Background: Food allergy is one of the most serious health concerns spread across the globe. Its awareness and management are undervalued, especially in children with autism spectrum disorders (ASD). The aim of this study is to explore the perception of parents of autistic children from Saudi Arabia on the prevalence, knowledge, awareness and management of food allergens. Methods: A cross-sectional exploratory self-administrated online survey was conducted in Saudi Arabia, where 125 parents of autistic children voluntarily took part in the survey from April to August 2022. Results: This study indicates that less than one-fourth of autistic children suffering from food allergies, while most of them are allergic to proteins mainly. Examination of the knowledge level of these parents regarding food allergies, depending upon the score of correct answers given by them, showed that a majority of parents had a moderate level of knowledge on food allergy. Even though there was awareness about food allergens, the use of medical interventions was not employed much. However, the parents were mindful of food labeling and found it to be useful in avoiding known food allergies. Mediating effects of food allergy were observed in the relationship between food allergy knowledge and its management. Moreover, the source of information about food allergies was also found to be significantly associated with the knowledge score and the level of awareness regarding food allergies. This study provides evidence that there is a significant influence of food allergy knowledge of parents of autistic children on its management among autistic children from Saudi Arabia, with awareness of food allergies as the mediator. Conclusions: This is the first study where the prevalence, knowledge and management, along with awareness of food allergy, has been empirically explored through the perception of parents of autistic children.  Food allergy can be described as the “adverse health effect arising from a specific immune response that occurs reproducibly on exposure to a given food”, which varies from food intolerance as the latter is a “nonimmune reaction that includes metabolic, toxic, pharmacologic, and undefined mechanisms” . The cliThe Codex Alimentarius  developeThe health conditions become even more concerning for individuals with developmental disorders, especially autism spectrum disorders (ASD) and many others . Autism The typical symptoms also for autistic individuals remain the same as others and include gastrointestinal, sleep disorders and skin-related reactions ,12. CommStudies dealing with food allergy among children from the Arabian peninsula are limited ,5 and paTo explore the level of prevalence of food allergy, the main types of allergens and symptoms among autistic children.To estimate the level of knowledge of parents about food allergies in children with autism.To understand the impact of parental knowledge of food allergy on its management to ensure healthy well-being of autistic children and mediated by awareness towards food allergy.None of the studies elaborate on the perception of parents with autistic children in terms of their knowledge and awareness of the concept of food allergy, even when the autistic abdominal symptom seems to be associated with food allergies ,12,24. MFor this study, a nationwide observational cross-sectional survey in Saudi Arabia through web-based questionnaire was formulated by the researcher. A positivistic exploratory research design employing a deductive research approach to understand the extent of food allergy management among autistic children was undertaken. The duration of the study was from April 2022 to August 2022.The sample population intended for this study comprised 125 parents of children with autism selected using the convenient non-probability sampling technique. The inclusion criteria included consent from the parents, age group of children in the range of 2 to 18 years, and diagnosis of autism or ASD. The exclusion criteria were as follows: (a) autism related to any genetic syndrome; epilepsy; celiac problems, (b) being a single child, (c) any known food allergy, such as lactose intolerance, nut allergy, etc., or (d) children on a special diet. This research was performed in conformity with the rules of the 1975 Helsinki Declaration. Approval was attained from the ethical committee of the College of Applied Medical Sciences in Taibah University, Medina, Saudi Arabia (2022/141/207/CLN) on 10 April 2022.A well-structured online questionnaire was prepared by the researchers based on the literature reviews of past studies in this area. This method was found to be appropriate because of its greater geographic distance coverage, reduced cost of traveling, and the easy maintenance of proper COVID-19 protocols during data collection ,26. The A scoring system based on the right answers was employed to calculate the knowledge score. Each right answer was given a score of one. Those parents who had a score of less than or equal to 8 were considered as having poor knowledge, while individuals answering 9 to 11 statements correctly were considered to have moderate knowledge and participants who identified 12 or more correct statements fell under the category of parents with good knowledge on food allergy. Awareness of food allergy and Management of food allergy with respect to medical interventions and understanding of food labeling was measured using 5-point Likert scale, ranging from 1 = Not at all to 5 = Always. In addition to this, the most common source of information about food allergies for the parents of autistic children was also probed. The final questionnaire was also translated into Arabic for a better understanding of the participants and sent to them through their emails. Under ethical considerations, it should be observed that the consent forms were distributed by the researcher before the administration of the questionnaires. Only after receiving acceptance of consent mail was the questionnaire sent to the voluntary participants. Moreover, the participants were assured that the data would be used only for academic purposes, be kept confidential and be inaccessible to any third party other than the researcher. p-value was observed to be less than 0.05 at 95% confidence level. Statistical software (SPSS version 24) was employed to convert the collected raw data into numerical data which was subjected to statistical analyses. This statistical tool has been successfully used for obtaining meaningful inferences . All thep > 0.5). The top three most common symptom of food allergy observed in autistic children was skin redness (72.4%), followed by skin rash (69.0%) and itching (62.1%). The other symptoms include shortness of breath (31.0%); swelling of body parts, especially the tongue (20.7%); abdominal pain (17.2%); nausea and vomiting (13.8% each); difficulty in swallowing and diarrhea (10.3% each) and runny nose and cough (6.9% each). The knowledge of parents of autistic children on food allergies was assessed by asking them true or false about 16 related statements . Based op < 0.01), nationality , educational qualification , and family history of food allergy . Poor knowledge was associated with young parents (18 to 30 years) and non-Saudi nationals with no family history of food allergy, which may be due to inexperience. Gender of the parent, their occupation and location of residence did not play any role in the knowledge of food allergy among these parents with autistic children. Furthermore, the association of the knowledge score of parents with their demographics was analyzed , and it With respect to food allergy awareness, the majority of parents (41.6%) felt that they were ‘somewhat’ aware of the food items that cause food allergy in their child and often felt that the food should be monitored before their child eats it (36%). The management of food allergies was evaluated through two sub-variables, such as the use of medical interventions and the understanding of food labeling. Within medical interventions, the majority of parents often kept an epinephrine pen handy (34.4%). More than 38% of them had to send their child to the emergency room (ER) or have been admitted to the hospital due to food allergies. Moreover, the parents very well knew which doctor to be consulted when their child got an allergic reaction. In terms of food labeling, more than half (52.8%) of the participants believed that food labeling is extremely helpful in avoiding known medical allergies. Almost half of them were aware of the information for labeling food allergens, while 46.4% of them were cautious about the contents in the food that was given to the child.p < 0.05) (Model 1). Analysing the indirect effects, results reveal that awareness completely mediates the relationship between knowledge and management of food allergy in parents with moderate knowledge of food allergy, but awareness of food allergy partially mediates the same relationship in parents with a high level of allergy knowledge. p < 0.01) and awareness of food allergy . It was observed that the advice of the doctor or the health care professional e.g. dietitians was considered a better source of quality information and the best source for food allergy compared to social media.In The findings of this study deal with knowledge and awareness of food allergy and its management among parents of autistic children in Saudi Arabia. Among the studied parental attributes, it was observed that the majority of the participating parents of the autistic children were in their middle age and non-graduates, as also observed by Alqahtani et al., , where tThe selected participants reported that less than one-fourth of the autistic children faced the issue of food allergy. Regarding the prevalence of food allergies in autistic children, the findings of the present study show a much higher degree of prevalence compared to the levels reported by others ,13, wherAmong all food categories, the primary allergen for autistic children, as observed by their parents’ involved food rich in proteins. This can be supported by Youssef et al., , whereinAmong the most common symptoms, redness was also observed in the majority of children as an allergic reaction by ,28 in chCompared to the findings of the present study, where the majority of them had moderate levels of knowledge on food allergy, the majority of mothers from a study in Saudi Arabia were found to have poor allergy knowledge . The knoContrary to our findings on the level of food allergy awareness, ,17 reporA significant influence of knowledge of food allergy of parents on the management of food allergy was observed, which was mediated by awareness of food allergy. The mediation analysis showed that parents with good knowledge of food allergy significantly influence food allergy management in autistic children. However, parents with a moderate level of knowledge have hardly any impact on allergy management. Therefore, awareness in this aspect is essential, especially for the population who have a moderate level of knowledge of food allergies. As expected, the management can be better controlled by enhancing knowledge and awareness of it. Therefore, raising awareness of food allergy is required for Saudi society, especially with regard to autistic children, as also realized by . In factSupporting our results from this study, social media has been argued to play a critical part in enhancing the awareness of parents, thereby altering their attitude towards food allergy . RegardiEven though this has been one of the pioneering contributions to the outlook involving food allergies in autistic children, this study was restricted in terms of sample size, the scope of bias and misreporting as this study was based on self-reporting rather than through clinical guidelines. Moreover, no immunological tests were conducted to actually assess the immune response of the affected children. In addition, no neurotypical children were considered for the study. Moreover, the degree of autism was also not studied during the course of the study. Therefore, increasing the sample size, obtaining validation from doctors about the genuine nature of food allergy, and comparing it with non-autistic children from the same area can lead to an in-depth analysis of the issue, which will be helpful in obtaining the whole picture as a part of future research. Furthermore, research should also focus on finding easier methods for identifying food allergies and understanding the various aspects of food allergy management, which will be beneficial in managing ASD as well. The present study explored the prevalence, awareness and management of food allergies through the perceptions of parents with autistic children and showed that food allergy can be a major problem among autistic children, even though this is yet to be supported by scientific evidence. A high prevalence of food allergies was observed in these children, thereby implying that it is crucial to spread awareness of food allergens among the population in order to have better management of reactions to food allergies. Moreover, this study also elaborates on the types of food allergens and the symptoms observed during allergies in autistic children. Since the overall knowledge among the majority of parents was found to be moderate, an increase in knowledge is urgently warranted, especially among parents of children with developmental disorders. Moreover, awareness was found to completely mediate the relationship of knowledge on food allergy management in terms of parents with a moderate level of knowledge, while for parents with a high level of food allergy knowledge, awareness only partially mediated the relationship. From our study, it can be suggested that awareness of food allergy should take precedence by the healthcare ministry. Moreover, the healthcare agencies, as well as the healthcare ministries, should start intensive programs that ensure an increase in correct and accurate knowledge about food allergies. Our results emphasize that food allergy management is not being considered seriously among this kind of population, which is a matter of concern not only for the patients but also for their caregivers, the government, doctors, hospitals and society as a whole. This task is essential for ensuring the healthy well-being of autistic children since these children are more affiliated to be impacted by food allergies compared to children who do not have ASD. However, this study in no way implies that food allergy is the causal agent of ASD among children and, therefore, needs to be confirmed through medical analysis. To the best of our knowledge, this is the first study exploring the awareness and management aspects regarding food allergy in children with autism as well the role of awareness as a mediator, where knowledge influences food management. Another key strength of this study includes the inclusion of participants from all regions of Saudi Arabia.


As an important spice, ginger has been widely distributed in the Chinese and the European Union (EU) markets, the two largest trading areas, in various forms. The ginger supply chain between China and the EU is long and complex, providing opportunities for fraudsters to deceive consumers. However, limited attention has been given to food fraud in ginger, and there is a lack of research on this topic. In this review, ginger was used as an example for interpreting the fraud issues within low-priced and high-trade volume spice products. This review aims to summarize the open access information from food and food fraud databases, literature, and stakeholders about ginger fraud, and to map, deconstruct and analyse the food fraud vulnerability in the supply chain. In addition, potential testing strategies to detect ginger fraud were also discussed. The investigation of food fraud databases, a semi-structured literature review and online interviews with stakeholders revealed that adulteration is the major fraud type in ginger products. And the most vulnerable ginger products are ground ginger and finely processed ginger. The ginger supply chain from China to the EU comprises nine stages and is medium vulnerable to food fraud, both in regard to opportunities and motivational drivers. To ensure the integrity of the ginger supply chain, there is a need to apply fraud vulnerability tools in the companies of the industry. In addition, screening and confirmatory techniques based on the characteristics of ginger should be utilised for monitoring fraud issues in the supply chain. Food fraud types include but are not limited to, adulteration, substitution, addition, tampering or misrepresentation of food, food ingredients or food packing; or false and/or misleading statements made about a product2. Food fraud has troubled the food industry throughout history3. The 2008 melamine-contaminated milk powder scandal in China and the 2013 horsemeat scandal in the European Union (EU) shed light on the problem again and highlighted that food fraud is a vital topic that has been greatly overlooked by the food industry for many years5. Food fraud can cause economic and reputational damages to food companies and the associated industry, in addition, some fraud incidents have resulted in serious public health risks such as allergies and poisoning7. The reported food fraud scandals not only caused significant financial losses to the food industry and brought about food safety or public risk events but also reduced consumers’ confidence in brands.Food fraud is generally defined as one of the behaviours that deceive consumers for financial gain8. Although only consumed in small quantities, spices play a significant role in the food industry as it is an important ingredient in a huge variety of foods and beverages. Its unique position in the food industry, complex supply chain and high price by weight make spice highly vulnerable to food fraud9. In addition, the time it takes from harvest to the consumption of spice can be years; further decreasing the transparency of the spice supply chain10. Nowadays, more research is being conducted on food fraud issues in the spice industry, especially on developing analytical techniques for spice authentication11. Nevertheless, limited research has focused on summarizing the fraud issues of a specific spice, as well as the intricacies of spice supply chain networks and the fraud risk factors hidden therein. In addition, low-priced and high trade volume spices receive limited attention compared with expensive spices such as saffron and vanilla. In 2018, a review by Galvin-King et al.12 gave a general insight into the spice supply chain and looked at the type and effect of fraud in spices and herbs. This review created a need for further research on the topic; especially focused on specific spices.The spice industry is one of the top three industries prone to food fraud13. Nearly 95% of the EU’s imports of spices come from developing countries, while China is the EU’s largest spice trading partner that mainly supplies ginger and capsicums14. Among all spices circulated worldwide, ginger is a representative of the low-priced and high trade volume spice products because of its mass trade volume and wide application in foods. Ginger is one of the most common spices used for flavouring dishes in China, and it is also one of the most important spices exported to the European market because of the huge import volumes15. In 2018, the import volume of ginger  was 127,259 tonnes, ranking first in the import of spices and herbs from developing countries, moreover, China accounted for almost 45% of ginger supplies from developing countries to the EU16.From a global perspective, the EU is one of the largest consumption areas of spice17, fraud issues in ginger products have not been investigated and summarized. The overall situation regarding ginger fraud remains unclear. Moreover, the current understanding of the ginger supply chain from China to the EU is still the general impression of the traditional system of the spice supply chain18. The hidden issues in the opaque ginger supply chain limit the ability of stakeholders to guarantee the authenticity of this important spice. Therefore, it is necessary to provide a general summary of food fraud issues in ginger products and to map, deconstruct and analyse the supply chain based on the current information. This paper aims to summarize the open access data in the food fraud databases and the literature about ginger fraud, comprehend the structure of the China-EU ginger supply chain to identify the most vulnerable nodes and propose potential technical solutions that can be used to mitigate ginger fraud. This review can be used as an example for the spice industry as a solution to the fraud issue in many other low-price high trade volume spices.However, even though ginger, especially ground ginger, has been labelled at high risk of food fraud according to the Food Fraud Risk InformationAn investigation of food fraud databases, a semi-structured literature search, online interviews with key stakeholders and a food fraud vulnerability assessment was performed to identify ginger products with fraud concerns, explore associated fraud issues, and map the ginger supply chain between China and the EU.The databases, as described in Supplementary Table For the semi-structured literature search, Web of Science, Scopus, and Google Scholar were used as databases to source relevant articles written in the English language, covering all publication years up to 2021. During the process, specific keywords, and the combination of these keywords with Boolean operators were included. For the search strategy to obtain information related to ginger supply chains, the following search string was used within all fields of the databases: “spice” OR “ginger” AND “supply chain” OR “supply chain network” AND “map” OR “diagram” OR “model”. For the search strategy of fraud issues related to ginger, the following search string was used within all fields of the databases: “ginger” AND “fraud” OR “adulteration” OR “unapproved processing” OR “undeclared processing” OR “mislabelling” OR “misrepresentation”.20. During the search processing, the inclusion and exclusion criteria  and organizations/authorities (food fraud databases). A total of five stakeholders  from three actor groups in the ginger supply chain were requested to participate in a 30-min online interview. All interviewees’ positions were quality assurance managers, two from China and three from the EU. The interviews were conducted online in English and Chinese, depending on the nationality of the interviewees, in three steps. First, the aim and major content of the interview were explained. Second, the interviewees were requested to introduce themselves and basic information about their companies. Third, the interviewees were requested to answer questions about their ginger products, supply chains and potential fraud risk factors. The full interview questions that were used in step three are shown in Supplementary Table 1. This is a science-based food fraud vulnerability self-assessment questionnaire consisting of 50 questions to evaluate the three key elements of food fraud vulnerability: Opportunities, Motivations and Control measures. Each question has three optional answers describing low, medium, and high vulnerability situations of the associated indicator. For the indicators from Opportunities and Motivations, answers with scores 1, 2 and 3 reflected a low, medium, and high vulnerability level, respectively. For the indicators from Control measures, the answers with the scores 1, 2 and 3 reflected a high, medium, and low vulnerability, respectively. The questions used in this study were pre-selected and slightly modified based on the available information acquired from food fraud databases, semi-structured literature search and online interview with stakeholders before being further used. The results were determined by the highest frequency of perceived vulnerability for all stages/indicators/elements. The frequency was determined by the following Eq. , Xij is the number of observations which get the score i in the j stages/indicators/elements, Yj is the total number of the observation in the j stages/indicators/elements.After mapping the ginger supply chain based on the information obtained from semi-structured literature search and online interview with supply chain stakeholders, the food fraud vulnerability of the supply chain was assessed to gain a better understanding of the supply chain from a fraudulent perspective. The food fraud vulnerability of the ginger supply chain from China to the EU was determined by using the free online food fraud vulnerability assessment tool, developed by the non-profit SSAFE organization in partnership with Wageningen University, VU University AmsterdamZingiber officinale) is one of the most commonly used spices21. Because of its unique flavour and potential health benefits to the human body and brain, ginger is widely used as a spice and traditional medicine22. The unique flavour of ginger makes it suitable to be used for various food products such as vegetables, confectionery, soft and alcoholic beverages, pickles, and biscuits. Ginger can be used in numerous forms, such as fresh, dried, grounded, pickled, preserved, and crystallized. The harvest time of ginger rhizomes depends on their intended use. For fresh, preserved, or pickled ginger, young and immature ginger is primarily used as it is juicy, with a mild taste and has a thin skin23. The content of fibre and volatile organic compounds of ginger continues to increase with age24. Therefore, for dried ginger, it is best to use mature rhizomes, which have a sufficient aroma, flavour and pungency25. In addition, the ideal type of ginger for cooking is ginger harvested eight to nine months after planting because the content of volatile organic compounds and pungent compounds reach a maximum of about nine months after planting26. In this section, the ginger products with food fraud concerns were summarized from the literature and food fraud databases and classified according to the degree of processing . According to the answers from the interviewees, it is the industry’s consensus that ground ginger is more vulnerable to food fraud, especially by adulteration with foreign material. This is consistent with the findings from the literature search results.The search results of the databases and the literature led to the same conclusions, adulteration, misrepresentation/mislabelling and unapproved/undeclared processing appeared in two information sources. Yet the details of information related to the adulteration of ginger products were quite different as can be seen in Table The results of the food fraud databases showed that food fraud in ginger, a low-priced and high-trade volume spice product, is not only an example in the literature but a real-world issue. The discrepancy between the search results of the food fraud database and the literature may be either because there is less adulterated ground ginger in the actual market compared with fine processed ginger, or the limited technology available together with no/restricted market monitoring means that the adulteration of ground ginger remains hidden. These two possible reasons may have contributed to the limited reports of adulterated ground ginger in the food fraud databases, in contrast to the high proportion (but undetailed information) of adulterated ground ginger in all literature.The complexity and transparency of a supply chain or indeed a network is an important characteristic that helps to determine where fraud risks exist. Therefore, it is pivotal to map and deconstruct the Chinese and the EU ginger market and to identify critical nodes along the chain.36. The associated fraud issues at each stage of the supply chain were also identified based on this Guidance.The information about the ginger markets in China and the EU was obtained from the Food and Agriculture Organization Corporate Statistical Database (FAOSTAT) as well as Tridge. The basic scheme of the ginger supply network from China to the EU was generated from 13 articles including five government reports  amounted to US$ 849.5 million, and the total export of crushed or ground ginger was US$ 81.5 million16. Based on the export value, the top five exporting countries of ginger are China, the Netherlands, Thailand, Peru, and India. China is the main producing and exporting country of ginger and has more than a 50% share of the global export market. China’s ginger exports in 2019 amounted to US$ 508.3 million, with an export volume of 490,500 tones37. Moreover, almost 80% of all suppliers from developing countries to the EU are Chinese suppliers. Among all ginger products exported from China, almost 90% are in uncrushed/unground (whole) forms, while only 10% are crushed or ground products16. Ginger production in China has been mechanized, which makes it more competitive than any suppliers. Some provinces in China, such as Shandong, Hebei, Liaoning and Fujian, are known as the main origins of ginger16.The demand for ginger is growing annually and is expected to increase in the coming years37. For the EU, most of the ginger is imported from other countries, especially developing countries. In 2018, more than 70% of imported ginger in the EU came from developing countries16. The Netherlands is the largest importer and marketer of ginger in the EU, where the import volume of ginger has grown significantly16. Germany is the second largest importer of ginger in the EU, with an import volume of 22,600 tonnes in 2018. Nearly 90% of Germany’s ginger product imports come from developing countries38. Italy, Spain and France are medium-sized importers of ginger in the EU and their main supplier is China16.In 2018, the import value of ginger worldwide amounted to US$ 826.4 million, with an import volume of 645,700 tonnes36. The nine stages are primary production, local collection, local processing, local market, local consumer, international trade, EU processing, EU market and EU consumer. The structure and the food fraud vulnerability of the supply chain were analysed by the stages to gain a better understanding of the supply chain from a fraudulent perspective.The ginger supply network between China and the EU follows a traditional system. The key actor groups in the ginger supply network are presented in Fig. A modification of the SSAFE FFVA tool was applied to assess the fraud vulnerability of each stage and the whole chain with indicators from the tool. The tool was developed as a self-assessment tool for food business operators. However, in the current study the tool was modified to allow a ‘bird’s eye view’ evaluation, i.e. as a third-party tool instead of a tool for a food business operator. The modification of the tool was based on the acquired information from the literature, the databases, and the interviews with stakeholders. The available information from the previous sections includes specific products, detailed fraud issues, potential adulterants, available techniques, the number of historical cases, etc. Therefore, only indicators related to the above-mentioned information were used in this study. Some food fraud factor/indicators of the SSAFE self-assessment FFVA tool focus on the company-specific food business environment. However, these factor/indicators cannot be used at the aggregated level for the ‘bird’s eye’ approach and were omitted in the current study. These inapplicable factor/indicators are listed in Supplementary Table The assessment of the opportunities-related vulnerability of the chain was conducted by accessing the opportunities-related vulnerability of each stage using stage-targeted fraud factor/indicators Table  and comb39. Regarding the ginger supply chain, activities in this stage related to the harvest, handling, and storage of fresh ginger before it moves to either processing or distribution. At this stage, farmers may use acid wash ginger or use sulphur smoke ginger (unapproved/undeclared processing) to improve the appearance of the ginger, as reported on social media41. Such fraudulent activities do not require advanced technology, methods and/or facilities suggesting the factor/indicator ‘Availability of technology and knowledge to commit food fraud on final products’ is high vulnerability  of the supply network, the collectors purchase ginger from farmers and rarely process the ginger. At this stage, collectors do not process ginger, the factor/indicator ‘Availability of technology and knowledge to commit food fraud on final products’ is not applicable at this stage. However, unapproved/undeclared processing of ginger may already happen at the primary production stage (Stage I), and it is still easy to be noticed. Therefore, the factor/indicator ‘Detectability of food fraud in final products’ is low vulnerability ; the wholesaler, retailer, food manufacturer and food service operators. The common fraud issue at this stage is deliberate misrepresentation/mislabelling36, the purchase of low-grade materials and the occurrence of mislabelling often happen at this stage in the herb and spice industry supply chain. The main fraud issue at this stage is the same as that at the local market stage. Consequently, the factor/indicators for this stage, including ‘Availability of technology and knowledge to commit food fraud on final products’, ‘Detectability of food fraud in final products’ and ‘Historical evidence of fraud in final products’ have the same vulnerability as the local market stage which were high, medium, and medium vulnerability, respectively. According to an interview with EU processors, to prevent food fraud, they only trade with exporters and agents who are trustworthy and have long-term partnerships. However, this cooperation model may lead to the EU processors being over-dependent on their exporters and agents. One of the interviewees from an EU spice company stated that all information about their purchase of ginger products came from their Chinese agents. Therefore, excessive reliance on agents or exporters creates fraud vulnerability at the international trade stage. To sum up, the opportunities related vulnerability at this stage is medium since the medium vulnerability has the highest frequency.At Stage VI, the ginger products from China are transported to the EU. Exporters and agents are working as an intermediary between the Chinese market and the EU market. According to the Guidance on Authenticity of Herbs and Spices53. Therefore, the EU processing stage has the same opportunities related vulnerability as the Local processing stage, which is high vulnerability. In addition, all interviewees at this stage claimed that they had confirmed the authenticity of their products and believed that the fraud issues they knew always came from other actor groups in the ginger supply chain. However, the questions related to food fraud may touch on the sensitivities of potential offenders, therefore, we presumed the interviewees might answer the questions in a more reserved or socially acceptable way. This behaviour is consistent with the ‘alien conspiracy theory’, which describes that crime as a problem from outside parties, rather than a part of the own direct environment/society54.The EU processors group of Stage VII is one of the most significant actor groups within the ginger supply chain network. Most of the ginger products in the EU market come from the EU processors. In addition to the basic processing such as cleaning, sterilization and grinding, the EU processors may further process ginger into other ginger products, for instance, pickled ginger, preserved ginger, and crystalized ginger depending on the companies. Like local processors in China, adulteration of ground ginger is still the main fraud issue at this stage, such as adding spent ginger to ground ginger43. Therefore, the same in the local market, the opportunities related vulnerability at this stage is medium.Stage VIII consists of six actor groups that directly sell ginger products to EU consumers. At this stage, the fraud vulnerability would be knowingly placing mislabelled products on the market55.At Stage V and Stage IX of the spice supply chain, local (Chinese) and EU consumers receive the final products circulating within the entire supply chain network. At these stages, it is likely that the products may already be tampered with if it has been vulnerable to food fraud at earlier stages of the network1.The nine stages of the ginger supply chain from China to the EU and corresponding opportunities and motivations related vulnerability have been compiled in Fig. In addition to the indicators targeting each stage, five additional Opportunities related indicators for the whole were also considered. The raw material (raw ginger) of the whole supply chain is consistent, therefore the factor/indicators related to raw material were considered based on the whole supply chain. For the factor/indicator ‘The complexity of committing food fraud on raw materials’, the physical status of raw ginger is in line with the description of Table 56. However, the export ban existing in a few countries makes ginger is not readily available all the time57. For the factor/indicator ‘Valuable components or attributes of products’, the ginger products fit the description of high vulnerability  guidelines, two key elements are needed to mitigate the risk of food fraud, food fraud vulnerability assessment and control plan59 used in this study, various other food fraud vulnerability assessment tools have been developed to determine fraud risks of companies within supply chains. Examples include the vulnerability assessment and critical control points (VACCP), food fraud mitigation guidance60, CARVER plus shock method61, NSF fraud protection model62 and the food fraud initial screening model (FFIS)63. In principle, the above-mentioned food fraud vulnerability assessment tools do not provide specific mitigation techniques for ginger fraud, as indeed is the case for most commodities and ingredients but they provide the possibility to find vulnerable points along with the ginger supply chain network. However bespoke risk assessment tools are required as has been shown in the case of beef fraud64.In the previous section, a modified food fraud vulnerability assessment tool  was applied to have a general impression of the food fraud vulnerability in the ginger supply chain. However, it is necessary to apply the fraud vulnerability assessment tools in the spice companies to reveal the real situation of the supply chain. Besides the SSAFE FFVA toolIn this study, the investigation in the literature indicated a lack of appropriate detection techniques for ginger fraud. The robust detection technique is one of the key elements in the control plan to mitigate food fraud. Therefore, in this section, ginger authentication in practice and potential detection techniques will be discussed to have a general impression on possible technical solution to ginger fraud.2 addition can be detected using wet chemistry. In terms of detecting the adulteration of ginger products, especially in the ground form, there are several problems with the current control measures. An interviewee stated that traditional wet chemistry is costly for companies and DNA profiling for spice adulteration does not work properly. The public databases for DNA analysis are not valid and lack verification. In addition, some processing of ginger may destroy DNA making profiling inaccurate. Therefore, more accurate, low-cost, and efficient techniques need to be developed to address the real-life fraud issues in ginger.According to interviews with stakeholders, to ensure the authentication and safety of their ginger products, some technical control measures have been taken on the raw material and the final products of ginger. For the raw material, undeclared bleaching and SO67.Although studies on ginger authentication are limited, many techniques have been applied for the characterization of ginger Table . TechniqPrevious studies on ginger characterization provide the possibility to explore different analytical techniques to detect ginger fraud. In addition, the limitation of current methods for ginger authentication in practice creates a need to develop better techniques. According to a database of food ingredient fraud and economically motivated adulteration generated by Moore et al. (2012), chromatography, vibrational spectroscopy, mass spectrometry and DNA-based analyses were the most common approaches applied. These analytical tools can be further divided into confirmatory methods and screening techniques. The principle of confirmatory techniques for spice adulteration is mainly based on the identification of specific markers of the spice, such as adulterants and specific chemical constituents . The application of screening techniques for spice adulteration are characterized as being rapid, low cost and non-destructive. Both confirmatory and screening techniques could be applied to detect adulteration in ginger products.69. These confirmatory techniques are characterised as being more labour intensive, costly, and accurate as opposed to screening techniques.Based on the principle of confirmatory techniques, certain adulterants in ginger products and some characteristic compounds in ginger can be used as specific markers in detecting ginger fraud. For the adulteration of processed ginger products, illegal dyes, unauthorized preservatives, and undeclared sweeteners are the most used adulterants. Researchers have demonstrated that these adulterants can successfully be detected by some techniques, such as high-performance thin-layer chromatography-mass spectrometry and thin layer chromatography70. Some non-targeted screening methods are more suitable for rapid quality testing. For instance, near-infrared (NIR) spectroscopy has been used to distinguish pure black pepper powder from adulterated pepper samples mixed with black pepper husk, papaya seeds, pinheads and chili powder71. Although still in the early stages of development and practical application, the advantages of non-targeted screening techniques on food fraud will make them one of the most suitable tools in combating ginger fraud.Screening techniques can be powerful tools for non-targeted analysis to detect ginger adulteration. In practice, they are applied to flag suspect products which can then be further investigated with the more accurate confirmatory methods. For ground ginger, like many spices, the list of adulterants could be endless73. For the adulteration of ground ginger and processed ginger at local processing and EU processing stages, the various potential techniques mentioned in the section: Potential ginger authentication techniques can be the analytical solutions in the future. According to the statements of the stakeholders, the current analytical control measures do not meet their expectations (as described in the section: Ginger authentication in practice). Therefore, the development of more promising and less costly analytical techniques is needed.One of the main aims of this review was to summarize the open access data about ginger fraud from the food fraud databases and the published literature. A second aim was to map the structure of the ginger supply network from China to the EU to identify the most vulnerable nodes along the chain and to propose analytical approaches that can be taken to detect and help mitigate fraud. Figure As a typical low-priced and high trade volume spice product, this is the study to investigate the food fraud prevalence in ginger products from the perspective of the supply chain. However, certain limitations of this study should be considered. First, there were only five participants for the stakeholder interviews, limiting the information from stakeholders and representing their perspectives. Second, only English literature and food fraud databases were used in this study. This could cause the omission of the food fraud information reported in other languages. Third, only open access information in the food fraud databases was included in this study. Despite these limitations, the current results still provide a good understanding of food fraud in the supply chain of ginger products and provide possible analytical solutions for detecting food fraud in the ginger supply chain from China to the EU.Food fraud is a constant threat to the spice industry. The results of the food fraud databases and the literature indicate that ginger fraud is a threat that has not been well investigated by researchers, especially the adulteration issues of ground ginger. Even though adulteration in ginger was widely reported in the literature, the available detection techniques, specifically focussed on ginger fraud, are limited. In addition, by mapping the ginger supply chain from a fraudulent perspective, the opportunities and motivation related vulnerability of the ginger supply chain was considered to be at a medium with the processing stages identified as the most vulnerable nodes along the chain. Confirmatory and screening techniques based on ginger characteristics analysis should be applied and developed in the future. In summary, attention should be given not only to extremely high valuable spice products, but also to spice products marketed at lower prices and sold in high trade volumes.Supplementary Material


Breast cancer patients and their families are under various pressures in the process of disease diagnosis and treatment, which seriously threaten their physical and mental health. Findings from existing research suggest that good family resilience can help breast cancer families better adapt and cope with adversity and challenges. However, there are only a few intervention studies on family resilience and no intervention studies on resilience among the families of breast cancer patients. Therefore, this study aims to explore appropriate measures to improve the resilience level of breast cancer families and help them better cope with the disease.The purpose of this study protocol is to demonstrate a coping-focused family resilience intervention to increase the level of resilience in the families of breast cancer patients and help them better cope with adversity.The trial will recruit 80 breast cancer families and randomly assign them to experimental and control groups in a 1:1 ratio. The control group will receive routine care, and the intervention group will receive a 6-week one-on-one online family resilience intervention based on the control group. Two groups of subjects will be assessed at baseline and at 1 week, 1 month, and 3 months after the intervention. The primary outcome is family resilience, and the secondary outcomes are coping style, social support, family disease burden, and levels of anxiety and depression.We hypothesized that after the intervention, the intervention group would have significantly higher levels of family resilience than the preintervention and control groups. In the intervention group, other aspects related to family resilience, such as family disease burden and anxiety and depression levels of patients and their families, were significantly alleviated, and disease coping and social support levels were improved accordingly.If the program works, it can help breast cancer families identify family strengths and resources to proactively address challenges so that families can successfully navigate the crisis and patient and family recovery can be facilitated. It can also provide a practical path for clinical workers to help breast cancer families adjust rationally.http://www.chictr.org.cn/ChiCTR2100052108).This study has been registered in the Chinese Clinical Trials Registry (Registration Number:  According to Global Cancer Statistics (GLOBOCAN), there were approximately 2.3 million new cases of breast cancer worldwide in 2020, ranking the disease first among all types of cancer . Global The diagnosis and treatment of breast cancer not only causes great distress to the patient physically, psychologically and socially but induces many physical, psychological and social problems for family members . A serieMeanwhile, when faced with the severe challenges of breast cancer, some families are able to adapt effectively and make positive changes that allow them to recover and grow . ResearcFamily resilience was first proposed by Walsh based on the concept of psychological resilience, which elevates resilience from the individual level to the family level . Dai YanAt present, family resilience has attracted increasing attention from scholars worldwide, and intervention research on family resilience is still in its infancy. From a previous literature review, only nine family resilience intervention studies have entered clinical trials , of whicDue to the influence of traditional Chinese culture and the introverted nature of Chinese people, people are not used to expressing their feelings and sharing family problems publicly. This is consistent with what we learned earlier. Patients and their families prefer one-on-one family meetings. Therefore, one-on-one family meetings may be more effective than multifamily group meetings. Meanwhile, the postoperative treatment and follow-up of patients are mostly performed in local hospitals or outpatient clinics, and there is no time to participate in an intervention. In addition, repeatedly making appointments for patients and their families to come to the hospital to participate in an intervention increases the burden on the family and the risk of contracting COVID-19. Therefore, online meetings can solve these problems very well. The online meeting time and location are more flexible. Participants only need to find a relatively quiet place to join the meeting. The meeting time can also be adjusted if participants require it. Additionally, online meetings can be recorded. If some participants are absent due to personal reasons, they can learn about the content of the meeting from the video. Online meetings greatly improved the implementability and convenience of intervention programs.Among the current family resilience intervention research, some studies are based on family resilience theory , and somWu Dy′s family resilience process model of breast cancer patients describes the attitudes, strategies and influencing factors of Chinese families coping with a family member’s breast cancer . The proWalsh’s family resilience framework places the family at the core of a unit, emphasizing that family resilience is the result of the interaction of individuals, families and societies . The thevia email for two rounds of expert consultation on the content of the intervention program. According to the opinions of experts, the content of the intervention plan was adjusted for the second time, and the final draft of the family resilience intervention plan for breast cancer patients was formed. Finally, the intervention program is put into clinical practice for large-scale randomized controlled trials.This intervention plan was based on relevant theories and combined with literature research to form the first draft of the family resilience intervention plan for Chinese breast cancer patients. Qualitative interviews were then conducted with breast cancer patients and their families, doctors and nurses in relevant departments. According to their comments, the content of the intervention plan was adjusted, and a revised draft of the intervention plan was formed. Experts in relevant fields were then contacted This study aimed at the family crisis of breast cancer patients and based on rigorous evidence, a coping-focused family resilience intervention program (CFFRI) for Chinese breast cancer patients will be validated. If the intervention proves effective, it could be used to increase the family resilience of breast cancer patients and help them better cope with crises and challenges.The research hypotheses are as follows:After the intervention, the family resilience level of the intervention group will be significantly improved compared with that before the intervention.After the intervention, the family resilience level of the intervention group will be significantly improved compared with that of the control group.After the intervention, other aspects related to family resilience in the intervention group, such as the family disease burden and anxiety and depression levels of patients and their families, will be significantly relieved, and the level of disease coping and social support will be improved accordingly.Due to the nature of the experiment, the interventionists could not be blinded in this study, so this study used a single-blind randomized controlled trial. Subjects will be included in the study in strict accordance with the inclusion and exclusion criteria. Eligible patients and their families will be included in the study according to their wishes. Participating families will be randomly divided into a control group and an experimental group according to computer-generated random numbers, with a distribution ratio of 1:1 . The conSubjects will be recruited from relevant departments of three general hospitals in Anhui Province and offered gifts and free medical exams. Recruiters will present the study to breast cancer families who meet the study criteria. If patients and their families are interested in participating in this study, they will be asked to sign informed consent forms and randomly assigned. Investigators should explain to participating families that the study will not adversely affect them and that participating families can opt out of the study at any time.Women with first pathological diagnosis of breast cancer18 years old and olderUndergoing surgeryUsing a smartphoneGood understanding and communication skills, no history of mental illnessInformed consent, willing to cooperateHaving other serious medical conditionsParticipation in other psychological interventionsA fixed patient caregiver (first-degree relatives)18 years old and olderGood understanding and communication skills, no history of mental illnessUsing a smartphoneInformed consent, willing to cooperateHaving serious medical conditionsParticipation in other psychological interventionsStudy sample size calculated by PASS15. Based on previous survey results , family A series of measures will be taken to reduce attrition during the intervention. First, during the intervention recruitment phase, the patient’s attending physician or other medical staff will be invited to answer the patient’s and family’s concerns to increase participants’ trust in the program. Second, a WeChat group will be established where researchers answer questions and share disease-related knowledge with participants. The third is to invite breast cancer treatment experts and nursing experts to control the quality of the entire intervention process, and timely answer questions from patients and their families about disease treatment and care. Fourth, during the intervention, participants can get in touch with the research team to get answers to any difficulties involved in the implementation and application of the intervention content. Finally, at the end of the program, the research team will present the participants with a nice gift to express their gratitude.Eighty random numbers will be generated by a computer and randomly divided into an intervention group and a control group with a distribution ratio of 1:1. The assigned numbers will be sealed in 80 opaque envelopes. Recruiters will enroll research subjects who meet the research conditions, agree to participate in the research, and sign an informed consent form. Subjects will randomly draw envelopes, enter their assigned groups, and have baseline measurements taken. Participant recruitment and assignment will be done by two independent researchers, blinding participants, recruiters and data collectors.Families in the control group will receive usual care. Usual care includes the following: First, the issuance of health handbooks, which include breast cancer-related knowledge, postoperative rehabilitation exercise guidance, clinical nursing practice guidelines for preventive behavior of breast cancer-related lymphedema and a breast cancer postoperative follow-up checklist. Second, a WeChat group will be established where researchers answer questions and share disease-related knowledge with participants. Finally, Everyone will be encouraged to share positive experiences related to the disease in the WeChat group to encourage and support each other.The experimental group will implement one-on-one online family resilience intervention on the basis of usual care. Intervention implementation will be led by a professionally trained nursing graduate student and a breast cancer-related unit nurse. A breast cancer therapist and a psychobehavioral specialist will guide and supervise the implementation of the intervention. The entire intervention process includes a preintervention program introduction, six family meetings, and a postintervention summary. The frequency of interventions is weekly, with each meeting lasting 25–30 min. The first meeting, combined with patient follow-up time, will be an face-to-face family meeting with participating families, and the next five meetings will be online family meetings. The first follow-up visit to the hospital after surgery is usually approximately 1 week after surgery. A quiet, undisturbed environment will be chosen for family meetings. The specific time for each family meeting must be agreed upon in advance with participating families.Before the intervention begins, the researcher will brief the intervention group families about the program and build a relationship of trust with them. Assessors will collect baseline data, and another researcher will teach participants to use online video software. The first family meeting will be held 1 week after the patient’s surgery, and the theme will be understanding breast cancer and family resilience. The second family meeting will be held 2 weeks after surgery, and the theme will be remaining positive. The third family meeting will be held 3 weeks after surgery, and the theme will be discovering available resources. The fourth family meeting will be held 4 weeks after surgery, and the theme will be improving family cohesion. The fifth family meeting will be held 5 weeks after surgery, and the theme will be facilitating effective communication. The sixth family meetings will be held 6 weeks after surgery, and the theme will be family problems and coping. The themes of the six meetings stemmed from Walsh’s family resilience framework. The themes for the first and second meetings were from the belief systems, the themes for the third and fourth meetings were from the organizational patterns, and the themes for the fifth and sixth meetings were from the communication/problem-solving process. Formation of the main contents of the six-week intervention plan through a literature review. Then, the form and content of the intervention plan were adjusted through structured interviews with patients, family members, and medical staff in breast cancer-related departments. Finally, through two rounds of expert consultation, the content of the intervention plan was revised to ensure the scientificity and feasibility of the intervention plan.One day before each meeting, meeting materials will be sent to the participants of the intervention group to inform them of the content of the meeting in advance. Two to 3 min before each meeting, there will be a review to summarize the content of the previous meeting. During the meeting, families of the intervention group will be guided to actively participate in the discussion through videos, pictures, questions, etc., to increase participation. After the meeting, participating families will be encouraged to review the content of the meeting through homework to improve the effect of the intervention. One week after the end of the intervention, participating families will be invited to assess the entire intervention process, and the assessors will collect postintervention data and give gifts to families to show appreciation for their participation. Details of the intervention plan are shown in Basic information of the study subjects, including sociodemographic information and clinical disease characteristics. Demographic information will include age, gender, education, religion, place of residence, marital status, monthly income, method of paying medical bills, occupation, and the patient’s relationship to the primary caregiver. Clinical disease characteristics will include disease stage, course, and primary treatment modality.The Chinese version of the Family Resilience Assessment (C-FRA) will be used to assess the family resilience level of the research subjects . This scThe Coping Style Questionnaire (CSQ) will be used to assess the coping style of the research subjects . It has The Social Support Scale (SSS) will be used to assess the social support level of the research subjects . The scaThe Family Burden Scale of Disease (FBSD) will be used to assess the family burden of disease in the families of the study subjects . It has The Self-Rating Anxiety Scale (SAS) will be used to assess the anxiety level of the research subjects . It has The Self-Rating Depression Scale (SDS) will be used to assess the depression level of the research subjects . It has First, the researcher will introduce the purpose of the study to the patients and their families and establish a trust with them. After obtaining informed consent from patients and their families, their baseline data will be collected. Baseline data includes sociodemographic data, clinical disease characteristics, and psychosocial variables. Psychosocial variables include family resilience, coping styles, family disease burden, social support, levels of anxiety and depression. Investigators will measure psychosocial variables of participating families at four time points: baseline and 1 week, 1 month, and 3 months after intervention . ParticiTwo investigators will enter and review data. SPSS23.0 will be used for data analysis with a one-tailed test and a significance level of 0.025. Descriptive analyses will be used for participants’ general data and the outcome variables, including means, standard deviations, and percentages. The t test or rank-sum test will be used for comparison if the baseline data of the two groups are continuous variables, and the chi-square test will be used for comparison if they are categorical variables. The effect of the intervention program will be assessed by observing changes in family resilience, coping styles, family disease burden, social support, anxiety and depression levels in the intervention and control groups. If the intervention effect within the group conformed to a normal distribution, the paired t test was used for evaluation; otherwise, the Wilcoxon rank-sum test was used. Repeated measures ANOVA will be used to assess the effect of the intervention at different time points between groups. AHP, multivariate adjustment analysis, and propensity score analysis will be used to control for confounding factors confounding the study results.Research shows that family resilience interventions for families in adversity can help families better adapt and cope with challenges . TherefoTherefore, we focused on the coping process of Wu Dy′s resilience process model of families of breast cancer patients and take Walsh’s family resilience theory as the framework to form the first draft of the family resilience intervention plan for breast cancer patients through literature analysis . Then, tIn addition, this intervention program is focused on the coping process, with belief systems, organizational patterns, and communication/problem-solving processes as the framework, and it comprehensively intervenes in the families of Chinese breast cancer patients by addressing six aspects: disease, attitude, resources, rules, communication and problem solving. This intervention is more comprehensive than other family resilience interventions that target only one aspect of family resilience, such as family communication or family problem solving. If this intervention proves to be effective, a comprehensive intervention for resilience in families of breast cancer patients will be recommended. Help these families make comprehensive and effective adjustments in awareness, behavior, and family cooperation, actively adapt to and deal with various problems caused by the disease and provide a practical basis for the clinical nursing of breast cancer patients and their families.Finally, this research protocol proposes a one-on-one online family meeting approach to provide resilience interventions to each family in the participating group. Compared with the multifamily group meeting adopted by other family resilience interventions, it is more suitable for the Chinese cultural context. In addition, online meetings can reduce the burden on families of breast cancer patients, prevent the risk of COVID-19 infection and is more suitable for the overall care needs of patients and their families. If the intervention proves to be effective, this form of intervention could also be applied to the home care of patients with other medical conditions.This study may have some limitations. First, there are many family meetings in the intervention program, and subjects may not be able to attend all of them due to physical or other reasons, which will lead to sample loss that may have an impact on the study results. Second, because of the nature of the study, it was not possible to blind the interventionists. Therefore, this study will arrange for independent researchers to collect and evaluate the data. Finally, while each family meeting will be held in an isolated quiet setting, some subjects may be contaminated due to subject recruitment and the first family meeting being held in the same department of the hospital. Therefore, when arranging meetings for families in the intervention group, researchers should try to choose an appropriate place and time to avoid crowd gathering and contamination between study subjects.This study aimed to demonstrate a coping-focused family resilience intervention to increase the level of family resilience in families with breast cancer and help them cope better with adversity. If proven effective, the intervention will provide a new rationale for clinical research, as it is the first coping-focused family resilience intervention for breast cancer patients. It will also help guide breast cancer patients and their families to successfully manage the disease. If the program is not effective, professional support can also be provided to the families of the intervention group to help them better cope with the disease. At the same time, it can accumulate experience for the further improvement of the later intervention program and provide a empirical basis for future implementation.The original contributions presented in the study are included in the article/supplementary material, further inquiries can be directed to the corresponding author.This study was approved by the Ethics Committee of Anhui Medical University (Ethics Number: 20190267).JG and J-XL participated in the research conception and design. Data collection and analysis was performed by J-YS and W-YC. H-PL, M-KZ, and S-SZ drafted and revised the manuscript. All authors participated in data interpretation, draft review and approval of the final manuscript. Everyone is ultimately responsible for the quality of the content and the decision to submit for publication.This research is supported by the Scientific Research Foundation of Education Department of Anhui Province of China (No. KJ2020A0221) and Anhui Medical University School of Nursing Seedling Cultivation Project (hlqm2021044). Funders are not involved in the development of this research.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.


This study explored the impact of financial literacy  on potential entrepreneurs' intent in Saudi Arabia. It also examined saving behavior as a mediator in the relationship between financial literacy and entrepreneurial intention. The study's data were collected by an online questionnaire sent to a sample of 270 potential entrepreneurs at Abqaiq Applied College, affiliated with King Faisal University. Data analysis was done using partial least squares structural equation modeling (PLS-SEM). According to the findings, there is no direct relationship between financial literacy and entrepreneurial intent. However, it has been reported that saving behavior can mediate between financial literacy and entrepreneurial intent. Entrepreneurship and the small and mid-size enterprise (SME) have been identified as critical drivers of economic growth and development, as well as a means of alleviating poverty . This is because a high level of financial literacy among individuals in general, and young people in particular, may contribute to promoting entrepreneurial activities such as autonomy and motivation, self-employment  of the Applied College of Abqaiq, affiliated with King Faisal University in Saudi Arabia. The study's target respondents consist of applied college students pursuing two types of programmes: Human Resource Management and Medical Secretary. Compared to other students with bachelor's degrees and other degrees, these students have the most difficulty finding jobs after graduation. As a result, they are expected to establish small entrepreneurial businesses.via an online link. However, before distribution, a pilot study with 15 respondents was conducted to assess the suitability of the measurers and the questionnaire. Because there were no issues with the questionnaire criteria, the questionnaire link was then sent to respondents and made available online for 1 month.The study respondents were chosen because they had studied a subject called “financial management,” which provided them with the necessary information for financial planning. They also learned about various topics and received specific entrepreneurship training. The study included both male and female participants. Similar surveys from previous studies were used to develop the study's questionnaire. The survey questionnaire was distributed to respondents As shown in The measures of the study were evaluated using a 5-point Likert scale, showing five in total agreement and one in complete disagreement.Two steps were taken to evaluate the data and interpret the study's findings: (1) examine the measurement model, and (2) examine the structural model.The purpose of the measurement model was to investigate the convergent validity and reliability of the study items and constructs. Thus, we began by assessing the so-called factor loading of all indicators. To ensure better reliability of the items used in the study, we recommended that the values of each indicator have a loading value of 0.70 or higher to ensure that the measured construct could explain 50% of the variance in the indicator used for analysis, revealing good reliability  was used. After examining various tests in the measurement model, we evaluated the first step in the structural model. To ensure that the regression results were free of bias, we began by investigating the collinearity issue. As a result, we put the so-called variance inflation factor to the test (VIF). Thus, if the VIF value was >5, the study would be deemed to have collinearity issues.R2), also known as the model's explanatory power. This test was carried out by calculating R2, the sum of the independent variables' effects on the dependent variables.After examining the collinearity, we reviewed the coefficient of determination (R2 in R2 because the outcome can vary based on the field of study and context.The model's explanatory power was deemed adequate because the In This section is important because it describes the bootstrapping procedure used to test the hypotheses with 500 resamples.P > 0.05). However, when saving behavior was included as a mediator between financial literacy and entrepreneurial intention, the findings revealed that saving behavior could fully mediate the previously mentioned relationships. As a result, H2 was accepted .This study investigated how the financial literacy of potential entrepreneurs  influences their entrepreneurial behavior and business establishment decisions. The study also aimed to examine how potential entrepreneurs' saving behavior can mediate the relationship between their level of financial literacy and their entrepreneurial intention. As a result of investigating the hypothesized relationships of the study constructs, intriguing results were discovered. It was first reported that financial literacy among potential entrepreneurs does not always result in the development of entrepreneurial intentions.This finding was surprising because it was revealed otherwise in most previous literature. However, this result could be attributed to the fact that, while those potential entrepreneurs may have the intention to start their small entrepreneurial firms, they may be hampered by other environmental factors, such as formal and informal institutions or a lack of necessary financial support, leading them to abandon the idea of starting a venture. This may confirm the need for financial support and the need to instill a saving culture in individuals' mindsets. This finding could also be attributed to the fact that those potential entrepreneurs have a limited understanding of financial literacy, which is insufficient to change their mindsets and direct their behavior toward business creation. This finding is similar to those of Ojogbo et al. , who repHypothesis H2, which stated that saving behavior mediates the relationship between financial literacy and entrepreneurial intention, was accepted. Acceptance was expected because as more people develop financial knowledge, literacy, or awareness, they become more knowledgeable about financial issues, save money, manage their personal finances wisely, and take advantage of the market's available finance and entrepreneurial opportunities . The study sought to examine the perceptions of 270 potential entrepreneurs at the applied college of Abqaiq, affiliated with King Faisal University, regarding financial literacy, saving behavior and entrepreneurial intention. The study found an interesting relationship between financial literacy and entrepreneurial intention and the ability of saving behavior to mediate the relationship between financial literacy and entrepreneurial intention in the study context. We also concluded that the greater individuals' financial literacy, the greater their potential savings. Furthermore, the more one saves, the more likely to engage in entrepreneurial behavior.As a result, policymakers and the private sector must focus on and collaborate on increasing financial literacy and saving behavior among potential entrepreneurs. This behavior can be accomplished by growing educational programmes on financial literacy and developing more saving products and services to encourage potential entrepreneurs. The entrepreneurs, in turn, would become more involved in them and as a result, develop a propensity for business creation. Finally, even though this study contains some intriguing findings, it is essential to note that it has some limitations regarding its sample and the concepts used. Because of the small sample size, it is difficult to generalize the findings. Consequently, it is suggested that future studies include larger sample sizes, more concepts on the regression process, control variables, and broaden the context of the study by comparing other countries to Saudi Arabia.The raw data supporting the conclusions of this article will be made available by the authors, without undue reservation.The studies involving human participants were reviewed and approved by King Faisal University. Written informed consent for participation was not required for this study in accordance with the national legislation and the institutional requirements.Both authors listed have made a substantial, direct, and intellectual contribution to the work and approved it for publication.This work was supported by the Saudi Investment Bank Chair for Investment Awareness Studies, the Deanship of Scientific Research, the Vice Presidency for Graduate Studies and Scientific Research, King Faisal University, Saudi Arabia [Grant No. 32].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.


Increased use of antibiotics in livestock is a public health concern, as it poses risks of antibiotic residues and antibiotic-resistant pathogens entering the food chains and infecting humans. A cross-sectional survey was conducted on 216 poultry farms to study knowledge, attitudes and practices of poultry farmers on the use of antibiotics in urban and peri-urban areas of Ouagadougou. Results show that only 17.13% (37/216) of farmers attended training on poultry production. Majority of farmers—85.65% (185/216) were not knowledgeable about the rational use of antibiotics. When there was a disease outbreak, 31.98% (63/197) of farmers used veterinary drugs without a prescription and 22.34% (44/197) consulted a community animal health worker. It should also be noted that 79.19% (156/197) of farmers reported using chicken meat as per normal if the bird died during or right after treatment with an antibiotic. Knowledge of rational use of antibiotics was positively influenced by a good attitude adopted by the farmer during the illness of birds and negatively influenced by disease treatment success and high level of education of the farmer. Lack of knowledge about the rational use of antibiotics including their use without a prescription are serious risk factors for the emergence of antimicrobial resistance. Awareness of farmers and other veterinary drug supply chain actors such as drug stockists and animal health workers on best practices in antimicrobial use and promotion of good biosecurity on farms are important to reduce the misuse of antibiotics. Intensification of livestock production has led to increased use of veterinary drugs, including antibiotics . AntibioThe study was approved by the ethical committee of the Ministry of Health, Burkina Faso, with reference number 2020-9-186. Informed consent was obtained from each participant before he/she was interviewed. Consequently, all participants gave their consent to participate in the study.A cross-sectional study was conducted between March and July 2020 in urban and peri-urban poultry farms of Ouagadougou. It is the most densely populated city, with 2,415,266 inhabitants [The sample size was calculated using the following conditions: in a study in Ghana, expected proportion of 12.1% of farmers who adopted good practices  , a risk The questionnaire used in the study was based on the ‘Antimicrobial use in livestock production systems’ (AMUSE Livestock tool) developed by the International Livestock Research Institute (ILRI)  to facilThe questionnaire consisted of five sections: (1) demographic information, such as the age of the farmers, education level, and sex, (2) chicken farms’ characteristics, (3) classes and frequency of drugs used in farms, (4) knowledge of antibiotics use, and (5) biosecurity practices and attitudes encountered on the farms. The questionnaire was translated into French and interviews were conducted either in French or in the local language (Mooré) depending on the level of education of the farmer. Responses were recorded using a database, Open Data Kit (ODK), a source-based smartphone platform that can be used to create electronic questionnaire forms for real-time data entry.Statistical analyses were performed with the STATA/SE 16.0 software. First, a univariate descriptive analysis was carried out to obtain an overall view of the data. This made it possible to define the characteristics of the farms surveyed, the most used practices, and the level of knowledge of antibiotics. For classes with less than five respondents, groupings were made to guarantee the reliability of the test, and in the case of the latter, Fisher’s exact test was used.Finally, to identify the potential determinants of the level of knowledge on antibiotic use, a multivariate logistic regression was used with the variable of interest. The outcome variable (knowledge about the prudent use of antibiotics) was defined as follows:Antibiotics are used  to treat sick animals: the answer is yes as antibiotics are mainly used to treat infection.Antibiotics are used  to prevent disease in animals: The answer is wrong as antibiotics are not systematically used to prevent disease. However, they can be used as a prophylactic in some circumstances.Antibiotics are used  to fatten animals: The answer is wrong as antibiotics are not systematically used to fatten animals. However, they can be used as a growth promoter.χ2 tests were performed. Twenty-one variables with a p-value ≤ 0.05 during bivariable analysis were included in the multivariate analysis. Unconditional logistic regression with stepwise backward elimination was used to obtain the final model, which retained 11 variables. These variables mainly explain the level of knowledge about prudent use of antibiotics. The statistical significance levels used in all estimations were 1%, 5%, and 10%.We coded 1 if the individual has a good knowledge of prudent use of antibiotics  and 0 otherwise (fail at least one out of three question). Bivariable analyses using The sociodemographic characteristics of the respondents are presented in The main farm characteristics are shown in Types of veterinary drugs and vaccines used in the last four weeks prior to the survey are shown in n = 95, 43.98%). Similarly, 59 respondents described using macrolides 3 times or more in the month, however 133 (61.86%) reported not using macrolides at all in the last 4 weeks. As for the vitamin/iron supplements, 182 (84.25%) respondents used them at least once a week.Respondents reported using tetracyclines four times or more in the month (The assessment of knowledge on prudent use of antibiotics was conducted by asking a series of three questions . Good knBiosecurity practices and attitudes observed during the study are presented in p = 0.005), referral to a professional for diagnosis and treatment (p = 0.025), and drug acquisition channels (p = 0.000).Farm size was associated to practices such as: attitude when the animals were sick (p = 0.032) and drug acquisition channels (p = 0.002). The results of the statistical tests are presented in Education level of the farmer was associated to practices such as: referral to a professional for diagnosis and treatment . It is unclear if these supplements contain sub-therapeutic concentrations of antibiotics. Nonetheless, this frequent use of vitamins suggest some poultry production challenges, and issues such as heat stress can make the use of vitamins inefficient .Respondents understood the role of antibiotics for therapy, prophylaxis, and growth promotion, which is reflected in their frequent antibiotic use, as shown in For future interventions to improve medically rational antibiotic use in livestock to be effective and sustainable, not only should farmers be targeted but also veterinary drug shops and animal health service providers. This approach has been used to reduce the misuse of over-the-counter human medicines, thus preventing the sale of medicines without a prescription from a doctor .The size of the farm was a factor that positively influenced certain practices. Those who tended to consult a qualified veterinarian in case of disease outbreaks were mainly those with larger farms. In addition, the larger the size of the farm, the more likely it was that those in charge would pay for veterinary drugs in formal drug stores rather than in informal markets. Education level was also a factor that positively influenced some practices. The higher the education level of the respondents, the more likely they were to use a qualified veterinarian for diagnosis and treatment of poultry. The higher the level of education, the more likely respondents were to pay for veterinary drugs from official pharmacies.The last occurrence of an infection and the attitude adopted during the disease episode had a significant and positive influence on the degree of knowledge of antibiotic use. Indeed, the better the individual’s attitude during the illness, the more likely it is that his or her level of knowledge about the prudent use of antibiotics is higher. At the onset of illness, the prudent approach would be to contact animal health professionals, which would reinforce the good knowledge by following their advice and prescriptions. The more the actors use good practices, the more it positively influences their knowledge on the prudent use of antibiotics. In the case of antibiotics, the technical support provided by the prescribing veterinarian influences their use . A studyThe success of treatment had a significant, negative influence on the degree of knowledge of antibiotic use. Contrary to what was expected, the more effective the treatment administered by the individual, the more likely they were to have poor knowledge of antibiotic use. If the treatment was successful, it could maintain their belief that antibiotics could be used to effectively prevent disease. In practice, the farmer may consider antibiotics as a factor of production and decide to use them according to the expected gain from the treatment . HoweverThe higher the level of education, the more the respondents used antibiotics for prevention or as growth promoters, all of which is misused. This could be explained by the fact that the higher the level of education, the more means (middle class) farmers have to buy antibiotics, which leads to their widespread use for prevention or as growth promoters. Moreover, contrary to what was expected, even those who often used a qualified veterinarian used antibiotics imprudently. This could be explained by the self-medication practiced by respondents. In fact, in the event of illness, after the veterinarian’s visit, the drugs prescribed were subsequently used beyond the veterinarian’s indications. The farmer seeks to secure his/her income by avoiding a major epidemic on the farm. This situation has been described in a survey conducted in the rabbit farming sector, showing a negative correlation between the income level and antibiotic consumption . This waOur study shows low levels of knowledge of farmers about prudent use of antibiotics. There is a need to increase awareness amongst farmers on the prudent use of antibiotics in food animals but there is also an urgent need to provide farmers with support to improve their animal husbandry practices; moreover, better regulation is also needed. It is necessary to reinforce the capacities of the various laboratories in charge of the control and monitoring of AMR . The mulThis study demonstrated the poor practices of poultry farmers on the rational use of antibiotics in Ouagadougou. These poor practices constitute a major problem that hinders the productivity of the poultry farms and constitutes a public health problem because of the interactions that exist between animals and humans, especially in areas of proximity such as urbans zones. Moreover, AMR disproportionately affects LMICs who have a high infectious disease burden, compounded by the relatively easy access to antibiotics and frequent over-the-counter sales without a prescription. There is a need to raise awareness and train all relevant stakeholders on rational use and the animal and human health risks related to misuse of antibiotics. To reduce irrational use of antibiotics in poultry farming in Burkina Faso, our results suggest targeting the following areas: reinforce the awareness of the actors on the whole poultry production chain, strengthen access to quality veterinary services, and set up multi-sectoral platforms to implement and monitor the national AMR strategy.


Epidemiological studies use biomarkers of fluoride exposure in pregnant women as surrogate measures of fetal fluoride exposure; however, there is little understanding of how pregnancy affects fluoride metabolism and its biomarkers. This narrative review summarizes the changes of pregnancy that have the potential to impact fluoride’s absorption, distribution and excretion, and highlights the limited body of evidence on the topic. The physiologic systems that experience pregnancy-associated changes relevant to fluoride’s metabolism are the cardiovascular, renal, metabolic and gastrointestinal, as well bone and calcium metabolism and the body’s acid-base balance. The available evidence indicates that fluoride is found in the maternal plasma and urine, placenta, amniotic fluid and fetus. Although plasma and urinary fluoride vary across gestation, there is insufficient quality evidence to determine the direction or extent of such variation. Furthermore, there is no doubt that fluoride from maternal blood crosses the placenta and is absorbed and excreted by the fetus; however, the biological mechanisms behind this placental passage are unknown. Research on maternal and prenatal biomarkers of fluoride exposure would benefit from studies on how pregnancy-associated changes affect the metabolism of fluoride across gestation, the mechanisms for the intestinal absorption of fluoride in pregnant women, and the placental passage of fluoride. EMBASE’s identified subject headings were “Fluoride or fluoride ion AND fetomaternal transfusion”. The inclusion criteria were original investigations conducted in humans and reported in English language. The exclusion criteria were articles for which the full text was not available, articles which focused on a different topic  or were grey literature. To remove duplicates, the citations from the papers that met inclusion and exclusion criteria from both databases, were exported to EndNote 20There is no data on the absorption of fluoride specifically gathered from pregnant women. In nonpregnant adults, and when ingested in the absence of inhibitors  , approxiFluoride in whole blood is the sum of ionic and nonionic fluoride. Ionic fluoride is the measure of significance for the health sciences and public health, and the one available to participate in biological reactions . Under sThe first studies on fluoride levels in maternal plasma were motivated by the interest in the placental passage of fluoride, and the hypothesis that ingested fluoride could prenatally incorporate into developing enamel to make it resistant to dental caries . As reseThe placenta is a complex organ that constitutes an interface between the mother and fetus , and hasThere is placental passage of fluoride from the maternal to the fetal circulation. This conclusion comes both from studies on the relationship between maternal plasma (or serum) and cord blood ,49,50,51The transfer of fluoride to the fetus depends on maternal fluoride exposure levels. Higher concentrations of fluoride are found in the placenta, maternal plasma (or serum) and cord blood from women living in fluoridated areas ,35,36. ICurrently, it is known that there are at least four different mechanisms of placental transport: passive diffusion, facilitated diffusion, active transport and pinocytosis ; neverth-, and the fluoride ion stays in the fetal compartment, a phenomenon that has been described in perinatal pharmacology as “fetal ion trapping”  is excreted through the feces % is excr. In the Although pregnancy is a physiological state that affects all major systems  with high potential to affect fluoride metabolism, the evidence on how these changes affect the intake, distribution, and excretion of fluoride, is limited in quantity and quality.Maternal plasma and urinary fluoride levels depend on fluoride exposure and vary across gestation, but there is not enough quality evidence to determine the direction (increase/decrease) of such variation.There is no doubt that fluoride from maternal blood crosses the placenta and is absorbed and excreted by the fetus. The biological mechanisms behind this transfer, are however, unknown.In order to maximize fluoride’s benefits and minimize its risks in potentially vulnerable populations, it is important to understand the metabolism of fluoride during pregnancy, and the mechanisms behind the fetal uptake of fluoride. Historically, most studies on fluoride and pregnancy have focused on the fetus, with the pregnant woman as a passive carrier. Instead, future studies should focus on the complex physiological changes of the pregnant woman, and how these changes affect the metabolism of fluoride. Furthermore, this area may benefit from mechanistic studies to understand the intestinal absorption of fluoride in pregnant women and the placental passage of fluoride.