Climate change is a global problem, which affects the various geographical regions at different levels. It is also associated with a wide range of human health problems, which pose a burden to health systems, especially in regions such as Africa. Indeed, across the African continent public health systems are under severe pressure, partly due to their fragile socioeconomic conditions. This paper reports on a cross-sectional study in six African countries  aimed at assessing their vulnerabilities to climate change, focusing on its impacts on human health. The study evaluated the levels of information, knowledge, and perceptions of public health professionals. It also examined the health systems’ preparedness to cope with these health hazards, the available resources, and those needed to build resilience to the country’s vulnerable population, as perceived by health professionals. The results revealed that 63.1% of the total respondents reported that climate change had been extensively experienced in the past years, while 32% claimed that the sampled countries had experienced them to some extent. Nigerian respondents recorded the highest levels (67.7%), followed by Kenya with 66.6%. South Africa had the lowest level of impact as perceived by the respondents (50.0%) when compared with the other sampled countries. All respondents from Ghana and Namibia reported that health problems caused by climate change are common in the two countries. As perceived by the health professionals, the inadequate resources reiterate the need for infrastructural resources, medical equipment, emergency response resources, and technical support. The study’s recommendations include the need to improve current policies at all levels  on climate change and public health and to strengthen health professionals’ skills. Improving the basic knowledge of health institutions to better respond to a changing climate is also recommended. The study provides valuable insights which may be helpful to other nations in Sub-Saharan Africa. There is clear evidence that climate change is affecting countries around the world and that it poses a threat to the achievement of the UN Sustainable Development Goals (SDGs) . CurrentFrom a regional perspective, some of the fundamental drivers of climate in Africa are the Inter-Tropical Convergence Zone (ITCZ), the El Niño—Southern Oscillation (ENSO) and the West African Monsoon (W.A.M.) ,6. ClimaAnother index of environmental distortions is the warming of the earth’s climate, which creates offshoots of ITCZ and ENSO movements. The evidence of these movements appears principally in Southern Africa and the Sahelian part of Western Africa, where there are increases in sea and air warming, which result in heavy rainfall and floods ,11. ThesThe United Nations (UN) reported in 2017 the impact of severe flooding in the West and Central Africa axes [In the Eastern part of Africa, where dry weather is prevalent, there have also been drought experiences due to the ITCZ-ENSO movements . ENSO’s Indeed, Africa is one of the most vulnerable regions to climate variability and change . The litAn increase in greenhouse gas discharges reflects increases in human socioeconomic activities . These sAn increase in vector-borne diseases, such as malaria, lymphatic filariasis, onchocerciasis, schistosomiasis, African trypanosomiasis, and Rift Valley fever, is linked to climate change impacts. These diseases are, therefore, higher in developing economies than in developed economies . Apart fClimate change worsens the already precarious situation seen in low-income countries’ public health systems . AfricanGlobally, the impacts of climate change on public health are inconsistent. This inconsistency is because of geographical variations and the varying capacities of countries to adapt to these changes. Sensitisation on the part of the representatives of public health systems on the health impacts of climate change is needed . TherefoOther areas of interest within the study include assessing the governments’ financial (budget) responses seen in the sampled African countries to deal with the observed human health impacts of climate change, the effectiveness of the available resources, and those needed to cope with the effects of climate change on human health. This study also aims to contribute to better policies to improve present and future generations’ livelihoods, despite the variabilities in Africa’s climate conditions. The overall aim of the study was to assess the preparedness of health systems, based on the responses by the surveyed respondents, who work in these countries and know the extent to which they are prepared to cope with the pressures posed by climate change. The use of the opinion of the respondents cannot be regarded as the sole criteria for the assessment of preparedness; however, it is an important one to the extent that such witness statements are unbiased and reflect the reality, being more reliable than government statements, which sometimes do reveal real trends.Conforming to the Intergovernmental Panel on Climate Change (IPCC) report, climate change impacts on Africans’ health have been quite enormous, especially for vulnerable groups, such as the poor, women, and children ,21,22. TSeveral studies have documented the impacts of climate change on health ,21,24,25Climate change will increase people’s exposure to water-related contaminants and cause illness by affecting fresh and marine water resources. Bacteria, viruses, protozoa, and other blue-green algae are pathogens and toxins that cause water-related diseases . A review of cholera seasonality suggests a long association with climate change and poor sanitation. The outbreak of cholera is associated with heavy rainfall and floods, particularly in Ghana ; NigeriaOther climate-sensitive water-borne diseases reported in many parts of the continent with severe health outcomes are the Buruli ulcer and schistosomiasis, occurring in Ghana  and NigeMalaria, leishmaniasis, Rift Valley fever, and tick and rodent-borne diseases are the most frequently occurring vector-borne diseases, causing myriads of premature morbidity and mortality rates in Africa . As one Further studies explored the health impacts of climate change on nutrition and food security across Africa. Stunted growth and underweight conditions among children in Mali, Kenya, Ethiopia, and Ghana (grey literature) due to malnutrition and food insecurity have a significant association with the severity of drought, floods, and extreme temperature ,44,45,46A study concluded that temperature and moisture influence fungal growth and aflatoxin production in cereals and legumes. Their presence inhibits infants’ growth due to the consumption of contaminated food ingredients . The delThe severity of atmospheric warming causes low crop production, which has, in turn, increased food insecurity and shifted the population’s attention to imported food, which affects the livelihood of the vulnerable in Nigeria, South Africa, and Ghana ,51,52,53Some other studies extensively reviewed the health impacts of extreme weather events on the African continent. The effect of floods from severe precipitation caused numerous fatalities and victims’ enforcement to leave their homes in the Eastern African countries, Central and Western Africa ,56,57,58From A cross-sectional study was conducted in six (6) different African countries to understand the country’s vulnerability to climate change impacts on human health and assess their health systems’ preparedness towards these impacts. The selected countries were (1) Ghana and (2) Nigeria, in West Africa; (3) Namibia and (4) South Africa, in Southern Africa; and (5) Kenya and (6) Ethiopia in East Africa see . The popThe authors searched for and tabulated some of the existing peer-reviewed literature  from eacThe authors employed a questionnaire-based survey to complement the literature on the vulnerability of the sampled countries to climate change impacts. The survey again aims to assess these countries’ health systems’ readiness to cope with climate change impacts. Primary data were collected between April and the first week of June 2019 through an online survey using a structured questionnaire with several closed-ended and very few open-ended questions see . In the One advantage of the sampled professionals is that they have expertise in climate change impacts on human health and improve resilience through adaptive measures. The authors divided the questionnaire into five (6) main parts. The first part addressed the background information of the respondents with their corresponding country. The second part examined the respondents’ knowledge and perception of climate variability and human health impacts in each sampled country; part three of the research question assesses each country’s vulnerability to climate change effects. Section four assesses the health professionals’ perception of the health systems’ preparedness in dealing with the health impacts of climate change in each country. The fifth section assesses the available interventions in dealing with the issues of climate change effects. The sixth section evaluates each sampled country’s available resources to deal with climate change impacts on human health and the health professionals’ resources to curb the effects. The authors analysed the survey data using IBM SPSS statistics 25, and the findings are presented in the subsequent parts of this paper.All the research questions relating to the study are presented in this section. Their discussion is followed in the next section. Tables are predominantly used in the results to give precise percentages. The necessary details of the respondents  are described. Information on climate change in the sampled countries, with its impacts on human health, as observed by respondents, is also presented. Other analyses tabulated include respondents’ perceptions of health professionals’ preparedness to cope with climate change’s health hazards. Finally, the health resources available and those needed to curb the challenges of climate change impacts on public health are also described.A purposive sampling technique that targeted only professionals in the health systems at various sectors see  with priInfectious diseases related to changes in vector biology, water, and food contamination.Injuries and fatalities related to extreme weather events and heatwaves.Allergic symptoms related to increased allergen production.Mental health consequences, civil conflicts, and population dislocation.It can be seen in Our survey results showed that climate change had extensively been experienced in the past years, as reported by 63.1% of respondents. In comparison, 32.0% claimed that the sampled countries had experienced them to some extent. Nigeria was perceived to have the highest climate experience (67.7% within the country), and Kenya (66.6% within the country). South Africa had the lowest climate change experience as perceived by the respondents (50.0% within the country) compared to other sampled countries.Respondents from West Africa  reported that floods and extreme temperatures are frequent, and those from Eastern Africa  mentioned drought and extreme temperatures. Extreme temperatures appear to be common in the Western and Eastern part of Africa. The Southern African countries (South African and Namibia) experienced much drought and extreme temperatures. To some extent, floods and erratic rainfall pattern were observed in all the sampled countries.Strengthening climate change adaptation capacity in Africa- case studies from six major African cities and policy implications [These responses confirm a reviewed article, ications , which iAbout half (50.8%) of the respondents revealed that the health impacts of climate change had been extensively observed in the sampled African countries, while 38.5% of the respondents reported that the effects were experienced only to some extent. All respondents from Ghana and Namibia (100%) revealed that the health problems caused by climate change are common in the two countries. In contrast, only 27.8% of South African respondents showed that climate change was observed. Malaria and other vector-borne diseases were reported in both Ghana (67.7%) and Nigeria (64.5%) as most prevalent. Nigeria and Ethiopia reported considerable percentages of food-borne illnesses, malnutrition, and food insecurity (48.4% and 57.9%). The respondents’ perceptions regarding the trend of the diseases from the past until now were examined, as shown in In total, 76.4% of total respondents predicted that the magnitude and severity of climate-induced diseases in sampled countries would increase in the following years if climate change were not accounted for in the planning and implementation of public health programs.The implications regarding the sampled country’s preparedness to effectively respond to climate change’s health impacts are presented in Respondents’ perceptions of disaster relief agencies in the sampled countries are presented in The National Disaster Management Organization (NADMO); The United Nations International Children’s Emergency Fund (UNICEF); The National Emergency Management Agency; USAID; World Vision; ADRA, National Disaster Prevention and Management Agency; Disaster Risk Reduction Commission; The Red Cross; Gift of the Givers, providing support in drought-prone areas; NEMA; LASEMA; The AYA Foundation; EHPs Disaster Risk Management; Meals on Wheel (N.G.O.); Public Health Emergency and Preparedness Agency; Catholic Relief Agency; and F.A.O.The financial response from the sampled country’s government and the needed funding/budget at the health sectors as perceived by the respondents are presented in Respondents reacted to the resources available within each sampled country to respond to climate change health problems in Having prepared for curative measures, most of the respondents further perceived preventive steps to control future climate change impacts by having an effective surveillance system in the country. When a coordination framework exists between the health systems and the meteorological department to access relevant weather and climate data, the health system plans and implements health programs towards future uncertainties. Again, South African surveillance systems undoubtedly perform better than other countries (44.4%).More so, almost all the responses mentioned that all the sampled African countries needed emergency response resources. The health systems’ preparedness towards future health problems to involve equipping the country, in rural and urban communities, with ambulances, fire brigadiers, and possibly helicopters to help control and prevent health emergencies caused by climate change impacts are an essential factor to contribute to the sampled country’s coping and adaptation strategies towards resilience.This study principally focused on assessing the preparedness of public health systems in African countries to cope with climate change health hazards. Our results revealed that climate change had been extensively experienced within the sampled African countries, with floods and extreme temperatures being experienced in West Africa, mostly in Ghana and Nigeria. The revelation is confirmed by several studies in the reviewed literature of this study ,59,64,65Extreme weather events experienced in the sampled countries have caused an increase in disease prevalence, such as malaria (endemic in most African countries) and other vector-borne diseases, particularly in Ghana and Nigeria, as the most affected countries. Malnutrition, food insecurity and food-borne diseases are notably occurring in Ethiopia and Nigeria. This confirms the assertion that drought, floods, and extreme temperatures are the most occurring impacts in these countries. Among the sampled countries, Ghana reported the highest effects of climate change on human health. A confirmation of this is seen in a study that applied a series of five hypothetical cases to review the climate impacts on the health and wellbeing of individuals and the population in Sub-Saharan Africa . AdditioOur survey again focused on relationships between climate change impacts and food insecurity. The findings showed that drought, caused by extreme temperatures, has a significant effect on food insecurity and affects the vulnerable population’s health in the sampled countries, most notably in Ethiopia and Nigeria, which respondents perceived to be the two most affected countries. A study conducted in the Horn and Southern Africa, where 14 million lives in Ethiopia, Kenya, Malawi, and Zimbabwe were endangered due to drought, confirmed this report regarding Ethiopia . An ecolClimate change management in the sampled countries needs more attention regarding adaptation and resilience strategies. The justification is found in the diversity of impacts across the continent and each country’s preparedness based on its available resources to deal with the effects. From the studied sampled countries, it was observed that South Africa is making significant progress in its readiness to deal with climate change health impacts. A justification of this is a study that systematically assessed climate change adaptation in the health sector in South Africa and finds significant progress in policy frameworks for climate change, surveillance systems and training curricula for health workers .Several studies argued that each affected nation’s emergency preparedness, response, and recovery activities should widely include human resilience building ,80,81. SEducation on the climate change impact on human health in the healthcare sector fails to give adequate attention to the roles of the larger eco-systems within which it operates . A studyThe risk and effects of climate change on mental health are increasing, and intervention to address the issue needs to tackle the problem in a holistic manner . A studyThis study revealed that the evidence of incorporating climate change into public health intervention is yet to be realised in the sampled countries. However, public health interventions or programs in the sampled countries are well observed. It is a compelling illustration of the local institutions’ weakness in response to climate change impacts on public health. This remark is in line with the result of a study that questioned how reinforcing the public health capacity to respond to extreme events had received less attention . An admiThis study’s critical findings provided clear evidence of ineffective and non-existent disaster relief agencies or programs to assist vulnerable populations and the state’s technical support on developing resources to help public health in case of climate disasters. Most respondents further perceived preventive steps to control future climate change impacts by having effective surveillance systems. When a coordination framework exists between the health systems and the meteorological department to access relevant weather and climate data, the health system plans and implements health programs towards future uncertainties. Again, South African surveillance systems undoubtedly perform better than those of other countries (44.4%).Improve policy frameworks to better consider the many health problems associated with climate change.Improve training provisions to raise awareness among professionals in the health sector about the connections between climate change and health.Improve frameworks for information exchange and the dissemination of best practice across Africa so that successful initiatives dealing with the nexus of climate change and health may be replicated.Policy applications in the sampled African countries regarding improving the present and future generations’ livelihoods in Africa’s climates conditions are lacking. Therefore, we raise the need for the sampled African countries to execute the following:Successful application of such policies will help close the gap and address the barriers to successfully implementing adequate coping and adaptation strategies.The methodology used to perform this study has some advantages. For instance, a survey seemed to be an appropriate way to access a significant group of participants across the African continent as a method. In addition, the technique used permitted the authors to collect data from each participant at a single point in time. Additionally, it provided a picture of the regularity of health hazards in the sampled countries at a precise moment. Moreover, through this methodology, the massive health needs of sampled countries are assessed, providing a sound basis to inform the planning and health authorities about some of the items they may need to consider in allocating health resources. This study’s evidence is also timely since it may help African countries adjust their health systems to cope with climate change. However, this study also presented some limitations. Firstly, it only focused on six African countries and did not have the ambition to cover the whole African continent. Additionally, some associations that were identified between climate change and health seemed challenging to interpret since they are not exclusive to climate change. Some structural problems also hinder the handling of various types of diseases. Moreover, because this methodology offers only a one-time measurement of exposure and outcome, it is challenging to evaluate the causal relationship from the data set available. The paper presents an overview of some of the health problems associated with climate change across Africa. A cross-sectional study involving six African countries  analysed the prevailing vulnerability to climate change’s impacts on human health on the one hand and the degree of preparedness of the health systems to cope with them, on the other.It identifies several trends. First, the levels of knowledge and perceptions about climate variability and public health impacts in the sampled countries are varied. The study also shows that the health impacts of climate change have been extensive, to a greater or at least to some extent, illustrating the fact that they are part of the routine in the investigated countries. Most of the respondents also stated that climate-induced diseases might increase in the future and that future climate changes are not addressed.The sampled health professionals’ view is that the degree of preparedness of their health systems to deal with the health impacts of climate change in their countries is somewhat limited, a trend that is a reason for concern due to expected increases in the intensity of climate change.Overall, the responses and examples provided from the sampled countries offer helpful insights into the nature of the nexus of climate change and health, their scope, and possible consequences. It is evident from the study that urgent action is needed to place African countries in a better position to handle the many challenges that climate change poses to them presently and in the future.The implications of the study are manifold. For instance, it shows that significant differences in the levels of interventions at the country level exist regarding their capacity to handle climate change’s health impacts. There also seems to be a perceived need for disaster relief agencies/organisations to emphasise climate change as part of their work.Climate change and the effects on human health, the environment, and society will continue to be significant issues in African countries, for which answers need to be found. They pose a challenge to health systems, the governments and health professionals in the coming years. Our findings will be widely shared with health professionals in African countries to support this process to address the barriers to implementing coping and adaptation strategies of climate change impacts on public health. There is a perceived need for a greater understanding of climate-related health impacts, which can only be addressed through interdisciplinary research across hierarchical levels and geographical and political boundaries. Because of the challenges that are and will be faced in Africa, it is necessary to sensitise the public and politicians to this topic and support health professionals’ work.


The administration of an accurate and effective POCUS course is a crucial tool in improving health education and thus the health care system in low- to middle-income countries. The development of the ultrasound curriculum in these countries during the pandemic era is a major challenge for medical educators. Therefore, this study aims to survey the learner experience after implementing the POCUS curriculum for first-year emergency medicine residents. All learners responded to the survey. Our results demonstrated that the ultrasound rotation and our ultra-sound learning materials were useful tools which showed a positive impact on POCUS knowledge for our learners. However, some obstacles of POCUS learning were identified to assist in closing faculty development gaps, including the availability of handheld devices, as well as the re-modeling of the ultrasound rotation course, which should be managed according to the feedback we received. This study demonstrated a clear need for constant updates in higher education, medical program development, accuracy of local learning materials, and the explosion of virtual and online learning platforms during this decade. A sustainable healthcare system is defined by the World Health Organization (WHO) as a system that improves, maintains or restores health, while minimizing negative impacts on the environment and leveraging opportunities to restore and improve it, to the benefit of the health and well-being of current and future generations. The development of novel knowledge and the technology referred to as the point-of-care ultrasound (POCUS) has shown great potential in providing sustainable health care.For the past two decades, the primary tools for bedside diagnosis are the integration of a patient’s history and a physical examination. This is especially true in resource-limited countries. After having been introduced as a bedside tool in the practice of emergency medicine, the POCUS is proving to play an increasingly crucial role in diagnosis and treatment in emergency patients globally ,2,3. POCHowever, there are some common POCUS errors or pitfalls for diagnosis in novice POCUS usage. Thus, to be professional in performing POCUS, this novel knowledge needs to be delivered, in addition to training, in a formal way, through a trainer or an established formal curriculum. Recent innovations in POCUS training and education have surged and should now be a key element in medical training.In 1994, the POCUS curriculum for training emergency physicians was developed and implemented in the United States and Canada . In 2001About 10 years ago, POCUS was introduced to the Emergency Department in Thailand by The World Interactive Network Focused on Critical Ultrasound (WINFOCUS). This organization collaborated with the King Chulalongkorn Memorial hospital to establish the WINFOCUS Thailand. After that, there was a certified POCUS training workshop for Thai emergency physicians. In 2018, the POCUS education for emergency medicine residents was established by the Thai College of Emergency Physicians (TCEP). Initially, the TCEP held an annual formal procedure workshop called “TCEP Resuscitative Procedure Courses”, which had multiple sessions of key procedures for resuscitation when using POCUS. The ability to perform emergency POCUS was included in the Thailand EM (Emergency Medicine) milestones in 2018 by the TCEP EM training board. EM residents are mandated to perform POCUS examinations and undergo an evaluation of POCUS skills according to entrustable performance activities (EPA) using the direct observation of emergency procedural skill assessment (DOPs) before taking the board examination.Our institution  is the medical academic center in the Northeast region of Thailand. We have been active in training emergency physicians across Thailand since 2007. Training in POCUS is a key component of EM. Thus, the ultrasound curriculum was first implemented in July 2019. Our faculty arranged POCUS training for first year emergency medicine residents in the 2019–2020 academic year and the 2020–2021 academic year. However, in the 2020–2021 academic year, the POCUS education program was remodeled into an online platform due to the COVID-19 pandemic. Alongside the development of POCUS education in our institution, the purpose of this study was to define the quality of the proprietary training in the field of POCUS by using the survey affiliated with our institution’s postgraduate EM training programs to assess the opinions of learners about our ultrasound curriculum and the learning materials used during this challenging time.A cross-sectional survey study was conducted at Srinagarind Hospital, Department of Emergency Medicine, Thailand from July 2019 to July 2021. This hospital has an average of 70,000 emergency patients visiting per year.Participants were all first-year emergency medicine residents who attended the ultrasound rotation during the 2019–2021 academic year. Participants who did not attend this rotation were excluded from this study.A 10–question survey was conducted . RespondThe residents, who were in the ultrasound rotation at the Department of Emergency Medicine at Khon Kaen University’s Srinagarind Hospital from July 2019 to July 2021, were enrolled in this study. Hence, based on a questionnaire study, we estimate that there were around eighteen residents who would meet our inclusion criteria. Assuming a participation rate of 60% , we expeThe ultrasound curriculum  was a twIn the 2020–2021 academic year, we were faced with the relentless threat of a resurgent Coronavirus pandemic; thus, we had changed all formerly in person POCUS training courses to online learning via various platforms, including the Zoom and LINE call applications. Moreover, bedside ultrasound teaching with a real patient was not provided that year .Thus, the difference of our POCUS curriculum before and after pandemic era was (1) the platform of learning was onsite before the pandemic and 100% online after the pandemic, (2) the number of learning hours was the same, (3) in terms of bedside learning, we used mock patients instead of real patients. The impact of the remodeling course was (1) students can learn from our online platform any time and repeatedly, (2) Thai students usually fear to ask questions if the learning platform is onsite; therefore, when students learn by online platform, they can ask more questions via the chat box.Objectives of the curriculum: by the end of this rotation, learners will be able to demonstrate:1. Competency in the following POCUS applications: identifying the presence of intraperitoneal free fluid, presence of pericardial fluid, measurement of IVC and aorta diameter, presence of cardiac motion, assessment of fluid status by using cardiac, lung and IVC ultrasound, confirmation of intrauterine gestation, hydronephrosis, pneumothorax and gall stone), and facilitation of vascular access.2. Competency in basic ultrasound protocols .3. The ability to provide good image acquisition and good image interpretation in core POCUS organs .4. Competency in clinical integration of ultrasound findings.In terms of the materials for learning POCUS, there is no standard textbook written by the POCUS specialists in Thailand. Our faculty developed “The Practical Ultrasound Flashcards with Augmented Reality” . The setIn terms of the ultrasound phantom, our faculty developed the ultrasound phantom for practicing ultrasound guided peripheral intravenous assessments (UGPIV), due to the high cost of the commercial model for practicing this skill. The model was created based on a study by Chao  and the In terms of the ultrasound machine, we provided 2 ultrasound machines in the emergency department for performing clinical practice with the patient and also for POCUS learning. The ultrasound machine was an M9  and Sonosite M turbo  equipped with a curved array probe, phased array probe, and linear probe. Moreover, we provided 1 handheld ultrasound named Butterfly IQ.Ethical approval was provided by the Khon Kaen University Ethics Committee for Human Research (HE641406). The written informed consent was obtained from each participant before the study.A total of eighteen EM residents attended the entire ultrasound rotation between July 2019 and July 2021. All of those responded to the survey (100%). All of the respondents (100%) had POCUS experience before attending this rotation. Most respondents reported the number of POCUS examinations in this rotation to be about 31–40 times and considered this to be useful in improving POCUS knowledge. The most useful learning activities were the bedside ultrasound teaching and the review of the ultrasound image, respectively. All respondents rated “Very Useful” to the ultrasound flashcard as the most useful of the ultrasound learning tool . RegardiThe POCUS examination type that respondents practiced in this class was displayed in The aim of this study was to explore the learners’ opinions regarding the ultrasound rotation, which included teaching activities, timing and length of training, ultrasound learning tools, the barrier to learning POCUS and the learners’ points of view to POCUS education.In terms of education methods, there are a lot of teaching methods utilized in the instruction of POCUS; for example, didactic lectures, formal quizzes or quizzes in the form of games, live model demonstration, simulation training, and direct patient scanning. The utility of each method was different . HoweverOur results indicated that most learners identified the teaching activities that can best improve POCUS knowledge were the bedside ultrasound teaching and the process of reviewing ultrasound images with a supervisor in both academic years, which is consistent with many studies ,17,18,19www.ultrasoundcases.info (accessed on 14 September 2021) and https://123sonography.com/point-of-care-ultrasound (accessed on 14 September 2021) for additional supplemental learning materials.Regarding the hands-on section, in the first academic year of the ultrasound rotation, we provided bedside ultrasound teaching by performing POCUS examinations with real patients. However, in the second academic year, the global community faced the COVID-19 pandemic, and we did not dare to arrange this section due to safety concerns. The EM residents were mandated to perform POCUS examinations with the mock patients or used each other as mannequins. Because of this, the supervisor was not able to demonstrate the real pathologic sonographic features. This was the issue that we were most concerned about, so we suggested some online resources, such as The next activity that learners preferred was the didactic lecture. This study designed the didactic lecture adapted from the American College of Emergency Physicians (ACEP) which consisted of 12 core ultrasound applications . MoreoveThe teaching activity that the learners rated of the least value according to scores was the journal club. In many medical curricula, there was no section or only a little section of the journal club in the POCUS education for medical students and residency programs, except for in the fellowship program. Most academic settings provided the journal club to encourage learners to develop critical appraisal skills and utilize current best practice . HoweverIn terms of POCUS examination types that learners had practiced in this rotation, most learners performed cardiac and lung ultrasounds every day. The next most frequent was the IVC examination, which most learners performed. These are comprehensive ultrasound examinations for the assessment of patients with cardiopulmonary complaints and undifferentiated shock, which is vital for novice users to recognize, gain practice in, and gain as much experience as possible to rapidly improve their skill. Interestingly, most learners reported they had no experience of OB-GYN ultrasounds nor those for the Appendix. This may be due to (1) a negligible number of OB-GYN patients in the ER, (2) most obstetricians prefer transvaginal ultrasounds that are not provided in the ER, or (3) in cases of appendicitis, the surgeon prefers formal ultrasounds from a radiologist.As for the number of scans conducted by students, our learners reported their number of scans in this rotation were 31–40 times in 2 weeks. Current ACEP guidelines suggest a minimum of 25 ultrasound scans for each type of scan performed in the practice of ultrasound scanning skill training . It shouThe design of a POCUS training program was a challenging task for our faculty due to many limitations, including (1) there was only one supervisor who is a POCUS specialist, (2) the already dense nature of the emergency medicine curriculum, (3) the limitation of the time in which learners have to participate in this rotation, and (4) a limitation of educational resources for learning POCUS in Thailand. Therefore, we arranged the ultrasound rotation for only 2 weeks for first year residents. This may affect the learners’ practical skill due to the insufficiency of practice time and retention of the knowledge. In a study about the retention of knowledge, it was found that the addition of a longitudinal component to ultrasound education may result in improved knowledge retention Our results clearly showed the length of training in bedside ultrasound teaching was very suitable for residents. In our experience, there is something that is more important to consider than the length of learning time and that is the limitation of the number of learners per supervisor per ultrasound machine and the number of POCUS examinations performed by learners in each class; this is consistent with the findings of other studies ,27,28,29In terms of the optimal number of total hours for the ultrasound rotation, there is quite a range from as little as 4 h to as long as one month ,31. HoweTo achieve the 2030 Sustainable Development Goals (SDGs) for health—specifically, goal 3  and goal 4 —effective medical education development is a crucial consideration. However, in low- and middle-income countries, the greatest limitation of health care and education is the budget. There are many varieties of POCUS teaching tools that are currently used commercially, such as Sonosim, which is an ultrasound training solution that provide hands-on online simulators, Insimo, which is another online platform ultrasound simulator, and iTeachU, which is a POCUS eLearning package, etc. The problem is that they are not affordable in lower income countries; for example, the popular commercial phantom, the Blue Phantom’s Branched 2 Vessel Ultrasound Training Block Model, has a price of around USD 500 per model. Thus, the development of their own tools with the incorporation of local ingredients may provide great help to the learners to access this knowledge and skill set. The first subject is the Ultrasound Flashcard using Augmented reality. This was the first POCUS education tool to be developed in our faculty, as well as in all of Thailand. In the pilot phase, our faculty implemented this tool to assist in the training of medical students who attended the emergency medicine rotation. There was clear evidence that medical students who used this tool to learn POCUS left with better knowledge scores than the others who attended the standard ultrasound training course only . This isThe main barriers in this rotation were the lack of time and a sizable number of patients in the ER, which is consistent with other studies ,37. Our The limitations of this study were (1) the small number of the participants and the single intuitional study that cannot represent all the POCUS learners experience, (2) this study used self-reported data; therefore, there were some biases, including selective memory and (3) this study was not designed to demonstrate the knowledge improvement of the learners and the retention of knowledge of the learners. This study focused on POCUS curriculum in first year emergency medicine residents, which may not be generalizable to other specialties. All outcomes reflect the EM residents’ perceptions of the learning activities and POCUS learning materials in our programs, which are potential sources of error. The current study only surveyed program residents; thus, no comparative of the statistic was provided. However, the strength of this study included that the study was the first survey about the POCUS learning in Thailand, which was high in response rate.POCUS education in low- to middle-income countries is still shrouded in mystery. We know that due to many limitations, namely budgetary ones, coupled with the need for expensive equipment and courses, that many of these programs are inadequate. One of the potential avenues to developing quality POCUS education programs is by creating their own POCUS learning materials. The limitations put upon academic and medical institutions by the pandemic must be dealt with creatively; materials should be developed in accessible formats, which include eLearning or the availability of other online materials. The main benefit of eLearning is providing the POCUS knowledge to the many learners who currently struggle with a limited number of POCUS specialists. Moreover, to provide a more substantive curriculum evaluation based on learning outcomes, our future work will focus on the more direct and long-term measures of the student performance, which are necessary in a competent EM practitioner.Further development of POCUS education through the implementation of the ultrasound rotation in emergency medicine residents’ curricula is the first step to enhance proper POCUS usage in Thailand. In our study, we developed an ultrasound curriculum and ultrasound learning materials, which included the ultrasound flashcards and the ultrasound phantom. With the arrival of the COVID-19 pandemic, the global POCUS education was disrupted in a major way. Remodeling of this course was necessarily developed. The virtual or online platform plays a crucial role for conducting POCUS training and making it accessible to learners. Our results demonstrated that all academic activities employed and the ultrasound learning materials were useful in improving POCUS knowledge. However, we found some obstacles in POCUS learning that needed to be improved, mainly the length of time of training. We believe that adopting this POCUS education and training method can lead directly to more effective treatment and be of great benefit to both future physicians and their patients.


The gastrointestinal microbiome is an important component of the human body and is closely related to human health and disease. This study describes the hotspots of the human gastrointestinal microbiome research and its evolution in the past decade, evaluates the scientific cooperation network, and finally predicts the field’s future development trend using bibliometric analysis and a visualized study.We searched the original articles from January 2010 to February 2021 in the Scopus database using the term “gastrointestinal microbiome” and its synonyms. CiteSpace was used to construct country and author co-occurrence map; conduct journal, citation cocitation analysis, and reference co-citation knowledge map; and form a keywords co-occurrence map, a clustering knowledge map, timeline view of keywords, and burst term map.A total of 4444 documents published from January 2010 to February 2021 were analysed. In approximately the past decade, the number of articles on the human gastrointestinal microbiome has increased rapidly, and the research topics focus on different populations, research methods, and detection methods. All countries and regions in the world, led by the US, are studying the human gastrointestinal microbiome, and many research teams with close cooperation have been formed. The research has been published extensively in microbiology journals and clinical medicine journals, and the highly cited articles mainly describe the relationship between gastrointestinal microorganisms and human health and disease. Regarding the research emphasis, researchers' exploration of the human gastrointestinal microbiome (2011–2013) was at a relatively macro and superficial stage and sought to determine how the gastrointestinal microbiome relates to humans. From 2014 to 2017, increasingly more studies were conducted to determine the interaction between human gastrointestinal flora and various organs and systems. In addition, researchers (2018–2021) focused on the gastrointestinal microbial community and the diversity of certain types of microbes.Over time, the scope of the research on the clinical uses of the gastrointestinal microbiome gradually increased, and the contents were gradually deepened and developed towards a more precise level. The study of the human gastrointestinal microbiome is an ongoing research hotspot and contributes to human health. It is currently well appreciated that diverse microbial communities reside within the intestinal tract, on the skin, and on nearly all of the exposed surfaces of the human body . The humCharacterizing the structure of knowledge, the evolution of research topics, and the emergence of topics have always been an important part of information science (IS) . BibliomThis study aims to visualize articles on the human gastrointestinal microbiome in the last ten years by using knowledge maps. We described the research hotspots of the human gastrointestinal microbiome and its evolution in the past decade, evaluated the scientific cooperation network, discussed the relationship between humans and gastrointestinal microbiomes, and predicted the field’s future development trend.The literature data used in this study were downloaded from the Scopus database, which is widely accepted among researchers conducting high-quality bibliometric analyses –26. We uCiteSpace , a freely available software tool for analysis, was used to make visualization maps in this study. Developed by Chaomei Chen in 2004 at Drexel University (USA), CiteSpace is usually used to analyze, detect and visualize trends and patterns in scientific literature . The priOverall, 4444 documents published from January 2010 to February 2021 were analysed. The number of annual documents during this period showed an exponential growth trend . The specific numbers of annual documents are shown in Fig. In the country co-occurrence knowledge map Fig. , 4444 arIn the author’s co-occurrence knowledge map Fig. , there aA total of 1255 journals published the 4444 articles on the human gastrointestinal microbiome. We analyzed the top ten journals that published articles on the human gastrointestinal microbiome , which attracted intense attention at the time . But sinFrom 2014 to 2017, increasingly more studies were conducted to determine the interaction between human gastrointestinal flora and various organs and systems  –85. For From 2018 to 2021, researchers shifted their focus from certain types of gastrointestinal bacteria to the gastrointestinal microbial community  and micrIt is worth noting that researchers are often inspired by animal experiments to explore the mechanisms of diseases caused by the gastrointestinal microbiome and modify the gastrointestinal microbiome to treat disease; then, they judge the feasibility and safety of treatment methods . HoweverThere are some limitations to this study. In this study, only articles in the Scopus database were retrieved. Although using the Scopus database to conduct high-quality bibliometric analyses is widely accepted by researchers, it is still possible that some studies related to the human gastrointestinal microbiome have not been included, which may change the results of the study. This study examined only the last ten years of research on the human gastrointestinal microbiome, which may miss the development process of the human gastrointestinal microbiome from the start.In this study, 4444 original studies from January 2010 to February 2021 related to the human gastrointestinal microbiome were downloaded from the Scopus database and analyzed using CiteSpace to generate knowledge maps. The number of articles on the human gastrointestinal microbiome has increased rapidly in the past decade, and the scientific cooperation network showed that cooperation between different countries and institutions has been sufficient. The research topics focus on different populations, research methods, and detection methods. In addition, the research scope has gradually increased over time, and the research content has been gradually deeper and moving towards precision medicine. In short, the study of the human gastrointestinal microbiome is an ongoing research hotspot and contributes to human health.


Eating disorders are serious conditions that cause major suffering for patients and their families. Better knowledge about perceptions of eating disorders and their treatment, and which factors that facilitate or hinder recovery, is desired in order to develop the clinical work. We aimed to explore and synthesise experiences of eating disorders from the perspectives of those suffering from an eating disorder, their family members and health care professionals through an overarching meta-review of systematic reviews in the field.A systematic literature search was conducted in the databases PubMed, PsycInfo, Scopus, and CINAHL. Inclusion criteria were systematic reviews of qualitative research on experiences, perceptions, needs, or desires related to eating disorders from the perspective of patients, family members or health care professionals. Systematic reviews that fulfilled the inclusion criteria were assessed for relevance and methodological limitations by at least two researchers independently. The key findings were analysed and synthesised into themes.We identified 17 systematic reviews that met our inclusion criteria. Of these, 13 reviews reported on the patients’ perspective, five on the family members’ perspective, and three on the health care professionals’ perspective. The study population in the reviews was predominantly girls and young women with anorexia nervosa, whilst systematic reviews focusing on other eating disorders were scarce. The findings regarding each of the three perspectives resulted in themes that could be synthesised into three overarching themes: 1) being in control or being controlled, 2) balancing physical recovery and psychological needs, and 3) trusting relationships.There were several similarities between the views of patients, family members and health care professionals, especially regarding the significance of building trustful therapeutic alliances that also included family members. However, the informants sometimes differed in their views, particularly on the use of the biomedical model, which was seen as helpful by health care professionals, while patients and family members felt that it failed to address their psychological distress. Acknowledging these differences is important for the understanding of anorexia nervosa and other eating disorders, and may help clinicians to broaden treatment approaches to meet the expectations of patients and family members.The online version contains supplementary material available at 10.1186/s40337-021-00507-4. The current paper brings together existing knowledge on experiences of eating disorders. We were interested in the views of patients, family members and health care professionals. A literature search identified 17 systematic reviews which addressed these questions. The identified research focused mainly on girls and young women with anorexia nervosa, while research on other eating disorders was limited. Overall, this review suggests that it is important to acknowledge that patients, family members and health care professionals may have different experiences and views regarding treatment of eating disorders, and that it is important to consider all these views in the development of the care of eating disorders.The online version contains supplementary material available at 10.1186/s40337-021-00507-4. Eating disorders (EDs) are serious psychiatric conditions that often have both psychological and physical consequences and significant societal costs , 2. An EED often require multi-disciplinary treatment . Most paThe recommended psychological treatment for adult patients is cognitive behavioural therapy (CBT), which has is strongest empirical support for patients with bulimia nervosa (BN) and binge eating disorder (BED), but is also increasingly recommended for patients with anorexia nervosa (AN) –10. FamiIt is estimated that about half of all people with AN are fully recovered after treatment. At ten-year follow-up, about 73 percent are in remission. The short-term effect of treatment is slightly better for other types of EDs, but there is a significant risk of relapse. In ten years' time, there are marginally more people recovering from BN compared with AN .Health care professionals often describe that patients with an ED are a challenging group of patients and that it can be difficult to establish a good treatment alliance . PatientAn improved common understanding of EDs from the perspective of those affected, their family members and caregivers can contribute to better care and treatment for those struggling with EDs and help reduce the strain on their relationships.Against this background, the aim of the present study was to investigate experiences of living with an ED and factors that facilitate or hinder recovery from the perspectives of patients, their family members and health care professionals.The current meta-review is based on an assessment conducted at The Swedish Agency for Health Technology Assessment and Assessment of Social Services . The litA systematic literature search covering literature published from January 1, 1990 to September 26, 2018, was conducted in the electronic databases PubMed (NLM), PsycInfo (EBSCO), Scopus (Elsevier), and CINAHL (EBSCO). A complementary, multi-database, search was also conducted. The databases Academic Search Elite, ERIC, Psychology and Behavioral Sciences Collection, and SocINDEX, were searched simultaneously through the EBSCO platform. The detailed search strategy is provided in Additional File Inclusion and exclusion criteria were specified in advance. We only included systematic reviews of qualitative research that were published in peer reviewed journals in English, Swedish, Norwegian, or Danish within the time period 1990 to 2018. To be included, a systematic review should cover experiences, perceptions, needs or desires related to EDs from at least one of the following perspectives: persons with eating disorders, family members or health care professionals. All types of EDs according to the DSM-5 classification were considered relevant except for pica, rumination disorder and avoidant/restrictive food intake disorder. There were no restrictions regarding the age of the informants. The targeted reviews were required to cover original studies of qualitative research or of mixed methodology. Systematic reviews using both broad and narrow search strategies were accepted. Grey literature, such as theses, book chapters, and conference abstracts, were excluded.The titles and abstracts retrieved from the literature search were examined independently by two of the authors using the web-based screening tool Rayyan. If at lSystematic reviews that fulfilled the eligibility criteria were assessed for quality by at least two authors independently, using a tool developed at the Swedish Agency for Health Technology Assessment and Assessment of Social Services  were analysed using the method of thematic analysis described by Braun and Clarke . For eacThe literature search identified 3,082 citations, after removal of duplicates Fig. . From thThe 17 systematic reviews with minor or moderate concerns of methodological limitations were published between 2009 and 2018 and were based on a total of 255 unique qualitative primary studies. An assessment of study overlap revealed that few of the primary studies were included in more than one review  and the ED was described as a "coping strategy" that helped them deal with difficult emotions and events. For the majority of patients, the other side of the coin was a difficult experience of losing, or giving up control, for example when entering treatment, or feeling trapped in their illness and symptoms. The subjects described how their whole life revolved around a compulsive focus on calorie counting and compensatory behaviours and how this resulted in a lonely and isolated existence , 31, 33.When seeking treatment, patients had often felt ill-treated and misunderstood, especially in general care , 30, 32,Instead, they emphasised that there must be room for conversation about thoughts and feelings and that the care they received should take their wider life situation into account. It was also felt necessary that the therapistwas able to adapt and change his/her approach during the course of the treatment. Initially, the patients might need a therapist that was proactive and took control. At a later stage when the patient was able to take responsibility, treatment should empower and encourage the patient to take control of his/her own life.Family-based treatment was common for young patients. These patients often felt considerable guilt towards parents and siblings, and they described that a positive aspect of family treatment was that it could help the whole family to feel better, bring them together, and improve their communication. However, patients also described feeling unable to talk about everything that was important to them in family treatment. This risked the treatment becoming superficial and focused on concrete behavioural changes instead of dealing with the underlying causes of the condition. The young patients therefore felt that it was important that family treatment was combined with individual therapy. Individual therapy was seen as an important forum for motivating, engaging and giving patients hope. Patients perceived that it was important to address issues such as relationships both within and outside the family, and to be seen as a unique individual, rather than simply as a person with AN , 30, 32.In the studies that focused on AN, patients consistently described recovery as something “greater” than the mere absence of an ED diagnosis. An experience of being healthy did not arise automatically once weight and eating were normalized. Patients described recovery as a process of getting to know themselves and daring to admit that the false sense of control that the ED had given them had actually come to control them. Recovery meant being able to stick to healthy behaviors even when it felt difficult , 27, 33.Four factors were described as central to recovery; to regain control and power over one's own life, changing the anorexic identity and finding and accepting oneself behind the disease; getting in touch with one's true feelings and acknowledging the consequences of the disease for oneself, thereby challenging the anorexic thoughts.In the systematic review that described recovery more generally for people with an ED, it was found that patients perceived the term "healthy" as including feeling well emotionally, socially and psychologically. It included having strategies for dealing with difficulties that arise in life and feeling a sense of belonging or feeling that life is meaningful.Recovery was described as a process that took place in stages and sometimes with setbacks. Recovery was facilitated by supportive relationships, such as with family and friends. Trusting relationships with family and friends could have a double impact, both by motivating the ill person to seek treatment  and by pThree systematic reviews included the experiences of health care staff , 32, 35,The health care perspective also revealed three themes: a tug of war over control, the necessity of physical recovery, and being let into someone’s world.The health care staff saw control as a central aspect of AN and they felt that besides the need to control their own body, patients also felt a need to control their family through the ED . The staThe health care staff used a biomedical model to understand AN , 32. AN The medical view of the ED was perceived as helpful by staff because it was considered to reduce the patient's and their relatives' feelings of guilt. Health care professionals found it helpful to see the disease as a phenomenon separate from the individual. The staff used this "externalisation" to distinguish between disease and patient as a treatment strategy , 32. It Even under this theme, a review by Salzman et al.  also empA good alliance between patient and therapist was considered essential , 32, 35.One of the systematic reviews examined the health care professionals' experiences of meeting relatives, in this case parents of people with an ED . The staFive systematic reviews covered the perspective of family members , 31, 32.The family members felt that the whole family was negatively affected by the afflicted person’s illness , 31, 32.Family members described a difficult balancing act between adapting to the ill person by, for example changing the family's eating habits and activities, andbeing more demanding. The family members tried to find a balance between controlling and making demands on the ill person, and at the same time reinforcing and encouraging positive steps and showing trust in her/him. To some extent, they felt that it was important to adapt the family's social activities and meals by, for instance, not having certain foods in the house. However, this sometimes resulted in them "walking on eggshells" and accepting behaviours that were counterproductive in the long term. Siblings were often critical of the parents' strategies and thought that they adapted too much.A common strategy to cope with this balancing act was to distinguish the disease from the individual and to see certain behaviours as “the disease that speaking”. This helped the family members to maintain a supportive attitude, even when they felt that the person with the ED was misbehaving , 31, 32.It was stressful to see the person with an ED suffering, and the family members felt anxiety, frustration and guilt. Their everyday lives were affected, both socially and professionally. Many informants reported that the family became more isolated and that they stopped associating with others. Several of the systematic reviews reported that family membersno longer had time for hobbies and that working life was affected , 29. AgaParents often felt that the health care model was too biomedical and focused too much on physical symptoms such as starvation. They perceived that the unique person behind each patient was not seen , 29, 32.The parents often blamed themselves for their child’s ED , 31, 32 Family members often experienced a lack of support from the health service, especially at the beginning of the illness , 31, 32.Our synthesis identified three themes in common among the views of patients, family members and health care professionals Table . The firThis meta-review brings together a substantial amount of qualitative research, including data from 255 unique studies, on the experiences of EDs from the perspectives of patients, family members and health care professionals. Three themes emerged from the synthesis; the patients’ need for control, balancing physical recovery and psychological needs, and the importance of trusting relationships in the treatment of the disorders. Although all three main themes were identified in the views of all three groups of informants, there were some differences in their expression that may be important to acknowledge.The ED causes a great deal of suffering for both the affected person and the family members, and both parties emphasise the importance of getting the right treatment. From our synthesis, however, there appears to be a divergence between ED patients and their family members on the one hand, and the health care staff on the other, regarding how the ED should be understood and treated. Health care professionals often represent a biomedical explanatory model, while ED patients and their family members feel that this model is not sufficient. These different approaches are not necessarily conflicting, but can potentially complicate the alliance building and pull the treatment in different directions, where the professionals place more emphasis on symptom reduction and weight rehabilitation, while the patients and their family members want a more holistic approach to treatment and recovery. This conflict, and suggestions for how to avoid it, was also emphasised in one of the studies involving health care staff . The maiIn today's health care, and among policy makers, there is an increasing focus on using manual-based treatments and on measuring the outcomes of treatment. Great emphasis is placed on questions about which treatment method has the best scientific support, and how to make sure that therapists actually deliver the method according to the manual . These aTreatment manuals are a set of principles designed to be applicable to each individual patient. When delivered flexibly and skilfully there is no reason why individualised care should be in conflict with the use of treatment manuals . HoweverOne limitation of this meta-review, which is a common problem in qualitative research syntheses, is the considerable variability in research aims, data collection approaches and methods of synthesis that were present in reviews as well as in the primary studies. Another problem that is difficult to avoid in qualitative syntheses is the possibility that the authors’ underlying assumptions may have introduced bias through selection of the experiences and views that are presented in the studies. The risk of overestimating the findings through data redundancy should also be considered, but is probably not a major problem in this meta-review since most of the included reviews had a unique focus and the study overlap was limited . Other sThe major strengths of this meta-review are its broad scope – including three different perspectives of key informants – and the rigorous methodology of the literature screening, which involves systematic assessment of methodological limitations in the included reviews. The tool that we used for assessment of qualitative systematic reviews was developed in parallel to this meta-review and incorporates elements from the PRISMA guidelines  and the The included reviews focused mainly on anorexia nervosa (AN) or on EDs in general, without specifying a particular diagnosis. None of the identified reviews exclusively evaluated individuals with bulimia nervosa (BN) or binge eating disorder (BED), which was somewhat surprising. The possibility to generalise our findings to other EDs than AN is thus limited. To our knowledge, no systematic review that specifically focuses on experiences of BN or BED have been published after our literature search was performed. Considering the high prevalence of BN and BED that have been reported , there iMost of the included systematic reviews concerned both women and men with EDs, but men were underrepresented relative to their expected incidence, which possibly reflects the proportions of women and men that are studied in the primary qualitative studies of EDs. This is confirmed by a recent systematic review on men’s experiences of ED treatment, which iSince our literature search was performed, a few additional systematic reviews have been published on EDs from the patients’, family members’ and/or health care professionals’ views. These mainly confirm our findings –45. HoweA systematic review by Johns et al. gave new insights about the perceptions of health care professionals, patients and their family members in terms of meeting professional staff with knowledge about EDs . AnotherTo our knowledge, this is the first meta-review of qualitative systematic reviews focusing on experiences of EDs. The compilation acknowledges some important similarities and differences between the views of the three different informants, where health care professionals felt that the biomedical model was helpful, while patients and family members felt that it was insufficient and failed to address their psychological distress. Viewing these perspectives as complementary rather than conflicting may contribute to a better understanding of the complexity of treating EDs. Acknowledging experiences from various perspectives may eventually lead to adaptations in health care that can hopefully improve treatment compliance and recovery rates for individuals with EDs.Our meta-review also indicates that there is a need for methodologically well conducted qualitative systematic reviews on EDs in which the population is clearly described regarding age, sex, and diagnosis. In particular, there is a need for systematic reviews on experiences regarding BN and BED.Additional file 1. Literature search.Additional file 2. Tool for assessment of methodological limitationsAdditional file 3. Table of overlapping primary studies


Introduction: At the beginning of 2020, the worldwide infection of coronavirus (SARS-CoV-2) changed many aspects of human lives. The controlled lockdown was not only an obligatory lifestyle change to communities across the globe, but it was also an emotional struggle. The aim of the presented study was to identify and compare the main difficulties that final-year students (both Polish and foreigners) of Dentistry, Faculty of Medical Sciences in Zabrze Medical University of Silesia had to cope with during the first wave of the pandemic. Application of the biographical method in the form of essays written was done. Authors discussed the following issues: possible losses and benefits subjectively felt by individuals due to the COVID-19 pandemic, adaptation to online type of studying, students’ opinions regarding change of habits, and psychological impact of the lockdown. Students’ responses varied between groups in the aspect of what they considered as the biggest struggle of the pandemic time period. Adaptation to e-learning was easier for the group of foreign students. The Polish group considered it as a serious stress factor. Foreigners were much more worried about not being able to help their families in comparison to Polish students. Polish students’ fear was related to the fear of virus transmission to their older relatives. Both groups were aware of how serious the situation was and of the possible impact of lack of practical classes on their future internships. As benefits of that situation, both groups listed development of new hobbies and increased sport activities. The Polish group emphasized improvement of interpersonal bonds during the lockdown in their families. The main conclusion proved an awareness of the seriousness of the situation in which students of medical, especially dental faculties found themselves. Concerns were related to the form of further studies and the possibility of taking up employment after graduation. Polish students declared more intense concerns about e-learning and remote study than foreign-language students who were more familiar with this form of communication. A particularly valuable form of teaching for students may be increased numbers of online consultations, since even though they cannot replace practical classes, they may still be helpful in explaining doubts and simply “being there”. Encouraging young people to discover constructive benefits of the pandemic can also be one of a task-oriented strategies of help. The first case of SARS-CoV-2 infection was confirmed in China in December 2019. Subsequently, patients with syndromes of high fever, dry cough, chest pain, and general fatigue were identified in many Chinese cities and provinces [Several studies indicated potential mental health consequences of facing lockdown, pandemic restriction, and obligatory lifestyle changes ,4,5,6. IUndoubtedly, the situation was an exceptional struggle for many students, as there was a sudden disturbance to their studies due to the closure of educational institutions. It might be especially difficult and stressful for the international students in their final year as not only were their studies interrupted, but they were also trapped in a foreign country due to the closure of the Polish borders. Imperative for rapid adaptation to new online form of classes, waiting for decisions about the new construction of exams must have been especially difficult ,7,8. SevThe outbreak of the COVID-19 pandemic forced dental schools all over the world to change the methods of teaching and implement new techniques. As was discussed by Bennardo et al., this completely new situation will undoubtedly change the future approach to dental education, and it is very probable that the e-learning technique would be implemented . In anotTo understand major concerns, fears, and possible benefits of the current crisis it is very important to look for a qualitative method which will give a chance to get an insight into human emotions. These requirements are fulfilled by the biographical method, widely used in sociological and educational studies. Creative forms of the biographical method include diaries, essays, narratives, letters, and records. This method is appreciated in many sociological and psychological studies as a valuable scientific tool for detecting a wide range of emotions ,18,19,20Our qualitative study applied the biographical method in the form of essays written by final-year dental students.identify and compare the main difficulties students had to cope with;analyze potential benefits and losses felt by each individual due to the pandemic and lockdown.The aim of the study was to:The study involved 40 (20 foreigners and 20 Polish) students in their fifth year of Dentistry at the Faculty of Medical Sciences in Zabrze, Medical University of Silesia in Katowice. The particular situation that students suddenly had to face was probably most stressful for those who were attending their last year of studies. The fifth year of studies is the one during which most practical classes take place, and it is obvious that for future dentists, practice is of special concern. Taking that specific situation into account, the authors decided to concentrate on that particular group of students.Inclusion criteria: Fifth year dentistry students who gave their written consent to take part in the study, who had online classes and stayed in Poland.Exclusion criteria: Students who did not agree to take part in the study, of different years than fifth, in case of foreigners—those who left Poland before the borders were closed.Final criteria: Students who discussed in their essays 4 aspects chosen by the senior researcher .The consent for conducting the research was obtained from the Bioethical Committee.Students were asked to write essays covering topics attached to a given framework. This preliminary framework was created by the authors to facilitate understanding of the initial concept of the study. Time allocated for writing essays was after the first wave of the COVID-19 pandemic ended. The form of essays enabled the participants to describe their feelings, emotions, and experiences in their own way. The given topic of the essay was very general: “Being a student during COVID-19 pandemic”. It gave the participants a possibility to choose what the most important issue they had to deal with was. They were invited to express their opinion on the influence of the pandemic on each aspect of their life, not only the one strictly connected to academic life.According to Creswell (1998) and Morse’s (1994) recommendations, it was decided to include in the study a small sample. Cited authors pointed out that small size makes it possible to analyze the data in detail. Szymaniak claimed that unlike other methods, the biographical method did not require a large statistical sample to be valid. Even single unit’s personal dramas, actions and dilemmas may constitute important information helpful in creating more general sociological conclusions .This claim also corresponds with the results presented by Dobosz and Gierczyk in their review considering the application of biographical method in the social sciences. The authors selected 30 studies from the literature for further analysis. Sample sizes of selected articles varied from 1 to 89 and the wide range of topics included the impact of the disease to the mental health, transboundary education, geographical migration, and effectiveness of educational programs . RobertsThe Interpretative Phenomenological Analysis (IPA) was used to analyze the data. IPA enables the detailed examination of single human-being experiences. As described by Smith et al. this research tool has three underpinnings: philosophical approach, interpretative endeavor, and being idiographic in its commitment to analyze each case separately .After the analysis of essays, the authors redefined the criteria of the study, with the supervising senior researcher having the greatest experience in conducting qualitative research. For the analysis to be more trustworthy, a second author coded the manuscripts. Polish students have been marked as P while English Division as E. Each student was given a number (1–20).adaptation to e-learning;closure of the boards;social distancing;risk of infection.The supervisor did not have classes with the students participating in the study. On the basis of essay analysis, it was discovered that the most frequent and important aspects in the essays were:After analysis of obtained the essays, the researchers decided that chosen aspect would be classified as important if it occurred in at least two essays in each group.The English Division students were composed of 20 students in the age range of 24–28. They came from the United Kingdom, Iraq, Sweden, Saudi Arabia, and Taiwan. Polish students that took part in the research were ages 24–27.Discussion of chosen aspects by the students is presented in All respondents declared that the necessity to attend online courses was a challenge. They all agreed that this kind of education has both advantages and disadvantages. For Polish students, the most stressful were technical issues related to the e-learning platform and with the quality of internet connection but also the loss of practical classes, which they took as a cause of lack of self-assurance in future clinical work. Saving time by staying home and no need to travel to the university was the main advantage of the e-learning mentioned by both foreigners and Polish students. However, they were worried about the lack of practical classes and its impact on their future skills . Both grThe information about the closure of Polish borders surprised both groups of students. It would seem that it would be more difficult to be accepted by the foreigners. However, most of them highlighted that since they took a decision about studying abroad, they live in a kind of lockdown, so that decision taken by the Polish government did not change their lives very much. They were much more scared that it will influence their future career as most of them planned to have their postgraduate internship in their countries. The problem of border closure affected one of the Polish students whose father worked abroad . For mosThe analysis of the students’ essays proved that all respondents from both groups had to face similar problems because of social distancing. They missed meetings with their friends and had a lack of activity due to the closure of gyms. Even though it was a difficult time for most of us, future dentists pointed that pandemic gave them a chance for self-development, new hobbies, getting new skills and improvement of others. Polish students mentioned the possibility of strengthening ties with their families . It needThere were only three students  who mentioned the aspect of fear about their own health. In the essays of English Division students, the problem of the virus and the disease was mainly discussed . All resDuring the coronavirus pandemic, students were exposed to a significant number of stressful situations, such as disturbances in the course of academic classes, reduced social and family contacts, especially in the case of foreign-language students who have remained in the country where they study, away from their families, as in the case of the analyzed group ,26,27. LAn additional distress, specific for students, may be the need for a quick adaptation to a variety of e-learning platforms and systems, self-motivation for online courses or accessibility of the internet ,32,33. PFor both groups of students, the health of their relatives and friends, especially those staying abroad, was very important. They were concerned that in case of disease they could not help their families. It might be caused by the fact that both groups of students had personal contact with the disease in their families. They experienced the risk of COVID-19, death of infected friends or observed their relatives suffering from it. Ossofsky emphasized that fear for relatives being ill was very strong di-stressor impacting mental health . This clThe main differences in the perception of the situation by foreign-language students studying at the university was due to restrictions on mobility and possibility of coming back to their home countries. Similarly to Polish students, foreigners felt particular anxiety about their loved ones left behind in their home countries. A good point of reference for such results may be the situation described in the comparative analysis of the feelings of students from Russia and Belarus, in which different ways of managing the pandemic were taken . OverallThe pandemic has already shown significant psychological symptoms related to anxiety, stress, and depression in analyzed social groups . StudiesDuring the current pandemic, Orgiles et al. analyzed and compared coping strategies used by adolescents and children selected from three different countries, Portugal, Italy, and Spain. Results varied from emotionally oriented coping style, combined with an increased level of fear and behavioral repercussions to avoidance-oriented or task-oriented strategies proving stronger adaptation abilities. The chosen methodological tool in their research was an online survey completed by the parents of children and adolescents in the age range of 3–18 . Reilly The biographical method is used in psychological, sociological, and pedagogical sciences. Studies by Szymaniak or Kelterchsman highlighted the importance of “critical incidence” which usually also constitutes a “meaningful incidence”. Personal respondents’ descriptions of these incidents were useful in further analysis to get an insight into human concerns and emotions ,39. The According to this recommendation, authors of this study constructed the preliminary hypothesis of potential emotional and educational difficulties for Polish and foreign students during the coronavirus pandemic. The next step was comparing and searching for differences and similarities between particular cases. Huber and Hyde claimed that selection of the research method should be based not only on reliability or data but focusing on finding an answer to the research question . StudentThe authors consider it as the main limitation of the presented study, because the context of individual cases, heartbreaking descriptions of emotional struggles or complicated family situation were much more clearly visible when analyzing the whole essay.The analysis of students’ essays allowed for a cautious but adequate assessment of the moods prevailing among Polish and foreign-language students. The main conclusion proved an awareness of the seriousness of the situation in which students of medical, especially dental faculties found themselves. Concerns were related to the form of further studies and the possibility of taking up employment after graduation.Polish students declared more intense concerns about e-learning and remote study than foreign-language students who were more familiar with this form of communication. As in other studies, the authors pointed out to the anxiety prevailing in the health and wellbeing of the family members—both those living nearby and those left behind in distant family countries. The need for further development of supportive strategies is emphasized in the literature ,40,41.A teaching form particularly valuable for students may be an increased number of online consultations, since even though they cannot replace practical classes, they may still be helpful in explaining doubts and simply “being there”. Encouraging young people to discover constructive benefits of the pandemic can also be one of a task-oriented strategies of help.