Alces alces) incisors, most of them pendants, were found in 84 burials in the Late Mesolithic cemetery of Yuzhniy Oleniy Ostrov, Northwest Russia. We analysed the manufacture techniques of elk teeth (4014), in the collection of the Peter the Great Museum of Anthropology and Ethnography, St Petersburg. A striking observation is that the manufacture of these pendants is similar in all burials. Teeth were worked by carving one or several grooves around the root tip. In addition to grooved ones, a number of teeth were not worked at all. The uniformity of the chosen species, tooth and techniques indicates that strict norms prevailed in the pendant industry. Despite the overall similarity, our study shows some variation in making pendants. A groove can cut the whole circumference of the root, or several distinct grooves can mark opposite sides of the root. Sometimes the grooves are deep and made carefully, and sometimes they are weak and made hastily. A typology of various groove types was created. In many graves, one groove type dominates. We interpret that this inter-burial variation and domination of one type resulted from personal choice and taste based on practicality. Such variation could also be associated with kin identifiers, but we did not find clear support for that in our study. Our study indicates that the groove types as such had no connection with particular ornaments, garments or hanging positions.More than 4300 Eurasian elk ( Cemeteries with rich burial finds and well-preserved human remains can be used to study the social structures of prehistoric hunter-gatherer societies. Such burial sites have been found in Scandinavia (e.g. Skateholm in Sweden and Vedbæk in Denmark) and the Baltic area , although the amount of burial features, number of grave goods and chronology may vary. Several excavated and analysed contexts with human remains reveal multiple burial practices in Northern Europe  is the largest known Late Mesolithic burial ground in Northeast Europe. The area with excavated burials, 177 in total, is approximately 2350 mAlces alces), Eurasian beaver (Castor fiber) or brown bear (Ursus arctos), fashioned into pendants by either grooving or perforating the root tips. The total known number of such tooth pendants there stands at approximately 6000, while one single grave can contain several hundreds of them. Moreover, occasional bones and artefacts made of teeth of wild reindeer (Rangifer tarandus), grey wolf (Canis lupus), dog (Canis familiaris) and wild boar (Sus scrofa), as well as bones of several birds, are present in the graves. Also, grooved bone pendants made of irregular long bone splinters, the os hyoideum of ruminants and the ulna of Eurasian beavers are present. Other osseous artefacts found in graves are hunting weapons like barbed and unbarbed points, harpoons and their fragments, as well as anthropomorphic and zoomorphic figurines. The stone artefacts are, for example, finely made flint arrowheads, large flat slate artefacts with holes on one end and quartz utensils. The total number of finds in graves at YOO exceeds 7000, of which more than half are elk teeth. Fish bones or mollusc shells, or artefacts made of such materials, have not been found in burials at YOO.Most of the graves at YOO have been furnished with grave goods of stone and osseous materials Gurina . The majA new program for studying the chronology of YOO at the University of Oxford, UK, has confirmed a period ca. 100–250 years  for the use of the cemetery . The narrow time frame of the burial activities and the high number of graves offer a unique possibility to study kinships and social diversity in a Mesolithic context. In previous publications, it has been suggested that YOO was used by a socially complex hunter-gatherer society Gurina . In thesLandscapes are socially constructed phenomena Zvelebil , and beiPrevious studies have divided the YOO cemetery into southern and northern parts, but so far it has not been possible to associate individual burials with each other. This paper uses elk incisor pendants to identify intra-burial and inter-burial clusters. We study the manufacture technology of the incisor pendants and the amounts and spatial distribution of their technological types relative to the graves. The idea originates from two observations that we made during our use-wear study of a sample of 100 elk incisors from four YOO burials  Making elk incisor pendants by grooving was a cultural feature of the population or populations using the cemetery. A strict norm prevailed for this basic technique, excluding the use of another possible technique, perforating. Yet, how many grooves were made per tooth and on which side or sides of the tooth root were not strictly controlled. Thus, several sub-techniques as well as a certain degree of freedom existed. (2) The observed variation in the making of the grooves could perhaps indicate discrete subgroups—families, kin groups or such—in the cemetery. Different grooves and groove types could perhaps be part of the cultural communication system, with conventions learnt from the closest relatives or allies and reproduced over and over again more or less consciously. Although comprising small and hardly visible details, the groove types can also indicate specific tying methods of the pendants, attachment systems or ornament sets that visibly characterized groups of people. (3) The decisions regarding the groove types may have been based on functionality, durability and practical solutions.The aim of this study is to investigate whether the intra-burial and inter-burial distribution of the discovered groove types forms distinguishable clusters or patterns in the cemetery. Close scrutiny of a large amount of tooth pendants, practical experiments and a spatial examination of the findings can reveal whether decisions about groove types were based on functionality and practicalities or personal choice and preferences, as well as other possible regulations, possibly on a kinship level. Creating a typology based on how grooves were made on the elk incisors, we investigate variation in the number, location and depth of the grooves and the distribution of different groove types in individual graves as well as at the whole burial site. Furthermore, we take into account the total number of elk teeth in the graves. We also carry out experiments with modern elk teeth and discuss the functions, meanings and purposes of the tooth pendants found in YOO graves.A total of 177 burials have been excavated at YOO. Of these, 144 burials contain artefact finds, while 33 do not have any finds. More specifically, 84 of the burials with finds have elk teeth, of which 77 were available for our analysis. According to Gurina , altogetAll 4014 pendants were studied in MAE with the naked eye and an eye loupe with magnification of × 7. The number, location and the approximate depth of the grooves were documented with three scales . We also documented other traces of processing and wear, such as wear marks on the root tip or surface or narrowing of the root by grinding. A typology was created according to the location and amount of grooves. We ended up using four types related to the location of the grooves on mesial, distal, labial and lingual root surfaces . Combinations of these types were marked with corresponding letter combinations in alphabetical order. The combination ABCD, if forming one continuous groove, was simplified by designating it as type E. In addition, we added five types related to other traces on the root surface: grinded (H), worn root surfaces , a drilled or carved hole (O) and an unworked root (Y). Descriptions of types are given in Table Although all available teeth in MAE  were scrutinized, 2347 of them appeared to be fragmentary and were excluded from our analysis. Thus, the total number of classified teeth was 1668. Moreover, after analysis, graves with intermingled multiple burials or less than eight classified teeth were considered non-representative due to a considerable share of broken teeth. In five graves, the number of teeth exceeded the number of teeth given by Gurina for this grave (perhaps due to mixing of the finds during storage). All of the graves where materials were obviously mixed or where the majority of the elk tooth pendants were broken were excluded from the final comparison.A number of graves and teeth in this comparison are 34 and 1352 elk teeth, respectively. By predominant groove type, we mean a type that has at least 50% representation in a grave. The number of elk teeth per grave is adopted from Gurina . The sexIn order to better understand the manufacture and attachment methods of the YOO tooth pendants, we conducted experimental grooving of modern Eurasian elk teeth purchased from licenced hunters in Finland and Russia. A total of 40 incisors from five different mandibles were grooved outdoors using flint blades and modern needle files and following the example of the groove types discovered in the YOO material. The pendants were also wrapped with suspension loops of artificial sinew thread (0.2–1 mm in diameter), twirled around the root tip and knotted tightly. After that, the pendants were suspended from leather patches for wearing experiments  appears to be a fairly simple and straightforward process, taking only a few minutes. The exact time needed depends largely on the number, depth and location chosen for the grooves. The most appealing sides of the elk incisor root for grooving are the mesial and labial sides with convex contours. While grooving these sides, the opposite distal and lingual sides with concave contours help to keep the tooth steady in place. Grooving the distal and lingual sides is possible but not as simple, because the tooth easily slips from the hand. The thin mesial side enables the making of a shallow groove less than 1 mm in depth (type A), whereas the thick labial side allows for a deep groove 1–3 mm in depth (type C), leaving space also for another securing groove on the opposing lingual side (type CD). The thin distal and thick lingual sides similarly allow for shallow or deep grooves , but these grooves are, as noted, more difficult to make. Making a circular groove around the whole root tip (type E) is more arduous than the other types and also risky, because it makes the tip very thin and prone to breakage.All of these groove types can accommodate a suspension loop that holds well. Even a single groove on one side of the root is good enough, provided that the groove is deep and the string in it is knotted tightly. A shallow groove can also work for a while, but in this case, the loop can suddenly come out. The safest way to attach the string is to make a perforation in the root, but that is a more delicate and time-consuming process than grooving. However, this process can be facilitated by narrowing the tooth root by abrading or grinding it into an even surface before starting the drilling (type H). Although little is known about Mesolithic tying methods, our experiments show that the groove type can affect the position of the hanging pendant: while a pendant with a C or CD groove tends to hang at a certain stable angle, a pendant with an A groove tends to hang at right angles. A pendant with a circular E groove, on the other hand, rotates rather freely in several directions.The distribution of 1352 analysed elk teeth according to groove types is shown in Fig. According to our measurements, most of the types have a characteristic depth of grooves, ranging from shallow A, B and D grooves (< 1–2 mm) to deep C grooves (1–3 mm). Circular E grooves and CD, AC and ACD grooves (1–2 mm) fall in between these extremes. These differences are easily explained by the oval cross section of the elk incisor root, which allows for different depths in accordance with the grooved side .The study material contains quite many broken tooth pendants that have been worn through the circular E groove and “repaired” by fashioning similar or other types of grooves after breakage Fig. . These bOnly two elk teeth in the study material, both deciduous incisors, have holes instead of grooves for fastening the pendant. Both of these teeth are derived from burial 127 . Such a strict control is not reflected in the manufacture of brown bear canines; their technology is multiple and contains various types of grooving, perforating and leaving the root unworked Gurina . The cenOn the basis of our results, we can conclude that the elk teeth are associated with lived life. The number of elk teeth in graves seems to vary between individuals, and not between age groups. For example, some mature and adult males have no elk teeth at all, and some have many. The individuals with the highest number of elk teeth are males and females at a virile age. Also, some children have elk tooth pendants in their graves, indicating that at least some members of these populations started to gather pendants already at a young age. However, none of the child graves have a high number of pendants, perhaps because children did not have time to collect them.Interestingly, very old age did not increase the amount of elk teeth. If we accept the idea that pendants were personal belongings and that the amount of such belongings was dependent on personal achievements, we can suggest that during their life, these persons were not in a position that allowed them to receive (a high amount of) elk tooth pendants.As demonstrated in our experimental study, practical reasons related to manufacture technology can affect the chosen groove type. Factors like time and the energy invested in making the pendant required durability of the attachment system, while the desired position of the hanging pendant could have affected the choice of how the groove was made or if the groove was made at all. In the following, we survey the groove types discovered at YOO from this practical perspective, trying to understand their distributions and functions.Types CD, Y and C are the most common groove types at YOO, followed by types A, ACD and E. In the case of types C and CD, this is understandable, because these grooves are easy to make, deep and enable a tight and safe fastening. Wear mark J, (traces of suspension loops on the ungrooved sides of 8% of the C pendants) proves that this attachment system held well in reality. In the case of type Y, the prevalence is not as readily understandable. While the unworked Y teeth did not require much preparation, they often have wear mark J or I around the root tips or in the middle part of the root, probably resulting from suspension loops and binding. This also indicates that these teeth were threaded as pendants and carried on clothes, ornaments or accessories, obviously for quite a long time, because such abrasions do not develop quickly. How the grooveless Y teeth could have been threaded tightly remains an open question. Perhaps gluing or some other technique was used to secure the suspension loops. In previous studies, elk or other animal teeth without grooves or holes have not been interpreted as pendants at all . Interestingly, traces of similar grinding can be found on a total of 24 elk incisors in grave 127. Two of them are perforated, one shows an unfinished hole on the ground side, and the rest have grooves on the unworked sides. This creates an impression that all of these teeth were perhaps meant to be perforated, but for some reason, the maker changed the plan. Was drilling elk teeth too difficult? Was drilling elk teeth inappropriate after all? The deceased in grave 127 is an adult woman. She has 90 elk teeth along her thighs and between her knees probably forming the remains of a decorative fringe on an apron Gurina . MoreoveThus, the groove types preferred by the Mesolithic makers can be at least partially explained by practical reasons, such as the convenience, quickness, firmness and durability of the attachment. However, sometimes the logic of the makers remains inexplicable to us, probably due to our limited understanding of the tying, lacing and sewing methods or the deeply rooted cultural traditions of the time. In some cases, the chosen groove types appear to give clues on the personal characteristics or personality of the artisans, based on how much attention was devoted to finalizing minute and hardly visible details like grooves. We even catch a glimpse of the decisive moment, when the artisan wavered between the two choices: whether to drill or to groove.When observing the elk incisor pendants in their archaeological find contexts, the most distinct pattern is that one of the common groove types—either CD, Y, C, A, ACD or E—tends to dominate per grave. On average, the proportion of the predominant type is 58%, but in many graves, with dozens of analysed teeth, the proportion is as much as 75–100%. The graves with the highest values are mostly located in the northern part of the cemetery or its centre. What do these predominance values mean? The most logical explanation is that the incisor pendants found in the same grave were grooved more or less on one occasion, possibly by one person and/or during a relatively short time. Indeed, sometimes the grooves in a grave are so similar that they seem to result from serial production. Because a large number of the pendants at YOO show traces of wear (with I and J resulting from suspension loops and binding), this production was hardly related to burial preparations or the making of burial clothes. Instead, it could be connected with the making of particular garments and the tooth ornaments attached to them. To validate this idea, we have to survey possible garment remains in the YOO graves.In 24 of our 34 analysed graves, it is possible to have a rough idea of the position of the tooth ornaments in relation to the overall costume or body parts of the deceased. In graves 65, 67 and 156, almost all the tooth pendants are clustered on the neck of the deceased, forming remains of some type of necklace or collar Fig.  Gurina  Gurina  Gurina  (Gurina The making of large numbers of composite tooth ornaments at once means that a bulk quantity of elk incisors was available for the artisans at the same time. As one elk has eight permanent incisors (or six incisors and two canines), the ornaments in graves 65, 76a and 102, for example, required the teeth of no less than 8–18 individual elks. This implies systematic storage or extremely successful hunting seasons, the outcome of which is revealed in spectacular ornaments on costumes and accessories and eventually in graves. However, a few graves with lower predominance values diverge from this overall picture in that they appear to contain a single tooth ornament with a variety of groove types Gurina .YOO is an ideal site for systematic analyses of tooth pendants because of the high number of burials made during a short chronological time span and the high number of elk tooth pendants deposited over a relatively short period. Unfortunately, many of the elk tooth pendants from the YOO burials are broken and could not be used in our analysis. An important finding of our analysis is that groove types did not reveal clusters which could be associated with kinship. In a couple cases, two closely situated graves have the same predominant groove type. An interesting pattern is that most burials with one predominant type are located in the so-called northern group. This supports previous observations suggesting a centre or “hotspot” in the northern part.Another important finding is that grooving is really the only method of making elk tooth pendants seen at YOO, with only two exceptions. This indicates a degree of shared aesthetics of the population and that norms regulated pendant manufacture. Such unity is also indicated by the restricted use of almost exclusively specific teeth from elks, beavers and brown bears for making tooth pendants. The third finding is that the most common groove type is the most efficient and handy one to produce and at the same time the most secure and durable. This indicates that pendant production was routinized and that pendants were an important part of the social identity of the people using YOO. This also supports that pendants were intended to last for a long time, perhaps one individual’s lifetime or even from generation to generation.Based on our observations, we suggest that elk teeth were associated with the lived life of the buried people and that pendants were personal belongings of the deceased. The amount of elk teeth clearly divides the deceased. Because the amount of teeth in the graves does not increase with the age of the deceased, the elk teeth cannot be understood only as signs of accumulated wealth or prestige gained during life. Their importance was something more profound and meaningful than a mere symbol of wealth. For example, some children have elk teeth, and some children do not have elk teeth. On the other hand, the graves of adult and mature men may contain plenty, few or occasional teeth, or they may completely lack elk teeth. Despite the number of elk teeth varying between burials at YOO , we do not think that this variation alone can be used as evidence of the social identity or “social rank” of the person. In our opinion, all individuals buried at YOO were somehow special and selected . For some still unknown reason, these persons were chosen to be buried on this cemetery island, unlike the majority of their community members.In sum, our detailed analysis supports the results from earlier studies that ornamentation and personal adornment formed an integral part of social identity and personhood. Animal tooth pendants can be sorted into types, based on their abundancy, distribution and manufacture technique. Such types can help to identify patterns (e.g. clan-based or family-based divisions). In our materials, even the teeth without any grooves show wear, indicating that they were also attached to clothes or accessories.


Critical congenital heart disease (CCHD) has been defined as structural heart defects that are usually associated with hypoxia in the newborn period and have potential for significant morbidity and mortality early in life. CCHD has been estimated to be present in ∼3 in 1000 live births, including Saudi Arabia. Pulse Oximetry Screening (POS) is a highly specific and moderately sensitive test for detecting CCHD with very low false-positive rates. The Kingdom of Saudi Arabia is among high-income countries with a population of more than 33 million and more than 600,000 annual live births. In 2015, the Universal Screening Program for CCHD using Pulse Oximetry was approved in Saudi Arabia. It is expected that any new national program will undergo a learning curve and face many challenges. We believe that developing countries may face different challenges during implementation of such national projects, but the success achieved by Saudi Arabia in implementing the program was mainly due to good preparation before launching the project and advancements in the use of the technology involved in this project. Since starting the universal CCHD screening in 2016, more than 900,000 babies have been screened in Saudi Arabia and many lives have been saved using this safe, non-invasive, inexpensive, and reasonably sensitive test. Congenital Heart Disease (CHD) refers to structural disorders of the heart and great vessels that are present at birth. CHD affects 8 per 1000 live births and is the most common type of birth defect worldwide, including Saudi Arabia ,3,4. GloCritical congenital heart disease (CCHD) is a term that refers to a group of serious heart defects that are present from birth. These abnormalities result from problems with the formation of one or more parts of the heart during the early stages of embryonic development. CCHD prevents the heart from pumping blood effectively or reduces the amount of oxygen in the blood. As a result, organs and tissues throughout the body do not receive enough oxygen, which can lead to organ damage and life-threatening complications ,7. IndivAlthough babies with CCHD may appear healthy for the first few hours or days of life, signs and symptoms soon become apparent. Babies sent home with an undetected heart defect are at risk of serious complications within the first few days or weeks of life that may require emergency care and may even be fatal. POS is an evidence-based tool that can identify most of these babies so they can receive prompt care and treatment .Pulse oximetry screening (POS) for CCHD has been shown to be a simple reliable method used to determine arterial oxygen saturation of hemoglobin in arterial blood and has been widely used in many areas of clinical medicine . ParticuThe Kingdom of Saudi Arabia is among the high-income countries with a population of more than 33 million and more than 600,000 annual live births . Saudi AIn 2012, the Saudi Ministry of Health (MoH) established a neonatal services improvement program to supervise, monitor and lead changes in neonatal care in the country. This program was fully funded and supported by the government. Furthermore, to ensure full coordination between the various departments in decision-making, a neonatal advisory committee was formed by the Ministry of Health. The committee members include doctors, nurses, representatives from health education, medical consumables and medical equipment departments. Since 2012, a neonatal services improvement program has been continuously working to support neonatal services in the country through more than 40 improvement projects, one of which is Universal CCHD Screening program.In 2014, the Universal Screening program for CCHD in Saudi Arabia was thoroughly discussed during several neonatal advisory committee meetings; the discussion included evidence-based studies, and international and local experiences. In 2015, the neonatal advisory committee approved the project and submitted their recommendations; first, that universal screening for CCHD using Pulse Oximetry should be routinely performed on all healthy newborns to enhance the early detection of critical congenital heart disease. Second, that optimal screening for CCHD disease should include a prenatal ultrasound, newborn physical examination and pulse oximetry screening. Third, that CCHD screening should be performed on the right hand and either foot. Lastly, that screening for CCHD should be performed for all newborns between 12 to 24 h of age.The committee recommendations were approved by the MoH and all hospitals were requested to start the implementation of CCHD screening in collaboration with the neonatal services improvement program, as the first and only country in the Middle East at that time. To ensure a successful national program with an optimal implementation rate, several steps have been taken by the neonatal services improvement program, such as:The national steering committee includes neonatologists, pediatric cardiologists and nurses. The committee conducts meetings every two months with main tasks including the supervision of the overall project and ensuring the comprehensiveness and quality of the service, a periodical database review to ensure appropriate services are provided to all positive case newborns, and to ensure proper education for both hospital staff and parents about CCHD screening.Each hospital was requested to form their own local team that would consist of one pediatrician, one pediatric cardiologist (if available) and one to three nurses, depending on the capacity of the hospital. The local team is responsible for the supervision of the project in their hospital; they must ensure service quality, training for the staff, education of the parents, and communication with the national steering committee.A two-day structured competency training was established for the nurses who would perform the newborn screening, including CCHD screening and entering of the results into the national CCHD screening registry. A certificate of “super-user” was given to those nurses who were competent to perform the screening. These nurses were also eligible to train other nurses on how to perform the CCHD screening. National CCHD screening policies and procedures were formulated and approved by the neonatal services improvement program in Saudi Arabia before being disseminated to all heath care facilities in the country. The approved policies and procedures are comprehensive, simple, and include steps on how to perform the CCHD screen. To reduce human error, only (smart) Pulse Oximetry Screening (POS) machines, with an integrated CCHD screening protocol, were used. These machines contain screening protocol instructions and integrated guidance, which can be easily followed by the operators; negative results are shown in green and positive results are shown in red.The MoH has created a national secure webpage system, with secure servers centrally located in the MoH, which track and save the results of the screenings of all newborns. To empower the national registry and to reduce error, the CCHD screening protocol was integrated in the national registry. The registry system was integrated with the national birth notification system to effectively obtain full reports. This high caliber registry system is an ideal means of providing the decision-makers with live dashboards to monitor the progress, compliance and screening results, as well as providing researchers with all the necessary data.To eliminate human error during data entry and to conserve the time taken to perform the screening, we have developed a unique worldwide integration system that connects screening devices with the national registry system. This allows the screening result to be retrieved automatically from medical devices without any human intervention.Each hospital receives detailed monthly report about their CCHD screening performance. This may encourage the local teams to carry out prompt and accurate corrective actions if necessary. Prompt and accurate feedback is essential to the success of the screening program.The CCHD screening program in Saudi Arabia was initiated in phases. The implementation phase of the screening began on 1 January 2016 in the largest 30 hospitals, a further 70 hospitals in 2017, and the remaining hospitals followed in January 2018. Parents are notified about the CCHD screening results by the screening team; furthermore, the result is documented in the baby’s medical record and in the vaccination card . The natDue to the unavailability of an echocardiogram facility in many local hospitals, short trainings and workshops were conducted for general pediatricians on how to use an echocardiogram machine and perform CCHD screening with the remote help of our pediatric cardiologists. This experience was very helpful and reassuring for both the general pediatricians and the parents. Despite good preparation before and during implementation of the CCHD screening, it is expected that any new national program will undergo a learning curve and face many challenges. The main challenges for our CCHD screening program were identified as follows: first, dealing with frequent changes in the local screening team, as the trained nurses involved in CCHD screening are frequently changing, and this may affect the performance and success of the program. Second, improving data entry and reducing human error. Third, close monitoring of the test-positive cases. Last, close monitoring of false negative cases. The steering committee is taking all possible action to resolve the issues. They are conducting continuous training for nurses to become super-users—competent nurses who are eligible to train other nurses on how to perform CCHD screening. With regards to the collection of data and reducing human error, automation of the process with frequent updates and a regularly upgraded registry system will help in reducing error and the time needed for screening. Newborns with positive results should undergo a thorough evaluation by the most responsible health care provider on duty to evaluate the baby and to decide if referral to a pediatric cardiologist is needed. If a pediatric cardiology service is not available at the local hospital, an urgent referral to the appropriate center should be made. False negative results are a real challenge, but we believe good communication between the different cardiac centers and the national steering committee can help in discovering these cases. Pulse Oximetry Screening (POS) is a highly specific and moderately sensitive test for detecting CCHD with very low false-positive rates ,11. CurrWe believe that developing countries may face different challenges during the implementation of such national projects. We believe that the success achieved by Saudi Arabia in implementing the program was due to good preparation before launching the project and advancements in the use of the technology involved in this project.Since starting the universal CCHD screening in 2016, more than 900,000 babies have been screened in Saudi Arabia, with 0.26% being positive screening cases, which is in keeping with published global studies ,13. Many


The coronavirus disease 2019 (COVID-19) pandemic has had a significant impact on the world of sports due to periods of home quarantine, bans against public gatherings, travel restrictions, and a large number of postponed or canceled major sporting events. The literature hitherto is sparse, but early indications display signs of psychological impact on elite athletes due to the pandemic. However, beyond acute effects from lockdown and short-term interrupted athletic seasons, the postponed and still uncertain Olympic and Paralympic Games may represent a major career insecurity to many athletes world-wide, and may lead to severe changes to everyday lives and potentially prolonged psychological distress. Given the long-term perspective of these changes, researchers and stakeholders should address mental health and long-term job insecurity in athletes, including a specific focus on those with small financial margins, such as many female athletes, parasports athletes, athletes in smaller sports, and athletes from developing countries. Implications and the need for research are discussed.  The spread of the SARS-CoV-2 virus, and the morbidity and mortality related to the coronavirus disease 2019 (COVID-19), constitutes an unprecedented threat to public health, financial systems, and occupational conditions world-wide. Beyond the obvious consequences of the virus and the severe physical disease surrounding it, researchers have expressed a growing awareness about COVID-19 as a threat against mental health in the population [While the COVID-19 crisis affects many  financial sectors in society, specific professions are more affected by the COVID-19 pandemic than others, particularly through feelings of insecurity about future working conditions . The worAn emerging line of scientific literature has highlighted the profound impact of the pandemic, particularly on the macrolevel business situation in the world of sports . Above tResearchers have documented early social media experiences of many top athletes supporting the need for action against the pandemic in a tone of accepting the current situation and engaging in what is important in society outside of sports . HoweverPrior to the particular situation of COVID-19, psychological distress and mental health in athletes have received increasing attention from researchers and relevant stakeholders in recent years. While the actual prevalence of mental health disorders in athletes is considered to be at a similar or slightly higher level than in the general population, its clinical picture may be different: stigmatization may be higher, help-seeking lower, and opportunities for professional and specialized treatment may be more limited. This has led to the overall interest in better assessment and treatment of poor mental health in athletes and in establishing specific chains of care for this particular group ,21,22,23The scientific literature is hitherto limited with respect to actual psychological effects on athletes from the lockdown in sports. However, in an online survey carried out in May–June 2020, a high percentage of top league players from three major team sports in Sweden reported a self-perceived negative psychological impact from the COVID-19 situation. A minority reported having increased their alcohol consumption and gambling during the pandemic, although no data are available for comparison. Importantly, more clinical measures of depression and anxiety were associated with self-reported worry about one’s own future in sports in the context of the COVID-19 pandemic. While the conclusions were limited by a low response rate, the study provided indications of negative psychological influence in three team sports highly affected by the acute phase of the lockdown situation . A multiLong-term consequences beyond relatively brief periods of confinement and the acute phase of the pandemic may persist and develop further. Among the major structural changes occurring in the world of sports was the cancelation and discontinuation of major tournaments and full seasons or playoffs in team sports world-wide. One of the relatively early consequences was the decision to postpone the 2020 Summer Olympics and Paralympics in Tokyo —a decisiSince the decision to postpone the Games, the impact of COVID-19 on the lives and working conditions of Olympic and Paralympic athletes continues because of severe restrictions and challenges, with the pandemic being prolonged and unlikely to diminish in the near future. The number of cases globally, and on more than one continent, displayed a new surge during autumn 2020 , leavingAs the planning for the 2020 Tokyo Olympic and Paralympic Games can be re-activated in the event of a more favorable pandemic situation, such a decision will have to take into account the highly diverse conditions for qualification and preparation world-wide, based on diverse phases of the COVID-19 spread. In addition, to reiterate, the insecurity about when and how such an event will be carried out may still be prolonged and may again be subject to further insecurity in the case of repeated surges in the pandemic. There is reason to believe that such feelings of uncertainty may lead to increased psychological distress. Handling insecurity is challenging for most people, and based on current cognitive models in generalized anxiety, an intolerance for insecurity can lead to an increase in worrying ,38. In aThe profound impact of the pandemic on the Olympic and Paralympic Games can be considered to represent a particular threat to athletes’ mental well-being, due to the nature of these events as a long-term and fundamental motivational target for athletes. Few professional areas affected by the COVID-19 pandemic are characterized by something similar to this four-year preparation cycle, now suddenly disrupted by COVID-19-related restrictions and subject to a high degree of job insecurity. Previous experience from the Olympic Games shows the nature of the Games as a key component in athletes’ careers ,40, wherGiven the early research data on psychological distress in athletes due to the COVID-19 pandemic ,26,30, tIn a study in team sports players in Sweden, a majority of respondents confirmed feeling concerned about their sport and about their future in sports due to the pandemic . HoweverIn addition, concerns have been raised about women’s sports being more strongly affected than men’s sports. The markedly increased challenge in women’s sports is based on the large gap in sponsorship income and other financial resources, as well as more challenging professional career opportunities for women and the lower worldwide media coverage of women’s sports than men’s sports. Altogether, these differences, evident prior to the current crisis, are likely to leave female athletes with narrower margins in the COVID-19 crisis . These cFrom a sporting event organizer’s standpoint, the COVID-19 pandemic is likely to affect many business sectors surrounding the travel and tourism industry, especially around large sporting events . More spAs the pandemic continues to spread globally, further enhanced by the surge of cases during late autumn and winter 2020, policy makers, clinical workers, and researchers have reason to actively consider the mental and occupational health of professional and semiprofessional athletes. It is becoming increasingly clear that such mental health concerns will have to be assessed far beyond the acute effects of regional or national lockdown decisions, or of home confinement during early COVID-19 phases. Importantly, psychological distress from COVID-19 in sports may need to be studied in the context of job and career insecurity, and in the context of a prolonged career-limiting situation of an uncertain duration and an unknown outcome. Beyond the career, an involuntary and unpredictable end of the career—potentially brought on by the COVID-19-related impact on sports—may be associated with difficulties in the transition from sports to another career, and this merits further research. Likewise, decisions to plan for a family may depend on the outcome of specific sporting events, where the disruption of the Olympic quadrennium may have a profound impact on such private-life decisions. When career termination is involuntary, as can happen during the pandemic situation and the cancellation of major sports events, it is considered to lead to a more problematic transition process . TherefoPsychological research on the impact of COVID-19 on athletes may need to focus on the long-standing consequences of the postponed and possibly canceled Olympic and Paralympic Games. Researchers have previously underlined the need to keep up therapeutic contacts with elite athletes in need of support throughout the pandemic . While cFrom a COVID-19 perspective, such strategies need to be intensified and should further specifically address the peculiar and context-specific challenges that athletes face in the current pandemic—that is, the insecurity regarding the Olympic and Paralympic Games and other upcoming major sporting events—and the effect of that insecurity on the individual’s life and career planning. Moreover, a special focus should be placed on the development and worsening of more severe clinical psychiatric manifestations due to the current situation. Therefore, relevant stakeholders are the domain of sport psychological support both in the applied setting and in clinical treatment units.In addition to a response to the effects of uncertainty while waiting for a decision, interventions may be needed if the Olympic and Paralympic Games are ultimately canceled. This would represent a previously unseen scenario (except for times of World War ), and a Moreover, as pointed out previously, in times of a crisis like the COVID-19 pandemic, business management surrounding the world of sports may need to be innovative in order to lessen the harm caused by the pandemic . Thus, bIn brief, recommendations for stakeholders within and surrounding the world of sports may be (1) to provide career support for athletes who are affected by the postponement; (2) to increase sports psychology support to meet the needs of the athletes, with a special focus on coping with insecurity about their career and their future; (3) to provide access to mental health providers in specialized or general psychiatric facilities for athletes who suffer from clinical symptoms; and (4) to formulate regional and global action plans for the potential impact on occupational situations and health in athletes and other affected stakeholders in the case of a final cancelation of the Olympic and Paralympic Games. In addition, a gendered approach to all stages of prevention and intervention in athletes’ mental health is of great value.Beyond the likely psychological effects on elite athletes from early phases of confinement and canceled sporting events during the COVID-19 crisis, the prolonged and highly uncertain future of the Olympic and Paralympic Games presents a potentially large mental challenge to athletes. Emerging data suggest that psychological distress in athletes is one of the consequences of the pandemic, and more knowledge is needed both in athletes in general, and with particular focus on the highly specific situation for athletes striving for the Olympics and Paralympics. Research, prevention efforts, and treatment interventions may need to focus on this uncertainty in the context of job insecurity, as athletes represent one of the occupational sectors most clearly affected. The everyday lives of many athletes—typically strictly planned and often involving a focus on the fixed time frame surrounding the typical Olympic quadrennium—are likely to be severely altered by this insecure situation. It is also important that research, prevention, and treatment initiatives involve gender aspects.


Coping with assessment tests are known to generate anxiety frequently in the students who face them. In academic circumstances with the continued presence of emotional disturbance, high demand, and stress, emotional and physical fatigue, typical of burnout syndrome, and can be detected. Anxiety and burnout are related to each other and even more closely in high-stakes tests. One of these tests is the examination imposed in Spain for access to the university. The objective of this work is to analyze the presence of anxiety and burnout and the relationship between them in students who face these tests, both during the confinement situation due to the COVID-19 pandemic and during the pandemic after the lockdown. For this purpose, we used a sample of 1,021 students with a mean age of 17.89 . Of these, 866 (84.8%) were students who were taking the test, while the rest were university students who had passed it recently. Our results show high levels of anxiety and burnout in students who face the evaluation test during the COVID-19 pandemic, sustained over time and especially in comparison with students who had already taken the exam. The association between higher levels of anxiety and higher levels of burnout in the students who take these exams was also verified. These results link the relationship between these two variables more solidly and suggest the need to include address anxiety to reduce burnout levels in these students. The results are discussed with regard to prior evidence and their applications. Given the escalation in the number of COVID-19 infections at the beginning of March 2020 in Spain, the government of the nation, after the convocation of an extraordinary council, declared a state of alarm on March 14 of that year . This deThe main decision derived from that declaration by the Spanish government was the imposition of a national quarantine. The measure came into force at 00:00 h on Sunday, March 15, and implied forced isolation of all Spanish citizens and foreigners residing in Spain .On April 28, the government announced the so-called the “Deconfinement Plan,” consisting of four phases that concluded in the “new normality” on June 21, thus ending the state of alarm at 00: 00 h of that day . During Some studies have already shown how the confinement situation in different countries has been associated with anxiety, mood changes, changes in daily life patterns  and worsening health-related behaviors, among other variables .Getting tired of performing activities continuously is normal. When these activities are inherent to work or responsibility and are carried out for long periods of time , they can lead to chronic fatigue, popularly referred to as being “burnt.” In Psychology, for a long time, this state has been called burnout and has been conceptualized as a state of emotional, physical, and cognitive exhaustion as a consequence of performing responsible activities under demand and stress . BurnoutWorrying about things of daily life is normal. However, worrying excessively and continuously or without justified cause is one of the most commonly recognized symptoms of anxiety or any of its associated disorders . AnxietyIn the educational context, anxiety is usually present at different times and situations, with evaluation tests being one of the most frequently associated situations . In factConcerning exams, anxiety is understood as a state and is characterized by a feeling of fear and tension, worry, and a perception of threat, together with negative physiological manifestations , moreoveExam anxiety has been associated with other psychological disorders and problems, including generalized anxiety, attention deficit hyperactivity disorder, phobias, or depression, among others .Regarding academic functioning, exam anxiety has been related to many different negative aspects that can affect the result of the exam itself or performance in general , as wellOne aspect that seems to increase exam anxiety is its possible consequences. As these are perceived by students as very important or threatening, anxiety levels may be higher, with high-stakes tests being especially anxiogenic . The uniTherefore, although the physical and emotional fatigue inherent to burnout and its association with anxiety during exams have been previously studied, not many studies have studied these aspects in subjects who face the university access exam in Spain. Still less attention was paid to the extraordinary situation of confinement suffered by these students between March and June 2020, when they were not attending the educational centers in-person to prepare this test.Consequently, in this work, we propose the following objectives. Firstly, we analyzed the levels of anxiety and burnout in the participants. Secondly, we explored the association between anxiety and burnout in students who take the university access exam after having been recently confined.Our third objective focuses on the evolution of anxiety and burnout sustained over time, as well as the levels in confined subjects compared with a control group. Finally, our fourth objective was to analyze possible differences in burnout according to different levels of anxiety in the students who take the access exam in a post-lockdown situation.The reviewed previous evidence makes us hypothesize that there will be a significant association between anxiety and burnout in the students who face the test. Moreover, higher levels of burnout will be found in subjects who have higher levels of anxiety before the selectivity test. On the other hand, we expect to find that the levels of anxiety and burnout will be maintained over time, and that the levels will be higher in subjects confined by COVID-19 and those who were taking the test, compared to control subjects.In this research, the design used was a retrospective or ex post facto study  with a cIn this research, participants were 1,021 students with a mean age of 17.89 years . Concerning gender, 638 were female (62.5%), 368 were male (36%), four had chosen the option “others” (0.4%), and 11 (1.1%) did not provide this information. All of them studied either in the city of Granada or in its province, in Spain.Of them, 866 (84.8%) were enrolled in their last year of high school: 390 (38.2%) were currently (during the assessment days) taking the university access exam, and 476 (46.6%) participants had been in a situation of national confinement due to the COVID-19 pandemic at least 2 month before taking it.n = 155, 15.2%) were considered a control group, with assumed normal functionality  because they had already taken the exam at least 3 month before the COVID-19 pandemic and were currently first-year university students. Of these, 60 studied Early Childhood Education, and 95 studied Sociology. These three groups  formed the three groups of subjects according to the time/situation of data collection. The remaining students  whose link was distributed to a sample of last-course high school students. For this purpose, we previously contacted the board of directors of various educational centers in the province of Granada (Spain) to request authorization and collaboration. Through them, a pool of specific professors was contacted who collaborated by distributing the request for participation and the link to the questionnaire among the students.The request to the students was accompanied by specific information detailed below, as well as the request to sign an informed consent. Students who were preparing their access to the university responded to the survey between April 1 and 30, 2020, while those who were taking the university access exam did so between July 7 and 9 of that year (the date when the tests are held in Granada). In these cases, the survey could be completed through mobile devices or PCs.The third set of data had been collected before the COVID-19 pandemic  from first-year university students of the specialties of Sociology and Early Childhood Education in the faculties of Sociology and Education Sciences of the University of Granada. Authorization had been requested from the professors in whose classrooms the evaluation was carried out and the data were collected in groups.The students who were evaluated during the university access exams were asked to fill in the questionnaire either at the end of the session of any of the tests that make up the exam or during the break in any of them, but not at the end when the exam had ended. In any case, the questionnaires were completed between July 7 and 9, 2020, either on the street or at home.Before requesting their consent, participants were informed of the main objectives of the research, the anonymity of the information collected, and the voluntariness of their participation. They were also requested not to leave any item unanswered and to be sincere. The criteria established by the authors of each specific inventory were taken into account.In this research, no personal data was collected that could allow the identification of the participants. The answers given in the questionnaires were transferred to a database for subsequent statistical analysis. Regulation (EU) 2016/679 of the European Parliament and of the Council of April 27, 2016 on the protection of natural persons with regard to the processing of personal data was followed at all times.The evaluation instruments were assembled in a questionnaire headed by the request to report their age and gender. Concerning gender, the participant could choose “male,” “female,” or “other.”The Spielberger State-Trait Anxiety Inventory (STAI), in its Spanish version , was useTo quantify burnout in the participants, we used the one-dimensional Student Burnout Scale , 2011 inData analysis included descriptive and frequency analysis, correlation analysis , and means comparisons tests, specifically one-way ANOVA, with analysis of minimally significant difference in some cases. The analyses were carried out with the SPSS statistical software, assuming in all tests a level of significance less than 0.05.Our first objective aims to descriptively analyze the levels of anxiety and burnout in the complete sample participants. Regarding anxiety, the distribution as shown in r = 0.46, p = 0.00), which clearly indicated that participants’ higher levels of anxiety were significantly associated with higher levels of burnout.For our second objective, we explored the association between anxiety and burnout in students who were taking the university access assessment test (post-lockdown situation). For this purpose, we only worked with this sub-group of the total sample. A Pearson bivariate correlation test was carried out  = 74.45, p = 0.000. The same relationship was also observed in burnout, F = 20.03, p = 0.000. The specific mean differences in burnout and anxiety between the three groups of participants are detailed in Our third objective was to determine possible differences in anxiety and burnout between the three established conditions: (a) at least 2 month before the exams, when the students were confined; (b) on the days of the exam ; and (c) first-year university students who had taken the exam in the past in normal social circumstances (control group). Therefore, we worked with the complete sample of study participants and carried out the respective mean comparisons (univariate ANOVA) with an additional minimal significant difference (MSD) contrast. The ANOVA indicated significant differences in anxiety between the three evaluation conditions, Concerning anxiety, the differences were generally significant but not exactly between the three groups. The highest levels of anxiety were observed in the group evaluated at least 2 month before the access exam (whose members were in a confinement situation), but the differences between this group and the group evaluated while taking the exam were not significant. The control or normal-functional group, assessed when already enrolled in the university, presented significantly lower—almost minimal—anxiety levels.Concerning burnout, the differences between the three groups were significant. The confined participants evaluated at least 2 month before the university access exam had higher levels than the students who were actually taking the exam, and both groups had higher levels than the control group.F = 38.77, p = 0.000]. The levels of anxiety were established following the scaling criteria proposed by the authors of this inventory  in Spain.That is why we first proposed to determine the presence of these variables in a sample of students. Our results have shown relatively high levels of anxiety and somewhat less burnout. These results agree with those found by other studies with different samples, where test anxiety is considered habitual and high .For our second objective, to determine the association between anxiety and burnout, in this case, we only analyzed the sample of students who were taking the university access exam. The significant and positive association between anxiety and burnout had been observed in students taking exams, but not in the case of the university access exam in Spain, in a national post-lockdown situation or with exceptional social interaction measures. However, these results are consistent with previous studies carried out in other circumstances .The results of our third objective were also highly interesting. We wanted to explore possible differences in anxiety and burnout between the three assessment moments or conditions: at least 2 month before the exam (lockdown), while taking the exam post-lockdown, and in students already admitted to the university . The comparisons of means revealed significant differences only between the lockdown condition (months before the examination) and the control group as well as between the post-lockdown condition (on the examination days) and the control group. However, no significant differences were found between the lockdown and post-lockdown situations, indicating that the levels of anxiety were already high at least 2 month before the access exam (when students were in lockdown), and remained so until the days of the exam. Anxiety levels were significantly lower in students who were enrolled in the university. This result coincides with others that had already found very high levels of anxiety in this type of exam in other countries . The resThe comparative analysis of the burnout means in the three groups of students also revealed significantly different levels of emotional and physical fatigue regarding their academic work. It is noteworthy that at least 2 month before the access exam (during the lockdown), participants showed an even higher level of burnout than during the days the exam was held. This result could be explained because, in the days of the exam, the end of a process that had lasted practically the entire academic year is perceived, which is liberating. As expected, the group with the lowest burnout level was the group of university students. This control group contextualizes the result of anxiety in the other two groups that face the access exam.Finally, to delve into the relationship between anxiety and burnout, our fourth objective explored possible differences in burnout according to different levels of anxiety only in the group of students who were taking the access exam. These students faced the access exam in exceptional historical circumstances, having been confined for 2 month before the exam and surrounded by social-health measures that were also unique . The differences in burnout between the low, medium, and high anxiety groups were significant. The relationship between higher anxiety and higher levels of burnout is clear and significant and in line with the findings of other studies in other populations . These rTo conclude, our study shows that coping with university access exams, considered high-stakes tests, generate high levels of anxiety and concern in these students, an aspect that was already studied in other samples and countries . AnxietyA possible limitation of our study refers to the sample of participants used. Specifically, given the type of sampling carried out, the sample may not represent the reference population and therefore our results must be taken with caution in order to generalize. Despite it, our results also open a line of reflection on these aspects of our educational system, which could harm students’ health. It should be kept in mind that anxiety is one of the most frequent psychological disorders worldwide , and is The raw data supporting the conclusions of this article will be made available by the authors, without undue reservation.Ethical review and approval was not required for the study on human participants in accordance with the local legislation and institutional requirements. Written informed consent to participate in this study was provided by the participants’ legal guardian/next of kin.AF-C conceived and designed the study, obtained the information, performed the statistical analysis, interpretation of the results, and wrote the manuscript.The author declares that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.


Driven by game theoretic considerations and inspired by the work of US National Research Council's Committee on Food Habits (1943) during WWII, and the post-WWII Yale Communication Research Program, the present research shows how to achieve enhanced adherence to health regulations without coercion. To this aim, we combine three elements: (i) indirect measurements, (ii) personalized interventions, and (iii) attitude changing treatments (IMPACT). We find that a cluster of short interventions, such as elaboration on possible consequences, induction of cognitive dissonance, addressing next of kin and similar others and receiving advice following severity judgements, improves individuals' health-preserving attitudes. We propose extending the use of IMPACT under closure periods and during the resumption of social and economic activities under COVID-19 pandemic, since efficient and lasting adherence should rely on personal attitudes rather than on coercion alone. Finally, we point to the opportunity of international cooperation generated by the pandemic.Following the outbreak of COVID-19 pandemic, governments around the globe coerced their citizens to adhere to preventive health behaviours, aiming to reduce the  While the basic reproduction number, R0, reflects the contagiousness or transmissibility of an infectious agent [R reflects the expected number of additional cases that one infected individual will generate, given the effectiveness of implemented health and social interventions. In other words, the more successful health interventions are, the lower the value of R, and the less people will move from the state of being susceptible to the state of being infected, within a specific period of time. If R < 1, the disease will gradually die out [The outbreak of the COVID-19 pandemic made governments around the world to coerce their citizens to comply with preventive health behaviours. These actions are expected to reduce the  die out –4.effective reproductive number of virus infections, governments enforced numerous emergency regulations. Individuals were asked to adhere to constraining behaviours, such as staying at home, keeping social distance, repeatedly washing hands and avoiding meeting seniors. Although restricting personal freedom, these behaviours generate health benefits for both the individual and the entire population. They are expected to lower contact probabilities with vulnerable populations, especially seniors or those with immune deficiencies; hence preventing hospitals from being overrun, flattening the infection curve, lowering its peaks and contributing to the lowering of R and the burn-out of the disease.To reduce the not expected to perceive the COVID-19 pandemic as a strategic interaction or analyse its game theoretic characteristics. Nonetheless, modelling social interactions under COVID-19 as Chicken games highlights two important aspects: (i) it suggests that the behavioural challenge of reducing the effective reproductive number R matches the motivations of the involved individuals. Hence, individuals' behaviour is not only the problem, but, given appropriate interventions, may actually become the solution. (ii) Since the Chicken game is a member of a category of games termed similarity-sensitive games (SSGs), cooperative behaviour may be induced simply by raising the perception of similarity with other players [Potential interactions among individuals, who may either be infected or susceptible to infection, form a social dilemma. Each individual benefits from others’ cooperation, yet is motivated to violate the restrictions himself . However players .Table 1To design appropriate health-promoting interventions under COVID-19, we address not only the cooperative nature of the Chicken game. We also aim to influence attitudes and risk perceptions, which have been shown to influence health behaviours in general ,13 as weTo construct non-coercive behavioural intervention measures, we draw on the work of the US National Research Council's Committee on Food Habits, conducted eight decades ago during WWII . MotivatWhile many studies have addressed the link between persuasion, attitudes and behaviour, we focus here on an assortment of studies that revealed simple and potent effects that can easily be adjusted to the behavioural challenges imposed by the COVID-19 pandemic. We also extend the search to relevant effects of decision-making, altruism and cooperation. The main criteria for the inclusion of these processes are their established efficacy and the simplicity of their administration and adaptation to a computerized survey disseminated via the Internet. We neither assume that the following list of effects is complete nor that it represents an optimal choice.The present study is first of all an intervention project that aims to benefit the participants by helping them to understand and develop internally motivated adherence. Being constrained by the goal of providing immediate benefits, we do not use a bottom-up methodology that studies isolated effects and progresses by testing ever more complex interactions. Instead, we apply a cluster of psychological effects, embedded in a short computerized survey that enables testing the overall efficacy of the entire bundle of attitudes. Initially, we assigned a few participants to a simple repetition condition, but once sufficient evidence had been collected, we continued by assigning all participants to the full intervention condition.1.1.Loss aversion is a crucial aspect of prospect theory [infected people (losses) rather than in terms of healthy people (gains).t theory . It assuThe Yale Attitude Change Approach suggests that the effectiveness of persuasive communication depends, among others, on the source of the message [ message  and the  message . As we aThe Elaboration likelihood model [od model  suggestsCognitive dissonance theory [e theory  suggestsAdvice taking under the context of virus infections [The study of fections  has showKin selection suggests that an organism favours the reproductive success of his relatives. Formalized by Hamilton [Hamilton , the benSubjective expected relative similarity (SERS) shows that cooperation in SSGs such as the Chicken game does not only depend on the expected pay-offs, but also on the extent of perceived strategic similarity with the other party [er party ,10. In sbandwagon effect shows that the probability of an individual to adopt an idea increases with respect to the proportion of others who have already done so. As more people believe in something, others are more likely to join [the group of people who adhere to health authorities' regulations in the closing remarks of the survey.The  to join . Althougfoot in the door technique is expected to induce compliance by asking for a small request followed by a bigger one. The compliance to the small request is expected to increase the likelihood of the compliance to the bigger subsequent request [The  request ,35. Alth2.Participants from various countries were approached via email and social networks, and asked to participate in a short survey by clicking on a specified link. Dissemination was channelled through academic and societal influencers, using personal requests, professional organizations, Facebook, Instagram and WhatsApp. Everyone who received the survey was also asked to continue and distribute it. Questionnaires and appeals were written in English, Hebrew, Arabic, Polish and German, as well as in Spanish, Dutch and French. Due to the yet insufficient numbers of responses in some of the languages, we report language-specific statistics only for the first five languages.As part of the worldwide struggle against the spread of the coronavirus, we develop behavioral interventions that help researchers and policymakers to improve the communication with the public and assist in the distribution of efficient COVID-19 related health instructions. We need volunteers to fill out and continue distributing short questionnaires, which takes no longer than 10 minutes to complete. This project is run by the laboratory for the study of Social Dilemmas at the University of Haifa, in collaboration with researchers from Princeton University, Adam Mickiewicz University, University of Cologne, and Technical University of Munich.The introductory message read as follows:Respondents that followed the link were first provided with a clear declaration of their rights as participants, including voluntary non-obligated participation, the right to refuse or to discontinue participation at any moment, confidentiality of the data and strict anonymity of participants' identity. About 20% of those viewing this page confirmed a mandatory consent statement and went on to actually participate in the survey.be infected with the Coronavirus. The second question asked how many individuals, out of 1000, that do not keep the specified instruction are likely to be infected with the Coronavirus.To indirectly measure initial, implicit, health attitudes, participants answered two questions regarding each of four health regulations. The first question asked how many individuals, out of 1000, that keep a specified instruction are likely to Unlike most surveys that take a direct interest in the actual values provided by the respondents, our approach does not require that participants provide correct or meaningful estimates that correspond with risks in the real world. In fact, we calculate the differences between the estimates within each pair of questions . This difference serves as an indirect measure of respondents’ attitudes. A small difference indicates disbelief in the efficiency of the specified health instruction addressed within the question pair, and vice versa. It is also important noting that taking into account the lack of actual knowledge, participants might rely on various heuristics for their probability judgements . They midoes not believe in the efficacy of a specific health instruction is likely to respond by providing similar numbers with only a small difference separating the two estimates of becoming infected by adhering or not adhering to suggested governmental guidelines, and vice versa. A person believing in the efficacy of the instruction is likely to provide different and more distinctive estimates for each of the two questions. After all questions were answered, the software identified the weakest attitude of each participant  for later use in two specific tasks. At this stage, participants were shown a paragraph from Wikipedia that briefly described the COVID-19 pandemic, its effects, spread and its recognition by the World Health Organization as a pandemic. This paragraph not only provided basic information, but also pointed to the credibility of its source, as proposed by the Yale attitude change approach .The 2019–20 COVID-19 pandemic is an ongoing pandemic of coronavirus disease 2019 (COVID-19), caused by severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2). The outbreak was first identified in Wuhan, Hubei, China, in December 2019, and was recognized as a pandemic by the World Health Organization (WHO) on 11 March 2020.The virus is typically spread during close contact and via respiratory droplets produced when people cough or sneeze. Respiratory droplets may be produced during breathing but the virus is not considered airborne. It may also spread when one touches a contaminated surface and then their face. It is most contagious when people are symptomatic, although spread may be possible before symptoms appear. The time between exposure and symptom onset is typically around five days, but may range from two to fourteen days.The questions addressed: leaving home for essential needs only or leaving home as usual, maintaining or not maintaining a social distance, keeping or not keeping hygiene , or being 65 years of age or older and meeting or avoiding relatives and acquaintances. The questions were presented in different orders. Motivated by prospect theory , all quekin selection and to the theory of SERS, asking ‘How do you propose to protect your family, your relatives and people similar to you?’, hence addressing both the next of kin and similar others. As both questions generate behavioural expressions in the form of written paragraphs, they also provide a form of enacted behaviour that should motivate the adjustment of attitudes in accord with cognitive dissonance theory. From this point onwards, we did not restrict participants' responses to specific attitudes. To further activate the increased likelihood of advice taking in the case of severe virus outbreaks [The survey then addressed the weakest attitude of each respondent  and asked him or her to provide a written answer for why this specific measure is important for stopping the spread of the Coronavirus. After completion, the following request was to compose a short sentence that could be used in the media to explain his or her reason. In this way, people who did not adhere to health regulations would experience a cognitive dissonance between their low regard for the effectiveness of this measure and the fact that they are having to account for its importance, which they could then resolve by adopting health-preserving attitudes and follow with actual adherence. These items also provided the opportunity for cognitive elaboration, as proposed by the elaboration likelihood model. The following question then made references to both utbreaks , we primThe final passage, although not measured any more, was also phrased in accordance with two persuasion techniques, the bandwagon and the foot in the door effects. We thanked the participants for ‘joining all those who have participated in this survey and are adhering to health authority guidelines', and also thanked them for their time and efforts in filling the questionnaire  consequently asking them ‘to continue following the guidelines of the health authorities’ (i.e. a bigger request).3.3.1.The link was clicked by 22 887 people, and 4361 participated and completed various versions of the survey. After running several pilot surveys and optimizing content and software, we analysed intervention and repetition group responses provided by 3102 participants . Responses were provided in the following languages: 1214 answered in English, 728 in Hebrew, 497 in Arabic, 466 in Polish, 126 in German and a few more responded in Dutch and Spanish. About half of English language responses were collected in the USA; Hebrew and Arabic responses were collected mainly in Israel. Pilot studies were run between 24 and 27 March 2020. The data of the repetition group were collected from 25 March to 2 April, and the data for the intervention group were collected between 28 March and 18 April 2020.The intervention group received the full interventions cluster reported above (intervention condition), whereas the repetition group only repeated their probability assessments a second time (repetition condition) without additional interventions in between.adhere to health regulations between the first and second set of questions; (iv) the shift in the number of estimated infected people who donot adhere between the first and second set of questions.Hereafter, we report results associated with four differences, illustrated in adhere to health regulations between the first and the second set of questions  if they do not adhere to the instruction. The smaller the gap the less effective the specific health instruction is perceived by a person, and vice versa. This indirect approach attempts to minimize socially desirable answers, the answers one gives because he knows they are appreciated and regarded as being correct. The questions we used are provided in appendix A.Here, we describe the indirect measurements of pre-intervention attitudes in our samples with respect to the four health regulations: staying at home, keeping a social distance, keeping hygiene and seniors avoiding contact with the relatives and acquaintances. To indirectly measure attitudes, we examine the set of numerical questions presented at the beginning of the survey, across and within languages. Perceived efficiency of each attitude is estimated by subtracting the number of people that are believed to contract the virus  if they After calculating these indirect measures, we rank-order the perceptions to determine the least and most efficient instruction for each participant. ‘Keeping social distance’ was regarded as the least effective instruction in all languages . English- and Hebrew-speaking participants regarded ‘seniors avoid meeting others' as the most efficient instruction (33 and 42%). In Arabic and Polish, ‘seniors avoid meeting others’ was tied with ‘keep hygiene’ (35 and 36%) and among German-speaking participants ‘keep hygiene’ was the instruction that was regarded the most effective (36%).3.3.Next, we tested the effect of the intervention. For each participant, we diagnosed the weakest personal instruction, which is defined as the health instruction for which the estimated likelihood of contracting the virus in the case of adherence is the most similar to the case of non-adherence. Therefore, it is the health instruction most likely to be ignored by the participant.repetition and the intervention condition averaged for adherence and non-adherence attitudes. The panels on the right show parallel non-personalized (non-targeted) indices, averaged across four health regulations. The upper two panels present cross-sample indices and the lower panels present samples collected in five languages. All figures depict meaningful improvement in health-preserving attitudes, highlighting the advantages of the intervention and the higher efficacy of the non-adherence route. non-adherence in the intervention group, revealing a shift of 26% across language samples . However, in the less effective adherence measure, the intervention group revealed a shift of −11%, while the repetition group revealed an even better shift of −19%. Testing the interaction between time (first and second set of questions) and condition (repetition or intervention) separately for adherence and non-adherence attitudes reveals significant differences between groups for both . Note that attitude improvements are reflected by positive shifts for non-adherence (i.e. more people will be infected following no adherence) and negative shifts for adherence (i.e. less people will be infected following adherence). Also note that adherence is associated with a single negative aspect, as the judgements assess the number of infected people, while non-adherence is associated with a twofold negative framing, as it relates to the number of infected people following non-adherence to health regulations.4.R. Analysis of the structure of the social dilemma underlying the situation, specifically the choice between adherence and non-adherence, revealed a typical pay-off structure of a Chicken game. This showed that in theory, individuals' adherence to health regulations is congruent with the public goal of reducing the effective reproductive number R. Since the Chicken game is a SSG, it also motivated one of the interventions, namely the addressing of similarity with the opponent as a means towards increased cooperation and enhanced adherence to health regulations.The present study was motivated by the social challenge imposed by the COVID-19 pandemic, namely the reduction in the effective reproductive number Indirect Measurements, (ii) Personalized interventions, and (iii) Attitude Changing Treatments (IMPACT). To achieve indirect attitude measurements, health attitudes were not inferred from isolated responses, but from the differences among responses within question pairs, referring once to the number of people that are expected to be infected if they adhere to a specific health regulation, and once to the number of people that are expected to be infected if they do not adhere to a specific health regulation. The smaller the gap, the lower the efficiency of the specific regulation is regarded. After eliciting initial health attitudes, we applied nine well-known effects in a single and relatively short intervention, and also ran a plain repetition condition. We repeated the attitude assessment process, allowing to test the effectiveness of the intervention cluster. Once sufficient evidence had been accumulated from the repetition condition, we ceased running it and assigned all additional participants to the intervention condition.We then took an action research approach, aiming to implement a behavioural intervention that enhances health attitudes and reduces the likelihood of individuals being infected with COVID-19. Three important aspects of the present study are: (i) Pre-intervention attitudes reveal the overall low weight assigned to social distancing and the much greater assumed efficiency of seniors not being infected when visited by relatives and acquaintances. Although The low weight assigned to social distancing comes as a surprise, as the best way to prevent illness is to avoid being exposed to the virus and exposing others to the virus. This is not the case for any of the samples. Hence, forthcoming economic recovery under COVID-19 that requires renewing employment and staffing of work places should strongly emphasize the critical role of social distancing. As shown in the present work, providing information about the disease and its prevention and motivating deliberate processing of the information helps to attain this goal.The instruction most people perceived as being most efficient is that of seniors avoiding meeting relatives and acquaintances. There are many explanations for the high perceived efficiency of the seniors avoiding meeting others measure. This finding is in line with rational concerns as well as classic findings and models of risk perception. Particularly, seniors are most vulnerable to be infected with COVID-19. Social quarantine measures (i.e. them not being visited by relatives and acquaintances) can, therefore, be assumed most helpful for them to decrease their infection risk on rational grounds. Furthermore, given that fatality rates are particularly high for the seniors, COVID-19 is particularly dreadful for them. Dread is the core determinant for risk perceptions in lay people ; therefocombined adherence and non-adherence attitudes, increasing the difference between first and second estimates. The improvements ranged from 36% to 94% across conditions and language samples, suggesting that those populations who may have had less information in regard of COVID-19 benefited more than others from their participation in the survey. Singling out the best way to improve health attitudes shows that a twofold negative framing approach  and the application of the entire attitude change intervention induced an average shift of 26%.Overall, we found that participants in the repetition and the intervention condition improved their Due to the use of a cluster of several effects, we are unable to point to strengths and weaknesses of specific effects or interactions. Such a study would require a bottom-up approach that does not coincide with the goals of providing health benefits and developing applicable methods in the shortest time possible. Clearly, some principles and interactions may be more potent than others in changing COVID-19 health attitudes. Moreover, many other psychological interventions may also contribute to achieving enhanced attitude changes. Among them, the arousal of a moderate amount of fear that motivates people to analyse the information more carefully ,40, the It is also important to extend the study to repeated application of the IMPACT process, thus attaining stronger and longer lasting effects. Assuming that attitude changes follow a typical learning curve, we may expect to see meaningful changes during the initial application phase, which are then moderated and gradually approach an asymptote. Future research should also examine ways to increase the attractiveness of the IMPACT process and improve its dissemination. We recommend embedding IMPACT in school and higher education curricula, integrate it in social agendas of both governmental and private organizations and provide participants with various benefits in award for their participation. Clearly, possible mutations of the virus and emerging health and economic developments require constant monitoring of the situation and the undertaking of timely adjustments and improvements of behavioural interventions. For example, the wearing of face masks has not yet been recommended while we initiated the described interventions, but has since become a key factor in the prevention of virus infections. As countries around the globe attempt to restore social and economic activities, more emphasis should be put on enhancing individual responsibility and adherence to health regulations. As shown by the present study, this goal may be attained by: Indirect Measurements, Personalized interventions and Attitude Changing Treatments.Finally, we would like to address a somewhat hidden spillover effect, which is not reflected in the responses we received, but in the origins of these responses. Addressing the pandemic, we obtained responses from people residing in 77 different countries. We obtained responses from: Albania, Argentina, Bahrain, Bangladesh, Belgium, Botswana, Chile, Colombia, Denmark, Egypt, El Salvador, Estonia, India, Indonesia, Morocco, New Zealand, Oman, Qatar, Syria, Turkey, Uganda and many more. Clearly, the motivation to cooperate was as widespread as the pandemic itself. Returning to the description of the behavioural challenge imposed by COVID-19 as a Chicken game where cooperation is motivated by fear that the other party is not likely to cooperate (i.e. a Maxi-min strategy) and by the perception that the other party is sufficiently similar, hence likely to choose the same alternative , we