This study aimed to assess the influence of an oral hygiene intervention on oral health, depending on the degree of dementia. A clinical evaluation of oral health parameters , periodontal screening index (PSI), oral hygiene index (OHI), and bleeding on probing (BOP)) was performed in 120 subjects assigned to five groups, based on the mini mental state examination (MMSE) at baseline and after 12 months. Each MMSE group , mild cognitive impairment , mild dementia , moderate dementia , and severe dementia ) was split into control (no intervention) and experimental groups . In total, 99 out of 120 subjects were included in the analysis. The dropout rate was high in subjects with modDem and sDem due to death. In subjects with noDem, mCI, and mDem, no changes in the DMFT were found, but improvements in the OHI, BOP, and PSI were observed. Subjects with modDem or sDem demonstrated a deterioration in DMFT; however, in these patients, OHI improved in all control and experimental groups, BOP improved in the experimental group only, and PSI did not improve at all. The scope of improving oral health parameters by increasing the recall frequency and by continuously using high fluoride toothpaste is at its limits in people with severe dementia. Multidimensional approaches should be sought to improve the oral health of vulnerable older patients. The number of people suffering from dementia is increasing worldwide. By 2050, the prevalence is predicted to have doubled or even tripled in most industrialized countries . SimilarOften, residents in long-term care facilities (LTCF) suffer from poor oral health and oral hygiene, combined with general dental neglect and many oral diseases . Higher Furthermore, the oral health awareness of caregivers in LTCF is not reflected in adequate oral health care for patients. There is a gap between the positive oral health-supporting attitudes of the caregivers and the adequate and preventive behavior of the staff concerning oral health and the actual oral health care of the patients . This isAs oral hygiene seems to be a major contributor to the quality of life of older people and may also prevent aspiration pneumonia and reduce the associated risk of death, its maintenance becomes even more important . There iIt can be assumed that an increase in recall frequency  can help to improve oral health. It must be clarified to what extent this effect depends on the degree of dementia. Therefore, this study aimed to assess the influence of intervention in oral health  depending on the degree of dementia. The authors hypothesized that an increase in the utilization of dental services  has a positive influence on the oral health-related parameters , periodontal screening index (PSI), bleeding on probing (BOP), and oral hygiene index (OHI)) of people with dementia.n = 12) or to the control group (n = 12) of the study part analyzed here was conducted randomly, based on the order of study participation (not influenceable but instead according to registration for study participation and appointment by uninvolved persons) within MMSE groups 1–5 .The data of this analysis are part of the OrBiD   pilot study ,24. In tSubjects either living at home or in LTCF, who were aged 60 years and older, were included regardless of their cognitive abilities. A prerequisite was sufficient knowledge of German to be able to participate in an interview and to follow the intervention instructions during the evaluations and the intervention appointments. Study participation for subjects with acute dental problems  requiring emergency treatment started after successful emergency treatment. Before the start of the study, all subjects should have had no or a maximum of one dental hygiene session within the previous 12 months. Subjects with physical limitations in the upper body  were excluded.® 5000 ppm, Colgate™; GABA Switzerland, Therwil, Switzerland) at least twice a day instead of the toothpaste previously used and the recommendation not to rinse, but only to spit out after brushing. The use of additional aids  was not advised. The procedure was explained directly to the subjects orally if they were cognitively able to perform their daily oral hygiene at home independently. In the case of subjects requiring assistance with daily oral and denture hygiene, or where a third person performed oral and denture hygiene, the procedure was explained to the persons involved, such as relatives, legal representatives, or caregivers.An instruction to intensify daily individual and professional oral and denture hygiene was given to all subjects in the experimental groups. The instruction included a recommendation to intensify oral hygiene at home, including the usage of a high-fluoride-content toothpaste . Tooth cleaning was carried out by the use of manual instruments or ultrasonic attachments . Denture cleaning was performed using an ultrasonic cleaning bath.Subjects in the control groups did not receive an oral hygiene intervention but were encouraged to continue their daily oral hygiene as usual. All subjects, whether in the experimental or control group, had access to dental treatment at all times, regardless of study participation.All clinical procedures and evaluations were performed by a single investigator, either in a large dental office  or in the LTCF  in the canton of Zurich, Switzerland.All subjects in the control and experimental groups were evaluated  at the beginning of the study (baseline) and 12 months after the baseline evaluation .The following parameters were evaluated: sociodemographic data ), the mini-nutritional assessment (MNA) , and theA power calculation was not performed for this pilot study because no literature on the endpoints was found. The sample size was determined based on similarly designed studies and the sample sizes used therein ,33.Since this study was a pilot study, the statistical analyses corresponded. Within the longitudinal component of the study, the effects of the intervention on oral hygiene have been compared. Descriptive and graphical tools were used where appropriate. Additionally, mixed linear models were tentatively used to account for the temporal dependency structure and to control for age and gender. Robust non-parametric tests have been used for the comparison between mental state and intervention effect if the parametric model assumptions were violated. In order to account for potential deviations of the research protocol, intention-to-treat (ITT) and per-protocol (PP) analyses were performed. Subjects lost to dropout were replaced with new recruits. Missing values, resulting from subjects who were not able to undergo a complete examination, were estimated by statistical means with a multivariate imputation algorithm.To visualize the influence of the intervention or the absence of the intervention on the outcome variables, differences (delta) were calculated between the evaluation time points . Additionally, for the delta PSI value, the quadratic weighting of the PSI code for baseline and final was done before calculation. Statistical analysis was performed using SPSS Version 23 .The study was approved by the competent cantonal ethics committee of Zurich (KEK-ZH 2017-00363). All subjects or their legal representatives gave written informed consent.n = 24; mCI n = 24; mDem n = 23; modDem n = 17; sDem n = 11). All dropouts (n = 21) resulted from the death of the subjects. As a result of the COVID-19 pandemic, the final evaluations of some subjects living in LTCF were conducted 4–8 weeks later than planned. Various subjects had also died during this period of time  and its parameters became worse with the increase in the degree of dementia in all subjects. Furthermore, the malnourished nutritional status increased with increasing dementia, independently from the control or experimental groups .The DMFT values were highly distributed in all MMSE groups, except the control group of the MMSE group with sDem . The majIn terms of the delta DFT values, only minor differences were observed between the MMSE groups. Subjects of the experimental group with sDem predominantly exhibited deterioration  .For delta PSI, an improvement in the PSI code was observed more often for the experimental groups of the MMSE groups with noDem, mCI, and mDem, compared to the control groups. This phenomenon was not observed for the MMSE groups with modDem and sDem .BOP was reduced in most subjects in the experimental groups of all MMSE cohorts, while all control groups showed a deterioration in BOP over time .In the majority of subjects, regardless of their MMSE group or membership in the control or experimental group, an improvement was observed in the OHI score (Δ OHI Score) and in the individual OHI components DI (Δ OHI Plaque) and CI . In the MMSE groups with noDem, mCI, and mDem, subjects in the experimental groups showed a stronger improvement in Δ OHI Plaque, Δ OHI Calculus, and Δ OHI Score than subjects in the corresponding control groups. For subjects in the MMSE group with modDem and sDem, this difference was not observed A–C.In this part of the “Oral Health, Bite Force, and Dementia” (OrBiD) pilot study, an intervention regarding oral hygiene care ) was established for subjects in the experimental groups, while subjects in the control groups received no oral hygiene intervention.The authors faced several challenges related to the sample of subjects in this study. The cooperation and compliance of people with dementia depend, on the one hand, on the individual and, on the other, on the daily cognition level of the patient. However, since cooperation was a decisive factor in the implementation of this intervention, the question arises as to what extent the results were influenced by reduced adherence to dental hygiene in people with moderate and severe dementia. In the literature, a procedure is described that should make it easier to carry out oral hygiene practices in people with dementia. The MOUTH program , a relationship-based intervention, aims to create a clinically realistic approach to managing refusal behavior . No suchThe results of the current study could be subject to bias because the subjects or caregivers who performed daily oral hygiene were informed about the study objective. Therefore, it cannot be excluded that a bias may be present in subjects in both groups because of increased efforts in their oral hygiene. Consequently, it should also be considered in further studies that, in addition to professional oral and denture hygiene, the influence of daily oral hygiene should be considered. Data on adherence to oral hygiene measures that might have affected intervention outcomes could not be collected in this study for organizational, financial, and personnel reasons. In addition, caregivers may have made more effort to perform oral hygiene in all subjects during the observation period because this study was organized in cooperation with the home management and the responsible medical practitioner and was also reinforced by the repeated presence of the dental team. This circumstance could explain the lacking or only slight differences in certain oral health parameters between the control and experimental groups. It is also unclear whether an effect can be really shown in people with moderate and severe dementia since the implementation of the intervention was, in some cases, very limited and, in many cases, no comparable situation could be established concerning the treatment side .If there was no medical diagnosis of dementia or if it was not evident from the requested medical reports, one single dentist performed the MMSE test. An additional professionally qualified physician would have been the ideal solution, but this was not possible due to financial and personnel constraints. The dentist involved in the study is a specialist in seniors’ dentistry. The dentist was certified by the German Society for Gerodontology. In the course of this specialization, the participants are trained in geriatric assessment tools and are also taught how to perform the MMSE test.Since the present study was designed to test the effects of an intervention that could be integrated into everyday clinical practice, the authors decided to use a modified classification of dementia severity, based on the MMSE scores described by Perneczky et al. . The basThe investigator was not blinded. However, the authors exclude a bias because clinical guidelines exist for all parameters collected and a subjective assessment can, therefore, be excluded to a high degree.The assessment of non-institutionalized patients was performed in the large dental office, while the evaluation of care-dependent subjects was carried out in the LTCF. Attempts were made to create similar conditions for the assessments by using appropriate aids in the LTCF .Due to the limitations of the study period, not all parameters collected may show measurable changes between evaluation time points. Time is an important factor in the development of carious lesions, their therapy, or the progression of periodontal disease. Therefore, there may have been an underestimation of the changes over time within the analysis.DMFT and DFT values showed no significant differences between the control and experimental groups of all MMSE groups at the end of the study. Moreover, no significant changes between the baseline and final evaluation in the DMFT and DFT values within all MMSE groups were identified, except in the case of DMFT in subjects with sDem in the control group and DFT in subjects with sDem in the experimental group. The intervention appears to have had no effect on DMFT and its individual components in subjects with noDem to modDem. Overall, only patients with sDem experienced a deterioration in this oral health parameter.An improvement of periodontal disease  was observed in subjects with noDem, mCI, and mDem in the experimental groups. This effect could not be achieved in the corresponding control groups of these MMSE groups. The influence of the intervention on the PSI could not be identified for subjects with modDem and sDem, although the BOP improved, as was the case in all other experimental groups in all MMSE groups. This observation may be explained by the lower adherence of patients with the intervention or by the higher PSI values in these subjects at baseline. It is easier to achieve changes in low PSI codes (1–2) than to reduce PSI 4 to lower values.The OHI and its components, DI and CI, improved in all subjects in the study during the observation period. Subjects with noDem, mCI, and mDem in the experimental groups showed a stronger improvement than subjects who did not receive an intervention. Again, the bias described above (no blinding of subjects and caregivers with respect to the study objective) could be responsible. Nevertheless, the intervention seems to have had an additional positive influence on these parameters.Overall, subjects with modDem and sDem showed a deterioration in the oral health parameters DMFT/DFT and PSI, independent of the intervention. For the OHI and its components, subjects with modDem and sDem also exhibited an improvement, regardless of whether they participated in the intervention. This phenomenon supports previous research showing that people with dementia have a higher incidence of caries, periodontal disease, pain, and other oral problems ,9,10,11.® 5000 ppm toothpaste (Colgate™) by the subjects of the experimental groups. In the literature, it is specified that dental hygienists have the skills and abilities to perform oral hygiene care and also to identify the majority of residents who should be treated by a dentist. Furthermore, they are able to develop appropriate hygiene concepts for residents in care facilities [The intervention of the study included the implementation of professional oral and denture hygiene at an increased frequency (four times per year) by a dental hygienist and the daily use of Duraphatcilities . TherefoIt has been shown that the use of high-fluoride-content toothpaste  in adults has a significant positive effect on the surface hardness of untreated root caries lesions . This phThere is currently no study in the literature with a comparable intervention in patients with and without dementia. Rather, the effectiveness of oral hygiene education programs in caregivers is often discussed.Studies point out the limited evidence for the effectiveness of the oral health education of caregivers to improve oral health in people with dementia ,23. For The literature also discusses a multidimensional approach based on individual needs as a concept for improving the oral health of vulnerable older adults . In thisEnsuring that the dentist is called upon in cases of reduced mobility and cases of incipient vulnerability, by implementing mobile dental concepts;Referral of patients with an initial diagnosis of dementia by the physician to the dentist, enabling the early admission of older vulnerable patients for dental care and treatment including prevention;Educational programs for relatives on the topic of oral health in old age—as well as its relevance in dementia;Strengthening of interdisciplinary cooperation with medical doctors, LTCF, nutritionists, etc., and the establishment of multidisciplinary health care teams ;A combination of comprehensive theoretical and practical training of nurses (according to the concept of “teach the teacher”) and relatives, thus enabling a reduction in psychological barriers to oral care;Reduction in barriers to the implementation of training concepts in the long-term care sector and an increase in financial support for the implementation of support measures, both from the state and from other cost units ;Improvement of evaluation programs, which are used in the care sector to estimate the need for care, to enhance dental problem detection ;Prompt admission of patients when a need for treatment is diagnosed, to avoid anesthesia;Minimum 6-monthly dental recalls and the professional cleaning of teeth and dentures ;Improvement of individual oral hygiene at home by setting up individual oral care programs .Future programs should include the following components, and their effectiveness should be evaluated in future studies:An increase in the dental recall intervals for professional oral and denture hygiene did not coincide with changes in the DMFT index in patients without dementia, up to mild dementia. Subjects with modDem and sDem exhibited a deterioration in this oral health parameter. The OHI and its components, DI and CI, improved in all subjects in the study during the observation period. Subjects with noDem, mCI, and mDem in the experimental groups exhibited greater improvement than subjects who did not receive an intervention. Subjects with modDem and sDem also showed improvement, regardless of whether they participated in the intervention. A reduction in the PSI was achieved in subjects with noDem, mCI, and mDem in the experimental groups as a result of the intervention. This effect was not observed in subjects with modDem and sDem, although the BOP did improve, as was the case in all other experimental groups in all MMSE groups.The scope of improving oral health parameters by increasing the recall frequency and continuously using high-fluoride toothpaste is very limited in people with severe dementia. Multidimensional approaches should be sought to improve the oral health of vulnerable older patients. A future program should always include the early identification of the patient’s geriatric oral health transition phase. Depending on the patient’s transition phase, oral health competence should then be increased, initially by the patient and later by the patient’s supportive environment, with a combination of concepts for individual daily oral and denture hygiene, professional oral and prosthetic care, and close-meshed control-oriented dental visits.


For decades, scientists have been trying to solve the problem of dementia, with no cure currently available. Semantic–lexical impairment is well established as the early critical sign of dementia, although there are still gaps in knowledge that must be investigated. In this study, we used fMRI to observe the neural activity of 31 subjects, including 16 HC  and 15 AD (Alzheimer’s Disease), who participated in the naming task. The neuropsychology profile of HC  and AD (Alzheimer’s Disease) are discussed in this study. The involvement of FG (Fusiform Gyrus) and IFG  shows dominant activation in both of the groups. We observed a decrease in neural activity in the AD group, resulting in semantic deficit problems in this preliminary study. Furthermore, ROI analysis was performed and revealed both hyperactivation and hypoactivation in the AD group. The compensatory mechanism demonstrated during the task, due to the effort required to identify an animal’s name, represents the character profile of AD. For many years, there have been attempts to cure dementia concerning all different research areas. It was difficult for doctors or professionals to even detect the signs of Alzheimers disease (AD) 45 years ago . Today, Numerous studies working on MRI/fMRI techniques have revealed the neural activity of dementia with various neuropsychology experimental tasks ,7,8. MosWhile episodic memory loss is the most common syndrome in AD, language impairment is a common problem and an early sign of AD; naming and fluency deficits are particularly prevalent ,13,14,15Naming and verbal fluency tasks are commonly used to assess language dysfunction in AD as they require intentional processing and can be a marker of semantic memory impairment ,23,24. PTo the authors knowledge, there are few studies using fMRI to investigate neural activity in AD related to language processing, specifically using naming tasks to utilize semantic processing, and there is still considerable divergence between them ,26. WierIn this work, we specifically designed the naming task to target semantic–lexical processing related to the neural activity of HC and AD subjects. Naming tasks are considered as cognitive tasks that can be used as a measurement tool of semantic impairment for AD . A task We hypothesized that there was semantic–lexical impairment in the pattern of neural activation among AD subjects compared to that of the HC group that could be exposed by this task. Brain regions such as the temporal, frontal, and parietal left perisylvian regions (the language region) could make a more significant contribution to the development of networks supportive of language processing components inclusive of recognition, syntax, and semantics .The regiThe study protocol was approved by the Institutional Review Board (or Ethics Committee) of Taichung Veteran General Hospital. A total of 31 elderly individuals participated in this preliminary study. Sixteen healthy controls  and 15 Alzheimers disease patients  as categorized by the Montreal Cognitive Assessment (MoCA) score and diagnosed by the clinician. One of the HC subjects (s2) was excluded because the T1 image was shifted during the scan, and one of the AD subjects (s23) was excluded due to the health condition of the patient . Participants with dementia were diagnosed by clinicians (the doctor and the psychologist expert in this particular area). All participants went through neuropsychology testing (MoCA) to determine their cognitive impairment level. All participants were confirmed to have no visual impairment and could clearly see the animal pictures on the mirror projected in the fMRI room. All participants were Taiwanese, meaning they could name the animal in their native language, which was Chinese or Taiwanese. All participants were right-handed. See The task for the stimulation was designed with 10 s of instructions  in Chinese, 18 s of a block-design naming task , and 18 s of cross-fixation for the baseline . Each block of naming tasks contained 6 pictures that were displayed for 3 seconds per image shown in . Before http://www.fil.ion.ucl.ac.uk/spm/l, accessed on 8 January 2020) which was implemented on MATLAB version 2016b. Dicom images were converted into NIFTI files . All preprocessing images  were performed with cautious observation. Statistical analysis was proposed using a general linear model (GLM) to measure each voxel activity. Each subject had two conditions, the naming task and rest (cross -fixation), which were used as regressors in the model. Parameter motions  were also included as multiple regression to reduce the motion effect during the scanning process. T-contrast was used to calculate the contrast within subjects for each of the conditions to produce the TMAP image. In group analysis, we used one sample t tests within the group (both HC and AD) and two sample t tests for group comparison. Region of interest (ROI) analysis was conducted using SPM to observe the contrast of parameter estimates within each subject, and the Marsbar  toolbox was used for the percentage of activated voxels within the fusiform gyrus and inferior frontal gyrus (pars triangularis). These regions were extracted on the basis of the anatomical region using the AAL MNI template. The visualization and interpretation of the statistical parameter map images (TMAP) were performed by using the BSPMVIEW tool box .MRI images were acquired using a p value < Individual TMAP images were observed one by one to make sure there was a common pattern of semantic task-related regions within each subject. Most participants demonstrated upregulation in the temporal lobe and frontal lobe, as these areas are known as semantic areas, even though the number of activation voxels varied between each subject. One sample t tests were used for group analysis in the HC group. Compared to the cross-fixation (resting period), the HC group showed normal upregulation in the bilateral hemisphere during the naming task, as shown in p value , and R fusiform gyrus , were located in the frontal cortex and appeared in both the HC and AD groups, as expected in our results.The overall result indicated that the pattern of activation among individuals in the HC group in these regions was found to be similar, even though there were some clusters that had a lesser amount of activation in some subjects. Similarities could be recognized in these regions among HC individuals who showed normal activation of the semantic network. Our findings indicate that the anterior temporal lobe, particularly in the fusiform gyrus, was more responsible for general linguistic knowledge, the identification and comprehension of facts, and stored concepts. As the number of activated voxels was higher, this corresponds to a greater involvement of the temporal lobe. The involvement of the frontal lobe, specifically the inferior frontal gyrus (pars triangularis), was accountable, and it is related to the lexical and retrieval process of finding a correct word . The fusThe domination of activation in ATL, particularly the fusiform gyrus, among AD subjects was found to be similar to that in the HC group in terms of location, but with decreased activation. The evaluated values from the fusiform gyrus were consistently large. The fusiform gyrus was also used in  as the rA scattered trend of hyperactivation and hypoactivation was observed among AD subjects when we performed the ROI analysis by the number activation of voxels. On the other hand, visual results from the HC group  conveyed a concentrated pattern, which indicated similar or consistent activation. Both hyperactivation and hypoactivation are common phenomena in AD, which make the process of statistical analysis difficult and the pathophysiology of AD hard to define . There iAs this naming task required the visual imagery of animal pictures, the activation of the occipital lobe unsurprisingly played a dominant role in the number of voxels that were activated in most subjects. The L precentral gyrus was also found to be activated in , which iThe complexity of abnormal pattern activity in AD makes it difficult to find an appropriate way to chart brain regions. Both hyperactivation and hypoactivation appeared as common patterns in dementia in this study. The problem with the statistical tools that are used currently is that they are limited by the homogeneity or similarity of the mean activation of the population within regions that had no distinct pattern of neuropathology in AD. Individual analysis needs to be conducted, along with an assessment of the clinical background of AD subjects. While there is no current effective way of mapping AD, as described in , longituThis study presents one approach to understanding the biological mechanisms of AD in semantic–lexical processing. First, we designed a simple protocol for measuring the neural activity of the semantic–lexical network utilizing the naming task designed specifically for the elderly. This has been demonstrated to be effective, as our target group is also the AD Group. Then, we found two regions with predominating activation that are associated with the semantic–lexical network within the temporal lobe and frontal lobe, respectively, IFG and FG. The involvement of regions in the temporal and frontal lobes, which are believed to be the semantic network, were exposed as expected and observed in subjects in both the HC and AD group in this study. The pattern of the lexical Vsemantic network in AD patients showed abnormal upregulation, as suspected. The number of voxels of the temporal lobe, particularly in the fusiform gyrus, showed diverse results among individuals with AD, which led to abnormal common patterns developing in AD . In line


Disproportionate distribution of air pollution is a major burden on the health of people living in proximity to toxic facilities. There are over 1000 Toxics Release Inventory (TRI) facilities distributed across the state of Illinois. This study investigates and spatially analyzes the relationship between chronic obstructive pulmonary disease (COPD) hospitalizations and toxic emissions from TRI facilities. In addition, this study investigates the connection between COPD hospitalizations and socioeconomic variables. Accounting for dispersion of air pollution beyond the TRI facilities source was attained using the inverse distance weighting interpolation approach. Multiple statistical methods were used including principal components analysis, linear regression, and bivariate local indicators of spatial association (BiLISA). The results from the linear regression model and BiLISA clustering maps show there is a strong connection between COPD hospitalizations and socioeconomic status along with race. TRI emissions were not statistically significant, but there are three major clusters of high COPD hospitalizations with high TRI emissions. Rural areas also seem to carry a higher burden of pollution-emitting facilities and respiratory hospitalizations. The influence of the built environment on health has been a topic of research for many years ,2,3. PasA program to track, record, and manage toxic chemicals emitted by industrial facilities, known as the Toxics Release Inventory (TRI) program, was created in the U.S. in 1986. As a result, 187 air pollutants were declared harmful to the environment and public health by the U.S. Environmental Protection Agency (EPA), and many of these are suspected of causing serious health effects . Prior tThe study of environmental impacts of pollution is a broad spectrum that can be assessed through the lenses of health disparities or environmental justice, or both. Findings have shown that chronic obstructive pulmonary disease (COPD), diabetes, myocardial infarction, and congestive heart failure occur at greater risk with air pollution . In addiExposure to air pollution is categorized as one of the leading public health concerns and causes of mortality and morbidity . The assIllinois has previously been studied for pollution and these studies have established the high rate of pollution in the Metro East of Illinois ,14,17, wThis study contributes to the growing body of literature focused on pollution, health, and demographics along with Illinois studies by focusing on COPD hospitalization and proximity to TRI facilities across the entire state of Illinois.Data needed for this project came from three sources: the EPA TRI, Illinois Department of Public Health (IDPH), and the United States Census Bureau. All data were downloaded for the year 2011. Multiple processes were applied in this study to provide both statistical and geospatial results. ArcMap 10.7, ArcGIS Pro 2.8, and GeoDa 1.20 were used for geospatial analysis and Statistical Package for Social Science (IBM SPSS 28.0) was used for the statistical analysis.The EPA TRI facilitates the reporting of toxic releases in the United States and allows users to generate reports on releases, transfers, and waste management. TRI facilities (1083) were found in almost all the zip codes in Illinois. However, only the TRI facilities (847) with releases more than 1 lb were analyzed and are shown in Using ArcMap 10.7, the total amount of toxic releases per facility was interpolated using IDW to capture the extent of local surface variations. The first step of the process was to convert the TRI facilities and the TRI emissions into raster layers by using the convert to raster function. This step produced a pollution surface for the entire state of Illinois. Next, this raster layer was interpolated using the IDW function. Third, the interpolated surface was converted into a point shapefile by the convert to vector function. This point layer contained the interpolated TRI emissions. Finally, a spatial join combined the TRI point layer to each Illinois zip code. This procedure transferred vectorized TRI data into zip code polygons as well as provided the mean (average) of the vectorized TRI emissions for each zip code.The IDPH provides inpatient and outpatient data collected by its division of patient safety and quality on discharge data from all Illinois specialty hospitals, acute care hospitals, and emergency hospitals. IRB approval was waived as the data contains no identifiable information for Illinois residents. This study includes all patients presenting or admitted for COPD (ICD-9 codes 492–496) during 1 January 2009–31 December 2011. Information obtained from the discharge records included a reason for utilizing the inpatient or emergency department, such as diagnosis, admission date, cost, and a unique hospital identifier, as well as information related to the patient, such as age, ZIP code of residence, race/ethnicity, and gender . Age-staThe United States Census Bureau is the source that provides different kinds of data related to geography and demographics. The shapefile of Illinois’ zip codes can be found on the U.S. Census Bureau’s website. The Tiger/Line shapefiles and demographic data for all zip codes in Illinois were extracted from the U.S. Census Bureau through the American Community Survey (ACS) five-year estimate for 2011, using Table S0601 .There are 11 independent variables listed in A linear regression model was utilized with the age-standardized COPD hospitalization rate as the dependent variable and the five components from the PCA as the independent variables. Residuals and ANOVA results were checked for accuracy.Spatial patterns are uncovered by analyzing the spatial distribution of the study’s dependent and independent variables. These maps enable us to interpret the zip codes with the highest, intermediate, and least emissions, demographics, and hospitalizations. Local Indicators of Spatial Association (LISA) are a geostatistical tool that gives an indication of the extent of significant spatial clustering of similar values around a specific observation. LISA is used to identify local spatial clusters, known as hot spots or cold spots. These clusters can be used as the basis for a test on the null hypothesis of no local spatial association . While iThere were approximately 293,000 hospitalization cases in 1321 zip codes for COPD. The hospitalization dataset indicates that the youngest population (under 5) is the most affected, with an average age of 33 for the hospitalizations due to COPD. There are 847 pollution sources with more than one pound of toxic release in the study area. Results from the linear regression model reveal that there does not seem to be a statistically significant relationship between pollution and COPD hospitalizations or the Hispanic and population density factor . Low SESWhile the previous results show the influence of the variables across the study area, the focus now shifts to how neighboring values influence the dependent and independent variables, simultaneously. The spatial association between the components and COPD hospitalization was established using BiLISA to present clustering maps for each of the five factors and COPD hospitalization.The BiLISA legend depicts the combination of the COPD hospitalization (first) and the component involved (second) ranking the influence of neighboring values as well as the number of zip codes in each category. The high-high category details that neighboring values for the two variables are high. Finally, Map E shows the COPD hospitalizations and pollution component. Three major groups of zip codes appear within the high-high clusters, which represent small metropolitan areas: Peoria to the north, Springfield in the center, and the Metro East in the south. Some of the major polluting facilities are located near these small metro areas as shown in This study found a statistically significant relationship between low socioeconomic status, race and unemployment, and COPD hospitalizations. Financial variables, such as median income and percentage of the population in poverty, population without medical insurance, and low educational attainment, were also statistically significant with COPD hospitalizations.The results of this study yield similar results to other research related to low-income residents having a higher burden of poor health . AdditioWhen analyzing the location of the TRI facilities, urban areas do have a higher number of these facilities, yet their emissions are low. The rural areas of the state have fewer numbers of facilities yet have the highest emissions from TRI facilities. When examining the COPD hospitalizations, the areas of the state with the highest hospitalizations exist in the rural areas. Analyzing the BiLISA maps , there aFour major limitations existed. The use of zip codes is not an ideal geographic unit for evaluation as these are utilized for efficient mail delivery routes, rather than demographic analysis. Even though this is not an ideal geographical unit to study, all data were analyzed at the zip code level and the health data is only available at this level. The second limitation was the use of data from 2011. While the data is almost 10 years old, it does provide a snapshot of not only hospitalizations for the area, but also what is occurring with TRI facilities at that time. The availability of most of the demographic data for this time provides a solid overview of the demographics for this year. Ideally, data that are more recent would be used, but the ability for all three datasets to maintain the same year is a strength.An additional limitation encountered is the unavailability of health insurance data for 2011. The U.S. Census Bureau started adding health insurance data in 2012, and this data was used with the other socioeconomic characteristics for 2011. A final limitation is regarding the hospitalization data. This data represents only those patients that go to a hospital for care. This health data does not record the data of people who have the disease under control through consultation and medications. Therefore, only the extreme cases of COPD are presented with the hospitalization results. COPD can be effectively managed under a doctor’s care and these numbers do not reflect the true number of Illinois residents dealing with COPD.There is a need to perform this study with more recent COPD hospitalizations and TRI data along with an examination of how the toxic compound makeup of the emissions impacts respiratory health. Incorporating additional years can identify changes regarding hospitalizations and pollution along with monitoring the zip codes with high categories of both respiratory issues and emissions. Adding this longitudinal component could show how reducing the reliance on fossil fuels could also reduce health burdens.This study’s findings contribute to the literature of the impact of pollution on health with its focus on every zip code in one state. Respiratory health in the form of COPD hospitalizations is statistically significant to components that include low socioeconomic status, race, and unemployment as well as percent male. These results also reveal that many of the TRI emissions impact more rural areas of the state. Therefore, it is imperative to include rural areas and not only metropolitan locations when studying the health impacts of pollution. While the two metropolitan areas of the state, Chicago and Metro East St. Louis, did have significant influences, the most clustering occurred in the rural, central, and downstate areas of Illinois. A specific area to focus on would be southwest Illinois. In addition, this study addressed and accounted for the dispersion of pollution by assigning TRI emissions to every zip code via interpolation. Policymakers can utilize this information for decision-making in helping to keep a safer and healthy environment for every Illinois resident across all socioeconomic backgrounds and in both metropolitan and non-metropolitan areas.


The literature indicates that cognitive stimulation interventions have shown promising results. Abacus represents a tool with great potential in such interventions. To carry out a systematic review of studies published in recent years that entailed the delivery of a cognitive training program using an abacus to boost target cognitive abilities of older persons and also other age groups, with or without cognitive impairment. A systematic review study was conducted in July 2020 involving PubMed, MedLine, LILACS, and SciELO databases. A total of 29 studies were retrieved, of which 8 aimed to identify the effect of abacus-based mental calculation (AMC) for different age groups and to determine its applicability as a method of cognitive stimulation for older adults. In AMC technique, participants first learn to use the physical abacus (PA) and after achieving proficiency they perform calculations using a mental image of the device, manipulating the beads of the so-called mental abacus (MA). The number of studies addressing abacus use as a cognitive training tool was rather limited, considering the relevance of the theme. Their interventions have shown benefits for cognitive functioning of individuals of various age groups, including older adults with cognitive impairment. Future studies that involve larger samples of healthy and/or cognitively impaired older adults with a longitudinal design and a more elaborate methodological design are suggested. These interventions include theory and practice with cognitive exercises to promote improved performance, and can have positive effects on the everyday lives of older adults.,,,Working memory (WM) is a cognitive mechanism defined as a short-term memory subsystem with the capacity to store and process data simultaneously in a short period of time.versus the control group in fluid intelligence, episodic memory, attention, inhibitory control and processing speed, but training effects were less marked for processing speed.Karbach and VerhaeghenAnother meta-analysis, by Schwaighofer et al.,,Some interventions have been run to document the benefits of abacus training in young children. These interventions aimed to stimulate attention and reasoning, as well as elucidate potential transfer effects to other cognitive abilities.,Studies show that abacus training in children improves development of structural and functional changes, white matter volume, the parameter of white matter diffusion and activation patterns in cognitive tasks.In the literature, the pioneering study of Matías-Guiu et al.In a literature review study,,It is known that the effects of training can extend to other domains, such as health promotionIn this context, the objective of the present investigation was to carry out a systematic review of studies published in recent years that entailed the delivery of a cognitive training program using an abacus to boost target cognitive abilities of older persons and also other age groups, with or without cognitive impairment.This is a systematic review research, carried out in July 2020. To guide the stages of identification, screening and eligibility of studies, we used the Statement of Preferred Reporting Items for Systematic Reviews and Meta-Analyzes (PRISMA)Publications in English, Portuguese and Spanish were searched using the following descriptors and their respective equivalents: abacus, cognitive training, cognition and working memory. To this end, the following combinations were used: ("ábaco" OR "abacus") AND ("treino cognitivo" OR "cognitive training" OR "entrenamiento cognitivo"); ("ábaco" OR "abacus") AND ("cognição" OR "cognition" OR "cognición"); ("ábaco" OR "abacus") AND . Due to the scarcity of studies identified in the initial search tests, it was decided not to determine a specific period of time, considering the studies regardless of the year of publication.The searches and selection of studies included in this review were carried out by three researchers. After the completion of each stage , the researchers met to jointly verify which studies would be included in this review. With regard to filters, we chose to select “full text”, to avoid records that contained only abstracts, and “randomized controlled trial”, according to the inclusion criteria adopted for this review.The inclusion criteria were: to be a cognitive training study, to use the abacus as a tool for the interventions performed, to have presented training methods by age group in their methods , and to present cognitive tools to measure the effectiveness of the training program offered. Exclusion criteria were: book chapters, doctoral theses, Masters dissertations, letters to editor, reflective essays and duplicate studies identified during the review. Articles with weak methods in terms of cognitive training protocol and measuring instruments used to determine the impact of the program on participants’ cognitive performance and the target abilities were also excluded.During the analysis of the studies included in the review, we sought to assess their objectives, methods and results. The following data were observed: the use of the abacus as a training tool; the age range of the population studied; the impacts of using the abacus on cognitive functions, such as impacts on WM; the application of pre and post-tests; considerations regarding MCI; and the number of sessions held during the proposed intervention.The initial search retrieved 29 articles, further reduced to 22 after exclusion of duplicate studies. The titles and abstracts were read, and articles that failed to address the review objective were excluded. A total of 13 articles were read in full, of which 5 were subsequently excluded based on the study inclusion and exclusion criteria. Details of the study selection and inclusion process are shown in the flow diagram,,,,,Regarding samples, 6 studies involved children,abacus-based mental calculation (AMC) technique, whereby participants first learn how to manipulate the abacus and, after achieving proficiency, perform calculations using a mental image of the device, manipulating the beads of the mental abacus (MA).The present study found only a few articles addressing the use of the abacus as a cognitive training tool. The interventions used in all studies was the ,,,,,,Seven studies showed an association between WM and AMC training.,,,,The objective of the present study was to carry out a systematic review of studies involving delivery of a cognitive training program using the abacus to stimulate target cognitive abilities. A total of 8 eligible studies were retrieved, whose objectives included investigating the effect of WM,,,,All 6 studies involving samples of children performed AMC interventions, in which a PA was used at only one stage to aid learning of AMC.,,,,Five articles showed that AMC training promoted improved arithmetic skills.Besides this effect, some studies have reported other positive results of AMC training in children. The results of the study by Wang et al.,The study by Wang et al.In the study by Bhaskaran et al.By contrast, the study by Barner et al.Results of the majority of studies involving cognitive training using the abacus in children showed that this type of training promoted improvements predominantly in arithmetic skills, but also led to transfer effects for WM. However, it is noteworthy that the results of the study conducted by Dunning et al.The study by Dong et al.Similarly, the study by Barroso et al.The meta-analysis performed by Karbach and VerhaeghenConversely, the findings of the study conducted by Thompson et al.,Overall, the findings of the studies in young adults analyzed in this review, with regard to the relationship between AMC and WM, are consistent with the results found for the studies in children. This suggests that AMC training is applicable for improving cognitive abilities in populations of different age strata.The study by Matías-Guiu et al.,The study results revealed improvement in general performance on the MMSE, suggesting a change in cognition after participating in the intervention. An association between better performance on the MMSE and memory training in healthy elderly was also found in the study of Irigaray et al.,Unlike the other studies analyzed in this review, with respect to the association between the use of the abacus and WM, the study by Matías-Guiu et al. In the study,Borella et al.,In the study by Netto et al.,The findings of the meta-analysis by Sala and Gobet also warrant mention.Considering the impact of WM training for older adults and the association between AMC training and WM observed in studies involving other age groups, it follows that AMC training may also promote WM gains in the older population. In addition, given that the study in younger adults,,Cognitive plasticity turns out to be an important field for clinical research, as it brings forth essential information about human aging,,,However, it is observed that cognitive training studies differ not only in terms of duration but also, in particular, in terms of the strategies taught and the methodology used, with great diversity in the literature regarding the magnitude of the cognitive benefits, the generalization for untrained tasks and the maintainability of long-term training.,,Through this review, it was observed that new designs of cognitive interventions are proving to be innovative, such as studies with training on the use of abacus, which has been adopted in elementary and high schools as tools to optimize the learning process of children and adolescents. Improvements in cognitive variables and in neuroimaging markers were found, reinforcing the hypothesis of cognitive plasticity.The integrative literature review carried out by Costa et al.As previously described, the AMC technique makes impacts related to the improvement of cognitive skills, such as WM, visuospatial WM and on the general cognitive performance of people of different age groups. In addition, the training phases with PA can promote the training of motor skills. Thus, the impacts of training in AMC and with PA are in line with those reported by Costa et al.The studies included in this review reported cognitive performance gains in individuals of different age groups after participating in cognitive training programs using an abacus. Therefore, considering the promotion of health and quality of life of the older population in terms of cognitive ability and all its related aspects, highlighting the applicability of AMC training programs during all phases of one's development is highly relevant.A limited number of articles addressing the theme was identified, most of which carried out with children, indicating that the use of abacus as a cognitive training tool is prevalent in this age group, which represents a limitation of the present study. In addition, as it is a traditional tool of some Eastern countries, inserted in the culture and daily life of this population, the studies analyzed in this review are mostly performed in countries with these origins. Thus, it is possible to point out as another limitation of this study the scarcity of researches that carry out this type of intervention in other populations, evidencing the need for future studies in this perspective.A limitation of the present study was the dearth of studies with well-designed methods, including the application of sensitive specific tests for measuring performance of cognitive training using an abacus, showing that you need research with more criteria methods.Another relevant finding of the present study concerning the results of the initial search was that, out of the 22 studies retrieved, only one focused on the elderly population, which indicates the need of carrying out a greater amount of research on cognitive training with older persons and with the abacus as a training tool, in different cultures, aiming to confirm whether the findings described for younger individuals are generalized to the cognitive skills of the older persons. Cognitive training is a potential intervention of cognitive reserve optimization.When considering the growth of the elderly population and neurodegenerative diseases, which accompany the aging process, investing in non-pharmacological cognitive interventions, such as the use of abacus, can be a good strategy for promoting health, quality of life and well-being. The present study also highlights the research gap in this area, indicating a problem for future studies to address. It is also suggested for future studies that they present in their methodological design interventions with the use of the abacus with an emphasis on healthy older adults and elderly people.


Digital health (DH) and the benefits of related services are fairly well understood. However, it still is critical to map the digital health care landscape including the key elements that define it as an ecosystem. Particularly, knowing the perspectives of citizens on this digital transformation is an important angle to capture. In this review we aim to analyze the relevant studies to identify how DH is understood and experienced by Australian citizens and what they may require from DH platforms.A scoping literature review was conducted across several electronic databases , as well as grey literature. Additionally, citation mining was conducted to identify further relevant studies. Identified studies were subjected to eligibility criteria and the final set of articles was independently reviewed, analyzed, discussed and interpreted by three reviewers.Of 3811 articles, 98 articles met the inclusion criteria with research-based articles–as opposed to review articles or white papers– comprising the largest proportion (72%) of the selected literature. The qualitative analysis of the literature revealed five key elements that capture the essence of the digital health ecosystem interventions from the viewpoint of the Australian citizens. The identified elements were “consumer/user”, “health care”, “technology”, “use and usability”, “data and information”. These elements were further found to be associated with 127 subcategories.This study is the first of its kind to analyze and synthesize the relevant literature on DH ecosystems from the citizens’ perspective. Through the lens of two research questions, this study defines the key components that were found crucial to understanding citizens’ experiences with DH. This understanding lays a strong foundation for designing and fostering DH ecosystem. The results provide a solid ground for empirical testing. During the last decade, advances in information technologies have impacted the delivery of traditional health care services. Emerging devices and advanced health care systems have been embedded into a network to link the complex health care landscape as an ecosystem. Referencing the foundational work on technology ecosystems by Adomavicius, Bockstedt, Gupta and Kauffman , 2, we dRecently, considerable research has been devoted to investigate technical and human issues which motivate the development and adoption of information technology (IT) in health services as part of progressing with a DH ecosystem. Specifically, numerous studies have explored the adoption of IT technologies by different user types, as well as the impact of IT interventions on health outcomes for individuals –9. In thThere is research conducted from the viewpoints of health care professionals and policy makers to understand how consumers experience DH , 11–14. DH research has also focused on the privacy and security of DH platforms, among which the regulation and policy of health data governance have been subject to extensive discussion . For insDespite this wide understanding of the importance of DH, and how the use of different technologies can provide solutions to optimize access to better and secure health care services, little is known about the citizens’ perspectives of the entire DH ecosystem . It coulIn order to bridge this knowledge gap, it was useful to review and map the relevant research terrain and identify contributing factors of digitally enabled health services, especially as they are experienced and perceived by “typical citizens” as stakeholders involved. This scoping review collated studies that explore DH services in the general Australian population. In this paper we aim to provide a macro view of the perspectives of Australian citizens on DH technologies through the review of current research and other relevant publications.The rest of the paper is organized as follows: Section 2 explains the research method, the strategy and protocols of search. In this section, we identify the questions of the research and describe the procedure by which studies were identified. The methods employed to extract data and analyze the information are also explored in Section 2. Section 3 reports the results and defines the themes extracted from the reviewed studies, illustrating Australian citizens’ perception of the DH ecosystem. Section 4 discusses the findings; Section 5 identifies some limitations of this research; and Section 6 summarizes the conclusions.This scoping literature review was conducted by a research team at the [REMOVED FOR REVIEW] consisting of individuals with deep expertise in DH, health and social informatics. The methodology used in the research is outlined below.This review was conducted in accordance with the Preferred Reporting Items for Systematic reviews and Meta-Analyses extension for Scoping Reviews (PRISMA-ScR) guidelines , 24. We In this study we set out to address the following key research questions via a structured literature review:What does the typical citizen in Australia (the “person in the street”) know about DH, if anything?What is the current experience with citizens’ requirements to DH?Studies were identified using a systematic searching method including pre-defined selection criteria. Our search of major library databases covered publication dates from 2014 to 2019 inclusive (a 5-year period).The review material included clinical trials, as well as exploratory, field, experimental, systematic review, qualitative, and quantitative studies associated with the objectives of the review. The challenge was to paint a big-picture out of the literature found on the topic, so the inclusion process was not limited to studies of one type. Consequently, a review included research articles and white papers that cover the objectives of the study either directly or indirectly. The inclusion and exclusion criteria are presented in consumer to cover this group of stakeholders, we consider a “citizen” as the core stakeholder. Applying this definition of a consumer, we included any research that directly or indirectly provided insights into the citizen or consumer perspectives on this topic. Moving forward we further categorized stakeholders by means of a qualitative coding technique.To classify the DH consumers in the identified dataset, we primarily referred to the definition of stakeholders suggested by Gagnon et al. . They idWithin the broad definition of the DH construct as the use of digital tools and interventions in health care and wellness, no restriction was made on the types of technologies included in the literature review. We argued that restricting the search to either one specific device or a range of tools could overlook the variety of the technologies that exist in the DH ecosystem.Based on our research questions, we formulated initial search keywords around three main themes, “citizen/consumer”, “Australia” and “digital health”. In the accessed bibliographic databases specified in the next section keyword searches were performed on title, abstract and keywords using Boolean operators “AND/OR”. The search syntax used is presented in Online database literature searches were performed in August to November 2019 to obtain relevant articles to review. The electronic bibliographic databases used were: PubMed, Scopus, OVID, IEEE, ACM, Science Direct, SAGE, Mary Ann Linhert, and APO. Some additional papers were included due to the authors’ knowledge of the newer publications from the individual authors and local research groups working in the area.To minimize the likelihood of missing relevant articles, we conducted a cited reference search for all the articles considered for the final review. Articles that were found this way were screened for duplication and for meeting inclusion criteria. We also used the Google Scholar search engine to identify all articles that have cited the original papers.The search results were imported either as CSV files where direct export was provided from the searched libraries, or added manually to an Endnote database, then merged in Excel spreadsheet. Duplicates were identified in the Excel or Endnote and were removed accordingly.As shown in During the second phase, papers were examined independently by two reviewers (the first and the third authors). In this phase, agreement between reviewers was assessed by calculating a Cohen’s kappa on their inter-coded decision points  . A kappaThe last phase included a full text review conducted independently by three reviewers . This comprehensive evaluation yielded a final sample of 98 papers.The final set of papers was considered from the point of view of the quality of the academic outlet. The SCImago Journal Rank (SJR) indicator was used as the primary source of the ranking of quality of these publications. During the screening phases, papers were coded in two dimensions. The first was regarding the reference details–specifically, authors, place of publication, year of publication, and type of study . The second dimension related to the level of relevance to the objectives of the study, methodology, and outcomes and recommendations for the papers to be included or excluded. During the analysis, each article was read in full and assessed by reviewers against these dimensions and relevance to the research questions. The personal evaluation of each reviewer was shared in a Google Drive spreadsheet template, a copy of which is found in In the review process, if a new category or subcategory that had not been identified in the selected studies was discovered, it was allowed to be added to the list of themes and categories to capture further information. To validate the new category, researchers independently confirmed and compared the coding with other subsets of catalogued types.The quality of the included studies is not usually assessed in a scoping review , 30. DueOverall, after applying the inclusion and exclusion criteria we identified 98 articles for this scoping review  of the selected literature.Regarding the locations where research-based articles were associated, the experiments and trials were conducted mostly across Australia (41.5%), with Queensland as the main state of their focus. The states of Victoria and New South Wales were ranked in the next level with almost equal contribution  that these interventions were associated with. Unsurprisingly, consumers were strongly factored into all the retrieved research. As shown in citizens/person [patients who demand and consume DH platforms for many reasons [individuals were also another significant subcategory that were specified in the eight studies. Healthy individuals, in particular, were discussed significant group in which individuals were users of wellness programs [professionals were also considered consumers who are affected by and interact with the DH platforms as part of their professional practice [As the basic category, consumers were specifically characterized in the literature by the concepts of s/person , 32. Ele reasons , 39–46. programs , carers programs , 51, andprograms , 50. Medpractice –38.public groups [governmental bodies [At the next level down, the stakeholders were categorized by c groups , 49, 59,l bodies , 92, 93.l bodies , studentl bodies , 90, faml bodies , and chil bodies , 87 werel bodies .Nine studies highlighted the importance of culturally and linguistically diverse (CALD) background as a directing factor in the use and design of DH technologies. In spite of the importance of CALD, only two studies have provided experimental figures on how CALD people experience DH technologies , 56. CALhealth information systems and devices were mentioned in the reviewed studies.The second theme comprised studies focusing on the apparatus used within Australia’s DH ecosystem. According to online services, telemedicine including wearables and video conferencing platforms, internet-based interventions including e-health, m-health and electronic health records. In particular, 16 articles addressed telehealth as the most widely used and acknowledged system among the consumers. Telehealth was employed in the studies to provide various remote health care services including dentistry [The most commonly referenced systems were entistry , paediatentistry , kidney entistry , and chrentistry , 115.phones including smartphones were the major devices that were employed or mentioned in the studies. This is explainable as these devices supported the infrastructure for accessing health care apps.Regarding the equipment, self-care, supporting and helping users regarding their diseases and wellbeing, and for clinical decision making including treatments, outcomes, and prescription of medications. There also was a contribution of education and health literacy on the functioning scope of DH. DH platforms were used to educate consumers and enhance the awareness about patients’ health conditions [care providers which consists of three subcategories. Eighteen studies demonstrated that the use of DH was situated in all services that are provided at clinics and hospital settings and at both private and public sectors of Australia. The special subcategory identified in five studies was supporting administrate tasks, such as booking appointments and processing admissions.Health care was the third major theme related to the aspects of the DH ecosystem. The review resulted in eight major categories that define DH as a means to provide, maintain and improve health care. As illustrated in nditions , 68. TheUnder the key category of diseases, 19 types of illnesses have been addressed in the literature describing DH initiatives in Australia. All of the stated diseases were mentioned in the studies in three different ways: 1) there were general health issues that were described in the participants during the research; 2) there were health conditions of users of technology  that were targeted for the DH research purposes ; or 3) dSeveral factors emerged relating to the fourth major theme that addressed how consumers can use or experience technologies and how that helps to achieve a health goal effectively, efficiently and satisfactorily See .use of technology and its usability when it comes to explaining the needs and expectations of DH consumers.The analysis provided strong evidence that the authors differentiate usability of DH technologies as experienced by the Australian population. As listed in user perception, accessibility, acceptability and ease of use were the most commonly mentioned factors. Under the usability segment, health consumers identified satisfaction and adoption of health technologies as very important design factors. Other key factors in usability of DH technologies were communication and engagement.Ten major categories were batched together regarding the engagement, four indicators were suggested in the literature to increase the involvement of consumers with DH health care services. Firstly, DH platforms should provide a personalized strategy that involves contextualizing the better experience for user and customer satisfaction [customizable. That said, consumers should be empowered to be involved in the design of the products or services and DH products should be adopted to achieve the personalization strategy for individuals or groups [collaboration between stakeholders or by receiving support from peers [Regarding sfaction , 123. Ser groups , 78, 103om peers , 70. Theom peers . The gamuse of DH technologies. Among the enhancing factors of the intention to use DH services, the literature highlighted the functionality of DH platforms, the deliverability of accurate services, training programs, and the relationship between consumers and providers. In addition, it became evident from the literature that citizens may best manage DH with a positive attitude towards the use of technology, and prior experience with computers or other digital technologies. The potential to boost adherence to DH services was also linked to technological performance, manageability and feasibility of systems and services, proper health care product design and the aesthetic value of the products. It was also found that DH consumers want these products developed with functionality, enabling screening and monitoring of their health status.Eighteen other categories were synthesized to define factors related to the barriers and limitations were listed as adversely impacting the use of DH platforms. More generally, it has been discussed that there will be no intention to use DH services if products do not provide practical assistance or do not ensure safe access to services [personal characteristics of the consumers, such as cognitive constraints and anxiety in using technology, can impede the adoption and acceptance of DH.On the other hand, several services , 116. Asneeds, preferences and requirements from DH platforms  What does the typical citizen in Australia (the “person in the street”) know about DH, if anything? And 2) What is the current knowledge about citizens requirements of DH? the first research question, there was a lack of evidence on how the different stakeholders including patients understand DH platforms and how such platforms work. At the same time, the review led to several interesting insights that are derived from what the analysis revealed indirectly. Many of the issues  are captured in a number of the dimensions derived on the basis of the thematic analysis, including the “Consumer/user” and “Use and usability” themes. For example, numerous papers indicated a good level of awareness of DH as evidenced through current, or intended, usage by citizens of classical DH tools such as apps [In terms of answering  as apps , 79 or v as apps , 94, 122 as apps  who examIn rural Australia, awareness of digital health care platforms is substantial. For instance, in a random survey of nearly 400 adults in South East Queensland, nearly 80% of them already had access to telehealth services . The selWith regard to DH platforms, several devices and information systems were reported in the reviewed studies, with apps being the predominantly assessed tools. These findings align with recent trends in Australian consumers’ perceptions of their use of DH technologies such as apps . HoweverOverall, the results of the review provide a strong indication that Australian citizens are willing to receive and ready to employ DH services. This is based on the perception that the effectiveness of platforms, or health-related outcomes and affordability of DH is associated with cost-effective or cost-saving processes. However, we did not find any specific report on economic data to use as evidence of the direct impact of DH interventions on health care ecosystems. There is no data available on the rates of increase in the health level or life expectancy of consumers, the reduction in outpatient-inpatient presentations, or decrease in cost and frequency of health care services due to the deployment of DH innovations. Additional research is needed to identify the impact of DH ecosystems on all key stakeholders  compared to traditional health care services.the second research question on the needs and desires of Australian citizens when it comes to DH tools and interventions, the literature review captured some key information.With regard to One important dimension that came up in the literature is the need for consumers to have trust in how their sensitive health and wellness data is stored and managed in the DH ecosystem. This issue is already considered to be of concern for DH ecosystem implementation, but our review identified some empirical evidence based on research studies conducted in Australia. An example includes the research on a relevant ethical framework conducted by Segura Anaya et al. . This isA study by Lupton  with a sIt is important to build a DH platform or new application based on the wants and needs of the customers , 103. ThAnother piece of research by Trawley et al.  providedA study by Anderson et al. , althougFinally, the culturally and linguistically diverse backgrounds, gender, age, and socio-economic status of consumers were recognized as enablers or barriers for DH ecosystems. For example, there is a lack of research particularly related to the use, perception, and delivery of DH technologies among Aboriginal and Torres Strait Islander people. Within the period of search, we discovered only four studies that had directly addressed the use of DH among Australia’s Indigenous population. Those studies are related to delivering diabetes care (tele-diabetes) and acceptability of telemedicine , 88, 89.This review was restricted to the published literature since 2019. We excluded studies published since 2020 due to the impact of the coronavirus pandemic. Evidently, the current worldwide outbreak of COVID-19 has been a catalyst to accelerate the use of DH platforms, and specifically telehealth , 132. HoGiven the systematic and inclusive nature of our approach, this review aimed to establish a contextual understanding of consumers’ perspectives rather than generalizable conclusions. The interpretation of small scaled experimental studies was considered carefully. We were cautious not to deduce knowledge from pilot results related to issues such as the effectiveness of the DH interventions on consumers’ health status. We included a few comparative studies between Australia and other countries such as India; however, our findings were only focused on the DH status in Australia. Hence, it would be interesting if treated as a benchmark to explore the issues of DH ecosystem components in other countries.Our study has highlighted a number of areas for future research. For instance, studies may further evaluate citizens’ appropriation of the DH ecosystem in the Australian context. In particular, a very significant area of research lies in better understanding the needs and perceptions of those who live in regional and remote areas, as well as those who are underprivileged such as migrants, culturally and linguistically diverse citizens, and those living with special health conditions. It is noteworthy that studies within the DH context have not examined specific categories of diseases  within Indigenous Australian patients (see: ). Also, Regarding the usage of DH platforms, future research should amplify the impact of technological interventions on consumers’ health outcomes by incorporating gamification which is a hot topic internationally, and could be an area that requires supplementary research in the Australian context (see: ).In this study, we did not seek to explore the design and implementation of digitally enabled health services as components of that DH ecosystem. Our intention, in terms of continuing research, is to go on to answer the question, what does a supportive DH ecosystem need to look like to satisfy the needs and desires of citizens when it comes to DH? In subsequent research we will more explicitly investigate how the dimensions identified in the current review can assist in forming a DH ontology to help in understanding the scope and structure of the DH ecosystem in Australia. Such understanding can in turn be used to guide the continued evolution of a sustainable and useful DH ecosystem.This scoping review provides an overview of how Australian citizens understand and experience DH and also identify what they require from DH platforms. The review examined the literature related to DH and health care research across five years (2014–2019). The results suggest that the available evidence for presenting a clear and succinct description of a DH ecosystem from the perspective of Australian citizens is currently fragmented and lacks maturity in general understanding of its dimensions. A literature review showed that most of the current studies have specifically defined conclusions and were oriented to investigate the practice of introducing or using specific technologies for specific groups of consumers in some explicit context. The findings, however, suggest that more research is required to fully understand the global perspective on DH ecology in Australia both as it stands, and as it needs to be extended, to optimally support its citizens. For these purposes, the themes identified in our review and the relationships between them provide a solid foundation towards creating such a global vision.It is essential to learn more about how technologies or platforms are used and perceived by different citizen groups. This comes with an additional step to understand how the efficacy of, and trust in DH tools and interventions can be facilitated by looking at common policies and procedures which were studied so far. Importantly, there is also a need to further assess if and how quality health care services are delivered to Australian citizens through DH–however, this is an exercise in ongoing vigilance.Last but not least, the advantage of considering health care provision via digital platforms as part of an optimal ecosystem is that such a perspective is focused on empowering consumers. Although it is not easy to indicate exactly what should drive the shift from passive to empowered customers, the key element is associated with provision of full control of their health and wellbeing (activation) and facilitating them to remain connected within that ecosystem (engagement). In this research we have identified the five key elements of and relationships within such a DH ecosystem. We have established a solid foundation that can scope such an ecosystem from an Australian citizens’ perspective.S1 Appendix(DOCX)Click here for additional data file.S2 Appendix(PDF)Click here for additional data file.S3 Appendix(TIF)Click here for additional data file.S4 Appendix(DOCX)Click here for additional data file.