Toxicities of the oral soft and hard tissues due to the radiotherapy of the head and neck cancer can potentially lead to interruptions of cancer treatment and/or dose reduction, resulting in poorer outcomes. The aim of this study was to assess the knowledge of dental practitioners in Saudi Arabia about oral and dental assessment for and complications of radiotherapy of head and neck cancer. An online, already validated, self-administered questionnaire was sent via an online link through WhatsApp groups and other Social Media platforms to reach out to the majority of targeted samples . Responses were statistically described and analyzed based on the different grouping factors: gender, specialty, working sector, region of work and experience. There were 370 respondents, 257 (69.5%) of them were males. Most of the respondents were general dental practitioners [144 (38.9%)], The percentages of the correct answers range from as low as 26.2 to as high as 97%. The per cent of correct answers by the respondents in 18 out of 31 questions was above 75%. Females, dental specialists , working in public sectors and in the central and western regions of Saudi Arabia were associated with higher levels of knowledge. Our results show highly variable knowledge of dental practitioners on oral and dental assessment for, and complications and management of radiotherapy to the head and neck area; that knowledge seems to fluctuate considerably with gender, experience, work sector and specialty. Head and neck cancer (HNC) is an umbrella term refers to a group of cancers developing in the oral cavity, pharynx, larynx, paranasal sinuses, nasal cavity, salivary glands, or lymph nodes of the head and neck; it is considered the ninth most common cancer worldwide . Oral cancer accounts for about 26% among all the head and neck cancers recorded annually in the Kingdom of Saudi Arabia (KSA), and greater number of them is detected at advanced stage. Oral cancer in KSA is strongly linked to the frequent use of smokeless tobacco (Shammah)  and to the chewing of qat , an evergreen shrub chewed for it’s an amphetamine-like effects . A large number of oral cancer cases are documented from the southwestern region of KSA especially in Jazan province and are invariably related to the consumption of Shammah.Surgery, radiotherapy, or chemotherapy are commonly employed, either individually or in combination, for treatment of HNC. Radiotherapy to oropharyngeal region may induce squamous epithelium destruction, inhibit proliferation of transit cells, and absence of cell regeneration leads to acute mucositis. Also, high-dose radiation to tooth-supporting bone results in hypoxia and reduces the vascular supply to the bone and soft tissues, causing fibrosis and vascular thromboses . Given the treatment-related toxicities to the soft and hard tissues of the oral region, cancer treatment might be interrupted, or dose might be reduced, resulting in poorer outcomes such as increased morbidity and possibly decreased survival . Oral and dental complications include mucositis, infections, pain, salivary gland dysfunction, taste change, dysphagia, trismus, and soft and hard tissue necrosis . Therefore, dental assessment and management of HNC patient pre and post cancer treatment is one of the cornerstones in the comprehensive care approach . The main aim of doing so is to eliminate or at least reduce the risk of the above mentioned complications. Thus, it is essential that all health professionals including dentists need to be aware of and knowledgeable about the prevention, diagnosis, and management of oral complications of radiotherapy in order to ultimately minimize the impact of these complications on the patient’s life . In this context, a few studies have assessed this issue and revealed variable knowledge among dental practitioners/students . No single study has been conducted to investigate the knowledge and awareness among dentists in Saudi Arabia towards oral and dental assessment and management of head and neck cancer patients pre and post-radiotherapy, and hence this study sought to do so.MethodologyThis study is of cross-sectional, questionnaire-based study design. The population framework was dental practitioners working currently in Saudi Arabia. The questionnaire’s items were taken from previously validated questionnaires used in the same context . For more confirmation, the questionnaire was administered to three experts in oral medicine and pathology, who had a clear understanding of the pre and post radiotherapy oral complications and proper managements. Their feedbacks were minor, and the questionnaire was corrected accordingly. Then, the questionnaire was administered to 18 dentists from different dental specialties and asked whether they had difficulty in understanding any questions. Their feedbacks showed that the questionnaire was appropriate and easy to understand; minor corrections were made at this stage. The questionnaire included 20-questions pertaining to the knowledge on oral/dental assessment for and management of HNC patients pre- and post-radiotherapy. The first 5 items of the questionnaire were about the participants’ demographic information . Of the other 15 items, 7 were directed to the oral/dental assessment and information prior to radiotherapy. The remaining 8 items are related to oral complications of radiotherapy and their management protocols. The stems and alternatives (answers) of all items are listed in th May and 18th June 2020.The study protocol was approved in advance and Ethical Clearance was obtained from College of Dentistry, Jazan University. The research was self-funded and there are no conflicts of interest to be reported.To confirm nationwide distribution, the authors were keen to target as many as possible dental practitioners with different background  at different working fields  and in the five regions of the KSA . To do so, the questionnaire was administered to the potential participants using Google form via an online link through WhatsApp groups and other Social Media platforms depending on friends in the different regions of KSA. Furthermore, five reminders were sent through these channels aiming to increase the response rate. Responses to the questionnaire were sensitive to the Internet Protocol (IP) Address assuring no duplicated responses. The time frame during which the questionnaire was circulated was between 26Statistical analysisData were obtained in “excel” format and exported into SPSS program, Version 21  for further analyses. As all data were qualitative, they were presented as frequencies and corresponding percentages. All variables were described for the whole sample, and analyzed by different grouping factors  using Chi square/Fisher exact tests as appropriate. For questions with multiple correct/possible choices , each choice was statistically dealt with as a separate variable with “positive/yes” answer when marked and “negative/no” answer when not marked. A P value of less than 0.05 was considered significant.There were 370 respondents, 257 (69.5%) of them were males. Most of the respondents were general dental practitioners [144 (38.9%)], followed by oral surgery/medicine/pathology specialists [57 (15.4%)], endodontists [34 (9.2%)], and periodontists [32 (8.6%)]; the other specialties represented up to 28%. Most of the respondents reported working in universities [234 (63.2%)], and half of them had less than 5 years of experience [183 (49.5%)]. More than 63% of the respondents worked in the central and western region of the kingdom . presentsGender-wise comparisons showed higher knowledge in favor of females . For exa presentsThe responses based on work sector are presented in . DentistFew differences were reported based on the year of experience as shown in , with noWith regard to the region of work, dentist and dental specialists working in the central and western regions showed the highest levels of knowledge in most of the included questions, while those working in the northern and to less extent those working in the eastern regions revealed the lowest levels of knowledge . For exaOral and paraoral complications of radiotherapy to the head and neck area are well-documented, and so are the proposed guidelines for management that are continually updated . However, little is known about the extent to which dental practitioners are aware and knowledgeable about these complications and their proper management. Hence, this study sought to assess the knowledge and practice of dental practitioners working in Saudi Arabia in this context. The results revealed astonishing knowledge in terms of the need for, and the proper timing of, dental/oral assessment for the cancer patients who are to undergo radiotherapy to the head and neck area . Contrastingly, the results unveiled highly variable knowledge levels when it comes to the individual radiotherapy complications and their individual management procedures; the correct answers ranged from as low as 26% to as high as 93%. Somewhat similar knowledge levels, or even lower, were reported in a similar study targeted Turkish dentists . The picture was worse concerning Turkish senior dental students; their knowledge levels ranged from 5.2 to 98.7 % . Variable knowledge was reported too in the approach of practitioners in restorative dentistry  and oncology  in context of radiotherapy for head and neck cancer patients. It seems that this issue is neither covered properly in the educating institutes nor dealt seriously by the dental/oncologic relevant authorities. Indeed, a recent study concluded that only 48.6% New Zealand and 2.5% Malaysian dentists followed formal guidelines or protocols for dental assessment of head and neck cancer patients, and hence recommended developing/[activating the current] clinical guidelines and generalizing them to all relevant practitioners in order to support effective medical/dental treatment and management strategies for this vulnerable population .It was surprising that 31% of the respondents reported that oral/dental assessment and management should include “Extraction of deeply impacted teeth without pathology.” It is an axiom that the intervention should not be performed on teeth that don’t represent sources of infection irrespective of the systemic conditions the patients have, or the treatment modalities planned. Basically, one of the guidelines for this class of patients is that “All healthy teeth as well as deeply impacted teeth without pathology are left in situ” . It was also surprising that 81% that “oral mucositis can increase the risk of oral pain and systemic infection.” Although oral mucositis represents a real problem associated with poor oral functions including difficulties in eating and swallowing which ultimately lead to poor quality of life , it is not linked directly with systemic infections. One of the low-scored knowledge items was that 71% of the respondents didn’t though that “oral complications may lead to lowering the dosages and possibly discontinuing cancer treatment”. In fact, the more sever the oral complications the more urgent the need to suspend the radiotherapy . More than 14% of the respondents reported that “alcohol-based mouthwashes” can be recommended for head and neck cancer patients before radiotherapy and 20% reported that these mouthwashes can be prescribed to control pain during or after radiotherapy. One of the main guidelines in management of the head and neck patients who are either to undergo or currently under radiotherapy, however, is to use alcohol-free mouthwashes and/or topical preparations .Although no differences by gender, age, experience and specialty were reported in Güneri study in Turkey, our study concluded contradicting results; female dental practitioners revealed better knowledge in many of the questionnaire items. In context of gender difference in knowledge on oral cancer, many previous studies revealed highly variable results . It is difficult to justify why females revealed better knowledge, but this can be partially ascribed to being more careful and they study harder during their graduate and postgraduate studies.It is a foregone conclusion that with higher level of educations  the knowledge is higher. In our study, the general dental practitioners scored the lowest knowledge compared to the other specialties. Although, it was expected that oral/maxillofacial surgeons/pathologist/medicine specialists would have had higher knowledge compared to others, the prosthodontists were the best in many key items. Again, this is difficult to explain at least in light of the cross-sectional design of our study. In a recent study on prosthodontists in Saudi Arabia, they reflected good knowledge about oral cancer .In our study, higher knowledge was obtained by those working in public sectors or universities compared to the private sector, and in the central and western regions compared to other regions of the Saudi Arabia. Concerning the working sector, this is simply due to the continuous educating programs conducted in the public sectors and universities, and the shorter working hours there in contrast to the private sector. Regarding the region of work, it is well known that the central and western regions of the Saudi Arabia are well developed and have had long time since the health infrastructures were established there compared to the other regions which are less developed. Consequently, for the health practitioners to persist in the central and western regions areas, they have to be highly competitive.Each study has its own drawbacks and positives. Among the drawbacks is being of a cross-sectional, questionnaire-based design, and it is well-known the inherent weakness such studies had in terms of the pyramid of evidence. It is highly encouraged to conduct a prospective study in which the knowledge is measure pre- and post-training workshop on the topic. Another drawback is the small sample size relative to the huge population framework , though we tried our best to increase the number through many reminders using the different social media and emails. Another limitation is related to the multiple comparisons conducted which inflate the possibility of false positive responses due to the multiple comparison bias, although this is an inherited feature of the questionnaire-based studies owing to the numerous items (outcomes) and numerous independent explanatory variables included. Nevertheless, the current study is exploratory (hypotheses-generating); that is to say any positive association  must be dealt as a hypothesis for further research, not to build on it a practice or policy. Accordingly, interpretation of the results must be cautious, away from being over-extrapolated. However, and up to our knowledge, this study is the first that assessed the knowledge of dental practitioners in Saudi Arabia complications and management of radiotherapy to the head and neck area.To sum up, our results show highly variable knowledge of dental practitioners on complications and management of radiotherapy to the head and neck area; that knowledge seems to fluctuate considerably with gender, experience, work sector, working region and specialty. The relevant authorities have the responsibility of provisioning and disseminating guidelines for proper approach in management of patients who are to undergo radiotherapy owing to head and neck cancer. Further, well-designed, large-scaled studies in this context are highly encouraged.The authors confirm contribution to the paper as follows: Study conception and design: Ahmed Shaher Alqahtani and Esam Halboub; data collection: Yaser Alhazmi, Yousef Alshamrani; analysis and interpretation of results: Esam Halboub; draft manuscript preparation: Ahmed shaher Alqahtani and Esam Halboub. All authors reviewed the results and approved the final version of the manuscript.


Some first investigations have focused on the consequences of the COVID-19 pandemic for the general mental health after its outbreak in 2020. According to multiple self-reporting surveys, symptoms of stress, anxiety, and depression have risen worldwide. Even some studies based on health care records start to be published, providing more objective and statistically reliable results. Additionally, concerns have been raised, to what extend the access to mental health care has been compromised by the COVID-19 outbreak. The aim of this study was to detect changes in prescription trends of common psychotropic medications in the Swedish region of Scania. The monthly dispensed amounts of selected pharmaceuticals were compared from January 2018 until January 2021, regarding the prescription trends before and after the outbreak of COVID-19. Using an interrupted time series analysis for each medication, no general trend changes were observed. On the one hand, a possible deterioration of the general mental health could not be confirmed by these results. On the other hand, the access to mental health care did not seem to be impaired by the pandemic. When interpreting findings related to the COVID-19 pandemic, regional differences and country-specific approaches for coping with the pandemic should be considered. The Swedish population, for instance, never experienced a full “lock-down” and within Sweden the time point of the outbreak waves differed regionally. In general, the effects of the COVID-19 outbreak on mental health are still unclear and need to be investigated further in an international comparison. Since the outbreak of the COVID-19 pandemic in spring 2020, it is generally assumed that public mental health was affected negatively by the worldwide situation . They haTo date, very few findings based on information from the health care systems have been published regarding the general mental health during the COVID-19 pandemic. Carr et al. explored the consequences of the pandemic for mental health using the primary care records of over 14 million patients in the UK . DiffereResearch on the Swedish population could contribute to a better understanding of the relation between the COVID-19 outbreak and alterations in mental health, since the measures taken against the pandemic in Sweden differ strongly from the ones applied in most countries. A real “lockdown” was avoided and the strategy of relying on recommendations, rather than restrictions, lead to an everyday life differing less from the conditions before the pandemic than in most parts of the world , 15. TheThe lack of analysed data based on mental health care systems impairs profound conclusions and fact-based decision-making in relation to the COVID-19 pandemic. One indicator for the mental health state and the contact to the health care system within the population are psychotropic prescription numbers. Thus, the aim of our study was to present an overview over the dispensed amounts of common psychotropic medications, compared between January 2018 and January 2021. As mentioned before, the Swedish population faced milder restrictions during the pandemic than most other countries and our results could therefore be especially interesting in the international comparison. We had access to all pharmacy records for the Swedish region of Scania, providing the possibility of studying the prescription numbers for the total population within this area. The goal was to detect any changes in prescription trends that could be related to the COVID-19 outbreak.This study included all dispensed prescriptions for a large number of selected psychotropic medications in the region of Scania in southern Sweden [1.38 million inhabitants in December 2019  analysis was performed using the software IBM SPSS Statistics 26. The applied model was a non-seasonal autoregressive integrated moving average (ARIMA) with the main parameter of interest being the change in slope. A periodicity of 12 months was taken under consideration and March 2020 was used as an intervention point, given that the COVID-19 outbreak in Sweden occurred within this month. Any slope, or change of slope, was considered significant for a As the study did not involve any individual clinical data that can be referred to an identified person, no ethical permission was required.p = 0.004). All trends, changes in trends, and their respective p-values are listed in Overall, the trends within the dispensed amounts of common psychotropic medications did not change after the COVID-19 outbreak in Scania. None of the analysed drug classes showed a significant change to the ongoing trend that had occurred before March 2020 see , 2. The In general, the prescription trends of common psychotropic medications did not change in the region of Scania after March 2020, with the sedative alimemazine as an exception. Thus, we interpret our results as negative findings regarding changes of prescription trends due to the COVID-19 pandemic. The mental health of the general population does not seem to be affected in a way that results in an increased use of psychotropic medication so far, even if other treatment and support options, such as psychotherapy and group meetings, have become more difficult to conduct during the pandemic .Most likely, the explanation for the recent increase in dispensed amounts of alimemazine is its application as a replacement for other sedative drug classes. Benzodiazepines have been criticised for their adverse effects and antihistamines are used as one possible pharmacological alternative . AccordiThe temporary spikes in dispensed numbers for almost all prescriptions in March 2020 were probably caused by a general uncertainty in the population at the beginning of the pandemic, which resulted in panic buying of certain goods, including pharmaceuticals. Additionally, certain information about a possible shortage of medication due to the pandemic was spreading in the media in March 2020, which presumably led to many patients taking out their medication in higher amounts than usual as a precaution .We expect the analysed prescription trends for common psychotropic medication to be a reliable indicator for more severe mental health problems in the general population, which seem unchanged by the pandemic. Furthermore, our findings could support the conclusion, that the access to mental health care in Scania has not been compromised during the pandemic. Since the prescription trends were not affected by the COVID-19 outbreak, patients seem to have received the help they needed within this area of treatment. On the other hand, a negatively affected public mental health state and impaired possibilities to seek help could potentially compensate each other in the recorded dispensed amounts of psychotropic medication and hence become undetectable by this study design. As mentioned in the introduction, several studies in Sweden suggest a deterioration in mental health and a compromised access to mental health care –19. EspeTwo factors should be considered when comparing these results to other studies. First, as mentioned in the introduction, Sweden chose a different epidemiological approach to the pandemic than most countries. On the one hand, this could have contributed to a less stressful experience for some individuals by protecting normal routines and possibilities. On the other hand, certain individuals, perhaps especially vulnerable to the pandemic, might have perceived the actions in Sweden as insufficient, resulting in increased stress. Even if Sweden is characterised by special circumstances during the pandemic compared to the rest of the world, our results are still valuable on an international level. The daily life might have been impacted in different ways in Sweden, but the Swedish population was equally exposed to the extreme changes worldwide, such as anxiety about the future or travel bans. Transferring our study design to other countries could create a comparability of the public mental health state in different countries during the pandemic that no other design could provide so far.The second factor possibly influencing the results of this study, are the special circumstances in the region of Scania during the pandemic. While most regions in Sweden were affected by the first wave of rapidly rising infection rates, starting in March 2020, the spread in Scania was much less severe during this time. Instead, the first wave in Scania occurred in autumn 2020 rather than in spring 2020 , 27. TakThe impact of the COVID-19 pandemic on mental health is a multifactorial and complex issue. To date, most conclusions are based on speculations rather than reliable data and much more research is needed to create a profound overview over the situation worldwide. General prescription trends are a suitable method to obtain a broad impression over the public mental health state. An additional study design could focus separately on prescriptions and diagnoses given for the first time during the pandemic and patients treated already before the pandemic. Thereby, the effect of the pandemic on previously healthy subjects and patients already in a vulnerable mental health state could be investigated more distinctly. Furthermore, survey studies performed within the psychiatric care system could provide more reliable and less biassed results than the ones obtained by questionnaires sent out to the general public. This approach could yield more detailed information on the actual personal situations during the pandemic and highlight possible causes for a negatively impacted mental health. However, data collected by addressing patients individually would be less suitable for examining broader trends or creating an overview over the general situation.On a final note, even without confirmed knowledge about a possibly impaired access to mental health care, the health care systems should be prepared for a considerable increase in new psychiatric patients in the aftermath of this pandemic. Many preliminary studies indicate a broad and detrimental effect on mental health by the recent situation, though their results are not sufficient for evidence-based conclusions yet .The dataset will be available from the authors upon request. Requests to access these datasets should be directed to mirjam.wolfschlag@kabelmail.de.CG and AH were responsible for concept and design of the study. AH obtained the data. MW performed the statistical analysis and wrote the manuscript. All authors contributed to manuscript revision, read, and approved the submitted version.AH holds a position at Lund University which is supported by the state-owned Swedish gambling operator AB Svenska Spel as part of its responsible gambling policies, and also has research funding from the research councils of that body and from the research council of the Swedish alcohol monopoly, Systembolaget. AH also has been the national sub-investigator of a pharmaco-epidemiological survey, carried out by the independent research institute Triangle Research Institute, United States, and financed by the pharmaceutical company Shire. No direct fees or compensations were paid to the individual sub-investigator. Also, a clinical follow-up study has been planned in collaboration with the company Kontigo care, which provides follow-up devices free of charge for a clinical treatment trial in gambling disorder, but without any further financial support to the research group or its members. None of the bodies mentioned above had any role in or influence on the present research. The remaining authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.All claims expressed in this article are solely those of the authors and do not necessarily represent those of their affiliated organizations, or those of the publisher, the editors and the reviewers. Any product that may be evaluated in this article, or claim that may be made by its manufacturer, is not guaranteed or endorsed by the publisher.


Prior to the introduction of the Burn Nurse Educator (BNE), at a growing and newly established burn center, the education of the Burn Trauma ICU staff was completed by the Burn Director and Burn Supervisor. In this burn center, large amounts of education became difficult to create and distribute by the current Burn Director and Burn Supervisor due to the demand of their respective job roles. The role of the BNE was to create initial and ongoing education for the Burn Trauma ICU Staff, Ortho-Trauma staff, ED staff, local EMS agencies, and the community.Floating into Burn Care, Burn Boot Camp, and Burns in the Pediatric Population. There was also the introduction of mock codes focused on the pediatric burn population. In addition to the formulation of these educational opportunities, the Burn Nurse Educator worked directly with the Quality Improvement Committee to find gaps in care. These gaps were then turned into project improvement plans and additional education was provided to the bedside staff. The Burn Nurse Educator formed relationships with local EMS agencies and was able to provide burn lectures and continuing education.The Burn Nurse Educator reviewed previous education that was provided to the staff, compared it to the Burn Nurse Competencies established by the American Burn Association, and was able to formulate a new education plan. The Burn Nurse Educator created several burn-based courses. These classes included: Burns in the Pediatric Population had a score increase from 46% to 94%. A sample size of 14 nurses had a score increase of 55% to 80% after enrolling in Floating into Burn Care. A sample size of 30 nurses who enrolled in Burn Boot Camp had a score increase of 71% to 95%. More importantly, the staff expressed a higher level of confidence when caring for a burn patient after these classes. The outreach with local EMS agencies also increased our EMS admits to the hospital, improved knowledge for caring for burn victims, and created a relationship with our local cities EMS.Each class offered had a pre and post test administered, all with improved scores. A sample size of 30 nurses who enrolled in It is anticipated that as the program continues to expand, the role of the Burn Nurse Educator will continue to grow and encompass new responsibilities. To ensure each nurse remains competent in their skill set, additional knowledge testing will be completed one year after a nurse has completed a class.


Introduction: In order to meet the sustainable development goals targets of sanitation, countries aim to increase access to safely managed sanitation services for its citizens. Safely managed sanitation services refers to improved sanitation technologies that are not shared with other households and where excreta is treated and disposed; or stored, transported and treated off-site. In most Sub-Saharan Africa (SSA) countries, on-site sanitation facilities such as latrines and septic tanks are common, with low-income urban settlements mainly using pit latrines. However, little is documented about the management of sludge from these facilities, especially in low income settlements in secondary and emerging cities. This lack of data is a major hindrance to public health, development and planning efforts by governments and planning agencies. This study specifically assesses practices and challenges along the sanitation value chain related to containment, emptying, transportation, treatment and recycling of fecal sludge.Methods: The study was carried out in low income settlements in Nakuru, a secondary city in Kenya. Over half the population in Nakuru live in low income areas and majority of these residents use pit latrines. A case study design was selected for this study and data was collected using qualitative methods. Data was collected through In-depth interviews and Focus Group Discussions using in depth interview guide and focus group discussion guides that had questions on sanitation practices along the value chain, challenges, opportunities available, and recommendations for improvement. Analysis was done through content analysis by reading the transcripts multiple times to gain a sense of the flow of the discussion. Thereafter, coding was done by following emergent issues and thereafter categories were identified which formed the basis for providing a picture of FWM practices in the settlements.Results: On site sanitation facilities are dominant in the settlements, but they are few and are shared by several households. These facilities were unclean, and they filled up at a fast rate because of the high number of users. The latrines were emptied by manual emptiers who used mechanized equipment but complemented with manual emptying using buckets. Sludge was transported to a central collection point using large and small scale means of transportation, before transfer to the treatment site for final treatment and disposal. Various stakeholders are involved in capacity building of emptiers as well as in the transportation, treatment and disposal of fecal sludge in the settlements. Challenges along the stages of the value chain included negative community perceptions and attitudes toward fecal sludge management.Conclusion: The results highlight the need to address the challenges along the chain by involvement of state and non-state actors. Low income areas have high populations and thus contribute huge amounts of fecal sludge. Deliberate efforts to consolidate such data from low income areas will result in availability of data, and informed decision making for stakeholders at national and international levels. In mostc tanks)  and the c tanks) . When thBy 2017, ~29% of Kenya's population had basic sanitation (facilities that are not shared with other households) and only 5% had access to the sewer system  where reConsiderable research has been done in primary cities, but very little is known about secondary cities in SSA. Population is booming in Africa's secondary cities which link remote and rural areas to urban centers, and provide alternative economic opportunities to public services and facilities. The devolved governance system in Kenya for instance, established county headquarters across the country, which have emerged as new centers of counter attraction for migrants from other rural and urban areas. This growth has created questions around the provision of critical infrastructure and services such as water and sanitation for the rapidly expanding secondary cities, especially among the most vulnerable segments of residents who live in low income settlements.The Kenyan government singles out the need to focus on non-sewered sanitation in urban areas and on fecal sludge management through the full sanitation value chain, as measures to meet the sanitation goals . MeetingNakuru town is the headquarters of Nakuru County, and is one of the rapidly expanding counties in Kenya. By 2019, the County's population was 2.2 million- an increase from 1.6 million in 2009 . ApproxiNakuru is the fourth largest urban center in Kenya and by 2019, the city had a population of ~400,000 persons . The towThere are several state and non-state actors involved in sanitation service provision in Nakuru town. The Nakuru County Government, like other county governments, is responsible for policy formulation, resource mobilization, service provision and policy implementation. The Nakuru Water and Sanitation Services Company (NAWASSCO) is the main water utility responsible for water and sanitation service provision in the County. Non-governmental organizations such as Water and Sanitation for the urban poor (WSUP) are involved in interventions aimed at improving access to sanitation in the county, and they work with several Community based groups. In 2019, the Nakuru Countywide Inclusive Sanitation Strategy and the Nakuru Countywide Sanitation Steering Committee (NACOSTEC) were launched. The strategy provides a framework for improving sanitation for all in the county and the steering committee co-ordinates the implementation of sanitation activities in the county.A case study design was selected for this study and data was collected using qualitative methods. For representativeness, low income settlements were randomly selected from Nakuru Town East and Nakuru Town West constituencies. The study was conducted in Flamingo, Kivumbini, and Biashara settlements (in Nakuru Town East Constituency); and Kaptembwo, Rhonda, and Kapkures settlements in Nakuru Town West Constituency.Different sampling strategies were used to select respondents involved in fecal sludge management along the sanitation value chain. Respondents were selected from the two constituencies as participants of In-depth Interviews (IDIs) or Focus Group Discussions (FGDs). IDIs were conducted with women and youth leaders, village heads, administrative leaders (chiefs/assistant chief), manual pit emptiers, and service providers at the treatment plant. Two women and youth leaders were selected from each of the constituencies to represent views from the settlements within their constituencies. Additionally, two village heads  who had lived within the settlements for averagely 10 years were selected to be included in the study, and one chief/assistant chief was purposely selected from each of the settlements. There were only two groups of organized manual emptiers at the time of the study, with one group operating in Nakuru Town East and another in Nakuru Town West; and thus one leader, who had served the longest, was selected from each of the groups. Some pit emptiers were not in any organized group, and since they were difficult to trace, snowballing was used to identify them if they worked in the settlements in Nakuru Town East and Nakuru Town West constituencies. Sanitation service providers along the sanitation service chain were purposively selected if they had been involved in service provision since the inception of such programs.FGDs were conducted with women, youth, and men groups; and manual pit emptiers. To select FGD participants, the men, women, and youth groups involved in sanitation related activities were identified from the two constituencies. Two groups of each of these categories were identified and included in the study. Participants were selected if they were members of these groups. Similarly, members from the two groups of organized manual pit emptiers were invited to participate in FGDs.The interviews were guided by an in-depth interview guide which had questions on sanitation practices along the value chain, challenges, opportunities available, and recommendations for improvement. Interviews were conducted in English and/or Swahili, and were held at a location convenient and comfortable to the participants . These interviews were conducted by trained research assistants who were accompanied by the researchers. The interviews were recorded using voice recorders and backed up with notes that were written in note books by the assistants. The interviews lasted for a maximum of 1 h. Selection and interviewing of participants continued until the point when new information was not forthcoming.Data was also collected through FGDs to complement the information obtained from the IDIs, and also since FGDs are useful in collecting information from people like pit emptiers who may not be easily reachable and/or may not readily divulge information through interviews. The FGDs had ~8–12 participants and were mainly held at community halls. The FGDs were conducted by a team composed of a moderator, a note taker and a team leader. The moderator guided the discussion, the note taker took notes and observed any non-verbal cues, and the team leader's role was to oversee and trouble shoot any problems, clarify any issues or questions from the research assistants, and perform spot checks to enhance quality of data. The discussions were guided by a guide that had questions on sanitation practices along the value chain, sanitation challenges, and opportunities and recommendations for improvement. Information was captured using voice recorders and supplemented by notes taken in notebooks. The discussions lasted for at least 1 h.Research assistants were selected if they had been endorsed by community leaders in the study sites, and if they had at least 5 years' experience in qualitative research. The assistants were trained for 5 days on the aims of the study, data collection process, data collection tools, and research ethics. The tools were pre-tested in Kaptembwo and Flamingo areas for 2 days using the local language. FGD guides were pre-tested with youth and men and IDI guides were pre-tested with women and a village head; all of whom who were not included in the study. The aim of the pre-testing was to assess if the questions on the tools were well-understood by both research assistants and interview participants, and ensure that any emerging questions were captured. After the pre-test, the tools were further refined to capture all emergent issues. During fieldwork, field supervisors accompanied the research teams to ensure that probing was done correctly and to assess any threats to data quality. Debriefing sessions were held at the end of each working day to highlight the major findings, to review effectiveness of probing techniques, and to assess progress.Ethical approval was obtained from AMREF Health Africa's Ethics & Scientific Review committee (ESRC), Ref No: AMREF-ESRC P375/2017 and also from National Commission for Science, Technology and Innovation (NACOSTI), Ref No: NACOSTI/P/17/99937/20578. Approval was also obtained from all the relevant authorities at county and community levels before commencement of study activities. Each participant received a research information sheet before the interview. The sheet contained information about the purpose of the study, study procedures, how the data would be utilized; institutional affiliation of the researchers; the right to withdraw at any time without reprisal; and measures to ensure confidentiality of information. The interviewer explained the contents of the information sheet to the participants and gave them an opportunity to ask any questions. Thereafter, participants signed a consent form if they voluntarily agreed to participate in the research. The recordings and transcripts were stored in a password protected computer that was only accessible to the investigators, all of whom signed a confidentiality agreement.Data analysis began during data collection and continued until data collection was complete. After data collection, researchers listened to the recordings again to familiarize themselves with the information. The recordings were then transcribed into MS Word, and cross checked by a third party to ensure that all the information had been captured in the transcript. The transcripts were translated to English (where necessary) and again cross checked to ensure that the translation did not alter the meanings of the data. After translation, the transcripts were imported into NVIVO 10 software  for coding and analysis. Each transcript had a unique identifier comprising of date and participant identifier to enhance anonymity and facilitate informed analysis. Analysis was done using standard methods of content analysis by reading the transcripts multiple times to gain a sense of the flow of the discussion. Thereafter, coding was done by following emergent issues (codes) such as sanitation facilities, emptying process, transportation process etc. This coding was applied to all transcripts and as new issues emerged, they were added to the list of codes and the transcripts read again to ensure that all the transcripts had been coded adequately. Issues that were similar were combined into single categories through consensus discussions. The next step entailed producing “tree nodes” or major categories that were inductively synthesized from the previous steps. The categories identified formed the basis for providing a robust picture of FWM practices in the settlements.A total of 14 FGDs were held with emptiers, women groups, youth groups and men leaders in the community, and 36 IDIs were conducted with emptiers, technical persons in the recycling plants, chiefs/assistant chiefs, village heads, youth and women leaders. This information is summarized in Residents made use of both onsite and offsite sanitation technologies. Onsite sanitation technologies included toilets connected to septic tanks and pit latrines, while offsite technologies included flush toilets connected to the sewer system. Most of the residents, however, used pit latrines whose construction costs were paid by plot owners. Due to a high population density in the settlements, these sanitation facilities were few and were usually shared among households, with respondents reporting high numbers of users sharing the available latrines.“We are sharing toilets, sometimes 100 people in the plot sharing 4 toilets….” .Participants further noted that these latrines were not clean, and women particularly were concerned about the effects of unclean toilets. Participants also complained of foul odor from the toilets due to the high number of users and poor cleaning practices. Due to this high number of users and the smelly and dirty toilets, participants admitted that they used other alternatives such as defecating in bags which were then disposed in the open spaces. Children's feces were also disposed in open spaces.With regard to structural attributes, the latrines had unlined and shallow pits, and were easily prone to collapse. Due to the high number of users and the shallow depths of the pits, the latrines filled up at a fast rate. Participants reported that when residents did not have money to pay for emptying, they poured a chemical substance that was believed to absorb the liquid in the pit, thereby reducing the volume of the sludge.“Sometimes when there is no ready money for emptying, we buy a  traditional substance and pour into the pits to prevent the pits from filling up fast.” .Emptying was done by manual pit emptiers using buckets or by using emptying equipment (gulper and Rama). These emptiers were organized in groups, and sometimes engaged themselves in other community activities such as solid waste management. Interviews with NAWASSCO staff revealed that the emptiers initially worked in the night and disposed the sludge in an unhygienic manner. NAWASSCO identified these emptiers, trained them on emptying techniques, and provided them with protective gear , disinfectant, and sprays. After training, the emptiers were given certificates and mechanized emptying equipment-the Gulper and Rama to complement manual emptying.According to the pit emptiers, lined pit latrines were usually emptied mechanically using the gulper and the Rama. However, since the equipment could not empty beyond a certain depth , they complemented with manual emptying. In addition, the emptiers noted that pit latrines had a lot of solid waste, making emptying difficult and necessitating manual emptying.“…you will find a cloth… a blanket… recently we found a human head inside the pit latrine… so before you begin emptying you start sorting and removing the solid waste…” (IDI Emptier Nakuru Town West).Unlined pit latrines were usually emptied manually mainly because they were prone to caving in during emptying because of poor construction.can make one sick” .Despite having been given protective gear, emptiers admitted that they sometimes worked without any protective gear, or they used tattered gear because of worn out gear. The emptiers, however, understood the risk of not using protective gear, as they admitted that working without protective equipment “Pit emptying costs varied between KES 1500 and KES 3000. The cost was often subject to negotiations and was determined by the size of the pit, the amount of sludge in the pit, the weather season , and whether the pit latrine was lined or unlined (lined pits were cheaper due to less risks compared to unlined pits). Recipients of the emptying service paid for the costs of emptying. Often times, tenants shared the costs of emptying among themselves.Pit emptiers highlighted that some landlords, especially the elderly who relied on rental income from the rental units they owned, did not pay in time, they paid less, or they did not pay at all. Due to the low proceeds from their services, caused by delays or non-payment, and the fact that emptying was not usually done every day; emptiers engaged themselves in other businesses like motorcycle riding or unblocking sewers to earn income when pit emptying work was minimal.Evidently, pit emptiers faced stigma from community members. An FGD participant for example, expressed her dislike for the emptiers by saying that“…They [pit emptiers] are dirty…they inhale dirty things while working and I would not engage them in my day to day activities” .Due to such humiliation from community members, the emptiers continued emptying the pit latrines at night, and others reportedly worked under the influence of alcohol and/or drugs despite efforts from the municipal council and public health officers to empower them against alcohol and drugs. The emptiers admitted that they engaged in drugs and alcohol as a way of disconnecting themselves from the stigma.“At times I have to use alcohol…so that I don't pay attention to comments from people… young women laugh at us…. They ask us who we shall marry …. If you are sober you can give up….” .After emptying, the waste was transferred to Primary Collection Points (PCPs). PCPs are 10 cubic meter-tanks distributed by NAWASSCO and erected at selected points in the community to facilitate collection of sludge from different points. These sites were selected after consultations with community members and the pit emptiers. When the tanks were full, sludge was picked by NAWASSCO staff and transported to the treatment plant.Private transport facilities were mostly used to transport sludge to the treatment plant because the county government had limited transportation services. Sludge was transported on small and large scale. Small scale transportation made use of buckets and wheel carts while large scale transportation used trucks. A few trucks were owned by the county government but majority of the trucks were privately owned. Because of the business opportunity presented by transportation of sludge, private individuals had invested in exhaust trucks to complement the few trucks from the County government. These private trucks were all registered by the County government, and they had a permit while awaiting licensing from NAWASSCO. Acquiring a means of transport from the County government was reportedly slow and challenging. According to the emptiers, the application process was tedious mainly because of bureaucracy. Additionally, emptiers reported that trucks were expensive to hire, and thus, they mainly transported sludge using wheel carts which were slow and which contributed to spillage of the sludge during transportation. Spillage also occurred due to untarmacked and hilly roads, as well as through cracks from some transportation trucks.The water utility company, NAWASSCO, was involved in large scale treatment of sludge. The treatment plant at NAWASSCO had been expanded (and set up as a prototype) to include recycling and reuse of fecal sludge. As a result, the company had begun the production of briquettes.At the plant, sludge was burnt under high temperature to kill microorganisms and clear foul odor, and was then taken for further processing and recycling into briquettes. The briquettes were then sold to community members and members of the public at KES 30 per kilogram. Staff at NAWASSCO highlighted that they had produced enough briquettes since the demand was more than the supply. The company hoped to acquire more mechanized equipment to enhance efficiency in the production of briquettes. They however noted that dust and smoke emissions were a challenge, despite efforts to minimize the emissions.Community members were trained by NAWASSCO on how to use briquettes during monthly meetings with the County Government and the community. Community members were thus aware of the advantages of sludge as a source of income, and the use of briquettes. FGD participants, however, complained that they had not been educated on how the briquettes were made, as well as their negative impacts.Generally, although fecal sludge management presented an employment opportunity, few people were aware of the available opportunities. Perceptions of recycling of fecal sludge varied, as some individuals had negative perceptions about the opportunities provided by fecal sludge. A female worker who was involved in recycling for example noted that“Not many people are aware of the jobs that come with fecal waste… many people in the community critique us for doing this job … and especially being a woman…” .This study has detailed fecal sludge management practices in low income settlements in Nakuru town in Kenya. On site sanitation facilities are dominant in the settlements, but they are few and are shared by several households. These facilities were unclean, and they filled up at a fast rate because of the high number of users. The latrines were emptied by manual emptiers who used mechanized equipment but complemented with manual emptying using buckets. Sludge was transported to a central collection point using large and small scale means of transportation, before transfer to the treatment site for final treatment and disposal. NAWASSCO and other stakeholders are involved in capacity building of emptiers as well as in the transportation, treatment and disposal of fecal sludge in the settlements. Various challenges along the stages of the value chain were evident, including negative community perceptions and attitudes toward fecal sludge management.The dominance of on-site sanitation facilities in the settlements was not surprising as literature has alluded to the high investment and operation costs of the sewer system and lower operational and maintenance costs of onsite sanitation facilities , 16. SucDue to space limitations, emptying is the most appropriate option for full latrines in low income settlements. Pit latrine emptying in Nakuru was akin to other cities in Africa , 19 wherA highlight of the study was the citing of primary collection points where sludge is contained before final transportation to the treatment and disposal site. Transportation of sludge is costly, and depends on factors such as distance and technology used for transportation , 25. As In Nakuru, the production of briquettes from fecal sludge was an avenue for business, resource recovery and reduction of environmental contamination from pathogens and heavy metals contained in fecal sludge , 27. ApaThese results show that achieving sustainable sanitation in the low income settlements requires the involvement of various stakeholders along the value chain, including community members, the private sector, and the relevant authorities. The community are end users of the recycled products, and need to manage their sanitation facilities, while the private and municipal sector facilitate emptying, transportation and treatment of sludge. These stakeholders need to work in tandem, to ensure achievement of the sanitation goals. By so doing, sustainable sanitation will contribute to sustainable urban development and the achievement of SDG targets . Proper We acknowledge however that this study was mainly qualitative, and is only limited to the low income settlements. Further studies, to collect quantitative data are needed to complement the information obtained in our study. Such information should also be used to complement available data on fecal sludge management in Nakuru town and Nakuru county as a whole, including updating Nakuru's shit flow diagram .This study sought to provide a situational analysis of practices and challenges related to containment, emptying, transportation, treatment and recycling of fecal sludge in low income settlements of Nakuru, a rapidly expanding town in Kenya. Following a lack of local context data from such towns to inform interventions and planning, this paper provides a qualitative assessment of fecal sludge management in the settlements, and notes the challenges of effective sludge management in low income settlements of growing towns in developing countries. The highlighted challenges serve as entry points to effective fecal sludge management in these settlements, thereby contributing to national and global tracking systems as well as planning and monitoring initiatives. Our study highlights the need for quantifying the amount of fecal sludge that is safely managed in the settlements, and comparing with data from the county level. The settlements host a majority of onsite facilities and a citywide assessment of the management of fecal sludge is necessary and will be useful for planning and monitoring of the country and global goals. Finally, this study points to possible areas of intervention; such as the safety and health of manual emptiers, and the possibility of other resources as by-products from of fecal sludge.The original contributions presented in the study are included in the article/supplementary material, further inquiries can be directed to the corresponding author/s.The studies involving human participants were reviewed and approved by the Ethics and Scientific Review Committee of Amref Health Africa. The patients/participants provided their written informed consent to participate in this study.SS wrote and revised the manuscript. IC supervised data collection and participated in manuscript writing and analysis. BM conceived the idea, provided overall supervision, and reviewed the manuscript. All authors reviewed the manuscript and approved it for submission.This work was supported by the Bill and Melinda Gates Foundation under Grant OPP1156241.The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.All claims expressed in this article are solely those of the authors and do not necessarily represent those of their affiliated organizations, or those of the publisher, the editors and the reviewers. Any product that may be evaluated in this article, or claim that may be made by its manufacturer, is not guaranteed or endorsed by the publisher.


Fall-from-height accidents are linked to severe and fatal consequences for impacted workers. A better understanding of the related variables is necessary to improve worker safety. This study analyzed all fall-from-height occupational accidents recorded in Spain from 2009 to 2019, selected significant variables, and evaluated the influence concerning the seriousness of the falls from height. Based on a total of 290,583 fall-from-height accidents, the study shows that a male inexperienced worker in a small company working in a non-habitual workplace is more likely to suffer fatal consequences once the accident happens. An improved knowledge of fall-from-height accidents will improve safety conditions. The workers should be trained and informed about their specific risk depending on the variables analyzed. Safety training should consider more risky profiles. Results from the current study can help identify suitable fall prevention and risk mitigation actions in safety programs for companies. Fall-from-height (FFH) accidents are a cause for concern in occupational settings because they can affect worker health and productivity . In thisSeveral causation factors for FFH accidents have been identified in the literature. such as human behavior, safety management, activity, and worksite conditions ,12. HumaOrganizational variables are one of the influential variables in FFH accidents. For instance, in a case-control study about factors related to fatal occupational injuries, temporary workers showed an increased risk of fatality after an occupational injury . Other aCompany size showed a relationship with the accident rates linked to FFH . Small cWork-site conditions are another relevant factor that was previously studied. In general, occupational accidents that take place out of the usual occupational setting, or workers conducting non-habitual tasks, showed an increased risk of a fatal result . On one A similar group of factors have been studied previously by other authors for a better understanding of occupational accidents. On one hand, Camino et al. used cited variables collected from accidents officially recorded in Spain to study construction accidents and occupational accidents with ladders ,31. On tAccording to Spanish Law, since 2003, every occupational accident should be recorded in the electronic system called Delt@ (Declaración Electrónica de Trabajadores Accidentados). Then every accident would be officially recorded and included in the cited database. For the current research, the Ministry of Labor and social security supplied all the accidents recorded from 2009 to 2019. Accidents recorded from 2003 to 2008 were not considered because their NACE codes (Nomenclature statistique des activités économiques dans la Communauté européenne) are different in cited period of time. A total number of 290,583 accidents due to falling from heights from all sectors was supplied. However, it is possible that some FFH remain unreported and avoided mandatory reporting. The distribution of the accidents is partially shown in FFH accidents were distributed among several different categories. However, if only fatal FFH accidents are considered, the total weight of construction groups  rises from 16.8 percent to 44.9 percent. In The research design was based on the methodology proposed in a previous paper  that wasAccident data provided by Spanish labor authorities included 58 variables per each accident. In a preliminary approach, all 58 variables were analyzed through contingency tables. Then, variables with a statistical significance lower than 95 percent were rejected because it was not possible to confirm the existence of more than a random influence for the severity value.Personal variables that show characteristics of the worker affected by the accident, such as sex and age, were included in this categoryOrganization variables that describe details about the activities were developed. This group includes worker contract, length of service, company staff and place of the accident.Material variables that include injury type and material agent were includedMaterial variables include injury type and material agentGeographic variables that include the zone of the accident according to their climatic parameters were included.After that, non-rejected variables included in accident reports with the statistical significance were categorized into the following groups:To test the independence of each variable with respect to the severity, contingency tables were created using SPSS 23. Statistical techniques, such as the calculation of chi-square values and corrected standard residuals (CSR), were used. Absolute values of the csr under 1.96 did not reach a statistical significance of 95 percent; thus, it was not possible to confirm the existence of more than a random influence for severity variable. According to the preliminary results, more statistically significant variables were selected for the current research, as shown in Severity values in an accident notification form are based on medical criteria at the following levels: light, serious, very serious or fatal. Accidents without long -term physical damage to the worker were considered light. In the case of serious accidents, more than 120 days of absence at work are expected, but the life of the worker is not at risk, and no disability is experienced by the worker. In contrast, in a very serious accident, for the life of the worker is at risk and/or a disability is linked to the accident. Finally, in fatal accidents, the worker dies as a consequence of accident damage.Additionally, accident ratios for the severity of accidents were calculated for a deeper analysis. The rates were calculated by dividing the number of accidents chosen in the category studied by the number of total accidents chosen ,34.FFH accident rates were calculated by dividing the number of accidents chosen in the group studied by the number of total accidents selected. Then, the total accident rate (TAR) was calculated by dividing the number of total accidents in the group studied by the number of total accidents analyzed. The light accident rate (LAR) was calculated by dividing the number of light accidents in the group studied by the total number of light accidents. The serious accident rate (SAR) was calculated by dividing the number of serious accidents in the group studied by the number of total serious accidents. The very serious accident rate (VSAR) was calculated by dividing the number of very serious accidents in the group studied by the total number of very serious accidents. Finally, the fatal accident rate (FAR) was calculated by dividing the number of fatal accidents in the group studied by the total number of fatal accidents.It is important to bear in mind that rates obtained are not the common incidence rate (number of accidents per worker exposed) because it was not possible to obtain the number of workers exposed disaggregated in each variable studied. However, all rates obtained are based in the total number of recorded accidents. Then, it is possible to compare calculated rates in a same category. For instance, a higher percentage of males in the total number of accidents can be motivated by a lower number of female workers. However, if the fatal accident rate of men is higher than total accident rate of men, it can be concluded that once the accident happens, men are more likely to suffer fatal consequences.Statistical results were obtained using the Statistical Package per Social Science (SPSS) version 23.The results in According to the results shown in Regarding worker contracts , self-emFFH accidents that happen in the first month of service are more likely to be fatal than FFH accidents in other periods, as shown in Regarding the company size, the results shown in Although 74.4% of the FFH accidents happened at the habitual workplace , only 51The distribution of the accidents throughout the week was analyzed to detect the possibility of the Monday effect ,56.HowevRegarding the material agent as the cause of the fall, construction or the surface upper level was involved in nearly half of the total falls and in 65.4% of the fatal falls . AnotherDepending on the part of the body affected , severitThe geographical location of an accident can be influenced by different factors, such as population, culture, economy or weather conditions . ConsideThis research showed that the severity of FFH occupational accidents was related to the variables studied. The most remarkable result was the difference found based on the gender of the workers. Results showed that after a FFH accident happens, a male worker is more likely to suffer a fatal accident than a female worker. These higher rates for men can be motivated by their activities at work and their attitudes regarding safety and occupational risks. Therefore, preventive measures, such as safety training, should be adapted to the gender of the workers and their tasks at the workplace. The age of the worker was indicated to be another relevant variable. Older workers were more likely to suffer fatal consequences once an accident happened. Therefore, senior workers should be specially considered when preventive and safety plans have been designed. Regarding worker contract, self-employed workers showed the worst fatality rates. Small and very small companies presented negative results, too. Therefore, these groups of workers should be protected by providing them with additional safety tools by contractors and labor authorities because frequently these companies do not have the economic resources for safety management. The experience of the worker was highlighted as another relevant variable, as the worst rates were concentrated in the first month of service. Thus, extra effort should be concentrated in safety training programs for inexperienced workers. The non-habitual workplace was identified as another relevant factor of fatal FFH accidents. Finally, geographical factors showed that regions with higher temperatures obtained statistically more significant results. A better knowledge of FFH accidents will improve safety conditions. The identification of the main variables in FFH accidents is the first step to reducing occupational accidents and their consequences. Specific safety training can be developed that considers specific requirements for each category of workers and for each type of company and organization. The workers should be trained and informed about their specific risk depending on the variables analyzed.Although in Spain it is compulsory to notify occupational accidents to the labor authorities, it is possible that some accidents that happened were not reported. Thus, a possible bias caused by underreported accidents might be considered. In addition, only variables included in Official Accident Notification Form were analyzed. Reports of fatal accidents include additional information, but these reports were not possible to obtain.Results from the current study can help to identify suitable mitigating actions in future safety planning. Thus, the development of safety programs based on the current results and an analysis of their effectiveness in the workplace should be explored. A study of the multiple effects of several variables simultaneously on the severity of FFH accidents might provide complementary results to those obtained in the current research.A combination of the analysis of official data with surveillance and interviews in the workplace in future research could improve the safety management and the risk of FFH accidents.


Canadian South Asians are being economically, socially, politically, and culturally impacted by the COVID-19 pandemic. There is currently a gap in the literature on the unique challenges faced by this specific group of individuals. People of color and ethnic minorities are being homogenized in the media and throughout the literature when addressing populations disproportionally impacted by the current situation. This commentary aims to add a new perspective to the current literature by specifically exploring factors that may contribute to the high rates of COVID-19 among South Asian communities in Canada. Another goal is to highlight the importance of providing tailored support and attention for this community and the negative consequences if this is not correctly done. Factors such as overrepresentation in essential work and financial instability are discussed. Pre-existing health conditions among South Asians such as diabetes, hypertension, anxiety, and mood disorder are considered, as well as how the history of these conditions within this population elevates the risk of severe health complications. This commentary presents suggestions for addressing this gap in research, as well as directions for future public health initiatives and policies. South Asians in Canada are disproportionately experiencing the negative effects of the COVID-19 pandemic, compared to the general Canadian population . Of the After Indigenous communities, South Asians in Canada have the highest rate of unemployment; over 17% of this population is documented as unemployed . The AssCompared to the Canadian white population, Canadian South Asians have a five to ten-fold greater risk of contracting the COVID-19 virus . In factThe Canadian South Asian population is at a higher risk of developing comorbidities and of falling seriously ill from COVID-19 ,15. For Connections have been made between the pandemic and negative mental health outcomes . A studyAccurate and robust data must be collected to assess the representation of this ethnic minority in essential services as well as to understand the underlying factors that contribute to the increased risk of COVID-19 among South Asians. In addition, support for these individuals should be provided in a way that is beneficial to and supportive of cultural practices . There iThe Canadian Government should consider extending financial support similar to the Canadian Emergency Response Benefit or including immigrant workers in the current criteria . WorkersWhen making future decisions and interventions to address the high rates of COVID-19 among the South Asian community, sociocultural factors must be taken into consideration [There is also minimal knowledge on how the results of the pandemic have impacted the mental health and well-being in this community. At this point in time, there are conflicting articles in the media on the spread of COVID-19 within this group . This laIn summary, attention needs to be given to the unique challenges faced by Canadian South Asians during the pandemic. This group of individuals are facing difficulty in accessing financial government support, work in unsafe conditions, and are largely represented in the country’s unemployment records. Given the high occurrence of pre-existing comorbidities and mental health conditions, specific assistance should be provided to this community. There is a pressing need for more data on the unique experience of this group, to better understand how and why COVID-19 is highly prevalent within this population. Public health messaging, policy development, and workplace environments must all consider the cultural, political, economic, and social factors that shape the experience of Canadian South Asians and how these factors influence their health outcomes in relation to COVID-19.


The impact of social participation (SP) on the health of the elderly has been widely recognized, and urban-rural differences in social participation have attracted attention. However, few studies discussed the impact of social participation on specific health indicators and the further subdivision of urban-rural differences. This research aims to use the dimensions of interpersonal behaviors and population density rather than simple urban-rural distinctions to justify community differences and compare these differences' direct and indirect effects on grip strength. This study used 15,871 respondents aged over 50 years from the China Health and Retirement Longitudinal Study (CHARLS). An SEM  analysis was used to explore the joint effect of interpersonal behavior and population density on social participation and the consequent impact on changes in grip strength and compare the differences among different genders, ages, wealth levels, and family relationships. The results indicated that community differences characterized by interpersonal behavior and population density have direct effects on grip strength and indirect effects on it through social participation. The conclusion is that the frequency of social activities, such as mah-jong and dancing in the Metropolitan Fringe and county-level cities is higher than that in Metropolitan centers. The high frequency of these activities has a positive and indirect impact on grip strength, and community differences have a more significant impact on women's social participation than men. However, the direct effect of community differences as defined by interpersonal communication and population density on grip strength is greater than the indirect effect of other factors through social participation. Grip strength is an essential indicator of muscle ability –6 and weAccording to the theoretical framework of social ecology, the environment (broadly defined), behavior patterns, and health status interact with each other. Some studies have emphasized the importance of the infrastructural environment , 20. ThiIn this study, based on a large sample from the China Health and Retirement Longitudinal Study (CHARLS), which was completed by Peking University, this article constructs a conceptual model of community differences, social activities, and change in grip strength through a structural equation model. This article aimed to reveal the joint effect of community differences and lifestyle habits on social participation and the consequent effect on changes in grip strength and to compare the differences among people with different genders, ages, wealth levels, and family relationships. Therefore, (1) This paper built an association model based on communication style and specific biomarkers and used a large sample size to test this relationship. (2) This article expected that a comparison of the intermediate and direct effects could show that non-interventional exogenous variables such as age and gender on grip strength will be partially endogenous (intervenable), rather than just controlling variables. (3) This paper proposed that it is not only the differences between urban and rural areas  but also the different population densities and cultural backgrounds of residential areas that should be used to classify communities here. In assessing community differences, this article scored types of communities differently than in the original questionnaire. By rearranging the scoring structure for different types of communities, this article revealed the characteristics of different urban communities and rural elderly SA in China and the impact of these differences on grip strength. (4) When discussing the relationship between social activities and grip strength, this article extended the measurable range of social activities. This article also included the occasional care of parents or grandchildren within the scope of active social activities.Grip strength is regarded as one of the indicators of the health of elderly people. The health of elderly people is divided into the following two categories : overallThe relationship between PA and grip strength was generally investigated in comprehensive studies of a series of health indicators as well as correlation studies .The effect of PA on grip strength is not very clear, and some studies have shown that physical exercise can improve grip strength in middle-aged elderly, and oldest-old groups , 30–33. Based on the conclusions of some studies with larger samples in the above literature, we propose Hypothesis HA: moderate PA has a positive relationship with grip strength.There are two lines of study of the relationship between SA and grip strength. First, social interaction directly affects health (broadly defined). There are definite conclusions about the impact of social interaction on mental and physical health. However, the positive and negative impacts need to be analyzed based on the specific SA , 37. ForThe second line of study examines the effect of SA on PA and therefore, on physical health. Socializing online and participating in groups promote PA and self-rated health , 42–44. Since it discusses a specific health index rather than a general concept of health, this study must find evidence that SA affects grip strength through PA. Studies have discussed the impact of SA and PA on cognitive function to a similar extent . SupposeBecause the mechanism of the relationship among SA, PA, and grip strength is not very clear, and because engagement in boring activities causes depression  due to , this arMany factors affect the SA of elderly people. Here, we focus on the factors that affect both SA and grip strength to compare their direct effects and the indirect effects through SA on grip strength. This approach will allow for a better decomposition of the effects. The community environment, family relations, economic status, age, and gender are of particular interest.The community environment includes the physical environment and social environment . China is an urban-rural dual social form. It is recognized that there are significant differences between urban and rural elderly communities in China. It is impossible to analyze the urban-rural differences of Chinese elderly life using the analyzing framework of the United States –50. HoweBy analyzing health data for elderly Europeans, Jancova-Vseteckova et al.  found thOnly a few articles in the literature, such as Celis-Morales et al.  providedhttp://charls.pku.edu.cn/Public/ashelf/public/uploads/document/2018-charls-wave4/application/CHARLS_2018_Users_Guide.pdf  on a 7-point or 6-point scale from low to high due to the comparability of quantity or frequency.The grip strength index uses the average values for the left and right hands from the second test. The measurement method lets interviewees “Stand, hold the dynamometer at a right angle and squeeze the handle for a few seconds, then Conduct the hand strength measurements (unit: kilogram).” This article did not use the grip strength-to-weight ratio because many studies have indicated that the correlation between grip strength and weight is not very strong. The grip strength-to-weight ratio was entered into the model as an explanatory variable. The result was not much different in terms of the direction of the odds ratios.2, respectively  were used in the study. SEM model is often used in such databases with many ordered variables –66. The CFA was used to measure PA, relationships with adult children, and SP. According to the results, the composite reliability and validity coefficients in all measurement models were high, indicating that all measurement models had excellent reliability and validity and were suitable for SEM analysis.Regarding the fit indexes of the entire sample model, the root mean square error of approximation (RMSEA) was 0.075, the ratio of chi-square to the degrees of freedom (X2/DF) was 4.902, the comparative fit index (CFI) was 0.912, the Tucker-Lewis index (TLI) was 0.903, and the standardized root mean square residual (SRMR) was 0.059; these fit indexes indicated that the models had a good fit, and they are shown in The total sample size was 15,871, including 7,807 males and 8,064 females. The average grip strength of males was significantly higher than that of females. The average community type score was 5.82, indicating that most of the respondents lived in non-large cities. Men had moderate PA levels that were slightly lower than those of women. Singing and dancing activities were more common among women than men. Women had higher levels of overall SA than men, but men engaged in more general social participation than women. Female upper-body pain was more common than male upper-body pain.The CR values of the measured variables ranged from 0.746 to 0.962; a CR value above 0.6 is recommended by Bagozzi and Yi  and FornAmong the three items, the reliability  was the highest for PA. The validity of the general social interaction dimension of SA was relatively low but was still above 0.5. The reliability of children's income and frequency of parent-child interaction was not very strong but was still higher than the standard. The item validity values were 0.946 (PA), 0.711 (SP), and 0.898 (CR), which were all >0.7, indicating that the items had an excellent explanatory ability for the selected dimension.When mediating variables are present in a model, the relationship between independent and dependent variables should be expressed as total, direct, and indirect effects. The correlation between the relationship with adult children and SA was significant (−0.023), and the correlation between smoking and grip strength was −0.302. The correlations of upper-body pain and grip strength (−0.198), SA and PA (0.247), and SA and grip strength (0.042) were all significant.According to the various direct and indirect effects for the male and female groups, the total effect of PA on grip strength was significant for both the male group (0.007) and the female group (0.016). However, in terms of the effect of PA on grip strength, the direct effect in the male group was significant, and the direct effect in the female group was not significant, indicating that PA did not directly generate changes in grip strength. In contrast, social activity significantly affected grip strength in both the male and female groups. The effects of community differences on grip strength were significant in terms of both the total effect (−0.062) and the direct effect (−0.06) . Thus, community difference was related to grip strength using the 95% confidence interval in the female group. Residents of areas with lower population density had lower SA levels, and residents of large cities had lower SA levels than residents of the urban-rural fringe and county-level cities. This finding shows that behavioral patterns based on an agricultural society and population density influence social participation. Notably, the direct effect of community differentiation (−0.06) on grip strength was more significant than the indirect effect (−0.002). This finding shows that community differences affect grip strength and social participation and may also affect grip strength through medical facilities and other reasons that are not yet clear. This discussion indicates a direction for follow-up research, but some studies have argued that this effect is not related to the question of whether infrastructure helps increase PA . The dirEssential expenditure also affected grip strength, indicating that nutrition or eating habits also affect grip strength. The indirect effect of basic expenditure rate on grip strength through social interaction (−0.002) was much smaller than the direct effect on grip strength (−0.031), which shows that there was no significant correlation coefficient between social identity and grip strength . See This article discussed the influence of SA and PA on grip strength based on a sample from the CHARLS, analyzed the factors that affect social interaction and PA and the interaction between the two variables, and finally examined these effects within structural equation models of the effect on the change in grip strength.Some studies have discussed the differences in behavior and health status between urban and rural areas in developed countries . Some paThe efforts of non- intervening exogenous variables such as age on grip strength can be found to be partially intervenable, rather than only be used as control variables , 75. HowQuirke et al.  believe The direct effect of PA on grip strength was significantly negative, and the effect of PA on promoting SA was significant. This result is similar to the idea of, Kuh et al.  and JenkAreas for further work include the identification of more variables in the questionnaire that better describe community differences and the use of more biomarkers to indicate weakness to allow the analysis of environmental differences in more detail as well as physical exercise, social participation, and the relationship between specific indicators of the health of elderly people. In addition, in the future, it will also be necessary to use longitudinal data to reflect the cause-and-effect relationship when the sample size and sample periods are sufficient.The relationship between cognition and SA was not examined in this study because cognition and SA have two-way interactions, and the relationship between grip strength and other variables such as cognition may also be two-way due to the complexity of the problem, rendering these variables more suitable for a separate research project.The relationship between regional differences and social relations, as well as the relationship between regional differences and grip strength, may not be limited to differences in economic conditions, environmental conditions, and SP; they may also involve other aspects of urban and rural differences in China, such as long-term physical labor vs. grip strength and differences in the nutritional structure during adolescence. Therefore, a study making comparisons based on regional differences to examine the relationship between grip strength and regional differences through social interaction may have the problem of missing variables.The social items on the questionnaire could be classified as general social interactions or different types of SP. However, according to this classification, the sample size for some types was too small, which affected the significance of the statistical results. In other words, due to the lack of data samples, such classifications could not be tested extensively. Therefore, our results suggest that general SA positively affects grip strength, and there is no way to distinguish between the differences among different kinds of activities.The grip strength-to-weight ratio was not used because the correlation between grip strength and weight is not strong enough, and adding weight may complicate the problem.There are some limitations to this study. First, a more detailed analysis by age group is recommended; the sample used focused on the 50–69-year-old population, and the elderly population over 70 years old was much smaller than the younger elderly sample. Since the sample sizes of each age group were so different, the age groups were ignored. Second, regarding whether to use confirmatory factor analysis, there are also many works on the health of elderly people that do not use latent variables but directly use all measured variables. We also tried to construct a structural equation model with a single measurable indicator, and the general conclusion was similar to the result using factor analysis. The structural equation model, including factor analysis, was used to correct the measurement errors at the cost of not performing more detailed analyses.The contribution of this study lies in (1) establishing a structural equation model including community differences, social activities, and specific biomarkers; (2) comparing the direct and intermediate effects of age and gender on grip strength, indicating that the effects of age and gender on grip strength can be intervened; (3) based on the difference of population density and social habits, we modified the scoring criteria of community types and ranked them, to reveal more insights into the difference of social activities between urban and rural areas on physical health indicators; (4) including the occasional care of grandchildren and elderly parents into the scope of active social activities. The positive effect of positive social activities on grip strength was further confirmed.This study enriches the research of grip strength in the elderly population, increases the complexity of the understanding of the intermediate effects, and indicates that the influence of non-interventional exogenous variables such as age and gender on grip strength is partially endogenous (intervenable) through the separation of the intermediate effects and the comparison of the indirect and direct effects. The community differentiation approach differs from that in the original questionnaire, revealing the characteristics of the SA of elderly residents in urban and rural areas in China and the impact of these differences on grip strength.The inspiration for this study to formulate policies and support for the elderly population lies in the importance of community differentiation. In contrast to common perception, the community interactions of elderly residents living at the junction of urban and rural areas are higher than those of elderly residents in large urban centers. This finding indicates that some behavioral patterns associated with agricultural society are beneficial to the SA of elderly people. In addition, according to the coefficient of the effect of basic expenditure level on grip strength, improving quality of life requires unremitting efforts to improve physical health. Finally, the importance of elderly people's interactions with their adult children for their health in East Asian countries needs to be emphasized. Encouraging childbirth is a policy option as circumstances permit.The datasets presented in this study can be found in online repositories. The names of the repository/repositories and accession number(s) can be found in the article/Ethical review and approval was not required for the study on human participants in accordance with the local legislation and institutional requirements. The patients/participants provided their written informed consent to participate in this study. Ethical approval for all the CHARLS waves was granted from the Institutional Review Board at Peking University. The IRB approval number for the main household survey, including anthropometrics, is IRB00001052-11015; the IRB approval number for biomarker collection, was IRB00001052-11014.All authors listed have made a substantial, direct, and intellectual contribution to the work and approved it for publication.This research was funded by the Project of the Natural Science Foundation of Liaoning Province, China (Grant No. 71490735) and Social Science Fund of Liaoning Province, China (Grant No. L19BGL035).The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.All claims expressed in this article are solely those of the authors and do not necessarily represent those of their affiliated organizations, or those of the publisher, the editors and the reviewers. 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