Nearly 60% of maternal and 45% of newborn deaths occur within 24 h after delivery. Immediate postpartum monitoring could avert death from preventable causes including postpartum hemorrhage, and eclampsia among mothers, and birth asphyxia, hypothermia, and sepsis for babies. We aimed at assessing facility readiness for the provision of postpartum care within the immediate postpartum period.A cross-sectional study involving 40 health facilities within the greater Mpigi region, Uganda, was done. An adapted health facility assessment tool was employed in data collection. Data were double-entered into Epi Data version 4.2 and analyzed using STATA version 13 and presented using descriptive statistics.Facility readiness for the provision of postpartum care was low . Availability, and use of up-to-date, policies, guidelines and written clinical protocols for identifying, monitoring, and managing postpartum care were inconsistent across all levels of care. Lack of or non-functional equipment poses challenges for screening, diagnosing, and treating postnatal emergencies. Frequent stock-outs of essential drugs and supplies, particularly, hydralazine, antibiotics, oxygen, and blood products for transfusions were more common at health centers compared to hospitals. Inadequate human resources and sub-optimal supplies inhibit the proper functioning of health facilities and impact the quality of postpartum care. Overall, private not-for-profit health facilities had higher facility readiness scores.Our findings suggest sub-optimal rural health facility readiness to assess, monitor, and manage postpartum emergencies to reduce the risk of preventable maternal/newborn morbidity and mortality. Strengthening health system inputs and supply side factors could improve facility capacity to provide quality postpartum care. There is a global average of 830 maternal deaths and 6700 newborn deaths daily from preventable causes with majority of these occurring in developing countries –3. In UgFacility readiness is a measure of how prepared health facilities are to provide health services and is measured by the availability of components required to provide services like adequate qualified and trained staff, guidelines on the provision of care, basic amenities, basic equipment, standard precautions, laboratory tests, and medicines and commodities , 12. FacHigh facility readiness is crucial for the achievement of the third Sustainable Development Goal (SDG) to reduce the maternal mortality ratios and neonatal mortality rates by 2030 , 15. OneThe World Health Organization (WHO) advocates that women and newborns receive care from motivated, skilled practitioners in a safe and dignified environment that regularly has the necessary equipment and drugs . Lack ofEnding preventable maternal deaths continues to be one of the most important goals internationally with a target of less than 70 maternal deaths per 100,000 live births by the year 2030 . Health This was a cross sectional study that employed quantitative methods of data collection using a facility assessment tool. This study design was adopted because we sought to collect data at a single point in time to assess how prepared the facilities were to provide care to women and babies within the immediate postpartum period.The study setting was in the greater Mpigi region found in central Uganda, which consists of three districts namely: Butambala, Gomba, and Mpigi. This region was chosen because it is centrally located and it has health facilities in both the peri-urban and rural settings, which serve a wide population. The health system in Uganda has several tiers including: health centers I, II, III, IV; general hospitals; regional referral hospitals; national referral hospitals; and national specialized hospitals. A health center I is located at the village level and provides basic home-based care and health promotion. The care at this level is provided by the village health teams comprised of volunteers in the community. Health center IIs are located at the parish level and provide outpatient curative services and outreach for health promotion. At the sub-county level, we have health center IIIs, which provide all the above and inpatient medical, antenatal and maternity care. Next is the health center IV at the health sub-district, where emergency surgical and maternity care, blood transfusion and laboratory services are available, together with the health promotion and outpatient curative care. Then we have the general hospital at the district level that provides all the care and services provided by the health center IVs, in addition to general surgical care, mental health care, dental care and some specialized services like physiotherapy. At the regional referral hospitals, clients can access specialized medical services. These also offer training for different cadres of health workers. There are 9 national-level hospitals, of which 5 are specialized. None of these national referral or specialized hospitals were included in this study.The target population for this study were all the health facilities in our study area that provide intrapartum care services and health facility based postpartum care which include: hospitals, health center IVs and health center IIIs according to the current Ministry of Health (MOH) policy guidelines for health care services , 21.The facilities in the greater Mpigi region that were eligible to participate in this study were those that conducted deliveries and had been providing the service for at least 6 months at the time of the data collection. The three district health officers and all included facility administrators provided administrative clearance for the study to be conducted at their health facilities. Thereafter, permission was sought from the maternity ward in-charges to conduct the study on their units. Informed consent was sought from all the midwives and mothers who participated in the study.The sample size of 40 health facilities was calculated using the simplified formula by Yamane  at a conThe data were collected using a facility assessment tool that has been adapted from the Ministry of Health’s original result-based financing (RBF) assessment and the SARA facility assessment tools . The MOHThe dependent variable for this study was the facility readiness for the provision of postpartum care, which was the median score for all the facilities based on the facility readiness assessment scores. The independent variables included: facility level, ownership, number of midwives, district, average number of deliveries per month, and number of postnatal beds.Data were collected over a period of 4 months between August and December 2020. After verifying the functionality of the facilities identified in the national health facility inventory  with eacVarious items were assessed in the facility readiness assessment tool including: length of hospital stay following a normal delivery; routine monitoring of postpartum care; availability of space; tracer medicines; commodities; equipment; sundries; a functional transport system; and a health education program for the postpartum women and their care givers. Completion of the assessment tool included verification of the presence or absence of the various equipment, drugs, postnatal charts, MOH guidelines for postpartum care, standard operating procedures for the provision of postpartum care, visual reminders for midwives / checklists for care provision, discharge guidelines, health education guides , brochures for information provision, examination room / couch, cleaning materials and cleaning schedule for the postnatal unit. For sections where there was observation of care being provided, the team requested to be present while care was being provided to a postpartum mother so as to observe the care provided to the client. No identifying information regarding the clients was collected, as the researchers were only interested in observing what the midwife did in providing care. The clients were informed about the study and requested for consent to be observed while receiving care. In facilities where there were no clients found at the time of the visit, the midwife was asked to describe what she does for each client from the time of delivery of the baby to the time of discharge, and this was assessed against the postpartum care guidelines for both the mother and newborn. The midwife was then asked to avail the team with policy guidelines and checklists that were being used for the provision of care and health education. She also took the team to the ward, store and laboratory where they checked for the availability of drugs, sundries , equipment, blood products, and laboratory equipment. Regarding the postpartum counseling done and documented by the midwife. We interviewed one midwife at each health center III and health center IV. At the hospitals, we interviewed and observed 3 midwives providing in-facility postpartum care but only one midwife who was the maternity in-charge assisted the researchers in ascertaining the presence of the required documents, drugs and equipment. The number of midwives assessed was based on the guidance from the tool and the availability of the midwives/ patients at the health facility at the time of the facility assessment. The team spent at least 1 day at each facility depending on the availability of the facility in-charge, midwife and the postpartum clients. Each filled assessment tool was reviewed for completeness before leaving the facility and any missed observations were completed before departure from the facility.Data were double entered into Epi data version 3.1, cleaned, and exported to Stata version 14.2 for analysis , 25. UniThe greater Mpigi region has three districts from which the facilities were selected. The majority of health facilities were government owned and half of them 20/40 were within Mpigi district Table . Among tOf the 40 facilities, 5/40 12.5%) had no dedicated postpartum beds available while the majority had 1-to-4 beds  of the facilities scored 5 out of 15 points Table  because The majority of the facilities 33/4082.5%) did not score any points in this section since they had inadequate space, no privacy and insufficient beds for their clients  of the facilities scored 0 out of 5 points Table  because The maximum score attained was 5 out of 15 points which was achieved by 20/40 (50.0%) of the facilities  scored 5 out of 15 points under this section  scored 5 because they had access to a vehicle to transport clients in need of referral  scored 0 under this assessment category Table  because .0 scoredThe overall median score for health facility readiness was 24% . The minimum score was 9.3% and the maximum score was 60% , while health center IIIs had the lowest median score . The private not for-profit facilities also had a higher median score  compared to government-owned and private for profit facilities which had median scores of 21.3%  and 24.0%  respectively  for the MOH facility assessment tool that is used for facility assessments in the RBF program being implemented in the region. RBF is a world bank funded government initiative in Uganda that is aimed at improving the maternal, newborn, child and adolescent health (MNCAH) services in the country through offering financial incentives to health facilities that achieve the desired performance for defined indicators for the MNCAH outcomes. It has been rolled out progressively in the country over the last 5 years and had just been rolled out in the greater Mpigi region at the start of the data collection for this study . Some ofThe study shows that the health facilities had not taken up the policies and guidelines that would improve facility readiness for emergency obstetric care. The MOH issued new guidelines in 2016 for the provision of postpartum care based on the WHO recommendations , 26, howThough the current guidelines were introduced over 5 years ago, the use of checklists for postpartum monitoring was reported to have been recently introduced in some facilities to meet the requirements by supervisors for the RBF activities in the region at the time of the study. As such, in some facilities where protocols had been enacted, the postpartum care documentation was noted to be incomplete or filled retrospectively. This is not surprising as it has been found that the translation of policies and guidelines into practice is slow and is usually dependent on the implementing institution’s ability to adapt and own the proposed guidelines . This prConsidering that this study was conducted at the start of the financial quarter for government facilities, many had the necessary equipment, drugs, and sundries. However, there were still several facilities that had shortages for essential drugs, and sundries . This is an impediment to facility readiness and is a hindrance to the effective provision of care to the clients, and could be a source of stress for the health workers as they provide care . This fiIt is important that healthcare providers are able to work in a well-functioning health system where good quality care can be provided. Adegoke et al.  describeThe findings of low facility readiness have implications for the quality of care provided. For example, influencing patients’ experience of care, which largely depends on the outcomes of the care and the relationship between the client and the health workers. A facility that is not ready to provide care will likely produce delays in accessing care and fail to provide services, which, coupled with health workers that are frustrated because of the system constraints in care provision, is likely to result in a negative or poor experience of care for the client , 46. OneWe note that, availability of facilities for patient care may not necessarily mean that these could be easily accessed by patients, further limiting validity of the facility readiness assessment tool. In addition, it does not mean that the guidelines or equipment are used for decision-making for patient care. For instance, although there were ambulances available at the government and private not-for-profit facilities , access to them by patients coming from lower health facilities was limited due to the fact that the patients needed to contribute funds for buying fuel before they were transported. These findings are similar to those of a study done in Uganda assessing the relationship between facility readiness and its effect on malaria outcomes, which found that availability of emergency transportation at health center III and II level was only 5.2% . A studyThe study also noted a lack of integration of services, which affects facility readiness. For instance, more than half of the facilities 72.3%) that were assessed provided family planning services to their clients (Table % that weOur study used a performance tool for the assessment of the facility readiness with a scoring criteria based on the all or no point score system for six of the eight domains. This could have led to some facilities scoring lower than they would have if the scoring criteria was cumulative or based on a scale. Hence the results of this study do not fully reflect which specific items under each indicator needs to be improved. Such composite soring criteria are usually used where one desires to compute the scores easily and also be able to compare the performance of different facilities. Critical review of the scores may be needed to define clearly what distinguishes the high performing facilities from the low performing ones as recommended by the article on composite measures in assessment of performance in health care .This study was conducted in three districts and included different facility levels in rural and peri-urban settings and focused on care from the delivery of the baby to the time of discharge for women having normal deliveries. We used an objective method of assessment, hence the findings of our study are verifiable. We used a tool that was adopted from the RBF assessment tool because, at the time of conceptualization of the study, we noted that most facility assessment tools like the SARA were very broad and lacked some of the variables we were interested in assessing. As noted earlier, the scoring criteria for the tool was performance based, with an all or nothing composite scoring system for six of its eight categories. This could have been the reason for the overall low scores seen in this study. The low facility scores do not mean that the facilities were unprepared to provide any postpartum care but that they had gaps in some areas that could hinder their postpartum care provision. Secondly, concerning the signal function assessment for readiness to provide emergency obstetric care, we did assess the functions that spoke to immediate postpartum care only hence lack some of the aspects assessed by the SARA . ThirdlyThe level of facility readiness for the provision of immediate and early postpartum care was found to be low. Since more than 40% of all maternal and newborn deaths occur on the day of delivery, there is a need to work at improving the facility readiness for postpartum care to reduce the maternal and newborn mortality rates in our setting. Development of hospital policies/ guidelines on postpartum care provision, improvements in infrastructure, distribution of the policies, practice guidelines and emergency transportation could improve the facility readiness for postpartum care provision.Immediate postpartum period: In this study, this is the time from the delivery of a baby to the time of discharge from hospital or 24 h after the delivery of the baby depending on what precedes the other.Facility readiness:This is the measure of the degree to which health facilities in the greater Mpigi region are prepared to provide postpartum care to their clients based on the availability of equipment, drugs, human resources, space, policies and standard operating procedures for postpartum care service provision. This was assessed using a facility readiness tool Table  which haLength of hospital stay: For this study, the length of hospital stay was measured from the time of delivery of the baby to the time of discharge following an uncomplicated vaginal delivery.Postpartum care: This is the care given to a woman and her baby from the time of the birth of the baby to 6 weeks after delivery. In this study we focused on the care provided in the first 24 h after the birth of the baby or till the time the mother and baby are discharged from the hospital whichever precedes the other.Postpartum assessments: Postpartum assessment meant the examination of the mother baby pair post-delivery while monitoring focused on the sequential recommended monitoring of the mother and baby based on the Ministry of Health guidelines at the time (immediately after delivery, every 15 min for the first 2 hours then every hour till the fourth hour after delivery, then at 6 hours and four hourly till discharge if all is well


This framework focuses on the importance of the consideration of the downstream intermediate and long-term health outcomes when a change to a screening program is introduced. The authors present a methodology for utilising the relationship between screen-detected and interval cancer rates to infer the benefits and harms associated with a change to the program. A review of the previous use of these measures in the literature is presented. The framework presents other aspects to consider when utilizing this methodology, and builds upon an existing framework that helps researchers, clinicians, and policy makers to consider the impacts of changes to screening programs on health outcomes. It is hoped that this research will inform future evaluative studies to assess the benefits and harms of changes to screening programs. Cancer screening programs aim to reduce morbidity and mortality through the early detection and treatment of cancers that would have otherwise have gone on to present at a later stage . When a The prompt assessment of the effects of new technology or screening protocols requires methods using short-term outcomes . Once a For a change to a screening program to increase its effectiveness, it should result in an increase in the diagnosis of clinically important early stage cancers, a decrease in interval cancers diagnosed between scheduled screenings, and ultimately a decline in the incidence of cancers diagnosed at late stage. However, if such changes are not seen, any additional cancers diagnosed via a change to the program may represent overdiagnosed cancers that would not have otherwise presented, or more slowly growing cancers that would have been detected in the old screening program without detriment ,10. The A reduction in interval cancers is sometimes used as a surrogate measure of a change in screening effectiveness . Previou(1)an increase in screen-detected cancers with tumour markers indicating aggressive disease; and(2)a decrease in the interval cancer rate between screenings, indicating that at least some of the additional detection is occurring in clinically important and rapidly progressing cancers.(3)an increase in the detection of screen-detected cancers with tumour markers indicating low risk disease; and(4)no or minimal changes in the interval cancer rate between screenings, indicating that the additional detection is of overdiagnosed or slow progressing cancers.However, if the change only increases the detection of clinically unimportant cancers, we expect to see:The relationship between screen-detected and interval cancers can be further identified by plotting the risk difference in screen-detected and interval cancer rates before and after the change. Rates are typically presented per 1000 screens.(1)The top left quadrant shows a decrease in screen detection and an increase in interval rates. This observation indicates that there is decreased rate of detection, including clinically important cancers, and therefore suggests an increase in underdiagnosis(2)The bottom left quadrant shows a decrease in screen detection and a decrease in interval rates. This result indicates that there is decreased detection overall, but an increased detection of clinically important cancers, and therefore suggests a decrease in overdiagnosis. Theoretically this could occur with risk-stratified screening .(3)The top right quadrant shows an increase in screen detection and no change, or possibly even an increase, in interval rates. Assuming no change in the background rates of cancer, this observation would indicate that the increased detection represents an increase in overdiagnosis.(4)The bottom right quadrant shows an increase in screen detection and a decreased interval rate. This finding indicates that the increased detection does include clinically important and progressing cancers, and therefore suggests a decrease in underdiagnosis. The second and fourth quadrants show the improved effectiveness sought with a change to the screening program.In It is important to look not only at the relationship between screen-detected and interval cancer rates, but also at the tumour characteristics of the cancers detected. Differences between technologies in both screen-detected cancers and interval cancers for tumour characteristics such as size, histological type, grade, node status, and stage, allow for further assessment of the prognostic changes in the cancers detected .We conducted a targeted review (R.F. & I.B.) of the literature to examine the way in which interval cancer rates have been used to assess the harms and benefits of changes to screening programs, to identify if similar applied methodologies used interval cancers, as described above. (For search strategy see Most of the included studies in this review reported on changes to breast screening programs and technologies ,41,42,43Studies that reflected on the relationship between screen-detected and interval cancers have often used this relationship as an indicator of benefit, but few have considered it as an indicator of harm ,5,44. OfThe limitations of sole reliance on interval cancers were noted with the importance of complementing the comparison of interval and screen-detected cancers with tumour characteristics, to ensure increases in detection rate are reflecting clinically important cancers ,37. In mOne example is a study that used interval rates to consider both benefits and harms, as does our framework, comparing tomosynthesis to digital mammography . This stIt is important to consider underlying cancer rates in the population, as they can affect the screen-detected and interval cancer rates. Comparisons of interval cancer should be limited to monitoring within screening services or programs, because comparisons between screening programs and countries is limited by heterogeneity . ChangesThe changes in screening programs have been associated with an initial increase in false positive rates ,49. ThisIn addition to the impact of changes in screening programs on health outcomes, it is important to consider the workflow, economic, and environmental cost-effectiveness of such changes. An example of this cost-effect analysis is when a change in technology has significantly shortened the acquisition time but has significantly increased the interpretation time . The iniThe design and implementation of screening programs around the world will continue to change. It is human nature to think that new technology is better, but the translation to improved health outcomes needs to be evaluated . The meaThis framework puts forward a methodology of utlising intermediate outcomes of screen-detected and interval cancers rates to contextualise and weigh the indicators of benefits and harms of changes to a screening program. This approach is important for the consideration of changes in cancer screening practice and policy accounting for both short- and intermediate-term health outcomes.


Among the various psychosocial interventions aiming at improving behavior, quality of life, and the well-being of people with dementia, one that has attracted recent attention has been object handling. This scoping review synthesizes available studies on object handling for people with dementia, their effects, and methodological characteristics and describes its components and likely domains.The search was conducted using CINAHL, PsycINFO, MEDLINE, PsycARTICLES, Academic Search Elite, and Art Full Text, plus review of reference lists and hand search. Data from the studies included were chattered and reported in narrative form.Eleven studies were included; of which, 9 described a group intervention and 10 investigated the distinctive value of heritage items. Studies used a mixed-methods or qualitative design and varied in their procedures, including number of sessions and length of intervention. Most studies reported positive effects on well-being, mood, and emotion in those with dementia. Qualitative investigations revealed that the co-construction of an object’s meaning facilitated new learning, social inclusion, and change in attitudes toward dementia. From the review and stakeholder consultations, a definition of object handling is proposed, which includes three components: presenting, receiving, and responding.The findings suggest that people with dementia may benefit from object handling interventions as a means of improving well-being, mood, and social inclusion. The review highlighted a variety of approaches used and a small number of studies were identified under the term of “object handling.” Further studies are needed to examine the complexity of object handling, its impact within dementia care settings, and that explicitly use the term “object handling.” Given the focus to date on heritage, archive, and museum objects, more studies involving the handling of everyday material objects are needed because these are by definition highly accessible. Translational Significance: An increasing number of studies have used object handling as a psychosocial intervention in dementia care. However, there is inconsistency in how this term is applied. This review explores the literature on object handling and dementia. The evidence suggests that people with dementia may benefit from object handling interventions as a means of improving well-being, mood, and social inclusion. The paper proposes guidance based on an atheoretical model to describe the components of object handling. The findings, definition, and model are recommended for use in future studies of object handling and dementia.Dementia is an umbrella term, describing a range of syndromes affecting one or usually more cognitive domains that substantially compromise social and/or occupational functioning of older people aged 65 and older and those with younger onset usually between 30 and 65 years of age . To suppObject handling involves several senses, including touch that plays a fundamental role across the life span . This seMore recently, increasing evidence supports the value of using material objects in health care. Much of this assesses the impact of items from museum and gallery collections, a practice defined here as heritage object handling. Findings from heritage object handling sessions show that manipulating and discussing heritage items can increase participants’ well-being, social inclusion, provide intellectual stimulation, and prompt memories as well as creating links to the present .Despite the growth in use of object handling in dementia care, there is no clear definition of what object handling is. There are however some elements common to the practice. This includes offering or choosing a material object, and participants having the opportunity to explore, reflect, and respond to it. This therefore excludes activities like pet or doll therapy where the aims are somewhat different, for example, an intention to modify behavior. The use of a wide range of objects, that is not just heritage items, could also be included. These may incorporate everyday items or other types of curio or memorabilia. These elements inform our working definition of object handling.The aim of this review is to provide an overview of available object handling interventions and to map the outcomes relating to the impact of the intervention on people living with dementia. It is anticipated that this will help to define what constitutes object handling in dementia care settings.A scoping review approach has been selected as the most suitable synthesis method for the current research, as it incorporates a range of study designs and addresses questions beyond those related to treatment efficacy . The scoThe inclusion criteria and methods for the review were prespecified and are presented below according to the Preferred Reporting Items for Systematic Reviews and Meta-analyses Extension for Scoping Reviews (PRISMA-ScR) checklist .Studies were included if they were written in English and where participants were considered by authors as having dementia even if specific diagnoses were not provided. No specific restrictions regarding geographical, time limits on the publication, age, subtype, and severity of dementia were applied.In the absence of an agreed definition of object handling, an operational definition was created for the purposes of the review by identifying some similarities in the implementation across studies. The definition of an object handling intervention was as follows. It consisted of a program based on offering or choosing an object, with participants having the opportunity to explore, reflect, and respond to it, before moving to another item. The object(s) used could be of any type, from everyday items to museum artifacts. Group or individual sessions were included. Studies were included if object handling was combined with another activity .Articles describing interventions for use solely by caregivers were excluded. Studies were also excluded if they did not meet the above definition of object handling. These included studies that focused on cognitive training, doll therapy, reminiscence therapy, occupational therapy, Montessori-based activities, art making, and art viewing. Unpublished papers, study protocols, dissertations, and websites were also excluded.The review search was conducted in November 2018 and updated in February 2022 to ensure that all relevant articles were included in the review. The studies were identified using a combination of key terms and databases . The seaElectronic search results were downloaded into New RefWorks, a reference management software. The lead author screened titles and abstracts identified by the electronic search and applied the selection criteria to potentially relevant papers. Titles for which an abstract was not available were included for subsequent review of the full article. For articles that could not be obtained through institutional holdings, attempts were made to contact the source author to procure the article.The full text of potentially eligible studies was read independently by the lead author and a second reviewer to assess eligibility. Some study authors were contacted asking for information or clarification if needed. Studies were excluded during this phase if they were found to not meet the eligibility criteria. Any uncertainties related to study selected during the screening process were resolved through discussion between reviewers.Data were extracted by the lead author using a checklist including authors, country, study design, study aim(s), participant demographic characteristics , intervention frequency and duration, materials, setting, outcome measures, and relevant outcomes related to the study aim(s). Furthermore, the terms and protocols used to refer to object handling intervention were extracted for each included article. Data charting process was verified by a second reviewer who checked the accuracy of the data on a random 30% sample of studies.The methodological quality appraisal of the studies included in the review was not conducted given that the focus of a scoping review is to provide an overview of the existing literature. This is consistent with the methodological framework used and standards for scoping reviews , 2021b.Studies included were presented in a narrative format in relation to the objectives of the review . The detn = 1,964), and inclusion and exclusion criteria applied. Based on titles and abstracts, 209 studies were selected to be further assessed for eligibility. A total of 11 articles (including 2 additions following hand search and reference check) were identified as meeting the inclusion criteria. These included five studies solely on object handling and six articles combining object handling with other activities that, despite the eligibility criteria focusing primarily on handling objects, was deemed by consensus to warrant inclusion because of the very few studies that assess object handling interventions and the overall aim to map the existing literature. Those studies involving multiple activities were included if their aim was not clearly one of the interventions listed in the exclusion criteria . An overview of the selection process can be seen in The literature search identified 5,738 articles. Duplicate articles were removed (n = 8) and supporting living facilities (n = 9). The authors did not provide information about the participants having a confirmed diagnosis of dementia as they were attending the intervention as “citizens or members of the public”  sessions were integrated and administered in a systematic way in In the object handling session delivered by A similar object handling protocol was used in four other studies . Camic eTen studies investigated the distinctive value of heritage object handling for people with dementia; of which, three  used a bThree of 10 studies reported how the objects were selected: based on their tactile, visual and kinesthetic properties , on the Among the 11 studies included in the review, 5 used a quasiexperimental design , 2018, wFour studies used interviews to gather data , visual n = 7) investigated the impact of object handling session(s) on the well-being either of participants with dementia or the caregivers supporting them. Five of those studies focused on the participants’ subjective well-being  and art viewing (p < .006) sessions but not after the social refreshment break. This effect was higher following object handling intervention than art viewing. Data from feedback forms showed that most participants (55%) preferred discussing and manipulating heritage objects compared with the art discussion session (36%).p < .001), wellness (p < .01), and happiness (p < .003) of participants compared with sessions based on looking at the same object presented as a photograph, as indicated by improved scores on visual analogue scales  in well-being in participants with early and moderate dementia who participated in object handling in both a museum and day center. The intervention benefits were significantly larger in younger participants (p < .03) and in those with early-stage dementia (p < .007). No gender differences were found in the well-being score.In line with this finding, p < .001) was also found in p < .026). When interviewed, participants commented that they felt absorbed while learning new information and skills during the session.Significant positive change between pre- and postsession in the total well-being scores . Overall, qualitative data indicated that staff and caregiver participants enjoyed the sessions, for example, Care professionals working in dementia settings reflected on how objects became the main topic in conversations. Participants found that talking about objects was a valuable way to stimulate and engage people with dementia. This scoping review included 11 studies focused on assessing the impact of object handling interventions in relation to mainly subjective and psychological well-being and emotional response. Other outcomes such as physical response, engagement, and interactions were investigated as well. Most studies used qualitative or quasiexperimental designs. These can offer insights into the most effective features of object handling and capture the benefits of object handling at an individual level and in relation to social interactions “in the moment.”Most of the studies on object handling placed the emphasis on using objects as tools to create a space where participants could engage and connect with the items and other participants “here and now.” Moving beyond reminiscence and shifting the focus from the past to the present experience of people with dementia recognizes the value of being in the moment. The concept of “in the moment” related to people with dementia has been recently defined as “a relational, embodied and multi-sensory human experience” embedded with personal value, significance, and meaning . This deSome evidence suggests that object handling interventions are associated with increased well-being, positive emotion, and social inclusion in participants with dementia, and can help to facilitate new learning and meaningful conversation for caregivers and people with dementia. However, the scoping review was simply concerned with describing the studies and the observed outcomes. Attempting a synthesis of their effectiveness was beyond its aim.Included studies encompassed different settings and varied greatly in terms of factors such as number of sessions and length of intervention. Most studies were delivered in museum and art gallery venues. This is in line with numerous studies and Camic and Chatterjee’s “cultural and health framework” that suggest offering health care interventions within cultural heritage organizations could promote health and well-being, for example, reducing social isolation, boosting the sense of connection, and belonging by offering nonstigmatizing and nonclinical activities within communities . Some stSeven of 10 studies reported the participants’ stage of dementia. Mainly, people with mild-to-moderate dementia were included and only one study involved those with severe dementia, so there is currently limited evidence as to what extent object handling may be useful for people with advanced dementia.Regarding the materials used, most of the studies incorporated museum, archive, and heritage objects. Given the historical and unusual features of museum, gallery, archive, and heritage objects, they are likely to have stimulated curiosity or to have connected with the earlier years of participants’ lives. One feature of studies using heritage and museum collections  was the This review provides an overview of the empirical evidence available on object handling interventions and reveals considerable variety of design and procedures used in the studies. Such heterogeneity may be due to a lack of definition of what an object handling intervention is. Therefore, from the review, the initial concept of object handing was reviewed, and a theoretical understanding of the components and likely domains of action of object handling was developed by drawing on the results of the scoping review, existing theories and evidence, as well as consulting with health and social care professionals, and dementia specialists.The results from the literature and stakeholders’ feedback enabled the generation of a list of components and domains, which fed into the development of guidance for object handling intervention . It is sThe way the object is introduced and presented may be influenced or even determined by environment, participant, and stimulus attributes ..— Environmental attributes include, for example, the location where the sessions are held; the number of people in the session; the social and cultural context; the level of temperature, noise, and light; the time of day of stimulus presentation, as well as the facilitator competencies. According to a fairly recent taxonomy , facilit.— Relevant participant characteristics include aspects such as age, gender, level of dementia, physical and sensory abilities, and their likely previous experiences and familiarity with the items..— Stimulus attributes include physical features of the material object, such as shape, size, weight, density, smell, and texture, as well as nonphysical or intangible aspects such as the object’s meaning, role, and history.The second component of object handling is the “receiving” stage, which refers to the moment when the participants interact with the material objects. This process is determined by the mutual intersection of material object, subject, and environment..— The physical spaces and social context in which object handling interventions are encountered can influence how the person engages with the items. For instance, a supportive and encouraging environment is more likely to be perceived by participants as a safe space to explore and engage with the objects (environment–stimulus interaction)..— The interaction between the sensory, physical, and material characteristics of the objects and the person’s attributes will influence how the person reacts on receiving the object. Some stimuli may be more interesting for individuals than others. One example of a participant–stimulus interaction is the degree to which the person has shown a preference for this type of stimulus in the past. How the person receives and interacts with the object will also be affected by their individual characteristics such as cognitive and sensorial impairments, and their past interests and experiences, such as hobbies or work.Receiving of the material object is followed by the participant’s response, which can be seen as complex patterns of emotions, cognitions, sensations, and interactions, that may be expressed through verbal and nonverbal communication see . EquallyLimitations of this study include the relatively narrow range of studies identified under the term of “object handling.” It may be that there are similar studies that have not used this specific term or the keywords used in the research strategy. To clarify the boundaries between object handling and other interventions in dementia care  and to strengthen the review process, it would have been useful to summarize the characteristics of the studies using material objects which were excluded from the review.The results of this review extend the initial definition of object handling, exploring the components and likely domains of the intervention action. Drawing on broader evidence provides a comprehensive overview of the concept and potential mechanisms affecting object handling outcomes. Although the object handling guidance was developed from papers included in the review, other papers identified through reference checks, and other key studies identified by professional stakeholders, there is the risk that relevant papers may have been missed.A further limitation lies in the lack of geographic diversity of the studies included which may affect the generalization of our findings. Indeed, most of the studies reviewed are from the United Kingdom. Given the focus on heritage objects in the studies so far published, there is a need for more studies involving the handling of everyday material objects because these are by definition highly accessible and may have wider relevance for diverse populations.The review highlighted that there are a relatively small number of studies of object handling in dementia. The studies varied considerably in their designs and methodologies. It is also important to note that heritage objects were used in most of the dementia-focused object handling studies. It is therefore important to bring together the published studies using object handling as their stated approach, with the aim of using more precise terminology and definitions, which will encourage consistency in study design and reporting.Given the evidence above, further research is needed to examine and assess the complexity of object handling intervention, its components, and the mechanisms by which object handling may exert beneficial effects. Indeed, there is little evidence to inform how object handling interventions work, apart from the fairly recent publication by Future studies could usefully apply theoretical rigor, for example, by using the principles that have been outlined in a empirically derived taxonomy of arts interventions . SupplemFuture research should focus on identifying the benefits and even negative impacts  of objecThis review, bringing together studies of object handling interventions, assesses the available evidence and explores the study designs and outcomes. Given the evidence outlined above, it can be stated that people with dementia may benefit from object handling interventions as a means of improving well-being, mood, and social inclusion. The results from this review have been used to build a better understanding of the factors involved in the process of object handling in people with dementia that can support implementation in health, social care, and community settings.igac043_suppl_Supplementary_TablesClick here for additional data file.


These models are intended to be incorporated into evolving priority-setting workflows and integrated strategies to support the screening and selection of chemicals for further testing and assessment by identifying potential endocrine-disrupting substances.An area of ongoing concern in toxicology and chemical risk assessment is endocrine disrupting chemicals (EDCs). However, thousands of legacy chemicals lack the toxicity testing required to assess their respective EDC potential, and this is where computational toxicology can play a crucial role. The US (United States) Environmental Protection Agency (EPA) has run two programs, the Collaborative Estrogen Receptor Activity Project (CERAPP) and the Collaborative Modeling Project for Receptor Activity (CoMPARA) which aim to predict estrogen and androgen activity, respectively. The US EPA solicited research groups from around the world to provide endocrine receptor activity Qualitative (or Quantitative) Structure Activity Relationship ([Q]SAR) models and then combined them to create consensus models for different toxicity endpoints. Random Forest (RF) models were developed to cover a broader range of substances with high predictive capabilities using large datasets from CERAPP and CoMPARA for estrogen and androgen activity, respectively. By utilizing simple descriptors from open-source software and large training datasets, RF models were created to expand the domain of applicability for predicting endocrine disrupting activity and help in the screening and prioritization of extensive chemical inventories. In addition, RFs were trained to conservatively predict the activity, meaning models are more likely to make false-positive predictions to minimize the number of False Negatives. This work presents twelve binary and multi-class RF models to predict binding, agonism, and antagonism for estrogen and androgen receptors. The RF models were found to have high predictive capabilities compared to other  Endocrine Disrupting Chemicals (EDCs) are a class of chemicals that interfere with human endocrine systems. The toxicity mechanisms for EDCs are diverse; however, certain chemicals may mimic hormones and interact with specific nuclear receptors, such as estrogen receptors (ER) or androgen receptors (AR), leading to endocrine-related effects . EDCs arIn vitro high throughput assays, such as accessing the ToxCast Chemicals Inventory database, are an example of level 2 data that can be used or generated in a cost and time-efficient manner compared to in vivo testing methods  models, which are computational programs that learn underlying patterns to make predictions. In chemical-based fields, a popular branch of ML models is Qualitative (or Quantitative) Structure-Activity Relationships ([Q]SAR) models) (Q)SAR models, and the broader group ML models, work by using easily calculable values, termed descriptors, to predict activities or properties. For example, in (Q)SAR models used in regulatory toxicology, structural or physical-chemical properties of a substance may be used to predict a toxicological endpoint of concern. In one such example, a variety of (Q)SAR models for different endpoints are available within the OECD (Q)SAR Toolbox SAR models to predict ER and AR activity, respectively, and are currently available to use through the freely available OPEn structure-activity Relationship App (OPERA) . The prove tools . CERAPP ve tools , Leadscove tools , DRAGON ve tools , and GLIve tools . The US ve tools . Althougin vitro and in vivo results as available. Twelve unique models were developed, six for estrogen activity and six for androgen activity, using the Evaluation datasets from CERAPP and CoMPARA, respectively. The six models for each receptor type were binary and multi-class for each activity: binding, agonism, and antagonism. The large datasets provided more data for the models to learn. Descriptors used were from widely available software such as Open Babel and PubChem. These models were developed to be robust, have predictive capabilities over a diverse and considerable number of substances, and be freely available so that any user can readily make new predictions. In addition, models were developed to be conservative, meaning that if the choice is to label a model as Inactive or Active, it will be more likely to be classified as Active. A conservative model will have fewer Active substances classified as Inactive at the expense of more Inactive substances to be classified as Active. The RF models developed in this work will be integrated into a priority-setting workflow to achieve a fuller understanding of the data landscape and toxicological profiles of substance inventories in Canada. These models will be one element of a tiered and integrated framework, providing robust in silico information to be weighed with further evidence from in vitro and in vivo information if available across the chemical space of interest.In this work, we develop (Q)SAR models to predict endocrine receptor activity, specifically estrogen and androgen receptor activity, to cover a broader range of substances than previous models, aiming to cover more of the Canadian DSL while maintaining high predictive capabilities. Using large datasets from US EPA, RF models were trained and optimized to be incorporated into a priority setting workflow that further compiles, integrates, and interprets various sources and types of information, such as in vitro data which was combined using a mathematical model to calculate an area under the curve score, which the authors noted was “roughly proportional to the consensus AC50 value across the active assays”   assays” . In contDatabase  and the Database . It shouThe number of substances presented in this work and thus used to train the RFs may differ from other sources as the datasets were further curated. The substances were converted to the (Q)SAR ready structures and then compared to each other to minimize duplication of substances  and easy and unambiguous to apply to multi-class problems.A cut-off requiring four or more sources was chosen as it gave the highest balanced accuracy (BA) while also containing many substances. BA is a term used in classification problems, such as for activities of substances, and is the average of the sensitivity  and specificity. A more generalized term is that the BA is the average of the recalls for each class in a classification problem, shown in the equation below. In that equation, The descriptors were comprised of multiple freely available structural fingerprints and some calculated physical-chemical properties for all chemicals. The structural fingerprints included were PubChem fingerprints , MACCS fThe previously described descriptors and activities were used to train the RF models. The RF code and underlying Decision Trees (DTs) were written in-house using Python programming. A pictorial example of a DT and an RF is given in For each RF, after it was trained, an in-house written genetic algorithm (GA) was used to optimize the RF . The GA n1/m to consider what is in and out of the AD, where n is the number of data points used to create the AD and m is a value determined to optimize the AD  were developed for each model. ADs are a region of chemical space in which accurate predictions about a chemical are likely to be made as the substance is chemically similar to the substances used to train the models. The ADs were calculated using an in-house program that used density k-nearest neighbors (dkNN) neighbors. The AD was developed using only the substances included in each RF model training data. For this approach, the pruned fingerprints were combined using principal components analysis (PCA) , with ene the AD . To optihttps://github.com/SeanPCollins/RandomForest).The RF, DT, and AD codes, as well as instructions for installing and running the codes, are available on GitHub under the Massachusetts Institute of Technology Licence SAR models that cover a broad chemical space were needed to implement into a workflow approach where the results are used in a weight of evidence approach. For substances that require more detailed information (such as in vitro or in vivo), the (Q)SAR models can be weighted into the overall conclusion. The conservative approach allows for substances that have the potential to be EDC to be flagged to prioritize further information gathering, research, or evaluation. This is seen in the confusion matrix seen in The RFs and their underlying DTs were designed to give as high predictive power over as wide a range of substances as possible. Another consideration put into the work was to develop models that would give conservative results. This is because the RF models, along with other In addition to the BA, coverage is an important term that is examined. The coverage is the percentage of dataset substances within the model AD. Higher coverage indicates a greater number, and likely more diverse, substances within the AD. Finally, when applicable, the precision and the recall are also examined. Precision is the ratio of substances predicted active by a model that are observed active. Precision gives an idea of how many substances are falsely predicted active  that, if not high enough, may lead to extraneous work in later stages of the workflow. The recall is the ratio of active substances predicted to be active. The recall is a crucial factor for this work, as these models are intended to be integrated into a priority setting workflow, so it is critical to have a high recall, even at a potential loss of precision.The results of this work use the CERAPP and CoMPARA Evaluation datasets, which are the same data used to train the RF models. For each RF model training, only 75% of the data was used to train. The remaining 25% was known as the test set for each model and used to validate the models. Therefore, when discussing the performance of the RF models, a focus will be placed on the performance of the models on their respective test sets.Multiple models, including the novel RF models, were tested using the CERAPP Evaluation data. Statistics of the models are shown in For binary ER activity, the RF model results showed good performance, with the lowest BA being 82% and the lowest coverage of 88%. Compared to the other models tested, the RF models appeared to have a good compromise as the results appear closest to the upper right corner of the graph, which is where the best performance is. For ER binding, the RF model is a good compromise between coverage and balanced accuracy and appears to have one of the highest recalls, although at the cost of precision. One model, specifically the CaseUltra ER Binding model, had a higher recall; however, that model had a low coverage of 64.9%. The overall trend appears similar to ER agonism, where the RF model shows a good trade-off between balanced accuracy and coverage and a high recall at the cost of its precision. The two ER agonism models that outperformed the RF model in the recall were the CaseUltra Agonist and Agonist Alpha models; however, their coverages were lower  while having similar or worse precisions. For ER antagonism, the trends were not as consistent. Although the RF model performed well for BA and coverage, it was one of the lowest performing models in terms of recall and precision. The three with better precision-recall performance underperformed in terms of their coverage, with the highest value being 80% compared to the 88.4% of the RF model.In addition to the binary models (Inactive/Active), multi-class models were also developed that categorized the potency of the ER effect into five classes from Inactive to Strong. BAs continued to be used as the key statistic for comparison; however, it should be noted that a theoretical minimum BA is the inverse of the number of classes, so for five classes, the minimum is 20%. This is because if all substances were classified as a single activity, that activity would have a 100% recall, but all others would be 0%, for an average of 20%, or the inverse of the number of classes. Confusion matrices for multi-class models are more complex than for binary models due to the increase in classes, with an example shown in The results for all ER multi-class models are in In addition to the ER activity, RF models were developed for AR activity; the results for the binary models are shown in The precision and recall were also assessed for all binary AR models, with those results shown in The results for the multi-class models for AR activity are shown in in silico and computational approaches can provide predictions about a toxicity endpoint of potential concern for human health on many substances that may otherwise go undetected (Q)SAR models are routinely used in regulatory toxicology SAR models can provide valuable information for screening and prioritizing substances for chemical testing and risk assessment. In the context of data-poor substances, incorporating xicology , such asxicology , CoMPARAxicology , or the xicology . These min vitro data developed initially by the US EPA for use under CERAPP and CoMPARA and further used to evaluate other (Q)SAR models. The datasets were subject to a consistency check where duplicated information was removed. Additionally the CERAPP dataset binding information had a threshold applied where only substances that contained more than three sources of information were considered, based on the current analysis and findings in the original CERAPP work  while still providing confidence that the substances most likely to have the potential for hazard and risk are detected. Although previous models have been developed for these endpoints, the RF models developed and described here demonstrate high performance compared to a variety of other models tested on the same dataset with a broader AD, providing added value for rapid screening of large chemical inventories.The overall development of this work demonstrates that these models are well suited to fit into a weight of evidence workflow for priority setting of substances for chemical risk assessment activities. These models can provide predictions on substances that may lack higher-level data  and multi-class (Inactive to Strong) models were developed. A comparative analysis of the models showed that for the studied toxicological endpoints, the RF models developed in this work were the highest performing models when considering the BAs and the coverage. These results were also found without the RF models having a decrease in precision or recall, which is advantageous for models which would be incorporated into an integrated workflow for priority setting. The high performance was especially notable in the multi-class models, which can be attributed to using a large dataset with enough substances to have a reasonable number and distribution across most classes. Overall, the RF models developed and examined in this work provide high accuracy predictions from simple descriptors while covering a diverse range of substances. These models are well suited to support large-scale screening efforts of diverse chemistries to determine if they are likely to be endocrine active and may warrant further exploration for potential as EDCs. These models are good candidates for integrating into a workflow for priority setting and tiered testing and assessment approaches. By implementing the predictions into a workflow that uses a weight of evidence approach, the predictions from these models can be used to support the identification of substances or groups of substances in a priority setting when


M = 14.18; SD = 2.52; 53.7% male). The Dark Tetrad traits predicted the victimization variables in the seven models analyzed, with the verbal abuse model being the model with the largest contribution. Of the four dark traits, sadism stands out as the trait with the highest specific contribution. Our results indicate, despite not implying a causal relationship, that those people with high scores in the Dark Tetrad traits tend to be more victimized by bullying. Knowing the personality traits of the bullying perpetrators and their victims, practitioners will have a complete picture of the personality variables that play a role in preventing bullying and its associated victimization.Bullying refers to physical and/or psychological mistreatment or abuse by one individual or group toward another individual or group. Bullying is widespread in our society and carries considerable negative consequences. This phenomenon is caused by multiple factors, which include personality. Much more attention has been paid to the study of the perpetrators' negative personality traits than the victims. Several studies have examined the relationship between these traits—the Dark Triad or Dark Tetrad—and being a victim of bullying (or mobbing) in adults, especially in the workplace. However, only two studies have been located that have studied these relationships in adolescents. Therefore, this study aimed to analyze the relationship between being a victim of bullying and the ark Tetrad traits, delving into the specific contribution of Machiavellianism, narcissism, psychopathy, and sadism in victims of bullying in Spanish adolescents. A cross-sectional study was carried out by administering the Short Dark Triad, the Assessment of Sadistic Personality, and the Peer Bullying Questionnaire to 393 adolescents aged 12–18 years ( Bullying, or peer bullying, is a type of aggression that refers to physical and/or psychological mistreatment or abuse by one individual or group toward another individual. This type of aggression can occur in different contexts  and in many different ways , making it a widespread phenomenon Olweus, . TherefoConsidering these high prevalence rates of bullying victimization, we must consider the consequences of being victimized by a bully. Suffering from bullying negatively affects the physical, mental, and socio-emotional health, as well as the wellbeing of the children who are bullied , and an instrument with three scales was used to assess victimization: social, physical, and verbal victimization. Gul and Fatima  suggest that the positive relationship discovered may be because some are also victims or become victims after being bullies  in being victimized by bullying in different ways  and in different contexts .1) and machiavellianism (H2), and no significant correlation with narcissism (H3). Regarding everyday sadism, although no studies have previously assessed this relationship specifically with adolescents, we hypothesize a positive relationship between scoring high in sadism and being victimized by bullying (H4). This hypothesis appears since sadism has also been shown to be a personality predictor of victimization in other situations where the pleasure of inflicting pain can incur some costs .Therefore, this is the first study to analyze the predictive ability of the Dark Tetrad traits for adolescent victimization. Following previous literature  that assessed these or similar relationships, we expect to obtain a positive correlation between psychopathy , and they were students in the first, second, third, and fourth years of compulsory secondary education and the first year of high school. Participants were able to complete the survey in two ways: on paper or in an online format through the DetectaWeb platform  from four high schools in the Province of Alicante. The mean age of the participants was 14.18 years . Participants were asked to submit an informed consent document signed by a parent.The CAI is a Spanish self-report that measures bullying behavior among peers   is a short self-reported instrument that measures the three personality traits of the Dark Triad: machiavellianism , narcissism , and psychopathy  is a 9-item unidimensional scale that measures everyday sadism (I have made fun of other people to let them know I am in control). It is answered on a Likert-type scale from 0 = https://www.ibm.com/es-es/analytics/spss-statistics-software). Means and standard deviations were obtained to know the scores on each instrument administered to the participants. For the calculation of the internal consistencies (reliability of the instruments), SPSS and the statistical program Jamovi  were used, which offered the values of Cronbach's alpha and McDonald's Omega.Descriptive statistics were calculated using the SPSS statistical software  were calculated for each variable.Correlations were also calculated with SPSS to know both the magnitude and the direction (positive or negative) of the relationships between the different variables. Regression models were also calculated with this statistical program to determine the predictive ability of the Dark Tetrad traits for the seven factors of bullying as victimization (criterion variables). Therefore, seven regression models were calculated; in the first block, the specific contribution of the sociodemographic variables (sex and age) was considered. The four Dark Tetrad traits were added in the second block to determine their influence. The percentages of the total variance explained , except for narcissism, threats, object-based aggression, and indirect social exclusion, with lower reliabilities ; and finally, sadism and psychopathy showed significant (p < 0.01) direct correlations with all the bullying as victimization dimensions.The four Dark Tetrad traits presented significant positive correlations with bullying as victimization factors see . Machiavp = 0.001) of bullying victimization behaviors, with verbal abuse being the model with the highest contribution. Of the four dark traits, sadism stands out as the trait with the highest specific contribution (reaching SR2 = 7.67%).Regarding the predictive ability of the Dark Tetrad traits for bullying as victimization, the interest lies in analyzing the influence of the traits for each of the seven bullying factors separately see . The resMore specifically, sadism is significantly (and positively) associated with six of the seven victimization variables . In contrast, psychopathy is significantly associated  with only two of the victimization variables . Narcissism is significantly associated with only one of the variables , but, unlike the previous traits, it does so in a negative sense. Finally, machiavellianism is not significantly associated with any of the seven variables.The main aim of this paper was to analyze the relationship between being victimized by bullying and the Dark Tetrad traits, delving into the specific contributions of machiavellianism, narcissism, psychopathy, and sadism in different ways of bullying victimization in Spanish adolescents.Firstly, the results obtained regarding the relationships between the traits of the Dark Tetrad and the different factors of bullying as victimization report interesting findings. Even though the four traits are considered negative or antisocial, significant positive relationships have been found. This finding might be explained since some bullies are or can also be victims and vice versa. Some authors conclude that this may be due to the tendency of some victims to react to the aggressions suffered. Moreover, on many occasions, victims may not perceive themselves as aggressors when, in fact, they do engage in bullying behaviors , so H3 is rejected.Regarding the links between the traits and the bullying dimensions, positive correlations were obtained between the seven factors that make up bullying victimization and psychopathy and sadism, supporting HThese results confront the findings of Gul and Fatima , in whicH5). Overall, these personality traits explain up to 14.00% of bullying victimization behaviors, contrary to the findings presented by Gul and Fatima  in adolescent victims of bullying . Specifically, the low internal consistency reliabilities are found in the dimensions measuring the narcissistic trait and those measuring being a victim of threats and object-based aggression. This could be due to the limitations that the scales used in this study could present . In addition, it is essential to note that self-reports, as is well known, have biases in their measurement, such as social desirability. Therefore, the participants may have slightly modified their answers due to social desirability  and suffering from bullying in a Spanish sample.A sociocultural shared belief is that “being bad” or presenting negative or dark personality tendencies usually determines malevolent behaviors, such as bullying, but it is less usual to expect that these same traits are related to suffering victimization. Given the cross-sectional nature of this study, it cannot be concluded with certainty whether victimization caused individuals to develop dark personalities or whether victims were already predisposed to these darker traits, but the need to know the personality of these victims is just as relevant as knowing the personality of bullies in order, for example, to design prevention and intervention programs aimed at all actors in bullying (perpetrators and victims). For now, this study shows that some of the traits of the Dark Tetrad, mainly sadism and psychopathy, are related to being a victim of bullying.https://osf.io/ej74h/?view_only=8b0697f31f294479bd2e658ebee9bf97.The datasets and analysis scripts used for this study can be found in the OSF repository: The studies involving human participants were reviewed and approved by Miguel Hernández University (reference DPS.JPR.04.16). Written informed consent was obtained from all participants' legal guardian/next of kin for their participation in this study.DP designed the study and oversaw all aspects of study implementation. JP acquired permissions for the research. AM-M and MG collected the data. MG managed the database. PR-B and JP performed the statistical analyses. PR-B wrote the first draft of the article. All authors reviewed the last version and approved the final manuscript.This study was funded by the Training of University Teaching Staff (FPU19/02233), a pre-doctoral contract funded by the Spanish Ministry of Universities.The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.All claims expressed in this article are solely those of the authors and do not necessarily represent those of their affiliated organizations, or those of the publisher, the editors and the reviewers. Any product that may be evaluated in this article, or claim that may be made by its manufacturer, is not guaranteed or endorsed by the publisher.


Relationships among siblings play a crucial role in early socialization and further social development. Siblings inherently belong to the system of family relationships; their observation without involving parent-child bonds, is to some extent, generalization. Therefore, our research analyzes with mutual connections between parenting styles and the characteristics of siblings’ relationships in a family using a quantitative design of data collection and processing. The outputs from the Sibling Relationship Questionnaire and Questionnaire of Parenting Styles in a Family were collected from 264 bachelor’s students. The study found the overall associations of positive emotional relationships and freedom provided by parents with generally desirable characteristics of siblings’ bonds and vice versa, and associations between negative emotional relationships and requirements with negatively perceived traits of siblings’ bonds. The unexpected outcome of our research is that it revealed more connections between paternal parenting styles and the characteristics of sibling relationships than with those of maternal parenting styles. To reflect the complexity of these relationships more precisely, complex structural equation models were created and successfully adjusted. The family is considered a group for primary socialization that substantially determines the development of human personality. Many studies have examined the significance of parenting style . AlthougAmong individuals, siblings form the longest close relationship with each other. Although bond quality may greatly vary, it considerably influences personality development. Adler’s classical work  laid theConsidering the gender specifics in the siblings’ constellation, the sisters’ relationships appear to be warmer, but also more conflictual , 8. SistAge-spacing is also has important. Furman and Buhrmester  refer toThe research on constellation variables is substantial; nevertheless, the complex quality of siblings’ relationships does not seem to be primarily determined by constellation influences , 10. ThiAnalogous to the whole family system, siblings’ relationships change with the development of their actors. Although the amount of leisure time among siblings varies with their age distance, and other constellational influences , it geneThe impact of these developmental tendencies on siblings’ relationships considerably depends on their mutual age spacing which determines whether they experience developmental shifts in similar periods, which enables sharing experiences and strengthens their relationships . NeverthThe mutual difference between siblings can also be explained from the viewpoint of social comparison , which iAccording to Furman and Buhrmester , similarSibling’ bonds do not exist in an interactional vacuum. They are mediated and modified by relationships with other members in society, particularly when they interact with their parents both indirectly  and directly  . As a chA substantial volume of research on parental styles is covered by the metanalytical study of Kuppens et al. . Based oThis theory inspired other classical authors, Maccoby and Martin , who detA conceptual framework for this paper is based on the dimensions of emotional relationships and parental behavioral control, which are analogous to warmth and strictness . To the Using conceptualizations described in this research, we need to consider certain simplifications of all the classificational theories of parenting styles. General parenting styles influence parent-child interaction in the concrete form of parenting practices. The relationship between parenting styles and practices is not straightforward, and its specifications should be studied and reflected .Gender specifics of parenting styles have been the subjects of many studies. De Bel, Kalmijn and van Duijn  revealedAlthough siblings’ relationships in early adulthood depend less on interactions with parents, we can track the influence of a positive family atmosphere, which leads to warm relationships between siblings. Distress in the family has a destructive impact on siblings’ bonds. According to Scharf et al. , this efStudying the subsystem of the sibling-parent-sibling triad, de Bel, Kalmijn, and van Dujin  revealedClearly, parental styles and attitudes influence the quality of sibling relationships. According to Milevsky et al. , authoriIn our study, we did not observe the influence of the constellation variables. According to Feinberg, McHale, Crouter and Cumsille , structuThe major goal of our current study is to extend the modest volume of research that does not observe family relations separately but analyze their interplay and mutual influences. We used the Questionnaire of Parenting Styles in a Family  and the H1: The emotional warmth of a mother does not influence the quality of siblings’ relationships.H2: Mothers’ behavioral control does not influence the quality of siblings’ relationships.H3: The emotional warmth of a father does not influence the quality of siblings’ relationships.H4: The behavioral control of a father does not influence the quality of siblings’ relationships.The present study was approved by the Ethics Committee of the Czech University of Life Sciences in Prague and conducted in accordance with the ethical principles stated in the Declaration of Helsinki (2013). All respondents were instructed and provided written consent to participate. Data were analyzed anonymously in accordance with the ethical standards of the American Psychological Association.Our research sample was constructed using a convenience choice method and involved 264 respondents (full-time bachelor’s students of the Czech University of Life Sciences Prague). The scope of the original sample was reduced because 32 students were only children and could not complete the Sibling Relationship Questionnaire. The remaining 232 respondents in the reduced research sample comprised 134 females and 96 males. Two respondents did not specify their sex. The mean age was 20.2 years with a maximum of 29 years and a minimum of 18 years.Considering the constellation variables, we had 155 respondents with one sibling, 51 with two siblings, 17 with three siblings, and 6 with four or more siblings (three respondents did not specify the number of siblings). The respondents received an instruction that in case of more siblings, they should fill in the Sibling Relationship Questionnaire considering their “nearest” siblings in terms of age spacing and emotional bond. A total of 101 respondents had a female sibling, and 124 had a male sibling. Eighty-two respondents had siblings of age distance up to 3 years, and as many respondents had siblings between 4 and 6 years of age distance. The remaining 68 respondents were 7 and more years far from their closest sibling.Considering the quantitative design of our research project, we used a battery of two standardized questionnaires. The Sibling Relationship questionnaire comprises 16 scales of fundamental characteristics of siblings’ interactions assessed in 48 items (39 in the shortened version). The composition of the scales was determined according to crucial categories stemming from interviews with respondents about the perceived qualities of their siblings’ relationships. After the initial coding process (three research assistants sorted the elements of the interview into separate categories), the authors created a coding manual that was used for the validation of the scale—all the interviews were processed by two naive assistants with the interrater agreement expressed by Cohen kappa coefficient between 0.66 and 1.00 by all scales. Furthermore, a questionnaire containing three Likert-type items on each scale was created. In the psychometric analysis of the subsequent validation study, the internal consistency coefficient  exceeded .70 for almost all scales . The mean test-retest reliability for all scales was r = .71 .The scale Prosocial behavior covers elements of siblings’ interactions such as sharing and doing nice things for each other. Affection refers to mutual caring and love between siblings; Companionship is related to cooperation and having fun together; Similarity covers a closeness of interests and preferences; Intimacy is related to sharing of secrets and deepest feelings. Admiration of/by sibling expresses mutual respect and pride on each other. Aspects of siblings’ mutual help and teaching new things are covered by Nurturance of/by sibling. The Dominance of/by sibling is understood as commanding or even forcing to do things. Paternal/maternal partiality is related to the perception of parental preference among siblings. Competition is understood as the tendency to win over other siblings. Antagonism refers to mutual offenses and means to each other. Quarreling is related to frequent conflicts and lack of mutual agreement , 6.In the subsequent principal component analysis, four factors were identified: Warmth/Closeness, Relative Status/Power, Conflict and Rivalry The closest factors were Conflict and Rivalry, the mutual correlations of the other factors were minimal. Regarding the constellation effect, Warmth/Closeness was identified as more intensive by narrow-spaced, same-sex siblings. Relative Status/Power showed a greater influence over younger siblings . Conflict is greater by wide-spaced siblings, whereas Rivalry is more intensive by younger siblings .In our research, we used the translated version of the shortened questionnaire with an age-related adaptation and a slight modification by Parental partiality, assessed only in the terms of better treatment of the respondent in comparison to their siblings. This methodological change was due to the unification of the scoring system, which helped to minimize mistakes in response processes and gain more reliable findings. Therefore, both scales of Parental partiality refer only to the parental preference of respondents and not to the possible preference of their siblings.The standardized questionnaire for the identification of parenting styles in a family was designed for children and young adults based on the two-dimensional model of nine parenting styles . The firThe first step in the data processing was descriptive analysis. Further, we assessed the normality of our data using the Shapiro-Wilk test of normality, which is widely recommended for its statistical power . To testApart from standard multidimensional statistical methods, we used the structural equation modelling methodology provided by IBM SPSS Amos v5 software to more precisely reflect the complexity of relationships between parenting styles and the quality of siblings’ relationships. The model fit will be evaluated on the basis of chi-square goodness-of fit statistics, comparative fit index (CFI), Tucker-Lewis index (TLI) and root mean square error of approximation (RMSEA). Moreover, two comparative fit indices for the tested and saturated model were considered: Akaike information criterion (AIC) and Bayesian information criterion (BIC).Our descriptive analysis covered the measures of central tendency, variability, and dispersion, including a confidence interval for the mean  of the sibling’s relationships characteristics that were proved as significant in the previous analysis of correlations with the dimensions of parental styles. Further, the direct influence of parental style was tested. Based on these analyses, the complex structural model was developed in two versions for mothers and fathers see Figs  and 2. TAccording to all conventionally used SEM criteria, except RMSEA, both versions of the model set the data well. From the viewpoint of the standard statistical method, the chi-square tests of both versions proved that rejection based on the data was not possible. In both cases, the fit indices reflected a well-fit model with CFI and TLI above .95. The AIC and BIC indices proved the good comparability of the tested models with the saturated models see . The onlUsing the data from Sibling Relationship Questionnaire  and QuesFamily relationships have their dynamics. From this perspective, our research observes a certain stage of their development when a large number of our respondents are separated from their families. We intentionally chose this stage because it enabled us to observe the long-term effects of social backgrounds . For exaOur data analysis indicates various influences of parenting styles on the quality of sibling relationships. Based on the two-dimensional model , we may Similar to the positive emotional relationship, we identified a connection between the desirable characteristics of siblings’ bonds and the freedom component of behavioral control. For mothers, freedom positively correlates with Admiration and Nurturance by sibling. The freedom provided by fathers is associated with the Nurturance by sibling, Affection and Admiration ‘of’ as well as ‘by’ sibling. Apparently, the freedom component correlates with Admiration and Nurturance by sibling in case of both parents. This finding leads to the constellation’s specifics in siblings’ relationship because perceived nurturance by sibling is more typical for younger siblings , as is tAnalogically, the negative emotional relationship with parents in our research sample is connected with negatively perceived characteristics of siblings’ bonds, namely with Paternal partiality by both parents and with Quarreling and Antagonism by fathers. Moreover, there was a significant negative correlation between Admiration by sibling. Again, there may be a self-reinforcing effect of perceived problems in siblings’ bonds that may elicit negativity in the relationship between parents and their children. These processes generally contribute to a negative atmosphere within a family.The associations between the positive emotional relationship and freedom provided by both parents and sibling characteristics are also evident in the structural model of our results, considering only the more statistically relevant relationships . We also tested the involvement of negatively perceived parental characteristics , but the resulting model was too robust and lacked the required levels of the indices. In addition, this step was relatively redundant because the actual model fits the data better and involved the influence of parental styles on all relevant characteristics of siblings’ relationships. Moreover, further analysis of the model proved the best values of the indicators based on the positive characteristics of sibling relationships. Apparently, their bonds to parental styles were stronger and clearer.Although Furman’s questionnaire refers to a four-factor model of siblings’ relationships involving Warmth/Closeness, Relative Status/Power, Conflict scores and Rivalry score , our comOur factor of Conflict comprises the same scales as in Buhrmester’s research, unlike the factor of Warmth. In comparison with Buhrmester’s Warmth factor , our correlation analysis simplified this construct to include only Companionship, Prosocial Behavior, Affection and Admiration by Sibling. This adjustment is understandable considering the developmental stage of our respondents. As siblings grow older, characteristics such as intimacy or similarity may lose their significance with a general decrease in the intensity of the siblings’ relationship .Our general observations are in agreement with the study of Scharf, Shulman and Avigad-Spitz , who worth century when the majority of our respondents were born. In the analysis of changes in parenting strategies in the Czech Republic between 1991 and 2002 [The negative traits of sibling’ bonds are expected to correlate with the requirement dimension of parental control. Our data analysis determined the relationship between Competition and Quarreling in both parents. Moreover, there was a correlation between the Paternal partiality, Antagonism, and Domination by sibling in fathers. This observation is remarkable because parental control was not originally perceived as undesirable. Optimal parenting styles involve positive emotional relationships and a medium level of behavioral control . Therefoand 2002 , the levThe described transformation was also observed in other countries  and shouGenerally, our research proved only a certain level of correlation between observed variables, not clear causality. Therefore, there may also be a supporting impact of positively perceived sibling relationships on the raising style of both parents. The interconnectedness of these processes points to the systemic nature of family relationships , 51. OurConsidering the gender differences between parents, we can observe more statistically significant correlations with siblings’ scales in all dimensions of paternal style. In the dimension of the positive emotional relationship, fathers share with mothers correlations with Admiration by sibling, Affection, Companionship and Prosocial behavior; moreover, their positive style correlates with the Admiration of sibling and Nurturance by sibling. These scales are more typical in younger children. This evokes the idea of fathers’ importance for these children because their involvement in childcare is more crucial in families with more than one child. Generally, we noticed higher level of involvement as well as control of mothers which may reflect a general tendency of mothers to spend more time with children in comparison with fathers. This conclusion was also reached in the study of Axpe .For negative emotional relationships, the correlation with Paternal partiality was the only significant one for mothers. This fact is interesting by itself and may indicate the existence of ‘unhealthy’ family coalitions of one parent with one sibling against the other one with the next sibling/s . RegardiThe fact of more correlations in fathers is plausible also for parental control. Whereas the requirement component is connected to Competition and Quarreling by sibling in both parents, fathers ‘succeeded’ in the Paternal partiality, Antagonism, and Domination by sibling. Similarly, the freedom component correlates with Admiration and Nurturance by sibling in the case of both parents. Moreover, the freedom provided by fathers is associated with the Affection and Admiration of sibling. Apparently, paternal emotional relationships, as well as behavioral control, are important for the Admiration of sibling. Thus, the positive perception of a father may coincide with an atmosphere of respect and admiration toward others in a family. Analogically, Antagonism appears to coexist with negative emotional relationships and requirements. Apparently, a negative perception of the father’s role elicits more symptoms of antagonism in siblings’ relationships.Our observation of the father’s role in the quality of siblings’ relationships contradicts the findings of De Bel, Kalmijn and van Duijn , who focGenerally, our findings on the importance of the parental role in the quality of siblings’ relationships may arise from the developmental specifics of our respondents. Regarding the problem of child anxiety, Verhoeven, Bogels and van der Bruggen  determinFurthermore, we should consider the cultural relativity of our findings and in/congruency in different cultural contexts. The original version of the conception of parenting styles was nested in the Euro-American, specifically the Anglo-Saxon, social environment , which sThe authors of the paper are aware that despite the benefits and potential implications of the findings, this research is not without certain limitations. First, the character of the relationship was reported only subjectively and thus judged from one side of the triad: child-sibling-parents. However, even though objectivity is limited, this perspective plays a prominent role in the development of children and adolescents. Moreover, this has the highest importance and practical implications for our findings. Relying only on respondents’ self-reports of perceived family relations may lead to incomplete information about the family system . HoweverThe second limitation could be seen in the slight imbalance in the gender distribution of the research sample . Moreover, the researchers who study parenting styles should be aware of the possible cultural bias because parenting styles are largely influenced by the socio-cultural context , 60.The present research provides a unique viewpoint to assess the connections between the characteristics of siblings’ relationships and parental styles. As the starting point for future research in this field, a closer focus on gender differences and age spacing between siblings should be considered. These characteristics were not deliberately incorporated into the data analysis. A further longitudinal study aimed at the development and transformation of the siblings’ relationships during adolescence could be designed, while researchers may build on the current findings and model of interactions proposed higher. The specificity of the father’s role and the impact of his parenting style in families with more than one child has not been closely examined in previous studies. Thus, this issue could also be examined in future research to set the question of parental partiality on siblings’ relationships.This study adds to the body of research that highlights the importance of the parental role to the quality of siblings’ relationships. In terms of practical implications, this suggests emphasizing the whole triad of the family system when dealing with a relationship problem in psychological counseling.For a specific group of students, we suggest incorporating focused programs into the curriculum, raising awareness of the impact of the functioning of the whole family system on the current behavior of students in their newly built relationship with peers. Understanding the background of their own actions may set a breakpoint in building self-concept and strengthen control over socially positive behaviors.S1 Data(XLSX)Click here for additional data file.