Sub-Saharan Africa continues to carry a high burden of communicable diseases such as TB and HIV and non-communicable diseases such as hypertension and other cardiovascular conditions. Although investment in research has led to advances in improvements in outcomes, a lot still remains to be done to build research capacity in health. Like many other regions in the world, Sub-Saharan Africa suffers from a critical shortage of biostatisticians and clinical trial methodologists.Funded through a Fogarty Global Health Training Program grant, the Faculty of Medicine and Health Sciences at Stellenbosch University in South Africa established a new Masters Program in Biostatistics which was launched in January 2017. In this paper, we describe the development of a biostatistical and clinical trials collaboration Module, adapted from a similar course offered in the Health Research Methodology program at McMaster University.Guided by three core principles , the Module aims to advance biostatistical collaboration skills of the trainees by facilitating learning in how to systematically apply fundamental statistical and trial methodological knowledge in practice while strengthening some soft skills which are necessary for effective collaborations with other healthcare researchers to solve health problems. We also share some preliminary findings from the first four cohorts that took the Module in January–November 2018 to 2021. We expect that this Module can provide an example of how to improve biostatistical and clinical trial collaborations and accelerate research capacity building in low-resource settings.Fogarty International Center of the National Institutes of Health. It has been recognized as far back as 1957 that, while recent graduates who specialize in biostatistics are usually adequately equipped to do biostatistical research, they are in fact inadequately prepared to practice as biostatisticians or clinical trial methodologists . AdditioSub-Saharan Africa continues to carry a high burden of communicable diseases such as tuberculosis and HIV, and non-communicable diseases such as hypertension and other cardiovascular conditions, as well as injuries , 8. AlthFigure We adopted the existing successful module at McMaster University in the Program . The ModFigure Guided by the three principles, the Module, with a total of 120 h learning time, was designed to comprise of 1/3 face-to-face lectures (40 h) and 2/3 practical work (80 h) implemented throughout the module. Table The objectives of lectures and practice include the following: (1) integrating statistical knowledge gained in the other modules and applying it during biostatistical and methodological consulting sessions with clinical researchers and students, 2) communicating effectively with researchers to gather information required to make a link between research questions and statistical methods by asking relevant questions, (3) providing guidance in study design, sample size calculations and statistical analysis plans for researchers, 4) effectively analyzing data from consultations on research projects within a variety of biomedical fields, (5) discussing results in a clear manner orally and in the form of a written report to researchers, (6) doing research on the relevant statistical methodologies and presenting findings to the audience, and (7) displaying teamwork and leadership in research collaborations. Details on the topics and practice including their contents and key references for the Module are shown in Table  communic effectivAs part of the Program, students participate in an internship program during the last three months (from July to September) of their second year of study. Although the internship is not included in the Module’s 120-h learning time, we utilize and link the internship as a supplemental platform of real-life practice for students in this Module. Moreover, we use the internship to help with summative assessment of students’ performances (details below).The internship placements may occur within research institutions or centers where biostatisticians are employed, and the students will usually organize their own placements according to their specific area of interest. The placement organization provides the student with opportunity to engage with researchers, conduct statistical consultation, and gain experience in communication and teamwork under the supervision of an experienced biostatistician. The learning outcomes are to apply theoretical concepts to day-to-day problems in a workplace environment, provide guidance in study design and statistical analysis plans, work in a collaborative environment, and successfully propose solutions to statistical problems arising from workplace environment. Thus, linkage with the internship is a significant way for students to put into practice what they have learned in the Module.The assessment of students’ performances for the Module is 50% formative and 50% summative. The key points for assessments consist of students’ ability to translate research questions into statistical questions, assistance with study design, analyses, interpretation and reporting of results, effective communications with non-statisticians, self-learning, teamwork, and leadership. The formative part is composed of a presentation  and two written assignments . For the presentation, students are expected to identify a biostatistical topic of interest and relevance to biomedical researchers and then present for 30 minutes to the audience from the Division of Epidemiology and Biostatistics as well as other interested researchers. Marks are awarded for choice of topic, clarity of presentation, knowledge of the subject, and how questions are handled. The written assignments are designed to cover issues that may or may not have been dealt with in the lectures but that are commonly encountered in real-life biostatistical collaboration. The rationale for the assignment settings is to expose students to the actual scenarios that biostatisticians encounter, encourage them to improve self-learning and critical thinking, and enhance their problem-solving ability. For example, one of the assignments concerns randomization in a large multi-center trial, where the treatment groups were not balanced due to chance after the trial ended. Students are asked to provide their suggested solutions, rationale for the solutions, expected analyses and reporting, and concluding remarks appropriate for future similar issues. In general, there are no explicitly correct or incorrect answers to these open questions; therefore, the assignments are marked as an essay with a rubric awarding marks to how well the student has given evidence to support their answer.The summative part, assessed after the internship, is entirely composed of a portfolio of evidence of learning . Since this Module is primarily applied, it is difficult to summatively evaluate the skills they have learnt using traditional examination format. A portfolio of evidence is a more valid way to help students to better incorporate the knowledge gained through lectures, readings, assignments, and during the real-life practice of their internship. Students document their learning process in biostatistical collaborations through their workplace placements using reflections, case studies reports, written reports to clients, and videos of consultations. The portfolio is assessed through a rubric that examines the depth of their reflection into the learning process as well as the overall quality of the portfolio.For the first intake in 2017, we received eight applications and five met the requirements and enrolled. These five students, three from Zimbabwe and two from South Africa, had backgrounds ranging from statistics to health science. They went on to take the Module in their second year of study from January to November 2018. All students were assigned a mentor during the Module who then became their research assignment supervisor. Subsequently, the interest in the program has grown and we receive more than forty applications annually. A further five students were enrolled in 2018 who went on to take the Module in 2019, of which four were Zimbabwean and one was Namibian. The 2019 intake, which took the Module in 2020, consisted of eight students, two of whom were South Africans, and the remainder from Zimbabwe, Namibia, Kenya, and Ethiopia. Thus far, the program has produced sixteen graduates. The 2020 cohort of students who took the Module in 2021 consisted of seven students of whom three were Ethiopian, two South African, one Kenyan, and one Zimbabwean.Immediately after each teaching block, the students were asked to rate each of the seven following domains of the Module on a scale of 1 (poor) to 7 (excellent): the Module overall so far; the clarity of the Module objectives; the organization of the Module; the relevance to career, educational goals, and interests; the usefulness of the class discussions; the usefulness of the course materials; and how students’ needs and expectations were met.Block 1 evaluations for 2018 to 2021 cohorts are shown in Table Additionally, students were given three open questions on the evaluation form: (1) What are the best features of the Module; (2) Did you feel that any aspects of the Module were not relevant; and (3) Which aspects of the Module would you change? The 2020 cohort of students were given an extra question on the online format of the course due to the COVID-19 pandemic and subsequent lockdown. In each case they were asked to elaborate on their answers. The responses regarding the best features of the Module were mainly around the lecturer’s passion, vast experience, and in-depth understanding of the subject. The real-life practical aspects were also appreciated. From 2019 onward, the responses to this question were mainly around the usefulness of the collaboration framework and the enjoyment of the role-play sessions. They also indicated a renewed appreciation for collaboration as a career and a taste of what to expect in the real world. In terms of the second question, all but one student felt that all aspects were relevant. The one student who felt differently highlighted that the Module placed too much emphasis on “soft skills” such as time management and stress management, at the expense of more important statistical topics. Suggestions for what to change included the addition of more information on sample size calculations and statistical analysis plans and research protocol development. We have considered all their feedback and are now trying to reach a consensus about how to incorporate appropriate changes into the future Module. Suggestions of what to change in future included having conversations with biostatisticians who work collaboratively in different fields or being able to observe real or simulated collaboration sessions. Responses from the 2020 cohort on the new online format of the offering were generally in favor of the format, with students feeling that not much was lost without face-to-face contact; however, one student acknowledged the challenges of internet connectivity and electricity interruptions which happened intermittently in South Africa.One of the improvements which were done to the Module since 2018 was to add a structured framework for managing and running statistical collaborations . FurtherWhile all students progressed well in the formative assessments, the summative portfolios displayed only surface reflections which were almost “report like.” We realize that proper reflection is a skill that has not been taught to the students and this will be incorporated into the future Module. On the positive side, the students tended to be brutally honest about the course and provided very useful feedback about what worked this year and which aspects needed improvement. Moreover, their documentation of the challenges they faced in the Module  was also helpful in knowing where the facilitators can be of more assistance in the future. For example one student wrote “The department should have field visits to assess the progress of the students and know challenges faced by students. Also, students should meet on a monthly basis to present their progress on projects and other reports or problems which they face while on field attachment.” Another wrote “More so, I was not spared from problem consultations where some postgraduate students wanted the statistician to do everything for them. Some supervisor who had little understanding of statistics and epidemiological study design would cause confusion between the consulting activities. However, through communication of the problems encountered to the head and seeking advice from other professionals around, I was able to solve and move on without further friction on how to conduct biostatistical collaborations.”Realizing the urgent need of statistical or methodological expertise and soft skills in biostatistical and clinical trial collaborations, we developed and implemented a module with the purposes of enhancing students’ capacity building at Stellenbosch University in the Program. The Module tried to advance our students’ both technical and non-technical statistical and methodological competencies, using an interactive approach combining in-class instruction, critical thinking and self-learning, and real-life practice. It not only equipped students for engagement to conduct research but also for engagement and communication to advance the use of research in healthcare decision making. Further improvement of the Module is needed in the future setting. It is our expectation that the Module can provide an example of how to improve the biostatistical and clinical trial collaborations and accelerate research capacity building in low-resource settings.


Improving access to health services is a way towards achieving universal health coverage (UHC) in oral health. The purpose of this review was to map the determinants of access to dental services within a UHC framework.Scoping review methods were adopted for the review. PUBMED, Scopus, ISI Web of Science and ProQuest were searched for academic literature on determinants of access to dental services in OCED countries. Articles published in the last 20 years were included. No restriction was placed on study methods; only articles in English language were included. Qualitative synthesis was conducted, along with a trend analysis and mapping exercise.A total of 4320 articles were identified in the initial search; 57 articles were included in the qualitative synthesis. The results indicate 7 main themes as the determinants of access to dental services: family condition, cultural factors, health demands, affordability of services, availability of services, socio-environmental factors, geographical distance. Defined determinants of access to dental services, family condition, cultural factors and geographical access to dental services can fill the population axis of the UHC cube. Health demands and affordability of services fill the gap of financial protection as another axis of the UHC cube and finally, availability of dental services and socio-environmental factors are aligned with the appropriateness of services, the third axis of the UHC cube.According to the results, family condition and cultural, health demands, affordability and availability of services, social environment, and geographic factors can affect dental health access and equality. Socio-cultural determinations also need to be considered in applied planning. Addressing these factors to improve access to dental services can pave the way for achieving universal health coverage in oral health and should be considered in different levels of policymaking.The online version contains supplementary material available at 10.1186/s12903-021-01765-z. All members of the World Health Organization (WHO) are committed towards achieving universal health coverage (UHC) . UHC canBusse et al.  introducAs a separate concept, access to health services refers to the timely use of health services by individuals and the community to achieve the best health outcomes . This coAt the same time, Campbell et al.  have refIn addition, although oral health is one of the forgotten levels in macro health policies setting, its importance should not be overlooked . AccordiOral health and access to dental services should be acknowledged similarly to other health services under UHC to reduce the existing inequalities in the populations. It has been reported that the elimination of financial hardship is not enough to achieve a sustainable improvement in equity unless other factors like geographical access are considered . HoweverInequality in dental services has been reported in all societies, including high-income countries, but no framework addressing determinants of access-related inequalities in dental services has yet been reported. Challenges to accessing dental services are seen in most countries, although these challenges are greater in low- and middle-income countries. There are more inconsistencies and knowledge gaps in oral policies in these countries , 18. At On the other hand, many countries of the Organization for Economic Co-operation and Development (OECD) have adopted different strategies to increase access to dental services that emphasise the need for these countries to manage and improve equality in this area . Among tA scoping review methodology was applied to allow the inclusion of a variety of relevant and heterogeneous literature simultaneously. Scoping reviews enable determining the main aspects of a concept and making a comprehensive map of evidence . In thisIdentifying research question, search strategy, data extractionThis main component has included the initial three steps of Table Clarifying and linking the purpose and research questionThe study aimed to explore the main determinants of access-related inequalities in dental services among the OECD countries. In this regard, the main research question was defined as: What are the main determinants affecting access to dental services in the OECD countries?Feasibility balancing with the comprehensiveness of the scoping processIn this step, the relevant keywords were selected to set the search strategy. The systematic search had been conducted from 01/01/2000 up to 08/08/2020 in 4 scientific databases, including PUBMED, Scopus, ISI Web of Science and ProQuest  which were available in English full-text and fulfilled the study purpose, were included. On the other hand, review articles , conference proceedings, editorials and commentaries were excluded from the study. Articles were first screened based on their titles and abstracts, then the full texts of the retrieved abstracts were thoroughly reviewed by two research team members (AG and PB) separately. At the time of any disagreement between the reviewers for including the material, the third person (DB) studied the paper and made the final decision. The Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) was applied for illustrating the approach Fig.  27]..27].Thematic analysis and Mapping exercise (towards UHC themes)This component has contained the final two steps of Table Incorporating a numerical summary and qualitative thematic analysisA data extraction form .According to Table Results of the study are presented in two sections: first, the description of the characteristics of the included studies and then the results of the thematic analysis and the thematic map.According to the present search strategy . Sorting the included studies by the publication year also revealed that most of the studies had been published in the last decade (40 articles). More information about these patterns is available in the Additional file Thematic analysis of the included studies led to 7 main determinants of access-related inequality in dental services as follows: family condition factors, health demands, cultural factors, affordability of services, availability of services, socio-environmental factors and geographical access Table . IncludeConsidering the 3 main dimensions of access to health services; financial, physical and acceptability of the services, Table As one of those determinants, family condition factors consist of different subthemes such as being a child, an elder or pregnant family member , 30, racBesides family condition, culture and attitudes toward oral health beliefs and behaviours can raise access related inequality in dental services .Health demands along with the affordability of the services by the patients are aligned with the financial dimension of the access to dental services. Health demands, in the reviewed literature, mainly emphasises the population’s oral health and dental needs. Therefore, society's unmet needs can impose a high financial burden on access to dental services  and shouFamily income  or insurAvailability of dental services, living or environmental conditions and geographical access are aligned with the physical dimension of access to dental services. Dental visit waiting-time  and applIn sum, these three dimensions of access; financial, physical and acceptability of services, along with their determinants, are considering as the main dimensions and the sub-dimensions of access to dental services, which have influenced the inequality in terms of access to dental services in the OECD countries Table .Trend analysis of the publications showed that the most published dimension of access to dental services is the physical dimension. Regarding the determinants, most studies covered the affordability of services (32 articles), while a small proportion covered cultural factors (4 articles) and socio-environmental factors (5 articles)  payments. The potentiality of the health system also influences the affordability of the dental services to provide appropriate services to the community with affordable prices. This factor and the socio-environmental status of the people representing their financial status, insurance status, and power of paying OOP can be considered Financial protection of the UHC cube.Service coverage as the third axis of the UHC cube defines how extensively a health system covers different services. This dimension can be adjusted by the availability of dental services and the individual's health status Fig. .Fig. 4DeIn this study, we discussed different determinants of access to dental services among OECD countries. According to the current results, access to dental services includes a vast dimension of physical access, financial access, and acceptability.Physical access is divided into the categories of availability of services, social environment and geographic and transportation regarding the current results. Similarly, according to the literature, geographical access to dental services is only one determinant of access to services . AlthougAlthough many OECD countries are at a high individual and national level of wealth and income, even among these countries, income distribution is not fair . This inTo increase the affordability of dental services, it is not sufficient to pay attention only to people’s income. Another determinant that can improve this dimension of access to dental services is being covered by insurance. Holding any type of health insurance, not just dental insurance can reduce health expenditures and thus increase the ability of people to pay for dental expenses , 49. HowFinally, family condition and cultural factors affect access to services in terms of the acceptability of services. Many studies addressed specific family and individual circumstances, such as age, pregnancy and education , 52, 53.In addition to racial factors, cultural determinants should be considered to increase the acceptability of services. In the included studies, the least attention was paid to these factors, while victimisation and oral health attitudes can affect the level of access to services . This exIn sum, inequality in dental health services can be caused as a result of inappropriate access to such services. At the same time, lack of physical and financial access and also the acceptability of dental services can deepen the inequality, particularly among those families with lower socio-cultural and income level. The role of public benefit packages the same as insurance coverage, should not be neglected , and botDespite the discussion about the dimensions of access and the UHC cube, according to Sanders et al.  there isAccording to the results, family condition and cultural factors, health demands, affordability and availability of services, social environment, and geographic factors can affect dental health access and equality. Socio-cultural determinants also need to be considered in applied planning. Addressing these factors to improve access to dental services can pave the way for achieving universal health coverage in Oral Health and should be considered in different levels of policymaking.As a focused scoping review requires a homogeneous population, we have limited this study to the OECD countries. Since access determinants to dental services in low- and middle-income countries can be different from the findings of this study, studying that context is also recommended. On the other hand, many the comprehensive studies conducted in OECD countries along with a separate review of two members of the research team who are familiar with the methodology, increased the robustness of the findings. In this study, due to the limitation in translating non-English texts, studies in languages other than English were excluded, which was one of the limitations of this project. We have tried to reduce the selection bias by conducting a scoping review that is more comprehensive than the other types of systematic reviews. However, this bias is an inevitable part of a review, so we encourage researchers to consider this. Distinguishing between the concepts of access and utilisation of services and mapping the identified determinants of access with the UHC dimensions was a novel aspect of this study and could help researchers and policymakers and thus be effective for the community.Additional file 1. Search strategy syntax and results.


There is a discrepancy between the educational needs and the opportunities to obtain reliable knowledge about sexuality in adolescence. This study aimed to assess the conjunctive influence of family and school in shaping this knowledge. Methods: Data were collected retrospectively within a cross-sectional survey conducted in Poland in 2017 . The respondents’ experiences in terms of the presence and quality of sexuality education (SE) at school and in conversations with parents about related issues were considered. Results: Of all the respondents, 31.1% had no sexuality education classes in school or rated them as useless, 41.5% never discussed sexuality-related topics with parents and both were true for 17.6%. Puberty and contraception were most frequently discussed with parents, while sexual pleasure and masturbation were discussed least frequently. The diversity of topics taken up with parents and the possibility of discussions with mothers turned out to be the most important factors for shaping adolescents’ knowledge. A relationship with the quality of sexuality education at school was additionally revealed for girls, while a relationship with talking to fathers was revealed for boys. Conclusions: Schools and families should work together to strengthen proper sexual development by meeting adolescents’ needs in the field of their knowledge on human sexuality. The right to a comprehensive sexuality education is one of the sexual rights written into the WHO Universal Declaration of Sexual Rights in 2002 ,2. SimilIn regards to the definition of sexuality education, the broadest and most common is that developed by WHO, UNDP, the Federal Office for Health Education (BZgA) and UNESCO, where comprehensive sexuality education (CSE) is defined as a curriculum-based process of education and learning about the cognitive, emotional, physical and social aspects of human sexuality. In this approach, it should be tackled holistically, treating sexuality education as a subject that enables young people to understand their own sexuality and relationships, and is capable of improving their quality of life . AccordiFocusing on the main and necessary issues that should be addressed in sexuality education, this knowledge should include topics on the components of human sexuality, feelings and emotions, pleasure, desire, intimacy, gender identification and identity, sexual orientation, anatomy and physiology, healthy and correct sexual development, body image, intimate relationships, sexual activity, abstinence, contraception, procreation, sexually transmitted infections, issues of sexual violence and sexual and reproductive rights ,17,18,19This knowledge should be provided by different people and institutions. The primary and most natural educational agenda  is the family environment . Hence, With regard to the situation in Poland, sexuality education continues to be a subject that generates many emotions and controversies. Two strongly polarised and mutually exclusive discourses  are present in the public sphere. The dispute in this context mainly concerns the need, purpose, assumptions, influence, forms, content or persons providing the sexuality education. These dilemmas concern not only the name of the subject itself or the age of pupils starting formal education in this field, but also the content and syllabus of such education; the choice and selection of appropriate educational methods, textbooks and educational materials; the preparation of teachers; the status of the subject; and the consent of parents to the participation of pupils in such classes.The situation is made worse by the fact that in Poland, formalised and institutionalised sexuality education  is mainly a tool of political and ideological struggle. This is evidenced by the social proposal of the bill entitled “Stop Pedophilia”, prepared by the pro-life organization and submitted to the Polish Parliament in 2019, that is still waiting for the voting. It has an implicit manipulation of reality, due to the use of the phrase “sexualisation of children”, which it equates with sexuality education. Consequently, this leads to the intimidation of sexuality educators willing to conduct classes in accordance with the WHO standards, and the proposal to prohibit sexuality education by persons representing NGOs working for sexual and reproductive rights. In addition, the following are clearly visible in the curricula: a lack of neutrality in terms of general worldview, the promotion of family values and a heteronormative model of relationships, the reproduction of stereotypes and atheoreticism  ,32. In pThe purpose of the study presented below was to provide a retrospective evaluation of the scope and usefulness of sexuality education during adolescence, as expressed by young Poles.The main research question was: what is the importance of the family for young people in the process of sexual education, and does the family environment determine the knowledge of adolescents about human sexuality? In addition, we decided to answer an additional question: what are the views of young people on sex education at school?An attempt was made to assess the extent to which discussions with parents concerning human sexuality and positively evaluated school classes had a synergistic effect on the level of knowledge declared during adolescence. Gender differences were also highlighted, including the impact of conversations with the father and mother on daughters’ and sons’ knowledge.p = 0.891 and p = 0.555, respectively). There were no gender-related differences for the other features that were analysed. Only the percentage of singles was significantly higher in the male group (p = 0.045). The sample characteristics showed no missing data, except for 21 cases of undefined employment status . In addition to the above characteristics, the assessment of family situation during adolescence is presented later.The survey was conducted in 2017 among a national sample of 2500 adult residents in Poland ,36. ThisThe data were collected in the respondents’ homes in the presence of an interviewer experienced in conducting social quantitative surveys. The research tool consisted of two questionnaires completed within the same meeting using the PAPI  method. The first questionnaire was filled out during the face-to-face interview, while the second questionnaire was completed by the respondent in person under conditions guaranteeing greater confidentiality. In this part of the survey, the interviewer did not participate actively, but was available to provide clarifications. Both questionnaires were labelled with the same ID number, which made it possible to link the data. The confidential questionnaire was returned in a sealed envelope and placed at random among other envelopes in the urn. Women were interviewed by women and men by men. The interview questionnaire contained 45 questions or blocks of questions, and the confidential questionnaire contained 137 items, totalling approximately 500 variables. Thirty-six variables from both tools were used in this paper. In addition to demographic data , five questions were selected from the interview questionnaire regarding relationships with the father and mother and living with parents during adolescence, and participation at any stage of education in classes addressing human sexuality and evaluation of the knowledge gained in these classes from the present perspective. Five questions were selected from the confidential survey, constituting a section on sexuality education. They related to opinions about the rationale for sexuality education in school, the postulated character of school sexuality education, having conversations with father and mother about sexuality during adolescence, the topics present in these conversations (13 topics) and evaluations of the influence of ten different people and institutions on the knowledge possessed at that time. The last two sets of questions were optional, to be completed only by those who previously declared having had conversations with their mother, father, or both parents. Consequently, the last question cannot be viewed as a complete profile of sources of knowledge, but only as an assessment of the influence of additional non-family factors. The exact wording of the questions and response categories for school and home-based sexuality education are provided in the following tables.As a first step, secondary variables were defined by combining information from the questions mentioned above. When assessing the usefulness of the knowledge obtained in school, a code of “0”, indicating no such activities, was added to the standard codes . A measure of the diversity of topics covered in conversations with parents was the number of conversations. Here again, no conversations were coded as zero topics. One item relating to conversations with parents was split into two (mother and father).p”. The nature of the dependency between the rows and columns of the contingency tables was analysed using adjusted standardized residuals.As a second step, the responses to individual questions were compared for young men and women and the relationship between selected factors was examined separately for both genders using the chi-square test (categorized variables) or the Mann–Whitney test . The results of the chi-square test (chi-sq.) are presented along with the degrees of freedom (d.f.) and the significance level “As a third step, linear regression models were estimated, in which the dependent variable was the assessment of family influence on adolescents’ knowledge about human sexuality. The explanatory variables were gender, age in years (18–26 yrs.), working or studying (1: yes), being in a relationship (1: yes), opinion about the usefulness of sexuality education in school (range 0–5), the quality of relationship with father and mother during adolescence (range 0–5), conversations with father and mother about sexuality  and the diversity of topics of these conversations (range 0–13). The final models were re-estimated for variables with a proven relationship so as not to reduce the sample size due to missing data. The goodness-of-fit was concluded on the basis of the R-squared coefficient. Significant interactions between the analysed factors were also sought using a general linear model (GLM). The results from this model are presented graphically as marginal means.The methodological framework and logistics of the survey were positively evaluated by the Research Ethics Committee at the Faculty of Pedagogy, University of Warsaw (opinion no. 5/2020). The opinion concerned the thematic scope of the questionnaire and the research procedure, including obtaining the consent of respondents, ensuring their anonymity and giving them the possibility to withdraw their participation in the survey.With regard to biological parents or their partners, 94.8% of respondents lived with them during adolescence, of whom 19.0% lived with only one parent. The relationship with the mother (or father’s partner) at that time was rated as very good or good by 80.5% of young people. With respect to fathers (or mother’s partners), the percentage of positive relationship ratings decreased to 65.5%.p = 0.024) than with the mother .Positive relations with the mother during adolescence were declared by 88.1% of men and 81.7% of young women. In the case of the positive evaluation of the relationship with the father, the percentages were 79.5% and 69.4%, respectively. Gender differentiated the opinions about the relationship with the father to a greater extent . The percentage of missing data was small, and only 6 out of 595 respondents in this age group refused to answer. More than half (53.6%) of those who participated in sexuality education classes felt that the knowledge gained was useful from their current perspective. However, in this group, 18.7% negatively rated the usefulness of such classes, which is presented in p < 0.001). The percentage supporting sexuality education in school was 81.1% in the group who had such classes themselves, 69.5% in the group who did not have classes and 50.8% in the group who could not or would not describe their experiences.Of the young people surveyed, 75.1% believed that sexuality education classes should be held in schools. Their own experiences projected this opinion . For example, 33.8% of males and 38.5% of young females were in favour of comprehensive education.In the population of young Poles, gender did not differentiate the above opinions on sexuality education at school . The lacYoung people answered the question whether during adolescence their parents (guardians) talked to them about human sexuality. No such conversations were indicated by 41.5% of the respondents, 24.7% had conversations with both parents, 27.9% with the mother only and 5.9% with the father only. There were large gender differences in the distribution of responses to this question, confirmed by the analyses of the standardized residuals . Boys were more likely than girls to have conversations with their father and with both parents, and were also more likely not to have conversations with their parents. In the case of girls, conversations with the mother only predominated with the highest positive residual .It was shown that the frequency of conversations about sexuality was related to the quality of the relationship with parents during adolescence . As the −31.1% had no sexuality education classes at school, or had classes rated as not useful;−41.5% did not talk to at least one parent about sexuality during adolescence;−17.6% had two of the above risk factors for lack of access to sexuality education.Summarizing the results of school and home-based sexuality education, it is worth noting that among the young adults surveyed in Poland in 2017:p = 0.032), masturbation (p < 0.001) and risky online behaviour (p = 0.033).Those who reported having conversations with their parents during adolescence about topics related to human sexuality indicated which topics were discussed. The ranking of topics is shown in p = 0.717; Mann–Whitney nonparametric test).A measure of the diversity of conversations undertaken with parents can be seen in the number of topics addressed. Looking at the median, it was shown that half of the persons talked about seven or more of the 13 topics given. No differences related to respondent gender were shown here . This was largely influenced by the higher percentage of girls talking to their parents.The 18–26 year-olds also rated the impact of various factors  on their knowledge of human sexuality experienced during adolescence. The question was asked conditionally if their parents talked to them about these topics at all (N = 323). Only data about the family impact are presented below. The family influence index was estimated for the whole sample of 595 individuals, taking the value of zero for those who did not talk to their parents, resulting in a mean score of 2.32 (SD = 1.82) and significant gender-related differences . School sexuality education scores were recoded into three levels .p = 0.005 level. In case of boys who talked to their mother about sexuality, their knowledge about sexuality was stable regardless of the quality of school sexuality education. However, this knowledge improved with higher levels of school sexuality education in the group of boys who did not talk to their mother about these topics. These analyses confirm that the gender factor affects adolescents’ knowledge in interaction with other factors.The results of many studies have indicated that adolescents show considerable interest in comprehensive sexual education, and access to sexual education is commonly perceived as a basic right . MoreoveThere is general agreement that parents are the first and most important teachers for their children. It has been pointed that a “quality parent” is one who strives to facilitate the child’s learning in a variety of ways and at different times. These parents see their children as apprentices in life who need to be guided by adults, and adults transform and socialize their children so that they can reach their full potential .Research on sexual communication points out the role of gender, psychological factors and family dynamics in the effectiveness of sexuality education. It has been found that most of the communication on sexual issues comes from the mother. In contrast, boys believe that the communicated content is mainly directed at girls’ experiences. Therefore, boys use other sources  to educate themselves on sexuality issues. Although parents want to talk to their children about issues related to sexual behaviour, they feel embarrassed and uncomfortable, and have neither the skills nor the knowledge to do so . In our Sexual communication in the family presents unquestionable challenges. Research indicates that girls are more likely to turn to parents and boys to peers about sexuality . In one Therefore, in the process of sexuality education, it is extremely important to emphasize the relational factor, which plays a significant role in the transmission of sexual content. Moreover, in the long-term perspective, it allows young people to create more satisfying interpersonal relationships. It is also impossible to minimize the role of proper communication aimed at the needs of children and adolescents.In a sexuality education that is democratic, community-based and collective, everyone would receive medically accurate information about contraceptives and their availability, and pleasure would be discussed in the context of pleasing the other person and making them feel comfortable. Students would research topics related to sex in society to become responsible citizens. They would receive knowledge of societal concerns about pornography, sexual violence, consent, sex work, objectification, relating and sexualization of children . HoweverIn one study, high school students completed questionnaires describing the frequency and importance of communication with their mother and father about 20 different sex-related topics. The study identified four major domains of sex-related topics: social development and concerns, sexual safety, experiencing sex and masturbation. The adolescents reported infrequent communication that varied by domain and the gender of the parent and adolescent. When communication did occur, the first two domains were most often involved. Mothers have been reported to communicate more frequently about sexuality than fathers, and girls have been reported to communicate more frequently than boys . In anotOur own research shows that puberty, pregnancy prevention and adolescent love were most frequently discussed with parents. The least frequently discussed topics were satisfaction in sexual life and masturbation; however, the topic of masturbation was more frequently discussed with boys than with girls. It is also worth noting that in the ranking of topics discussed with parents, pornography and sexual violence occupied a distant position, which indicates that these topics are not popular. Currently, specialists point to the need to treat sexual violence not only as a crime, but also as a public health problem . ApproprIn our study, half of the participants talked about seven or more of the 13 topics listed. Research indicates that adolescents have a significant interest in understanding the feelings and perceptions of the opposite sex and acquiring this knowledge can be beneficial in building emotionally and physically satisfying relationships . In ordeBased on the premise that sexual experiences and sexual communication are shaped by the messages we receive in our youth, the impacts of sexuality education received at home and in school are complementary. The data showed that more than half (53.6%) of those who participated in sexuality education classes felt that the knowledge received was useful from their current perspective. In this group, 18.7% negatively evaluated the usefulness of the discussed classes. There are other models of sexuality education in scientific literature that could increase the usefulness of these classes. One of these models of comprehensive sexuality education goes beyond education about reproduction, risks and diseases, and includes respecting the sexual rights of boys and girls. Complex and holistic sexuality education is guided by a comprehensive curriculum that focuses on human rights and gender equality, while influencing efforts to prevent HIV, sexually transmitted diseases, unintended pregnancies and gender-based violence . It is aCombining the dimensions of sexuality education provided by parents and school, it is worth noting that despite the overwhelming support for the inclusion of sexual health education in schools, few parents perceived the sexual health education that their child/children received as very good. Parents supported teaching about important new areas, such as sexuality, sexting and media skills related to sexual content on television, pornography and in advertising .The limitations of our analysis result from the fact that we used an element of a larger study aimed at the adult population and various issues related to its health and sexuality. The number of available questions on school and home-based sexuality education was limited and the extracted sample of 18–26 year-olds was not very large. However, being limited to an age-homogeneous group of young adults is an advantage of this study. These are individuals who grew up in similar circumstances, have parents of similar age and have a good memory of adolescence . The design of the questionnaire included a number of filters to avoid questions, which streamlined the survey process but resulted in further limitations. In view of the filters used, for example, it was not possible to fully assess the scope of non-family sources of knowledge about sexuality for adolescents who did not discuss the indicated topics with their parents, including the scope of school education. Moreover, family communication was analysed with a focus on conversations about human sexuality, their frequency, involved family members  and the topics discussed. Other studies also paid attention to the conformity aspect, defined as the degree to which children feel obligated to hold the same beliefs as their parents. This approach, grounded firmly in family communication patterns theory, should be used in future research on sexual education and its impact on the behaviours and decisions undertaken by youth .However, this study has a number of advantages that compensate for the above weaknesses. The data are still up-to-date, and in the light of the knowledge available to us, this is one of the few quantitative studies combining the topics of school and home sexual education in Polish conditions, with a strong emphasis on the characteristics of the latter.The results of our research indicate the limited access of Polish adolescents to sexuality education. It was found that girls receive more information on sexuality than boys and the thematic range of the discussed content, both within the school and the family, is limited. There is a real need for supplementary, broad-perspective, comprehensive and science-based sexuality education.In view of the unfavourable atmosphere surrounding school sexuality education in Poland, strengthening the role of parents seems to be an important course of action. However, the results of the analyses indicate that the family together with the school should take care of the proper sexual development of adolescents by responding to their demand for knowledge. Our findings also support prioritizing the training of teachers and parents to increase their comfort with the subject matter and improve the communication of sexuality education content.


Pain is a kind of complex physiological and psychological symptom, which makes the person debilitated and uncomfortable. Some persistent pain is unbearable for the patients, reducing the quality of life and bringing considerable pressure to the individuals and society. Pain killers seem to be effective in analgesia for patients, but their safety and addiction are crucial issues. From the theory of traditional Chinese medicine (TCM), the blocked meridian is the main cause of pain, and effective acupuncture can play a positive analgesic effect. Acupuncture that can date back thousands of years is one of the ancient medical practices in China. Its safety and effectiveness are respected. Based on its superior safety and inferior side effects, it has been gradually recognized as a therapeutic intervention method for complementary medicine, which is also generally used to treat multiple pain diseases. It is shown by modern medical studies that neurotransmitters are the material basis for the acupuncture effect, and the effect of acupuncture analgesia is related to changes in neurotransmitters. However, the specific mechanism has not been elucidated. This review aims to comprehensively discuss the historical evolution of acupuncture analgesia, clinical research of acupuncture analgesia, comparison of acupuncture and drug therapy, the neurotransmitter mechanism of acupuncture analgesia, the effect of acupuncture manipulation on analgesia, and bibliometric analysis of acupuncture treatment for pain, to explore the superiority and related mechanism of acupuncture analgesia from different aspects, and to provide a more effective treatment for alleviating patients' pain. Pain is often the main compelling reason for seeking medical attention, and it can seriously affect the quality of life , 2. PainAcupuncture is also the mainstay of pain management . As a thIn 1997, the National Institutes of Health (NIH) recognized that acupuncture alleviates pain. Although basic research has attempted to explain the underlying mechanisms of its effects, these mechanisms have not yet been determined . AcupuncIn ancient times, the Chinese discovered that using stones (those sharp stones are the prototype of the current needle) to press on the painful parts of the body can relieve the pain. Along with the science and technology development, needle material has changed from stone and bone to gold, silver, copper, and iron. At present, the most popular one is stainless steel . AcupuncAcupuncture is an effective method of therapeutic intervention for alternative medicine that has been widely accepted around the world. Acupuncture was introduced to the West as early as the 16th century, and it was not until the 19th century that it began to be used in clinical practice by Western medicine. Acupuncture analgesia was once introduced in the condition of the use of acupuncture in surgical anesthesia. The first operation of acupuncture analgesia was reported in 1958 in China , and it From the perspective of TCM, acupuncture is based on the theory of meridians and uses the needle to penetrate specific acupoints of the human body to cure diseases. The potential rationality of acupuncture is that diseases related to Qi (energy as considered in TCM) can be treated by stimulating related acupoints . In the Since its origin in China, acupuncture has been used in more than 180 countries and regions. Forty-three diseases used for acupuncture treatment have been acknowledged by the World Health Organization (WHO) . The indThe option of the proper control group is beneficial for improving the feasibility of acupuncture research . HoweverIn terms of reducing the pain effectively, acupuncture combined with other therapies also has a powerful effect. Compared with a single therapy, acupuncture combined with medical training therapy is more effective than routine care . Based oIn summary, acupuncture analgesia is widely believed to be superior to placebo needles, but a large amount of low-quality evidence has been provided clinically due to the shortcomings in RCT methodology and deficiency of rigorous trial design. However, in almost all clinical trials, the acupuncture group was superior to the usual care group, which provides abundant evidence that the effect of acupuncture analgesia is credible. Since the placebo effect is ubiquitously present in RCTs and seems to have a great connection with patient expectations, which seems inevitable and can only minimize the placebo effect, therefore further studies are needed to confirm that acupuncture is not a powerful placebo. Due to the wide range of indications, there are lots of clinical studies on MA and EA. Research on other acupuncture therapies is still insufficient. However, based on the current indications for these acupuncture treatments, to further enhance the analgesic efficacy, acupuncture combined with these therapies should also be advocated. Crucially, rigorous clinical trials must be carried out so that effective interventions for acupuncture analgesia can reasonably be provided.Compared with addictive opioids, as a valid agent for pain management, nonsteroidal anti-inflammatory drugs are one of the most widely prescribed drugs . HoweverThe analgesic effect of acupuncture in certain pain disorders is as effective as NSAIDs, even has a faster and longer-lasting action in acute pain analgesia. Cho et al. divided 45 patients suffering from chronic neck pain into three groups, and after three weeks of treatment, there was no difference in VAS scores between the acupuncture-treated group and the NSAIDs-treated group, and acupuncture could provide excellent analgesia . MurugesAs a safe analgesic therapy with low side effects and low economic burden, acupuncture has a lower incidence of adverse events than drug therapy. It even shows excellent superiority in the treatment of some diseases. For patients who cannot use NSAIDs or other analgesics, acupuncture can be an effective alternative for better pain relief. However, the effectiveness of acupuncture for analgesia is not limited to traditional MA or EA. Other related acupuncture modalities based on acupuncture theory have also demonstrated great superiority. When combined with drugs to treat pain diseases, acupuncture can enhance the analgesic effect and reduce patients' dependence on drugs and even reduce the side effects of drugs. Therefore, acupuncture may play an essential role in formulating the analgesic treatment plan, effectively ensuring patients' quality of life and lowering the ratio of drug use .γ-aminobutyric acid, norepinephrine, and 5-hydroxytryptamine) have been found to exert analgesic effects by modulating the prescribing pain modulatory pathway  mainly plays an inhibitory role in the CNS. EA analgesic mechanism is closely related to GABA expression. It is well known that GABAA and GABAB can participate in pain regulation. GABAA and GABAB are the main subtypes involved in EA analgesia [γ-2 subunit participates in EA alleviating neuropathic pain [µ-opioid receptors of GABAergic neurons [nalgesia . In the nalgesia . PAG is nalgesia . GABA renalgesia . In the nalgesia . After Enalgesia . EA seemnalgesia . GABA manalgesia . GABAA rhic pain . Other t neurons . Consequα2-adrenoceptor can achieve analgesic effects [β-endophilin to achieve analgesia [α2-adrenergic receptor [α-receptors, against EA analgesia [Studies have shown that norepinephrine combined with  effects . EA can  effects . The invnalgesia . The anareceptor . EA contreceptor . Tolerannalgesia . Its tol5-Hydroxytryptamine (5-HT) is generally renowned as serotonin. It is the neurotransmitter of the descending inhibitory system of the brainstem involved in analgesia. 5-HT secretion increased in the brain during acupuncture analgesia . It is mThe most widely spread neurotransmitter in the CNS is glutamate, which plays a vital role in excitatory ascending pathways. It is a crucial excitatory neurotransmitter that efferents from the dorsal horn of the spinal cord . GlutamaIn conclusion, the frequency of EA is fixed and controllable. The release of neurotransmitters seems to be related to a fixed frequency, with different frequencies releasing different neurotransmitters. The analgesic effect is closely related to the quantity of acupuncture stimulation. Most of the current studies on acupuncture analgesia are based on animal models, and the choice of acupuncture points in different models is diverse. Whether the different anatomical locations affect the release of different neurotransmitters remains to be clarified. The neurotransmitters released are different when acupuncture is applied to rapid analgesia and slow analgesia. How to shift the analgesic phase and release neurotransmitters to maximize the analgesic effect remains to be further investigated. There are other mechanisms of acupuncture analgesia. How to combine multiple mechanisms to achieve the best analgesic effect deserves our attention.Plenty of clinical trials and molecular mechanism studies have proved that acupuncture analgesia is indeed effective. But the analgesic effect of acupuncture still has limitations, for instance, placebo as mentioned above effect and the inadequacy of RCTs design such as the design of an effective control group. The specificity and quantity of acupuncture also deserve further exploration.The manipulation of acupuncture closely relates to physicians' personal clinical experience, and it is hard to achieve standardization. Heterogeneity among practitioners may bias the analgesic effect of acupuncture. There are high-quality meta-analyses of acupuncture trials for chronic pain that demonstrate a more significant variation in treatment efficacy among different practitioners than would be expected by chance . BetweenThe quantity of acupuncture is related to the number of acupoints, the number of needles, the frequency of acupuncture, and the duration of treatment , 115. HiThere are a few bibliometric analyses on acupuncture analgesia. In recent years, studies related to acupuncture analgesia have gradually increased. We attempted to analyze the progress and research trend of acupuncture analgesia by bibliometric method to observe the discipline's current research hotspots and frontier areas. All data were retrieved from the Web of Science on December 31, 2021, with the search terms (acupuncture) AND (pain). We selected publications from the last decade, with publication dates from January 1, 2011, to December 31, 2021. A total of 4781 articles were included in the bibliometric analysis after excluding articles that could not be used as full-text duplicate publications. We used VOSviewer v.1.6.17 to carry out descriptive statistical analysis on publications from journals, keywords, authors, and countries. We used Excel 2019 to analyze the trend of literature published in the past decade.A total of 4781 papers were identified for this study. The number of articles published each year is shown in 4781 articles on acupuncture treatment for pain came from 1043 journals. Among them, Evidence-Based Complementary and Alternative Medicine published the largest number of publications (7.8%), followed by Medicine (4.8%) and Acupuncture in Medicine 4.8%; . Table 1Based on the frequency of keywords, the current research area can be identified. The keywords in 4781 articles were analyzed by VOSviewer, and a total of 11,483 keywords were mentioned in all articles of which 80 were mentioned more than 85 times. We divided these keywords into four groups by VOSviewer. As shown in We found a total of 18,841 authors by VOSviewer, of whom 27 authors have more than 25 articles. From A total of 91 countries have published publications on acupuncture treatment for the pain of which 32 countries have published more than 20 articles. As shown in Acupuncture is an effective method of analgesia. Since acupuncture analgesia was discovered, its effectiveness has been confirmed by numerous clinical and molecular mechanism studies. Acupuncture has been widely applied to alleviate several pain diseases and incorporated into guidelines, and it is an effective method of coping with the opioid crisis and is widely respected due to its safety, low price, and low addiction. The use of acupuncture helps to increase the levels of neurotransmitters in the body, which can be targeted for the treatment of different pain disorders according to different activation mechanisms while maximizing the analgesic effect according to their quantity requirements. However, acupuncture analgesia still suffers from the following deficiencies: (1) Acupuncture can be used to treat various pain diseases, but the spectrum of diseases has not been well defined, and its indications should be further expanded. (2) The design of RCTs related to acupuncture is still flawed, and how to improve the design methods of RCTs to avoid bias is also an urgent issue to be solved. The placebo effect seems to affect the essence of acupuncture analgesia, and avoiding the placebo effect requires further examination. (3) Whether acupuncture can be an effective alternative therapy to drugs in the treatment of certain diseases or to develop individualized treatment plans based on acupuncture analgesia. (4) The analgesic mechanisms of the different acupuncture modalities have not been elucidated, but most of them seem to be based on the same neurotransmitter mechanism. Different frequencies of acupuncture can lead to the activation of neurotransmitters at different sites. The related mechanism has not been clarified. The mechanism of action of different neurotransmitters for analgesia also needs to be further demonstrated. (5) The choice of different acupoints would induce different analgesic efficacy, and the variability between acupoints remains to be clarified, and the choice of the correct acupoint should be based on a large body of evidence. (6) How to avoid bias produced by acupuncture specificity remains to be addressed, and the criteria for acupuncture quantification are unclear. (7) Through the literature measurement tool, we can clarify the current research trend and the cross-research between disciplines and even countries, which is significantly beneficial to the research progress of acupuncture treatment of pain, but there are still deficiencies. The literature selected in this paper is in English, while other languages are not included, which may lead to bias in some aspects. If it includes the literature in Chinese or other languages, it may make the analysis results more comprehensive. Second, the results of the bibliometric analysis may be subjective, and the results may be different due to the different settings of software applications. However, the analysis of keywords and publications in this paper can accurately determine the current prominent researchers and research hotspots, which is conducive to the induction and research of acupuncture treatment for pain. In a word, effective analytical methods and considerable basic and clinical research are still vital to confirm the related mechanism of acupuncture analgesia, thereby providing an effective means of diagnosis and treatment for the medical service.


Rhizophagus irregularis has been demonstrated to increase the yields of various crops. However, there is a paradigm that AMF colonization of roots, as well as the plant benefits afforded by inoculation with AMF, decreases with increasing phosphorus (P) supply in the soil. The paradigm suggests that when fertilized with sufficient P, inoculation of crops would not be beneficial. However, the majority of experiments demonstrating the paradigm were conducted in sterile conditions without a background AMF or soil microbial community. Interestingly, intraspecific variation in R. irregularis can greatly alter the yield of cassava even at a full application of the recommended P dose. Cassava is a globally important crop, feeding 800 million people worldwide, and a crop that is highly dependent on AMF for P uptake. In this study, field trials were conducted at three locations in Kenya and Tanzania using different AMF and cassava varieties under different P fertilization levels to test if the paradigm occurs in tropical field conditions. We found that AMF colonization and inoculation responsiveness of cassava does not always decrease with an increased P supply as expected by the paradigm. The obtained results demonstrate that maximizing the inoculation responsiveness of cassava is not necessarily only in conditions of low P availability, but that this is dependent on cassava and fungal genotypes. Thus, the modeling of plant symbiosis with AMF under different P levels in nature should be considered with caution.A vast majority of terrestrial plants are dependent on arbuscular mycorrhizal fungi (AMF) for their nutrient acquisition. AMF act as an extension of the root system helping phosphate uptake. In agriculture, harnessing the symbiosis can potentially increase plant growth. Application of the AMF  Phosphorus (P) is an essential nutrient for plants that affect the productivity of crops . UnfortuIn nature, plants interact with diverse microorganisms to improve P uptake . One of In vitro experiments have demonstrated that under P limitation, plant roots increase the production of signal molecules stimulating the establishment of the symbiosis  is known to be one of the crops that are most responsive to AMF inoculation , using a landrace and an improved cassava variety at each location. The soils at the three locations were considered very-low to medium-low P content soils  reported by The experiments were established at three different locations: (1) Ukwala-Kawayo, Siaya County, Kenya ; (2) Kayenze, Biharamulo district, Tanzania ; and (3) Kijuka, Sengerema district, Tanzania  variety that had been bred for disease resistance and a locally grown landrace  and mixed with a sterile inert carrier . The culture conditions, including the type of medium and temperature for incubation, were previously described by R. irregularis cultures were chosen based on preliminary results of a previous field trial conducted at Ukwala-Kawayo, Kenya that was performed with a greater number of fungal cultures and the cassava landrace Fumba chai  were inoculated with 1 g of diatomite carrier containing 1,000 fungal spores of a given fungal parental isolate or SSL, and this was placed around the stem of the cassava at planting. Fertilizer was applied between 30 and 45 days after planting (DAP). The amount of fertilizer applied was determined by the initial soil nutrient content, nutritional requirements of cassava, and fertilizer efficiency . The nutg ha−1 K . The souanalyses . The amoIn Kayenze and Kijuka (Tz), the trials were established in January 2018 and harvested a year later. In Ukwala-Kawayo (Ke), the trial was sown in March 2018 and also harvested a year later.−1) was measured at harvest time. Cassava fine roots were collected at a depth of 0–30 cm. Plants were uprooted by removing the soil around the stem and starchy roots with a shovel, and then manually pulling them out to assure that many of the fine roots came out with the main starchy root. Then, 3 g of fine roots were collected from the main roots after pulling out the plant from each cassava plant and stained following the method of −1) showed a strong linear correlation  with root dry weight (kg plant−1) regardless of the cassava variety  and root fresh weight  was conducted first to assess the general effect of each of the main factors on root fresh weight . The resBecause there were large variations in cassava root weight among locations and cassava varieties, and because the cassava varieties were not always the same at each location, an overall analysis considering locations and cassava varieties as random effects resulted in the loss of statistical power. Therefore, we separated the dataset by location and cassava variety to further investigate the effect of P treatment on cassava root fresh weight and AMF colonization. This analysis revealed location-specific and variety-specific responses to P fertilization, which were masked in the analysis of the whole dataset . P fertiThe fertilization of cassava with different levels of P did not affect the AMF colonization of cassava roots in Kayenze in either variety . In KijuEven though in this study, we were not able to distinguish root colonization of the inoculated AMF from that of the native AMF community, there was no significant difference in root fresh weight and AMF colonization between the non-inoculated controls and inoculation treatments at different levels of P supply, in each plant variety and at each location. In general, there was no significant difference in root fresh weight or AMF colonization observed in non-inoculated controls following different levels of P application . Only onTo focus on the effect of AMF inoculum, we next tested whether the inoculation responsiveness of cassava decreased with increasing levels of P fertilization. Inoculation responsiveness of cassava was, indeed, significantly affected by the level of P fertilization, but this effect was not the same in each location and each of the two cassava varieties at each location . InoculaTo investigate the effects of P fertilization on the inoculation responsiveness of cassava to the different AMF inoculation treatments, we further analyzed inoculation responsiveness to P fertilization in each cassava variety and each AMF inoculation treatment. Out of 36 tests, eight tests revealed that inoculation responsiveness of a cassava variety differed among P treatments but depended on the fungus the plants were inoculated with We tested whether the inoculation responsiveness of cassava to different inoculation treatments was the same among cassava varieties and locations under different P fertilization treatments. We observed that inoculation responsiveness to the different AMF treatments, at a given P treatment, was sometimes completely opposing, depending on the cassava variety. For example, the inoculation responsiveness of the Mkombozi variety in Kijuka at 0% P, when inoculated with C2, was positive, while that of plants inoculated with C3.16 showed negative responsiveness . HoweverThe P inhibition paradigm, where increased P supply suppresses AMF colonization, as well as plant growth responsiveness to the symbiosis, has been fundamental in choosing where the application of AMF is considered appropriate. This study showed that in tropical soils, AMF colonization and responsiveness to inoculation with increasing application of P fertilizer did not follow the trajectory expected from the P inhibition paradigm. Therefore, the first hypothesis of the P inhibition paradigm is rejected. We found that AMF colonization and responsiveness to inoculation, indeed, differ with increasing P application but not in a way that is predicted by the paradigm. Effects of location, cassava variety, and AMF isolate all play a significant role in determining AMF development in cassava roots and plant responsiveness to inoculation at different levels of P application. The results of this study supported the second hypothesis that genetically different AMF isolates do not have the same effect among cassava varieties and locations under different P fertilization levels, even though the AMF isolate identity was not the sole determinant of plant responsiveness to AMF inoculation under different P supply. We discuss these in more detail below and point out where these results help to suggest where research should be focused on to make successful AMF applications more predictive in agriculture.We observed that the way cassava root weight, AMF colonization, and responsiveness to inoculation responded to increasing P application was strongly influenced by location. Despite the soils in these locations being very deficient to moderately deficient in available P, increased P application only induced greater cassava productivity in three of the six cases surveyed in the present study: two varieties at one location, Kayenze, and one variety at Kijuka. However, in these cases, AMF colonization was either unaffected (in Kayenze) or higher in the 50% P treatment than in the 100% P treatment (Kijuka). In Kayenze, responsiveness to inoculation was suppressed with increasing P treatments, but in Kijuka, responsiveness to inoculation was significantly lower in the 50% P treatment compared to both of the other treatments, thus not following the hypothesized pattern. In Ukwala-Kawayo, P application had the complete opposite effect on AMF colonization to that predicted by the P inhibition paradigm, with AMF colonization increasing with increasing P application in both cassava varieties. In these cases, responsiveness to inoculation also did not follow that expected by the P inhibition paradigm.Interestingly, the variety of cassava did not play a very important role in determining the AMF colonization responses to increasing P application but greatly affected responsiveness to inoculation. In Kijuka, responsiveness to inoculation in the two varieties was opposite, with responsiveness being highest in one variety at 50% P application and lowest in this treatment in the other variety. Again, these results are not consistent with the P inhibition paradigm. This was especially true for certain fungal treatments where responsiveness to inoculation differed among P treatments but in an opposite way in the two cassava varieties . ResponsOne possible explanation for the lack of P-induced mycorrhizal suppression is that added P fertilizer was not available to the plants because of P fixation in these soils. Although P availability after the application was not measured, this appears highly unlikely because cassava root weight was P responsive in some cases regardless of location. Furthermore, a significant P application effect on the responsiveness to inoculation, with maximum responsiveness at 50 or 100% P application, is not consistent with the hypothesis that the added P had been fixed in the soil rendering it unavailable. The suppressive effect of P application is known to be attenuated by limited N availability , but in Among-location differences in P responsiveness may reflect differences in the physical or chemical characteristics of the soils. Such characteristics have previously been shown to affect the AMF-plant symbiosis and alter P uptake and exchange of other nutrients between partners . HoweverOne large difference between many published experiments that demonstrate the existence of the P inhibition paradigm and these field trials is that most of the studies have been conducted in sterile soil where plants were inoculated with one AMF isolate. In agricultural soils, AMF is almost always present. Thus, many previous studies have assessed how colonization by one AMF taxon, in the absence of other microbes, responds to the effects of P application. In infield trials, AMF colonization represents the response of the pre-existing AMF community, plus the introduced taxa, to different levels of P supply. In several cases, P supply did not suppress mycorrhizal colonization and even had the opposite effect. This indicates that either the taxa we added and/or all or some of the components of the AMF community were not adversely affected by increased P supply. Indeed, the AMF community structure in both the soil and the root can be altered by P supply . Thus, wR. irregularis isolates or their offspring to cassava in tropical soils has been shown to alter both the alpha and beta diversity of AMF communities (Because of the pre-existing AMF community and microbiome in agricultural soils, measuring the responsiveness to inoculation in field trials represents the response of plants to the inoculant, in the presence of the AMF community and other components of the microbiome, compared to the effect of the pre-existing AMF community and microbiome alone. This is very different from pot experiments comparing an inoculated plant to a non-mycorrhizal control. In several cases, in this study, we report responsiveness to inoculation that is inconsistent with the P inhibition paradigm. Phosphate availability to roots can be dynamic in time as there should be a gap between the timing of P depletion near AMF hyphae in soil, the growth of new foraging hyphae, and plant uptake of soil P. Consequently, this can affect the temporal patterns of plant P nutrition that can further modulate the AMF community colonizing roots and affect plant responsiveness to inoculation. However, the inoculation responsiveness was measured 1 year after inoculation and is, therefore, based on the accumulation of all possible temporal changes in plant P nutrition and the associated AMF community until the harvest. Therefore, the accumulated effect can help the understanding of the overall impact of inoculation under different P supply. We see the addition of the introduced mycorrhizal taxa as a potential perturbation of the community and that change in the existing microbial community. While we did not measure the effects of inoculation on the AMF community at different levels of P application, it is already known that adding AMF can alter the structure of existing experimental AMF communities . Indeed,munities . TherefoR. irregularis strains, in the presence of a pre-existing AMF community and with 100% P fertilization, can alter cassava productivity by up to 300% in these soils (Given the overwhelming number of experimental studies, we do not put into question the existence of the P inhibition paradigm and the mechanism afforded by plants to limit AMF colonization. However, the results of this study strongly suggest that the paradigm cannot be used as a valid generalization for whether or not inoculation will be effective in tropical soils or that AMF should only be applied in P-deficient soils in the absence of P fertilization. The fact that the location, plant variety, and AMF identity all play a role in how P fertilization affects responsiveness to inoculation means that we do not currently have a way of predicting where and in what management conditions, AMF inoculation will be effective. Despite this, the fact that inoculation with different se soils  shows thThe original data collected in the present study are included in the article/RAPV conceived and conducted the experiments, analyzed the data, interpreted the data, and wrote the manuscript. S-JL analyzed and interpreted the data, and wrote the manuscript. MT conceived and conducted the experiments. DM conducted the experiments in Tanzania. CM and BV conceived the experiments. AR and IS conceived the experiments, interpreted the data, and wrote the manuscript. All authors contributed to the article and approved the submitted version.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.