This study investigated gender differences in exposure to hazardous factors, health problems, and work environment satisfaction and identified the effects of such differences on farmworkers in Korea. Through the 6th Korean Working Conditions Survey (KWCS) conducted by the Occupational Safety and Health Research Institute (OSHRI), the raw data on 2347 farmworkers were analyzed to present descriptive statistics for demographic characteristics, exposure to hazardous factors, health problems, and work environment satisfaction. We compared genders using chi-squared tests and investigated the effects of gender-specific working conditions on work-related health problems and work environment satisfaction using multivariate logistic analysis. The results were presented as an odds ratio (OR) with 95% confidence interval. Job position predicted work-related health problems in male farmworkers and work environment satisfaction in female farmworkers. Furthermore, female farmworkers perceived themselves to have more health problems than male farmworkers. Nevertheless, female farmworkers received less health and safety information and had lower work environment satisfaction compared to male farmworkers. The findings may improve the occupational welfare of farmworkers through continuous enhancement of the agricultural labor environment. The agricultural sector in Korea confronts a multitude of obstacles, including a higher incidence of accidents compared to other industries, a progressively aging and predominantly female workforce, and the pressing demand to secure a labor force that enables sustainable agricultural management. The injury rate in the agricultural sector stands at 1.4 times higher than the average injury rate for all industries . For insAs of 2021, the agriculture, forestry, and fisheries sector accounts for a meager 0.2% of all industries and 0.3% of the total workforce . NeverthHowever, the proportion of farm owners has increased in recent years due to a rise in the number of new farmers, including young adults, female farmers, and those transitioning from other industries . The numIn 2020, female farm owners accounted for approximately 20% of all farm owners , and thiTo advance various research and development endeavors and strengthen policymaking, it is important to examine the gender differences in farming work environments and identify their associated factors. Men and women have differences in physical characteristics, and their work characteristics and conditions may also differ, resulting in different trends in the incidence, type, and cause of work-related diseases and injuries. The physical work capacity of women is about 70% of men’s, and there are also differences in their physiology, such as muscular strength and oxygen consumption . Female However, there is a lack of research on gender differences in work environment satisfaction in the agricultural sector, which hinders the understanding of the gender differences in the effects of agricultural work conditions on health problems and work environment satisfaction.This study investigates the gender-specific exposure to hazardous factors, health problems, and work environment satisfaction among farmworkers and identifies the gender-specific predictors of work-related health problems and work environment satisfaction. Using data on farmworkers in the 6th Korean Working Conditions Survey (KWCS) conducted by the Occupational Safety and Health Research Institute (OSHRI), we ultimately aspire to present foundational data to enhance agricultural working conditions and facilitate relevant research.The raw data from the 2020 (6th) KWCS conducted by the OSHRI were used. The KWCS is conducted every three years on 50,000 economically active Korean residents aged 15 years and older. Economically active individuals are defined as “individuals who have worked at least one hour for income in the past week”, which includes “self-employed individuals without any employees”, “self-employed individuals and business owners with employees”, “wage workers”, “unpaid family workers”, and “workers on temporary leave”. The survey contains about 130 items pertaining to worker characteristics  The participants were sampled via stratified sampling in consideration of region, size of region, and type of housing to establish a sample representative of the farmworker population in Korea.From 50,538 participants of the 6th KWCS, we analyzed data on 2347 participants classified as farmworkers. In accordance with the KSCO or Korean Standard Classification of Occupations , farmworkers were defined as individuals engaged in crop cultivation (90.7%), horticulture and landscaping (4.0%), and animal husbandry and livestock-related work (5.3%).Variables unrelated to agricultural field were excluded from the items on the 6th KWCS. We selected the following variables appropriate for investigating agricultural working conditions. Gender and age were used as demographic characteristics, while job position, duration of farming career, exposure to hazardous factors, work-related health problems, and work environment satisfaction were selected to analyze gender-specific working conditions.Questions Q28 and Q29 were used to survey exposure to hazardous factors among farmworkers. For Q28, data on exposure to “vibration”, “noise”, “high temperature”, “low temperature”, “inhalation of smoke/fume/power/dust”, and “handling of chemical products/substances” were used. For Q29, data on exposure to “postures that cause fatigue or pain (excluding postures of continuous standing or sitting)”, “pulling/pushing/moving heavy objects”, “continuous standing”, “sitting posture”, and “repetitive hand/arm movements” were used. The responses “all throughout work hours”, “during most of work hours”, “during three-quarters of the work hours”, “during half of the work hours”, and “during one-quarter of work hours” were defined as “exposure to the corresponding hazardous factors”. Meanwhile, the responses “almost no exposure at all” and “absolutely no exposure” were defined as “no exposure to the corresponding hazardous factors”.Q70 of the 6th KWCS asks about participants’ perceived health problems in the past year (or after commencement of work if the participant has not yet worked for a full year). Participants’ perceived “low back pain”, “upper extremity muscle pain (shoulder/neck/arm/elbow/hand)”, “lower extremity muscle pain (hip/legs/knees/feet)”, “headache/eye strain”, and “anxiety” were coded as 1 for the response “no” or 2 for “yes”. Q71-1 asks about their perceptions about whether these health problems are work-related, and the responses were also coded as 1 for “no” or 2 for “yes”.Q30 of the 6th KWCS asks about whether participants receive “information about factors that threaten health and safety regarding their work”. “Factors that threaten health and safety” refers to various work-related hazards that may potentially cause mental and physical harm. The responses “I am given adequate information” and “I am given adequate information in general” were coded as “given information”. The responses “I am not really given much information” and “I am not given any information at all” were coded as “not given information”.Q77 of the 6th KWCS, which asks about “overall satisfaction with the work environment”, was used to investigate work environment satisfaction. The response options in the KWCS are “very satisfied”, “satisfied”, “dissatisfied”, “very dissatisfied”, but we changed the coding to “satisfied” and “dissatisfied”. The responses “very satisfied” and “satisfied” were defined as “satisfied”, while “dissatisfied” and “very dissatisfied” were defined as “dissatisfied”.Statistical analyses were performed using the SPSS ver. 18.0 software. Demographic characteristics, exposure to hazardous factors, health problems, and work environment satisfaction were analyzed using descriptive statistics, while gender-specific differences were analyzed through chi-squared tests. Furthermore, the effects of working conditions on work-related health problems and work environment satisfaction in male and female farmworkers were analyzed using multivariate logistic regression and presented as an odds ratio (OR) and 95% confidence interval (CI)t-test. Among men, 44.2% were under 60 years old, and 35.0% were age 65 or older. Among women, 40.8% were under 60 years old, and 59.2% were age 65 or older. There were no significant differences in the age groups between male and female farmworkers. As for job position, there were more “self-employed farmers without employees” among men (73.9%) than women (47.5%), and there were more “self-employed farmers/business owners with employees” among men (21.7%) than women (10.8%). On the other hand, there were more “wage earners (employees)” among women (3.8%) than men (2.9%), and particularly, there was a markedly higher percentage of “unpaid family workers” among women (38.0%) than men (1.5%). Regarding length of career, there were statistically significant gender differences in the percentages of workers with “less than 10 years of farming career” , “between 10–29 years of farming career” , and “≥30 years of farming career” .On the other hand, there was a significantly higher percentage of men exposed to “vibration generated by hand tools/machinery” (32.1%) than women (17.5%).There were no significant differences for “handling/contact with chemical products/substances” between men (11.0%) and women (9.2%). However, a significantly higher percentage of men (20.5%) were exposed to “inhalation of smoke/fume/powder/dust” than women (15.0%).Regarding ergonomic risks, there were no significant differences in exposure to “repetitive hand/arm movement” between men (80.5%) and women (81.6%), but exposure to other ergonomic risk factors significantly differed between genders. Women (81.0%) were more exposed to “sitting posture” than men (69.0%), while men (89.2%) were more exposed to “continuous standing posture” than women (84.3%). “Pulling/pushing/moving heavy objects” was more common among men (69.4%) than women (22.0%), while “posture that causes fatigue or pain” was more common among women (70.5%) than men (64.2%).Regarding the availability of health-and-safety-related information for farmworkers by gender , 67.9% oGender differences in work environment satisfaction among farmworkers were analyzed . The perTo analyze the effects of work conditions on work-related health problems among farmworkers by gender, we performed a multivariate logistic regression with presence of work-related health problems as the dependent variable. Job position, length of career, exposure to hazardous factors, and availability of health and safety information were assigned as the independent variables .Among male farmworkers, self-employed farmers/business owners with employees had 3.298 times (95% CI 1.479∼7.353) higher risk of low back pain, 4.062 times (95% CI 1.828∼9.028) higher risk of upper extremity pain, 17.366 times (95% CI 4.703∼64.121) higher risk of lower extremity pain, and 5.153 times (95% CI 1.700∼15.620) higher risk of headache/eye strain compared to farmers/business owners without employees. Among female farmworkers, wage earners (employees) had 0.268% lower odds (95% CI 0.087∼0.827) of acquiring low back pain than those who were self-employed without employees.The length of career was associated with the risk of developing work-related health problems in both male and female. Those with a career of ≥30 years were 3~6 times more likely to develop musculoskeletal symptoms compared to those with <10 years of career.Regarding exposure to hazardous factors in male farmworkers, the risk factors for low back pain were: high temperature (OR = 1.907 [95% CI 1.052∼3.457]), contact with/handling of chemical substances (OR = 3.086 [95% CI 1.061∼8.974]), pulling/pushing/moving heavy objects . The risk of upper extremity pain was 3.322 times higher (95% CI 1.876∼5.885) for those who handle heavy objects, 4.254 times (95% CI 2.354∼7.696) for those with exposure to repetitive hand/arm movement, and 2.799 times (95% CI 1.642∼4.770) for those not given health-and-safety-related information. The OR for lower extremity muscle pain was 2.721 times (95% CI 1.460∼5.070) for those who handle heavy objects, 0.279 times (95% CI 0.124∼0.625) for those who work in a sitting posture, 4.242 times (95% CI 2.183∼8.242) for those who engage in repetitive hand/arm movement, and 2.036 times (95% CI 1.097∼3.782) for those who are not given health-and-safety-related information. The risk for work-related headache/eye strain was 2.774 times higher (95% CI 1.102∼6.985) for those who engage in repetitive hand/arm movement. The risk for anxiety was 5.071 times higher (95% CI 0.945∼27.223) for those working in a posture that causes fatigue/pain and 11.371 (95% CI 2.224∼58.138) for those who handle heavy objects.In female farmworkers, the risk of low back pain was 2.105 times higher (95% CI 1.090∼4.066) for those who work in a continuous standing posture, 2.289 times (95% CI 1.197∼4.378) for those who engage in repetitive hand/arm movement, and 1.892 times (95% CI 1.029∼3.479) for those who were not given health-and-safety-related information. The risk of upper extremity muscle pain was 2.874 times higher (95% CI 1.499∼5.508) for those who handle heavy objects, and 2.018 times (95% CI 0.989∼4.118) for those who were not given health-and-safety-related information. The risk of lower extremity muscle pain was 2.739 times higher (95% CI 1.292∼5.806) for those who engage in repetitive hand/arm movement. The risk of headache/eye strain was 2.195 times higher (95% CI 1.091∼4.415 for those who handle heavy objects and 2.260 times (95% CI 0.973∼5.250) for those not given health-and-safety-related information. The risk for anxiety was 4.358 times higher (95% CI 1.189∼15.975) for those who handle heavy objects.In terms of work environment satisfaction among male farmworkers, the OR was 0.487 (95% CI 0.322∼0.736) for those with ≥30 years of career compared to those with <10 years of career, 0.748 (95% CI 0.571∼0.981) for those exposed to high temperatures, 0.739 (95% CI 0.551∼0.990) for those working in a sitting posture, and 0.312 (95% CI 0.229∼0.450) for those not given health-and-safety-related information. Among female farmworkers, the OR for work environment satisfaction was 3.090 (95% CI 1.481∼6.449) for self-employed farmers/business owners with employees compared to self-employed farmers without employees, 0.354 (95% CI 0.198∼0.631) for those with ≥30 years of career compared to those with <10 years of career, and 0.554 (95% CI 0.368∼0.834) for those not given health-and-safety-related information.We investigated the gender differences in exposure to hazardous factors, health problems, and work environment satisfaction. Also, we identified the effects of gender-specific working conditions on work-related health problems and work environment satisfaction among farmworkers using data from the 6th KWCS conducted by the OSHRI.In our study, job position affected work-related health problems in men and work environment satisfaction in women. Among male farmworkers, the odds for work-related low back pain (3.298 times), upper extremity pain (4.062 times), lower extremity pain (17.366 times), and headache/eye strain (5.153 times) were higher among the self-employed/business owners with employees, compared to the self-employed without employees. Moreover, Lee (2017)  reportedFurthermore, previous studies have reported that job position and years of working are occupational characteristics that predict self-rated health status  and thatIn our study, we observed that there are gender differences in the exposure to hazardous factors. Men were more likely to be exposed to vibration, inhaled smoke/fumes/powder/dust, continuous standing posture, and pulling/pushing/moving heavy objects than women. On the other hand, women were more likely to be exposed to sitting posture and postures that cause fatigue or pain. A farmer survey conducted by the Rural Development Administration  also repIn our study, male and female farmworkers also significantly differed in their perceived health problems. Women perceived more musculoskeletal pain , and headache/eye strain than men. Our results for musculoskeletal pain were consistent with previous reports that the prevalence of musculoskeletal disorders is higher among female farmers than male farmers ,11,12. HFemale farmworkers were also found to be less satisfied with their work environment than male farmworkers, which is inconsistent with the findings of Kim et al. 2010) , where t10 , wherWe further observed significant gender differences in exposure to hazardous factors that influence work-related health problems among farmworkers. In men, high temperature, contact with/handling of chemical substances, pulling/pushing/moving heavy objects, and repetitive hand/arm movement affected low back pain, but, in women, continuous standing posture and repetitive hand/arm movement affected low back pain. Meanwhile, upper extremity pain was affected by pulling/pushing/moving heavy objects and repetitive hand/arm movement, with no significant differences between the gender groups. Lower extremity pain was affected by pulling/pushing/moving heavy objects and repetitive hand/arm movement in men and repetitive hand/arm movement in women. The predictors of headache/eye strain also significantly differed between genders, which were repetitive hand/arm movement for men and pulling/pushing/moving heavy objects for women. Although there is a dearth of studies that can be compared with our findings on the predictors of work-related health problems among farmworkers, Kim et al. (2010)  reportedAdditionally, although female agricultural workers in this study were found to experience more health problems than their male counterparts, they received less health-and-safety-related information and exhibited lower work environment satisfaction. Furthermore, both male and female farmworkers who did not receive health and safety information were less satisfied with their work environment. Between the two groups, the odds for work-related musculoskeletal pain were about twofold higher among those who did not receive health-and-safety-related information in men, while the odds for work-related headache and eye strain were about twofold higher among those without safety-and-health-related information in women. Despite being exposed to more hazardous factors than general workers, farmworkers receive less information about health and safety . BusinesMeanwhile, the only mental health issue that can be identified through KWCS data is anxiety, and, in this study, the prevalence of work-related anxiety was higher among female farmworkers than male farmworkers   also sugPrevious research has also discovered the following on farmers’ mental health: older women, older adults without a spouse, and economically vulnerable older adults display a higher level of depression and anxiety ,32, and Overall, there is inadequate research and discussion on anxiety and its underlying causes among farmworkers. A comprehensive understanding of the level of anxiety and the multifaceted personal, social, and occupational factors contributing to anxiety among farmworkers is crucial to explore potential solutions for improving their mental health.The use of the KWCS data for the present study brings about some limitations. First, we were unable to precisely identify ergonomic risk factors intrinsic to farming activities, such as crouching, arm-raising, and bending over. Second, work-related health problems were limited to musculoskeletal pain in the low back and the upper and lower extremities as well as eye strain and headaches, and we used anxiety only as an indicator of mental health. Third, there is a lack of survey data that shed light on the labor environment for foreign seasonal workers, a population with increasing presence in the agricultural sector. Lastly, the KWCS utilized in this study is intended to investigate the standardized working conditions in various industries. Since the health problems that could be relevant for the entire working population were selected, we had limitations in identifying health problems that are specific to the agricultural field.Nevertheless, a key strength of this study is that the findings can be generalized to the entire farmworker population in Korea, as we analyzed nationally representative sample data for the Korean working population. Another strength is that we confirmed that there are gender differences in working conditions, health problems, and work environment satisfaction among farmworkers and identified the specific working conditions that predict work-related health problems and work environment satisfaction.In the future, standardized research and surveys are needed to examine hazardous factors specific to different types of farming jobs and identify predictors of work-related health problems and occupational welfare. Such findings will be useful for enhancing occupational welfare for farmworkers through continuous improvement of agricultural work environments.Regardless of gender, work-related musculoskeletal pain increased while work environment satisfaction decreased with increasing length of career among farmworkers. Moreover, there were gender differences in exposure to hazardous factors, perceived health problems, and work environment satisfaction among farmworkers. Female farmworkers were found to be given less health-and-safety-related information, displayed lower work environment satisfaction, and experienced more health problems compared to their male counterparts.


Transparent conductors(TCs) represent key componentsin many applicationsfrom optoelectronic devices to electromagnetic shielding. While commercialapplications typically use thin films of indium tin oxide, this materialis brittle and increasingly scarce, meaning higher performing andcheaper alternatives are sought after. Solution-processible metalswould be ideal owing to their high conductivities and printability.However, due to their opacity to visible light, such films need tobe very thin to achieve transparency, thus limiting the minimum resistanceachievable. One solution is to print metallic particles in a gridstructure, which has the advantages of high tunable transparency andresistance at the cost of uniformity. Here, we report silver nanosheetsthat have been aerosol jet printed into grids as high-performancetransparent conductors. We first investigate the effect of annealingon the silver nanosheets where we observe the onset of junction sinteringat 160 °C after which the silver network becomes continuous.We then investigate the effect of line width and thickness on theelectrical performance and the effect of varying the aperture dimensionson the optical performance. Using these data, we develop simple models,which allow us to optimize the grid and demonstrate a printed transparentconductor with a transmittance of 91% at a sheet resistance of 4.6Ω/sq. However, thesematerials are often brittle, expensive, and scarce,5 which has led to the exploration of a number of alternativematerials and deposition methods to address these shortcomings.Transparentconductors (TCs) are criticalmaterials in the fieldof printed electronics where they constitute core components of solarcells,2. To achievethis, processing in solution and deposition by printing is advantageousdue to its speed, scalability, and low cost and much work has beendone on a range of printable transparent conductors. Conductive polymerssuch as PEDOT:PSS have been investigated due to their solution processibilityand high transmittance when printed into a thin film. Although as-depositedconductivities are quite low (∼1 S m–1),post-processing techniques can raise this by several orders of magnitudeto ∼104 S m–1 [ref , conduction in printed networks of both materialsis almost always suppressed by the inter-sheet/inter-tube junctions,which limits the conductivity to the range of 102–104 S m–1 [ref ,10 and copper (CuNW)11 have been demonstrated as transparent conductors with each showingsimilar or superior performance to ITO thin films. The high porosityassociated with a nanowire network (>90%)12 confers a high transmittance, and the metallic conductivity (>106 S/m is possible)10 allows lowsheet resistances to be achieved. However, the as-deposited conductivityof the networks can be low owing to large junction resistances wherethe nanowires come into contact within the network unless annealingis performed.9 In addition, the porosityof the nanowire network can make it difficult to integrate with activelayers. The nanowires themselves can also penetrate active layersin devices such as solar cells, which leads to reduced device performanceor, in the worst case, an electrical short.1To achieve low sheetresistances, networks of various metallicnanowires such as gold (AuNW),13 or copper (CuNP)14 have also been investigated as transparent conductors buttend toform densely packed networks with low porosity meaning they appearopaque and highly reflective to visible light. This requires a griddesign to be printed where the grid lines are composed of the metallicnanomaterial leaving the apertures in between completely transparentto incident light.15 In such a structure, T is controlled by the ratio of aperture width-to-line width,while RS is controlled by line dimensionsand the conductivity of the material. As AgNPs or CuNPs often havediameters in the range of 20–80 nm and are roughly sphericalin shape, the inter-particle interface is small, which leads to poorinter-particle charge conduction and low as-printed conductivities.This means that thermal post-treatments are required to sinter theparticles and lower the sheet resistance of the network, a processthat again is usually incompatible with flexible substrates. The sheetresistance of the grid can also be lowered by coating the grid ina continuous network of CNTs,16 PEDOT:PSS,17 or even ITO.18 Whilesuch coatings will clearly lower the transmittance, they often resultin only modest reductions in sheet resistance meaning the added processingcomplexity and decreased transmittance may outweigh the potentialelectrical improvements.Other metallic nanomaterials such as nanoparticles of silver(AgNP)RS) is usually limited by the junctions betweenthe particles.7 In AgNW and AgNP networks,the junction is size-limited by the diameter of the wires/particles,which in turn limits the minimum achievable junction resistance. Forexample, AgNW networks can have junction resistances of tens of Ohmsfollowing annealing.19 However, in recentwork,20 we reported silver nanosheets (AgNS)as a printable conductor with a high as-printed conductivity owingto their two-dimensional (2D)-like geometry with large basal planesleading to low junction resistances of ∼3 Ω. In addition,they form films with smooth surfaces and interfaces, which makes themideal for preventing electrical shorting in vertical heterostructurescomposed of porous networks. The 2D-like geometry is also highly beneficialfor creating networks on flexible substrates as they are more robustagainst crack formation compared to silver nanoparticles under bendingtests.21As all of the printed thin films discussedso far are composedof discrete components, achieving a high conductivity , scanning electron microscopy (SEM), andelectrical measurements. We then evaluate the way in which the dimensionsof the printed lines affect the sheet resistance of the grid. We varythe aperture size to characterize its effect on both transmittanceand grid sheet resistance. With these parameters known, we can thenprint a grid that performs with a 20 These grids displayed an as-printed conductivityof ∼7.5 × 106 S m–1, higherthan all reported as-printed AgNW networks, and RS in the range of 2–5 Ω/sq (see Supporting Information S1). However due to theresolution limits of this printer, there is a lot of scatter in thedata and the minimum line width is ∼500 mm [ref  was preparedfollowing the procedures reported in ref  while holding a and b constant. We plot 1 – T  against positionthen allows one to estimate the shape of the lines making up the grid. a) and also peak-to-peak distance  as demonstratedin SI S2. Finally, the thickness of thegrids can be measured using white-light interferometry (WLI) producingmaps such as that shown in Supporting Video 1 and shown in SI S3. Thefused edges then create a large sintered junction with an area of∼13,500 nm2 for the junction in 2 for AgNW with a diameter of 50nm. 6 S m–1 to be reached,once the network is annealed above 150 °C, the AgNS become acontinuous sintered network. Furthermore, we also observe the formationof filaments across the pores in the network where they can reachlengths up to 250 nm (SI S4).7 S m–1 at 175 °C. This coincides with the onset of junction sinteringshown in SI S3. However, the C/T ink isnon-conductive until 150 °C owing to the large amount of residualhigh-boiling-point solvent remaining in the network. Following theonset of conduction, this ink plateaus at 1.1 × 107 S m–1 at 175 °C as the sintering of the junctionsnegates the effect of residual solvent. The lower value at saturationmay be caused by the unevaporated high-boiling-point solvents remainingin the network. This compares to AgNW networks where the conductivitymaximum occurs between 225–300 °C depending on the diameterof the nanowire.23 We note that these networks aremeasured and stored in ambient where, absent any encapsulation, weexpect the conductivity to fall to approximately 66% of these valuesafter a period of one year.20 For the restof this work, we print a C/T ink using an aerosol jet printer to creategrids, which are annealed at 200 °C for 15 min following printing.To evaluate the optimalannealing conditions, wecompared a water-basedink (inkjet printed on a paper substrate) and a C/T-based ink (aerosoljet printed onto glass). a and b, were set to be constant at a = 85 μm and b = 1.15 mm while successivelayers were printed. These parameters are controlled by the settingson the aerosol jet printer, where a is determinedby the sheath and carrier flow rates while b is setby the toolpath where it indicates the center-to-center distance ofthe grid lines. a, with thicknesswhere we see it remain approximately constant up to thicknesses of350 nm. For the thicker grids, we see a broadening of the line width,which we attribute to solvent accumulation that can occur when usinghigh-boiling-point solvents and a large number of layers. We findthat the line width in the x-direction is (85 ±4) μm but (69 ± 4) μm in the y-direction.This means the columnar deposition by the aerosol jet is not perfectlycircular, which can occur when material becomes lodged inside thenozzle.To investigate the effect of line thickness on the structural,optical, and electrical characteristics of the grids, RS,G, on the inverse thickness, t–1, is shown in RS,G = (σGt)−1, which gives a grid conductivity (including the effect of contactresistance), σG, of 3 × 105 S m–1, approximately 30× lower than that of an individualline (∼7.5 × 106 S m–1).20 In GS,L , andplotted it against the thickness. These data were then fit to GS,L = t(a*σL)/L, where σL is the conductivityof the line, and L is the length of the line. With L = 5.6 mm, this gives a σL of 4.7 ×106 S m–1. This value is ∼2.5×lower than that reported in ref (6 S m–1 and may approach the network conductivity of >107 Sm–1 mentioned above. SI S5).The dependence of the 2-probe grid sheet resistance, d in ref 1B used tt ∼ 200 nm) and line width (a ∼ 100 μm). SI S5, assumingthe AgNS lines are fully reflective, the transmittance of a grid isgiven bya is the line widthand b is the aperture size. b/a, with a fixed at 100 μm. We find the data to be in perfectagreement with With the effect of grid thicknessdetermined, we then investigatedthe effect of varying the aperture size while maintaining constantthickness −1, represents the sheet resistance of a single line, RS,L. The fit indicated by the dashed line in Lt)−1 = 0.43 Ω/sqimplying a conductivity of σL = 1.2 × 107 S m–1 for t = 200 nm (consistentwith the data in 20).The relationship between the grid sheet resistance, T and RS,G, RS,G has beencorrected for contact resistance by subtracting 3.85 Ω in allcases, see RS,G = 7.12 Ω and T = 87%, which areextremely promising compared to most of the literature. The data arewell fit by combining SI S7) intoLt)−1 = 0.38 Ω/sq. This impliesa conductivity of σL = 1.3 × 107 Sm–1 in agreement with the value found in SI S8, where we find the aperture transmittance is highly homogeneousacross a given grid for b/a >8.However, below this, the aperture-to-aperture variation begins toincrease, which we attribute to the line-edge roughness and oversprayby the aerosol jet deposition becoming more apparent as size of theaperture approaches that of the line width. We also find that theprinted lines are highly uniform along their length with a low coefficientof variation.To evaluate the relationship between Lt. Asour measured value of σL = 1.1 × 107 S m–1 is already very high, the simplest routeis to increase grid thickness, t. To demonstratean improved AgNS-based transparent conductor with characteristicsin the region indicated by the blue box in a = 125 μm, b = 1.7 mm, and a much-increasedthickness of t = 2.5 μm. This corresponds toa b/a of 13.6 which, following theanalysis in SI S8, means the transmittanceof such a grid is homogeneous across a large area. We found that sucha grid does indeed display enhanced performance, T = 91% and RS,G = 4.6 Ω/sq, andis represented by the red triangle in It is worth considering how to improve the performanceof thesegrids. 10 The AgNS grids also show a higher transmittancefor a given RS than AgNPs13 even when the AgNP grid has been spin-coated in eitherPEDOT:PSS17 or carbon nanotubes.16 This demonstrates that silver nanosheets areexcellent candidates for use as transparent conductors in applicationssuch as large-area displays or wearable optoelectronic devices thatdo not require a high level of uniformity.Looking at the literaturefor a range of transparent conductorsprinted from various materials 4E, we seT ≥ 90% with an RS ≤ 10Ω/sq requires a network ∼2.4 um thick and with a b/a of 13.5. This work demonstrates thatsilver nanosheets are highly suitable materials for use in printedtransparent conductors.Wehave demonstrated that silver nanosheetscan be printed intogrid structures that are suitable for use as transparent conductors.The AgNS are highly conductive immediately following inkjet printing,which allows low sheet resistances to be achieved; however, the lowresolution of the printer means that large aperture sizes are necessaryto simultaneously achieve a high transmittance. Aerosol jet printingallows high-resolution grids to be printed in the range of 1–10Ω/sq following corrections to contact resistance. The transmittanceof the grid scales with the ratio of aperture size-to-line width,with high transmittance reached at the highest ratios. Using a simplerelationship between sheet resistance and transmittance, we determinethat printing a grid that lies in the region where –1 that is confirmed by vacuum filtration and weighing. Once a stockdispersion is made with a known concentration, it was then dilutedwith DI water to 20 mg mL–1, which is suitable forinkjet printing with a Canon Pixma MG2550 thermal inkjet printer.The silver nanosheets (AgNS) were purchasedfrom Tokusen USA (N300 Nanoflake) and are delivered in a thick water-basedpaste. From this, 0.5 mL is diluted with 100 mL of deionized waterto give a stock dispersion of approx. 80–100 mg mLg for 120 min and the all of the supernatantis discarded. The sediment is redispersed in a blend of 18 mL of cyclohexanoneand 2 mL of terpineol using a vortex mixer and 15 min in a sonic bath.This centrifugation/redispersion step is repeated twice to minimizethe amount of water retained in the ink following the solvent exchange.To create a cyclohexanone/terpineol (90:10) based ink at 20 mg/mL,5 mL of the stock water-based dispersion (80 mg/mL) is centrifugedat 3700Printing using the Canon Pixma MG2550thermal inkjet printer was performed following the procedures outlinedin ref . Briefly–1. Prior to use, the substrates were cleaned in KOH and dried withcompressed N2.In this study, we used an OptomecAJP 300 with a 150 μm nozzle and an ultrasonic atomizer. Thesheath and carrier flow rates were set to 90 ± 5 and 17 ±2 sccm, respectively. The temperature of the chiller used to coolthe ink was set to 10 °C and the platen was set to 90 °C.2 mL of ink was used at a time with the atomizer current set to ∼0.5A. All printing was performed at platen speeds of 1 mm s2 with a step height of 50 nm,confirmed using AFM. The profiles were levelled (three-point level),and their step heights were determined using ProfilmOnline (Filmetrics)software. Step heights were determined using the histogram step-heightsetting in ProfilmOnline, which outputs a histogram of the heightof each pixel. From this, the baseline height and the top surfaceof the deposited network were found to calculate the average stepheight across the area. Once a profile is drawn, it is some smoothedto remove “invalid” pixels using a “remove outliers”function on the ProfilmOnline software. This crops the z-axis to remove any stray high or low pixels and then fills in pixelswith an average value of the neighboring pixels.The three-dimensional(3D)surface profiles were collected using a Profilm3D Optical Profiler(Filmetrics) operating in white-light interferometry (WLI) mode witha 50× Nikon DI objective lens. For samples <100 nm, phaseshift interferometry (PSI) mode was used, which has increased heightresolution for thinner profiles. The profiler was calibrated usinga gold thin-film on Si/SiOThe conductivity and sheetresistance measurements were measured using a Keithley 2612A sourcemetercontrolled by a LabView program. The sourcemeter was connected tothe samples using a Suss probe station.The transmittance was measuredusing flatbed transmission scanner (Epson Perfection V700 Photo) witha bit depth of 48-bits per pixel and a spatial resolution of 6400dpi. The signal-to-transmittance relationship was found empiricallyby scanning neutral density filters.Direct observation of weld formationat elevated temperatures was achieved through in situ transmissionelectron microscopy (TEM) using a DENS solutions Wildfire TEM holder.AgNS were dropcast onto a DENS solutions Nano-Chip, which consistsof a microelectromechanical system (MEMS) based chip design with electrontransparent SiN windows. The temperature of the chip is controlledby a 4-point probe. The TEM was subsequently performed on a FEI Titan80–300 Thermo Fisher Scientific, fitted with a Schottky fieldemission gun. The operating voltage was set to 300 kV, and imageswere recorded using a Gatan UltraScan CCD camera. The temperatureramp rate was set to 15 °C/min and heated from RT to 200 °C.Heating was paused for 2 min at 120 °C and at every 10 °Cincrement after that. Images were captured every 20 s.


To assess the inter-relationships between residual depressive symptoms (RDS) and Internet addiction (IA) using network analysis among clinically stable adolescents with major psychiatric disorders during the COVID-19 pandemic. RDS and IA were assessed using the Patient Health Questionnaire-9 (PHQ-9) and the Internet Addiction Test (IAT), respectively. Central symptoms and bridge symptoms in the network model were examined. A total of 1,454 adolescents met the study criteria and were included in the analyses. The prevalence of IA was 31.2% (95% CI: 28.8%-33.6%). In the network analysis, the nodes IAT15 (“Preoccupation with the Internet”), PHQ2 (“Sad mood”), and PHQ1 (“Anhedonia”) were the most central symptoms in the IA-RDS network model. Bridge symptoms included IAT10 (“Sooth disturbing about your Internet use”), PHQ9 (“Suicide ideation”), and IAT3 (“Prefer the excitement online to the time with others”). Additionally, PHQ2 (“Sad mood”) was the main node linking “Anhedonia” to other IA clusters. Internet addiction was common among clinically stable adolescents with major psychiatric disorders during the COVID-19 pandemic. Core and bridge symptoms identified in this study could be prioritized as targets for the prevention and treatment of IA in this population. Coronavirus disease 2019 (COVID-19) caused by Severe Acute Respiratory Syndrome Coronavirus 2 (SARS-CoV-2) was declared a pandemic on March 11, 2020, by the World Health Organization (WHO) .Internet addiction, a growing public health concern, is common among adolescents. A recent meta-analysis found that the overall prevalence of IA in adolescents was 13.62% . Of noteTo address these concerns, network analysis offers a novel approach to visualizing the interactions between various symptoms of psychiatric disorders/syndromes  and estiTherefore, we examined the relationships between comorbid IA and RDS among clinically stable adolescents with major psychiatric disorders during the COVID-19 pandemic from a network analysis perspective. Given the negative consequence of the COVID-19 pandemic on mental health, such as the increased risk of IA in adolescents , 10, 12,This was a multicenter, cross-sectional survey carried out between April 29 and June 9, 2020, in three major tertiary mental health centers on children and adolescents located in northern (Beijing), southern (Fujian province), and central areas of China (Henan province) . With thInternet addiction was assessed using the validated Chinese version of the Internet Addiction Test (IAT) , 48. The“graph” [The network model of IA and RDS was computed using the R software . We comp“graph” .“graph” [The importance of each node in the network was examined by estimating centrality indices of the network structure, with the R package “graph” . Specifi“graph” . Followi“graph” , to redu“graph” . In addi“graph” , we used“graph” . Node-sp“graph” –62.NetworkComparisonTest” package (Version 2.2.1) [Following previous studies , 64, then 2.2.1)  with 100A total of 1570 adolescent patients were invited to participate in this study, of whom 1454 met the study criteria and were included in the analyses. The prevalence of IA was 31.2% (95% CI: 28.8%–33.6%) among adolescent psychiatric outpatients during the COVID-19 pandemic. The mean score of RDS was 8.12 (Standard Deviation (SD):8.42)  had the highest EI centrality, followed by PHQ2 (“Sad mood”) and PHQ1 (“Anhedonia”) in the network ), which indicates that 75% of the sample could be dropped, and the structure of the network would not significantly change Fig. . The resPrevious studies found that “Anhedonia” was strongly associated with the development of IA behaviors in both adults and adolescents , 66, 67.P = 0.521) and edge weights  , PHQ2 (“Sad mood”), and PHQ1 (“Anhedonia”) were the most central symptoms in the network model of comorbid IA and RDS. Bridge symptoms included IAT10 (“Sooth disturbing about your Internet use”), PHQ9 (“Suicide ideation”), and IAT3 (“Prefer the excitement online to the time with others”). Additionally, PHQ2 (“Sad mood”) was the main node linking Anhedonia to the IA community.Internet addiction is usually associated with a preoccupation with the Internet; i.e., adolescents with IA often think about using the Internet when they are offline and often fantasize about surfing on the Internet even if they are concentrating on other things . Not sur“Sad mood” and “Anhedonia” were also central symptoms in the IA-RDS network model, which is consistent with previous findings , 81 thatThe common mechanism involving dopamine in both depression and IA could presumably explain the association of IA with anhedonia and sad mood. For instance, the occurrence of depressive symptoms was associated with decreased levels of dopamine secretion . Levels The bridge symptoms in this network model included “Sooth disturbing about your Internet use”, “Suicide ideation”, and “Preferring the excitement online to the time with others”. A recent network analysis of problematic smartphone use in adolescents revealed that bridge symptoms included “Peer attitudes towards smartphone use”, “Peer pressure for smartphone use”, and “Fear of missing out” , which aSuicidal ideation is one of the key symptoms of depressed mood . The socPrevious studies , 66, 67 The results of the network analysis on RDS and IA have important implications. Regular screening for RDS and IA among adolescents with psychiatric patients is important even when they are clinically stable. Effective interventions that target the identified central and bridge symptoms should be provided to those with comorbid RDS and IA to reduce the risk of negative outcomes such as impaired functioning and suicidality. For example, cognitive-behavioral therapy (CBT) approaches that such as writing a diary of Internet activity and general time management skills , behaviThe strengths of this study included the large sample size, multicenter study design, and use of network analysis with reliable findings. However, certain limitations should also be acknowledged. First, a cross-sectional design was used; therefore, causal relationships between comorbid RDS and IA could not be inferred. Second, this study focused on clinically stable psychiatric adolescents, which limits the generalizability of findings to other patients in different phases of psychiatric disorders. Third, for logistical reasons, certain factors associated with comorbid IA, such as comorbidities, and use of psychotropic medications, were not recorded. Finally, the type and doses of psychotropic medications used were also not recorded.In conclusion, the core symptoms  and bridge symptoms  identified in this study could be targets for prevention and treatment of comorbid IA and RDS in clinically stable adolescents with major psychiatric disorders during the COVID-19 pandemic.supplementary materials


The COVID-19 pandemic has exacerbated the mental health burden on the general population, resulting in increased demands on mental healthcare professionals, including psychotherapists. This cross-sectional study assessed the challenges and resources encountered by 513 psychotherapists based on an online survey conducted between April and May 2022.Qualitative methods content analysis of written reports was employed to investigate the emerging challenges and sources of support during the pandemic. A comparative analysis of burdens, resources, sociodemographic factors and daily physical activity was conducted to discern patterns of good and poor well-being.The predominant burden identified was mental health-related issues, followed by global crises and government-imposed restrictions to mitigate virus transmission. Essential resources encompassed social connections, mindfulness, work satisfaction, and internal processes. Notably, psychotherapists demonstrating good well-being were older, more physically active, had a lower proportion of females, were employed in private practices rather than in institutionalized settings, had more years of professional experience and treated more patients weekly than their counterparts with poor well-being. Furthermore, they exhibited greater optimism, health focus, and satisfaction with their coping methods.These findings can help develop support systems, policies, and educational programs to better support mental health professionals during global crises and offer strategies for individual practitioners to maintain their well-being. AustriaAlready the initial lockdown in Austria resulted in a surge of mental health concerns, including depression 20%), anxiety disorders 19%), and insomnia (16%) among the general population 0%, anxie, 7. The %, and inResearch has indicated that the COVID-19 pandemic has substantially impacted the well-being of frontline healthcare professionals across the world. This is exemplified by the outcomes of various meta-analyses, highlighting increased anxiety, depression, sleep disorders, and burnout among physicians and nurses . HoweverMoreover, further research is required to decipher why psychotherapists, despite this confluence of strains, still show lower odds of exceeding cut-offs for clinically relevant depression , anxiety , insomnia  and moderate to high stress levels  compared to the general population. Previously assumed factors contributing to this relative resilience include high professional motivation, a secure social background and the possibility of independent time management since most are self-employed .It has been found that both psychotherapists and clinical psychologists in Austria experienced better mental health than the general population during the COVID-19 pandemic . ThroughThe stress level experienced by mental health professionals can significantly impact their approach to coping with challenging situations and vice versa. Research has demonstrated that avoidant coping strategies  are linked to heightened stress levels, leading to decreased overall well-being. Conversely, active coping strategies, such as maintaining a positive attitude, problem-solving, and seeking social support, positively impact well-being and are inversely related to psychological distress . In thisOur study, conducted in April and May 2022, seeks to augment the current body of research on the mental well-being of psychotherapists throughout the pandemic. Our principal objective is to examine self-reported burdens and the resources psychotherapists rely on to manage distress. Additionally, we aim to shed light on group variances in self-reported burdens and resources anchored on individuals’ well-being status 2 years into the pandemic. To comprehensively understand each group’s attributes, we also conduct a comparative study of sociodemographic factors, including the participants’ work setting and physical activity levels. We consider psychotherapists’ work setting because previous studies indicated that self-employed individuals generally experience higher job satisfaction than their salaried counterparts, largely attributable to increased autonomy, flexibility, and effective skills utilization , 36. On 2.2.1.From April 11 to May 31, 2022, we conducted a cross-sectional internet-based survey using Research Electronic Data Capture  . The pre2.2.2.2.1.Participants were inquired about their gender, age, years of professional experience, form of employment , and their level of physical activity. Per previous studies , 40, phy2.2.2.What are your primary current sources of burden?How are these burdens manifesting themselves at present?Looking back on the past 2 years, what impacts have you observed of the pandemic on your mental health and well-being?What strategies have you employed to manage the adverse impacts of the pandemic?Have there been any positive impacts resulting from the pandemic as well?To assess the challenges and resources experienced by psychotherapists during the ongoing crises, the survey included five open-ended questions (1–5) and one structured question (6):For questions 1–5, respondents were provided with an open-ended response format. They were allowed to describe their personal experiences in their own words, ranging from single-word answers to lengthy paragraphs. Respondents also had the option to leave the answer field blank and skip any of the free-text questions.2.2.3.On a scale of 1 to 5, how satisfied are you with your implemented coping strategies? Please rate your level of satisfaction as follows: 1 - very satisfied, 2 - satisfied, 3 - neutral, 4 - dissatisfied, 5 - very dissatisfied.For question 6, respondents were given a numerical response format, encouraging them to express their answers using a designated value. The participants had to understand that question 6 was related to question 4.All questions and free-text answers were initially formulated in German.2.2.4.We employed the 5-item World Health Organization Well-being Index (WHO-5)  to gauge2.3.2.3.1.The qualitative data obtained from the open-ended questions were analyzed using conventional qualitative content analysis  by two cN = 513) for questions 1–3 on burdens varied between 1 to 12, while for questions 3–6 regarding resources, it ranged from 1 to 16. The written reports ranged from being multiple lines in length with nuanced expressions to being presented as brief bullet points.Following an initial data assessment, the research team determined that collectively analyzing the responses to questions 1–3 and 4–6 would be the most effective approach. The former questions could be thematically grouped as psychotherapists’ burdens, while the latter pertained to their resources. For questions 1–3 (burdens), 167 questions remained unanswered. Thirty nine participants did not answer all three questions, 12 did not answer two questions, and 26 did not answer one. For questions 3–6 (resources), 125 questions were ignored. One participant did not answer all three questions, 39 did not answer two and 44 missed only one. Respondents could mention various aspects in their responses so that multiple categories could be assigned to each answer. The number of codings per case (The first coder (MB) analyzed the responses to questions 1–3 regarding the burdens, while the second (BS) coder focused on questions 4–6 regarding resources. Both coders familiarized themselves with the data by reading it thoroughly before categorizing it. The first author (YS) supervised the coding process, providing the coders with a deductive code list from a parallel similarly designed study on burdens and resources of Austrian clinical psychologists . The assThe coders used the ATLAS.ti vers. 23.1.0  software2.3.2.n = 171) .To conduct a comparative analysis of sociodemographic factors, physical activity, burdens and accessed resources according to groups, we partitioned our sample based on their levels of psychological well-being, following de Girolamo et al. . They usn = 171) . The gro3.3.1.530 psychotherapists participated in the survey, yielding a response rate of approximately 7.6%. Of these, 513 completed all outcome variables, resulting in a completion rate of 96.8%. The analysis considered only psychotherapists with complete data. Detailed characterization of the sample compared to the total sample of all licensed Austrian psychotherapists is provided in our companion paper . In briep = 0.027). The “Good WB” group, on the other hand, displayed a higher percentage of older individuals (60–69 and 70+ years), whereas the “Poor WB” group comprised more participants aged 41–49 and 50–59. Both groups exhibited a similar percentage of individuals under 40 (p = 0.038). Additionally, the “Good WB” group encountered more weekly patients  than the “Poor WB” group . A more significant percentage of the “Good WB” group operated exclusively in private practice (80.4%) compared to the “Poor WB” group (71.9%). Conversely, significantly more psychotherapists in the “Poor WB” group were employed by institutions (28.1%) as opposed to the “Good WB” group . Physical activity patterns differed between groups, with the “Good WB” group participating more frequently (4+ days/week) and the “Poor WB” group less regularly .3.2.N = 90) reported experiencing no or only minor adverse impacts. The results are described in more detail, starting with the largest category.Inquiring about their burdens, psychotherapists were presented with three open-ended questions. Qualitative content analysis showed that psychotherapists in Austria face numerous challenges, including mental health, global crises, COVID-19 restrictions, work, physical health, dissatisfaction with societal development, finances, and uncertainty about the future. Only a minority of participants (17.5% or 3.2.1.N = 368) reported burdens related to mental health, which can be further categorized into seven subcategories. Among psychotherapists, negative feelings such as irritability, impatience, disappointment, or despair were identified as the most prevalent burden, accounting for 34.9% (n = 179). For example, one respondent stated having “felt high levels of inner aggression due to the sometimes pointless seeming measures.” 18.9% (n = 97) of psychotherapists reported symptoms of exhaustion, including reduced resilience, fatigue, or less energy. Excessive demand was also a common issue, with 18.5% (n = 95) of respondents describing not having enough time, having difficulty managing their resources, or worrying about being unable to meet the required workload. One participant said, “I often felt confined to work alone and isolated from the other facets of life.” 16.4% (n = 84) of respondents identified rumination as a burden and described constant worrying and repetitive thoughts. 12.7% (n = 65) mentioned problems with sleep, such as difficulty falling asleep or staying asleep, shortened sleep duration, or poor sleep quality. Depressive mood was mentioned by 4% (n = 21), and only 2% (n = 10) expressed concern about the mental health of a friend or family member.71.7% of respondents (3.2.2.N = 192), expressed concerns about the repercussions of four major global crises, which they perceived as burdensome. 33.1% (n = 170) cited the Russian aggression against Ukraine as a source of worry, using statements like this: “The war in Europe - the suffering, destruction, and fear of it spreading to other countries .” Furthermore, 10.9% (n = 56) raised issues regarding the pandemic. 8% (n = 41) expressed their apprehension about the climate crisis, and 1% (n = 5) expressed worries about the well-being of refugees.A significant proportion of the respondents, precisely 37.4% (3.2.3.N = 189) pertained to the COVID-19 restrictions. These individuals commented on the various restrictions, including lockdowns, mandatory vaccinations or masks, and the resulting consequences. Limited opportunities for recreational activities and the lack of social interaction were also frequently mentioned. For instance, one respondent said: “Hugging people behind protective screens or being asked by a policewoman to stand up from a public bench because it is ‘not allowed’ to sit during the pandemic - all of these experiences are disturbing for the psyche.” On the other hand, the relaxation or absence of restrictions was also viewed negatively, as some respondents felt inadequately protected when meeting people with a critical stance towards vaccinations and protective measures.An additional concern raised by 36.8% (3.2.4.N = 163) of the respondents experienced work-related strain. Of those, 24% (n = 123) felt burdened by a high workload, including long working hours and many patient requests. Respondents also expressed concerns about the increased prevalence and complexity of mental disorders among their patients and how they were affected by similar issues. One respondent stated, “The increasingly challenging conditions of my patients are on my mind more often than usual; I find myself reflecting more on my psychotherapeutic interventions and setting. The themes of my patients overlap more frequently with issues that also affect me personally, resulting in a stronger emotional involvement in my work as a psychotherapist.”31.8% (N = 50) experienced burdens related to their working conditions, such as an unstable working situation, postponed appointments, and too few or too many health insurance positions. Only 1.6% (n = 8) experienced burdens related to the workplace atmosphere, such as interpersonal and workplace conflicts within their team. Finally, 1.2% (n = 6) felt burdened by the lack of patients.In addition, 9.8% (3.2.5.N = 153) of the participants expressed concerns about their “physical health.” Among them, 23.8% (n = 122) reported experiencing “somatic complaints” such as muscle tension, back pain, tinnitus and headaches. Additionally, general concerns, e.g., in the context of ageing, smoking, weight gain or chronic disease, were also expressed. Furthermore, 8.8% (n = 45) of the participants reported anxiety about the physical health and mortality of loved ones, including pets.29.8% (3.2.6.n = 112) conveyed concerns related to their social network. 18.1% (n = 93) reported interpersonal conflicts, often partnership problems or conflicts related to divergent attitudes toward the COVID-19 containment or vaccination measures. 3.9% (n = 20) were troubled by issues concerning their children, such as their progress in school or childcare. Additionally, 16.4% (n = 84) of the respondents expressed dissatisfaction with societal development, such as the division of society, poverty or the world situation. Out of these, 9.2% (n = 47) were particularly unhappy with the way politics and media reacted to the pandemic: “I am deeply concerned about the current state of society, which appears to be increasingly radicalized and characterized by inadequate crisis reporting and insufficient attention to the urgent issue of climate change. Also, the potential weakening of democratic values is a troubling development.” Furthermore, 9.2% (n = 47) of the respondents reported financial concerns. Among them, 4.5% (n = 23) expressed general worries about their personal financial situation, 3.9% (n = 20) were concerned about inflation, and 1.6% (N = 8) felt that they were being underpaid. Finally, 13.3% (n = 68) indicated worries about the distant future, such as the world’s future, society’s future, or the future of their children or grandchildren.21.8% (3.3.n = 62) reported that they had not experienced any positive impacts. Our subsequent description shall explicate the reactions to questions 4–5 in greater detail, commencing with the most salient category, followed by a descriptive statistic of the ratings (question 6).After answering inquiries 1–3 about the issue of burdens, psychotherapists were posed with two open-ended questions , 5 that 3.3.1.N = 295), was further divided into five subcategories. Among these, 41.7% (n = 214) cited “partners, family, and friends” as a source of support, highlighting the increased opportunity to spend quality time with loved ones and strengthen existing relationships during the pandemic. Additionally, 15.4% (n = 79) of respondents mentioned the value of social interactions and conversations in general, while 4.9% (n = 25) referred to their colleagues as a source of social support. Interestingly, while social contacts were generally viewed as a positive resource, a small proportion of respondents  expressed relief at having fewer social obligations and options for social withdrawal during the pandemic, such as avoiding gatherings. Finally, 4.3% (n = 22) of the respondents identified their pets as an essential source of support.The category of ‘social contacts,’ which proved to be an essential resource for 57.5% of respondents (3.3.2.n = 264) of respondents. Eight subcategories emerged from their responses. The first, “slowing down,” was mentioned by 22.6% (n = 116) of respondents. This category was characterized by a sense of calmness and a reduction in the pace of everyday life. Respondents reported feeling less pressure to be productive during leisure time and, particularly during curfews, retreating from public life and focusing on their private lives.Mindfulness practice proved to be a valuable resource for 51.5% (n = 92) of respondents. They reported positive impacts such as concentrating on essential matters and “what you can do and not on what is out of your control.” While this could be considered a form of mental mindfulness, the respondents did not refer to specific techniques or practices but rather to a sense of serenity resulting from a more conscious way of navigating life.The second subcategory, “focusing,” was identified by 17.9% (n = 70) of respondents referred to “self-care,” including answers such as “I cultivate a loving approach towards myself” or “I watch out for what nourishes me.” Mental techniques and exercises such as yoga, breathwork or meditation were embraced by 11.9% (n = 61). 3.7% (n = 19) reduced media consumption, 2.7% (n = 14) practiced gratitude, 2.3% (n = 12) drew on religion or spirituality, and 1.8% (n = 9) practiced acceptance.Another subcategory identified by 13.6% (3.3.3.n = 210) of the sample identified “recreational activities” as a resource. This category consisted of three distinct subcategories: “physical activity,” “being outside,” and “hobbies.” Across all responses, individuals mentioned the impact of the pandemic on their ability to find time for personal pursuits. 23.2% (n = 119) of respondents reported engaging in various physical activities such as running, gymnastics, mountain climbing, and other forms of physical activity. The subcategory “being outside” was embraced by 21.8% (n = 112). It included activities such as walking, socializing, simply appreciating nature or even “freeing one’s mind in nature.” One respondent declared that “I ‘have to’ go for a walk in the forest daily.” In addition, 13.5% (n = 69) found engaging in a hobby helpful. They referred to reading, gardening, dancing, painting and listening to music. One participant put it like this: “I engaged with art and culture in the form of books or documentaries, light-hearted films, and music.”40.9% (3.3.4.N = 197) of respondents reported work-related changes due to the pandemic. This category comprises five subcategories: “flexible working conditions,” “work in itself,” “supervision/intervision,” “less work,” and “recognition of psychosocial services.”38.4% (n = 98) of respondents mentioned the “flexible working conditions” subcategory positively, with some reporting the ability to work from home or digitally, saving them time and mental energy. Some respondents recognized benefits for their patients, citing the positive impacts of digital psychotherapy on severely ill patients, including the ability to establish an intensive and positive therapeutic relationship and even provide opportunities for creative approaches. Furthermore, 12.7% (n = 65) of respondents regarded their work in general as a resource during the pandemic. Another noteworthy subcategory pertained to attending professional support formats, such as supervision or intervision, which was mentioned by 5.7% (n = 29) of respondents. Additionally, 4.5% (n = 23) reported decreased clients, appointments, and work commitments, particularly during the curfews implemented during the pandemic’s first year. Finally, it is vital to highlight the increased recognition of psychosocial services, which was positively noted by 2.1% (n = 11) of respondents. These individuals observed that the pandemic had brought mental health and psychological disorders to the forefront of professional attention, thereby contributing to the destigmatisation and normalization of seeking psychotherapeutic support.Notably, 19.1% (3.3.5.N = 175) of respondents, related to inner processes as a resource during the pandemic, such as “a positive attitude,” “resilience,” “self-reflection,” and “resistance.” 15.6% (n = 80) of respondents cited their “positive attitude” as a key resource throughout the pandemic. They described focusing on the positive aspects of their situation and looking confidently towards the future. One respondent, for example, reported: “What helps me above all is my incorrigible optimism and my attitude towards life, my faith and trust in people who live in a solution-oriented way.” 12.3% (n = 63) of respondents referred to their flexibility and adaptability. They identified their courage, emotional stamina, confidence, and competence in handling the pandemic situation or confronting their fears. One respondent said: “My trust and inner stability, which I have gained through my long-term path of personal development, has helped me greatly.” Such statements, focusing on personal development as a source for dealing with prolonged crises, were categorized under the subcategory of “resilience.” 8.6% (n = 44) of respondents cited self-reflection as a resource, reporting that they confronted their feelings and used the pandemic as an opportunity to develop self-awareness. For example, one respondent described the pandemic as “training in independent and courageous thinking and decision-making” Actively reflecting on the pandemic situation also enabled the respondents to develop new perspectives for coping with COVID-19 measures. A mere 2.1% (n = 11) attested to adopting a stance of “resistance” against the COVID-19 protective measures that they perceived as capricious and pointless. As one respondent succinctly put it, “What helped me was the pursuit of information from alternative sources, the conversion of fear into indignation, and the subsequent surge of bravery that spurred me towards action - be it through participation in demonstrations, vocalizing my stance in parliament, taking up political activism and so on.”Another major category, identified by 34.1% (3.3.6.N = 53) said to have relied on “other resources.” 4.7% (n = 24) of respondents recognized the benefits of structure, routines, and self-discipline in their personal and professional lives as valuable resources throughout the pandemic. 4.5% (n = 23) participants also cited having drawn support from “vacations,” whereas an augmentation in their “financial resources” due to reduced expenses or increased income was reported by 1.4% (n = 7).10.5% (3.3.7.N = 34) participants, was an increased focus on “health.” 3.9% (n = 20) of respondents reported seeking “professional support for their health,” such as psychotherapy or medical care. 2.7% (n = 14) of the respondents expressed an “increased importance of health,” endorsing the implementation of protective measures against illnesses, as one participant said: “Due to wearing masks, I have had significantly fewer colds and flu-like infections.”A favorable consequence of the pandemic, noted by 6.6% . The corresponding percentages of their evaluations are illustrated in 3.4.3.4.1.Across all burden-related categories and subcategories, the following exhibited significant differences with more codings in either the Good Well-Being (“Good WB”) or Poor Well-Being (“Poor WB”) group:p = 0.010).In the category of “family and friends,” the subcategory of “interpersonal problems” was significantly more frequently reported by the “Poor WB” group compared to the “Good WB” group , “negative feelings” , problems with “sleep” , and symptoms of “exhaustion”  than the “Good WB” group.In the “mental health” category, the “Poor WB” group reported significantly more “excessive demand”  and somatic complaints  than the “Good WB” group.In the “physical health” category, the “Poor WB” group reported significantly more physical health burden .No or little adverse impacts were reported by a substantial 26.6% in the “Good WB” group and only 2.9% in the “Poor WB” group  or Poor Well-Being (“Poor WB”) group:p = 0.020).The “mindfulness” category but not any specific subcategories displayed an overall difference, with the “Good WB” group reporting lower levels of mindfulness , with the “Good WB” group likewise reporting fewer recreational activities. Among the subcategories, only the “physical activity” subcategory revealed a significant difference, with the “Good WB” group reporting less frequently that physical activity was a significant resource .In the “recreational activities” category, a substantial overall group difference was observed . Among the subcategories, solely the subcategory “positive attitude/optimism” revealed a significant difference, as the “Good WB” group reported more frequently sporting a “positive attitude/optimism” .Conversely, a significant overall difference between the groups was observed in the “inner processes category,” with the “Good WB” group demonstrating more inner processes .No significant difference between the groups emerged within the main category of “health.” However, only members of the “Good WB” group registered in the subcategory “increased importance of health” . In more detail, 43.4% stated to be “very satisfied” with their coping strategies (vs. 19.6% in “Poor WB”), whereas they were less often “neutral” (6.6 vs. 25.6%), dissatisfied (1.2 vs. 4.8%), or very dissatisfied (0.6 vs. 1.2%).Regarding “satisfaction with coping,” the “Good WB” group reported significantly higher levels of satisfaction  and Poor Well-Being (“Poor WB”) group, partitioned based on levels of psychological well-being .4.3.1.The “Poor WB” group consisted of more females. It was younger, less experienced, with fewer psychotherapists in the age groups 60–69 and 70+ and more in the age groups 41–49 and 50–59. The “Good WB” group” on the other hand, reported participating more frequently (4+ days/week) in physical activity compared to the “Poor WB” group (0–2 days/week). This disparity is especially pronounced when considering the proportion of psychotherapists who abstain from physical activity entirely: a mere 5.6% from the “Good WB” group, as opposed to a significant 14.6% within the “Poor WB” group. An overrepresentation of women, younger individuals, and physically inactive persons within a cohort exhibiting poor well-being aligns with prior findings from the general population, suggesting that the pandemic has particularly affected these demographics , 67. Givp = 0.013) also seems to have bolstered – or was an expression of – better well-being of psychotherapists. One potential explanation could be that the “Good WB” group, perhaps due to fewer care responsibilities and a more liberal work setting with reduced administrative tasks, had more time to treat patients, which might have felt gratifying  worked exclusively in private practice compared to the “Poor WB” group (71.9%). Conversely, a greater percentage of psychotherapists in the “Poor WB” group (28.1%) were employed by institutions, in contrast to the “Good WB” group (19.6%). This observation seems to corroborate our prior assumptions regarding what makes “work” a frequently cited resource and a less frequently cited burden for psychotherapists  and what gives them the freedom to engage in global problems (such as the climate crisis or the Russian war against Ukraine) rather than more personal problems. The enhanced flexibility of working conditions for self-employed professionals, characterized by a higher degree of autonomy and adaptable time management, contrasts with the more restrictive conditions and high workloads of institutional environments during a pandemic , 36, theatifying , 63.4.3.2.Regarding the burdens faced, psychotherapists belonging to the “Poor WB” group encountered heightened “interpersonal difficulties” and a more pronounced strain across various mental health realms, such as “excessive demand,” “negative emotions,” “sleep disturbances,” “fatigue,” “physical health,” and “somatic complaints.” Notably, 40.4% of participants within the “Poor WB” group reported somatic complaints, which doubles the frequency observed in the “Good WB” group. The reported somatic complaints encompass not only those typically categorized as psychosomatic such as tense muscles, back pain, tinnitus or headaches but also chronic physical ailments, age-related issues, and more. Unsurprisingly, the “Poor WB” group also declared significantly less often to have experienced “no or little adverse impacts” of the pandemic (2.9 vs. 26.6%).We think that this pattern points not only to more individuals with poorly integrated personalities in the “Poor WB” group but also to more individuals suffering from chronic illness, age-related ailments and other factors related to the demographics specific to this group, such as the burden of care typical for the age group between 40 and 60 or a more detrimental work environment as pointed out above in the demographics section.4.3.3.In examining the resources utilized, the “Good WB” group intriguingly reported a less frequent reliance on mindfulness, potentially due to a diminished need for coping. This notion is reinforced by their significantly higher “positive attitude/optimism” and “increased importance of health,” suggesting that they were able to perceive constructive aspects in the containment measures rather than solely regarding them as burdensome.de facto physical involvement among the “Poor WB” group could be ascribed to their struggles in various mental and physical health domains. Possibly due to a combination of overall better well-being and greater ease in accessing helpful resources, particularly physical activity, the “Good WB” group reported higher satisfaction with their coping strategies, with nearly half being “very satisfied” compared to only one-fifth in the “Poor WB” group.The “Good WB” group also reported participating in recreational activities less frequently, especially “physical activity.” This observation contradicts the previously mentioned finding that the “Good WB” group engaged in “physical activity” considerably more often (4+ days/week) compared to the “Poor WB” group (0–2 days/week). It is plausible that they reported “physical activity” more frequently due to discovering sports as a resource only during the pandemic, while the “Good WB” group, having consistently engaged in physical activity prior to the pandemic, may have deemed physical activity less noteworthy to report. The reduced propensity for 4.4.This study presents several limitations. Firstly, the written format of the study constrains the potential to glean more contextually rich and coherent information, as would be feasible through personal interviews. Secondly, all questions were posed during a period of fewer pandemic-related restrictions, potentially leading to recall bias when inquiring about the challenges and resources experienced throughout the pandemic. Additionally, we did not distinguish timeframes in the burdens category, even though questions one and two pertain to the present, and question three relates to the entire pandemic period. Thirdly, other crises, such as the war in Europe and corresponding high inflation rates, likely influenced the reported burdens and resources. Fourth, physical activity was not assessed objectively but rather by one self-report question. Fifth, the WHO-5 scale is a global measure that does not capture nuanced experiences of stress or specific psychiatric constructs such as anxiety or depression. With regard to our comparison of psychotherapists with clinical psychologists , we woul5.Psychotherapists identified mental health-related phenomena as their primary source of burden, suggesting heightened awareness of their own declining psychological well-being. Global crises, notably influenced by the war in Ukraine, represented the second most significant category of burden, overshadowing complications brought about by the pandemic. However, the pandemic’s repercussions, particularly discomfort from containment measures, emerged as the third principal stressor. The key resources for managing these challenges were social connections, mindfulness, work fulfilment, and internal processes. Notably, individuals with better well-being were characterized by increased physical activity, older age, more years of professional experience, a lower ratio of females, being self-employed in private practice rather than employed in institutional settings, and handling a higher patient caseload compared to the group with poor well-being. This “better well-being” group also tended to exhibit a more optimistic outlook, a greater focus on maintaining good health, and higher satisfaction with their own coping methods. Our findings underscore the potential for shaping more effective support systems, policies, and educational programs that bolster the resilience of mental health professionals amidst global crises. Moreover, they highlight strategies that individual practitioners can adopt to preserve their own well-being during challenging times.The raw data supporting the conclusions of this article will be made available by the authors, without undue reservation.The studies involving humans were approved by Ethical number: E.K. G.Z. 11/2021–2024. The studies were conducted in accordance with the local legislation and institutional requirements. The participants provided their written informed consent to participate in this study.YS, AJ, EH, and TP: conceptualization. YS: methodology, validation, and writing—original draft preparation. MB, BS, YS, and EH: formal analysis. EH: investigation, data curation, and project administration. YS, EH, AJ, TP, and CP: writing—review and editing. YS and EH: visualization and supervision. All authors contributed to the article and approved the submitted version.The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.All claims expressed in this article are solely those of the authors and do not necessarily represent those of their affiliated organizations, or those of the publisher, the editors and the reviewers. Any product that may be evaluated in this article, or claim that may be made by its manufacturer, is not guaranteed or endorsed by the publisher.


To evaluate the outcomes of corrective surgical treatment for craniofacial asymmetry using four different methods with the aim of developing the best technique for craniofacial asymmetry assessment.CBCT images of twenty-one class III subjects with surgically corrected craniofacial asymmetry and twenty-one matched controls were analyzed. Twenty-seven hard tissue landmarks were used to quantify asymmetry using the following methodologies: the asymmetry index (AI), asymmetry scores based on the clinically derived midline (CM), Procrustes analysis (PA), and modified Procrustes analysis (MPA).Modified Procrustes analysis successfully identified pre-operative asymmetry and revealed severe asymmetry at the mandibular regions compared to controls, which was comparable to the asymmetry index and clinically derived midline methods, while Procrustes analysis masked the asymmetric characteristics. Likewise, when comparing the post-surgical outcomes, modified Procrustes analysis not only efficiently determined the changes evidencing decrease in facial asymmetry but also revealed significant residual asymmetry in the mandible, which was congruent with the asymmetry index and clinically derived midline methods but contradictory to the results shown by Procrustes analysis.In terms of quantifying cranio-facial asymmetry, modified Procrustes analysis has evidenced to produce promising results that were comparable to the asymmetry index and the clinically derived midline, making it a more viable option for craniofacial asymmetry assessment.Modified Procrustes analysis is proficient in evaluating cranio-facial asymmetry with more valid clinical representation and has potential applications in assessing asymmetry in a wide spectrum of patients, including syndromic patients. Aesthetic faces have been proven to influence individuals’ personality development, which can dictate their social, economic, and health status , 2. In tThe advent of 3-dimensional (3D) imaging modalities has provided additional diagnostic tools for clinical use . AccuratProcrustes analysis.” Several studies have analyzed facial asymmetry using clinical midline and Procrustes methods; however, flaws associated with these methods, such as unreliability and falsified presentation of true asymmetric features, have also been reported [A midsagittal plane (symmetry plane) is central for the quantification of facial asymmetry and can be constructed by manually selecting the reference landmarks not affected by the asymmetry , 16–18 oreported , 19, whiBy considering the mean difference of 0.66 mm (standard deviation of 0.5) as clinically significant , togetheT0) and post-surgical CBCT scan (T1) taken at least 6 months after surgery, (4) had no history of craniofacial syndromes or craniofacial surgery, and (5) were not diagnosed with hemifacial microsomia or orbital dystopia.Twenty-one subjects  aged 18 to 40 years (23.0 ± 3.4 years) from the orthodontic-orthognathic pool who sought surgical treatment at the Prince Philip Dental Hospital, University of Hong Kong, between April 2012 and July 2019 were chosen if they fulfilled the following inclusion criteria: (1) soft tissue chin deviation > 3 mm, (2) bimaxillary surgery with no genioplasty, (3) pre-operative cone-beam computed tomography (CBCT) scan (Twenty-one age (23.0 ± 3.3 years) and gender  matched subjects from the same hospital who had taken CBCT scans in 2015 for nonsurgical purposes and who satisfied the following inclusion criteria were recruited for the present study. Inclusion criteria: (1) imperceptible maxillo-mandibular asymmetry (soft tissue chin deviation < 3 mm), (2) class I skeletal pattern, (3) decently aligned dental arches, and (4) no previous record of temporomandibular disorder, craniofacial syndromes, or craniofacial surgery. Table ProMax 3D Mid  with the following parameters: 90 kVp, 400 μm voxel size, 4.7 s scan time, and 20 cm × 17 cm field of view. Each subject was seated with the head positioned such that the Frankfurt horizontal (FH) plane was parallel to the ground while maintaining a mild contact of the lips to their teeth and labio-mental soft tissue at rest throughout the scanning process. CBCT scans were saved in Digital Imaging and Communications in Medicine (DICOM) format and then imported to 3D Slicer 4.10, an open-source medical image processing software platform (http://www.slicer.org) for analysis [Each patient was scanned using analysis .Four different methodologies, the asymmetry index (AI) , 14, 22 Editor tool.” Next, “Markups tool” enabled manual digitization of bilateral orbitale and left porion landmarks, to establish the horizontal plane (HP), while the nasion and sella to define the midsagittal plane (MSP) perpendicular to the HP. Coronal plane (CP) was built passing through the left porion and perpendicular to the HP and MSP. Using slicer extension “Align2FH_SagittalPlane,” the HP plane was aligned along the x–z plane, and MSP was aligned along the y–z plane, while the porion was set to lie on the x-axis. Thereafter, the CBCT volume and its corresponding 3D model underwent automatic reorientation via the “Transform tool” appertaining to the reference planes mentioned above. Later, using a 2-step semiautomated registration technique, pre-operative (T0) and post-operative (T1) CBCTs of each patient were superimposed based on selecting the region of interest (ROI) involving predetermined stable cranial structures unaffected by the surgery. Detailed methodology for orientation and registration of CBCT volumes can be referred from the previously published study [T0, T1 and control patients and the distance of each landmark to the three reference planes was measured as dR, dA, and dS in millimeters (mm) . Next, the 3D 27-landmark configuration  along with a “clinically derived midline”  was generated. Following this, the centroid (geometric center) for each 3D configuration was determined, and scaled to a common centroid size, which was then used to generate a “reflected” 3D landmark configuration by mirroring the 3D original configuration about the “clinically derived midline.” Thereafter, “Euclidean” distances between each pair of landmarks  were measured  of the 3D landmark coordinates including the coordinates (Nasion and Sella) for generating the “clinically derived midline” were imported to “The 3D landmark configuration , as mentioned previously, was imported into MATLAB software. The 3D configuration was then aligned with the help of a new code using PA. As described earlier, this technique determined the centroid for each 3D configuration and scaled them to the same centroid size. Next, a reflected configuration was created by mirroring the original 3D configuration, this time about an arbitrary plane instead of the clinically derived plane. Finally, to achieve the best fit between the original 3D configuration and its reflected configuration, the latter configuration was rotated and translated over the static original configuration until the Procrustes distance  was minimized . This involved importing the 3D landmark configuration  into MATLAB software, computing the centroid and re-scaling the configuration to a common centroid size. A reflected configuration was then created by mirroring the original version around an arbitrary plane. Next, the original configuration was kept static while rotating the reflected configuration until the sum of the squared distances between four stable landmarks  was minimized to achieve the best fit between them unlike PA, wherein all the landmarks were utilized to obtain the best fit between the original and reflected configurations . A 2-week interval was maintained amid the first and the second alignments and landmarking procedures to minimize memory bias.  The Dahlberg formula  was usedt-test. Similarly, an independent t-test was used to assess the pre- and post-operative means against controls. Probabilities of p < 0.05 were considered significant.All statistical analyses were performed using IBM SPSS Statistics for Mac, version 25.0 . Facial asymmetry was evaluated by computing the asymmetry scores of 9 regions for all the patients. Patients’ pre-operative and post-operative measured variables were compared using a Students paired The intra-examiner reliability measurements were excellent, with a mean intraclass correlation coefficient (ICC) of 0.95 (range 0.90 to 0.99), and method error ranging from 0.03 to 0.38 mm.p = 0.023), followed by the lower facial region, including the mandibular midline  and mandibular bilateral region . After surgery, substantial correction of asymmetry was noticed regarding the total facial skeleton (p = 0.046), total mandible (p = 0.018), and mandibular midline (p < 0.001). However, even after surgery, the asymmetry was more pronounced in the total maxilla, bilateral maxilla, and bilateral mandibular regions. Despite significant improvement in asymmetry post-operatively, the symmetry achieved was not comparable to controls at the total facial skeleton (p = 0.002), total mandible (p = 0.006), and mandibular midline (p < 0.001).The results of the AI comparison between different groups are summarized in Table p < 0.001 and < 0.001, respectively; zone AS), mandible midline and mandible bilateral , chin and ramus , as assessed by higher mean asymmetry scores compared to C  and total mandible (p = 0.010) post-surgery when asymmetry scores were compared against T0  and from 6.99 to 3.14 for the chin region (p < 0.001) after surgical correction. When post-surgery asymmetry scores were compared with controls, mean asymmetry scores at all regions of zone AS ; maxilla bilateral and mandible bilateral ; and ramus  were found to be significantly higher for the post-surgery group  and chin  regions.Table o C Fig. a. Signif T0 Fig. b. Specifp < 0.001 and p < 0.001, respectively; zone AS), mandible bilateral , and ramus  , total maxilla (p = 0.02), and total mandible (p < 0.001); bilateral maxilla (p = 0.04) and bilateral mandible (p < 0.001) of part AS; ramus (p < 0.001); and area AS exhibited significantly higher mean asymmetry scores after surgery when compared with controls  Fig. a. After ant Fig. b. In addols Fig. c.Table 6p < 0.001 and < 0.001, respectively; zone AS), mandible midline and mandible bilateral , chin and ramus  except for the maxillary region   and chin region  compared to T0 , albeit significant correction. The results for the intergroup comparison of MPA-derived asymmetry scores are summarized in Table Pre-surgical asymmetry scores were observed to be significantly higher when matched against controls, implying severe asymmetry at all the facial regions including total facial skeleton and total mandible (AI) Fig. a. Substa T0 Fig. b. When p T0 Fig. c. In addMatching symmetry or object symmetry defines bilateral symmetry as portrayed in biology. Matching symmetry is characterized as a structure created by 2 distinct replicas (mirror images), each located on either side of the body. Object symmetry refers to a structure that is symmetric within itself, thus devising its own internal plane of symmetry, attributable to the left and right halves as mirror images of each other , 32. TwoAssessment of facial asymmetry consists of 2 steps: (1) establishing a symmetry plane that fits the asymmetric craniofacial structures and (2) gauging the degree of deviation from symmetry . In an aIn an effort to maintain accuracy, the same coordinate system for pre- and post-surgery craniofacial structures was used for assessing the changes following surgery to avoid the deviation of the clinical midline that could have affected the results. AI, CM, and MPA proved the surgery to be successful in decreasing asymmetric characteristics of the mandibular region, but concomitantly where CM and MPA showed substantial improvement Fig. a and c, modified Procrustes analysis” stemmed on morphometric analysis quadrate with each other, while PA, a morphometric method, showed quite paradoxical results  is a promising and reliable method for the assessment of 3D facial asymmetry and is clinically applicable for class III patients seeking orthognathic surgery. Furthermore, this method has potential applications in assessing asymmetry in a wider spectrum of patients, including syndromic patients, given that symmetrical arbitrary landmarks can be located.