With the changes in human work and lifestyle, the incidence of cervical spondylosis is increasing substantially, especially for adolescents. Cervical spine exercises are an important means to prevent and rehabilitate cervical spine diseases, but no mature unmanned evaluating and monitoring system for cervical spine rehabilitation training has been proposed. Patients often lack the guidance of a physician and are at risk of injury during the exercise process. In this paper, we first propose a cervical spine exercise assessment method based on a multi-task computer vision algorithm, which can replace physicians to guide patients to perform rehabilitation exercises and evaluations. The model based on the Mediapipe framework is set up to construct a face mesh and extract features to calculate the head pose angles in 3-DOF (three degrees of freedom). Then, the sequential angular velocity in 3-DOF is calculated based on the angle data acquired by the computer vision algorithm mentioned above. After that, the cervical vertebra rehabilitation evaluation system and index parameters are analyzed by data acquisition and experimental analysis of cervical vertebra exercises. A privacy encryption algorithm combining YOLOv5 and mosaic noise mixing with head posture information is proposed to protect the privacy of the patient’s face. The results show that our algorithm has good repeatability and can effectively reflect the health status of the patient’s cervical spine. Cervical spondylosis is ranked as one of the most common pain problems, especially in Asia. According to , China hIn particular, head pose estimation (HPE) is an important part of the whole evaluation process, which is the task of obtaining a 3D head pose deflection angle parameter through the analysis of a 2D digital image. The methods of head pose estimation can be broadly classified into two types based on whether they depend on landmarks.Landmark-dependent methods: The core idea of this type of methods is to extract the landmarks on a human face first and then substitute these landmarks into the formula to calculate the head pose. In recent years, with the rapid development of convolutional neural networks (CNN), many CNN-based face landmark extraction methods have been proposed. For example, Liu et al. proposed a head pose estimation approach including two phases: the 3D face reconstruction and the 3D–2D matching keypoints. They first used CNNs, jointly optimized by an asymmetric Euclidean loss and a keypoint loss, to reconstruct a personalized 3D face model from the 2D image, and then used an iterative optimization algorithm to match the landmarks on the 2D image and the 3D face model reconstructed before under the constraint of perspective transformation [ormation . Ranjan,ormation . Guo et ormation . Howeverormation . Some meormation .Landmark-independent methods: This type of method has the advantage that the task of head pose estimation does not rely on the quality of the landmarks, which enhances robustness in a sense. Ruiz, N. et al. designed a loss including a pose bin classification and a regression component for each head pose Euler angle to compose a multi-loss network. When combined with data augmentation, their method has a good performance in estimating head poses in low-resolution images [n images . Huang en images . Cao, Z.n images . Dhingran images . Thai, Cn images .Based on what has been mentioned above, landmark-independent methods perform slightly better than landmark-dependent methods in terms of accuracy of head pose estimation, but the network structures of landmark-independent methods are usually so heavy and complex that they are unsuitable for running on mobile and embedded platforms. In contrast, landmark-dependent methods run faster and have a smaller computational scale, which is more in line with the requirements for a lightweight estimation system in this task.Head pose estimation has a wide range of applications in research areas such as driver attention detection ,19, gazeContributions: To fill the vacancy in the area of an unmanned evaluating and monitoring system for cervical spine rehabilitation training, in this paper, we proposed a complete cervical spine health condition assessment system with a face encryption algorithm, and constructed a cervical exercise dataset which can be utilized in related studies. We adopted Mediapipe to acquire the necessary landmarks on human faces for the calculation of Euler angles. Mediapipe Face Mesh offers high-precision real-time detection of 468 3D face landmarks. Its lightweight architecture, together with GPU acceleration, enables the model to run on mobile devices with only a single camera input [ra input . We estiThe remaining chapters of this paper are as follows: With the gradual maturation of computer vision technology, the application of computer vision in the medical field to improve the efficiency and accuracy of diagnosis has become a hot research topic in the academic community. However, little work has been done on the intersection of cervical spine health assessment and its rehabilitation guidance with computer vision, and the task focus and methods used in these works are different. For example, Xiong, J. et al. used computer vision and AR technology for acupuncture point selection in acupuncture therapy for cervical spondylosis and achieved an effective rate of 95.13% . MurugavThe proposed evaluation model can calculate the head posture and other information by tracking the key points of the face in the input cervical spine exercise video and calculate the cervical spine score accordingly to generate a cervical spine health status assessment report; at the same time, it generates an assessment video with mosaic-processed face and real-time head posture data attached, which aims to provide scientific spine health status assessment and rehabilitation guidance while protecting the privacy of patients. The model architecture is shown below in The specific working steps are as follows:Step 1: Face Landmarks ExtractionThe landmark points on the human face are first extracted using Mediapipe Face Mesh and are then inputted into the angle calculation module.Step 2: Euler Angle CalculationThe formula that provides an accurate angle estimate with the least number of landmarks, is easy to understand, and reduces the computational overhead, is the one we choose for calculating the head pose based on coordinates.Step 3: Face EncryptionYOLOv5 is used to detect and localize human faces, and grain-size-adjustable mosaics are put on the detected area to protect patients’ privacy.Step 4: Feedback Video Synthesis and Evaluation Report GenerationContinuous head pose information is inputted in temporal sequence into the scoring system to get the final evaluation report, and a feedback video with encrypted face and head pose data attached is generated.You Only Look Once (YOLO) is a widely used algorithm, especially in the field of target detection. As its name suggests, the most important feature of YOLO is that it can output detection results at once after inputting the images to be predicted into the network, truly realizing the task of end-to-end target detection. Its lightweight network, extremely fast detection speed and excellent detection results make it widely used in many target detection-related scenarios. However, YOLO was not perfect in the beginning and many endeavors have been made by numerous scholars to improve YOLO’s performance.The first version of YOLO is based on GoogLeNet, including 24 convolution layers and two fully connected layers . It can In the construction of our face encryption model, since the location and contour of the face in the video to be processed by the model are very clear and moderate in size, it is not necessary to pursue the ultra-high performance of the algorithm in the field of small target detection or other specific fields, but rather to focus on achieving a good balance between accuracy, processing speed, stability, flexibility, and ease of deployment. Taking the above factors into account, we decided that YOLOv5, with its high accuracy, fast detection speed, and customizable model, is the most suitable algorithm for our task.YOLOv5 has four different networks, and the width and depth of the network can be adjusted according to the parameter configuration in the .yaml file . On the Many other tricks are also used, such as abandoning the more complex activation function Mish and replacing it with LeakyReLU and Sigmoid to speed up inference; adopting a warm-up strategy when adjusting the learning rate to avoid using a larger learning rate at the beginning of training, which helps avoid early overfitting and ensure the stability of the model; and, as shown in Equation    4) appeaThe mosaic is performed by dividing the selected face area into several small squares, each of which is unified into the color of the pixel in the upper left corner of the small square. The process of mosaicking is irreversible due to the loss of information during the encryption process, which effectively protects the patient’s privacy. Equation  for the A complete set of cervical spine exercise movements was designed, including axial rotation, lateral bending, flexion, and extension in each direction three times.To evaluate the method on videos of cervical vertebra rehabilitation, continuous videos were collected for two steps.First, the cervical spine exercise of a volunteer was recorded as a standard video to test the repeatability of this algorithm. Then, another ten volunteers  were invited to do this exercise and the validation dataset for the scoring system was constructed.All the volunteers’ movements were recorded by the OV9734 azurewave camera on a laptop at 30 fps, and Assuming the cervical spine exercise in one of the videos represents standard movements, the relationship between the standard angle and time is shown in n = 10 in Equation s(x)The results are as shown in Consistency test statistics charts are generated in three dimensions. The horizontal coordinate in each graph is the number of video frames, and the vertical coordinate is the standard deviation of the deflection angle of each frame in the video in one dimension after ten tests. The orange horizontal line is the average of the standard deviation of all frames, which can reflect the repeatability of our head pose estimation algorithm in that dimension. The average of the standard deviation in pitch, yaw, and roll is 0.0217, 0.0362, and 0.0432, which are all relatively low, and that means the algorithm has good repeatability.In this section, a cervical spine condition scoring system is given and 10 volunteers  were tested and analyzed for their cervical spine condition using this system.The range and speed of the head motion are two significant scoring indices of the health condition of the cervical spine. Calculation of head motion amplitude can detect problems such as joint misalignment and abnormal cervical curvature, while calculation of head motion speed can reflect the flexibility of the cervical spine and the degree of stiffness of related muscle groups. Many methods of assessing cervical spine health conditions only consider the range of head motion in all directions ,43,44, tOhberg, F. et al. evaluated the importance of the range and the speed of head motion in , which iAccording to the research of Lind, B. et al. , the norAdditionally, a video of a volunteer’s cervical spine exercise was recorded as standard movements and the extreme values of angular velocity were calculated as standard values. The cervical exercise videos of 10 volunteers were tested with this scoring system and the variation of head deflection amplitude and angular velocity in three dimensions over the time domain are plotted in The cervical spine health scores of 10 volunteers in Their more detailed scores on head movement amplitude and movement angular velocity in the three dimensions are shown in In a practical application scenario, the general health status of a patient’s cervical spine can be assessed based on the overall score, and the patient’s cervical spine problems can be localized based on the detailed score of each index.A human-in-the-loop method was adopted to evaluate and compare the quality of different scoring standards. Professional cervical spine physicians were invited to score the cervical exercise of each volunteer based on their medical examination reports and extensive clinical experience as physicians, and this assessment was set as the benchmark score. In the final output video, the size of the mosaic can be adjusted according to the resolution of the video, the diagnostic needs, the patient’s request for personal privacy, and other factors. The encryption effect of five different sizes of mosaic on the face was tested on our cervical exercise video with a resolution of 1920 × 1080, as shown in In this paper, we proposed an evaluation method for cervical vertebral rehabilitation based on computer vision. The method first uses Mediapipe to construct a face mesh and extract several important landmarks to calculate the angles of head poses in three degrees of freedom. Then, the angular velocity in three dimensions over the time domain is calculated based on the angle data acquired before. After that, the health condition of the patient’s cervical vertebra can be evaluated generally and in detail using the scoring system. Finally, we use YOLOv5 to localize the human face, put mosaics on the detected area, and compose the full video with head posture information attached.We validated the repeatability, scoring performance, and encryption effect of the proposed evaluation method by experiments based on the cervical exercise videos of volunteers with even gender distribution. The experimental results showed that our algorithm has good repeatability and that our scoring system can effectively reflect the health status of the patient’s cervical spine.In the future, we plan to work with hospitals to access cervical spine data from real patients to expand the dataset to patients all of ages and study the correlation between changes in various indicators of the patient’s cervical spine during treatment and the patient’s recovery progress, and further improve the assessment indicators and weights in the scoring system. In addition, we will also try to expand and transfer this method of assessing patients’ rehabilitation status with the help of machine vision to more medical fields to better utilize the advantages of cross-disciplinary research.


Life expectancy at birth  and longevity are established indicators of population health  and the Lifespan has increased substantially since the previous century, with a person born in 2014 expecting to live an average of 25 years longer than any person born in 1900 ,4. By 19The increased life expectancy and longevity since 1900 parallels an epidemiological transition with a rapid decline in the incidence of and deaths caused by infectious diseases followed by an increase in non-transmissible and chronic diseases ,7. Most This editorial explores the role of diet and lifestyle in the human capacity to survive past the average age of death  or, more specifically, to live until becoming a centenarian.Besides nutrition and lifestyle, many factors have contributed to increased life expectancy since the late 19th century. Socioeconomic development, especially more and better jobs and higher incomes  and assoOn the other hand, many factors have negatively impacted life expectancy over the same period. Among them, the growth in cigarette smoking, poor diet, and physical inactivity have contributed to epidemic levels of cardiovascular and cancer deaths and the leveling off of the life expectancy gains of the early 20th century, particularly among men . EnvironThe biology of centenarians, described in this review, provides us with clues for intervention to promote healthy ageing in the general population. One of the major reasons for this healthy ageing has to do with the genetic signature that is specific to centenarians and certainly different from octogenarians who do not enjoy the extraordinary qualities of centenarians .Researchers have identified fifty genes with the potential for regulating gene processes and lifespan, with strong evidence for the critical role of DNA damage in life expectancy . The conBesides the contribution of genes (20–40%), diet and lifestyle appear to add substantially to longevity and the lasting functionality of centenarians.We postulate that a healthier diet and other lifestyle factors  combined with a supportive socio-ecological environment may interact with genes to affect a person’s health and longevity.The so-called blue zones—populations known to have a high prevalence of centenarians—are scattered around the globe, but they have some things in common: healthy diets, continual physical activity, either for leisure or due to the need to perform the activities of daily living, a strong social network based on cultural values, and health habits such as mindfulness and a purpose in life ,33,34. IDiet and lifestyle are related to mortality among Chinese people aged 80 years and older ,37. In aDiet is the most important determinant in shaping the composition, diversity, and richness of gut microbiota . StudiesThe scientific literature also underlines the positive effects of exercise on the physical capacity and longevity of incredibly old people such as centenarians . UndertaThere is evidence that smoking is incompatible with successful aging and compromises life expectancy even in extreme longevity . Among mFinally, a greater purpose in life is associated with a reduced risk of all-cause mortality among community-dwelling older persons .Almost every individual over the age of 60 is affected by a chronic disease/condition, from a simple cataract to complex cardiac problems. Thus, the question is, how can we determine who the healthy ones actually are? In a recent study, “centenarians presented, in general, lower morbidity and treatment burden and lower use of both primary and hospital healthcare services than octogenarians and nonagenarians, suggesting a better health status” . The WHOIn an ageing population, with increasing numbers of centenarians and a growing prevalence of non-communicable chronic diseases, health promotion will need to rely on encouraging individuals to adopt healthy habits such as exercise and meditation, a balanced diet, and social interaction ,62. FromIn our short editorial review of the role of diet and lifestyle change in centenarians, we explored the mix of factors that contribute to longer life expectancy and longevity. We found strong evidence for an additional role of both diet and lifestyle changes as agents for longer life and reaching centenarian status. In this Special Issue, we expect researchers to add to this knowledge about increased life expectancy and longevity through studies of centenarians, including original research and synthesis on the role of diet and lifestyle changes.


Anxiety is a common mental health issue that affects a significant portion of the global population and can lead to severe physical and psychological consequences. The proposed system aims to provide an objective and reliable method for the early detection of anxiety levels by using patients’ physical symptoms as input variables. This paper introduces an expert system utilizing a fuzzy inference system (FIS) to predict anxiety levels. The system is designed to address anxiety’s complex and uncertain nature by utilizing a comprehensive set of input variables and fuzzy logic techniques. It is based on a set of rules that represent medical knowledge of anxiety disorders, making it a valuable tool for clinicians in diagnosing and treating these disorders. The system was tested on real datasets, demonstrating high accuracy in the prediction of anxiety levels. The FIS-based expert system offers a powerful approach to cope with imprecision and uncertainty and can potentially assist in addressing the lack of effective remedies for anxiety disorders. The research primarily focused on Asian countries, such as Pakistan, and the system achieved an accuracy of 87%, which is noteworthy. Anxiety, sociopathy, emotional stability, and desire are just a few psychological factors affecting human behavior . Human bVarious techniques can be used to predict anxiety at early stages . One of The importance of the fuzzy expert system lies in its ability to predict anxiety at an early stage. It is a useful tool for healthcare professionals to identify the risk of anxiety disorder and to provide early intervention to patients. The system utilizes a knowledge base, which makes it more reliable and accurate in predicting anxiety. On the other hand, the use of machine-learning techniques also provides a promising approach to the prediction of anxiety, but the accuracy of the model is dependent on the quality and quantity of the input data. The questions that arose after learning more about the issue were:RQ1. Which symptoms can lead to anxiety in a patient?RQ2. How much accuracy can be obtained by predicting anxiety at certain levels?To answer these research questions, our research objectives and key research contributions are outlined below.A fuzzy inference system (FIS) is proposed, taking the symptoms as inputs using them to predict outcomes. Patients suffering from anxiety report their basic symptoms to the system. The system uses these symptoms as inputs and predicts whether the patients are suffering from anxiety. The study offers a workable method for the precise diagnosis and prediction of anxiety while advancing our understanding of anxiety and its effects on people and society. The early diagnosis and treatment of anxiety can have major advantages because they can improve treatment outcomes and lessen the toll the condition takes on sufferers, their families, and society. In its early stages, when symptoms may be subtle or ambiguous, anxiety is a complicated disorder that can present in various ways and may not always be obvious. As a result, the creation of a fuzzy expert system that can reliably predict anxiety at an early stage may be extremely helpful in assisting medical practitioners in making prompt and knowledgeable therapeutic decisions.The rest of this paper is organized as follows. In In recent years, systems based on artificial intelligence (AI) have been increasingly utilized to improve the quality, sensitivity, and timeliness of the diagnosis of psychiatric disorders, including anxiety disorders. These systems employ AI techniques such as fuzzy logic, neural networks (NNs), support vector machines (SVMs), and decision trees (DTs) ,12,13. A< w: word >: The presence or absence of the anxiety-related word.< t: timing >: More than two posts during odd night hours.< f: frequency >: More than thirty posts in an hour.< s: sentiment >: On average, more than 25% of posts over 30 days with negative polarity.< c: contrast >: The presence of a polarity contrast of more than 25% in posts within the past twenty-four hours.Moreover, Susanto et al.  proposedFurther, Khullar et al.  proposedFurthermore, Devi et al.  proposedFrom the literature review presented above, we can conclude that anxiety symptoms can be different from person to person and that they can also be different across regions. For example, people in Asian countries, such as Pakistan, may show different anxiety symptoms. Therefore, it is necessary to create a fuzzy logic system that can target the Asian continent in particular, in order to predict the disorder correctly. To this end, we will used symptoms widely shown in patients with anxiety in Pakistan to build our fuzzy expert system. A FIS system uses fuzzy logic to map input and output variables based on rules. An expert system can make decisions or predictions based on fuzzy reasoning. The FIS consists of three main components: the fuzzifier, the inference engine, and the defuzzifier. The fuzzifier converts input data, which may be crisp  or fuzzy , into fuzzy sets representing the degree of membership in a particular category. The inference engine applies a set of rules defined by experts or generated automatically from data to determine the appropriate output based on the input data. Finally, the defuzzifier converts the fuzzy output into a crisp output value. The FIS system can be used in various applications, such as control, decision-making, and pattern-recognition systems. They are particularly useful in studies with high levels of uncertainty or imprecision in their data.The proposed system uses fuzzy logic as the ideal methodology for decision assistance. Fuzzy logic was chosen because it enables flexible and nuanced decision making through the IF-ELSE-based methodology. It can handle values in points, which conventional rule-based systems cannot. In this study, which focused on predicting anxiety levels, fuzzy logic’s capacity to collect and interpret data more granularly was beneficial and in line with the study’s goals. Therefore, fuzzy logic was chosen for its usefulness, its compatibility with the study’s goals, and its ability to handle values in points.Our proposed system can predict anxiety at different levels . The fuzzy system’s architecture is depicted in The input and output of the fuzzy system are depicted in Five symptoms were taken as input variables and one output variable was used for this system simulation. Fuzzy inputs Nervousness and Panic had three fuzzy terms , while inputs sweating, trembling, and increased heart rate had two fuzzy terms (no and yes). Creation of FIS rules was executed with the guidance of experts in the field. The rules were defined using a combination of linguistic terms and mathematical expressions. In order to accurately define the rules, a thorough analysis of the available linguistic terms was conducted, and they were mathematically combined to form a comprehensive set of rules. The linguistic terms were categorized based on the number of values they represented to facilitate the creation of these rules. This was achieved by separating the terms with two values from those with three. In this way, we effectively managed the vast array of terms and created precise rules. The rules were defined using a mathematical expression resulting from multiplying the number of linguistic terms with two values by the number of terms with three. This expression yielded a total of 72 rules, each of which was carefully crafted to ensure accuracy and reliability in the FIS system. Overall, creation of these rules was a rigorous and meticulous process involving the input of domain experts and the use of advanced mathematical techniques.Further details are shown in Membership functions are essential in fuzzy logic as they represent an element’s degree of membership in a fuzzy set. This is important because fuzzy sets have continuous boundaries, which differ from crisp sets with clear boundaries. Membership functions enable the representation of uncertainty and imprecision in the input data, facilitating more flexible and nuanced decision-making. They are commonly used to perform mathematical operations on a given dataset and are applicable across different platforms. Defuzzification is the process of converting fuzzy logic sets and related membership degrees into a calculable or quantifiable output in crisp logic. Fuzzy logic is a form of reasoning that deals with imprecise or uncertain information, while crisp logic deals with precise or certain information. Defuzzification takes the fuzzy input and output values from a fuzzy set and converts them into a crisp value that can be used for decision making. There are several methods for defuzzification, including the centroid method, mean-of-the-maximum method, and weighted-average method. Each method has advantages and disadvantages, and the choice of method depends on the specific application and the desired level of accuracy.The demonstration-and-evaluation phase consisted of three activities. The experiment results generated using MATLAB were discussed in the first activity, while the second activity featured the prediction of anxiety by the fuzzy expert system. The third activity featured a detailed description of the comparative evaluation of the proposed system and a discussion.MATLAB is a widely used tool in scientific computing, image processing, data visualization, and numerical computation. In this study, it was used to calculate the experimental results. The figures, specifically The anxiety-prediction system uses various anxiety-related symptoms as inputs from the user. These symptoms include nervousness, sweating, trembling, increased heart rate, and panic. By analyzing these inputs, the system can predict the user’s anxiety levels, which can be categorized into four levels: no anxiety, low anxiety, mild anxiety, and high anxiety. The proposed system can be visualized as shown in The data were collected from the research center of Shalimar Hospital in Lahore, Pakistan. The data were organized during the examination of patients in the outpatient department (OPD). Doctors diagnosed the disorder by collecting the symptoms, which were subsequently used to evaluate the accuracy and results of our system. Patient 1 has high anxiety according to the expert opinion and medical reports; our system also accurately established that this patient has high anxiety. Furthermore, patient 2 has high anxiety according to the expert opinion and medical reports, and our system also accurately predicted the high anxiety of this patient. Patient 3 has no anxiety according to the expert opinion and medical reports, which our system also accurately predicted. Patient 4 has low anxiety according to the expert opinion and our proposed system, while the medical report suggests that the patient has mild anxiety. Patient 5 has no anxiety according to the expert opinion, the medical report, and our proposed system. The data were collected in a random manner. We evaluated a total of 15 patients in We evaluated our system by comparing its results with expert opinions and the results from medical reports. The expert opinion represented the doctor’s diagnosis before any medical results were reported. The medical reports represented the results from the GAD test, which is essentially a test to examine anxiety disorder. After comparing the results of our system with expert opinions and medical reports, we determined the accuracy of our system. The answers to the research questions were formulated at the beginning of this research.RQ1. Which symptoms can lead to anxiety in a patient?Anxiety can manifest in many ways and the symptoms can vary from person to person. Some common anxiety symptoms include nervousness and panic, excessive sweating, trembling, increased heart rate, and restlessness.In Asian countries, such as Pakistan, where there are high stress levels due to various factors, such as financial instability, political turmoil, and societal pressure, anxiety can be a prevalent issue. Additionally, cultural factors, such as the stigmatization of mental health issues and a lack of awareness and education, can further exacerbate the problem.RQ2. How much accuracy can be obtained by predicting anxiety at certain levels?Th prediction of anxiety at certain levels can be challenging due to the complex nature of the disorder and the variability of symptoms from person to person. Anxiety can occur in short-term and long-term forms and present differently depending on the individual. It is important to carefully select the symptoms to use as indicators of the disorder to predict anxiety at different levels accurately. A proposed system was developed in a research study to predict anxiety at four levels. The system used a combination of patient symptoms and medical reports to predict anxiety levels. The study’s results were then compared to patients’ medical reports and expert opinions. The system was found to have an accuracy of 87% in predicting anxiety levels. This suggests that the system accurately identified the different anxiety levels in the studied patients.It should be noted that the system’s accuracy may vary depending on the population studied and the specific symptoms used as indicators of the disorder. Further research is needed to validate the system in different populations and to improve its accuracy. However, the results of this study provide a promising start in the development of effective tools for predicting anxiety at different levels.This paper proposed an expert system that utilizes fuzzy inference techniques to provide an objective and reliable method for detecting anxiety levels in patients early. The proposed system’s success in achieving an accuracy of 87% an Asian country, Pakistan, is noteworthy and provides hope for the early-stage diagnosis and treatment of anxiety disorders. The proposed system is an innovative approach that aims to predict the levels of anxiety in patients by using a combination of fuzzy enhanced rule-based sets and patient symptoms as inputs. Our results indicate that the system has a level of accuracy that is comparable to an expert opinion, which can potentially assist clinicians in diagnosing and treating anxiety disorders. However, a limitation of this work is that it only predicted anxiety and did not predict other psychological disorders, such as depression. In future work, the system’s scope can be expanded to predict the outputs based on the symptoms of both anxiety and depression, thereby providing a more comprehensive assessment of a patient’s mental health. By addressing the limitations of this work and incorporating more symptoms and relevant information, the system’s accuracy can be further improved, making it more useful to medical professionals in providing accurate assessments and treatment recommendations for patients. Overall, this expert system represents a promising tool for the early detection and treatment of anxiety disorders.


To analyze the interprofessional team’s perception of the actions carried out by means of responsible hospital discharge, and their contribution to improving the transition and continuity of patient care.A qualitative study was carried out in two hospitalization units, in October – November 2020, interviewing health professionals from a teaching hospital in the state of São Paulo. The reports were transcribed and subjected to thematic content analysis.Twelve professionals participated  and three thematic categories emerged from the interviews: 1. informational continuity in responsible discharge; 2. interaction between professionals and services for the transition of care; and 3. workload management for better transition and continuity of care.The team recognized interprofessional advances and challenges in responsible discharge related to the informational and relational continuity of patient care and highlighted the (over)workload as an unfavorable aspect in the transition process, generating impacts for patients, professionals and health services. Thus, the interdependence of practices allows to coordinate actions and plan collaboratively for the patient’s discharge, which makes the journey of care less stressful and safer.The development of a common therapeutic project, a dialogical relationship, recognition of the different types of knowledge and the participation of the patient/family in the care are attributes that make it possible to differentiate the effectiveness of teamwork,5, other professionals in the healthcare team play an important role in the discharge process, identifying eligibility criteria, adopting educational programs and accompanying patients during their hospitalization and after they leave the institution. When drawing up guidelines for de-hospitalization, transition and continuity of care in the Health Care Network (RAS in the Portuguese acronym), the Brazilian health system proposed the term “responsible discharge”. It highlights attributes such as patient/family autonomy, coordination between the hospital network, primary care and other levels of care, as well as interprofessional actions centered on the patient/family.Despite the emphasis on the role of nurses, doctors, physiotherapists and social workers support the importance of communication and interprofessionalism, as well as networking, for the discharge process. This is important because continuity of health care is achieved through interpersonal relationships, the sharing of information and the effective coordination of interventions, being these elements a needed part of transitional care. Otherwise, poor communication, the absence of common objectives and the lack of coordination of actions compromise the process.Nurses.There are studies associating transition actions and continuity of care with a reduction in unplanned readmissions and lower disease complications, mortality and costs. It is therefore important to understand how these interventions adapt to different healthcare settings and which approaches are most effective.Continuity of care is discussed worldwide as a representation of the patient’s experience of healthcare and the interconnection of these elements in the care journey, aligned with their needs and preferences, doctors and social workers or physiotherapists. Nationally, interprofessional work (IPW) and the transition of care in the de-hospitalization of patients have been gaining prominence. However, the operationalization of responsible hospital discharge based on individual, collective and environmental forces, proposed in this manuscript, has been little explored in the literature. In de-hospitalization, it is essential that professionals work both with the patient’s needs and potential and with family structuring and organization, with the support of the RAS and with interprofessional collaboration among services.The majority of studies highlight the work and problems arising from the continuity of care (or lack of thereof) by focusing on individual categories, such as nursesThis research is part of a master’s dissertation dealing with nursing time and the effectiveness of care transitions and is linked to the Health and Nursing Services Management research group (GESTSAÚDE in the Portuguese acronym). Its aim is to analyze the interprofessional team’s perception of the actions carried out during responsible hospital discharge and their contribution to improving the transition and continuity of patient care. Thus, it seeks to answer the following question: In the perception of the interprofessional team, what actions are carried out during the responsible discharge process that contribute to improving the transition and continuity of patient care?. This theory advocates patient/family-centered care, aimed at developing autonomy and self-care, through collaborative practice and health promotion and prevention actions. It identifies individual and external competencies, capacities and resources as strengths. The Consolidated criteria for reporting qualitative research (COREQ) tool was used to guide the design and presentation of the research.This is a descriptive, exploratory, qualitative study applying semi-structured interviews and based on the theoretical framework of Strengths-Based Nursing CareThe study was developed in two inpatient units, one medical-surgical and the other for palliative care, of a teaching hospital of special size, a reference in high complexity, located in a city of the state of São Paulo. Together, the units under study had 86 beds, with patients from different specialties requiring attention regarding the use of invasive devices  and post-discharge care.The responsible discharge process was established at the institution in November 2015. In the model adopted, healthcare professionals work concurrently in patient care and are also trained to carry out discharge planning, which should begin within the first few hours of the patient’s admission. The following eligibility criteria are taken into account: patients hospitalized with chronic diseases, in palliative care, using devices such as probes, catheters and stomas or health equipment, high-risk pregnant women, puerperal women with any comorbidity and premature newborns.This process begins when the nurse identifies the frailty or eligibility criteria defined by the institution and then calls in the other members of the healthcare team to draw up the therapeutic project and discharge plan in an interprofessional manner. Throughout their hospitalization, patients must participate in care activities, receive guidance and be encouraged to make decisions about their treatment. The bed management service makes the connection with the RAS and thus monitors the process for drawing up the referral and counter-referral guide containing the post-discharge care proposal.All 15 health professionals, including doctors, nurses, physiotherapists, nutritionists, speech therapists and social workers, who were members of the care team and also responsible for discharge planning in the units investigated, were invited to participate. In order to take part in the study, they had to meet the following criteria: work during the daytime and have at least one year’s experience in the responsible discharge process; those who were on vacation and/or on different types of leave were excluded.Health professionals were contacted in person and by message via telephone application. After consulting on the best strategy for carrying out the interviews, due to the COVID-19 pandemic period, the decision was made to meet in person, in a reserved and easily accessible place within the institution. Security measures were duly complied with and data collection took place between October and November 2020.One of the researchers with experience in the discharge process conducted the sessions that were held solely with the researcher and the invited professional. First, clarifications were made about the study and, after consenting, the participants answered sociodemographic questions .How do you perceive the structuring/organization of the responsible discharge process in this institution in relation to the favorable aspects ; and those that could be improved? 2) Is there integration between professionals and coordination between actions? 3) Is the time you dedicate to each patient sufficient/adequate? 4) Does the responsible/qualified discharge process effectively prepare the patient for continuing care at home?The participants were then asked: 1) . It was reached when the twelfth interview was completed with two professionals from each area of knowledge.Data saturation was used as a parameter to determine the number of answers to the proposed questionsThe reports were recorded and the interviewer also recorded aspects to be clarified during or at the end of each meeting. Only one interview was carried out per professional, in the morning or afternoon, lasting approximately 20 minutes. The transcriptions were made in a Microsoft Word document, keeping the words in their entirety., without the aid of qualitative data management software, following the stages: pre-analysis, exploration of the material and treatment of the results. In the pre-analysis, the material was organized by grouping the professionals’ answers according to the interview questions: structuring and organization of the process; collaboration in the transition of care; time dedicated and preparation of the patient to continue post-discharge care.The study adopted the thematic content analysis and based on strengths. As an exploration procedure, the material was coded into recording units and the deductive process was used to identify converging variables. In order to qualify the findings, the codes and themes were independently delineated by two researchers and then validated by a third.The analysis began with a floating reading of the material and the organization of main points to formulate hypotheses based on the assumptions of continuous care and the literature on interprofessional work,2, discharge planning, transition and continuity of patient care,11,12,16.To process and interpret the results, we proceeded with synthesis, data selection and inferences to extract the thematic categories agreed upon by the researchers and based on the theoretical frameworkThe study is compliant with Resolution 466/2012 and was cleared by the Research Ethics Committee of the study institution under opinion number 4.347.495/2020. Data collection was carried out after the study objectives had been explained to the participants, and acceptance was obtained by signing the Free and Informed Consent Form.In order to preserve anonymity, the participants were randomly identified with letters and numbers  and professional category .The study included 12 female professionals, two from each professional category , with an average age of 37.7  years. They had been working at the institution for an average of 9.5  years; eleven of them had a specialization course in various areas and the average length of experience in the responsible discharge process was four  years.We found that nine codes emerged from the analysis of the reports: early discharge planning, patient/family participation in discharge, guidelines for continuing care, repercussions of post-discharge actions, communication between professionals , nurse mediator, (dis)articulation between services, dedicated time, telephone contact and post-discharge home visits. Three thematic categories were then extracted: Informational continuity in responsible discharge; Interaction between professionals and services for the transition of care and Workload management for better transition and continuity of care, the first of which was made up of the subcategories “Communication between professionals”, “Guidance for the patient/family/caregiver” and “Results perceived by the team”.In order to plan hospital discharge and start transition actions, according to the interviewees, early communication from the medical team would favor the actions of the other professionals in the process. Although there were moments of interaction between the professionals, the decision on discharge proved to be centred on the doctor and the information shared did not occur in a timely manner or was not sufficient for the organization and qualification of the responsible discharge.(...) often the team calls it a qualified discharge, but in practice it doesn’t happen... the qualified discharge patient leaves... and there wasn’t a program. (E8 – Nutritionist)I think the medical team could give more advance notice. (E11 – Nurse)I think that communication between the team could be improved, because it’s not every day that there’s a visit (...) so sometimes there’s a lack of organization and communication. (E2 – Physiotherapist)They also highlighted moments of inclusion of the patient/family/caregiver in clinical decisions and guidelines for the development of care at home, but expressed social challenges, such as the difficulty of identifying the main caregiver to ensure the continuation of care.Most caregivers, family members who are accompanying the patient, do participate in the planning. From the very first moment that some device is put in place, then we start with the guidelines. (E11-Nurse)(...) they participate during hospitalization... especially with conscious patients, who are oriented, they have the right to choose, if they’re going to use the tube, if they want the tube (...) (E5 – Physician)(...) it’s very important to identify this main caregiver... throughout hospitalization, but often this isn’t possible,(...) it depends on the family’s profile, social and cultural condition,(...) what they understand(...) .In the practitioners’ view, when the team was able to provide the necessary information and develop self-care skills in the responsible discharge process, there was greater de-hospitalization and bed turnover and a lower rate of unnecessary re-hospitalization.(...) it was good for this, for us to prepare the companions, the caregivers... thus avoiding unnecessary re-hospitalization.(E2 – Physiotherapist)(...) the team treatment, we can manage the patient more quickly, so we de-hospitalize, (...) we discharge more people, we generate less costs for the hospital, (...) (E5 – Physician)Also, regarding the institution I see that maybe it helps financially, bed turnover...” (E8 – Nutritionist)However, they recognized deficiencies in the guidance provided to patients/family members/caregivers within the hospital, and a lack of follow-up after discharge. Only one doctor suggested telephone contact and home visits as strategies for assessing and clarifying doubts after discharge.(...) I think that sometimes there are still gaps, that we still see patients leaving without receiving any guidance (...) (E3-Speech-language therapist)(...) it helps a lot, but I think it’s not 100% effective because of this lack of follow-up (...) (E7-Nutritionist)(...) if there was more time, more days to give guidance, (...) because sometimes it’s all on the same day,.. the family is full of information and they get home and there’s doubt(...) to give guidance by video(...) not just in writing. (E3 – Speech-language therapist)(...) making a brief telephone contact seven days after discharge, or/and making a home visit after discharge(...) could avoid a lot of readmissions(...) (E6 – Physician)Preparing the patient for post-hospitalization care requires effective communication between professionals and with the patient/family. According to the reports, the communication process during responsible discharge needs to be improved, both in terms of hospital structure and organization and in terms of dialogue and collaboration between people, services and the community.Interaction between professionals was facilitated by the use of the social media WhatsApp and by team meetings, even though it was still considered to be fragmented. There was recognition of the nurse as a mediator between the doctor and the interprofessional team and obstacles in receiving feedback from Primary Health Care.(...) WhatsApp groups make it much easier for [professionals] to work together. (E3 – Speech-language therapist)(...) the nursing team (...) who make the link between the doctor and the multi-professional team (...)[nursing] is a key part of this, which helps a lot in this qualified discharge (...) (E8 – Nutritionist)(...) there could be more team meetings (...) drawing up this plan together with all the professionals (...) it [team meetings] exists, but in a very fragmented way (...) (...) we have multi-rounds twice a week, not every day (...) this could be improved (...) it’s still in the process of being improved (E2 – Physiotherapist)(...) we don’t know if they’re doing [post-discharge follow-up] in the municipality because there’s no feedback, if they manage to do it (...) (E12 – Nurse)In addition to informal interaction, the team requires frequent interprofessional meetings and discussions to improve discharge planning. Despite the dialogical relationship, the collaborative construction of a common therapeutic project for transition and continuity of care is not routinely practiced by the team. In this context, a responsible discharge movement is identified, with weaknesses in the articulation of professional knowledge and the different points of the RAS.The professionals reported high demands for patients with criteria for inclusion in the responsible discharge process, as well as other activities, not allowing to attend all the team meetings and devote enough time to preparing the patient/family member for the transition and continuity of care. They also stated that some appointments were not made.(...) we have a very heavy workload, there are a lot of patients, so I can’t always take part in all the qualified discharge meetings, (...) sometimes the patient leaves and (...) we miss out, we can’t provide guidance (...) (E3 – Speech-language therapist)(...) so that’s an average of thirteen patients a day (...) I think the time is always short (...) (E6 – Doctor)(...) the time could be longer (...) as productivity is demanded; sometimes, we reduce the time (...) (E7 – Nutritionist)(...) most of the time [the time] isn’t adequate, not least because of the demand, (...) it ends up being a time that varies a lot with the demand, the needs, the complexity of each patient. (...) we always have two or three [patients] to deal with every day (...) there should be more time for us to dedicate to this (...) (E11 – Nurse)The overload of the clinical team hampers performance in the responsible discharge process, and was found in the investigated site, to be a critical factor in the transition and continuity of patient care.,12 and how challenging it is to empower the patient/family and develop self-care, as proposed in the theory of strengths and in national policy. These difficulties were also emphasized in a recent study involving professionals from the Swiss health system.The responsible discharge process in the studied context was structured around interpersonal communication with significant deficiencies and centrality in medical decision-making. The findings highlight the importance of informational continuity. Dialogue is one of the characteristics of the IPW and the definition of common, patient-centered objectives contributes to meeting the required needs. However, the proposal of organizing services in order to meet the patient’s health demands in accordance with collaborative interprofessional practice confronts the persistent hegemonic model of care, especially in hospital institutions.It is known that the exchange of information between team members is a determining factor in discharge planning and continuity of care. This corroborates the findings of the present study. The interviewees valued the opportunities to meet and exchange knowledge between the different professionals, with special attention to the medical professional, and stressed the need to systematize and regularize team discussions. However, in practice, the definition of common objectives for patient discharge is not prioritized.A Canadian study showed that medical collaboration is a differential in the discharge process. When physicians get involved with the other team members and engage personally and regularly in interprofessional discussions, a bond is built and there is a greater possibility of shared decisions with a positive impact on discharge planning negatively affect the process. There have been suggested educational interventions in order to develop more collaborative teams capable of understanding the different perspectives and reaching a consensus on the discharge plan,20, and to strengthen relational continuity,12, as well as informational continuity.The different views on patient care, inherent in the training process; the difficulty in recognizing the role/knowledge of others; and the weakness of team communication; however, issues related to lack of regulation, confidentiality and data security have emerged. Team meetings were also established, but work overload and a lack of systematization were negative aspects that led to fragmented care. More dialogical relationships require frequency, spaces and instruments to standardize the information transferred.Interaction/communication between the professionals investigated was facilitated by the use of the social media WhatsApp. This technology has been widely used by health professionals to save time and improve sharing of information,5,11. Considering that this is a complex process that requires networking, time commitment and specific skills, European,26 and North American institutions have adopted discharge management teams or nurses with exclusive dedication, that are called linkage, liaison, case managers or navigators, in order to coordinate and facilitate counter-referral and continuity of patient care. In these models, even if there is a process coordinator, there are mainly professionals who provide direct assistance to the patient/family in the hospital units.Nurses have been recognized as mediators of interprofessional relationships and have been assigned the task of coordinating transition actions, i.e. management continuity. The participants in this study reaffirmed this limitation, as they carried out various activities in the hospital routine, in addition to those related to responsible discharge, and the time constraints limited the quality and quantity of assessments and guidance they would need to carry out. This situation has also been identified by other authors.In the Brazilian landscape, the exclusive role in discharge planning and continuity of care is still limited and, in most institutions, the actions are responsibility of the clinical team alongside other duties, which can compromise the effectiveness of the process, but in addition to the interaction between different professionals, the decision-making process for hospital discharge involves inter – and extra-organizational factors.In addition to the informational, relational and managerial restrictions in the micro-context of practice, there was a lack of coordination between the different levels of care. Electronic medical records have been identified as a facilitating channel for the transfer of information between healthcare services. Patients value this post-discharge follow-up experience and the combination of these interventions (nurse home visits and telephone follow-up) has proved effective in preventing unplanned readmissions.Only one of the interviewees (a physician) suggested monitoring the patient through telephone contact after discharge and scheduling a home visit depending on the care demands. It is known that telephone contact and home visits are important strategies for continuing and evaluating care after dischargeThe interviewees confirmed the involvement of the patient/family/caregiver during hospitalization to clarify doubts about care and jointly decide on the proposed interventions. However, they revealed vulnerabilities in the process, such as: high workload, ineffective communication and social issues of the patient/family, which made the centrality and continuity of care unfeasible from the perspective of the patient’s autonomy., were not clearly mentioned by the professionals who emphasized problems as the logic of care. In addition, the concentration of information on the last day of hospitalization, especially without prior planning and involvement, is a mistake in preparing for discharge. It is known that early identification of needs, participation in therapeutic decisions, guidance received, emotional support, as well as continuity of access, information and relationships are factors that have a significant impact on the patient’s/family member’s experience of the journey. This experience of continuous care throughout the healthcare journey is the desirable process to achieve.The strengths portrayed by skills and personal and family resources, as well as the support network and services availableThe professionals interviewed associated better transfer of information and promotion of autonomy with better results . However, this effectiveness needs to be better investigated. for better effectiveness in the transition and continuity of health care. Furthermore, the teams are challenged to expand care beyond the problems, understanding the individual and external strengths of the subject as potential for care after hospital discharge.The hospital under study instituted the responsible discharge model more than seven years ago and the team has experience in the process, but in addition to piling up other activities added to the relevant tasks for the responsible discharge, interprofessional work and ensuring post-discharge care remain challenging. Structural and procedural issues, i.e., the organization of the service, collaboration between team members and the centrality of care for the patient still need to be improved, as well as better coordination within the RAS. It is necessary to invest in the triad composed by information, interpersonal relationships and coordination of careAs limitations, in this study, the reports represented the perception of some professionals from a teaching hospital at pandemic times. Other contexts, health situations or other professional categories could identify new demands. Individual interviews do not allow for interaction between professionals, which could have generated different contributions. Therefore, further research into responsible hospital discharge could explore both the professional experience, and the experience of patients, individually and/or collectively; and also investigate outcome indicators, confirming or refuting the views emerging from the group interviewed.The findings of this research allow for providing guidance for health teams regarding the challenges to be overcome in the responsible hospital discharge process, helping managers as well, to plan, implement and evaluate critical points in the transition and continuity of patient care. Thinking of strengths-based care as a theoretical model guiding nursing practice and focused on the potential of the patient/family/community and the RAS, with an emphasis on collaborative practice, is another relevant aspect of this study. The dissemination of these attributes in the nurse training process and in educational actions in service are still fragile and need to advance. In addition, the model would need to go beyond nursing knowledge and interventions, in order to be recognized and adopted by the health team as a philosophy of comprehensive and continuous care that would apply to responsible discharge with transitions based on strengths.Faced with still fragmented health care, professionals, managers, educators and researchers are provoked to (re)think effective strategies for collaborative interprofessional practices, centered on the patient and their strengths, with better articulation between the different points of the network to obtain successful experiences of continued care.The staff interviewed acknowledged that responsible hospital discharge can have a positive impact on both the institution (higher bed turnover) and the patient (reduction in unnecessary readmissions). However, interprofessional work needs to be strengthened to ensure the informational and relational continuity inherent in the process. The various activities undertaken by the professionals made it impossible to devote more time to responsible discharges, so effective management of the workload proved to be a relevant factor in improving the transition and continuity of patient care.


This study aims to explore the association between exposure to neighborhood violence and the presence of common mental disorders (CMDs) among Brazilian adolescents aged 12 to 17 years. Additionally, we aim to analyze whether sex, age and race are modifiers of the effect of this association.The study comprised 1,686 adolescents residing in the municipality of Rio de Janeiro, situated in the Southeast region of Brazil. To measure exposure to community violence, we constructed three crime indicators using data from Civil Police of the State of Rio de Janeiro: crimes against property, nonlethal crimes, and lethal crimes. Employing geospatial analysis based on the adolescents’ residence location, logistic regression modeling was performed to measure the association between violence and CMDs.Adolescents living in regions with higher rates of the three types of violence studied herein were more likely to have CMDs, with odds ratios (ORs) ranging from 2.33 to 2.99. When stratified by sex, age and race, girls, older adolescents and blacks have a greater magnitude of effect on the measure of association, indicating a heightened risk for CMDs.This study provides important contributions to the public health field, as it reveals new information on the influence of community violence on the mental health of adolescents. Given the elevated rates of violence globally, knowing the effects of such violence on adolescents becomes crucial for the prevention and treatment of CMDs within this population. Common mental disorders (CMDs) correspond to a group of symptoms encompassing anxiety, depression, and somatic complaints, though not necessarily indicative of pathologies . CMDs arIdentifying risk and protective factors for CMDs in adolescents is of paramount importance. Community violence (CV) has been shown to be an important risk factor for mental disorders in adolescents  and can The influence of CV on the mental health of adolescents has been the subject of two meta-analyses and three reviews recently , 8–11. ACMDs are more prevalent among girls than boys . One plaRegarding age, it is remarkable that older adolescents often engage in greater social interactions and consequently encounter higher levels of exposure to community violence (CV). Conversely, some literature hypothesizes that they might also possess a greater degree of emotional maturity and a more extensive array of psychological resources for effectively coping with adversities, hence the findings within the literature vary . ConsideRegarding race, a meta-analysis investigated the relationship between racism and physical and mental health and revealed a significant association between experiences of racism and poorer mental as well as physical health . HoweverWe justify the present study based on the high prevalence of CMDs among adolescents and the high incidence of violence occurring in communities. Both CV and CMDs are public health problems and are amenable to interventions. The literature points to a clear relationship between exposure to CV and an increased risk of CMDs, but the effects of race, sex and age on this relationship still need to be clarified. In addition, few studies have been carried out in low- and middle-income countries, where CV rates are substantially higher. We can suppose that in places with greater exposure to violence, its effect on the mental health of adolescents may be different from that in places with lower rates. Finally, few studies in the literature have used indicators of violence based on criminal statistics, since differences may exist between objective and subjective measures of violence in the association with mental disorders in adolescents. More studies need to be carried out with these indicators.Brazil, and more specifically, the city of Rio de Janeiro, possesses social, cultural, and economic characteristics that have been largely associated with increased prevalence of mental disorders. Notably, exposure to violent communities stands out as a factor with significant impact on life quality, particularly among adolescents who are beginning to explore the environment more freely. Our hypothesis is that exposure to community violence is a significant risk factor to increased prevalence of common mental disorders among adolescents. Furthermore, we hypothesize that the older, the females, and the black skin adolescents encounter amplified risk compared to their peers. Through an examination of these associations, our study aims to demonstrate the impact of community violence on mental health and to address potential discrepancies among distinct groups within the adolescent population. With this study we also aim to provide insights for potential interventions and support in health care systems.This study includes a subsample from the Cardiovascular Risk Study in Adolescents (ERICA). ERICA was conducted with a random sample, with national and school representativeness, and included 74,589 adolescents aged 12 to 17 years who were students at public and private schools. The inclusion criteria for ERICA were as follows: students aged 12 and 17 years who were enrolled in public or private education between the seventh year of elementary school and the third year of high school. The exclusion criteria were as follows: students who were physically disabled and unable to perform anthropometric assessments, students who were obese and students who were pregnant. Data were collected from March 2013 to December 2014. Individual data from the adolescents were collected through a self-administered questionnaire using an electronic personal data assistant (PDA) .The subsample used in this study included 1,694 adolescents living in the municipality of Rio de Janeiro, which is located in the Southeast region of Brazil. Among these adolescents, eight were lost due to a lack of information; therefore, the final sample consisted of 1,686 adolescents. The reason for selecting this subsample was the possibility of georeferencing residential addresses; this information was available only for adolescents who had blood collected for ERICA and allowed access to public safety data based on neighborhoods in the municipality where the adolescents resided. The geocoding success rate was 75%.The study subsample comprised adolescents participating in ERICA and residing in the municipality of Rio de Janeiro, and for which we had addresses for georeferencing and data from the Public Security Institute. Therefore, the study did not encompass the entire metropolitan region of Rio de Janeiro, focusing solely on adolescents within the municipality area.To measure CV exposure, based on the definition of CV as violence occurring outside the home and mostly by unknown people, we used three crime indicators based on the Proposed Indicators of Violent Crimeepolate command in Stata 14.0.The information for the construction of these indicators was obtained from records at the Civil Police of the State of Rio de Janeiro (CPSRJ). The population of individual neighborhoods in the municipality of Rio de Janeiro was also used; the data are available on the website of the Pereira Passos Institute (Instituto Pereira Passos—IPP). To obtain the estimated populations for the year that the data were collected (2014), interpolation was performed using the populations in 2000 and 2010 and the QGIS 3.16 software.To better capture CV exposure for each individual in their neighborhood, the crime indicators and geocoded residential addresses of the study participants were plotted on a map of the Rio de Janeiro neighborhoods. Buffers (circles with a radius around a point) of 500 m were created around each individual, and the weighted averages of the indicators of crime of all the neighborhoods overlapping with the buffer area were calculated. The weights used were proportional to the overlapping area. Thus, the exposure for each individual was measured not only by the crime rate of their neighborhood but also by the rates of the adjacent neighborhoods for individuals with buffers overlapping more than one neighborhood. All the geoprocessing was performed using CMDs were identified using the validated Brazilian version of the General Health Questionnaire (GHQ-12), which was answered by each adolescent. This instrument consists of 12 questions used to assess psychological distress—non-psychotic mental disorders, defined by anxiety and depression symptoms, inability to deal with ordinary situations and lack of self-confidence. Questions are related to mood, sleep and attention symptoms in the previous 15 days. Each positive response is scored one point, and a score greater than or equal to three was classified as positive for CMDs. The questionnaire is widely used in several countries  and has Socioeconomic status (SES) was used as a covariate and was constructed based on the Brazilian Economic Classification criterion, which uses information on the possession of goods, the number of bathrooms, having or not having domestic servants, and the education level of the head of the household to establish economic classes, with A corresponding to the highest economic class and E corresponding to the lowest class . All ansSex, age and race were considered possible effect modifiers and were constructed from the responses provided by the adolescents .The exposure variables were transformed to their natural logarithm, due to its asymmetrical nature, and then classified as either low or high, with the low level being used as a reference in the regressions. Considering the distribution of crime indicators in the study population and the lack of a consensus regarding their categorization in the literature, we used the median as the cutoff point for division into categories.Stata version 14.0 was used for the analyses.Univariate logistic regression modeling was performed, to estimate the gross effect of each independent variable on the dependent variable, followed by adjustment for SES covariates, age, sex, and race. The raw models are not presented herein but may be available upon request. Multivariate logistic regression models were adjusted using the same covariates described above and stratified first by sex, then by age, and finally by race. In the stratified models, the stratification variable was not included as a confounding variable. A statistical significance level of 0.05 was adopted for all analyses, and svy module of Stata software was used. Thus, in the presentation of the study population, the number of participants from each stratum corresponds to the sample size, and the proportions and respective confidence intervals presented refer to the weighted proportions considering the sample weights, i.e., the total ERICA sample.Because the sample was complex and the analyses involved three stages , all analyses considered sample weights. For this purpose, the Table Figure Table Figures The exposure variables were constructed as described before and classified into two levels—low and high, with median as the cutoff point for division into categories. The lower level was used as a reference in the regression models. Sensitivity analyses were performed by operationalizing the indicators into quartiles and quintiles; no benefit was observed.Table The main hypothesis of this study proposes that exposure to community violence acts as a significant risk factor for a higher prevalence of common mental disorders in adolescents. The main results showed that adolescents living in regions with higher rates of the three types of violence were more likely to have CMDs, with ORs ranging from 2.33 to 2.99. The greatest effect was observed for crimes against properties. Since this type of crime is more common and the proportion of people with CMD is fixed across the analyses for all types of crimes (i.e. the same study population), it is reasonable that the proportion of CMD positive people exposed to higher levels of this crime indicator is slightly higher than for other less common types of crime. Thus yielding a slightly higher effect size estimate.An additional hypothesis was that older, girls, and black adolescents encounter an even greater risk compared to their peers. The results also confirmed this—when stratified by sex, age and race, it becomes clear that the older, the girls, and the black adolescents have higher risks of CMD than their counterparts.Regarding the first finding – adolescents living in regions with higher rates of violence have higher chances of CMD, no consensus has been established in the literature regarding the association between exposure to CV measured by crime indices and the mental health of adolescents. Two studies conducted in Colombia found positive associations for some outcomes but not for others. The first study, which was performed by Vellez-Gomez, classified regions (communes) based on homicide rates and divided the outcome (depression) into subscales, with a greater likelihood of feelings of ineffectiveness  for adolescents aged 10 to 12 years exposed to high levels of violence; however, the same was not observed for other symptoms of depression . The secOn the North American continent, Gepty revealed an association between living in more violent regions and depressive symptoms. However, such conclusions pertained only to adolescents who presented rumination, i.e., a pattern of persistent thoughts related to past events and difficulties in life, as a psychological coping strategy. These authors used as exposure variable the rates of violent crimes, such as homicide, rape and armed robbery, and compare with the rates of nonviolent crimes, such as theft and simple robbery . GrinshtThe lack of standardized community violence rates presents a challenge in the comparison of studies. Consequently, the formulation of crime rates, encompassing not only homicide rates but also broader crime categories, could offer a potential solution to enhance the comparability of future studies.Regarding the second finding of this investigation, the heightened risk magnitude for girls in developing CMDs subsequent to exposure to the three types of violence when compared to boys, we can conclude that sex operates as an effect modifier in this association. This result is consistent with some results reported in the literature. When studying the associations between CV and anxiety and depression in adolescents, Bacchini analyzed the difference between sexes and observed that girls had a higher likelihood of developing associated symptoms than boys . Boney-MRegarding the third finding, that older adolescents (15 to 17 years old) had a higher risk magnitude of having CMDs than younger adolescents (12 to 14 years old) for the three types of violence studied, we concluded that age was an effect modifier in this study, although the literature is inconsistent about his findings. When performing a meta-analysis evaluating the risk of developing mental disorders related to CV exposure, Fowler found a difference regarding to age; children, adolescents, and young adults were considered, and the risk was higher for adolescents (12 to 25 years) than for children (less than 12 years) . Other rLatino individuals compared to white individuals, suggesting that desensitization is present in other ethnic minorities. In a meta-analysis performed by Fowler [Regarding the fourth finding, that black individuals had a higher risk magnitude of having CMDs than non-black individuals after exposure to high levels of CV for the three types of violence studied herein, we concluded that race was an effect modifier in this study. These results are of fundamental importance because despite the large difference between black individuals and white individuals among victims of CV, with young black individuals being predominantly affected , few stuy Fowler , race coSome studies emphasize the experience of black individuals with regard to CV. Borowsky studied a sample of approximately 20,000 adolescents who answered a question about fearing an early death (before age 35), with 25.7% of black individuals answering yes but only 10.2% of white individuals answering yes . When an. conducted a study using data from the National Household Sample Survey (PNAD) of 2009, collecting information directly from the interviewed individuals regarding being victims of theft, robbery or physical aggression in the last year and whether the incidents were reported to the police. The results indicated a hidden number rate in Brazil of 62.55%; in the state of Rio de Janeiro, the average rate was 63.19% for three types of crime . Through probit regression, sociodemographic factors were associated with hidden figures for robberies and thefts; the rates were found to be higher for females, people with lower education levels and younger age groups. Therefore, the crime indicators constructed in this study are likely to be significantly higher than those measured through criminal records [An important consideration that can influence our results is the hidden figures not included in crime indices. These hidden figures are understood as the number of crimes not reported to the government. Caetano et al records , which mfavelas are territories where the state is almost always unable to guarantee its sovereignty and enforce constitutional order, and this absence is often filled by individuals involved in the illicit drug trade and militias. The author indicates that racism arising from the continuing legacy of the colonial-slave model established in Brazil is currently perpetuated in institutional mechanisms through which the state acts on black people [. The facts presented do not invalidate the results but reinforce the need to evaluate them from the perspective of unequal underreporting, which may represent an even greater effect of CV among black adolescents and favela residents.As pointed out by Casseres, k people . Therefok people . The facFinally, we address the issue of homicides perpetrated by the police. Brazil has a high rate of homicide caused by the state, which is concealed under the guise of acts of resistance, a specific procedure for recording the deaths of civilians resulting from police actions . Thus, hThe main strength of this study is the measurement of exposure to CV. Measuring this variable through the creation of crime indices has some advantages, such as the elimination of respondent bias. This bias could have occurred when an adolescent provided information about his or her exposure to violence and mental health because the former can change how he or she perceives the environment and how he or she reacts from an emotional point of view . The claLosses from and the selectivity of the georeferencing process were limitations because these losses were higher in less urbanized neighborhoods and for adolescents with irregular occupations and a lower SES , possiblThis study provides important contributions to the field of public health, as it reveals new information on the influence of CV on the mental health of adolescents. Among the main findings are the greater likelihood of CMDs for adolescents living in violent regions who experience both crimes against property and crimes against people, as well as the greater vulnerability of girls, older adolescents and black populations.Given the high rates of violence globally, which are even higher in low- and middle-income countries, knowing the effects of violence on adolescents is critical to prevent and treat CMDs in this population. There is a pressing need for additional studies that delve into the roles played by race, gender, and age, particularly in regions characterized by elevated violence rates. Such research is essential for identifying the most susceptible demographic groups, thereby contributing to the formulation of effective public policies.


The International Council of Nurses’ 2021 code of ethics mandates nurses to provide evidence-informed care to patients. Globally, using research evidence has led to improvement in nursing and midwifery practice, according to the World Health Organization. A study in Ghana found that 25.3% (n=40) of nurses and midwives use research in clinical care. Research utilization (RU) increases therapeutic effectiveness, improves health outcomes, and enhances the personal and professional development of clinicians. However, it is uncertain the extent to which nurses and midwives are prepared, skilled, and supported to utilize research in clinical care in Ghana.This study aims to develop a conceptual framework that can facilitate RU among clinical nurses and midwives in Ghanaian health facilities.This will be a cross-sectional study with a concurrent mixed methods approach. It will be conducted in 6 hospitals and 4 nursing educational institutions in Kumasi, Ghana. The study has 4 objectives which will be executed in 3 phases. Phase 1 follows a quantitative approach to describe the knowledge, attitudes, and practices of clinical nurses and midwives on the use of research in their practice. Using a web-based survey, 400 nurses and midwives working in 6 health facilities will be recruited. Data analysis will be conducted using SPSS, with statistical significance set at .05. Qualitative methodology, using focus group discussions with clinical nurses and midwives, will be conducted to identify the factors influencing their RU. In phase 2, focus group discussions will be used to examine and describe how nurse educators in 4 nursing and midwifery educational institutions prepare nurses and midwives for RU during their education. Views of nurse managers on the RU in Ghanaian health care facilities will be explored in the second section of this phase through one-on-one interviews. Inductive thematic analysis will be used to analyze the qualitative data, and Lincoln and Guba’s principles of trustworthiness will be applied. In phase 3, the stages of model development proposed by Chinn and Kramer; and Walker and Avant will be used to triangulate findings from all objectives and formulate a conceptual framework.Data collection started in December 2022. Publication of the results will begin in April 2023.RU in clinical practice has become an acceptable practice in nursing and midwifery. It is critical that nursing and midwifery professionals in sub-Saharan Africa shift their practice to embrace the global movement. This proposed conceptual framework will empower nurses and midwives to improve their practice of RU.DERR1-10.2196/45067 The 2021 code of ethics of the International Council of Nurses mandates that nurses across the globe should provide evidence-informed health care to patients ,4. EBP iRU is defined as the process of analyzing, disseminating, and implementing research-produced knowledge to influence or improve current nursing practice ,9. This Globally, the use of research in nursing practice has been found to have enormous benefits for both providers and recipients of care . The benIn Ghana, most of the studies that have been conducted on nurses and research have focused on EBP ,19-21 wiIn addition, there is an urgent need for formal training of nurses and midwives on how to utilize research evidence in their practice. However, there have not been any studies focusing on how nurses are prepared to implement RU in Ghana. This has led to a dearth of information on how well RU is incorporated in both the undergraduate and postgraduate curriculum and the extent to which they are prepared to implement RU after their training. Moreover, leadership plays a key role in the implementation of programs that ensure improved clinical care, which includes RU . Nurse mGlobally, research evidence use in nursing practice has become imperative due to increasing knowledge and technology . Using rFurther, due to the enormous benefits of RU and the interplay of factors that influence its implementation, evidence suggests that the recurring problem of implementing research in clinical nursing practice can be resolved by offering a framework to guide the implementation of evidence in practice ,22,34,35The study will be cross-sectional, using a concurrent mixed method approach. The quantitative methodology will be used to identify the knowledge, attitudes, and practices of RU among the nurses. Concurrently, the researcher will collect qualitative data to explore the barriers to and facilitators of RU, the preparation of nurses and midwives, and the views of nurse managers on RU in health facilities. This will ensure synergy of the results to help in the development of a conceptual framework to facilitate RU in Ghanaian health facilities. This study will be implemented in 3 phases, chronologically. Quantitative data will be collected and analyzed independently, as well as the qualitative data. The results will then be interpreted and triangulated to inform the development of the conceptual framework of RU.The study will be conducted in health care facilities and nursing and midwifery educational institutions within Kumasi city, in the Ashanti region of Ghana. The study sites are 6 health facilities and 4 nursing educational institutions, depending on the study phase and objective. Specifically, the health facilities are 1 teaching hospital, 1 quasi-health facility, and 4 Ghana Health Service facilities. The facilities were selected for the study because each represents an agency of the Ministry of Health in Ghana, which regulates their activities. The educational institutions are 2 degree-awarding universities and 2 diploma-awarding training colleges. The institutions were selected based on ownership, that is, private or public, and the level of education—diploma or bachelor’s degree. This is to ascertain whether there are variations in the preparation of nurses and midwives based on the ownership and level of training.This phase will be divided into 2 sections based on the specific objectives to be achieved. The study sites for this phase are 6 health facilities.The goal of the first part is to describe the knowledge, attitudes, and practices of clinical nurses and midwives regarding the use of research in clinical practice in Ghana. The quantitative research methodology will be used to achieve this objective.Nurses and midwives who work in the clinical units of the health facilities with a minimum educational qualification of a diploma in nursing or midwifery and who have worked for not less than 2 years post qualification will be included in the study. Nurses and midwives who will be on leave at the time of data collection or are working on a part-time basis will be excluded. A sample size of 400 was calculated using Taro Yamane’s formula for calculating sample size and a 10% dropout rate. Multistage sampling, including proportionate and systematic sampling methods with a sampling interval of 9, will be used to achieve the target sample size in each health facility.All the data for this PhD study will be collected by the primary investigator (LBO), who is also trained in qualitative and quantitative research methods. For this study phase, data will be collected using an adapted Evidence-Based Practice Questionnaire created by Upton and Upton , as permP value of .05.Quantitative data will be analyzed using SPSS  and Stata . Exploratory data analysis will be carried out for the sociodemographic characteristics of the respondents. Inferential statistics will be used to ascertain the association between demographics and knowledge, attitudes, and practice levels. The chi-square test for independence and its alternative the Fisher exact test will be used to examine the association between categorical variables, while the nonparametric signed rank test will be used to examine the difference in the participants’ knowledge scores, and the Pearson and Spearman correlation coefficients will measure the degree of agreement between the scores. Structural equation model and factor analysis will be adopted to assess the effect of demographic characteristics  on RU in practice. Statistical significance will be established at To test the validity of the modified data collection tool, face validity was established by sending the questionnaire to 5 expert nurses and midwives who have a bachelor’s degree and work in the clinical area. Their inputs were used to modify the questionnaire. Pretesting was then carried out with 40 nurses and midwives, representing 10% of the sample size, who work in 2 health facilities located within the study area but not included in the study, using a web-based survey. Results of the pretest and inputs from the study supervisors as well as consultant statistician were used to modify the questionnaire. Cronbach α was calculated for the tool after modification to ensure reliability thereof. The overall Cronbach α factor for the tool was .8438, which is acceptable.The second objective of phase 1 will be to identify barriers and facilitators influencing RU by nurses and midwives in clinical practice. Qualitative methodology, specifically focus group discussions (FGDs) that will be held via Zoom for each facility, will be used to achieve this objective. The population will be the same as those who participated in objective 1 with 6-8 participants per group as suggested by Busetto et al  and OchiThe study in this phase will be used to achieve objectives 3 and 4. It will take place in 2 settings with 2 populations as follows: nurse managers in the selected health facilities used in phase 1 and nurse educators in 4 nursing and midwifery educational institutions.The objective here is to explore and describe nurse educators’ preparation of nurses and midwives toward RU in nursing and midwifery educational institutions. The phase 2 study sites will be the 4 nursing educational institutions stated earlier.The study will purposively sample nurse educators who have not less than 2 years of teaching experience and teach core nursing courses like pediatric nursing, medical and surgical nursing, neonatal nursing, public health nursing, and puerperium in the selected institutions. FGDs via Zoom will be held under the direction of an interview guide. The guide has 3 broad, open-ended questions to lead the discussions, with an emphasis on how the nurse educators prepare the nursing and midwifery students for RU, the challenges students experience in RU after nursing education, and the strategies that nurse educators could use to enhance RU in clinical practice. The number of participants per group, the duration of discussions, and the number of discussion sessions will be same as phase 1, objective 2.The second part of phase 2 is aimed at exploring the views of nurse managers on the RU in health facilities using qualitative methodology.Nurse managers in the 6 health facilities used in phase 1 will be engaged in a face-to-face key informant interview through purposive sampling. The interviews will be guided by a semistructured interview guide to solicit the nurse managers’ views on RU in their various health facilities. Data collection and thematic analysis will be done simultaneously and terminated when data saturation is reached.Data will be thematically analyzed using Braun and Clarke’s thematic analysis process . The recA total of 2 researchers will analyze the data independently and hold coding meetings until they reach intercoder agreement. Themes which emerge will be discussed with a group of participants to achieve member checking, thereby ensuring credibility. Also, method triangulation where the use of FGDs and individual interviews for data collection will be done so that the limitations of each method is counterbalanced whiles their strengths are projected . Again, This phase aims to develop a conceptual framework to facilitate RU by clinical nurses and midwives in Ghana. Findings from phases 1 and 2 will be triangulated and used to develop the conceptual framework. Data triangulation which uses data from multiple sources  will be The study has been approved by the Health Research and Ethics Committee of North-West University in South Africa (NWU-00070-22-A1), the Ghana Health Service Ethics Review Committee (GHS-ERC 003/07/22), the Komfo Anokye Teaching Hospital Institutional Review Board in Kumasi (KATH IRB/AP/152/22), and the Committee on Human Research, Publication, and Ethics of the School of Medicine and Dentistry at the Kwame Nkrumah University of Science and Technology in Kumasi, Ghana (CHRPE/AP/762/22).Data collection started in December 2022. It is envisaged that the results from phase 1 will unveil the knowledge, attitudes, and practices of clinical nurses and midwives regarding the use of research as well as factors influencing research use by nurses and midwives in clinical practice in Ghana. Phase 2 will identify the views of nurse managers on RU in nursing practice in their facilities and how nurse educators prepared student nurses and midwives to utilize research. Once all the findings from different groups of participants have been analyzed, we expect that the conceptual framework will be developed.Globally, RU is of utmost importance in health care and therefore cannot be downplayed -12. A syThe outcome of this study will have clinical, scientific, and socioeconomic impacts as it aims to produce a conceptual framework that will guide nursing and midwifery practice. The use of this framework will enhance the scientific practice of nursing and midwifery by enhancing evidence-based nursing care through the introduction of innovation to practice. Clinically, the outcome of this study, which is the development of the RU framework, when implemented, will improve patient outcomes by implementing tried and tested treatment modalities that will guide nurses and midwives’ decision-making and support their professional development. Socioeconomically, the implementation of the RU conceptual framework that will be developed at the end of this study will save time and money by improving the quality of patient care through cost reduction and effective treatment.The study should be considered with the limitation that the study will not validate the conceptual framework that will be developed since it is beyond the scope of this study. However, we believe that the strong theoretical underpinning, the methodology, and the population used in the study, as well as the triangulation of the results of the study that will be used to develop the conceptual framework, will make the framework a must-use approach in clinical practice to enhance nurses and midwives RU. We again believe that future studies will be conducted to validate and pilot the use of the conceptual framework.RU in clinical practice has become an acceptable practice in nursing and midwifery. It is critical that nursing and midwifery professionals in sub-Saharan Africa shift their practice to embrace the global movement. This proposed conceptual framework will empower nurses and midwives to improve their practice of RU.