Where ticks are found, tick-borne diseases can present a threat to human and animal health. The aetiology of many of these important diseases, including Lyme disease, bovine babesiosis, tick-borne fever and louping ill, have been known for decades whilst others have only recently been documented in the United Kingdom (UK). Further threats such as the importation of exotic ticks through human activity or bird migration, combined with changes to either the habitat or climate could increase the risk of tick-borne disease persistence and transmission. Prevention of tick-borne diseases for the human population and animals (both livestock and companion) is dependent on a thorough understanding of where and when pathogen transmission occurs. This information can only be gained through surveillance that seeks to identify where tick populations are distributed, which pathogens are present within those populations, and the periods of the year when ticks are active. To achieve this, a variety of approaches can be applied to enhance knowledge utilising a diverse range of stakeholders . Without this information, the application of mitigation strategies to reduce pathogen transmission and impact is compromised and the ability to monitor the effects of climate change or landscape modification on the risk of tick-borne disease is more challenging. However, as with many public and animal health interventions, there needs to be a cost-benefit assessment on the most appropriate intervention applied. This review will assess the challenges of tick-borne diseases in the UK and argue for a cross-disciplinary approach to their surveillance and control. Disease surveillance is the systematic collection, analysis and dissemination of data on infections of importance to public or animal health. This informs appropriate action that can be taken to either prevent or limit further spread of disease. Data collected can then inform risk assessment, resource management and vaccination programmes where appropriate. For vector-borne diseases, the identification of the vector, its behaviour and abundance, and the infection rate of associated pathogens are also critically important to understand disease transmission dynamics. Ticks are one of the principal vectors responsible for the transmission of pathogens to humans , domestiIxodes ricinus), which will seek hosts when temperatures rise above 7 °C for 5 days consecutively and when the saturation deficit is low [Borrelia burgdorferi sensu lato [I. ricinus, which is particularly abundant in upland grazing areas and some lowland areas, the less abundant red sheep tick, Haemaphysalis punctata, has re-emerged as a source of infectious disease in livestock in southern England [Dermacentor reticulatus. Beyond these dominant tick species, there is limited information on other ticks present in the UK and the pathogens they transmit [Ixodes uriae, are present in the UK and associated with many viruses, but rarely encounter mammalian hosts and do not appear to transmit diseases to them [Ixodes hexagonus, commonly associated with wild mammals, and Ixodes frontalis, which feeds preferentially on birds, can play a role in maintaining pathogens within wildlife reservoirs [There is growing evidence that tick distribution and tick-borne disease transmission are increasing across Europe ,5,6. Thet is low . Howevernsu lato , and oft England . A similtransmit . Species to them . Howeverservoirs .Two recent papers have comprehensively reviewed the threats of arthropod-borne pathogens posed to human  and animIxodes ricinus, is the most abundant and widespread tick species in mainland Europe [I. ricinus spends the vast majority of its life-cycle within the vegetative layer, surviving in areas where humidity levels remain above 80%. Across Europe, this species is found in deciduous woodland or mixed forest. In some countries, notably the UK, I. ricinus is abundant in upland grazing areas, as well as in lowland grazed grassland, including conservation grazing. It is also increasingly being discovered in urban green spaces such as public parks, where the opportunity to encounter and transmit pathogens to humans and companion animals may be significant [While other Ixodid or hard tick species can be encountered within the UK, one species dominates in terms of distribution, abundance, biting and disease transmission A–D. Ixodd Europe . Despitenificant . Factorsnificant .Ixodes ricinus host seeking activity is thought to follow two temporal peaks, one during the spring and early summer between April and June, and then a second late summer peak between August and September, although there is little evidence in southern England for this second peak. As a consequence of diapause, all feeding stages of I. ricinus will have emerged during summer and autumn, including those ticks which had fed during summer/autumn of the previous year [Ixodes ricinus is a generalist feeder and has been reported on over 160 vertebrate hosts [I. ricinus can act as a vector for a large number of pathogens to a wide variety of hosts. Despite being one of the most highly studied tick vectors of disease, many questions remain about its ecology and effective means to reliably predict and control pathogen transmission by this species [ous year . There ite hosts , with ad species .There are over 20 species of ticks considered to be indigenous to the UK . Non-indHyalomma rufipes, a competent vector of Crimean Congo haemorrhagic fever virus (CCHFV), on a horse that had not travelled outside of the UK [Hyalomma rufipes is indigenous in Africa and a possible explanation was the introduction of the tick as an engorged nymph attached to migrating swallows (Hirundo rustica) during the Northward spring migration from Africa along the Western Palearctic route. This was considered likely as swallows were nesting at the location where the horse was stabled.A key priority of tick surveillance is to identify the routes of introduction into the country, identify the species of discovered ticks rapidly and investigate to assess the potential animal and public health impact. If necessary, control measures to prevent establishment of a population may be required. Past experience in the UK has identified a number of potential routes of entry for the introduction of ticks. This includes the movement of companion dogs, highlighted by the appearance of a cluster of cases of canine babesiosis, a disease exotic to the UK, in southern England , the impf the UK . HyalommRhipicephalus sanguineus [Amblyomma variegatum ticks [Haemphaphysalis longicornis [Rhipicephalus spp. from Mexico [Rhipicephalus microplus, originally a resident of South-East Asia, but which has successfully established in many regions of Africa, Australia and South America [With the exception of infestations of domestic properties by the dog tick, nguineus  there isum ticks , Theilergicornis , and them Mexico . Among o America  and is aDermacentor reticulatus ticks [D. reticulatus ticks infected with B. canis in grassy areas adjacent to a carpark where owners exercised their dogs. In the absence of this pathogen in the UK, it is likely that the ticks were recently introduced on dogs entering the country from southern Europe [Amblyomma species from a consignment of 800 leopard tortoises  imported from Zambia [On-going surveillance, in the form of submissions of ticks by members of the public and private veterinary surgeons (PVS), has been instrumental in identifying the species associated with these occurrences and identified the routes of entry. The source of an outbreak of canine babesiosis in southern England in 2016 was initially recognised by a PVS treating anaemic dogs and traced to a population of us ticks . Isolateus ticks . Howevern Europe  or contam Zambia . This fom Zambia .Surveillance aims to acquire information that can inform both disease prevention and control measures. The acquisition of information on ticks and tick-borne diseases can be facilitated by a range of methods.The most commonly used method of surveillance is the monitoring of disease trends in ‘at risk’ populations. This is mainly reactive to clinical disease presentation and reliant on diagnostic confirmation of the disease in samples submitted from the patient or infected animal. Collation of data in time and space can identify trends in disease incidence and suggest corrective actions. A retrospective study of Lyme borreliosis in the UK between 1998 and 2016 demonstrated an increase in annual incidence . This waThere are a range of methods for both surveying and collecting ticks from the environment, the most appropriate being dependent on the behaviour of the tick and the resources available for the collection process . IdentifFor tick species that ambush potential prey whilst questing on the tips of vegetation, a common method for collecting ticks on vegetation is that of ‘dragging’ or ‘flagging’. This involves drawing a cloth or wool blanket attached to a pole over the vegetation. Questing ticks will attach to the cloth and can be collected. Pale material is favoured so that the ticks are easily visible against a light background. This can be used in an unstructured way to detect the presence of ticks and collect large numbers of all life stages of the resident tick population. Alternatively, structured surveys using standard sizes of cloth, are drawn at repeated intervals over a defined area to compare estimated density in different locations and at different times ,42. OtheI. ricinus ticks are increasing in abundance and distribution [An alternative method to collecting ticks from the environment is the collection of ticks directly from animals, including humans. This gives the added benefit of providing some context to the tick-host-pathogen interaction, but also raises a number of problems. Clearly, removing a tick from an animal demonstrates that the tick is either feeding, or about to feed on a particular host. If attachment has occurred it can demonstrate the parts of the host to which the tick preferentially feeds such as the ears, axilla or inguinal areas ,47. Engoribution .A growing trend in surveillance is to use non-specialists to contribute to data collection, so called “Citizen Science”. The traditional method to engage non-specialists to generate data on disease prevalence is through the use of surveys. Responses to a series of questions are analysed to identify a range of useful parameters associated with a particular problem. This remains a useful means of approaching tick-borne disease in both humans  and animTargeted surveys have involved PVS submitting ticks that have resulted in publications on infestations in domestic dogs  and catsCitizen science offers a number of benefits, especially the cost-effective generation of large datasets and engagement with non-specialists, e.g., the general public. However, it does have a number of limitations . FirstlyThe appearance of clinical signs in a susceptible host is usually the first step in detecting tick-borne disease. Some disease signs may provide a strong suspicion of a particular disease, for example the initial rash or erythema migrans that can sometimes develop in cases of Lyme borreliosis in humans and the appearance of blood in urine for bovine babesiosis. However, many disease signs are non-specific, such as febrile episodes, and require confirmation by a diagnostic test. This may involve isolation or microscopical identification of the causative agent, detection by serological means or molecular detection such as polymerase chain reaction assays.For many pathogens of livestock, a large array of tests are now available to detect the aetiological cause of disease . SerologThe control of diseases has biological, social and political elements that require an interdisciplinary and collaborative approach in managing such health emergences ,67. The I. ricinus, a three-host tick that feeds on a diverse range of host species, including humans [I. ricinus and its role in disease epidemiology. Nevertheless, the potential role of other UK tick species should always be considered.One tick species in the UK dominates both in terms of distribution and abundance, and in the transmission of endemic diseases. This is g humans . Other sI. ricinus on a country-wide scale, and to better understand seasonality of activity and biting.Long-term surveys to characterize the distribution and abundance of Determination of the presence and prevalence of tick-borne pathogens in at risk host populations and within indigenous tick instars that transmit pathogens.Provide evidence-based information for public and animal health policy to identify, mitigate and control tick-borne pathogen transmission and disease spread.Rapid detection of introduced tick species and timely responses to reduce potential impact and prevent establishment or spread to the wider environment.Collate robust data and develop climate-based assessments for future exotic tick establishment and disease risk.The key objectives for UK surveillance for ticks and tick-borne pathogens should include:I. ricinus adults and nymphs. For animal diseases, the detection of ticks within livestock habitats can confirm the source of disease. Identification of exotic ticks requires expertise to identify key morphological traits that should differentiate to genus level, but ideally to the species as this is critical to indicate potential pathogen associations, the populations at risk and implementation of control measures. If morphological identification is not possible either due to lack of expertise or access to detailed keys, or the state of the specimen precludes identification, other methods including polymerase chain reaction linked to sequencing or mass spectrometry [Tick identification is critically important to identify the species involved in human biting and to assess the clinical risk associated with a particular tick species . For exatrometry  offer exI. ricinus that would reduce options for control.On discovery of ticks attached to humans, the tick should be removed in such a way as to completely remove the tick mouth parts from the wound to reduce the risk of pathogen transmission or development of a skin infection. For companion animals, ticks should be removed where possible and a spot-on acaricide treatment applied to prevent further infestations . LivestoExpert committees offer a critical role to assess disease risk, suggest intervention measures and identify research proposals. Within the UK, such committees include the Veterinary Risk Group  and the From a 1H perspective, national coordination and reporting of tick-borne diseases provides national level indicators to support an evidence-base for policy and advocacy to international organisation. This information is also relevant to community needs, priorities, and capacities, and should be included in national and community-based multisectoral coordination of tick-borne disease control. Citizen science projects can also be used to enhance surveillance projects by explicitly highlighting the role of the community. Going forward, surveillance in the UK should be enhanced by further developing a flexible and adaptable legal-policy framework with a national strategic plan and finance strategy for surveillance of tick and tick-borne diseases.More focus is needed across the veterinary sector to match that of the public health sector, to quantify the true burden of TBD in animals within the UK, particularly monitoring changes to tick and TBD transmission affecting livestock, companion animals and humans. There is also a need to provide evidence for trends that might be driven by both climate and anthropogenic change. Critically this would include better integration and data sharing to support both public and animal health. A response along the lines outlined for American control of TBDs  is approThe benefits of well delivered surveillance include increased knowledge of tick distribution and abundance, and associated pathogens of public and animal health. This data can support disease vector distribution modelling and highlight risk areas for disease transmission when overlaid with other datasets such as susceptible livestock distribution and climatic factors that influence tick habitats and life-cycles. Comprehensive surveillance will also support studies that seek to understand genetic variation within tick and pathogen populations that might influence disease transmission and in the case of ticks, the genetic basis for the emergence of acaricide resistance. Finally, improved surveillance would provide the baseline for both vector and pathogen associations and incidence against which changes associated with climate change can be measured. Currently, change is being monitored by the appearance of disease in at risk populations, which is arguably too late to facilitate effective control measures.


With societal and technological developments, mobile Internet has become the most popular and widespread means to use the Internet in China. Thus, exploring the relationship between mobile Internet use and the self-rated health and mental health of the Chinese population is of great importance. This study empirically examined the impact of mobile Internet use on residents’ health using data from the China Family Panel Studies 2020 and conducted a heterogeneity analysis. The results revealed a significant negative association between mobile Internet use and the self-rated health of the population, but a significant positive association was found relative to their mental health. The results of this analysis passed a robustness test. The results of the heterogeneity analysis showed that mobile Internet use had a more significant association with the health of residents with secondary school education and university education compared to those with primary school education or below and graduate education. Furthermore, this study addresses the endogeneity problem using the propensity-score matching model, which is shown to be better at eliminating sample selectivity bias. If endogeneity is not addressed, the negative association with mobile Internet use on residents’ self-rated health will be underestimated and its positive association with their mental health will be overestimated. The Chinese government should issue guidelines on the duration of Internet use, strictly regulate exaggerated and harmful content on mobile network platforms, and strengthen people’s online skills through training to improve their digital literacy, especially for rural populations. Health is important for the development of populations and societies. Since the reform and opening up of China, there have been rapid developments in medical and health care in the country, and the health condition of the residents has hugely changed . AccordiIn recent years, scholars have explored the relationship between technological progress and population health. For example, using data from a survey in China, Yang and He found that Internet use had a significant positive impact on population health . SimilarThus, the above studies indicate that the extant literature has not yet reached a consensus on the connection between the Internet and people’s health. It is worth noting that some studies have focused on the Internet as a single entity while not differentiating general Internet use from the use of mobile Internet. However, the majority of Internet users in China use mobile devices to access the Internet. Thus, this study explores the relationship between mobile Internet use and health using data from the latest China Family Panel Studies 2020 (CFPS), with the aim of providing new empirical evidence to further understand technological advances and their impact on population health.This study uses data from the latest China Family Panel Studies 2020 (CFPS). The CFPS is carried out by the Institute of Social Science Survey Center of Peking University, China, with a large sample size and strong representation. CFPS was launched in 2010. The survey covered 25 provinces  across the country. The CFPS sample is a multi-stage probability sample drawn using the implicit stratification method. The multi-stage sampling design was adopted both to reduce the operational costs of the survey and to take into account the social contextual differences in Chinese society. In terms of sampling design, the CFPS database first divides the 25 provinces/municipalities/autonomous regions in China into two categories: One category of provinces and municipalities is the inferred sample at the provincial level to meet the requirements of provincial inference. Five provinces/municipalities were selected for these data, namely, Liaoning, Shanghai, Henan, Guangdong, and Gansu, also known as large sample provinces. The second category of provinces/municipalities include the 20 provinces/municipalities/autonomous regions outside the above 5 provinces/municipalities. The sample size of this category of provinces/municipalities does not allow for inference at the provincial level and is also referred to as small sample provinces. The weighing of the data from these two types of samples provides a valid estimate of the overall 25 provinces/municipalities/autonomous regions, which can then be used to make inferences for the entirety of China. The survey involved 16,000 households, and it was conducted once every 2 years. Only adult data were published for the 2020 CFPS, with a total of 28,590 adult respondents. The 2020 questionnaire includes modules on basic information, educational status, income, and health care. The sample was screened, and responses with missing data and outliers were eliminated, resulting in a valid sample size of 7962. As CFPS is a national questionnaire, it involves various types of respondents from different populations, different occupational backgrounds, and different regions. Therefore, when faced with the limitations of different research questions and various types of variables, there may be too much data missing. This is still generally representative of the Chinese population.The independent variable in this study is mobile Internet use and the dependent variable is the self-rated health and mental health of the residents. According to previous studies ,22,23, sSince the dependent variable in this paper is a multicategorical variable, an Ordered Probit regression model is set to analyze the relationship between mobile Internet use and the physical and mental health of the population ,25. The In Equation (1),  effects ,27. All As seen in Regarding the control variables, in terms of gender, men showed better self-reported health status than women. In terms of age, self-rated health deteriorated with increasing age, whereas mental health improved. In terms of marital status, marital status is negatively associated with the mental health of the population; however, there was no significant association with marital status on self-rated health. In terms of literacy, higher levels of education were associated with poorer self-rated health but better mental health. In terms of lifestyle, smoking was related to poorer health status. Finally, health status increased with increasing frequency of exercise, indicating that physical activity is an important way to improve health.In order to ensure the robustness of the model results, robustness checks were performed using a substitution econometric model approach. Since the dependent variable in this study is a multicategory variable, the ordered logit model was used as a replacement model for the analysis. The results of the robustness tests are shown in Limited by differences in endowment resources, significant heterogeneity can occur in the impact of Internet use on the health of different populations. To further explore the association between mobile Internet use and population health, we examined heterogeneity from a literacy perspective. The results of the heterogeneity analysis are shown in Individual mobile Internet use is influenced by a series of factors, including age, income, and education level; it is an individual choice made by individuals based on their own endowment resources. Therefore, the model can generate endogeneity problems. To overcome this problem, this study used a propensity score matching model. Compared to baseline regression, the PSM model can effectively eliminate the effect of confounding variables on the estimation results ,29. As aAccording to the empirical results, mobile Internet use has a significant negative association with the self-rated health of the population. This result is inconsistent with the results of previous related studies ,12,13,30The results indicate significant heterogeneity in the effect of mobile Internet use on the health of people with different levels of education. The connection of mobile Internet on the health of people with elementary school education and below was not significant. This result is similar to the results of Wang’s analysis . This maFirst, the government should issue guidelines on the duration of Internet use and guide citizens to use the Internet in moderation. According to relevant data, China’s Internet users spend approximately 28.5 h per week online, with an average of more than 4 h per day in the morning. Therefore, relevant policies should be formulated in the future to guide the population to access the Internet in moderation. For example, by setting reminders in mobile apps or cell phones, when the screen use time exceeds a certain limit, the phone will automatically sound an alarm to guide people to control their time of Internet use and avoid Internet addiction and dependence. Second, it is advised that the content created and encouraged by mobile network platforms should be strictly supervised to create a healthy network environment. To tap into a larger “viewership”, some online platforms create exaggerated content to attract people’s attention, which leads to people with poor self-control falling prey to it and become unable to extricate themselves. In particular, younger people, whose world views and values have not yet matured, are easily influenced by harmful and exaggerated information. Therefore, the supervision of online platforms should be increased in the future to strictly control the dissemination of undesirable information and block such information from the source to prevent its harmful association with the self-rated health and mental health of the population. Third, the population’s Internet skills should be strengthened and their Internet literacy should be improved. Most Internet users in China reside in rural areas. Limited by literacy and material conditions, they tend to have low digital literacy and are easily influenced by the Internet. Therefore, the government should strengthen the Internet skills of users in rural areas, guide them to access the Internet in a healthy manner, and improve their digital literacy through training and other means. For example, community-based training can be conducted from time to time to spread general knowledge of the Internet among the population and improve their digital literacy level and information screening ability.The innovations of this study are as follows. First, this study empirically examines the relationship between mobile Internet use and the self-rated health and mental health of the Chinese population from the perspective of mobile Internet, using the most recent nationally representative data. This provides new empirical evidence to understand the relationship between Internet use and health over time. Second, this study takes into account the sample self-selection problem. The propensity score matching model is used to eliminate the sample’s selectivity bias, thus ensuring the robustness of the model estimation results. This study also has some limitations. First, the health status of the population is a long-term dynamic development process; thus, using cross-sectional data will inevitably lead to biased results. Therefore, we will further test this relationship in the future using multi-year tracking data. Second, this study did not examine how different mobile Internet apps and Internet usage time affect the self-rated health and mental health of the population. This question will be the focus of studies in future research. Third, in terms of indicator selection, the measurement questions selected in this paper regarding mobile Internet use are too general. This may have some measurement error. In addition, in terms of mental health, we used “feel sad and upset” as a measure, which may not be representative of the overall mental health of the population. Therefore, these areas are where we will make further breakthroughs in the future.This study empirically examines the relationship between mobile Internet use and the self-rated and mental health of the Chinese population using data from the 2020 China Family Panel Studies. The results showed a significant association between mobile Internet use and self-rated and mental health. In terms of self-rated health, there was a negative relationship between mobile Internet use and self-rated health. In terms of mental health, there was a positive relationship between mobile Internet use and mental health. The degree of negative impact of mobile Internet use on self-rated health is higher than the degree of positive impact on mental health. Heterogeneity analysis showed significant heterogeneity in the effects of mobile Internet use on the health of people with different levels of education. The association of mobile Internet use on the health of people with secondary school and university education was more significant than that on people with elementary school education and below and graduate education. We also performed robustness tests using a substitution analysis model. The results show that the conclusions obtained from this study are well robust. In addition, we used a propensity score matching model to estimate the net effect of mobile Internet use on the demographic impact. The results show that PSM model is effective in eliminating sample-based bias. If endogenous problems are not eliminated, the negative relationship of mobile Internet use on the self-rated health of the population will be underestimated, whereas its contribution to mental health will be overestimated.


Remote treatment, or telehealth, has shown promise for children with cerebral palsy (CP) prior to 2020; however, the beginning of the global COVID-19 pandemic limiting access to hospitals for face-to-face treatments has driven the need for telehealth and led to a surge in its development. Due to the recent developments, there has been limited synthesis of the available evidence of telehealth for children with CP.This study aimed to analyze and summarize the existing evidence for telehealth interventions for the treatment of children with CP and identify any areas requiring further research.A scoping review was performed. A systematic search of available literature in MEDLINE and PubMed was performed during July 2021. Inclusion criteria for articles were primary research and systematic reviews that investigated telehealth, included children with CP, were published between 2010-2021, and were written in English. Exclusion criteria were secondary research other than systematic reviews; interventions that did not meet the World Health Organization definition of telehealth; or studies where all participants were aged >18 years, children’s results were not reported separately, or there were no results reported for children with CP. A scoping review was chosen due to the expected heterogeneity of the participants, as well as the expected small sample sizes and inconsistency of measured outcomes; therefore, a narrative reporting of the results was considered appropriate.In all, 5 papers were identified, which included the results of 11 studies—2 of the included articles were systematic reviews, which included the results of 3 studies each. These 6 studies, together with 5 primary research articles, were included in this scoping review. The existing evidence is of low methodological quality, primarily consisting of case series. There is some evidence that the requirements of telehealth differ depending on the children’s developmental stage and functional level. Telehealth is reported to reduce caregiver burden. There is mixed evidence on children’s compliance with telehealth. Overall, the results of telehealth interventions for the treatment of children with CP were positive, indicating either comparable or improved results compared with children receiving usual face-to-face care.The evidence base is lacking in breadth and methodological quality to provide robust clinical recommendations. Most studies investigated hand function only, indicating the limited scope of existing research. However, this review shows that telehealth has demonstrated potential to improve function for children with CP while making health care services more accessible and reducing caregiver burden. Areas requiring further research include telehealth interventions for the lower limb, postural management, and pain control and the barriers to implementing telehealth. Cerebral palsy (CP) is an umbrella term for neurological and movement disorders caused by nonprogressive disturbance to the developing fetal or infant brain ,2.CP affects approximately 1 in 400 children in the United Kingdom and represents a lifetime disability with substantial socioeconomic consequences . FunctioCP can be further classified by neurological pattern as dystonic, dyskinetic, ataxic, and mixed . In 70% CP affects many aspects of a person’s activities of daily living including movement and posture, speech and communication, and swallowing (eating and drinking) and causes a range of health problems such as osteopenia, excess saliva, pain and discomfort, stress and anxiety, depression, and sleep disturbances. Therefore, the treatment options and requirements are vast.Modern clinical management has evolved to allow clinicians a greater variety of treatment options and offers patients more tailored treatment for their needs. Telehealth (TH) and remote interventions to facilitate the use of TH are at the forefront of this evolution. The World Health Organization (WHO) defines TH as “the delivery of healthcare services, where patients and providers are separated by distance. TH uses information and communication technologies for the exchange of information for the diagnosis and treatment of diseases and injuries, research and evaluation, and for the continuing education of health.” .TH has shown promise for patients with CP prior to 2020 ,8. HowevThe aim of this scoping review was to analyze and summarize the existing evidence for TH interventions for the treatment of children with CP and identify any areas requiring further research.This review is timely due to the ongoing COVID-19 pandemic increasing the need for and development of TH interventions. This study will contribute to the current evidence base as despite 2 previous systematic reviews having been conducted in this area, neither was specific to children with CP, and 1 focused only on therapy for the upper extremity ,11.A scoping review was chosen as the appropriate methodology, as the substantial heterogeneity of the participants, small sample sizes, and an inconsistency of measured outcomes were expected. Therefore, narrative synthesis and reporting were considered the most appropriate. A scoping review also allowed a broad research question to highlight gaps in the literature and provide recommendations for TH as a method to assist children with CP in their ongoing treatment. The methods for the scoping review are summarized in For the purpose of this paper, we used the definition of TH described by the WHO  as discuA database search was conducted in the MEDLINE and PubMed databases. The MEDLINE search was completed using the OvidSP search platform, and the website-specific search engine was used to search the PubMed database. The search strategy used in the MEDLINE database is included in The International Journal of Rehabilitation Research was also manually searched for further articles that met the eligibility criteria, as it was identified a priori as having published several important papers in TH for people with CP. Backward reference searching was also conducted on all papers identified for inclusion through the previous search strategies. Authors were not contacted for further data.The management of children with CP is multidisciplinary and includes a variety of aspects of their complex disability. For the purpose of this study, we did not limit the definition of “treatment” to 1 or more of the disciplines but rather considered children’s management globally, including all relevant disciplines involved in their care.Inclusion criteria for articles were primary research, systematic reviews, and meta-analyses that investigated TH, included children with CP either as all participants or results reported as a subgroup, were published between 2010-2021, and were peer-reviewed articles reporting results that are available and written in the English language.Exclusion criteria were secondary research other than systematic reviews and meta-analyses; interventions that did not meet the WHO definition of TH; animal studies; or studies where the participants were aged >18 years, children’s results were not reported as a separate subgroup, or there were no results reported for individuals with CP.These criteria were assigned due to resource and funding constraints of this scoping review. Due to the recent advances in TH, it was considered that research completed before 2010 would be outdated.Abstracts identified by the search strategy were screened by 2 investigators (MPS and TT) for eligibility using the above criteria. If it was unclear from the abstract whether the article met the eligibility criteria, the full article was retrieved for assessment.The search strategy is represented in The search was conducted on July 2, 2021. The systematic search strategy produced 231 abstracts. After reviewing the titles and abstracts, 214 articles were excluded as they were duplicates or did not meet the eligibility criteria. After reviewing the full text of 17 articles, 13 were excluded as they did not meet the eligibility criteria. From the backward reference searching of the 4 eligible articles, 1 further article was included. Therefore, 5 articles were included in this scoping review. Additionally, 2 of the included articles were systematic reviews, which included the results of 3 relevant studies each. Therefore, the results of 11 studies were included in this review ,11,13-20Preston et al  investigHung and Fong  publisheStaszuk et al  investigThe TH process used cameras to look at the patient’s hand movements and a “TeleReh” application  where a The main technology behind this system was image processing. The proposed stages included (1) processing the video into picture frames and (2) using local thresholding to identify homogenous areas, which led to (3) hand detection based on hand texture, colors, and shapes. This research concluded that TH has potential to assist health care services and children in making health care more accessible, personalized, and available to all .Tanner et al  comparedA further systematic review was conducted in 2020 by Camden et al , investiA paper by James et al  was inclThis systematic review also included the only study that investigated a full-body intervention. All other included studies investigated interventions for the hand only. Mitchell et al  conducteFinally, Chen et al  meta-anaThe aim of this scoping review was to analyze and summarize the existing evidence for TH interventions for the treatment of children with CP and identify any areas requiring further research.We have found the existing evidence for TH interventions for the treatment of children with CP to be scarce and of poor quality, primarily comprising of underpowered pilot studies. There was reasonable consistency in the domains of outcomes measured, with most studies investigating activity, participation, and patient and parent satisfaction. However, most studies measured these domains using different tools; therefore, result comparison across studies was limited. Most studies did not include an adequate description of participants and often lacked CP neurological type or GMFCS level; therefore, the results were difficult to interpret for clinical application.The scope of the research into TH was often broad, whereas patient recruitment was limited, leading to underpowered results. Difficulties in assessing the efficiency and efficacy of these devices and services, as well as the broad definitions, make it difficult to directly compare their outcomes and combine results.However, in the aggregate, the results of TH interventions for the treatment of children with CP were positive, indicating either comparable results with children receiving usual face-to-face care or in some domains, the results were improved. Notably, there is some evidence that TH may increase participant motivation with therapy, reduce caregiver stress, increase functional abilities, and may improve the accessibility of health services. These findings are supported by previous reviews, which have found that assistive technologies for children with physical disabilities increase motivation and reduce caregiver burden .The only study that did not demonstrate any promising results was the study by Preston et al , who invThe results for TH without a computer-based or web-based game aspect also showed potential for functional improvements in children with unilateral spastic CP. Ferre et al  taught cAlthough these results are promising for TH as an intervention for the hand in children with CP, it should be noted that there is insufficient evidence on TH interventions for other areas of the body, including the lower limbs or body posture. Mitchell et al  conducteImportantly, we have not identified any investigation on pain management through TH. This TH type is particularly important as more than half (67.1%) of children with CP report acute pain , and thiOf critical and immediate importance to improving the existing evidence base for TH for children with CP is the development of studies with good methodological quality and a sufficient cohort to draw appropriately powered conclusions. The majority of the included studies in this scoping review were case series, which notably complicates the interpretation of results, as where results conflict, it is difficult to assess whether this conflict is due to intervention differences, problems with study methodology, or type II error.There is some evidence that the requirements of TH vary depending on developmental stage  and GMFCThere is also limited evidence of the barriers to TH implementation, particularly in the longer term. Most of the existing evidence is anecdotal or a short description of the reasons for attrition from studies. A larger qualitative study, investigating the reasons for dropout from TH studies or noncompliance with TH necessarily implemented during the COVID-19 pandemic, would provide a much greater understanding of the barriers to TH uptake.Future work would benefit from focusing on outcomes that are important to children with CP. Considering outcomes, such as pain and spasticity, that have been shown to have deteriorated through the lack of in-person treatment during the COVID-19 pandemic would also be useful. Parent-reported outcome measures were commonly gathered across TH studies, allowing the collection of data remotely. The most commonly used outcome measure was the COPM. However, it should be noted that the COPM has only been validated for children with spastic CP. Further work would be required to validate its appropriateness for children with ataxic and dyskinetic CP . The valFinally, more evidence is required to support the use of TH in the treatment of the lower limb or postural control for children with CP. The existing evidence is strongly focused on the upper limb. It is possible that retrospective studies of routinely collected clinical outcomes during the COVID-19 pandemic may provide some valuable insight into this area of TH.This scoping review included the results of 11 studies—a small number despite the broad eligibility criteria, which included any therapy, study aims, and outcomes measured. There are limited trials that have been conducted in this area despite the drastic increase in TH consultations reported through the COVID-19 pandemic. Retrospective research using routinely collected outcome measures in this patient group gathered throughout the COVID-19 pandemic may add important findings and context for the potential benefits of ongoing TH consultations. We would recommend the publication of any data gathered by health care professionals on their changing interventions in this time. As COVID-19 has affected the need for more TH, this subject is likely to expand exponentially in the future and more reviews similar to this paper will be needed for further assessment.Second, the substantial heterogeneity of participants made comparison of outcomes between studies challenging. To reduce the heterogeneity, classifications systems such as the GMFCS have been used. However, the GMFCS levels or CP neurological type were not consistently reported; therefore, it is unclear if the results are generalizable to the population or comparable to other forms of TH. This result has limited our drawing of clinical recommendations on TH for the treatment of children with CP, but it has helped identify limitations in the literature as a whole and addressed a key issue that needs careful consideration in future primary research investigating CP treatment.Third, due to the heterogeneity of participants and the inconsistency in outcome measures used, it was not possible to directly compare the results of studies through meta-analysis. Therefore, we were unable to directly compare the quantitative results of the studies and examine statistically and clinically significant differences across smaller studies, which has affected our efforts to chart data and directly visualize results quantitatively. As the technological advancements increase and the quality of the research improves, we hope that in the future, there will be more quantitative data to enable direct analysis and comparison, which will inform clinical recommendations for TH.Finally, due to time and resource constraints, we were unable to perform a formal critical appraisal of the included studies, which may mean that the results are unduly influenced by research with poor methodology. We have tried to identify notable areas of concern with research methodology within the narrative review, as a less formal critical review. However, future work in this area should consider a formal critical review.This scoping review provided for the first time an up-to-date account of the current evidence on TH for children with CP. The evidence has been shown to be lacking due to poor study design or underpowered results; therefore, clinical recommendations were not possible. However, this scoping review has shown that TH has demonstrated its potential to improve hand function while making health care services more accessible. TH interventions have shown similar or improved results compared to face-to-face treatment. To understand precisely how this technology will benefit children with CP, further research is required, with a focus on the lower limb, postural control, and quite importantly, pain—a substantial barrier to interventions being accepted by children. Further work to identify barriers to TH implementation is also required.


Birth is a physiological act that is part of the morpho-functional economy of the maternal body. Each stage in the act of birth has a predetermined pathway that is neurohormonally induced and morpho-functionally established through specific and characteristic adaptations. Like maternity, childbirth also has an important impact on the maternal body as a biological structure and psycho-emotional behavior. Cesarean section performed at the request of the mother with no medical underlying conditions besides the prolonged hospitalization risk can also cause breathing problems in children, delayed breastfeeding, and possible complications in a future pregnancy. Vaginal birth remains the path of choice for a physiological evolution pregnancy. Although erroneously considered safe and easy today, cesarean section delivery must remain an emergency procedure or a procedure recommended for pregnancies where birth is a risk to the mother and to the child, as cesarean section itself is a risk factor for negative outcomes for both mother and baby. This review summarizes the impact that both cesarean section and natural birth have on mother and newborn in their attempt to adapt to postpartum events and extrauterine life. When we talk about vaginal birth or cesarean birth, we have in mind childbirth, that is, the process by which the product of conception—the newborn—separates from the maternal environment and begins its life under completely new conditions. Physiologically, this passage is gradual and phased, equally including maternal participation and fetal adaptation in an absolutely physiological manner that characterizes labor for the human species ,2. The WThe aim of this review is to summarize the impact that both cesarean section and natural birth have on mother and newborn regarding their physical and emotional health in their attempt to adapt to postpartum period and childcare for the mother and to extrauterine life for the newborn.To understand the adaptation effort to which the mother and newborn are subjected, a brief incursion into the physiology of birth with its two components is necessary. First, the maternal component prepares the act of childbirth through a series of morpho-functional changes facilitating the evolution of birth. Thus, labor, for example, is preceded by hormonal changes starting 3 to 4 weeks before the actual moment . Labor iNote that all these changes occur over time, and their actual performance in childbirth takes 8–12 h. Apart from the local pelvic-genital changes, there are changes and adaptation incurred by all organs, apparatuses, and systems of the maternal body. Thus, the rhythm and amplitude of breathing increases by about 20% (24–26 rpm and 600 mL of the current volume), heart rhythm increases to 80–85/min, AP increases by 10–20 mmHg, and cardiac output by 20–30% ,16; withIn labor context, maternal suffering is notable and is characterized by pain (labor pain) generated by uterine contractions, compression, and traction on the pelvic-genital structures . Labor p A separate remark must be made as regards the psychic component through the emotional state, depression, and stress it implies, which may interfere negatively with the evolution of pregnancy. It is estimated that the global prevalence of postpartum depression (PPD) is approximately 17%, directly associated with country development and national or regional income ,24. The The major impact of the act of childbirth on the baby is the absolute need for immediate and subsequently gradual adaptation to a new environment of life: the extrauterine medium where the conditions are completely different and require a considerable effort of adaptation from the newborn. However, it is a complex physiological process that is verified in time and that, under normal circumstances, is concluded with the emergence of the parent–child couple ,9. BeyonThe exact nature of fetal pain remains unknown, but there is evidence that the fetus experiences pain in the third trimester of pregnancy . The perSimply, the newborn can express pain only at the moment of his first breath, which is nothing more than a scream of pain followed by crying that most of those present consider an expression of life and vitality when it actually comes from an underlying pain accumulated throughout birth. Crucial changes, however, are the functional changes that occur with birth because the morphological changes are reduced to skull changes, as it becomes ovoid by overlapping the sutures due to the compression of the pelvic-genital passage with the risk of hemorrhage  . The preHowever, a certain degree of perinatal stress is beneficial during childbirth, as it increases the synthesis of cortisol and catecholamine in the infant’s blood; these are hormones of great importance for the achievement of pulmonary maturity and for the adaptation of the circulatory system to extrauterine life ,45.Of vital importance, however, are the functional changes of the vital organs of the lung and heart that provide the vital functions: breathing and circulation, which occurs spontaneously with the sudden passage to the extrauterine life. According to Schuler et al.’s study, newborns delivered through the birth canal achieve higher cortisol levels and present an increased expression of pain compared to neonates delivered by cesarean section .The lungs are still full of liquid until the first breath. The first inspiratory effort plays a critical role by generating an active pressure gradient that allows the fluid to pass into the interstitial tissue, from where it will be gradually removed by pulmonary and lymphatic circulation . The firAll these will be followed by specific care, natural nutrition , and the psycho-affective and environmental stimulation of the mother–child couple, which will be the expression of the normal physiological evolution of vaginal birth. We emphasize that the above mentioned can be circumscribed to 95% of births .Every obstetrics textbook has a chapter entitled pathology of labor, which, of course, refers to situations where, for various reasons, birth does not progress, progresses slowly, or stops evolving.Many situations that affect birth belong to the pathology of pregnancy, which can be equally maternal, i.e., consuming diseases, basin dystocia, or congenital malformations; related to pregnancy, i.e., twins or malformations; or they may be related to the fetus, i.e., position dystocia, congenital malformations, hydrocephalus, or other situations that make it impossible or risky to give birth through the birth canal . Today, In India and Egypt, it was practiced since the year 600 BC, and the legal regulations were instituted in the time of the Roman King Numa Pompilius in the Lex Regia, which specifically provided cesarean as a mean of extracting the child from his deceased mother. This provision could also be found in Lex Caesarea during the time of Emperor Julius Caesar somewhere between 46–44 BC, hence the name Cesarean section ,52.The first mention in a medical book dates back to 1350, and the first measures to apply for the parturient in difficulty belonged to Ambroise Paré in 1550 and Jeremias Trautmann in 1610, whose patient died 25 days after through septicemia. Hemorrhage, peritonitis, and septicemia were major hazards until 1882 when Sänger introduced the surgical wound suture , in 1876 when Foster introduced asepsis and antisepsis, in 1847 when Simson introduced anesthesia, and in 1907 when Frank of Bonn and Hugo Selheim performed the incision on the lower uterine segment, bypassing the contractile area of the uterus and implicitly the peritoneal layer ,53. ModeIn many developed countries, the number of cesareans has increased, and attention has been focused on strategies to reduce its use, as it does not provide additional health gain but may increase maternal risks, and it may have implications for future pregnancies and health services ,58,59,60Another common reason for cesarean section is the phenomenon of defensive medicine. Defensive medicine seems to be related to gynecologists’ fear of legal actions promoted by their patients for medical malpractice and negligence .Additional concerns and controversies related to cesarean section include inequalities in the use of the procedure not only between countries but also within countries as well as the costs they impose on health systems ,64. For A contributor to the increased cesarean section levels might be the remuneration system that pays the same amount for vaginal and cesarean birth regardless of the prolonged assistance hours given in vaginal deliveries .The highest cesarean section rates are found in Latin America and the Caribbean (40.5%), and the lowest rates are found in sub-Saharan Africa , indicatIt is true that modern technical possibilities also highlight many situations that could negatively influence the evolution of pregnancies that would require a cesarean section as a necessity .Cesarean surgery is actually a brutal interruption of cohabitation of the fetus with his mother through the surgical separation that this procedure implies. It can be said that although the intervention is scheduled, and the psychological preparation of the mother is fulfilled, physiologically, neither the maternal nor the fetus’s body is prepared . It meanWHO’s recommendation of initiating breastfeeding is within one hour of birth . AlthougAs for the number of cesarean sections a woman can have, research has not established an exact number of repeat cesarean sections considered safe. Compared with primary caesarian section, multiple repeat caesarean sections (MRCS) are associated with additional risks including placenta previa, abnormal placental invasion, and difficulties in surgical dissection ,82. FurtThis impact is not less important because the same intervals that physiological birth implies are bypassed through cesarean. The slow adaptation to the new living environment involved by the passage through the pelvic-genital canal is brutally interrupted. The first breath is no longer the result of decompression of the thorax that passed through the pelvic strain but the result of artificial skin stimulation, thoracic massage, or ventilation with the balloon. The presence of the anesthetic in the fetal circulation diminishes the tone and reflexes of the newborn, delaying the immediate adaptation reaction.It is known that the newborn needs >5 min to attain an arterial oxygen saturation >80% and almost 10 min to reach 90% during a normal postnatal transition . CesareaKnigin et al. evaluated the effect of maternal hypotension after spinal anesthesia for elective cesarean and the time from anesthesia to delivery as risk factors for neonatal acidosis. Anesthesia-to-incision and incision-to-delivery intervals, use of vasopressor treatment, and sustained spinal hypotension were independently associated with neonatal acidosis. However, no neonatal complications such as transient tachypnea of the newborn, respiratory distress, or admission to NICU were encountered. Other factors such as maternal age, the number of previous cesarean deliveries, gestational age, neonatal birthweight, and fetal presentation were not associated with neonatal acidosis . In terms of newborn cerebral oxygen saturation measured immediately after cesarean delivery, Willfurth et al. concluded that cerebral tissue oxygenation in neonates during immediate transition after birth was similar after maternal general and spinal anesthesia despite differences in SpO2, heart rate (HR), and APGAR score in term neonates. In preterm neonates, there were no statistically significant differences in SpO2, HR, and cerebral oxygen saturation between the two groups of study. Only the APGAR score in the 1st minute was significant lower in the general anesthesia group . In contThe absence of positive stimuli determined by the mother–child relationship that is delayed in cesarean delivery would negatively influence the child’s adaptation, especially because nutrition is delayed by the absence of lactation or the impossibility to practice it during the first 24 h ,2,8. TheRegarding the pediatric consequences of cesarean section, several studies concluded that cesarean section is a risk factor for respiratory tract infections, asthma, obesity, and neurological disorders in children . CurrentDuring the last years, the relationship between cesarean section and childhood asthma has been a subject of debate, with contradictory opinions available in the literature. Darabi et al., in their systematic review and meta-analysis, concluded that cesarean section, whether elective or performed for emergency reasons, increased the risk of childhood asthma . The lacLavin et al. compared the risk of obesity in childhood of children born through cesarean section (elective and performed in emergency) and children born through vaginal birth. Their findings suggested that there might be an association between cesarean section and childhood overweight . ConcernCesarean section is thought to have a negative effect on early brain development. Zhang et al. conducted a systematic review and meta-analysis to evaluate neurodevelopment and psychiatric pathologies in children delivered via cesarean section compared to those born through vaginal birth. They concluded that cesarean section was associated with an increased risk of several disorders. Autism spectrum disorder (ASD) and attention deficit/hyperactivity disorder (ADHD) were most statistically significant . SimilarBirth is a physiological act that is part of the morpho-functional economy of the maternal body. Each stage in the act of birth has a predetermined pathway that is neurohormonally induced and morpho-functionally established through specific and characteristic adaptations. Like maternity, childbirth also has an important impact on the maternal body as a biological structure and psycho-emotional behavior as well as on her social life and relationships.The passage through the pelvic-genital canal in the act of childbirth is accompanied by important functional processes with a decisive role in adapting the newborn to extrauterine life, with beneficial effects on both the mother and child. Mother–child cohabitation and breastfeeding can be restored after the physiological birth.Vaginal birth remains the path of choice for a physiological evolution of pregnancy. Although erroneously considered safe and easy today, cesarean section delivery must remain an emergency procedure or a procedure recommended for pregnancies where birth is a risk to the mother and to the child.


Results: Here, 1320, 246, and 139 students completed our questionnaires in the different time intervals. The international students reported significantly lower values in terms of perceived social support. Concerning depression, the international female students reported higher values than the domestic female students. Significant correlations were found in both samples between vital exhaustion and depression, as well as between perceived social support and depression. Conclusion: In this study, the international students reported lower levels of perceived social support and higher levels of depression, particularly among females. The correlations between depression, social support, and vital exhaustion might highlight protective and risk factors. These findings emphasize the importance of addressing social support and mental health among university students, especially among international students who have a difficult time finding social support during times of stress, such as during the COVID-19 pandemic.Background: Our study aimed to assess the differences between domestic and international students in terms of social support, vital exhaustion, and depression during the period of COVID-19 and to examine the relationships and potential effects of these factors on each other. Methods: The online cross-sectional survey was conducted via Google Forms The first cases of coronavirus disease were declared on 4 March 2020 in Hungary, and shortly after the educational institutes switched their teaching method to the online form and a nationwide lockdown was announced .Anti-pandemic regulations can disrupt social interconnectedness, which is associated with an increased risk of psychological difficulties . During Previous researchers have found that college students are more likely to have mental health problems  and alsoThe fact that international students who study in a host country away from home have more mental health problems than those who study in their home country has long been supported by research, which has already drawn attention to the importance of social support, which can alleviate mental health problems for international students as well ,11,12.Concerning depression, men have a lower prevalence rate than women but a higher suicide rate, and because of this many kinds of research investigate gender differences regarding depression to be able to adequately detect it ,14.The conceptual separation of depression and vital exhaustion has been debated in the literature for years ,16. In aThe purpose of our study was to compare the levels of perceived social support, vital exhaustion, and depression and to examine their relationships to each other among university students in Hungary during the COVID-19 pandemic in three periods, using three validated assessment tools for each factor. By conducting the survey in three different time periods, we were able to observe the differences and relationships among the examined factors caused by the effects of changing circumstances related to the pandemic within the rounds. We wanted to see the differences not only in terms of the student status  but also in terms of the gender. We hypothesized that students away from home receive less social support, and this may be related to the degree of depression and vital exhaustion. Furthermore, we believed that it is easier for women to find social support that would be thought to counteract depression . BecauseOur study used a cross-sectional design in three time intervals with the help of self-administered questionnaires we created in Google Forms.The first round of the survey administration process was carried out in the period between 30 April 2020 and 15 May 2020. At the start of the pandemic, it was often claimed that the virus was brought into the country by foreigners or Hungarians traveling home from abroad .The second round took place between 15 June 2020 and 29 June 2020. During this phase, there were perhaps the fewest new cases, the lowest rate of positive tests, and minimal deaths. The restrictions had been lifted almost without exception .The third round of questionnaires was filled out by the participants during the period between 20 July 2021 and 7 August 2021. During this time, the country was past two very big waves, and the third wave’s downturn took place. Vaccinations had been released, which were also available to international students, and the Head of the Prime Minister’s Office ranked Hungary as one of the safest countries [We conducted our study at the second largest university in Hungary. According to the university’s website, there are 28,593 students, of which at least 6297 are international students .International and Hungarian students were included in our sampling. The targets were reached through social media platforms , and also the university’s official student administration system (Neptun) was used to reach out to them. We assumed that our survey reached every student at the university. The questionnaires could be filled out anonymously during the determined periods, meaning of a convenient sampling approach was utilized.Four international scales were applied in the development of the survey, collecting data about perceived social support, vital exhaustion, and male and female depression. Domestic students filled out Hungarian versions of the questionnaires, while international students were asked to complete English versions of them.Multidimensional Scale of Perceived Social Support (MSPSS). The 12 items are rated on a seven-point Likert scale in the English version, while the 10-item Hungarian version uses a five-point Likert scale. Three subscales were identified, each addressing a different source of support: family, friends, and significant others [To assess the amount of social support, we used the t others . The orit others ,24.The Shortened Maastricht Vital Exhaustion Questionnaire and its Hungarian version served as tools to assess vital exhaustion. Vital exhaustion is related to an individual’s general well-being, which is measured using five dichotomic items. The internal consistency of the item group proved to be good for the Hungarian validation (Cronbach- α =0.78) , as wellFemale depressive symptoms in the sample were assessed using the revised version of the 21-item Beck Depression Inventory (BDI). The participants are asked to rate the range to which they have experienced particular depressive symptoms in the past week using a four-point Likert scale ,28.The level of male depression was measured with the Gotland Male Depression Scale (GMDS). Both the English and Hungarian versions of the questionnaire have 13 items, and it assesses not only the so-called “traditional” depressive symptoms but male depressive symptoms as well . The respondents used a four-point Likert scale to answer the questions ,30.To compare the extent of depression between the genders, we divided the results into three groups according to previous recommendations ,31: no, p-value of less than 0.05 was set for statistical significance.The required data were extracted from Google Forms in an Excel sheet. First, we checked the quality of the data and coded it in a format that we could analyze with SPSS (v.25). The presentation of the descriptive and summary statistics was appropriate. To appraise the differences between groups  in accordance with the level of perceived social support, vital exhaustion, and depression, we used non-parametric Mann–Whitney U tests, since the variables had no normal distributions. We also used Spearman’s rank correlation to evaluate the relationship between the investigated factors within the international and Hungarian groups. A The Hungarian Ethical Review Committee for Research in Psychology provided the ethical permission (Reference number: 2020-45).The demographic characteristics are shown in The perceived social support levels of the university students were investigated according to gender via Mann–Whitney U test in each round and also in both samples.p < 0.001). The other rounds showed no significant differences between genders.The examination of Hungarian students’ perceived social support is shown in We also investigated gender differences among Hungarian students according to the MSPSS subscales. The perceived social support subscales differed significantly based on gender, as women had significantly higher values in the first round in all aspects of the questionnaire .p = 0.05) higher median (62) than the male students (55). In the last period, the median for the female students was 45 compared to 67 for the male students (p = 0.036)  .Similar to the Hungarian sample, the international women’s perceived social support subscale levels were higher in the first round than the men’s, although only significant the family and significant others subscales were significant. We also found significantly higher values in the female group during the second period of administration in the friends subscale. In contrast to these findings, the values for men’s perceived social support from their family and friends were significantly higher in the third round .As the Hungarian and English versions of the MSPSS differed both in the numbers of items and scales, we converted the results into percentages, which allowed us to compare the samples.p < 0.001). During the second round, the Hungarian level of perceived social support was also higher (M = 80.00%) than the international students’ (M = 63.89%) . Similar to the first two rounds in the last period, domestic students also reached higher scores (M = 75.00%) than international students (65.97%), although the difference was not significant (p = 0.056)  .Comparing the two samples in terms of the subscales, the international students had lower values for social support in all of the examined factors. The results were significant in every subscale during the first period of questionnaire administration, as well as in the second and third rounds for the friends and significant others subscales .p < 0.001).Examining the level of vital exhaustion regarding genders in the Hungarian sample, we found that women had higher values in each round , althougp = 0.022).In the international sample, similar results can be observed . Women rThere was no significant difference between the Hungarian and international students concerning vital exhaustion.According to the results of the BDI completed by the females, the average scores for international students were significantly higher than for the domestic students in every period. There were no significant differences in GMDS scores between the two samples. The results of the depression questionnaires are shown in As mentioned previously, both scales can be aggregated into 3 groups according to the scores, allowing us to examine the differences between the genders in terms of depression. In the Hungarian group, there were no significant differences and both genders’ medians were the same. Among the international students, the women suffered from significantly more severe depressive symptoms in the first round; this difference decreased during the second round, while the difference was not significant in the third round .We correlated the vital exhaustion, perceived social support, and depression values using Spearman’s rank correlation . SignifiPrevious studies have proven that social networks among individuals play an essential role in mitigating psychological problems ,33. As eBased on the previous investigations ,37, our International students are prone to being exposed to more psychological stressors because of the separation from their home environment and their different cultural values, language, levels of academic preparation, and study habits; they also tend to have less social support ,41, whicAmong university students, depression is one of the most prevalent psychological disorders ,43. InteStrong positive correlations were observed regarding depression and vital exhaustion in both samples, which indicates the potential role of vital exhaustion as a risk factor related to depression. On the other hand, the moderate negative correlations between depression and perceived social support designate one’s perceived social support as a protective factor and a moderator against depression among university students.The differences between the social support levels of domestic and international students gradually decreased. The reasons behind that phenomenon could be numerous, including the vaccine, which gave the freedom and courage to international students to re-open to the world; the decreasing number of restrictions; and the initial shock caused by the poor quality of media communications having been alleviated.The shift between the extent of perceived social support and the severity of depressive symptoms is an interesting phenomenon; while international female students perceived greater social support at the onset of the virus, males experienced less, and this difference gradually narrowed. In contrast, the depressive symptoms started higher in women, and the gender gap disappeared again over time. It is worth comparing this phenomenon with the change in correlations between social support and depressive symptoms in international women and men. While initially the correlation was negative for men, it reversed in the third round, and in women there was a huge negative correlation change in the last round.At the onset of the virus, the domestic students seemed to perceive significantly more social support in all areas than their international counterparts, but social support seemed to level off between domestic and international students as a result of the increasing time spent under the threatening factors. This raises the possibility that in the event of an outbreak of a protracted danger, the provision of well-chosen information and communication and mental support to foreigners by a host country can have particularly constructive effects, and can even serve preventive purposes. This is because social support can counteract vital exhaustion and depression. Regarding depression, the most vulnerable group seemed to be the female international student group. Using different gender-specific questionnaires, it became apparent that after the initial shock, men are just as vulnerable as women when it comes to depression.Although this study was conducted as a cross-sectional survey and not a longitudinal study, we were able to examine the differences in these factors within the three time periods. Additionally, the sample size was relatively small in the second and third rounds. The results may not be generalizable to the wider population of university students in Hungary. Further research, including with longitudinal studies, is needed to better understand the factors influencing the mental health of university students during the COVID-19 pandemic and after the lifting of restrictions.Our cross-sectional study found significant differences in the levels of perceived social support between domestic and international university students in Hungary during the COVID-19 pandemic. The international students reported lower levels of perceived social support in all three periods of the survey. These differences were statistically significant in the first and second rounds, but not in the third round. When examining the subscales of perceived social support, the international students consistently reported lower levels of social support from family, friends, and significant others compared to Hungarian students, with these differences being statistically significant in the first period for all subscales and in the second and third periods for the friends and significant others subscales. These findings suggest that international students may be more vulnerable to experiencing low levels of social support, which could have negative consequences for their mental health as compared to domestic students. There was no significant difference in vital exhaustion levels between Hungarian and international students, although the female students did report significantly higher levels of vital exhaustion in both samples, with this difference being significant in the first round of the survey in the Hungarian sample and in the second round of the survey in the international sample. In terms of depression, the international female students scored higher than Hungarians. The female international students had higher levels of depression than the male international students in every round, but this difference was not statistically significant in the third round. Strong positive correlations were observed between depression and vital exhaustion in both samples, and moderate negative correlations were observed between depression and perceived social support in both samples.Overall, the results of this study suggest that social support plays a significant role in the mental health of university students during the COVID-19 pandemic. Given the outcomes of this research, it is important to focus on providing mental health resources and support, especially for international students during times of stress and uncertainty. It is crucial to highlight that international students are far away from some of their social support resources and may be more vulnerable to experiencing low levels of social support in a foreign country, which could have negative consequences on their mental health. Our findings also suggest that vital exhaustion may be a risk factor for depression, and that gender may be a contributing factor to the experience of these mental health factors. The strong correlations observed between depression, vital exhaustion, and social support emphasize the importance of addressing these issues in a comprehensive and interconnected manner. The future research should involve a longitudinal study to further examine the dynamic relationships between these factors and the impacts of changing circumstances related to the pandemic.