Technology has played a vital role in modifying the lifestyle of individuals and the emerging countries are progressing so fast as no one has ever thought before. With the progression of technology boosting, the pattern of energy resources consumption has also been the center of attention for researchers in this decade. China has been one of those countries that have adopted such energy strategies in its industrial regime. The economists and information technology (IT) working together have done wonders in digitalizing and sustaining the economies that will lead to sustainable development goals. This study has been an effort to understand the role of technology and the availability of affordable energy resources in obtaining a sustainable digital economy with the mediating role of sustainable development. The population of this study was IT professionals and economists. The survey data were collected from 285 respondents selected based on purposive sampling. The software adopted for data analysis was SmartPLS 3.3.3. This study showed that technology utilization had been an important predictor of sustainable development, contributing to a sustainable digital economy. Similarly, low operational cost also moderated the relationship of sustainable development and sustainable digital economy that has been the major focus of developing countries. Moreover, the strategy of cutting down the operation costs to bring it down to the level of affordability is a major challenge for the economies such as China that have been among the low production cost. Studies on the sustainable digital economy with respect to technological use are very limited. Hence, this study will find many advantages for economists and IT professionals in the future with respect to devising the strategies taking into account the sustainable development goals and the achievement of a sustainable digital economy. The rapid digitalization of economic systems has a major impact on the lives of people, governments, and markets. Many individuals are adapting to the digital economy, so authorities must devise regulations quickly as possible to take advantage of the benefits of the digital revolution. These regulations must include minimal risk associated with job displacement. Digital economic development results from general technology utilization, which can convert into a change driver for increasing productivity throughout all the industries. Digital technology could lower the cost of economic and social activities for businesses, individuals, and governments by lowering the cost of information. The current technological revolution, such as all the revolutions, is hugely damaging and economies will face issues such as increased inequality, instability, and privacy issues. The technology transformation is very well begun and affects huge manufacturing, logistics, banking, and retailing. Digital transactions are fast-growing and in industrialized economies, they now account for 20% of all the transactions .The transformation of jobs will be severely impacted by digitalization. According to a 2017 study by the McKinsey Global Institute, one-third of the United States workforce will likely undergo job reprofiling by 2020. Cellphones, robotics, and artificial intelligence are ushering in a new era of commerce. There is no going back now as the pace of digital technology is anticipated to pick up in the next years. Delivery of skills, migration of labor, and productivity will be under strain in developing countries. Less developed economies are swiftly adopting these innovations and assuming the lead in digital technology such as land registration of India, e-payments in Kenya, and e-commerce in China. Real emphasis will need to be paid to the possible marginalization of workers whose abilities have deteriorated and the prospect of increasing wealth concentration. In the next 5 years, four change drivers are likely to impact corporate growth: strong mobile connectivity, broad acceptance of big data analysis, artificial intelligence, and cloud technology .According to the World Economic Forum (WEF) study, people will perform only 58% of jobs in 2022, down from 71% in 2018. Machines will take care of the rest. The educational and skill development systems are lagging behind the rate of change. At the same time, the digital economy can accelerate labor market dynamics by creating new doors. It also renders old skills outdated. Firms must be more adaptable and flexible as a result of the transformation. Unless governments keep improving investment environments, investing in proper health and education, and support effective governance, the full benefits of the digital transformation will not be realized. Digitalization has not increased productivity or reduced inequality in countries where these fundamentals remain inadequate. Technology transformation and technology can generate social and economic growth .The old commercial sector has moved to a digitalized one and the digital transformation of the economy is heavily reliant on big data and new technology. Digitalization is no longer a feature of software companies; in fact, the top most valuable corporate organizations of the world are in the digital sector . VariousFurthermore, it is in line with reducing adverse repercussions; as a result, specific manufacturing activities might be established to foster a circular economy . Our daiConsidering the advantages of a hybrid of digital technologies and their rapid effect across industries, societies are taking shifts in current and future strategies. In today’s world, assessing and monitoring digital transformation might be critical. Smart and sustainable concepts are not interchangeable; yet, from a policy standpoint. The strategic level of the European Union is intended to contribute to the digital transformation toward sustainable development. This study aims to present an indicator-based understanding of the main elements of digitalization that promote long-term development. In the formulation of policy, it is also crucial to be able to support various sectorial and geographical development projects on various dimensions from various perspectives, depending on the situation. Climate change, digitalization, and sustainability are all the issues that need to be addressed. There are few conclusive scientific findings about the detailed role of digitalization in achieving sustainability in the literature on sustainable development, particularly in central Europe.A distinct study gap has to be filled, especially in the investigated field, due to the low number of assessments focused on the interrelationships between digitalization and each dimension of sustainable development. Emission controls, waste disposal, sustainable production, transportation, and logistics and sustainable development are all the sectors where digital technology-driven methodologies and solutions may play a critical role . Rural aAccording to international studies, many countries have not devised policies to combine rural development and energy . The EurResultantly, recommendations appear to adhere mostly to the idea of giving “fixes” to a constant mastery of nature and the market as the fundamental driver of progress. Market failures can have negative social and environmental implications that can go unrecognized. Respective assessments and published reports commonly trace on confirmed samples of mainly small renewable sources to provide proof for efficiencies. They typically refer to possible positive economic effects without being explicit about the necessary functionalities, prerequisites, and mechanisms for realizing these potentials and effects. Furthermore, the importance of market conditions and renewable energy support, which has evolved from guaranteed feed-in tariff programs to auction models, remains unchallenged .To identify the energy strategy for sustainable development in rural areas based on the analysis of the sustainable digital economy, this study was planned, which revolved around certain objectives as: (1) To identify the role of technology utilization in achieving sustainable development, (2) To analyze the role of affordable energy resources in achieving sustainable development, (3) To estimate the relationship between sustainable development and sustainable digital economy, (4) To evaluate the moderating and mediating roles of operational costs and sustainable development.The definition of sustainability has gained universal acceptance among outcome and power players worldwide . The UniThe problem of “whether technical advancement can minimize the influence of economic development substantially to eliminate the need for other sorts of innovation” is at the core of the matter over the possible effectiveness of sustainable growth . ChangesSuch operational technologies should be utilized, which consume less water, electricity, and raw materials, while reducing waste outputs . For exa1:HTechnological utilization plays a role in achieving sustainable development.The prevailing economic and environmental issues necessitate a rapid shift to low-carbon energy technologies . AlternaConsequently, policymakers must devise economic recovery strategies in order to create economic and energy facilities for a long-term future . This isAlternative energy sources, especially biomass in the form of firewood for burning and hydroelectric for generating electricity, have traditionally been employed in underdeveloped nations . Renewab2:HAffordable energy resources play a role in achieving sustainable development.The construction industry includes a wide range of businesses, from small-scale, low-tech industries to large-scale global corporations that harvest and process minerals using cutting-edge technology. Materials, particularly mineral-derived fuels, are critical resources for civilization advancement . The IndThe spread of digital technology across all the technical and social strata has resulted in large-scale changes. These changes would eventually influence the mineral and natural resources sector and the science and technology continuum. Resultantly, an unprecedented growth among some technology solutions , the need for technology solutions, and indeed the seamless transitions of a variety of processes  can be observed . The conOnly the application of advanced technology allows for the efficient development of commodities markets in digitalization. It is effective to construct a technological development system based on intelligence concepts and procedures . The int3:HSustainable development leads to sustainable digital economy.On a daily basis, operating costs are linked with the upholding and administration of a business. Running costs include direct costs of goods sold and additional operating expenses such as rent, salaries, and other overhead costs and raw materials and maintenance costs, which are referred to as selling, general, and administration costs. Non-operating expenses connected to finance such as debt, acquisitions, or foreign exchange conversion are not included in operating costs. Companies must keep account of both the running and non-operating costs such as interest charges on a mortgage. These expenses are reflected separately in records of the company; members can view to figure out how costs are linked to revenue-generating activities and whether the company can be operated more efficiently.In general, the leadership of a firm will strive to increase earnings for the company. Since profits are decided by both the amount of revenue earned and the amount spent to run, profit may be enhanced by both the growing revenue and cutting operating costs. Due to decreasing costs appearing to be a simpler and more accessible approach to rising earnings, managers will frequently choose this strategy . SustainThe primary goal of operational cost control is to identify and describe the cost and income variations. Horngren designed this diagnostic control system to assess if and how well a corporation is operating in comparison to its goals. Cost control, on the other hand, has a broader scope. The existing study discusses a number of cost-control specifics such as staff motivation and goal alignment and approach evaluation . Kaplan 4:HLower operation cost moderates the role of sustainable development in sustainable digital economy.One of the major issues of the poor countries is obtaining and implementing the requisite technologies, which confront in achieving sustainable development. While financial resources play a role in gaining access to technology, this is not the only solution. The import/export, transfer, and use of technology for sustainable development are frequently hampered by legal and institutional frameworks. Quotas and tariffs can hamper the ability to import technologies. Subsidies may also encourage the adoption of technology that squander energy, water, or other resources. Furthermore, when choosing technologies, decision-makers should take cultural norms into account .The United Nations Sustainable Development Goals (SDGs) (2015) are a set of 17 global targets with 169 targets. Actions to reduce poverty, increase education and healthcare, and enhance wealth and well-being while taking ecological sustainability into account are among them. In fact, the SDGs cover a wide range of topics such as welfare programs , economic growth , environmental sustainability , and effective regulatory rules and governance  . Digital5:HSustainable development mediates the role of technological utilization and sustainable digital economy.Over 1 billion people around the world lack access to power and countries with adequate electricity have the dual issue of fast rising energy consumption and environmental concerns. Nuclear power is a safe, low-carbon energy source that many nations are contemplating or incorporating into their energy mix as part of their attempts to reach the United Nations SDGs of ensuring universal accessibility, dependable, sustainable, and energy services. Keeping in focus the energy strategies, experts can utilize the [International Atomic Energy Agency (IAEA)] energy planning and modeling tools and pieces of advice to help them plan the energy future of their country, which may or may not involve nuclear power. These technologies assist countries in taking into account all the aspects of energy supply and demand, while sticking to long-term development objectives. Over 135 countries and 20 international organizations have already adopted the tools. Hence, sustainable development is associated with affordable energy resources.On request, the IAEA provides advice and support to countries considering or creating a nuclear power project including building and managing a nuclear energy program in accordance with globally recognized safety standards and security requirements. The IAEA also aids countries new to nuclear technology in creating the necessary infrastructure to enable them to achieve long-term energy security. The IAEA provides technical assistance in all the parts of the nuclear fuel cycle and the life cycle of nuclear power plants and assistance with new revolutionary technologies . All theThose barriers are intimately connected to personal and social rules and morals, which profoundly influence the attitudes and acknowledgment of affordable and renewable energy technology and information implementation effects by individual people, groups, and societies, in addition to business and economic obstacles . The int6:HSustainable development mediates the role of affordable energy resources in sustainable digital economy.Based on these hypotheses, this study was designed and the following conceptual framework was designed see .This study is quantitative in nature and follows the postpositivist approach. This study has incorporated the quantitative techniques for data analysis with a deductive approach for verifying the theories developed in the literature review and demonstrated in the theoretical framework. The software used in this study was SmartPLS 3.3.3. Economists and information technology (IT) professionals of China were taken as the population for this study, since they are directly related to the sustainable digital economy. The sample size of 285 was achieved using purposive sampling because approaching all the firms, if near impossible. The demographic profile of the respondents is shown below in The instrument used in this study has been adapted from the past studies according to the need of this study . The queThe results for reliabilities of the scale can be seen in Similarly, the validity of the scale was checked with factor loading and the AVE. Factor loadings have been set to be above 0.6 ; howeverAnother measure for validity is the Fornell and Larcker criterion, which has been applied in this study. This checks the correlations among the variables of this study. For the results to be significant, the value in each column should be greater than the rest of the values. This study meets these criteria of validity as well and the results can be seen in R2 for sustainable digital economy showed a higher contribution to this framework than sustainable development; however, both have been proved to be the important variables in this study. With respect to hypotheses, H2 and H6, it did not find significant results showing any contribution of affordable energy resources in sustainable development and, hence, no role in a sustainable digital economy. On the other hand, technological use predicted sustainable development significantly , hence contributed to sustainable digital economy . The results can be seen in 3: t-statistic = 6.884, p-value = 0.000) and lower operations cost also moderated this relationship . Further elaborations of the results have been discussed in the next section of this study.The structural model of structural equation modeling (SEM) analysis is shown in This study was based on several hypotheses to analyze energy strategy for sustainable development in rural areas based on the analysis of sustainable digital economy having a mediating role of sustainable development. Similarly, the other main relationship of this study was to find the moderating role of lower operational costs on the role of sustainable development and sustainable digital economy. A theoretical framework was designed and questionnaires were sent to the participants. The results mostly supported the hypotheses. The results were also in accordance with many researchers and some were of a different opinion. The possible reasoning for the obtained results is also discussed here. A total of 57% of the respondents were men and 43% were women. They all had different education levels ranging from higher secondary to doctorate level.The cut-off value for reliability is said to be 0.7 . All theR2 for the sustainable digital economy that showed a higher contribution to this framework than sustainable development; however, both have been proved to be the important variables in this study. This is due to the fact that sustainable development and sustainable digital economies are the ultimate goals of any devising strategies for the success of businesses, affordable energy strategies in this study.This is usually the subsequent stage of the measurement model. The significance of the relationships is usually expressed in the form of path analysis, which either shows the direct effects or the indirect effects. The direct effects are the general linear regression; however, indirect effects indicate the mediating variables. The results showed the adjusted 2 and H6, results were not significant showing no contribution of affordable energy resources in sustainable development and, hence, no role playing in the sustainable digital economy. This could be possible due to a lack of study in the targeted area of this study. The respondents could have less knowledge about the role of affordable energy resources in sustainable development and sustainable digital economies. On the other hand, technological use predicted sustainable development significantly (H1) hence, contributing to a sustainable digital economy (H5). These results were obtained due to the understanding of the respondents toward changing trends due to the utilization of technology in the modern world. Similarly, sustainable development also predicted the sustainable digital economy (H3) and lower operations cost also moderated this relationship (H4).With respect to the hypotheses, HSuch results could be obtained due to the fact that sustainable digital economy is directly related to sustainable development and lower operations costs play an important role in sustainable development. All the hypotheses were supported in this study, except for affordable energy resources significance toward sustainable development and sustainable digital economy. This happened due to the fact that respondents are not directly involved in managing affordable energy resources for sustainable development and sustainable digital economy.Technology is surprising the world every now and then. These technologies are revolutionizing not only individuals, but economies as well, particularly for the emerging economy of China that is ruling the world with its lowest production costs. This study has also been a bridging step to fill the gap in the literature that addresses the role of technology in sustainable development. This, in turn, contributes to the sustainable digital economy. This study has found the significant moderating role of low operation cost that boosts the relationship of sustainable development and sustainable digital economy. The results of this study are supposed to be very helpful for the economists and IT developers in realizing the importance of their roles in the coming years. This study has several implications for the future researchers and policymakers who are interested in repeating this study with their available resources in different regions. These can be exploited well in finding new avenues for certain studies.This study had certain limitations, which could be further investigated and rectified. Most of them were associated with affordable energy resources such as low capacity of electricity generation, unreliability of the renewable energy resources, unreliability of efficiency levels of this kind of energy, lack of large upfront capital, lack of space to install the energy resources, lack of funds for storage of such renewable energy, and uncertainty about the generation of pollution. Few other limitations could be considered in future such as precautions about data security, crime, and terrorism associated with the digital world, complexity of the processes, privacy concerns of the stakeholders, social disconnectivity, workload capacity, and manipulation of the digital media among users. In future, working on these variables things should also be triggered in mind.The original contributions presented in the study are included in the article/supplementary material, further inquiries can be directed to the corresponding author.All subjects gave their informed consent for inclusion before they participated in the study. The study was conducted in accordance with the Declaration of Helsinki, and the protocol was approved by the Royal Holloway, University of London, United Kingdom.ZW contributed to the conceived and designed the concept. YZ contributed to the literature review, data collection, and wrote the manuscript. Both authors have read and agreed to the published version of the manuscript.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.


Other factors such as emotional intelligence (EI) and resilience have also been related to students’ performance and quality of life. The present study has two clearly delimited and interrelated objectives. First, to study the mediational role that engagement plays in the relationship between EI and resilience on quality of life. Secondly, and similarly, to study the mediational role of engagement in the relationship between EI and resilience, but in this case on academic achievement. (2) Methods: For this purpose, four scales frequently used in the literature to measure emotional intelligence, resilience, academic engagement and quality of life were administered to 427 students of the University of Jaén undertaking education degrees. In addition, students were asked to indicate their current average mark as a measure of academic performance. Two mediational models based on structural equations were proposed to analyse the relationships between the proposed variables. (3) Results: The results obtained showed that emotional intelligence and resilience directly predicted students’ life satisfaction, but this direct relationship did not result in academic performance. In addition, and assuming a finding not found so far, engagement was shown to exert an indirect mediational role for both life satisfaction and academic performance of students. (4) Conclusions: The findings of the study support the importance of engagement in the design and development of instructional processes, as well as in the implementation of any initiative. The academic achievement of students has been a constant concern for educational research. Studies on effectiveness in educational contexts have focused on identifying the factors that can best predict achievement in order to provide early intervention in the education process and reduce academic failure. International organisations such as the OECD  and inteStudies on life satisfaction have mostly been situated in the general context of subjective well-being research ,10. ThisSeveral studies have found that life satisfaction is closely related to job occupation, education, financial resources, leisure and family ,21,22. IBelow, it reviews a set of personal resources and/or strengths of university students that play an important role in explaining academic achievement and quality of life within this group. Among these resources, the focus will be on emotional intelligence (EI), resilience, and academic engagement. Taking into account that achievement, as explained above, has been predicted by multiple factors, an attempt will be made to explain the achievement variable as well as life satisfaction in university students through these strengths to which it has been mentioned.The most widely accepted conceptualisation of emotional intelligence defines it as an ability to perceive, assimilate, understand and regulate its personal and other people’s emotions . AccordiSeveral studies have found a positive relationship between EI and academic achievement ,35,36. APsychological resilience is generally defined as the ability of individuals to adapt to stressful and challenging situations. It is also conceptualised as a stress-resistant attitude and it represents the ability to cope with adverse situations . ResilieEngagement in the field of education corresponds to academic engagement, which refers to a state of psychological well-being and commitment to studies . AcademiThe interest in positive psychology and its applications in educational settings has grown exponentially in recent years . In relaTo study the mediational role of engagement in the relationship between EI and resilience on quality of life. Specifically, we hypothesize that EI and resilience will explain part of the quality-of-life relationships directly and indirectly through their relationship with engagement see A.To study the mediational role of engagement in the relationship between EI and resilience on academic achievement. Specifically, we hypothesize that EI and resilience will explain part of the academic achievement relationships directly and indirectly through their relationship with engagement see B.Specifically, it sets out two main objectives in this research:The study was carried out with 427 students from the University of Jaén (Spain), with an average age of 21.50 years (SD 3.61). Of the total, 88.3% were female and 11.7% were male. These percentages are proportional to the distribution of males and females in the total population of students undertaking ed in Spain . RegardiPreviously, the minimal sample size was calculated at 95% confidence level, with a 5% confidence interval at 80% of statistical power. The estimated minimum sample size was 385. According to Hair et al. , the genWong and Law Emotional Intelligence Scale :This scale is composed of 16 short sentences used to evaluate four dimensions: self-emotion appraisal (SEA), other’s emotion appraisal (OEA), use of emotion (UOE) and regulation of emotion (ROE). Respondents are asked to rate their agreement with the sentences on a five-point Likert scale ranging from 1 (strongly disagree) to 5 (strongly agree). We used the Spanish version  which haResilience Scale (RS-14) ,69,70:This instrument is designed to assess the level of individual resilience through Equanimity, which refers to a balanced perspective on life and experiences, and could be seen as the ability to accept and adjust to circumstances as they arise, thus moderating extreme responses to adversity, a construct often related to mood. RS-14 scale validated by Sánchez-Teruel and Robles-Bello  was usedUtrech Work Engagement Scale for Students (UWESS-9) :The instrument has 9 items measuring the dimensions of vigour , dedication  and absorption  to studies. The response alternatives are presented in a 6-point Likert format . The reliability of the instrument is good in its adaptation to the Spanish context. In fact, the Cronbach alpha was 0.84 for vigour, 0.89 for decision making and 0.79 for absorption.Quality of Life Scale :This is a five-item inventory that measures the satisfaction with life, with questions such as “In most cases my life is close to my ideal” and “I am satisfied with my life”. The SWLS was designed as a 7-point Likert-type scale, whose response range is from 1 (strongly disagree) to 7 (strongly agree). The Spanish version was adapted by Díaz Morales , with a In order to measure students’ academic achievement, we asked for their average mark to date of their degree .The instruments were administered using Google Form tool . The researchers attended the classes to find potential participants and to ask permission for participation and then, researchers explained the purpose of the research. The researchers were present while the participants completed the questionnaire and answered any potential questions they had. They were also provided with the researchers’ emails in case they had any further questions. Participation in the study was completely voluntary, according tothe Declaration of Helsinki in 1975 and its next adjustment from Brazil in 2013 , respectAll analysis in this study was conducted with the R software . The α value for all statistical tests was set to 0.05. Data screening was performed before the factorial analysis to evaluate the distribution of data and assumptions. Before the treatment of the data obtained with the scales, the validity and internal consistency of the scales was verified by confirmatory factor analysis. Confirmatory factorial analysis (CFA) and SEM model analysis were conducted with lavaan R package . Diagonap < 0.01). Data screening showed that the linearity assumption was not fulfilled as no item showed multicollinearity (r > 0.90), nor singularity (r > 0.95). To analyse the homogeneity and homoscedasticity assumptions, it was analysed the residuals resulting from the regression between our data and randomly generated data. Any anomalies in the distribution of the residuals were due to the behaviour of our data [Prior to the factorial treatment, the distribution of the data and the assumptions for the factorial treatment were analysed. The results of Mardia’s Multivariate Normality Test showed that the data did not maintain a multivariate normal distribution  shows the relationship of the engagement measure (ENG) between emotional intelligence (EI) and resilience (RES) with life satisfaction (SWL). Panel B (Lower) shows a similar mediation model to the previous one, except that the dependent variable in this case is the students’ academic performance measured by the academic record (AR). Results of the relationships of the different relationships proposed in the mediational models are presented in Results of the present research have shown significant relationships between personal strengths  and the criterion variables . More specifically, model A A showed Regarding model B , no direOur results are in accordance with those of Urquijo and Extremera , who anaIn terms of limitations, one of them it refers to our design. It is a cross-sectional design which does not allow to establish a causal relationship between the variables under consideration. Further research on this topic should consider and evaluate mediational models through a longitudinal design, in order to gain a better understanding of the associations between these variables. Another limitation refers to the use of self-reports to assess variables leading to a multicollinear effect. In this study, SEM was used to reduce such effects, but it would still be advisable for future studies to use performance or execution means to obtain more information about possible differences in the relationships between variables and reduce subjectivity at the same time. Another limitation is the composition of the sample. Further studies should consider the use of samples from different universities and degrees in order to be able to generalise the results. Finally, the scarcity of studies carried out with university and higher education students that analyse and contrast the mediational effect of academic engagement in the relationship between EI and resilience on quality of life and academic achievement  is another limitation when it comes to supporting and contrasting the results obtained.The European Higher Education Area (EHEA) is based on a reorganisation of knowledge, an emergence of new expectations, an internationalisation of education, and real links between business and universities. It is in this construction of a new vision where special importance is given to not limiting oneself to purely academic and cognitive knowledge, but rather to develop other skills such as emotional intelligence and resilience in order to be able to face new challenges of adaptation. Given the overall observed benefits of the connection between EI, resilience, and academic engagement for both life satisfaction and school achievement, the implementation of EI and resilience interventions should be considered a priority for university students.Several studies argue that emotional intelligence may be modified through programmes and experiences ,85,86. TThe combination of both types of training would result in an improvement in academic engagement and thus in the academic achievement and quality of life of university students.This study provides empirical evidence of the importance of EI, resilience and engagement in predicting life satisfaction and academic achievement.This study argues for the importance of providing students with essential tools in order to facilitate their adaptation to the university environment. In this manner, the importance of EI, resilience, and positive psychology elements such as academic engagement in higher education is highlighted. Furthermore, this study is truly innovative in that it also analyses the importance of EI and resilience on academic engagement, which influences the quality of life of university students.


African Americans are more likely than non-Hispanic whites to be diagnosed with and die from diabetes. A contributing factor to these health disparities is African Americans’ poor diabetes medication adherence that is due in part to sociocultural barriers , which negatively affect diabetes management. In our prior work, we engaged with community stakeholders to develop and test a brief version of a culturally adapted intervention to address these barriers to medication adherence. The objective of this study was to elicit feedback to inform the refinement of the full 8-week intervention. We utilized a community-engaged study design to conduct a series of meetings with two cohorts of patient advisory boards of African Americans with type 2 diabetes who were adherent to their diabetes medicines . In total, 15 peer ambassadors were paired with 21 African American participants  to provide specific intervention support as peers and serve in an advisory role as a board member. Data were collected during nine board meetings with the patient stakeholders. A qualitative thematic analysis of the data was conducted to synthesize the findings. Feedback from the patient advisory board contributed to refining the intervention in the immediate-term, short-term, and long-term. The inclusion of African American community members living with type 2 diabetes on the advisory board contributed to further tailoring the intervention to the specific needs of African Americans with type 2 diabetes in the community. Engaging patients and community members as stakeholders in research heightens the importance of the study for the target population and strengthens the quality of the research . This tyUsing a community-engaged approach is particularly important for research focused on addressing health disparities experienced by underserved/marginalized populations because it facilitates building trust by creating an equal partnership between the academic researchers and the community and emphasizing a two-way exchange of knowledge ,4,5. An Studies suggest that prior interventions to improve medication adherence among African Americans may not have been effective because they were not culturally tailored  or becauWe have used a community-engaged design throughout the entire iterative process to develop a culturally tailored intervention to provide African Americans with diabetes information, skill-development, and motivation to address psychosocial/sociocultural concerns and enhance diabetes medication adherence . InitialSubsequently, we developed a brief 3-week intervention that was tailored according to the feedback from African American community members. It involved peer support and group sessions as recommended by the focus groups ,13. AddiWe utilized a community-engaged approach working with two patient stakeholder boards in different cities comprised of PAs to implement, elicit feedback about, and refine the Peers Supporting Health Literacy, Self-efficacy, Self-Advocacy, and Adherence (Peers LEAD) intervention.The focus of this study was not on the delivery of the intervention; however, details of the intervention are provided as context for understanding the feedback PAs were providing. Peers LEAD is an 8-week educational–behavioral intervention that provides African Americans with culturally tailored diabetes and medication information, one-on-one peer support from African Americans with diabetes, and skills related to self-efficacy/provider communication to enhance medication adherence. This intervention builds on our prior developmental work in which we elicited input from African American community members in focus groups and then designed a brief 3-week intervention that incorporated the focus group findings from African American community members. Based on recommendations from the focus groups ,13, the The design of the intervention involved three 2 h group sessions  and five phone calls between the PAs and PBs (weeks 3–7). The first group session was led by an African American diabetes educator and included a discussion of beliefs and misperceptions surrounding the cause of diabetes and beliefs about how diabetes affects one’s life, such as how it affects one’s emotions and how much control one feels one has over one’s diabetes. This culturally tailored content was based on our prior work exploring African Americans’ perceptions of diabetes and characterizing sociocultural factors that influenced their perceptions of the disease ,13. The Weeks 3–7 of the intervention involved the PAs making weekly calls to their PBs for a 15–30 min phone call. PAs guided the discussions and addressed five different intervention topics, including building self-confidence to take medicines correctly, coping with diabetes, fear, frustration, and emotional distress related to having diabetes, etc. The intervention implementation, collection of feedback from the community, and refinement of the intervention involved three groups of stakeholders: (1) academic collaborators (research team), (2) patient advisory boards composed of African Americans with type 2 diabetes, and (3) consultants from the Wisconsin Network for Research Support (WINRS) . First, the interdisciplinary research team included experts in medication adherence, behavioral science, and chronic illness self-management among African Americans. The primary investigator (PI), who has expertise in illness perceptions, beliefs about medicines, and medication adherence among underserved populations, guided the intervention implementation and refinement. The academic collaborators contributed their expertise in addressing cultural health beliefs, experience in designing and implementing African American community-based interventions, and background in research on contextual challenges experienced by African American populations that make it difficult to manage diabetes. Monthly meetings were held with the PI and academic collaborators throughout the study to discuss how to engage the African American community in the intervention refinement and implementation and the best approach for incorporating the African American community’s perspective in the implementation and refinement of the intervention. Second, similar to our prior work, we again convened patient advisory boards . The inclusion criteria for PAs was self-identifying as African American or Black, being between the ages of 30 and 65 years old, taking one or more oral diabetes medicine, being diagnosed with type 2 diabetes for at least one year and the ability to communicate in English. Additionally, PAs had to be adherent to their diabetes medicines, which was assessed using the Adherence to Refills and Medication Scale—Diabetes (ARMS-D) . To be eThird, as we have done in the past , we collPurposive sampling was used to recruit PAs. To identify potential PAs, we collaborated with community partners and individuals who served as PAs in our prior study ,15. ThisThe intervention and the community-engaged process to refine the intervention were conducted in 2019 and 2020 in two midwestern cities, involving two separate cohorts of PBs and PAs. PAs served dual roles in this study: they delivered components of the intervention by providing support to the PBs and they served as PAB members providing feedback on the intervention design, refinement, and implementation. Details of their role in delivering the intervention are published elsewhere . The PABThe PI facilitated all PAB meetings using structured guides that were prepared in collaboration with WINRS. WINRS consulted with our research team on all PAB meetings and co-facilitated the board orientation and training meetings with the research team. Additionally, WINRS staff helped design program logistics, developed agendas and activities for meetings, drafted facilitator scripts/guides for each stakeholder meeting, and debriefed with the research team throughout the program to problem-solve emerging issues and identify strategies for improving the intervention processes and materials.The meetings were held prior to, during, and after the 8-week intervention and each meeting focused on discussion topics related to the most recent intervention activities. After each PAB meeting, the research team shared the meeting documentation notes with WINRS and met in person to debrief and discuss. All feedback was considered, and a consensus was reached about whether the recommended changes were feasible to be implemented in real-time  or for future studies or whether they warranted further consideration and exploration. When relevant, the research team also discussed the PAB feedback with the academic collaborators to get their expert input on how to best address the feedback and what implications it may have on the study design or methods. A study team researcher with expertise and experience in qualitative data analysis conducted a thematic analysis of the PAB meeting notes to synthesize the feedback into themes and sub-themes.In total, 15 African American PAs were paired with 21 PBs to provide specific intervention support as peers and serve in an advisory role as a board member. The 2019 and 2020 cohorts were comprised of 8 and 7 peer PAs, respectively. PAs (57 ± 7.5) were similar in age, had been diagnosed with diabetes for similar lengths of time (a mean of approximately 10 years), and were mostly female across both cohorts. Details of the intervention feasibility outcomes, including recruitment and retention of the PAs and PBs, are published elsewhere [All PAs participated in a similar number of board meetings. Those in the 2019 cohort participated in five board meetings—all of which were held in person in the community. The PAs in the 2020 cohort participated in four meetings , two of The engagement with the PABs was meaningful and successful in accomplishing the aim of eliciting feedback about the intervention to inform refinements. The feedback provided by the PAs can be categorized into four key themes: (1) the training, resources, and tools provided to them to implement the intervention, (2) additions or modifications to the intervention education session content, (3) how the intervention was tailored for African Americans, and (4) barriers to and facilitators of engaging with the PBs. Feedback from PAs had a significant impact and contributed to refining the intervention both in the immediate-term, short-term, and long-term. The PA feedback resulted in the research team making some immediate, real-time changes to the intervention, such as removing the icebreaker question from the agenda for subsequent virtual meetings and having the research team immediately respond to a request to provide PAs and PBs with additional help for navigating the technology for virtual meetings. In the short-term, some of the feedback from the 2019 cohort PAB was applied when implementing the intervention for the 2020 cohort. For example, the research team changed the checklist documents for the 2020 cohort, making two versions of the form that were less repetitive to better capture the evolution of the relationship and the research team changed the sequence of sessions for the 2020 cohort so that all three group sessions were conducted prior to the phone calls. Additionally, the research team is considering other PA input for future changes to the intervention. The research team has continued to refine the intervention by incorporating PAB feedback and planning a study to test the addition of a diabetes self-management program to Peers LEAD to address topics such as diet, exercise, and the addition of a community health worker to help address access to community resources. Some PAB feedback is still being considered by the research team.This study utilized a community-engaged collaborative approach involving patient stakeholders throughout the research process by directly engaging African American community members with diabetes who are successfully taking their medicines to utilize their experience, knowledge, and advice ,4.Overall, the engagement with the PAB was successful, which we attribute to several key factors. First, the academic study team collaboration with WINRS to develop the training and feedback meeting agendas/activities ensured the incorporation of strategies for effective engagement during meetings. All meetings began with an ice breaker exercise to allow the PAB members to get to know one another on a personal basis. Meetings also included reminders about respectful interaction with one another and an acknowledgement that all opinions and voices were welcome. Second, at each meeting the study team told the PAs how their contributions were making a difference in refinements that were being made to the intervention. This demonstrated the value of the PAs’ perspectives and was a recognition of how they were making a difference. Third, the structure and frequency of the PAB meetings provided an opportunity for PAs to build rapport and trust with each other, as well as with the PI and study team, which facilitated the development of an equitable partnership. Fourth, the study team supported PAs through weekly phone call check-ins to respond to questions and help to problem solve or address any concerns. This frequent, consistent, one-on-one communication may have enhanced the sustained involvement of PAs in the PAB. Lastly, the study team made efforts to accommodate PA’s practical needs by compensating them for their time, holding the meetings at a convenient time of day in their community, and providing diabetic-friendly meals. Many of these strategies are recommended best practices for successful engagement ,21.Despite these successes, we also encountered some challenges in our engagement efforts and learned some valuable lessons . Some PAAnother notable challenge was the emergence of COVID-19 in March 2020 and statewide stay-at-home orders that interrupted the 2020 PA cohort. This was particularly challenging considering the disproportionate number of COVID-19 hospitalizations and deaths in the African American community and the unknown effects on individuals with diabetes . The cohThis study contributes to the community-engaged research literature by documenting our process of engaging with patient stakeholders and its impact on the refinement of a medication adherence intervention. While the approach of engaging with patient stakeholders in designing and conducting research has become more prevalent over the last decade, research focused on the engagement process and outcomes is a growing body of literature ,24,25. BOur findings also contribute to the field of community engagement in research focused on addressing health disparities experienced by underserved/marginalized populations ,4. We deThere were some study limitations. First, we did not use a structured process and/or validated tool to evaluate PA’s skills in communicating with and supporting PBs. PAs who met the inclusion criteria may not have been well-equipped to take on the role of providing peer support. Second, we assessed PA medication adherence using a self-report measure, which is not objective and may not accurately reflect the PA’s level of medication adherence. If a PA was not adherent to their diabetes medicines, they may have struggled to provide peer support and address misperceptions about illness and medicines with which PBs were struggling. Third, we changed our method of data collection from in-person for the 2019 cohort to online for the 2020 cohort due to the COVID-19 pandemic restrictions on meeting in person. Research comparing in-person and online qualitative data collection has found differences in the quantity of data collected via each method; however, some research suggests that the richness of the data is comparable across both methods . Fourth,In this study, three stakeholder groups  collaborated to implement and refine a peer-led medication adherence intervention by providing feedback throughout the process. Feedback received from the PAB was considered by the research team and consultants and many changes were made to the intervention either immediately or in the short-term. In addition, the research team plans to implement several changes moving forward and continues to consider others for potential future changes or additions to the intervention. The inclusion of African American community members living with type 2 diabetes as the advisory board contributed to further tailoring the intervention to the specific needs of African Americans with type 2 diabetes in the community. We continued to engage with the African American community for a recently completed study testing the next iteration of the intervention that pairs the culturally tailored peer support and group education sessions with an evidence-based diabetes self-management program for a new cohort of PBs and PAs. Future studies should engage with underserved/marginalized communities when designing, implementing, and refining an intervention to ensure that interventions are aligned with and address the needs of the community.


Comprehensive data is key for evidence-informed policy aiming to improve the lives of persons experiencing different levels of disability. The objective of this paper was to identify the environmental barriers — including physical, social, attitudinal, and political barriers — that might become priorities for cross-cutting policies and policies tailored to the needs of persons experiencing severe disability in Cameroon.N = 559) using random forest regression to determine and compare the impact of the environmental factors on the experience of disability.A secondary analysis of data obtained with the WHO Model Disability Survey was completed in the Bankim Health District  were the most important for persons with moderate and severe disability, followed by attitudes of others and issues with accessing health care.Our study provides country policy makers with evidence for setting priorities and for the development of evidence-informed policies for the Bankim Health District in Cameroon. In the spirit of “leaving no one behind” , the SDGCountries that are developing disability policies are particularly interested in understanding which issues are most relevant for persons with disability and which actions need to be taken. Comprehensive disability data can meaningfully contribute to the effective development of targeted disability policy by defining priorities at the micro-, meso- and macro-level.The MDS is grounded in the International Classification of Functioning, Disability, and Health (ICF) , and opeThe MDS was developed based on three key principles . FirstlyFor measurement purposes, two concepts are used in the MDS to operationalize disability: capacity and performance . CapacitThe MDS was implemented as a regional survey in the Bankim Health District, Adamawa region, Cameroon in 2016 to shed light on the situation of persons with disability living in this region and to guide the identification of intervention targets. The implementation of the MDS in Cameroon meets calls for efforts in the investigation of the life situations of persons with disability in Cameroon . The surWhich factors of the environment are most relevant for persons with mild, moderate, or severe levels of disability?To what extent does the relevance of environmental factors change depending on the level of disability?Which aspects of the environment should become priorities for disability policies?In the present secondary analyses, we used data from the MDS implementation in Cameroon to address the fourth objective described above. Our overall objective was to identify the environmental factors — including hindering and facilitating factors of the physical, social, attitudinal and political environment — that might become priorities for cross-cutting policies and for policies tailored to the needs of persons experiencing severe disability in Cameroon. Specifically, we aim to answer the following questions:It is important to stress that in response to emerging needs for research in the context of ongoing developments, we used an approach to data analysis that goes beyond the usual disaggregation of information by disability status and instead focuses on the study of environmental factors from a broad perspective. Based on the comprehensive information collected with the MDS, we established a ranking of the relative importance of various environmental factors for persons with different levels of disability. Policy makers working in Cameroon, a country in which persons with disability face a range of barriers – such as the lack of public transportation, stigma, poor health care or few employment opportunities – might be overwhelmed by the breadth of problems faced and challenged by restricted human and financial resources. By providing a ranking of the most hindering barriers experienced by persons with mild, moderate, or severe disability, we provide stakeholders with the evidence needed for prioritization of policies and public health investments in light of limited resources.The original data collection and implementation of the MDS in the Bankim Health District, Cameroon was carried out by WHO in two phases. After a pretest in December 2015, the full implementation took place during the first half of 2016 with 559 interviews. The present study is a secondary data analysis performed between April and July 2018 using the data collected through individual interviews. In this secondary analysis, we followed a two-step approach. In the first step, we identified which type of environmental factors – physical environment, social support, social network, attitudinal environment, access to information, medication, personal assistance, assistive devices, and responsiveness of health care system – were the most relevant for the whole sample overall as well as for specific groups, namely persons with moderate, severe or mild disability. In a second step, we identified which specific aspects of three types of environmental factors – physical environment, attitudinal environment, and responsiveness of health care system – were the most relevant for the whole sample as well as for persons with moderate, severe or mild disability. This approach should provide stakeholders with precise information about which areas to target to improve the lives of persons with disability.The WHO MDS was conducted in the Bankim Health District of the Adamawa region in Cameroon in 2016. The objectives of the implementation of the MDS were to estimate the prevalence of disability and its current distribution in the Cameroonian population in the Bankim Health District and to identify needs, barriers and inequalities faced by persons with different levels of disability. The survey comprises a household questionnaire and an individual questionnaire completed by a random adult (aged 16+) member of the household. The individual questionnaire includes sections on (1) socio-demographic characteristics, (2) work history and benefits, (3) environmental factors, (4) functioning, (5) health conditions and capacity, (6) health care utilization and (7) satisfaction, personality, and well-being.http://www.who.int/disabilities/data/mds/en/.The questionnaires and further information on the MDS are available at 2 of the Bankim health district in 2015 [The population of the Adamawa region at the time of the survey was 1,205,861 inhabitants. An estimated 97,790 inhabitants lived in the 2700 kmInformation about disability has been collected in the 2010 census and in the Multiple Indicator Cluster Survey  in 2011.Performance was the dependent variable in our study. It describes the level of disability experienced by a person and is defined as how a person performs in daily life given their health state as well as the different facilitating or hindering aspects of their environment. The questions of Module 4000 of the MDS assess the extent to which a person experiences problems in multiple domains of functioning. The information from this module was combined to create a single performance score ranging from 0 (no problems in performance) to 100 (extreme problems in performance) using Polytomous Rasch Analysis , 10 in tGroups with different disability levels were determined based on the distribution of the performance score. Persons with scores lower than the mean minus one standard deviation (SD) are considered to have no disability; persons with scores higher than mean minus one SD but lower than the mean are considered to have mild disability; persons with scores higher than mean but lower than the mean plus one SD are considered to have moderate disability; persons with scores higher than the mean plus one SD are considered to have severe disability.Predictor variables were included to capture the multiple dimensions of environmental factors, namely the physical environment, social support, social network, attitudinal environment, access to information, medication, personal assistance, assistive devices, and responsiveness of the health care system. The entire list of environmental factors included in the analysis are found in Annex 1.use of personal assistance and additional need,” “use of personal assistance and no additional need,” “no use but need for personal assistance,” and “no use and no need for personal assistance.” Information on assistive devices in the areas of mobility, seeing, hearing, work, education, home, or community was aggregated and categorized in the same way as for personal assistance.The variable capturing the participants’ social network size was created by adding up the total number of close relationships among family, friends, co-workers, and neighbors. The network size represented a 5-level ordinal variable with categories grouping 0, 1, 2–4, 5–14, or 15+ close persons. Relationships were understood as close if one could, for instance, talk about personal affairs, get help, or enjoy spending leisure time with the other person. The MDS assessed the access to information with the question “Do you have access to the information you need or want?” with five response options ranging from “not at all” to “yes completely”. The regular intake of medication for the treatment of chronic disease was assessed with the binary question, “Do you take medicines on a regular basis?”. Information on personal assistance was summarized in a variable categorizing “Polytomous Rasch Analysis was used to create metric scores with a range from 0 to 100 for the variables describing hindering or facilitating physical environment, social support, attitudinal environment, and responsiveness of health care system in the scope of the original data analysis carried out by WHO.Age, sex, education, work, and capacity were included in the analysis as control variables. Educational level and work status served as proxy for socio-economic status. Capacity refers to a person’s health state. It is measured in Module 5000 of the MDS and targets the difficulties a person may have in his or her life due to health without considering environmental barriers and facilitators. Disability is defined as the result of the interaction between a person’s health and their environment. Therefore, the analysis was adjusted for capacity to obtain an unbiased estimate of the impact of the different environmental factors on disability. The capacity measure was operationalized using a metrical scale created with Polytomous Rasch Analysis in the scope of the original data analyses.We used random forest regression to determine and compare the impact of the environmental factors on the experience of disability. Random forests are statistical learning methods that are based on decision trees . An enseThe model fit of the random forest was assessed using the root mean square error (RMSE) as measure of prediction accuracy. The test set for measuring the prediction error is composed of the part of the observations that is not used in the training of the trees due to the bootstrap sub-sampling, called out-of-bag observations (OOB).We derived the permutation variable importance (VIM) from the random forest models to serve as a measure of the association between the predictors and performance score and used it to create a ranking of importance of the predictors. It is defined as the mean decrease in prediction accuracy after permutation of the predictor variable in the OOB test set, quantifying how much a given variable adds to the accuracy of the model. The mean square error can serve as reference against which to compare the VIM.The first random forest model was built to include the variables physical environment, social support, social network, attitudinal environment, access to information, medication, personal assistance, assistive devices, and responsiveness of the health care system. Further models included the single questions of the MDS related to physical environment, attitudinal environment, and responsiveness of health care system, respectively. Annex 1 contains the survey questions for each of these areas and their MDS-codes.The models were applied to both the total sample and groups with low or high levels of disability. For this purpose, we divided the sample into no or mild disability and moderate or severe disability. The threshold for the cut-off between these two groups was the sample mean of the performance score.Analyses were run in R v3.4.4. The R function cforest from the R package party v1.3–0 was used to perform the random forest regression , 14. TheThe performance score, the dependent variable in the present study, had a mean of 40.2 in the total sample Table . As repoThe gender distribution in the sample was fairly even. Most of the sample (50.6%) belonged to the age group 16–39 years.Table The physical environment is one of the most relevant environmental factors across disability Table . The anaThe five aspects of the attitudinal environment with the highest VIM for the total sample were problems getting in involved in society, considering yourself a burden on society, feeling accepted by others, living with dignity, and feeling respected by others Table . When stTable Using data from a regionally representative implementation of the World Bank and WHO Model Disability Survey in the Bankim Health District, Adamawa, Cameroon, allowed identifying which environmental factors were the most relevant ones for persons with different levels of disability. Among the whole population, the physical environment had by far the highest impact on disability, with transportation, toilet of the dwelling, and the dwelling itself being the most important aspects. Aspects inside one’s own home were the most important for persons with moderate and severe disability, indicating that for this group accessibility improvements in the public sphere will likely have little effect until the barriers in their homes are addressed.The district is poor, and the infrastructure is deficient in several aspects. There is no public transportation, and private cars are expensive, so the areas outside of Bankim are only accessible by motorbike or only during the dry season. This considerably hinders access to health facilities, especially for persons with mobility problems. Our results reflect the negative impact of inexistent public transportation on the district’s population, especially on persons with moderate to severe disability. The communal development plan of the commune of Bankim from 2015  states tFor instance, a study using data from a Spanish Survey on Disability including 17,303 adults identified discrimination, economic benefits due to disability and support from family and friends as the most important predictors of disability levels . A largeIn Cameroon, there are meaningful differences in the environmental factors that were the most important and had the highest impact on disability across different individual disability levels. For instance, the attitudinal environment, especially not feeling as if one is a burden on society and living with dignity, were much more important for persons with moderate and severe disability than for those with no or mild disability. This suggested that social stigma against persons with disability in Cameroon has a disproportionate impact on those who experienced the most severe levels of disability. In order to reach the most vulnerable in the Adamawa region, policy makers must invest not only in increasing accessibility of dwellings but also in changing society’s mindset towards disability. Dedicated disability surveys, as the MDS, which are representative, focus on levels of disability and include a comprehensive inventory of environmental factors that impact disability (not only assistive technologies) are essential to perform situation analyses that can support a meaningful implementation of the CRPD.Responsiveness of the health care system is an environmental factor and was generally ranked positively across disability levels in the Bankim region. However, there are large differences within this factor. Domains related to convenience  were the most important factors for persons with no and mild disability. However, for persons with moderate and severe disability, domains related to fundamental rights  were the most important ones. This indicates that as Cameroon works to improve its health care system, it is important to ensure that basic rights of all health care recipients, including persons with severe disability, are respected. These results were in line with published literature in other settings , 19.In a next step, policy makers must come together with other stakeholders to define priorities, suitable interventions, and timeframes, taking into account the cultural, political, and economic reality of this region. WHO has supported countries with policy dialogues, particularly in the African region, through the preparation of detailed policy briefs . The resThe present study must also be understood in light of its limitations. Firstly, the sample size was calculated as the minimum size needed to represent the district while still maintaining a low budget. The sample size was estimated using Lorenz’s sample size determination formula for cross-section studies, and a minimum of 545 households was required. The individual within the household was selected randomly. The low sample size made it possible to implement the survey in the Bankim health district, but it does not allow for high levels of disaggregation. Secondly, the health district of Bankim and the region of Adamawa are very particular; while presented results can be generalizable to some similar regions, they do not reflect Cameroon’s situation in general. Nevertheless, the results of this study are essential and substantive in the light of the concerning lack of information on disability in Cameroon.Our study provides stakeholders in Cameroon with specific information for the prioritization of intervention areas and the development of evidence-informed policies. It especially shows the importance of going beyond disaggregation, not only for informing progress towards the SDGs but also for guiding a meaningful, targeted, evidence-informed implementation of the CRPD. Future work to strengthen the conclusions here should include additional regionally or national representative implementations of the MDS, including implementations after any significant disability policies are implemented in order to monitor changes over time.


Alcohol is toxic to human health. In addition to providing nutritional information, labels on alcohol products can be used to communicate warnings on alcohol-related harms to consumers. This scoping review examined novel or enhanced health warning labels to assess the current state of the research and the key studied characteristics of labels, along with their impact on the studied outcomes. Four databases  were searched between January 2010 and April 2021, and 27 papers were included in the review. The results found that most studies were undertaken in English-speaking populations, with the majority conducted online or in the laboratory setting as opposed to the real world. Seventy percent of the papers included at least one cancer-related message, in most instances referring either to cancer in general or to bowel cancer. Evidence from the only real-world long-term labelling intervention demonstrated that alcohol health warning labels designed to be visible and contain novel and specific information have the potential to be part of an effective labelling strategy. Alcohol health warning labels should be seen as tools to raise awareness on alcohol-related risks, being part of wider alcohol policy approaches.  Globally, 5.3% of all deaths and 5.0% of all disability adjusted life years are caused by ethanol , a toxicDespite alcohol’s detrimental effect on a variety of health outcomes, public awareness about some health risks associated with alcohol consumption remains relatively low. A 2018 review of 32 studies found that while awareness of alcohol as a risk factor for cancer varies by country, in most studies, less than half of the respondents correctly identified the alcohol–cancer link . This fiOne of the approaches to raise awareness of the health risks associated with alcohol consumption can be product labelling. A review from 2013 on enhanced labelling  identifiThere is little available evidence on the effectiveness of health warning labels that would inform consumers about the risks associated with alcohol consumption. Most older studies examining the effectiveness of implemented health warning messages report on the US health warning label, which focuses on risks surrounding drinking during pregnancy, and has not changed since its introduction in 1989 ,30. MoreThe importance of labelling is recognised by the World Health Organisation, whose global strategy to reduce the harmful use of alcohol  calls foThus, the aim of this scoping review is to examine the peer-reviewed literature studying novel or enhanced health warning labels and to answer two research questions: (1) what is the scope of the current alcohol HWL research , and (2) what is the impact of the labels and key label characteristics on the studied outcomes?To answer the research questions, we used scoping review methodology, guided by the methodological framework of Arksey and O’Malley . ScopingTo be included in the review, studies had to evaluate new or enhanced alcohol health warning labels in any population. By “new”, we considered labels developed for the purpose of the research and not previously implemented in practice, and by “enhanced”, we considered improved versions of existing labels already implemented in practice. Studies had to include experimental or quasi-experimental methodology with clearly delineated independent and dependent variables, in order to be able to synthesise results based on the manipulated variables and to identify the key characteristics of effective labels. Only peer-reviewed articles in the English language published in 2010 or after were included, as in the previous reviews, there were no older experimental studies of new messages. Studies that did not include health warning messages, that focused on qualitative data or were only cross-sectional evaluations were excluded.Four databases  were searched with the abovementioned restrictions on language and dates . Additionally, we complemented the database searches with inspection of reference lists of relevant articles and reviews, and we undertook a Google Scholar search. The search strategy contained a combination of terms related to alcohol labelling: [alcohol AND (label OR label*) AND (message OR information OR warning) AND ].Study selection was performed by one researcher according to the abovementioned inclusion and exclusion criteria, with ambiguous cases being resolved through consultation with the second researcher. After the removal of duplicates, the studies were first screened by title and abstract, followed by full text examination and final article selection. Next, the data were charted to answer the main research questions. Next to general information on the papers’ aim and methodology, information on label development and implementation was charted, as well as the independent studied variables and the results for each of the outcomes. Papers rather than studies were taken as the units of interest, as the focus of the review was to appraise the scope of the published literature and to identify results for all the studied outcomes.In total, we identified 27 papers that fit our inclusion criteria , as well as at the content and format of the studied labels.In terms of study aims and studied independent variables, five papers (19%) compared only new or enhanced labels with no or regular labels ,53,54,63The majority of papers investigated more than one outcome . The mosThe tested labels were predominantly developed by the researchers themselves, based either on other research  or on own development and piloting , or both. In the four papers related to a real-world intervention ,52,53,54In terms of label content, eight studies studied a single message; the remaining were either comparing different labels (or groups of labels) or used several messages as a single intervention. Most commonly, the messages were referring either to cancer in general  ,67,71,75In terms of label format, the majority of the papers formatted the labels to be clearly visible. This meant putting labels on the front of the pack, with a predetermined size and clear contrast between text and background and separation from the rest of the label experimental research on novel and enhanced alcohol health warning labels and to identify the key characteristics of the effective warning labels. Twenty-seven papers were included, the majority of which were published in 2018 or later, indicating an uptake in interest surrounding the topic from the research community . This iIn terms of content, most commonly, the studied messages were referring to cancer—70% of papers included at least one cancer-related message, out of which the most commonly mentioned cancers were bowel, breast and liver cancer. This was followed by liver cirrhosis or liver disease messages, used in a third of papers. Other topics of messages were heart disease, mental illness, brain damage, pregnancy, drinking and driving and other . This brings us to the question on how to select the content of the message to be included on the labels. In the papers included in this review, researchers have commonly either developed messages based on “evidence on alcohol-related harm” or have taken messages used in other studies. We would argue that the message first has to reflect evidence-based risk , and thNext, the focus of research implies the researcher’s theory of change—the mechanisms by which they consider labelling to work —and thisThe second theory of change sees labelling as a tool to raise awareness of alcohol-related risks as a part of a comprehensive strategy to reduce alcohol-related harm , and emphasises optimising labels to increase attention to and cognitive processing of the information on the labels, leading to increased knowledge . This approach is more in line with system perspectives  and its It is important to note that this study  was implThus, while there should be some lessons from tobacco taken for alcohol health warning labels, we must be careful to still consider alcohol in its own context, and note that the evolution of alcohol legislation lags behind the tobacco field by a couple of decades. There is evidence for the effectiveness of pictorial labels for tobacco , but eveThe main implications for research and policy based on the results of this review are summarised in Our review is subject to general limitations of scoping reviews: we did not appraise studies for quality, and the conclusions are still somewhat broad and qualitative. In terms of this specific review, we narrowed the scope of our investigation to health warning labels and overall outcomes and we did not focus on other labels, such as lower-risk drinking guidelines or standard drinks, even though some research suggests it might be worth taking them into account simultaneously. We also did not investigate differential impact of labels on different subgroups. Evidence from Canada points to some subgroup differences in cognitive processing of the labels, although concludes that vulnerable populations still attended to the labels . Our seaThe majority of the current evidence regarding alcohol health warning labels comes from very short interventions in the online or the laboratory setting as opposed to the real world, and there is rather large diversity in the content and format of labels being evaluated. Nevertheless, evidence from real-world, long-term interventions shows that alcohol health warning labels designed to be visible and contain novel and specific information have the potential to be part of an effective labelling strategy. Labelling should be seen as tool to raise awareness and a small part of wider alcohol prevention and policy approach. Future research could focus on importance of labels in a broader societal context, and go beyond individual behaviour change, recognising that change in social norms can be a complex, multifaceted and long-term process.


In recent years, there has been a significant increase in the incidence of Crohn’s disease. Despite significant medical progress, the treatment options available today do not meet the needs of all patients. Recent reports indicate that external environmental factors, including diet, are key in the pathomechanism of the disease. It was proven that the so-called Western dietary pattern is associated with an increased risk of disease. In the pediatric population, exclusive enteral nutrition is the only nutritional therapy option recommended today with proven high efficacy in inducing remission. Recent publications that indicate at least comparable efficacy and significantly better tolerability of a specialised elimination diet, the Crohn’s Disease Exclusion Diet (CDED), provide the basis for a change in recommendations. This article discusses the mechanism of action, principles of use, and scientific evidence evaluating the efficacy of CDED in the treatment of children with Crohn’s disease. The incidence of Crohn’s disease (CD), a chronic inflammatory disease of the gastrointestinal tract, has increased dramatically over the past two decades . IncreasRecent data suggest that the development of chronic inflammation in CD may be related to specific external environmental factors. One of the key factors that can negatively impact the delicate immune balance between the microbiome and the intestinal mucosa is diet ,7,8. ThiThe primary goal of treatment for CD is to achieve deep remission, i.e., clinical, biochemical and histopathological remission ,12. In tThe mechanism of action of EEN is to exclude ingredients from the diet that negatively affect the homeostasis between the microbiota, the intestinal mucosa and the immune system ,7. The lThe etiology of CD is unknown. Currently, interactions between environmental factors and the intestinal microflora and immune system  in individuals with a genetic predisposition to develop the disease are considered the most likely pathomechanism  20]. Th. Th20]. by influencing the activity of immune cells and their migration to the site of inflammation, they exhibit anti-inflammatory effects;by nourishing colonocytes, providing them with a primary source of energy;by reducing the pH in the intestine, positively influencing the composition of the intestinal microbiota .Epidemiological studies proved the influence of the Western diet on an increased incidence of CD and, conversely, a lower incidence among those following a Mediterranean diet ,10. One On the other hand, in the absence of sources for SCFA production, the mucus layer that protects intestinal epithelial cells can be used by bacteria as a medium, allowing their translocation through the intestinal mucosa ,25.Other features of the Western diet with potential negative effects on CD development include high consumption of red/processed meat, animal fat, and wheat  6]. For. For6]. A summary of Western dietary factors considered as particularly important in the pathomechanism of inflammation in CD is shown in The achievement of deep remission with healing of the intestinal mucosa has a fundamental impact on long-term treatment outcomes and is an essential goal of CD treatment today . In the EEN is a safe, effective, and so far, the only causal treatment concept that achieves clinical and endoscopic remission in the majority of treated children  5,15,1616,27,28.The CDED diet is a new generation of nutritional therapy—in its initial stages, aimed at inducing remission, it involves a combination of partial enteral nutrition (PEN) with selected natural diet products. The primary mechanism of action is to exclude or limit exposure to dietary factors with potentially deleterious effects on the pathogenesis and course of CD .The direct effect of the elimination diet on restoring eubiosis, normal intestinal barrier function, and immune response, causes the quenching of inflammation and healing of the intestinal mucosa .The auxiliary mechanism of CDED involves consideration of the supply of specific components that may provide additional benefits ,30,31. AIn the first phase, due to the greatest restrictions regarding the allowed foods, 50% of daily energy demand must be satisfied by enteral diet. Phase 2 is the time of reintroduction of some foods that had to be eliminated during the first 6 weeks. Due to the increasing variety of foods that are allowed, the recommended % of energy provided with the formula is reduced to 25% of the demand. Satisfying some nutritional needs with the use of a complete enteral diet is aimed at preventing deficiencies and maintaining/improving the nutritional status in the period of the greatest restrictions, i.e., in the first 2 phases of the diet. The principles of formula selection are the same as the guidelines for exclusive enteral nutrition in children. Standard polymeric, normocaloric  diets are recommended. In justified cases, that is in patients with food intolerances, allergy to cow’s milk proteins or insufficient tolerance of the polymeric preparation, preparations containing hydrolysed protein should be recommended.Foods that can be consumed in the first two phases of the CDED are divided into foods that are:–mandatory, i.e., recommended for daily consumption. Their role is to provide adequate nutritional value of the diet as well as substrates for the production of SCFA;–neutral, which are supposed to add variety to the daily menu, but do not necessarily have to be consumed.–forbidden.In phase 3 (maintenance), patients should function according to the principle of controlled exposure to dietary components with potentially negative effects on pathogenesis and the course of the disease. Therefore, for five days a week, they should compose their meals based on products allowed in phase 2 as well as selected additional products. During these days, especially in the case of patients who did not normalise the parameters of their nutritional status despite good treatment effects, it is recommended that supplementation with formula be continued. In addition, on selected consecutive days it is possible to eat two meals composed of products that are not recommended for daily consumption. Patients should still avoid particularly harmful foods, mainly highly processed products, i.e., processed meats, frozen, ready-to-eat foods and sweetened beverages. CDED was developed in 2010 by Professor Arie Levine . The first reports—results of a retrospective analysis of treatment results of CDED followed for 12 weeks by a group of 47 children and young adults with active CD—were published in 2014 . After thttps://modulifexpert.com/ (accessed on 6 July 2021). Apart from lectures, it includes auxiliary materials as well as regularly held seminars that supplement the latest knowledge on CDED [In 2019, the ModuLife software, developed by the creators of CDED in collaboration with Nestle, was made globally available for use. The primary goal of the project is to train CDED specialists and popularise the method among patients. The application for patients contains a recipe/meal database and provides a lot of help in everyday diet. Access to the platform can only be granted by a CDED expert. The training for specialists is available at:  on CDED .As of today, EEN is the sole method of nutritional treatment with proven efficacy in inducing remission in children with active Crohn’s disease that is recommended in the official guidelines. This form of dietary treatment, however, has significant limitations that have a negative impact on the possibility of its wide use and long-term maintenance of its positive effects. It seems that the groundbreaking reports concerning CDED, a modern method of dietary treatment, which indicates that it is at least comparable with EEN in terms of its effectiveness in inducing remission and that is much better tolerated by patients, CDED will be included in the latest guidelines of scientific societies.