Dental care utilization is known to have a strong socioeconomic gradient, with lower socioeconomic groups utilizing less of these services despite having poorer dental health. However, less is known about the utilization of dental services in the population concurrently in the public and private sectors in different socioeconomic groups. Additionally, evidence on how different sectors contribute to the overall socioeconomic gradient in dental care utilization is scarce. This study examines visits and absence of visits to public and private dentists in the years 2017–2018 by education, occupational class and income. Comprehensive register data was collected from the total population aged 25 and over in the city of Oulu, Finland . The data were analyzed with descriptive methods and with multinomial logistic regressions for the probability of visits and with negative binomial regressions for the number of visits, adjusted for sociodemographic covariates. The results showed a clear socioeconomic gradient for the probability of visits according to income and education: the higher the income and the higher the education, the more likely was a visit to a dentist–especially a private dentist–during the two-year period. Similar results were obtained for the number of visits. Higher socioeconomic status was less associated with public dentist visits. While those with the lowest income visited public dentists more frequently than private dentists, their overall visits fell below that of others. Adjusted estimates by occupation did not show a clear socioeconomic gradient. The socioeconomic inequality in dentist visits in a country having a universally covered public dental care scheme puts a challenge for decision makers in designing an equal dental health care system. Experimenting with lower co-payments is a possible option. Poor dental and oral health has been associated with chronic diseases –4 and loA social gradient has been reported for dental health: those having lower socioeconomic positions have poorer dental health –9. SocioIn many countries, dental care is offered by both public and private health care schemes. The Finnish dental health care provision is an example of a two-sector system where dental care provided through the public sector is universally covered for all residents and dental care provided in the private sector is free-market based . MunicipBecause of the universal coverage in the public sector, the demand for public sector services has been excessive, which has showed up as long waiting times. For example, in October 2018, the proportion of patients with non-urgent appointments to a public dentist who had to wait for longer than three weeks was 45% . The priDifferential utilization of public and private sector services among different socioeconomic groups can be a contributing factor to the polarization of the overall use of dental care. In Finland, even with the strong subsidization of health services, socioeconomic inequalities in utilization have remained pronounced in both regular health care –25 and dThe aim of this study was to examine how different socioeconomic factors are associated with the use of dental health care in the public and private sectors in Finland. Using comprehensive register data on the adult population of one Finnish city over a two-year period 2017–2018, we aimed to estimate the associations of education, occupational class, and income with using either public or private dental services or both, or not using dental health care at all. While education, occupational class and income are partly intertwined, they may also be related to the use of health care through different mechanisms. Education may correlate with the interest in maintaining good health and care demand, and relate to skills in navigating the health care system . OccupatData were collected from several registers for the population aged 25 and over of the city of Oulu, Finland, for the period 2017–2018. Oulu, which is situated in Northern Finland, is the fifth largest city of the country, with approximately 200,000 residents. Data from different registers were linked using pseudonymized individual identifiers .First, population data were derived from the registers of the Social Insurance Institution of Finland, including information on place of residence, age and sex. Second, register data on educational level and occupational class were retrieved from Statistics Finland. Third, annual-level information on taxable income was gathered from the Finnish Tax Administration. These data include both earned income and capital income. Fourth, register data on utilization of public dental health care services was obtained from the city of Oulu. This register contains information on the date of the visit, the type of service and contact, and the occupational class of the health care provider. Fifth, information on visits to private dental health care services was collected from the private health care reimbursement register, maintained by the Social Insurance Institution of Finland. This register includes all records of visits and procedures reimbursed by the NHI. We restricted the data to reimbursements of dentist visits.We defined the study population as those who were residents of the city of Oulu during the whole period 2017–2018. This sample included 183,536 persons. We limited the study population to adults aged over 25 and non-students according to the information on their occupational class. The final sample included 118,397 persons.In both public and private dental health care registers, a visit may contain several recorded procedures. As the primary interest was in visits, we distinguished individual visits by their date and patient identifier, that is, we set each patient to have a maximum of one visit per day. Additionally, concerning public dental care, we limited the data to contacts that were actual visits  using information on the contact type. We measured visits with a binary variable, i.e., whether an individual had no visits or at least one visit during the two-year period 2017–2018, and with the total number of visits during this time. We separately measured whether an individual had no dental health care visits, only public visits, only private visits, or visits to both private and public dental health care during the two-year period. We chose to use a two-year period for two reasons. First, it is typical for dentists to recommend booking a visit for regular checkups for every other year only. Second, in 2016, the NHI reimbursement was changed to cover visits in the private sector for only every other year.Age was categorized into 10-year age bands: 25–34, 35–44, 45–54, 55–64, 65–74, and 75 and over. Additionally, we included a covariate for the sex of the resident. We measured socioeconomic background by education, occupational class, and total income. For age, occupational class and education, information from the beginning of 2017 was used. Total income was measured as the sum of earned income and capital income from the two-year period 2017–2018.Based on highest obtained qualifications, the educational level was divided into groups of upper tertiary (over 15 years of education), lower tertiary (13–15 years), secondary (11–12 years), and up to basic level education. According to the classification of Statistics Finland , occupatWe started by crudely examining the proportions of persons who had public and/or private dentist visits or no visits by their socioeconomic background during the two-year observation period. To further investigate how socioeconomic differences are related to dental health care use and to adjust for the confounding association between sex, age and other socioeconomic characteristics, we estimated a multinomial logit model by maximum likelihood . The depFinally, to examine how socioeconomic differences are associated with the number of visits to dentists, we estimated negative binomial regression models by maximum likelihood estimation . We chosThis study was conducted using register-based data, and no human subjects were contacted in the data collection. The Finnish National Board on Research Integrity does not require an ethical review statement for studies conducted solely with register-based data . We follThe proportion of residents with a visit to a dentist and a visit to a private dentist was higher among those with higher educational attainment. The self-employed had the highest proportion of those who visited only private dentists (41%). Among manual workers and unemployed persons, the proportion of those with private dentist visits was lower than average. However, the unemployed had a higher proportion of those with public visits, which diminished the overall difference in the proportion of those who had no visits. The proportion of those who had no visits to dentists was lowest among the upper and lower non-manual workers.The higher the level of income, the higher was the proportion of persons having private visits. The proportion of only private dentist visitors was 46% in the highest income quintile, while in the lowest income quantile it was only 13%. Those with higher income had also a higher overall proportion of those with a visit to a dentist. In the lowest quintile, half of the residents did not have a dentist visit over the two-year period while in the highest quintile, 28% did not visit a dentist.When adjusted for other covariates, the likelihood of visiting only private dentists and higher occupational class was less notable. Compared to unadjusted results in In line with Similar to the results from the multinomial logit regression, self-employed residents had the highest expected number of private visits. While the unemployed and retired residents had lower expected number of private visits, their higher expected number of public visits compensated for this, and the overall expected number of visits was not below that of others. Interestingly, upper-level non-manual employees had a lower expected number of both private and public visits than manual workers. In contrast to the unadjusted estimates , and in Moving from the lowest income quintile to the highest income quintile increased the incidence rate of visiting private dentists by almost a factor of 3.5. Conversely, the expected number of visits to public dentists was not increased with income-level. The coincidental increase in the IRR of total visits and income seemed to result solely from private visits. All the estimated coefficients remained similar when estimated separately for younger and older residents .In this paper, we examined the utilization of public and private dental health care by different socioeconomic factors using comprehensive register data for an adult population residing in a Finnish city over the period 2017–2018. We studied separately the utilization of only public and only private dentists, as well as abstaining from visiting dentists entirely. First, we provided crude descriptive evidence of dental health care visits within different educational, occupational, and income classes. Second, we estimated the adjusted association of these socioeconomic factors and the likelihood and the expected number of visits to public and private dentists.The main finding is that the overall utilization of dental health care clearly differed between residents with higher and lower educational attainment and income. Especially high income was strongly associated with a higher likelihood of having at least one dental health care visit and with a higher total number of visits. The difference mainly stemmed from visits to private dentists, as higher socioeconomic status was less associated with the utilization of public dentists. For the lowest-income population, the number of visits to public dentists was not frequent enough to compensate for the lower number of private dentist visits, and the overall number of dentist visits fell below that of other groups. While those with a higher occupational class, i.e., upper or lower-level non-manual employees, had a higher than average probability of dentist visits in the unadjusted assessment, this association did not hold in models that simultaneously adjusted for the socioeconomic variables and other covariates.Previous studies have shown that there is socioeconomic inequality in the use of dental care, so that the more privileged population groups utilize more of these services –12 despiPrevious studies that have been able to measure occupational status have mainly measured it by employment status , 16, 27 The special contribution of our study to the literature was the ability to examine both public and private dentist visits by socioeconomic groups and to assess their joint contribution to the overall socioeconomic differences in utilization of dental care. The results showed that the observed socioeconomic inequality largely stems from a higher probability of using private dental care in the higher socioeconomic groups. Also, the overall utilization followed a similar pattern, albeit the distribution of the visits in the public sector partly mitigates the socioeconomic gradient. In terms of number of visits, the highest income group utilized more private sector services and less public sector services than the lower income groups. However, the number of public dentist visits was not large enough to close the gap in the difference in the overall number of visits. While previous studies have examined associations of socioeconomic characteristics with either choosing a public or private provider using survey data , 27–30, The Nordic health care system is based on a strong public sector that provides care for all residents with little or no charges. The public scheme aims to provide care that is affordable and accessible also to the disadvantaged population. The latest major reform in Finnish dental health care took place in 2001–2002, with the aim of improving provision and accessibility of dental care to the whole population. After the reform, all adults became entitled to subsidized public dental care and the NHI partial coverage was extended to private dental care for the total Finnish population . Before How monetary-based subsidization schemes increase the utilization of dental services and dental health of the most disadvantaged population is still unclear. Some results from the literature suggest that extending dental insurance coverage in the general population is associated with increased use of these services –44. HoweWe gathered population-wide register data from the city of Oulu and merged detailed individual-level demographic and socioeconomic characteristics as well as data on both public and private dental care visits from administrative registers. Register-based data are deemed to be highly reliable, have very little missing information and no loss to follow-up. In comparison to survey-based data, we were able to observe real utilization choices of different sectors and abstaining from dentist visits. Survey data may suffer from response bias that inflates the answers. For example, individuals may be ashamed of not visiting dentists and feel pressured to give socially desirable answers in surveys. Additionally, individuals may not remember correctly their past visits. It is common that the response rates in questionnaires are low and that those who answer the questionnaires can be systematically different from those who do not answer. These factors bias the results and the real magnitude of dental service utilization may remain unclear. The aforementioned challenges are largely tackled with register data.A drawback that stems from the Finnish NHI scheme is the biannual coverage of visits. As the data contained only visits that were covered by the NHI scheme, some of the visits to private dentists may have been left unobserved. However, our use of a two-year follow-up period mitigates the problem. Nevertheless, the estimates regarding the number of private dentist visits should be considered as lower bound. Another drawback is that we did not observe dental health. Without observed dental health, inferences on whether higher utilization of dental services originates from poorer dental health and whether absence of dental service use is explained by good dental health cannot be directly made based on our data. However, previous literature strongly suggests that the disadvantaged population who consume the least dental care also has poorer dental health –9. AssumThe data were drawn from one geographical area, the city of Oulu, which is the fifth largest city in Finland. Even with the comprehensiveness of the data, it is useful to recognize the potential problems in the external validity of the results to the Finnish population. Naturally, the thickness and the size of the private dental health care market affect the supply side and the possibilities to choose to visit a private dentist. Likewise, the excess demand for public dentists and long waiting times can limit the choice to visit a public dentist. These two factors are quite similar in the largest cities in Finland, and thus, the results are likely to be very generalizable to other large cities. Instead, rural areas typically have low number of private dentists, which may hamper the generalizability of our results to these areas. In total, however, as 71% of the Finnish population lived in urban settlements in 2018 , the extBecause of the lack of an experimental study design, our estimated coefficients do not have a causal interpretation. Unobserved confounders may simultaneously affect an individual’s educational attainment, occupation, income, and utilization of dental services. For example, more health-conscious individuals who utilize dental services regularly may also aim for higher educational attainment and higher paid jobs. Thus, the estimated associations may be partly explained by uncontrolled confounders. Also, individuals with higher income may more frequently purchase voluntary private insurance, which may be associated with more frequent use of private services. However, in Finland, private insurance does not typically cover dental care, and therefore this factor is unlikely to explain our results.Higher income and education was associated with higher a probability and number of visits, especially to private dentists. Visits to the public sector mitigated some of the gap in the visits between high-income and lower-income groups. Those in the lowest income and education group had the highest absenteeism rate.The Finnish health care system is in the midst of a major structural reform where the goal is to increase the efficiency of health care provision and to reduce inequalities in access and use of services. The plan is to provide more centralized health care by transferring the responsibility from municipalities to larger geographical areas. According to the plan, also the financing of health services is shifted to these larger areas. Putting more resources to experimenting with lower co-payments and automatic recall systems in the low-income population are potential directions in reducing inequality. In order for policy makers to comprehend the present state of the use of health services and to design an equal health care system, it is crucial to have up-to-date information on the use of different sectors. Evaluation of various reforms, experiments, and system-specific differences using registers should be regular.S1 FigStudy population: non-student (aged over 25) residents of Oulu in 2017–2018 .(TIF)Click here for additional data file.S1 Table(DOCX)Click here for additional data file.S2 Table(DOCX)Click here for additional data file.S3 Table(DOCX)Click here for additional data file.S4 Table(DOCX)Click here for additional data file.


Generic drugs were instituted in 1984 in the United States. Since that time, many studies have been conducted in several countries into consumer attitude and behavior when purchasing generic drugs. Understanding the factors that can influence attitude and purchasing intention in this segment has been a challenge. Thus, this paper aims to present a mapping of the literature on the attitude toward and intention to purchase generic drugs and capture insights that can help define and improve promotional strategies for the use of these products. To identify articles related to the theme, we selected the Web of Science, Science Direct, Scopus, Lilacs, Pubmed Central, Springer, and Embase databases time limited to June 2020, using the keywords “generic drug”, “purchase intention”, and “attitude”. The results indicate that this topic is relatively new, with publications in the leading journals in the area demonstrating its importance. Analysis revealed five strategic insights and showed that the research theme could be grouped into three clusters: (i) consumer attitude and behavior, (ii) perspective of patients and health professionals, and (iii) assessment of the risks associated with generic medications to determine which factors can influence purchase intention, providing decision makers with a broader view with regard to directing public policy strategies in healthcare. The pharmaceutical industry is one of the players that most invests in research and innovation . In the According to the Food and Drug Administration (FDA), a generic drug is identical or bioequivalent to the brand name drug (reference listed drug) in (i) dosage, (ii) safety, (iii) concentration, (iv) route of administration, (v) quality, (vi) performance characteristics, and (vii) intention to use . GenericThe Global Generic Drugs Market (2020) highlights that generic drugs saw a worldwide compound annual growth rate (CAGR) of 8.7% between 2016 and 2020, in a market dominated by many companies such as Mylan, Teva, Novartis, and Sun Pharmaceutical, which together account for 35% of the market share. For companies, understanding consumers’ attitude and intention to purchase pharmaceutical products ,14 is fuAttitude towards purchasing generic drugs can be influenced by the perceived quality, product attributes, past experience, and doctors’ recommendations . ProductTo define purchase intention, this study was based on the definition proposed by ,19,20. TStudies that evaluate perceived risk show that this is a multidimensional construct involving psychological risk, time risk, physical risk, and social risk . PhysiciAttitude and purchase intention for generic drugs have been highlighted in several studies ,27,28,29(i)More affordable prices for generic drugs .(ii)A legal obligation to prescribe low-cost generic drugs .(iii)Creation of computerized systems that assist in the prescription of generic drugs .(iv)Policies that facilitate the replacement of reference drugs with generic .Strategies to accelerate the promotion of generic drugs vary according to public health policies in each country . Some stHowever, the increase in the market share of generic drugs remains slow . In thisGeneric drugs have increasingly attracted the interest of many stakeholders as a means for patients to receive the same treatment at a lower cost . At the Despite the importance of this theme and the growing number of publications on generic drugs, some controversy remains . UnderstThis study used the protocol proposed by  and the The resulting database was analyzed by VOSviewer software (version 1.6.15)  and Biblioshiny . The analysis of the journals was tabulated and evaluated using the Scimago Journal Rank (SJR), while the spectroscopy of the year of publication was performed by analyzing how frequently references were cited in the publications of the research corpus from the year of publication and demonstrated through peaks .https://mapchart.net/world.html). To identify the researched field’s intellectual structure, co-citation analysis of the references was used with a minimum number of citations for the references. This bibliometric indicator was assessed through the research corpus and demonstrated through networks [To carry out a literature mapping, there is a need to understand which countries make up the corpus of recent research . For thinetworks .The thematic evolution was based on the word network and clustering through the methodology inspired by , whereasn), data analysis (type), focus of the study, main findings, and references.Given the topic’s importance based on the growing number of publications on generic drugs, some questions remain controversial. Therefore, it was necessary to evaluate the literature on attitude and intention to purchase in order to capture insights that can help define strategies to promote the use of generic drugs. As a first step, we analyzed the visibility and prestige of journals based on Scimago quartiles. Cluster 2 is formed by four studies related to the theme of patients and health professionals’ view of generic drugs, with emphasis on the work of . These aCluster 3 is composed of three references on the theme of risks associated with generic drugs, evidenced in the study by  that evaThe implementation of specific regulations to encourage the production and use of generic drugs around the world occurred at different times and in different ways . LikewisResearch on intention to purchase generic drugs in India has the strongest relationship with the words “health” and “medicines”. As previously described, India is an important producer of generic medicines, but the Indian public have difficulty in accessing medicines, principally for chronic diseases . The jouIn summary, this work evaluated the evolution of consumer attitude and intention to purchase generic drugs over two different time periods due to the fact that there has been an increase in the number of publications since 2013. As shown in In this study, we analyzed a literature gap by conducting a systematic mapping of the attitude and intention to purchase generic drugs. We realized that the factors associated with attitude and purchase intention can bring insights in directing strategies to promote the use of such products. There is a need to generate positive perception for doctors, health professionals, and the patient. As far as we know, this is the first study involving a systematic mapping of the literature on the subject.We identified studies that highlight the challenges involved in implementing policies for the industrialization and commercialization of generic drugs, even though such policies can generate savings for the public health services ,81. The The first insight is related to the concentration of the studies. The main journals that published on the topic are classified in the Q1 quartile of Scimago, and there is no concentration of publications, which demonstrates that the evaluation of purchasing behavior based on attitude and intention to buy pharmaceutical products is a discipline which covers several areas. The second insight was related to the frequency of citations of articles since 1980. Given the relevance of the topic, it reflects the importance of prior knowledge for the dissemination of research. It demonstrates that most of the research in this respect is recent, primarily between 2009 and 2013, and highlights an opportunity for additional research. These insights can guide strategies for future research into consumer behavior in the generic drug segment, focusing on the promotion and use of these products.The main finding of this study is related to the third insight, highlighted in the textual corpus of the research that identified the grouping of three clusters: (i) consumer attitude and behavior, (ii) patients’ and health professionals’ perspective, and (iii) assessment of risks associated with generic drugs, corroborating the study by , which eThe fourth insight is related to the implementation of specific regulations to encourage the production and use of generic drugs. The review showed that the implementation of such regulations occurred around the globe at different times and in different ways, in accordance with studies by . LikewisTo illustrate the importance of the generic drug segment, in the USA, 90% of prescriptions are for generics. This factor is intended to boost market competition and the availability of generic drugs . In turnThe fifth insight shed light on research on generic drug purchase intent in India see . ResearcLikewise, the risks cluster can be divided into (i) medicines, (ii) generic substitution, and (iii) patients’ attitude, which may suggest that patients are suspicious about the effectiveness of generic drugs. This insight suggests the need for improvements in the communication strategy between doctors, health professionals, and the final consumer. This finding corroborates the studies by , principThe purpose of this article was to conduct a systematic mapping of the literature on attitude and intention to purchase generic drugs, and to capture insights that could help guide strategies to promote the use of such products. The objective was to pinpoint which factors influence consumers’ buying decisions based on evidence from the behavioral areas “purchase intention”, “attitude”, and “generic drugs”, and capture insights that can be used to target strategies to promote the use of generic drugs.Our results achieved the proposed objective by answering the key research question. We discovered that consumer attitude and intention to purchase generic drugs are related to three main factors, formed by the three clusters of (i) consumer attitude and behavior, (ii) patients’ and health professionals’ views, and (iii) risks associated with generic drugs. We also identified five insights from the current research available on this theme, which can also provide companies marketing generic drugs with strategic direction. The main finding of this study sheds light on how the gap in the relationship between the consumer patient, doctors, public policy makers, and the pharmaceutical industry can be narrowed. On the other hand, there is a need to generate more positive perceptions of generic drugs to increase purchase intention and lower the barriers between different health systems in order to implement policies and promote industrialization, commercialization, and access to generic drugs.The risks associated with generic drugs in this review were also evidenced in the study by  regardinConsumer behavior based on attitudes and intention to buy in the generic drug market is a broad and complex topic of which this article did not intend to cover every angle and possibility. Therefore, there is scope for future studies related to the intention to purchase generic drugs, as this is a growing and important market for the pharmaceutical industries, public health policy makers, and consumers. Future research can be conducted with the aim of testing the theory through hypotheses in a meta-analytic study, since a systematic review was conducted without the presence of meta-analyses.In order to expand the use of generic medicines, the pharmaceutical industry, public health policy makers, doctors, and other health professionals need a better understanding of consumer attitudes and behavior regarding generic drugs. Understanding the key drivers behind consumers’ purchasing intentions will help to guide policies and promotional strategies to lower barriers and encourage a greater uptake of generic drugs.The main limitation of this study lies in the fact that the available literature is relatively scarce and distributed over few countries. On the one hand, the study has the advantage that it was based on the literature from several continents. On the other hand, there are differences in consumer attitudes and behavior and public health polices from one country and region to the next.


Using data from the 2019 CIRP Freshman Survey and the Your First College Year (YFCY) from the Higher Education Research Institute at UCLA, this study explores the differences between the characteristics and behaviors of the first-year students with autism spectrum disorders (17) and those of students with learning disabilities (102). The findings indicate that the characteristics of these two groups of first-year college students were similar except for gender, ethnicity, first college generation, and parents’ income. Compared with first-year college students with LD, students with ASD were less likely to engage in risk-taking behaviors, use health services and the writing center. The prevalence of autism spectrum disorders (ASDs) has steadily increased over the past few decades . One in The low college participation and completion rates result in high economic and personal costs for youth with ASDs, their families, and society. Based on national high-school graduation estimates , the preResearch on college persistence and retention show that the success of students without disabilities is affected by a combination of individual and family characteristics coupled with higher education institution characteristics . Three cFor students with disabilities, methods for increasing college retention and success have focused on providing access to both physical and other disability-related resources . However, access to disability-related resources is conditioned by student’s self-disclosure of their disability. Students with disabilities transitioning to higher education encounter a new legal framework under which the responsibility for accessing disability-related supports shifts from the school to the student. In high school, special education is governed by the Individuals with Disabilities Education Act of 2004 ; schoolsThere are various reasons why students do not disclose their disabilities, including difficulties in understanding and navigating the process or a conscious choice made by the student . AdditioSome common characteristics of students with ASD present additional challenges in their transition to college. For example, social impairments, communication difficulties, and repetitive behaviors  may leadBeyond the educational challenges of entry requirements and the shift to a new legal framework, students need to develop a level of independence during the first year of college. They need to learn the necessary skills for managing accommodations, finances, catering, and meeting increased demands . StudentPeer mentoring is another effective strategy to support students with ASD in higher education. Siew et al.  implemenStudent success and retention continue to be of concern for higher education institutions. Broader participation, combined with lower completion rates for nontraditional students, highlights the need for new ways of understanding the student experience to ground policy and practice. The first year of college plays an essential role in students’ adjustment to college life, but it is also a great indicator of student retention and success ,50. The Therefore, it is essential to explore how students with ASD behave during the first year of their higher education program. The CIRP Freshman Survey and the Your First College Year (YFCY) provide a unique opportunity to explore the characteristics of students with ASD and how they behave during the critical first year in college. Moreover, data from these two surveys allow us to explore the differences between college students with ASD and those with Learning Disabilities. Preliminary research on college students with ASD pinpoints some specific challenges, and thus, specific needs to help them be successful in college ,41,42,44What are the individual and familial characteristics of college students with autism spectrum disorders, and how are these different from those of other college students with learning disabilities?What type of supports are accessed by college students with autism spectrum disorders, and how are these different from those accessed by other college students with learning disabilities?Data for this study were retrieved from the 2019 CIRP Freshman Survey and the Your First College Year (YFCY). Both surveys collect data on students with disabilities in odd years. The CIRP Freshman Survey is designed for administration to incoming first-year students before they start college. In 2019, the survey included 95,505 first-time, full-time (FTFT) first-year students entering 148 baccalaureate institutions across the United States who responded to this survey. The survey collects extensive information that allows higher education institutions to know their students before they experience college. Critical sections of this survey examine the following: established behaviors in high school, academic preparedness, admissions decisions, expectations of college, interactions with peers and faculty, student values and goals, student demographic characteristics, and concerns about financing college. Many of the CIRP Freshman Survey items are pretest questions included in the CIRP follow-up surveys titled Your First College Year (YFCY), which provides a longitudinal examination of cognitive and affective growth during college. The CIRP Freshman Survey is the only survey that includes a question asking participants to disclose their disability; because the same participants receive the follow-up survey YECY at the end of the first year, these two surveys provided longitudinal data on how students with ASD behave during their first year in college.https://heri.ucla.edu/instruments/ (accessed on 8 November 2021).The YFCY was developed through a collaboration between the Higher Education Research Institute at UCLA and the Policy Center on the First Year of College at Brevard College to identify features of the first year that promote students’ learning, involvement, satisfaction, retention, and success. Any colleges wishing to improve their first-year programs and retention strategies can use these data. Specifically, the survey collects information on several academic experiences of first-year students, including classroom activities, academic engagement and disengagement, and interaction with faculty. Additionally, several questions on YFCY assess students’ experiences with various campus programs such as orientation, honors courses, first-year seminars, remedial coursework, service-learning opportunities, academic advising, learning communities, and interaction with campus advisors, counselors, and other support personnel. YFCY is designed to help institutions assess how their students have changed since entering college as a follow-up instrument. When combined with CIRP Freshman Survey data, the YFCY serves as a longitudinal measure of students’ cognitive and affective growth during the first year. More information about YFCY and CIRP Freshman Survey can be found at this address CIRP Freshman Survey We used Cross Tabulation tests to examine whether there was a relationship between two categorical variables. One of the benefits of using Cross Tabulation was that it demonstrated a breakdown of the data by using two categorical variables, and chi-squared tests showed whether the relationship of the two categorical variables were statistically significant or not. In this study, we intended to examine the relationship between disability status and the following variables: (a) first-year interactions . (b) Self-rating , self-confidence , and understanding of others). (c) act in college  on campus and working (for pay) off campus). (d) Services .The Fisher exact test was used to assess the association between disability status and 1st-year college behaviors and accessed support services. The Fisher exact test is an appropriate test for small samples because it is calculated using the exact null randomization distribution, which, for small samples, can substantially differ from the distributions assumed by other parametric tests . BecauseParticipant demographic characteristics are shown in p-value (0.04) of the Fisher exact tests indicates that students with ASD are significantly different from those with LD, showing that students with LD are more likely to exhibit risk-taking behaviors during their first year of college than their peers with ASD.As part of the 2019 YFCY surrey, students were asked to rate themselves on several traits in comparison with the average person their age. Respondents were asked to select only one of the following options: highest 10%, above average, average, below average, and lowest 10%. Self-confidence  was the only self-rating category for which students with ASD reported a higher level than students with LD See . Studentp-value of the Fisher exact test was not significant.A large majority of first-year students with ASD and LD reported not working for pay on or off campus; only a small percentage of students with LD reported working for pay on campus. p-value of 0.01) and the writing center . These values indicate that students with LD are more likely to use both health services and the writing center during the first year of college.Students with ASD and those with LD can use various support services available at their higher education institution during their first year . A vast This study had two aims: to identify the characteristics of first-year college students with autism spectrum disorders and the type of support services they are using; and an additional aim was to examine the differences in terms of characteristics and behaviors between them and their peers with learning disabilities. The unique characteristics of students with disabilities add to the challenges of their first year in college compared to students with other types of disabilities or those without disabilities. As the number of college students with disabilities increases, their graduation rates continue to be low compared to peers without disabilities . Thus, iOverall, the findings of this study indicate that the characteristics of students with ASD and those with LD were similar with few exceptions . These findings support previous findings that showed that the characteristics of college students with ASD were similar to those with other disabilities . On the The differences in the demographic characteristics between the two groups included in this study are worthy of further exploration. For example, 65% of students with ASD in this sample were males, while the dominant gender among students with LD was female. Moreover, 85% of students with LD were White, with a very small percentage of students representing other races/ethnicities. Students with ASD, on the other hand, included more students from different races/ethnicities, although the majority were still White. Previous research indicated that demographic characteristics should be examined to find disparities between students with ASD and students with other disabilities. For example, Anderson et al.  demonstrSimilarly, Anderson et al.  conducteGiven the characteristics of ASD, it is not surprising that students included in this study reported low levels of risk-taking or social aspects of self-confidence. These findings might support previous studies that found postsecondary students with ASD are prone to loneliness, anxiety, and depression ,57. HoweSocial interactions were found to play an important role in college retention and success. This study found that students with ASD largely interacted with friends and family but less with faculty. Barnhill  also idePrevious studies have argued that the support offered by higher education disability offices might not address the needs of students with ASD and call for institutions to identify and provide supports beyond those offered by the office of students with disabilities . Both stThere are several significant limitations of the present study that should be acknowledged. First, the low number of students with ASD included in this study means that its power is relatively low regarding the detection of differences, and some that are not significant might still be meaningful. To address this limitation, we used the Fisher exact test to examine the significance of the differences between the two groups in their use of support services. Despite a low number of students with ASD included in this study, this exploratory study raises awareness about the importance of better understanding who students with ASD are as soon as they start their first year in college. Another limitation is that we performed multiple hypothesis tests to identify differences between students with ASD and those with LD, and we did not correct for multiple tests. If a correction for multiple tests had been used, some of the significant differences seen would not have been significant. The reason for not using corrections was that power was already low, and we did not want to miss meaningful differences; however, the significant differences are somewhat less likely to be replicated in future research. Lastly, the data used in this study are self-reported; thus, the responses to survey items could not be independently verified. Despite the limitations mentioned above, the findings of this study confirm the need to continue exploring the characteristics of college students with ASD and those from different disability categories. Notably, further research should explore how students with ASD behave in their first year of college and how better guidance should be provided to higher education institutions and their disability support personnel.As more students with disabilities enroll in postsecondary education programs, higher education institutions must recognize and address the needs of their diverse populations, including those with ASD. For example, providing training to the faculty about universal design for learning to address the broad needs of all students. Letters from the Office of Disability Services to the faculty may provide more descriptions of the student needs and a list of useful resources. The college preparation of students with ASD must start during secondary education as part of their transition services. However, students with ASD and their parents report little student engagement in transition planning before college . It is pThis study provided preliminary results that depicted the unique challenges faced by students with ASD, such as low levels of risk-taking or social aspects of self-confidence; however, the results also showed that students with ASD report higher rates of the intellectual aspects of self-confidence. The findings revealed that when providing support and services for students with disabilities, it is essential to examine students’ strengths and support they really need, due to the varied characteristics of this population. Future research may further explore characteristics of different disability categories and establish the resources that are needed for students with disabilities.


We aimed to determine the characteristics of the deceased victims of deaths caused by exposure to humidifier disinfectants, and present the distribution of the victims’ data submitted for damage application, demographic characteristics, imaging findings, characteristics of humidifier disinfectant exposure, and distribution of the causes of death.An integrated database of victims was established using the medical records data of 1,413 victims submitted during the application for death damage caused by exposure to humidifier disinfectants, and the demographic characteristics, medical records, imaging findings, exposure characteristics, and cause of death were examined.The average numbers of data submissions of each applicant for death damage were 3.0 medical use records. A total of 608 (43.0%) victims had more than one finding of acute, subacute, or chronic interstitial lung diseases. The average daily and cumulative use times of the victims were 14.40 and 24,645.81 hours, respectively, indicating greater exposure in this group than in the survivors. The humidifier disinfectants’ components comprised polyhexamethylene guanidine (72.8%), chloromethylisothiazolinone/methylisothiazolinone (10.5%), other components (15.0%), and oligo-[2-(2-ethoxy)-ethoxyethyl] guanidine chloride (1.5%). The components’ distribution was 67.8% for single-component use, which was higher than that in the survivors (59.8%). The distribution of the causes of death were: respiratory diseases (54.4%), neoplasms (16.8%), and circulatory diseases (6.3%). Other interstitial lung diseases (65.5%) were the most common cause of death among those who died due to respiratory diseases.Careful discussions of appropriate remedies should be conducted based on a comprehensive understanding of the characteristics of the deceased victims, considering their specificities and limitations. The humidifier disinfectant accident was an unprecedented major environmental disaster that occurred in Korea due to the use of household goods . HumidifVarious health-related problems caused by the exposure to humidifier disinfectants have been reported, including physical diseases, psychiatric problems, and pulmonary diseases, and damage cases are still being reported -6. AccorIf the objective data for damage determination, such as medical records data and radiological findings, are submitted, the damage recognition can be discussed in detail; however, if the relevant data are not submitted, a passive approach is inevitable due to the absence of objective data, and several factors may limit the recognition of damage. In particular, the deceased victims are the most prone to these limitations, with many difficulties remedying the damage because they have already died and cannot submit data to prove their health damage. Considering these specificities and limitations of victims who died of health damage due to exposure to humidifier disinfectants, the damage remedy for them should be comprehensively discussed; therefore, a basic understanding of the characteristics of victims who died due to exposure to humidifier disinfectants should be considered.Thus, this study aimed to report the characteristics of individuals who had applied for death damage caused by the exposure to humidifier disinfectants for the first time in Korea, to present the distribution of the data submitted by these applicants, their demographic characteristics, imaging findings, characteristics of exposure to humidifier disinfectants, and distribution characteristics of the causes of death.The medical records data of 1,413 applicants for death damage  were provided by the National Institute of Environmental Research (NIER). A database was established by reviewing all submitted medical records of each individual and by classifying them using the deceased victims’ personal identification codes, medical use information, test results , and information on exposure to humidifier disinfectants. Two health information managers constructed the database and performed data cleansing under the supervision of a pulmonologist under cross-coding according to the variable frame, and the data were finally completed and reviewed by a statistical expert after the revision. For the X-ray or CT findings, data were coded after a comprehensive review by several pulmonologists.Health damage caused by exposure to humidifier disinfectant is defined as “any damage to life or health caused by exposure to a humidifier disinfectant containing toxic chemical substances” under the Enforcement Decree of the Special Act on Remedy for Damage Caused by Humidifier Disinfectants, and those who wish to be recognized as having experienced health damage caused by exposure to humidifier disinfectants have to apply to the Comprehensive Support Center for Victims of Humidifier Disinfectants of the Korea Environmental Industry and Technology Institute (KEITI). The procedures in recognizing health damage caused by exposure to humidifier disinfectants is as follows: (1) When a victim applies. (2-1) Environmental exposure investigation  and (2-2) medical investigation  are conducted. (3) Based on these findings, the special committee for examination performs a comprehensive determination of the health damage. (4) The committee on remedying the damage caused by exposure to humidifier disinfectants deliberates and resolves the final examination and determination results. Lastly, (5) the committee informs the applicant of the final outcome.After the revision of the Special Act on September 25, 2020, the scope of the recognition was expanded to comprehensively recognize damage and determine the grades of injury by reviewing the overall health condition without specifying the disease; the distinction between remedial benefits and remedy accounts was abolished, and the criteria for both categories were integrated into the remedial benefits. The information on the health damage examination and determination of humidifier disinfectants used in this study were provided by the KEITI, with data on the damage determination of 1,413 people who had submitted damage applications in December 31, 2019. Recognition information on health damage due to pulmonary disease, fetal damage, asthma, adult interstitial lung disease (ILD), pediatric ILD, bronchiectasis, and pneumonia damage are included. Considering the current status of support for damage caused by exposure to humidifier disinfectants, which is not limited to specific diseases but broadens the scope of damage recognition in this study, the victims’ health damage was recognized and diagnosed as due to any of the following diseases: stage 1 or stage 2 of pulmonary disease during remedial benefit determination, fetal damage, asthma, or stage 3 pulmonary disease during remedial account determination, adult/child ILD, bronchiectasis, pneumonia, or asthma. If health damage caused by at least one of the above mentioned diseases was recognized, the individual was classified as a defined victim. If it was not recognized in the damage recognition examination and determination, the individual was classified as a unrecognized victim.The environmental exposure investigation involved data analysis of deaths using the data of applicants for damage caused by exposure to humidifier disinfectants, obtained from the KEITI. The investigation was performed as follows. An experienced investigator confirmed the applicant’s personal information by phone and schedules a visit. Next, a face-to-face investigation was conducted when visiting the place where the humidifier disinfectant was used (residence or workplace). The exposure investigation table prepared while conducting the investigation was reconfirmed and constructed by coding the contents on the table as environmental exposure investigation data. The investigation contents include the use of and status of exposure to humidifier disinfectants, including the time of disinfectant use, the period from the start to the end of the exposure to the disinfectant, total months of use, the distance between the humidifier and the respiratory organ, the direction of humidifier spraying, the use of humidifier disinfectants when sleeping, the location of use, and the amount of onetime use (unit: cc). Details in this regard can be found in the previous study .This study used the data of a customized sample cohort from 2002 to 2018 obtained from the National Health Insurance Service (NHIS). Using identifiable information of the deceased victim received from the NIER, data related to the victims’ deaths were extracted from the Microdata Integrated Service of Statistics Korea and linked to customized sample cohort data to determine the cause of death.Since the NHIS’s customized sample cohort data were only accessible until December 31, 2018, the causes of death of 1,341 people were identified, excluding those of 72 individuals who had died since January 1, 2019.This study analyzed the distribution of data submitted by the applicants for death damage, their demographic characteristics, imaging findings, and characteristics of exposure to humidifier disinfectants by linking the medical record data of applicants for death damage caused by exposure to humidifier disinfectant, investigation and determination data of health damage caused by exposure to humidifier disinfectant, and environmental exposure data. Additionally, the distribution characteristics of the causes of death among applicants were analyzed using the NHIS customized sample cohort. The specific analyses performed were as follows: First, the distribution of the data submitted by the applicants for death damage was identified by analyzing the database constructed using the medical record data of death damage applicants. Second, to analyze the difference in characteristics depending on whether or not health damage caused by the exposure to humidifier disinfectant is recognized, the general characteristics and imaging findings of the applicants for death damage were analyzed by recognition of health damage. Third, the distribution of the daily humidifier disinfectant use times, cumulative exposure time, and components used in the humidifier disinfectant were evaluated by analyzing the environmental exposure data of the applicants for death damage. Lastly, the distribution of the causes of death of the damage applicants was evaluated by analyzing the NHIS customized cohort data, and the distribution was analyzed by classifying the total causes of death and deaths caused by respiratory system diseases . All data processing and statistical analyses were performed using SAS version 9.4 .This study was approved by the Institutional Review Board of Ajou University Hospital (IRB No. AJIRB-20-047).The general characteristics of 1,413 applicants for death damage are presented in The average daily humidifier disinfectant use times were 14.40 hours for deceased victims and 12.93 hours for survivors . The totThe distribution of the causes of death for 1,341 deceased victims is presented in This study reported the characteristics of deceased victims caused by exposure to humidifier disinfectants using their medical records, investigation and determination data of health damage caused by humidifier disinfectants, environmental exposure data, and NHIS data. Considering the limitations and specificities of the remedy for death damage caused by humidifier disinfectants, the characteristics of deceased victims were comprehensively presented so that the remedy for damage could be comprehensively discussed.This study, which included 1,413 applicants for death damage caused by exposure to humidifier disinfectants, observed similar demographic characteristics with those of 4,482 victims who survived from exposure to humidifier disinfectants included in a previous study . Males wThe characteristics of exposure to humidifier disinfectants of the deceased victim were compared with those of the survivors. To our knowledge, this was the first study to report the exposure characteristics of deceased victims caused by humidifier disinfectants in Korea, and it was impossible to compare them with those of previous studies. Hence, the exposure investigation data of applicants for damage caused by exposure to humidifier disinfectants owned by the research team were used and compared with those of the survivors. The average daily use time (mean± standard deviation) was 14.40±6.74 hours for the deceased victims, which was longer than that of the surviving victims (12.93± 5.93 hours). Similarly, the cumulative exposure time to humidifier disinfectants was 24,645.81± 37,960.78 hours for deceased victims, which was longer than that for the surviving victims . Although the absolute exposure amount cannot be compared, it can be inferred from the study results that the deceased victims were relatively more exposed to humidifier disinfectants than the survivors.The characteristics of the causes of death of the victims of humidifier disinfectant exposure were compared with the statistical distribution of the causes of death in the Korean population in 2018 . RegardiApplications for damage due to humidifier disinfectants have continued from the first application in November 2011 to the fifth application in current. With the revision of the Special Act on Remedy for Damage Caused by Humidifier Disinfectants in September 2020, there have been specific changes to the wide recognition of damage by reviewing the overall health status. However, 40% of the deceased victims among the applicants for damage caused by humidifier disinfectants are still not recognized, leading to blocking of the remedy for damage. In the case of the deceased victims, they have already died and can no longer submit data to prove their health damage. In particular, infants and children are likely to have insufficient evidence such as imaging data and clinical progress notes due to sudden death. Moreover, it is complicated for non-professionals to recognize infrequent and unique health damage, such as specific health damage caused by humidifier disinfectants, to prepare related data for damage recognition and prove the health damage. Hence, a comprehensive discussion is warranted to ensure appropriate remedy for the damage by considering the characteristics of the applicants for death damage along with the data submitted by them. Based on the results of this study, the applicant characteristics that can be considered in the process of comprehensive discussion are as follows. First, it is necessary to attain a comprehensive determination by linking the medical record data with the NHIS data in consideration of the fact that the number of submitted medical records is relatively low, with an average of 3.0 cases per individual, and that it is impossible to submit data in the future. Second, since applications for many infants and children were submitted for death damage caused by exposure to humidifier disinfectants, who may have unique characteristics compared with the general population, discussion with various expert groups, including those from related fields, may be necessary to clarify the characteristics of this patient population.In summary, many applicants for death damage caused by humidifier disinfectants have not been recognized, and the complexity and various issues of damage determination are piling up. Hence, further efforts should be made to appropriately remedy the applicants for damage and continue the conduct of related studies and discussions ,12. In pThis study is significant because it is the first study to report the characteristics of deceased victims of deaths caused by exposure to humidifier disinfectants in Korea. However, since it does not affect the determination results of the victims, this study focused on the causes of death and exposure characteristics of the deceased victims, excluding the part of the determination results as much as possible. The limitations of this study are as follows. First, the causes of death in the statistics database provided by Statistics Korea could not identify the precise cause of death because the ICD code used was not subdivided. Second, regarding the past medical history, since the analysis was based on the data submitted by the applicant when receiving damage, data on patient’s disease history that were not submitted could not be considered. Lastly, if the characteristics of deaths from damage caused by humidifier disinfectants were compared with those of the general population group or the group that did not use humidifier disinfectants, more meaningful conclusions, such as differences in characteristics between the humidifier disinfectant victim group and the general group, could be drawn; but a comparison could not be made due to the lack of relevant studies.


Cancer is one of the most challenging health problems in the world today. The challenges are multifactorial. First, the burden of cancer is already enormous with close to 19 million new cases expected in 2020, projected 10 million deaths, and the 5-year prevalence of cancer exceeded 43 million people in 2018. These numbers are expected to increase to 24.5 million new cancer cases in 2040 and 16.4 million deaths globally. Most of the growth in cancer cases is expected in low- and middle-income countries (LMIC), which are currently ill prepared to meet this challenge. In addition, cancer is one of the most complex health challenges. A single term cancer refers to hundreds of distinct disease entities, affecting every part of human body, any age, sex, and people all over the world. Cancer uses most health services ranging from the simplest to the most sophisticated.1. However, there are huge disparities in cancer outcomes in the world with much lower survival rates observed in LMIC.2Cancer is also one of the best documented diseases. Population-based cancer registration started in the Europe and the United States 80-95 years ago. Huge improvements in cancer screening, early detection, and treatment have been made, and now, more than 50% of patients survive 10 years or more in the United Kingdom3 Among one of the best documented gaps in care is the lack of access to radiotherapy. The Lancet Oncology Commission on Expanding Global Access to Radiotherapy as well as many other publications documented the size of the problem, calculated the cost of scaling-up the access, and modeled the potential for saving lives and contributing to the economic growth.3Much has been written about the lack of access to cancer care globally.Recent attention to the radiotherapy problem brought to light many efforts to help to remedy the situation. In the last few months, several papers addressed various initiatives that are desperately needed to be addressed to facilitate the progress.4 In addition, the IAEA provides extensive research, education, quality assurance, and advisory function for procurement of new equipment to LMIC.Much has been written about the gaps in access in almost every part of the world. Cancer and radiotherapy have some advantages in the global health arena. First, the International Agency for Research on Cancer is a WHO research agency fully dedicated to cancer. Besides extensive research effort on cancer etiology and prevention, it also engages in epidemiology research and provides first-class data on cancer incidence, mortality, and prevalence all over the world. The International Atomic Energy Agency (IAEA), another United Nations agency, has radiotherapy as part of their human health portfolio. The IAEA maintains the Directory of Radiotherapy Centres database that registers all available radiotherapy equipment in the world.However, despite all the resources and efforts, the progress in closing the gap in access to radiotherapy is extremely slow. In fact, if there is no major change in the current programs, the situation in some parts of the world, especially sub-Saharan Africa and parts of Asia, may even deteriorate with the growth in the cancer burden eclipsing the growth in resources available. The global cancer and radiotherapy community wants to help and is extremely frustrated by the lack of guidance and realistic opportunities to contribute their expertise and resources to change this sad reality.There is continuing improvement in the gross national product of LMICs. With that being said, there will be investment in health care. What is needed is local leadership and expertise to leverage the developing economy and harness new resources for cancer control.One of the avenues for realistic assistance is in education. Radiation oncology departments worldwide offered training opportunities to many LMIC trainees; however, training abroad is expensive and often leads to the ‘brain drain’ where LMIC specialists decide to remain in a high-income country and not returning to their community. Most professional societies offer education courses abroad but often the curriculum is driven by the high-income country experts and is not applicable to the LMIC situation.5 describe the frameworks for radiation oncology global health initiatives in US residency programs.5 It is clear that the tide of interest in global cancer is changing with a wave of interest on the part of the younger faculty and trainees.There is an increasing awareness that to expand the access to radiotherapy, we must build local capacity. That means supporting education of radiation oncologists where they are, either through partnership or twinning arrangements or support through multi-institutional multidisciplinary tumor boards between organizations. Technology is available today to connect experts around the world and permit exchange of ideas, common problem-solving, and give free access to educational resources. Benjamin et alA growing number of publications refer to the use of the information and communication technologies in education and in medical practice. Telemedicine has the potential to mitigate a number of barriers to enable more equitable access to education and health care such as time and distance barriers. In radiotherapy, where computerization and automation are pervasive, telemedicine has huge potential to overcome the barriers and facilitate a more rapid adoption of precision.6 description of brachytherapy training of professionals in a number of LMIC published in this journal provides an excellent example of that can be done with minimal resources to scale up the capacity for modern radiotherapy delivery in LMIC.6 The authors provided online training to a group of physicists, radiation oncologists, and dosimetrists from cancer centers located in Egypt, Ghana, Iraq, Jordan, Nepal, Nigeria, Mozambique, and Zambia, showing positive educator and learner experience. There is a need for systematic application of online learning opportunities with evaluation of the short-term and long-term outcomes in terms of not only learning outcomes but also translation of this new capacity into improved access to state-of-the-art radiotherapy and improved outcomes in recipients’ environments.Hatcher et al's7 describe an initiative to assist radiation oncologists in Latin America in gaining expertise in modern precision radiotherapy. Rather than imposing their own curriculum, they surveyed interested colleagues in Latin America regarding their needs, which enabled them to tailor the curriculum to their needs.7What is of particular interest is engaging experts in LMIC in leading these efforts. In another paper, Mailhot et alThere is a visible shift from north to south giving and paternalistic model of collaboration to the true demand-driven partnerships and focused assistance. There is also a need for capacity building in high-income countries to increase a cadre of professionals engaged in global health. Global health, and in particular global cancer, has been considered a hobby in many academic centers. Some well-meaning professionals engaged in not-for-profit nongovernmental organizations that provide assistance to LMIC, and others travelled to countries needing assistance offering their individual services. While such endeavors help individuals, they have no impact on building local capacity, influencing policy, and are not sustainable.Fortunately, there is new interest in a more long-term career development in global health founded on appropriate training by engaging in systematic broad institutional or organizational initiatives that are built on partnership with local professionals and trust and focused on sustained engagement. What is needed is an academic career development pathway for young professionals backed up by faculty opportunities and resources.


Life expectancy is increasing in most high-income countries, but gains in life years are maximized if spent in good health and if cognitive abilities are maintained until old age. Age-related decline of cognitive abilities does nevertheless occur, but the pace of decline is decisive. This was the starting point for our study that aims to examine cohort effects of cognitive aging in women and men in Germany, Spain and Sweden by analyzing changes from 2004 to 2013 by estimating cohort effects within age groups starting from the age of 50 years.A cohort study was conducted that was based on data of the surveys 2004  and 2013  from the Survey of Health, Ageing and Retirement in Europe (SHARE). The analyses were based on data of female and male respondents aged 50 years and older. Age-specific means of verbal fluency and delayed recall from the German, Spanish and Swedish samples were the cognitive domains considered in the study.In both domains of cognitive ability the achievements in the later surveys were higher than in the earlier ones. This was found in all countries, abut achievement levels increased markedly in the German and the Spanish samples, while the scores of the Swedish samples were not significantly different.While the highest scores were found for Sweden, Germany ranked in the middle and the lowest scores were found in the Spanish samples. Over time, the scores of the German samples approached those of Sweden.From the first to the second survey, improvements of older adults’ cognitive abilities were found for all countries considered. This may indicate improvements of the underlying educational systems, but also increasingly stimulating general living conditions. Preserving cognitive abilities until old age is a main prerequisite for maintaining good health. Studies have shown that the lifetime spent in states of disease and disability was decreasing at the same pace or even faster than life expectancy was increasing ,2. In orStudies have consistently reported improvements of measured intelligence and cognitive abilities from one generation to the following one. This development became known as the “Flynn-effect” that was described in particular for Germany, France, Israel, Japan, Kenia and the Netherlands, while smaller increases were reported for Brazil, Ireland, New Zealand, Great Britain, and the USA –9. In poIncrements of cognitive abilities were already found in surveys conducted seven years apart ,11. For Direct comparisons between countries have rarely been published. In a meta-analysis, no achievement levels but only increments were reported as they were based on findings from different types of tests . FormaneTo summarize, the bulk of research refers to selected groups, and comparisons between countries have combined time periods and countries instead of differentiating by age groups, time periods, and countries.Comparisons between age groups and between countries were beginning at the age of 50 while earlier reports started at the age 65 or 70.Cases of possible dementia are excluded after having screened the samples with the Mini-Mental-Status Examination (MMSE) .Comparisons are performed with smaller age intervals, what makes it possible to analyze continuous developments of cognitive abilities over time.Our study aims to examine cohort effects of cognitive aging in women and men from Germany, Spain and Sweden by analyzing changes from 2004 to 2013 by estimating cohort effects of age groups. Endpoints are verbal fluency as a measure of executive functioning and delayed recall as a measure of episodic memory. These two central domains of cognitive ability are related to fluid intelligence and susceptible to age-related decline . The finDoes age-dependent decline of cognitive abilities in terms of delayed recall and verbal fluency occur from the fifth decade of life into old age?Do younger cohorts reach higher levels of cognitive abilities in the two above mentioned domains than older ones, and does this occur likewise in Germany, Sweden, and in Spain?Do Germany, Sweden, and Spain differ with respect to cognitive ability levels, and does age-related decline proceed dependent on the country considered?Against the backdrop of the considerations above, three research questions will be dealt with:http://www.share-project.org/data-access.html). The authors had no special access privileges, and the data were accessed in the same way as stipulated by the owner.Our study was based on data of the Survey on Health, Ageing and Retirement in Europe (SHARE) that started in 2004 . SHARE iWe used data from Germany, Sweden and Spain from two survey waves conducted in 2004 (first wave) and 2013 (wave five) in order to examine cohort effects by comparing the same age groups.Before performing the statistical analyses, the number of cases was reduced by several reasons in order to exclude effects that may distort the age and cohort effects we wanted to examine: At the first step, the sample was confined to respondents who participated in the survey for the first time. In earlier studies it was shown that repeated testing may cause training effects thus leading to increased achievement levels ,27,28. TVerbal fluency was measured by listing as many animal names as possible within a minute. Thus, the range of values may vary between 0 and a theoretically upper end. Double or non-existing animal names were not counted, and every correct naming was counted as one point. Delayed recall as a measure of memory was assessed by remembering a list of ten words presented by an interviewer after having performed a distracting task. Again, any correctly remembered word was given one point. Thus, the range of values ranges between 0 and 10. The Mini-Mental-Status-Examination (MMSE) was used in order to exclude cases of possible dementia [Verbal fluency and episodic memory are two domains of fluid intelligence that were assessed as part of computer- or telephone- administered surveys. dementia . In SHARcorrected is the corrected a-level after correction, αchosen a priori is the α-level chosen for accepting a test difference as statistically significant, and n = number of comparisons.After having inspected the descriptive data over countries and survey waves, multiple regression analyses were performed by using age, gender, wave and age x wave- interactions with each of the two cognitive domains as dependent variables. Confidence intervals were estimated by means of 2000 bootstrap samples in order to obtain normally distributed residuals . Age wasSTATA 16 MP was used for all analyses .Exclusions directed towards prevention of retest effects led to the reduction of 2914 German respondents from the fifth survey, 3604 cases from the Spanish and 4763 cases from the Swedish sample who had participated in at least one of the preceding waves one, two, or four. The third wave was not considered as no cognitive tests were applied. The results of exclusions due to the occurrence of missing values and due to suspected cases of dementia are depicted in The basic characteristics of the three subsamples that entered the final analyses are depicted in In the following analyses, gender was taken into account, but no separate analyses are presented for women and for men. The reason for this decision was the absence of gender differences in preparatory analyses with our data. With respect to the scaling of the two cognitive tests, gender effects  were rather small as documented in the following results of the regression analyses.Germany, verbal fluency decreased monotonously with age by using the youngest age group (50–54 years) as reference category. The same occurred for delayed recall, but the findings from the age above 90 years were based on small case numbers. This applies to survey 2004 as well as to 2013, albeit both were starting from different levels of cognitive ability  was about the same size. Thus in these two countries, achievement levels had improved over time. For Sweden, no difference between samples emerged as the overall difference was only Diff2004/2013 = 0.13 points which is rather small given the open-ended scale  of cognitive achievements for Sweden and Germany, steeper negative slopes in terms of age and cognitive ability were found for both domains in our data. Spain started at lower achievement levels, but the curve of age-related decline was rather flat. This finding is in accordance with findings reported by Formanek et al.  who mergIt had already been mentioned that we did not perform separate analyses for women and for men as differences either did not emerge, or were very small in magnitude. These findings are in line with earlier papers with German data using other databases and other tests ,50. StudFinally, some limitations of our study have to be acknowledged. In order to examine cognitive aging in healthy populations, individuals with cognitive impairments and dementia were excluded. However, other potential reasons for exclusion such as traumatic brain injury, stroke or medications had not been included in the dataset used for our study. In addition, by excluding repeatedly participating respondents, training effects should be controlled for ,27. ThisOur study was confined to verbal fluency and episodic memory as domains of fluid intelligence. It might have been worthwhile to extend the analyses to other domains, but we finally decided against it because considering more cognitive domains would have inflated the results section further as the presentation of results had to include illustrated comparisons between countries and their educational systems. The second reason refers to the completeness of data. In the Seattle longitudinal study, it was reported that numeric abilities had deteriorated over time . It was Taken together, we have shown that levels of cognitive ability in adults aged 50 and older had increased over time in terms of delayed recall and verbal fluency, that cognitive decline had already started at the age of 50, and that there were considerable differences in cognitive abilities between the three countries considered. Finally, the amount of decline depends on the levels achieved before which may be taken as a strong argument for striving for high population levels of formal education. So far, one might be satisfied with the findings and expect this development to continue until having reached a plateau where further increments are less likely. There are however findings that indicate that the development may also go into the opposite direction depending on the age cohorts and on the cognitive domains considered ,41.