programs in the field of health care that had college students as the learners and older adults as service receivers.The results of the search for the selected articles should also respond to the type of research and/or application carried out through the SL experience in a field related to the subjects of health with older adults, excluding internships, scholarships, or volunteering. A team of four researchers applied the inclusion criteria. To ensure reliability in the application of the criteria, this research occurred after a one-day moderation. For the most part, the decision to include articles was relatively straightforward, because there was clear evidence of whether the papers were aligned (or not) with the review’s purpose.The initial search within the two databases yielded 753 potentially relevant articles. After reviewing title, keyword, and abstract information, the sample of potential articles was reduced to 141. No other interesting publications were found among their reference lists. There were 38 repeated publications, 16 records were excluded because they were abstracts that did not provide enough data, and 44 articles did not meet the inclusion criteria, leaving 43 articles for review. Each of the papers in the final sample was classified according to the following descriptive categories: Frequency and geographical distribution, sample and duration of the program, research methodology, data collection instruments used, and main outcomes investigated. The PRISMA literature search methodology is graphically represented in According to the publication dates, the results do not show clear patterns in terms of frequency . The mosAnother aspect that should be noted is the geographical distribution of the programs, because this will reveal the world’s leading research centers for college SL involving health promotion among aged people. The majority of articles (83.7%) were developed in the United States. Apart from this, the rest of the sample does not show more relevant patterns.SL programs may vary widely depending on features such as aim, service learners, scope of action, or service receivers. We may note a disparity in both the number of students giving service and the number of elders receiving it. In terms of the former, this number of individuals ranges from 16 in the works of Fruhauf et al.  and SingIn terms of the length of the programs and sessions involved in the investigations, it is worth noting the complexity of classification and analysis due to the varying information provided in each text. The majority of papers present studies or experiences that are part of larger programs, as in the cases of Timmermans et al.  or LynchSeveral differences appeared among the research methodologies. In this sense, Creswell  differenRegarding our sample, 34.8% of the publications employed a qualitative method, whereas 13.9% used a quantitative approach. In addition, nearly half of the sample (46.5%) used a mixed approach. The remaining two papers (4.8%) do not evince any type of methodology because they are devoted to a description of experiences  and a piMoreover, in this field it is important to analyze whether the effects of SL remain or disappear over time for both populations, service providers and service receivers. In this sense, only four out of 43 articles  used long-term designs.The instruments used to gather the data are another relevant aspect. A total of 30 articles employed surveys and/or questionnaires. Specifically, there were four articles that only used standardized questionnaires ,29,42,43The main objectives addressed by researchers can be principally divided into two areas of interest: The effects of SL on the students who provide the service and the impact on the older adults who receive it. The majority of the articles (65.1%) generated results related to the college students. A wide range of aspects was considered, for example, Andreoletti and Howard , AugustiIn addition, 25.6% of the sample examines both older adults and college students ,31,38,41At this point, it is important to note that only four studies used long-term designs (4.6%), two analyzed community service involvement and positive attitudes on students ,33, and It is noteworthy that one of the articles examines the particular effects of SL on the program as a pedagogical process , and twoFinally, seven articles (16.3%) refer to the general satisfaction with the SL program, four of them (9.3%) indicate that college students were satisfied, whereas three (7%) refer to the older adults’ general satisfaction. The synthesis of all of papers that met the inclusion criteria for this review is presented in According to the data obtained in this systematic review, higher education SL has been used on a number of occasions for health-care promotion among older adults and to encourage community participation. The experiences that constitute the sample enabled both college students and older adults to overcome stereotypes and biases to gain multigenerational perspectives, which triggered an improvement of mutual understanding and cohesion while favoring older adults’ wellness. However, there are many alternatives through which this area of study might be improved by future researchers and to provide better SL programs addressing issues related with the health of aged people.The analysis of the literature shows that the frequency with which SL articles on older adult populations have been published does not follow a gradual development, although it is a recurring topic since the beginning of the 21st century. The programs described may vary widely depending on features such as study methodology, duration and intensity of the SL program, location, service learners or service receivers, and scope of action. There is great diversity in terms of program length, but the most repeated ones were programs lasting one semester and providing 20 hours of service, which is a result consistent with the reviews made by Chiva-Bartoll et al.  or CopacRegarding the type of research methodology employed in settings that opt for SL as a way to promote health care among older adults, there is a clear predisposition towards qualitative or mixed approaches. This result is in line previous literature on SL ,60 and rIn the pedagogical context it is important to know the lasting effects of the SL programs implemented. This systematic review found four long-term studies published, two referring to attitudes of college students ,33, one The main issues investigated in the papers analyzed in this systematic review may be classified into two categories: Those relating to students and those relating to older adults. Some studies reported positive results in learning outcomes related to the personal perceptions of students, as well as the acquisition of professional skills. The benefits to college students are positive and well documented : The knoIn general, the majority of published results report better social stimulation and understanding of young people after a SL intervention and the general satisfaction of older adults. In addition, a program managed by Zucchero  with a pThe literature review shows that the United States is a country with a great tradition and proven experience in SL. Indeed, the term SL was first used in the United States by Ramsay et al. in 1967 , and theAccording to the political dimension of civic activities, college students might become more quickly and profoundly aware of the benefits of voluntary service among older adults thanks to their own SL experience. The result may be a progressive increase of college students implementing SL with older adults and, consequently, developing social cohesion between these two groups of people. Another important aspect is the wide variety of differentiating aspects among SL programs and the scope of action in which are implemented ,9, incluTo conclude, consistent with Novak et al.  and Warr


Evidence from randomized control trials suggest that coupled with smoking cessation interventions, CVD events can be reduced significantly if hypertension and diabetes patients are properly managed, raising practical what-if questions at the population level. This research aims to develop a dynamic simulation model using the systems modelling methodology of system dynamics, to evaluate the medium to long-term impact of hypertension and diabetes management, as well as smoking cessation intervention on CVD events, CVD deaths and post-CVD population.The systems modelling methodology of system dynamics was used to develop a simulation model to evaluate the impact of aggressive hypertension, diabetes and smoking cessation management on CVD outcomes at the population level.The insights from this research suggest that despite that at the individual level, hypertension management is associated with the highest risk reduction for CVD (50%) compared to diabetes and smoking (20%) and is also the most prevalent risk factor, at the population level, diabetes management interventions are projected to have higher impact on reducing CVD events compared to hypertension management or smoking cessation interventions. However, a combined intervention of diabetes and hypertension management, as well as smoking cessation has the most impact on CVD outcomes.Due to aging population and the increasing prevalence of chronic conditions in Singapore, the number of CVD events in Singapore is projected to rise significantly in the near future—hence the need for proactive planning to implement needed interventions. Findings from this research suggest that CVD events and its associated deaths and disabilities could be reduced significantly if diabetes and hypertension patients are aggressively managed.The online version of this article (10.1186/s12889-019-7429-2) contains supplementary material, which is available to authorized users. Cardiovascular disease (CVD) is one of the four leading causes of death around the world –4. In 20Evidence from randomized control trials suggesting that CVD events can be reduced significantly if hypertension –9 and diModeling and simulation methods applied to CVDs include Markov Model, Agent-Based Modelling, and System Dynamics . Markov in-silico, where pathways from interventions to outcomes may be indirect, delayed and possibly affected by nonlinearities or feedback loops  by 2040 in the base-case scenario. The number of people with hypertension is projected to increase from 659,958 in 2010 to 1,067,049  by 2040, representing 61.6% increase. The number of Singaporean smokers 18 years and older is projected to increase by 17% from 414,789 in 2010 to 485,524  by 2040. In the hypothetical scenarios experimented, the proportion of diabetes patients under management is projected to increase from 44 to 81% by 2040; whereas hypertension patients under management is projected to rise from 43 to 84% by 2040 and the proportion of the population using tobacco (smoking) is projected to decrease from 13 to 9.2% by 2040.Due to an aging population and lifestyle changes, the number of Singaporeans with diabetes is projected to increase 142% from about Table In response to population increase and aging, the number of Singaporeans with diabetes and hypertension is projected to surge. Concurrently, the smoking population is projected to rise. As a result, CVD events, CVD deaths, and post-CVD Singaporean population 18 years and older is projected to increase. The results from the quantitative simulation suggest that based on the current demographic composition of Singapore and available evidence from randomized control trials on the impact of diabetes, hypertension and smoking cessation interventions on CVD –11, 61, The insight that despite the fact that at the individual level, hypertension management is associated with highest risk reduction for CVD (50%) in comparison to diabetes and smoking (20%) while being the most prevalent risk factor, at the population level, diabetes management interventions are projected to have higher impact on reducing CVD events when compared to hypertension management or smoking cessation interventions. This is because the risk of CVD events associated with diabetes is significantly higher  than those associated with hypertension ; hence, the adjusted risk for CVD events at the population is expected to reduce significantly with diabetes management intervention rather than hypertension management intervention. For smoking, although the risk of CVD events associated with smoking  is comparable to that of diabetes, diabetes management interventions are expected to be significantly more effective for improving CVD outcomes relative to that of smoking cessation management intervention due to the rate of smoking being projected to increase moderately (17%) compared to that of diabetes (139%).This insight suggests that CVD outcomes are likely to improve if policymakers place more emphasis on identifying and managing individuals with hypertension and diabetes. Policymakers must thus be increasingly proactive in implementing chronic disease policies that prioritize care continuity, with emphasis on screening, and effective management of hypertension and diabetes, in order to reduce the incidence, death and disability associated with CVD. In addition, policies focusing on educating the public to adopt a healthy lifestyle to reduce the risk of chronic diseases should be promoted, such as the emphasis of the importance of regular exercise, maintaining a healthy diet and abstaining from tobacco products. Singapore has declared war on diabetes  due to pThe strength of this paper lies in the use of aggregate data at the population level to estimate the impact of diabetes and hypertension management and smoking cessation on CVD outcomes. Estimation of the impact of diabetes and hypertension management and smoking cessation will then allow policymakers and care providers to estimate the number of people who are likely to suffer from CVDs and allocate the resources required to provide adequate services to meet the health needs of the society. In addition, policy makers can now project the budget impact of interventions by estimating the number of individuals with diabetes and hypertension that need to be managed over time and the cost for management. However, the simulation model presented herein has some limitations. First, only individuals 18 years and older were included in the model, leading to a likely underestimation of the number of people with the risk factors of diabetes, hypertension, and smoking. Second, due to lack of data, we assumed an even distribution of individuals with risk factors into the health state of individuals with comorbidity. Lastly, the risk engine used in the model is from non-Asian population, which could lead to an over or under estimation of the probability of CVD events. Although a Singapore specific risk engine is currently unavailable, future models should make the effort to include such a risk engine as the populations are likely to differ.As a result of an aging population and the increasing prevalence of chronic conditions, the number of CVD events in Singapore is projected to rise significantly in the near future. The findings from this research synthesize data from a variety of sources and suggest that CVD events and associated deaths and disabilities could be reduced significantly if diabetes and hypertension patients are aggressively managed. Although health policy in Singapore is increasing emphasis on the prevention and management of chronic conditions, a recent noble policy that declared a war on diabetes should be expanded to include a war on hypertension in order to fully benefit from the combined impact of diabetes and hypertension management.Additional file 1:Figure S1. Behavior validation graphs. (TIF 124 kb)


Aging, the multifactorial process in which a progressive decline at the cellular, tissue, and organismal levels leads to death, has perpetually fascinated human beings around the world. In addition to the apparent signs of aging, such as gray hair, skin wrinkling, and muscle atrophy, other potential biological markers that are of predictive values still deserve to be determined. The most recent efforts on this topic have discovered two biomarkers that are of significance in the aging research field: telomeres and epigenetics .Telomeres are a repetitive sequence of nucleotides (TTAGGG) at the end of chromosomes. Since being discovered, they have been hypothesized as the fundamental aspect of cellular senescence. In particular, the length of telomeres gradually decreases as cells divide. In humans, the length of telomeres is ~5,000–10,000 base pairs for newborns, which begins to decline at the rate of 20–40 base pairs/year. Accumulating evidence has found that shorter telomeres were associated with cardiovascular diseases , diabeteYang et al. reported a study that examined the relationship of telomeres with C-peptide  and found a negative/inverse association between longer telomeres and lower levels of C-peptide. C-peptide is a short polypeptide with 31-amino-acid and relates insulin's A-chain to its B-chain in the proinsulin molecule. It was first described in connection with the discovery of the insulin biosynthesis pathway half a century ago. In clinical settings, patients with diabetes may have their C-peptide levels measured to distinguish type 1 diabetes and type 2 diabetes. The study performed by Yang et al. made multivariate adjustments and controlled for a few other factors, including age and sex, and thus offered new evidence to support that telomeres are associated with glycemic traits, albeit with a small magnitude.In the first article, Pavanello et al. presented a study that examined the interaction between obesity and locus at CYP27A1  and their associations with cardio-metabolic risk factors and telomeres . The authors found that telomeres were shortened in obese participants with more than three risk alleles of CYP27A1, and suggested that the role of CYP27A1 on the relationship between obesity and telomeres provided further insights into mechanisms linking obesity with the biology of aging. This study was hypothesis-driven; the genetic variants were selected for being previously and substantially genotyped. The big sample size and the rich panel of other biomarkers allowed the authors to conduct much more detailed analyses on this topic.The second article by Provenzi et al. proposed their perspectives on the role of telomeres in premature birth and discussed the potential implications for early adversity and care in the neonatal intensive care unit . Indeed, the speculation of telomeres in aging begins in the premature aging syndrome. It is thus interesting to examine if telomeres also play a role in premature birth/infants. The perspectives presented by Provenzi et al. are of interest in both theory and clinical practice and definitely need to be investigated further in the future.The third article by Lin et al. studied dietary copper intake and its relation with telomeres. The authors found that in this study sample, telomeres were longer for people with more dietary copper intake . The significant positive association did not change substantially in the multivariate analyses. Copper is one of the essential trace elements and major components for enzymes in humans and other species. While the proposed research topic is interesting, there is not too much evidence to support the speculation as noted by the authors. As dietary copper intake differs from environmental copper exposure, the study by Lin et al. may offer novel insights into the biological benefits and/or mechanisms of dietary or even circulating copper in human health.The last article by In summary, we assembled articles from diverse researchers in the field of telomeres and aging. It is a pity that we did not have articles on epigenetics. The articles collected so far could add new knowledge, evidence, and perspectives on the roles of telomeres in endocrinology.All authors listed have made a substantial, direct and intellectual contribution to the work, and approved it for publication.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.


The average life expectancy for people with a severe mental illness (SMI) such as schizophrenia or bipolar disorder is 15 to 20 years less than that for the population as a whole. Diabetes contributes significantly to this inequality, being 2 to 3 times more prevalent in people with SMI. Various risk factors have been implicated, including side effects of antipsychotic medication and unhealthy lifestyles, which often occur in the context of socioeconomic disadvantage and health care inequality. However, little is known about how these factors may interact to influence the risk of developing diabetes and poor diabetic outcomes, or how the organization and provision of health care may contribute.This study aims to identify the determinants of diabetes and to explore variation in diabetes outcomes for people with SMI.This study will employ a concurrent mixed methods design combining the interrogation of electronic primary care health records from the Clinical Practice Research Datalink (CPRD GOLD) with qualitative interviews with adults with SMI and diabetes, their relatives and friends, and health care staff. The study has been funded for 2 years, from September 2017 to September 2019, and data collection has recently ended.CPRD and linked health data will be used to explore the association of sociodemographics, illness, and health care–related factors with both the development and outcomes of type 2 diabetes in people with SMI. Experiences of managing the comorbidity and accessing health care will be explored through qualitative interviews using topic guides informed by evidence synthesis and expert consultation. Findings from both datasets will be merged to develop a more comprehensive understanding of diabetes risks, interventions, and outcomes for people with SMI. Findings will be translated into recommendations for interventions and services using co-design workshops.Improving diabetes outcomes for people with SMI is a high-priority area nationally and globally. Understanding how risk factors combine to generate high prevalence of diabetes and poor diabetic outcomes for this population is a necessary first step in developing health care interventions to improve outcomes for people with diabetes and SMI.ClinicalTrials.gov NCT03534921; https://clinicaltrials.gov/ct2/show/NCT03534921 Severe mental illness (SMI) refers to a set of disabling conditions such as schizophrenia, schizoaffective disorder, or bipolar disorder. People with SMI, who account for around 1% of the population -5.Diabetes is a significant contributor to the increased morbidity and mortality experienced by people with SMI. The condition is 2 to 3 times more prevalent in this population -8, and cwhole person [There is strong evidence that people with SMI are more likely to be socially disadvantaged than people without SMI -24, expee person , such moe person ,28, and e person .There is conflicting evidence about the quality of diabetes care for those with and without SMI ,30-34. IImproving diabetes care for people with SMI is a high priority nationally and globally ,37. UndeThis study aims to identify the determinants of diabetes in people with SMI and to explore variation in diabetes outcomes for people with SMI to develop potential health care interventions that can be tested further.The study has the following objectives:In people with SMI, to identify which sociodemographic, illness, family history, and lifestyle factors are associated with the development of diabetesIn people with SMI and diabetes, to identify which sociodemographic, illness, family history, and lifestyle factors are associated with variation in diabetes and mental health outcomesIn people with SMI, to compare health care interventions, physical and mental health outcomes in those with diabetes, and those without diabetesIn people with diabetes, to compare health care interventions, physical and mental health outcomes in those with SMI, and those without SMITo understand the factors that influence access to, and receipt of, diabetes care for people with SMI and explore the experience of diabetes health care by people with SMITo compare diabetes care provision for people with and without SMI, and estimate costs for theseTo identify which health care interventions  may be associated with better diabetes outcomes for people with SMI and diabetes.The underpinning theoretical framework for the study conceptualizes socioeconomic conditions as a fundamental cause of health inequalities . Under aThe mixed methods design is underpinned by a pragmatic paradigm, which acknowledges that data types, when integrated together, will enable the development of a more complete understanding of health inequalities in this population than would be possible from either method alone . InterroThe study is supported by DIAMONDS VOICE, a patient and public involvement (PPI) panel that contributes to a wider research program called Diabetes and Mental Illness: Improving Outcomes and Services. The panel was involved in prioritizing the research questions during the design phase of this study and reviewed all patient and public-facing documentation before submission to the National Health Service Research Ethics Committee. The panel will continue to contribute to the study in the following ways: advising on how to ask sensitive questions, acting as practice interviewees, advising on minimizing participant burden, promoting the study at local events, and advising on recruitment and dissemination strategies. Both the project management team and the study steering committee have service user representation to ensure that the patient perspective is incorporated in project decisions.A data use agreement for CPRD records and linked Hospital Episode Statistics (HES) and Office for National Statistics (ONS) mortality data was granted by the International Scientific Advisory Committee (ref: 17_161R). Approvals for the qualitative study were granted by the National Institute of Health Research Health Research Authority and the Greater Manchester West Research Ethics Committee (ref: 18/NW/0005), following a submission made through the Integrated Research Application System (ref: 235328).The study is registered on the NIHR Central Portfolio Management System  and ClinicalTrials.gov (record identifier #NCT03534921).This workstream examines the impact of potential risk factors on the development and the time to onset of diabetes in people with SMI and variation in mental and physical health outcomes in people with comorbid SMI and diabetes. Diabetes health care and outcomes for people with SMI and diabetes will be compared with outcomes for people with either condition alone. Variations in diabetes screening, monitoring, and management will be examined and costs estimated. The role of these interventions in contributing to health outcomes will be explored.The primary study population comprises adult patients (age ≥18 years) living in England who are registered with a general practice contributing up to research standard data to CPRD and who have remained within CPRD for the study period, from April 1, 2000, to March 31, 2016.CPRD is the world’s largest computerized database of anonymized longitudinal medical records from primary care. Information includes records of symptoms, diagnoses, referrals, prescriptions issued in primary care, records of immunizations and vaccinations, laboratory test results, lifestyle information , and all other types of care administered as part of routine general practice. Currently, data are collected on over 5 million active patients from 674 general practices, covering around 6.9% of the UK population registered with a general practitioner .Records for 3 population groups will be extracted from CPRD. The datasets will be structured as shown in Electronically linked data for individuals in the study population will be obtained from the following sources: HES data for hospital admissions , ONS forThe following outcomes listed in Analyses may be limited by the quality and availability of data for some of the above variables, but wherever possible, validated code lists will be employed.Known risk factors and covariates for developing diabetes and diabetes complications will be included in the analyses to determine their relative association with the development and progress of diabetes in people with SMI. The list of factors will be determined by evidence synthesis, complemented by expert consensus, and will be responsive to emerging findings from the qualitative interviews.The candidate risk factors include patient demographics and socioeconomic markers , lifestyle , social vulnerability markers such as housing status, hyperlipidemia, family history, type of SMI and diabetes (including order and timing of diagnosis), length of diagnosis, illness severity, and multimorbidity.It is anticipated that there will be around 5 to 6 years of data on each individual, which will enable more robust analyses than cross-sectional data would permit. Longitudinal data afford better control for unobserved characteristics, at either the individual or practice level that plausibly impact both practice performance and patient outcomes , and which may otherwise confound important relationships. In addition, repeated observations at practice or patient level allow the investigation of lags in the relationship between diabetes management and outcomes, as the timing of events can be observed. Both these factors are crucial in identifying plausible causal mechanisms linking diabetes management to outcomes.ghost patients, conducting sensitivity analyses, and evaluating the potential for unmeasured confounding and the size of any observed effects.The potential for confounding will be addressed by matching on index date to avoid inclusion of nested within patients who in turn are nested within practices. Linear, logistic and survival regressions will be applied as appropriate depending on the outcome variable of interest. Multilevel mixed effects will be estimated to account for the correlation in the longitudinal health records of the same patient, as well as the unobserved correlation at practice level. An outline of planned analyses by study objective is given in A range of regression models will be used for statistical analyses, taking account of the hierarchical structure of the data, where, for example, activities are Under all objectives, analyses will be conducted in line with the inequalities framework to quantify the absolute and relative effect of social inequalities on quality of care and outcomes. Under objectives 1 and 3, the disparities will be modeled within the SMI population, under objective 2 within the SMI and diabetes population, and both within and between the diabetes populations (SMI and non-SMI) under objectives 4 to 7. Specifically, where sample size permits, analyses will be stratified, for example, by ethnicity and or deprivation and disadvantage markers such as IMD; housing status and rurality will be used as independent variables to estimate gap or gradient effects.All statistical models will include a set of relevant patient, local population, and practice covariates where possible to control for confounding and interacting influences potentially masking the relationship between diabetes management and outcomes.expiring) or time-independent (nonexpiring) variable and as specific to the refused treatment or as a general marker of noncompliance. Noncompliance will be used to create offer of treatment explanatory variables, facilitating intention-to-treat type analyses.In sensitivity analyses, noncompliance  will be included as an independent variable in the models. Sensitivity analyses will be conducted with noncompliance treated as either a time-dependent  adults with SMI and diabetes  living in the community (n=30-50), (2) relatives or friends who are involved in the care of a person with SMI and diabetes (n=15-20), and (3) health care staff .People with SMI and diabetes will be included in the study if they are:Aged 18 years or olderDiagnosed with a SMI and not currently experiencing an acute relapseHave a diagnosis of diabetes Live in the communityHave capacity to consent to the study.Maximum variation purposive sampling will be used, informed by demographic and illness characteristics identified during the descriptive analysis of CPRD data and the social inequalities theoretical framework to gain understandings of the diversity of experience in this group. People with SMI and diabetes will be sampled from rural and urban areas, areas of wealth and deprivation, and areas with diverse communities.To ensure representation from different health care disciplines, health care staff will be sampled purposively. GPs, practice nurses, diabetes nurses, mental health nurses, case managers, psychiatrists, and diabetologists will be invited to take part in the study.The sampling strategy in all groups will be continually monitored as the study progresses to ensure that diversity of experience is captured. Recruitment will continue until data saturation is reached, that is, no new themes are emerging from the interviews .Evidence suggests that around 20 to 30% of people with SMI are supported solely within primary care . TherefoPatients will also be recruited via existing research cohorts and clinic and website advertisements. Patients from existing cohorts who have agreed to be contacted for future research will receive a study pack. Patients or relatives who express an interest in participating after seeing an advertisement will also be provided with the pack. Patients who contact the study team will be asked to provide permission to access medical records to screen for eligibility.To recruit relatives or friends to the study, participating patients will be asked to identify a person who supports them who will then be approached by the research team. Relatives who are known to clinicians will also be provided with a study pack.For health care staff recruitment, lead clinicians in participating general practices and mental health services will be asked to identify health care staff with experience of providing services to this population.Written or audio-recorded informed consent will be obtained from all participants. Study information will be provided  using materials that have been developed with the PPI Group. Capacity to participate will be assessed by staff with appropriate experience during contact telephone calls and again before interview.All interviews will be conducted using semistructured topic guides see , which wInterviews will be conducted by an experienced qualitative researcher and will last for a maximum of 90 min (patients and relatives) or 45 min for health care staff. With participants’ permission, interviews will be audio-recorded.Data will be analyzed using NVivo 11 . The framework method  will be The study was funded for 2 years, from September 2017 to September 2019. Data collection is ongoing in the qualitative workstream and is expected to be completed by the end of December 2018.In the later stages of analysis, the findings from the qualitative study will be merged with quantitative analyses using established integration techniques such as comparison matrices to validate, confirm, or refute findings, and joint data displays . These aFindings will be considered in 2 multistakeholder workshops involving service users, family members, researchers, clinicians, commissioners, health service managers, and representatives from third sector organizations to develop recommendations to improve diabetes care for people with SMI. The first workshop will review the merged findings, identify further analyses that can be conducted, and will create draft recommendations to improve health care. The second workshop will use the final analyses to refine the draft recommendations and to design and assess the feasibility of interventions or care pathways where the need for these has been identified empirically.A range of channels will be used to communicate study findings to participants, stakeholders, and likely beneficiaries of the research. Key audiences will include patients, family members, health care staff, policy makers, voluntary and commercial sector organizations, and researchers. Representatives from these sectors will be invited to a dissemination event at the end of the study.Research outputs will take the form of written reports, journal articles, oral presentations, and content distributed through international, national, and local networks, websites, and social media.People with SMI face significant health inequalities compared with the population as a whole, experiencing poorer physical health and having a reduced life expectancy of 15 to 20 years. Diabetes contributes to this inequality, occurring 2 to 3 times more often in people with SMI. Although various sociodemographic, genetic, illness, and health care–related factors are thought to increase the risk of developing the condition, the relative influence of these factors, and how they might interrelate, remains poorly understood. Furthermore, evidence suggests that people with comorbid SMI and diabetes experience poorer diabetic outcomes than those without SMI.This research will provide greater understandings of why people with SMI are more at risk of developing diabetes and why their diabetic outcomes may be poorer than those without SMI. Associations between diabetes screening, monitoring and management, and health outcomes will be investigated to identify interventions with the potential to improve outcomes in this population. In addition, exploring the health care needs and health care delivery concerns of people with comorbid SMI and diabetes, relatives or friends who support them, and health care staff will enable the development of a more comprehensive understanding of the factors that contribute to poor outcomes and the drivers of improved health outcomes in SMI and diabetes.


Recognition of human actions form videos has been an active area of research because it has applications in various domains. The results of work in this field are used in video surveillance, automatic video labeling and human-computer interaction, among others. Any advancements in this field are tied to advances in the interrelated fields of object recognition, spatio- temporal video analysis and semantic segmentation. Activity recognition is a challenging task since it faces many problems such as occlusion, view point variation, background differences and clutter and illumination variations. Scientific achievements in the field have been numerous and rapid as the applications are far reaching. In this survey, we cover the growth of the field from the earliest solutions, where handcrafted features were used, to later deep learning approaches that use millions of images and videos to learn features automatically. By this discussion, we intend to highlight the major breakthroughs and the directions the future research might take while benefiting from the state-of-the-art methods. Activity recognition involves an understanding of human actions. A human action is harder to define than to understand, and many attempts have been made in the literature to define it in one way or the other. Turaga et al.  providedThe recognition of human actions form videos is a challenging task. It requires work in multiple disciplines to be effectively executed and combined such as object recognition, background and foreground processing, semantic segmentation and human dynamics. There are two major types of recognition systems: one that involves the use of wearable sensors or associated devices and the other that uses cameras and wireless radio frequency modules. Among the first kind, a few approaches to action detection have involved the use of dedicated sensors such as mobile sensors ,5,6 or pObject scope understanding where only the positions of persons and objects are detected.Tracking scope understanding where the trajectories and correspondence of objects are analyzed.Pose-level understanding that involves the analysis of the position of human body parts.Analysis of human activities and events.Video analysis has been performed at various levels of detail depending on the information we require from them. The few significant ones were given in a study by :Object There are several existing surveys that have explored the techniques for activity recognition. Some of these have divided these recognition approaches into single-layered and hierarchical approaches, as in the works of Aggarwal and Ryoo  and ChenHandcrafted feature extraction techniques paired with classifiers have been used for action recognition for quite some time and with considerable success . HoweverThe rest of the paper is organized as follows: In the next section, we discuss some of the challenges of action recognition using data from videos. Inter-class variations: Different people perform different actions in their own ways, which at times show very low resemblance to one another, e.g., walking methods may differ in stride length or speed.Intra-class similarities: Actions belonging to different classes may appear similar such as jogging and running.View point variations: The same action if observed from two independent viewpoints can appear to be different, and the data collected as a result may indicate separate classes.Environment: Cluttered or complex backgrounds can make the task of identification of clear human shapes much more difficult.Temporal variations: Temporal variations occur both in terms of action performance/completion and action observation.The activity recognition process involves quite a few challenges and constraints that need to be dealt with at the time of both feature extraction and classification. Poppe has listed some of the significant ones in . These aAll these issues are addressed explicitly by the action recognition approaches as and when they arise. However, depending on the datasets that are being used and the feature selection techniques employed, the impact of these constraints may vary. There is, thus, no single strategy that can be applied for any particular problem while using different action recognition techniques. In the subsequent sections, we provide a review of various action recognition techniques along with their shortcomings. The organization of the techniques is based on the time of introduction and the growing complexity of the presented techniques.The interest in human action recognition is not a recent one, and scientists and researchers have over time been utilizing various techniques for action identification. Using spatial information about the human pose, which is generated by extracting various image features, we can classify human pose based on the similarity of the pose to some action.Among the earliest attempts at action recognition, Johansson  used a sAs a pioneer work in this field, these simplistic experiments paved the way for many more methods based on the same idea. The two predominant techniques that emerged as a consequence of this work are the (i) representation of motion as a 2D sequence of actions and (ii) generation of 3D models from 2D representations to recognize actions . The varOthers have built on such models as well ,33; someHolistic representations do not require identification or marking of individual body parts unlike the body models discussed in the previous section. These approaches work by preprocessing the images by performing fundamental tasks such as background subtraction and feature extraction. Most techniques make use of contours and/or silhouettes of the human body ,37,38.Darell and Pentland  created Work by Bobick and Davis  has had Elgammal et al.  and WeinThe results of holistic representations are promising, but are incapable of handling viewpoint variations ,61. ImprWork by Laptev  on spaceEarlier works in action recognition have used cuboid models for body representation ,65, but Histogram of oriented Gradients (HoGs) were used for motion detection by , and latOne criticism to cuboid representations is that over a span of frames, the detected interest point may not lie at the same spatial location within the temporal bounds of a cuboid. Action trajectory is the tracking of a feature in the time domain. Trajectory-based action representations were widely adopted after the works of Messing et al.  and MatiHandcrafted approaches are complex to build and hard to modify. These cannot be readily adapted to new or complex datasets, which has hindered their ability to provide a unified global solution. This was changed by the rapid increase in use of deep architectures for image analysis techniques. Given in the next section are various approaches based on deep learning; some of which also make use of handcrafted approaches in a limited capacity.With the advent of deep learning approaches that enable the learning of features along with the classification of them, we have seen the application of these in the field of action recognition with considerable success. In particular, convolutional neural networks have revolutionized the field of image classification and recognition ,78,79,80In general, we can categorize deep approaches into two major schemes based on network function: supervised approaches and unsupervised approaches. The supervised approaches include (i) networks that extract features from deep models and use other classifiers and (ii) networks that use deep models for end-to-end classification, as well as (iii) networks that use handcrafted features in conjunction with deep networks for classification ; while uThe supervised approaches are split into three architectures or combinations and/or evolutions of these three architectures: Convolutional Neural Networks (CNN), Recurrent Neural Networks (RNN) and Long Short-Term Memory networks (LSTM).CNN: CNN consist of a number of convolutional layers, each of which is responsible for feature extraction. The lower layers extract simple features, while the higher layers extract complex features by the use of filters at each layer. The filters are designed on the principle of weight sharing, which enables reducing the number of parameters to learn. Each layer that increases the depth and complexity of a network also inadvertently increases the dimensionality of the convolved features. CNN are used as effective feature learners, but their greatest strength is their ability to be used as end-to-end models for classification .RNN: Recurrent neural networks have the ability to process feedback connections, which allows them to model sequential behavior. RNNs have found considerable success in handwriting recognition ,84 and sLSTM: Long short-term memory models are used in conjunction with various CNN and/or RNN models in order to represent long-term temporal dynamics and to do away with the vanishing gradient problem.Handcrafted features have given promising results over the span of decades, where more and more sophisticated features emerged with time ,73,74,75The three-dimensional convolutional neural networks aim to extract spatial features using the normal 2D transforms and employ the third dimension to extract temporal information . The 3D Research has been focused on how to successfully incorporate the time dimension in deep networks. Ng et al.  have worUsing 3D filters increases the number of parameters and inevitably increases the cost and complexity of the network. Sun et al.  addressee et al.  and Donae et al.  have usee et al. . In the e et al. , the netMulti-stream models have been built on the idea of the separation between the spatial domain and temporal domain. Simonyan et al.  introducOther works that have explored the idea of multi-stream networks are  in the fThere is an ever-increasing amount of video data that are available over the Internet, but since most of this is consumer generated, thus they are not labeled. The potential of being able to use these data in an unsupervised environment to understand and predict the action sequences can give rise to endless possibilities. Generative models built for sequence analysis ,109 haveimitives ,111,112.imitives ,114,115 imitives  capturedSirvastava et al.  created The datasets for action recognition have evolved over time and have become more complex and realistic . The earThe most challenging datasets are the ones that involve YouTube videos and sports videos. These have the most variable backgrounds and viewpoint variations. Some YouTube videos are from user devices and have low camera stability and low resolution. A list of techniques and their accuracy is presented in It is interesting to see how the deep approaches in action recognition perform with respect to handcrafted or local approaches; since in terms of images, we have seen that deep architectures have outperformed the previous approaches by quite a wide margin . An accuEven though much of the research has shifted towards adapting deep networks for action recognition tasks, deep networks have not completely replaced the traditional handcrafted approaches. A few approaches have focused on getting the benefit of both techniques, i.e., handcrafted features and learned representations, by employing the concept of ‘transfer learning’ as in the works of . Dense tIn deep networks, spatio-temporal networks and two-stream networks have given better performance than their counterparts. Both of these solutions build on the traditional 3D convolutional architecture by using 3D filters. To obtain temporal information, dedicated streams that use optical flow trajectories have been used, which have been very successful on datasets ,107, butOne area that will require further exploration in the future is the idea of pairing video recognition architectures with image recognition ones . FurtherThe ability of machines to understand images and scenes has driven many researchers to find incredible solutions by machine learning. We saw that from simple techniques like MLD (Moving Light Displays) to deep approaches, over time, many solutions have been proposed to find a solution to this problem. Techniques that were used for image understanding have been extended to work for action recognition through videos, as well, with considerable success. However, the problem of action recognition through videos is far more complicated than image analysis. A discussion has been presented to find the techniques that have been used over time and to highlight the most successful ones, in the two dominant categories of ‘deep learning’ approaches and ‘non- deep learning’ approaches, while finding the direction for future research.


Alcohol Health & Research World salutes the advances that have been made over the past 25 years in the field of alcohol research. The following pages feature commentaries on important articles published in the field. Each commentary discusses the impact that the article has had on the direction of alcohol research, the changes that have occurred in the field since the article was published, and the future trends that are developing as a result of this research. Much of this research, but not all, has been funded by NIAAA.In this special section, These 16 seminal articles were chosen after an arduous selection process. Although the papers represent only a fraction of the important work taking place in the field, they clearly show the direction and scope of alcohol research: They reflect the multidisciplinary nature of alcohol research and the promise that this field holds in reducing the incidence of alcohol-related problems in society. It is now well accepted that alcohol abuse and dependence are biomedical disorders and are not the result of personal moral turpitude or depravity. However, 40 years ago, the conceptualization of alcohol problems as illness rather than personal deviancy was not well accepted in American society. Scholars have noted that “the transformation of alcoholism from depravity to disease began with a clinical report by two eminent neurologists, Drs. Victor and Adams, in 1953” , p. 265.Victor and Adams thoroughly evaluated 226 men admitted to the Boston City Hospital for alcohol-related illness. Beginning at 6 to 8 hours after their last drink, the patients’ behaviors and symptoms were carefully observed and recorded until 72 to 96 hours after cessation of drinking. Victor and Adams observed and described for the first time specific types of alcohol withdrawal symptoms. These symptoms ranged in severity from mild to moderate tremens of the body, which Victor and Adam’s patients described as “the shakes or jitters,” to major seizure disorders and very severe symptoms and behaviors, such as delirium tremens. These basic clinical studies provided the foundation for the development of new treatments, such as the use of medications to reduce the duration and severity of alcohol withdrawal disorders, including the life-threatening consequences of delirium tremens.Victor and Adams believed that their systematic study of the onset, severity, and duration of the alcohol withdrawal syndrome was consistent with a long tradition of scientific inquiry in the practice of medicine. During scientific society meetings, they often quoted an observation made centuries earlier by Hippocrates, “if the patient be in the prime of life and . . . if from drinking he has trembling hands, it may be well to announce beforehand, either delirium or convulsion” , p. 266.The pioneering studies performed by Victor and Adams in 1953 also provided the stimulus for other carefully conducted, well-controlled studies. Prior to the studies by Victor and Adams in 1953, alcohol withdrawal syndrome was considered by many to be the result of problems not specifically related to chronic alcohol intake or cessation of drinking. A variety of causes were invoked to account for severe disorders, including delirium tremens and alcohol seizure disorders. Such causes included poor nutrition, alcohol-induced disorders of metabolism, and even a simpler and more hostile conceptualization–possession of the alcohol consumer by demonic spirits. Victor and Adams, as competent physicians, recorded their observations in a systematic and unbiased manner. Then, based on these observations, they provided the best description of the relationships between the causes and consequences of alcohol dependence. Their characterization of alcohol dependence provided a firm basis for the establishment of alcohol-withdrawal problems as a biomedical as well as biosocial disorder. The studies that they carried out represent not only major contributions for increasing knowledge about alcohol abuse and dependence but serve as an exemplary model for the conduct of clinical investigations in medicine generally. In many ways, the original investigations of Victor and Adams concerning the effect of alcohol on the nervous system highlight the ongoing quest for attainment of excellence in both clinical research and the practice of medicine.


As social change agents (SCAs), occupational therapists (OTs) are expected to defend the rights of their clients, advocate for and with them, and try to influence organizational and political decision-makers. However, OTs do not generally feel equipped to take effective action. The overall goal of this research partnership is to support practising OTs in acquiring the knowledge and skills required to act as SCAs through a specific SCA training program and a toolkit that summarizes the key training points.The study will include three iterative phases  and use a participatory process. The design of the training program and toolkit will draw on the expertise of the researchers , a professional provincial partner and study participants . To evaluate the training program and toolkit, a self-administered evaluation questionnaire, facilitator observation grid and semi-structured guide designed to facilitate focus group discussions will be used. The quantitative and qualitative data will be analyzed using descriptive statistics and thematic analysis, respectively. The results of the initial implementation and evaluation phases will inform improvement of the training program and toolkit before starting the cycle with the following groups.In addition to training about 100 OTs, this study will produce three main benefits: 1) development of two products, namely the SCA training program and toolkit, that are easy to reuse and potentially transferable to other professionals; 2) ownership of these products by the partner through its close involvement in all stages of the study; and 3) development of a sustainable partnership between a team of researchers and a recognized organization with networks across Canada and internationally. These three spin-offs will provide a solid basis for an increasing number of permanent implementation initiatives, in Québec and elsewhere in Canada, not just in occupational therapy but also in other professions. To support the social inclusion of people with disabilities, including participation in meaningful social roles and access to public services, occupational therapists (OTs) are key professionals . As expeIn promoting occupational justice  and addrCommunication has been highlighted as one of the many important and necessary skills of the SCA. According to the Competency Profile, OTs should be able to communicate adequately inside their system (as a competent agent) and outside their system (as a proficient agent) . The litThe knowledge and skills SCAs require therefore differ from the clinical skills taught in entry-level graduate programs for OTs . The knoDespite the importance of the SCA role, OTs do not feel equipped to take effective action , 21. In This perceived inability to act as a SCA could be attributable to the nature of OTs’ entry-level training. To date, only one occupational therapy program in Québec appears to formally include multidisciplinary SCA knowledge and skills in its curriculum , and thiBearing all this in mind, supporting OTs to act as SCAs is one of the priorities of the Canadian Association of Occupational Therapy (CAOT)  and its Based on recognized pedagogical principles and currently available evidence, the overall goal of this research partnership is to support OTs in acquiring the knowledge and skills required to act as a SCA. The specific objectives are to: 1) develop a SCA continuing education program and toolkit, 2) implement them, and 3) evaluate them according to the participants’ perceptions of acquiring the knowledge and skills required to act as a SCA.Two theoretical frameworks support the conceptualization and operationalization of this approach. The first, the SCA Systematic Action Planning Model , describTo achieve the study objectives, a cyclical, iterative and participatory process involving design-based research  will be By mobilizing researchers in the fields of pedagogy and rehabilitation , OTs , as well as an associative partner at the stage of identifying needs, this innovative project takes a cross-sectoral, co-constructive approach. Using the iterative and participatory process chosen, this strategy will ensure the relevance of the products developed by considering the needs expressed by CAOT-Qc and OTs  and feedback from OTs .Using Miller’s theoretical framework , this phn = between 12 and 50 OTs per group), based on their different clients  and intervention communities . The recruitment strategy will be broadened by posting the invitation on the CAOT-Qc website and including a link to the page via CAOT-Qc Facebook and Twitter accounts. Interested OTs will be invited to contact FV if they have any questions. FV will relay the contact information of the interested participants to MB and SR, who will be responsible for calling each participant and ensuring that the objectives and overall study are explained and understood, and that all questions pertaining to the study are answered. Potential participants who are still interested will be sent the consent form by email or mail, at their discretion. All interested OTs and CAOT-Qc members will be eligible to participate in the training. Once free and informed written consent has been obtained , recruited participants will be asked to respond to a Doodle to identify a common training date for their group outside of working hours. FV, MB and SR will deliver the training session and present the toolkit to the OT participants (Obj. 2), one group at a time.Following ethics approval, FV will email OT members of CAOT-Qc interested in participating in the training program and evaluation. These OTs belong to six pre-existing groups  and adapt their design accordingly, the team developed various tools, which were validated by two methodological and content experts. These tools are a self-administered evaluation questionnaire, facilitator observation grid and semi-structured guide to facilitate focus group discussions. First, immediately before and after the training session, all participants will complete a self-administered evaluation questionnaire. The facilitators  will complete an observation grid. A convenience sample of 5 to 8 OTs will be invited to participate in an audiotaped focus group meeting lasting 60 to 90 min. To identify and recruit these participants, a separate sheet will be included with the self-administered questionnaire specifically asking participants about their interest in participating in a focus group meeting sometime after the training session. The meetings will be held outside working hours and the discussion will be facilitated by a trained research assistant with 10 years of experience in group animation and pedagogy. To ensure that, on the one hand, participants have enough time to reflect on the training program and toolkit – specifically, how they met their needs as SCAs – and that, on the other, those reflections are still fresh in their minds, the focus group meeting will take place approximately 1 week after the training session. After each training session, the collected data will be analyzed  and the results will be considered with a view to adapting, modifying or improving the next training session and toolkit before starting the Implementation-Evaluation cycle with the next group. After this analysis, the evaluation tools will be reviewed. To document the process, a logbook will be completed by MB and SR, with the support of the team.This form includes three sections: pre-training, post-training and sociodemographic data. The pre-training section includes questions about the participant’s intended goals and perceived ability to act as a SCA. Derived from the Participant Workshop Evaluation assessed by Dagenais et al. , the posThe facilitator observation grid highlights the elements to be improved and/or maintained with respect to the training process and participation in the different activities . Due to the iterative nature of this study, the observation grid will be an important tool for helping to improve the training over time.Using open-ended questions, the focus group will discuss the themes from the evaluation form in order to generate in-depth feedback. For example, “Training participants’ perceived increase or decrease with respect to knowledge, skills or confidence between the beginning and the end of the training. What do you think this increase/decrease is attributable to?” Elements of the facilitators’ observations (e.g. degree of commitment to the training activities perceived by the participants) could also be validated or expanded upon with the group.The logbook completed by the research trainees will track the progress of the study, changes to the training program and toolkit, and areas for improvement according to the team. It will also be used to note the methodological choices made and any preconceptions influencing the team during the analyses.The data from the evaluation form, observation grid and focus group meeting will be compiled and transcribed. The quantitative data from the form will be analyzed using descriptive statistics. The qualitative data will be analyzed thematically by at least two members of the team. First, saliency analysis  will be In addition to participating in developing the research protocol, CAOT-Qc will provide logistical and technological support (e.g. teleconference) to facilitate interactions between research team members and group leaders. CAOT-Qc will also be very active in the recruitment, design, organization and facilitation of training for different groups. To this end and as required, CAOT-Qc will offer the use of its material and information resources for teleconferences, webinars, and hosting interactive training modules, including video capsules, PDF or other documents. In addition, CAOT-Qc intends to play a significant leadership role in the dissemination of the project and its results.First, this research partnership will provide OTs with a long-term opportunity for professional development based on available evidence concerning SCAs. More specifically, this project will provide professionals with highly contextualized training on the role of SCA, a socially important role that is currently under-invested in. It will also lay the groundwork for creating more opportunities to implement the training program by a multiplying agent (FV). Combining knowledge from various disciplines  and using participatory research methods, this project will be a unique training opportunity for two research trainees. Finally, this innovative process will contribute to the development of knowledge regarding cross-sectoral participatory research and may be used by other groups to increase the flexibility of their own training process relating to complex roles. Methodological choices will ensure the scientific rigor of the study and make it easier to obtain rich data through in-depth focus group meetings and prolonged field exposure (data collection over more than a year) . The proThe research protocol has been accepted by the Research Ethics Committee of the CIUSSS de l’Estrie–CHUS. A consent form outlining the purpose of the study and potential benefits and risks will be presented to each of the participants. All participants will need to give their free and informed written consent . Anyone This project will develop the role of OTs as SCAs which, despite its importance and presence in the Competency Profile , remainsIn addition to the traditional methods , forums with knowledge users (OTs and their clients) will be organized in more remote regions of Québec by FV with the support of AC, EJ and CAOT-Qc’s logistical infrastructure. These forums will stimulate regional OTs’ interest in the training program and, hopefully, its broader implementation. To do so, these forums will discuss the role of an “effective SCA” and the usefulness of the training program and toolkit in addressing the barriers to social inclusion reported by OTs and their clients in light of the research findings.OTWeekly (CAOT’s email newsletter), as well as to the Alliance of Canadian Occupational Therapy Professional Associations (ACOTPA), Association of Canadian Occupational Therapy University Programs (ACOTUP) and various partners  through work meetings. CAOT-Qc gives the team access to its information technology resources  for advertising purposes: the information will be widely disseminated and easily accessible.In addition, CAOT-Qc will present the results of the study to the board of directors of the national organization (CAOT). The findings will also be disseminated to CAOT’s 16,000 members, OTs and students via The study began in May 2018 with the review and synthesis of relevant literature and development of the protocol, including collection tools. Ethics approval was obtained from the Research Ethics Committee of the CIUSSS de l’Estrie–CHUS on 23 July 2018. The data collection and analysis will take place from January 2019 to March 2020. Results will be disseminated from March to May 2020. Table