Low-carbon travel has emerged as a topic of interest in tourism and academia. Studies have offered reasons tourists may engage in low-carbon travel; however, these explanations are scattered throughout the literature and have yet to be integrated into low-carbon travel motivation and constraint constructs. This study develops a low-carbon travel motivation scale (LCTMS) and a low-carbon travel constraint scale (LCTCS). It performs reliability and validity testing to measure the low-carbon travel motives and obstacles. Items were collected primarily by literature review, and, then, by surveys of 382 tourists from low-carbon travel destinations and 390 from non-low-carbon travel destinations. Through a rigorous scale development process, this study identifies six dimensions of the LCTMS  and four dimensions of the LCTCS . Carbon dioxide emissions resulting from travel and tourism activities account for 5–14% of the world’s total carbon dioxide emissions . They are rising at a rate of 3.2% per year [The push and pull factors commonly studied in tourism motivation research  serve asOn the other hand, most tourists recognize the benefits of low-carbon activities but are reluctant to plan low-carbon travel activities . The keyVery few studies have integrated and developed scales for two constructs in a sole paper ,15. HoweTherefore, this study identifies and clarifies low-carbon travel motivations and low-carbon travel constraints, from a theoretical perspective of the two concepts, and adds to the related research. These low-carbon travel motivation and low-carbon travel constraint constructs can help researchers and tourism operators understand the reasons and limitations of tourists engaged in low-carbon travel, while also providing appropriate market segmentation criteria in tourism. Understanding the motives and constraints of low-carbon travel will help the tourism industry provide the services that tourists want and need, and assist the operators in planning their corresponding marketing strategies.Based on the background above research and topics, the objectives of this study are as follows: (1) To explore the motives and obstacles to engaging in low-carbon travel, review the literature to identify their significant implications, and then clearly define constructs for low-carbon travel motivation and low-carbon travel constraint. (2) To develop a low-carbon travel motivation scale (LCTMS) and a low-carbon travel constraint scale (LCTCS) and, then, perform letter and validity testing to measure the low-carbon travel motives and obstacles.Travel motivation is a broad and complex concept. McIntosh and Goeldner  divided As visitors in different travel situations may hold different motivations, researchers have used many aspects to discuss tourism motivation and develop different travel motivation scales. For example, rural tourists are generally motivated by relaxation, social interaction, education, family gatherings, novelty, and excitement . Cruise Although these researchers have mainly used factor analysis or cluster analysis to determine the various travel motivations of their subjects, since the nature of travel is a series of travel activities to satisfy people’s inner social-psychology needs or the external cultural seeking of a destination, tourist motivation has tended to revolve around the concepts of “pull” and “push” . Most diResearchers have proposed numerous factors that motivate tourists to engage in low-carbon travel. However, these explanations are scattered throughout the literature, have not been integrated into a low-carbon travel motivation construct, and are inconsistent with general tourism motivations. To address these discrepancies, this study applies the push and pull theory  to exploPush motivation is a psychosocial need that motivates individuals to travel, and that motivation drives or guides individual travel choices . Common Moral motivation refers to tourists participating in environmental protection behavior based on their social awareness of green products and service consumption as well as a positive self-image. Tourists choose low-carbon destinations because of environmental appeal or green policies promoted by the tourism industry . When HoEmotional motivation mainly refers to the joy  and happAccess motivation refers to tourists’ desire to improve physical fitness and acquire new knowledge. Regarding physical fitness, Garrido-Cumbrera et al.  used focPush motivations are usually intrinsic, whereas pull motivations are external and are related to destination choice, destination traits, attractions, and attributes. Pull factors attract people to destinations such as sunny beaches or snowy mountains and influence the perceptions and expectations of travelers. Common pull factors are natural and historical environments, cost, convenience, safety, accessibility, novelty, and education .ESCR characterizes low-carbon travel. Generally, tourists engage in low-carbon travel activities to directly reduce carbon emissions and their carbon footprint while on holiday ,10. MoreSome tourists reduce their travel by plane once they understand the importance of reducing their carbon footprint . GarridoResearch by Kuo and Dai  revealedEmpirical research has focused on identifying tourism motivation factors and measurement scales. A variety of different motivational factors have been used to explain the behavior of visitors in different travel situations. In the past, researchers proposed a variety of motivations to explain why tourists engage in low-carbon travel. However, no research has integrated this into the low-carbon travel motivation construct. Understanding tourists’ low-carbon travel motivations will help us identify the factors that drive tourists to participate in low-carbon travel. Industry operators will be better able to plan low-carbon travel activities to maximize tourist satisfaction, inspire and change attitudes, and reduce environmental stress . Thus, bTravel constraint is a multifaceted concept that refers to the factors that prevent or reduce the frequency, proportion, or fun of individuals engaging in specific activities ,34. KhanThere are a few classic conceptual models of barriers to leisure participation. The leisure constraints model developed by Iso-Ahola and Mannell  placed tTan  explaineIn the low-carbon travel context, researchers e.g., ,42 have Poor health and low-carbon travel awareness are the most common intrapersonal constraints. The subjects of Kuo and Dai  believedAlong with poor health and lack of awareness, another cause of intrapersonal low-carbon travel constraints is tourists’ unwillingness to sacrifice general tourism’s advantages and personal travel benefits. Respondents of Dällenbach  believedTourism research has determined a lack of friends as the primary interpersonal constraint ,41. HoweAccording to Dällenbach , most toThe characteristics of low-carbon travel, including short-distance travel, less travel, and more extended stays at destinations, are different from general travel planning and are the factors tourists consider most ,27. SincThe structural constraints of low-carbon travel are that its planning and arrangement are different from general tourism. Although all survey participants are aware of climate change, they lack explicit action means. Moreover, many people firmly believe that they are not responsible for carbon emissions related to tourism travel. To a large extent, travelers are limited by tourism products. For example, if it is challenging to take a bicycle on a train, but it is easy to take a bike on low-cost airlines, low-carbon bicycle travelers may engage in high-carbon aircraft travel .Many studies have interviewed travelers who generally do not consider alternative transportation on reducing airplane tours ,42,44. DTravel constraints have been studied extensively in the field of tourism. Although many tourists refuse to embrace low-carbon travel, studies have not integrated the various constraints into a construct of low-carbon travel constraint. Therefore, this study applies the three-dimensional constraint architecture, proposed by Crawford and Godbey , to clarThis study aims to explore the motivations and constraints of tourists engaged in low-carbon travel and to develop LCTMS and LCTCS. This study mainly uses a literature review to collect tourists’ potential low-carbon travel motivations (based on push-and-pull factors) and low-carbon travel constraints . It adopts interviews to supplement more possible items. The researcher and the transcribed responses conducted in these interviews would be coded, and a grounded theoretical context would be used to guide the coding process . MoreoveSchmid  suggesteTo collect a variety of low-carbon travel motivations and low-carbon travel constraints as well as to improve data quality and generalization, this study adds some items through interviews. From 1 February to 31 March 2015, 14 low-carbon tourists and 11 non-low-carbon tourists participated in in-depth interviews by snowball sampling. The open-ended interview questions are shown as Next, three judges who have rich low-carbon travel experience and two judges who have research experience in low-carbon travel are invited to assist in classifying and naming the results of the literature review and in-depth interviews. The content analysis produced 113 valid low-carbon travel motivation units and 115 valid low-carbon travel constraint units. These units were grouped into 33 low-carbon travel motivation-related and 30 low-carbon travel constraint-related subcategories. The inter-judge reliability is 0.87 (98/113) and 0.91 (30/33) for low-carbon travel motivation and 0.88 (101/115) and 0.90 (27/30) for low-carbon travel constraint. These low-carbon travel motivation and constraint subcategories were then transformed into preliminary items for the initial item pool.The researchers also carefully review the conceptual narrative of the above items, so that the item content conforms to the appropriate words of low-carbon travel motivation and low-carbon travel constraint, to achieve reasonable surface validity. The results indicate that low-carbon tourists and non-low-carbon tourists have different motivations and constraint experiences. For clarity, 33 low-carbon travel motivations are divided into two categories: push motivations and pull motivations. The 30 low-carbon travel constraints are divided into four categories: intrapersonal constraints, interpersonal constraints, structural constraints, and the not a travel option.After pooling the initial items, the researcher submits the preliminary research to an expert panel of four experienced low-carbon tourists and five scholars specializing in tourism and low-carbon travel for assessment. Chang et al.  stated tThe formal questionnaire is based on previous methods of measuring travel motivations and constraints. This study uses the intensity concept  to measTo increase the reliability and validity of the measurement tools, this study uses SPSS 23.0 software to individually evaluate each item, confirm that the items measure the same concept and form an intrinsically consistent scale, and exclude items that do not meet this standard . The corTo ensure the ability of the questionnaire to measure low-carbon travel motivations and low-carbon travel constraints, this study conducts a pre-test to confirm the clarity and comprehensiveness of the questionnaire content. The basis of filtering items is item analysis and a critical test. Item analysis can eliminate ambiguous or misleading items in the scale development process. In this way, researchers can consider whether items on a scale are necessary or not . This stThe first formal data collection covers low-carbon destination visitors. Low-carbon destination refers to destinations with low-carbon footprints and low-carbon travel concepts, such as travel planning and merchant services . QingdaoIndependent tourists generally plan and arrange their travel, holding a wealth of knowledge regarding the purchase and use of travel products. Independent tourists desire to satisfy their inner social and psychological needs through tourism. So, compared to group tourists, independent tourists are much more attracted by tourism attributes. Independent tourists also consider the constraints of planning travel routes more than group travelers. Therefore, independent tourists require more time and energy to decide whether to start or continue low-carbon travel. This study selects Laoshan Scenic Area and Zhanqiao Scenic Area in Qingdao as the survey sites for low-carbon destinations. The survey population is independent tourists visiting these scenic areas. This study adopts random sampling to ensure the sample is representative.Survey interviewers were two doctoral students, three master’s students, and two college students with considerable investigative skills training. The researchers used the convenience sampling method from 1 June to 14 June 2018. To ensure the validity of the sample, interviewers reviewed each item in the collected questionnaires to ensure that respondents answered all questions. This study collected 497 questionnaires, of which 382 were valid, for an effective sample recovery rate of 76.9%. Roscoe  suggesteData from the first survey are used to purify the LCTMS and LCTCS to determine the scale’s factor structure. Data from the second survey are used to revalidate the stability of the scale factor structure and perform a reliability and validity analysis. The sample and travel characteristics of the low-carbon tourist sites collected in the first survey are detailed in Normality assumptions were examined using skewness-kurtosis tests. Under univariate normality, we consider variables with a skew index higher than 3 and a kurtosis index higher than 10 to violate the usual distribution assumption . The study items were assessed by determining the range of skewness (−1.43 to 0.26) and kurtosis (−0.79 to 2.32). Thus, the first formal survey data did not appear to violate the assumptions of normality.This study uses exploratory factor analysis (EFA) on low-carbon travel sites to determine the measurement scale constructs. The principal component analysis method obtains the co-interpreted variation between all measurement items and excludes items with cross-load quantity, by the orthogonal rotation axis of the maximum variation number. Items with factor loading values above 0.5 are retained. The EFA results of the LCTMS are presented in The EFA results for the LCTCS are presented in Reliability is generally reflected in the consistency or stability of the measurement tool, and it refers to the trustworthiness of the measurements. Criterion-related validity is used to test the validity of LCTMS and LCTCS. Carvache-Franco et al. , and Božp < 0.01. Therefore, the criterion-related validity of LCTMS and LCTCS is supported.The Pearson Correlation between intention and motivation and intention and constraint is used to evaluate criterion-related validity. The results demonstrate that environmental protection (r = 0.62), experience seeking (r = 0.60), escape and social connection (r = 0.52), environmental protection claims and measures (r = 0.43), low-carbon products (r = 0.47), and green transportation (r = 0.49) are significant positively associated with low-carbon travel intention. At the same time, structural constraints (r = −0.10), intrapersonal constraints (r = −0.19), the not a travel option (r = −0.42), and interpersonal constraints (r = −0.13) are significantly negatively associated with low-carbon travel intention. All these correlation coefficients are significant at The present study evaluated the presence of common method variance (CMV) by the Harman single-factor test . The sixThrough the first data collection and analysis process, this study establishes 24 questions for the LCTMS and 23 questions for the LCTCS. Next, this study evaluates the reliability and validity of the scales in another different sample, as recommended by Churchill (1979). The second phase investigates independent tourists in non-low-carbon destinations. Since all the counties and cities in Shandong are actively developing sightseeing, most tourists engage in mass tourism. This study selects the metropolitan areas of Weihai City in Shandong as representative samples of non-low-carbon destinations. Data were collected from 15 June to 28 June 2018. Four hundred and eighty-five questionnaires were collected, and 390 questionnaires were valid, for an effective sample recovery rate of 82.3%. The ratio of samples to low-carbon travel motivation items is 16.6:1, and the ratio of samples to low-carbon travel constraint is 17.3:1. The items were assessed by determining the range of skewness (−1.17 to 0.32) and kurtosis (−0.59 to 1.02). Thus, the second formal survey data appear in line with the assumptions of normality.The sample profile and travel characteristics of non-low-carbon travel sites are presented in Confirmatory factor analysis (CFA) is used to confirm the factors’ structure of the LCTMS and LCTCS, obtained from the previous EFA results. LISREL 8.80  analyzesIn 2/df is 780.31/237, GFI is 0.86, AGFI is 0.82, NFI is 0.98, NNFI is 0.98, CFI is 0.98, IFI is 0.98, SRMR is 0.05, and RMSEA is 0.08. These evaluation indicators are all acceptable, indicating that the sampling data exhibit high goodness of fit with the structure of the LCTMS, which suggests a proper scale [2/df is 661.38/224, GFI is 0.88, AGFI is 0.86, NFI is 0.93, NNFI is 0.93, CFI is 0.94, IFI is 0.94, SRMR is 0.08, and RMSEA is 0.08. These evaluation indicators are at acceptable levels, indicating that the sampling data exhibit high goodness-of-fit with the structure of the LCTCS, which suggests a sufficient scale.Next, this study explores whether the scale’s measurement mode’s absolute and relative fit indicators meet the criteria. In the overall model of the LCTMS, the χer scale . From Tap < 0.05), reaching the statistically significant level. These suggest that the potential variables of this study have ideal convergence validity [Convergence validity refers to the observation items used to measure the same construct, and these should have a high correlation with each other. The standard factor loading of all items in the scale is 0.50, and the estimated parameters  are more significant than 1.96  and LCTCS with four main factors . The other one is a second-order model. LCTMS showed push and pull as the primary factors as well as the six sub-factors, and LCTCS only showed constraint as the main factor as well as the four sub-factors. The fit indices for all four models are separately presented in The CFI, SRMR, and RMSEA indicated adequate data to model fit, for all models based on the general guidelines. To compare the first-order and second-order models, the researcher examined the NCP, AIC, and ECVI. Although the first-order models were marginally better, the second-order models were both reasonably close and significantly easier to use in research and practice. Pan et al.  pointed This study surveys independent tourists from low-carbon travel and non-low-carbon travel sites and evaluates the reliability and validity of two scales. The results exhibit high goodness of fit, supporting the second-order two-factor structure of low-carbon travel motivation with six potential constructs and the second-order single-factor form of low-carbon travel constraint with four possible constructs. The CR of each construct is at least 0.7, indicating that the scale reliability is acceptable. This study ensures that each scale has reasonable validity through construction, convergence, differential, and criterion-related validity. The results indicate a need to explore the essential constructs and contents of low-carbon travel motivation and low-carbon travel constraint for independent tourists and tour operators, to confirm why tourists do or do not engage in low-carbon travel.Scholars have been increasingly interested in determining the motivations and constraints behind tourists’ decisions to engage in low-carbon travel ,8. This The relevant literature has stressed that low-carbon travel contributes to sustainable tourism development ,8—Horng Since few studies have comprehensively examined the low-carbon travel motivation and low-carbon travel constraint in the tourism industry, this study is based on a push and pull structure of tourism motives as well as a three-dimensional framework for constraints and, then, emphasizes the diversified orientation of low-carbon travel motivation and low-carbon travel constraint. This study suggested various critical factors indicators gathered from in-depth interviews and questionnaires. Furthermore, there are still many studies that continued to explore the relationships between travel motivation, constraint, and experience. Compared to past studies, this study provided the necessary concept and measurements of tourists’ low-carbon travel motivation and constraint in the low-carbon tourism context; the LCTMS and LCTCS developed in this article highlight the independent tourists’ perspectives.Based on the scale development process recommended by Churchill , this stLow-carbon travel is a broad concept, and independent tourists’ decisions on it vary according to their different motivations and constraints. The researchers believe that an in-depth understanding of motivations and constraints can help tourism operators encourage independent tourists to overcome those constraints and engage in low-carbon travel. Thus, the research results reveal the primary low-carbon travel motivations and low-carbon travel constraints of independent tourists, regardless of a tourist’s travel purpose or mode.The practical contributions of this study are (1) helping the tourism industry identify why independent tourists may or may not engage in low-carbon travel, (2) enabling the industry to provide the services that tourists want and need, and (3) assisting the industry in planning its corresponding marketing strategy. Theoretically, this study integrates the different motivations and constraints of low-carbon travel and lays out a reasonable theoretical foundation. The construction of the LCTMS and LCTCS adds to previous knowledge as well as provides a practical assessment and guidance tool for tourists and scholars. The two scales are appropriate tools for low-carbon travel market segmentation.This study confirms the stability of the LCTMS and LCTCS and the structure, reliability, and validity of the low-carbon travel behavior scale. Therefore, the LCTMS and LCTCS can, indeed, provide low-carbon travel operators and authorities with why tourists choose to engage or not engage in low-carbon travel and, then, motivate tourists to overcome constraints and practice low-carbon travel. Concerning the spirit of theoretical construction, the significance of using this research scale is to understand the psychological and behavioral context of independent tourists engaged in low-carbon travel.From theoretical development, researchers have focused on the theory of planned behavior  and the Tourists and tourism authorities can further apply the content of these two scales, integrate recreational resources, policy dissemination, media, and, even, knowledge acquisition, and strengthen independent tourists’ low-carbon travel motivations and reduce their constraints. Thus, this study has several implications for management.Low-carbon travel differs from other types of tourism, in that it emphasizes ESCR and lessens the adverse effects on the environment. The competent authorities of tourism destinations should actively educate independent tourists about environmental protection. As independent tourists increasingly favor ESCR, reduce their resources waste, and lessen the harmful effects of tourism on the environment, their motivation to engage in low-carbon travel will increase. Second, the competent authorities of tourism destinations should improve low-carbon travel services and the environment to provide independent tourists with more opportunities to explore the culture of tourism destinations. This approach makes it possible for independent tourists to understand the difference between low-carbon travel and general tourism.Third, the competent authorities of tourism destinations should emphasize the escape and social interaction aspects of low-carbon travel. So, independent tourists can also escape from their daily life or work, enjoy physical and mental relaxation, spend time with relatives and friends, and, even, meet people with the same hobbies or interests. The tourism industry’s environmental protection appeals and measures are a fourth powerful motivation. The tourism industry should apply different environmental protection labels according to their current conditions or ability to improve, propose specific environmental protection slogans and demands, and provide ESCR facilities through multiple avenues. The above measures will help independent tourists better understand where to choose low-carbon operators.Lin  discoverNowadays, in contrast to group tourists, independent tourists make their arrangements and consider the constraints of many ESCR measures in low-carbon travel. The tourism industry and authorities should provide independent tourists a convenient ESCR and comfortable tourism situation, along with much low-carbon travel information to improve tourist views of low-carbon travel. For example, Horng et al.  believedIndependent tourists wanting to engage in low-carbon travel face more intrapersonal constraints than group-package tourists. Since time and budget planning are more casual for independent tourists than group-package tourists, the tourism industry and competent authorities of low-carbon travel destinations should provide sufficient knowledge to tourists and plan marketing programs to attract independent tourists by giving incentives such as time, finance, and a low-carbon journey.Third, the competent authorities of tourism destinations should strive to promote low-carbon travel and encourage independent tourists to adopt low-carbon travel to develop a thriving low-carbon travel market. The tourism industry and the authorities of low-carbon travel could encourage independent tourists to travel with family and friends, by offering discounts and actively communicating that low-carbon travel can strengthen emotional connections with family and friends.First, the two scales constructed in this study are designed from the perspective of independent tourists. They may not suit group tourists. Since tourists primarily seek convenience and comfort, it is impossible to comprehensively consider the practice of low-carbon energy conservation, to explore the motivations and constraints of low-carbon travel from the perspective of group tourists. Further studies may adopt hieratic analysis to explore individual tourists’ low-carbon travel motivations and constraints in group tours.Second, further research can be conducted on low-carbon travel and non-low-carbon travel sites in other regions or countries, covering tourists with and without low-carbon travel experiences to test the external validity of these scales. Third, researchers can use the two scales to further examine the relationships between tourists’ low-carbon travel motivations and low-carbon travel constraints and other variables  to strengthen the theoretical basis of relevant research, such as the theories of planned behavior  and protFinally, further research can use cluster analysis and spectral concepts to study high-carbon tourism, moderate and mild low-carbon travel, and non-low-carbon travel experiences, comparing the low-carbon travel motivations and low-carbon travel constraints of tourists’ groups with the different levels of the low-carbon travel experience.


Private providers unaffiliated with the National TB Program (NTP) in Nigeria are not diagnosing or treating drug-susceptible TB patients according to NTP guidelines, resulting in an urgent need to engage non-NTP providers and improve the quality of their TB services. A majority of Nigerians seek TB care from the private sector, yet private providers who are not affiliated with the National TB Program (NTP) do not receive training on guidelines for diagnosis and treatment.Nearly 40% of private unaffiliated providers we surveyed self-reported using acid-fast bacilli for TB diagnosis. However, a much larger percentage used 5 other TB testing approaches not approved by the NTP to make a definitive diagnosis.Only 32.4% of providers surveyed prescribed the correct drug regimens. Five of the treatment regimens reported in our study contained streptomycin, which is against NTP recommendation.The enormous gaps in the quality of TB diagnosis and treatment among unaffiliated NTP providers in this study have wider implications for TB control efforts, particularly case notification, spread of drug-resistant TB strains, cost of prescribing unnecessary tests, and prolonged treatment duration.National and subnational TB program managers need to prioritize the rapid engagement of non-NTP providers into NTP surveillance systems, routine TB update trainings, and supportive supervision and monitoring to help increase the quality of their services. TB diagnosis and treatment practices among private providers not affiliated with the Nigeria National TB Program (NTP) have implications for TB control efforts. Studies evaluating these practices among non-NTP providers are scarce. We aimed to investigate TB diagnosis and treatment practices among non-NTP private providers in urban Lagos State, Nigeria.We conducted a cross-sectional study among doctors and nurses operating private facilities not formally affiliated with the NTP for TB case notification. Between May 2018 and January 2019, we implemented a survey using a pretested questionnaire among 152 doctors and nurses attending TB sensitization seminars in Lagos, Nigeria. We used descriptive statistics to summarize the sociodemographic information and proportion of non-NTP providers with different self-reported TB diagnostic, prescription, and monitoring practices.Private non-NTP doctors and nurses self-reported diagnosing TB using 8 different types of tests. Acid-fast bacilli was the most common (39.8%) means of diagnosing TB. Private non-NTP providers also self-reported prescribing 23 different TB regimens, including streptomycin, to treat TB. Only 32.4% of providers self-reported using the correct combinations of anti-TB drugs to treat TB. Additionally, 58.3% of providers prescribed the standard 6-month treatment duration for pulmonary TB patients, and the remaining 41.7% either undertreated or overtreated TB.A large proportion of private doctors and nurses not formally affiliated with the NTP in Nigeria were not following the NTP guidelines in the diagnosis and treatment of TB. Overtreatment and undertreatment were common. Engagement of these practitioners by the NTP in the form of supervision, on-the-job mentorship, and other strategies can mitigate the negative effects of their current practices on TB case notification and the spread of drug-resistant strains in Nigeria. Nigeria is 1 of the 30 high-burden countries identified by the World Health Organization for TB, TB/HIV, and multidrug-resistant TB.–––,,There are concerns that private providers lack the knowledge to implement proper TB case management.Private providers in Pakistan also lacked the required expertise for TB diagnosis and treatment compared with those from the public sector.There are also concerns about the quality of TB care received by patients among private providers. A multicountry review showed that less than 40% of patients with TB symptoms were properly managed in private settings in studies conducted in India, Kenya, China, and South Africa, with less than 30% referred to the national TB program. Other issues related to the quality of care in the private sector include low testing and referral rates, with gaps between knowledge of TB care and correct practice of TB care by private providers.Standardized mystery clients have been used to assess TB care provided by the private sector. In India, of 250 patient-provider interactions, only 21% were appropriately managed for TB. Correct management was about 2 times higher among medical doctors.Although 60% of Nigerians initially sought care in the private sector when they were sick, they contributed only 11% to TB notification in 2017.–Private non-NTP providers who are not affiliated with the NTP do not receive standardized TB/DOTS training, supervision, and tools to provide quality services that affiliated providers receive, although they may occasionally receive TB sensitization organized by the NTP. Among non-NTP providers, common shortcomings of TB case management include using GeneXpert to monitor treatment, serology for TB diagnosis, inappropriate treatment regimens, and poor case-holding skills.Private non-NTP providers do not receive the structured TB/DOTS training, supervision, and tools for quality service that affiliated providers receive.A key component of the National TB Strategic Plan (2015–2020) was integrating non-NTP providers in the Global Fund Private Public Mix (PPM) program, which aimed to engage the private sector in providing more people with TB prevention, diagnosis, and treatment services. The implementation of this strategic plan would increase the country’s TB case notification by activating and integrating additional non-NTP affiliated entities  into the NTP surveillance and reporting systems.There is a need for a systematic survey and needs assessment of TB case management practices specifically among non-NTP private providers. Results will help to reevaluate current PPM strategies and generate further policy discussions on engagement strategies among policy makers, program managers, service providers, and implementing partners. Our study aimed to assess how non-NTP providers diagnose and treat TB patients in Lagos State, Nigeria.Supplement).Our cross-sectional study used self-administered questionnaires to assess TB diagnostic and treatment practices among non-NTP providers across 13 local government areas (LGAs) in Lagos State, Nigeria  is a regulatory agency embedded within the Lagos State Ministry of Health to register private and public hospitals before they can operate. The agency also supervises and monitors private and public hospitals for compliance with standards of care. More than 3,500 private hospitals in Lagos have registered with HEFAMAA in 2015. HEFAMAA uses a supervisory checklist to routinely monitor quality of care provided by all private and public hospitals in Lagos. However, the tools assess processes and practices that are not necessarily TB-specific.In 2003, the LSTBLCP  was inaugurated, and in 2008, it was expanded to engage the private sector. Engagement of private clinics with the LSTBLCP ensures TB cases detected in the private sector are notified and captured within the NTP surveillance system. Unfortunately, only less than one-third of private hospitals registered with HEFAMAA have been engaged with LSTBLCP under the PPM program while other unengaged private hospitals that may also manage TB cases fail to report to the NTP surveillance system. By 2015, Nigeria adopted GeneXpert as the first and preferred method of diagnosis for all forms of TB, and sputum AFB remains the test used for follow-up investigation.Despite attempts to engage private clinics in the NTP surveillance system that captures TB cases, many have not registered or fail to report.In Nigeria, public and private facilities engaged by LSTBLCP manage all drug-susceptible TB patients for 6 months using a fixed-dose regimen , except patients diagnosed with osteoarticular TB and TB meningitis, which are treated for 12 months. Private providers do not manage cases of drug-resistant TB (DR-TB) but instead refer them to a designated DR-TB treatment center.We purposively selected 13 high-burden LGAs in Lagos . The 13 LGAs consist of both urban and semiurban populations. We selected and recruited participants through the private-sector associations of doctors and nurses . To avoid double counting and including already engaged private providers, we requested the list of engaged private facilities from LSTBLCP and excluded any repeated non-NTP-affiliated facilities from the list shared by the private-sector associations. We leveraged quarterly association meetings to organize a TB sensitization workshop for the members. Pretested multiple choice questions were administered before the commencement of TB sensitization. The questionnaire assessed TB diagnostic and treatment practices among non-NTP-affiliated facilities. The study took place between May 2018 and January 2019.Participants were private sector doctors and nurses who were not formally affiliated with the NTP to provide TB services but who unofficially manage TB patients and report to the Integrated Disease Surveillance and Response systems. These include doctors and nurses from hospitals as well as nursing and maternity homes. To be included in the study, the provider needed to own, manage, or comanage a private practice , not be engaged by the NTP, be aged 18 years or older, and have diagnosed at least 1 TB case in the past. We excluded private providers who were already trained and engaged by the NTP to notify TB, who had never diagnosed any TB case in the past, or who were younger than 18 years. Providers from both urban and semi-urban areas and from private hospitals of various sizes were included to avoid selection bias.A 4-stage sampling technique (summarized below) was used to select participants for the study. Sample size was determined using the formulaThe level of a=1.96 and d=0.05 at 95% confidence interval. Dosumu et al. previously estimated 9.8% as the prevalence of knowledge and practice of TB DOTS-plus among private providers in Nigeria, resulting in b=0.098.We purposively selected 13 LGAs with a high TB burden and private sector presence in Lagos, Nigeria.We stratified the TB facilities in Lagos into private NTP-affiliated and private non-NTP-affiliated categories and used a convenience sampling technique to select the private non-NTP-affiliated facilities from the target LGAs.www.randomizer.org) to produce random numbers from the list of private non-NTP affiliated facilities in each of the 13 LGAs in Lagos state.We filtered all the NTP-affiliated private facilities from the universal list of all private facilities by cross-checking the NTP list with those of HEFAMMA and private sector associations. We used a systematic random sampling approach to select the required numbers of assessment private non-NTP facilities in each of the LGAs in a representative sample of LGAs in the state, using Research Randomizer  interviewed in the selected health facilities. We selected the medical director (a doctor) for the private medical facility and the nursing director for private nursing homes. Where the medical director or nursing director was not available in a facility, we selected a representative doctor or nurse who met the inclusion criteria. If more than 1 health worker met the inclusion criteria, we used simple random balloting to select respondents to be interviewed.We included both categorical and continuous variables. Categorical variables included age group, gender, type of health facility, practice setting, outpatient department attendance, non-NTP qualification, previously managed TB patient, and previous TB training. Continuous variables included years of practice and number of years since last TB training. Continuous variables were recoded into categorical based on median value. For yes or no questions, yes was coded as 1 and no as 0. Open-ended responses were categorized based on the type of responses and coded accordingly.The questionnaires included 17 questions in 2 parts. Part 1 comprised 13 closed-ended questions on participants’ sociodemographic characteristics, such as age, gender, outpatient department attendance, practice setting, qualification, and years of experience in TB diagnosis and treatment.Mention the combination of anti-TB drugs used to treat drug-susceptible pulmonary tuberculosis in your hospital.For how many months do you treat drug-susceptible pulmonary tuberculosis in your hospital?What diagnostic test do you use to diagnose TB in your hospital?What test do you use to follow up drug-susceptible TB patients on treatment in your hospital?Part 2 comprised the following 4 open-ended questions to assess TB diagnostic practice, treatment monitoring practice, treatment duration, and TB regimen prescription practice.We pretested the questionnaires across 10 selected non-NTP facilities that were not part of the study. The LSTBLCP reviewed the questionnaires and gave input. Subsequently, participants self-administered the questionnaire following extensive explanation and preinstructions by the study coordinator in a bid to minimize completion errors. Participants received additional clarification about the questions where needed. Once participants completed the questionnaires, they were double-checked for completeness and any omissions were addressed unless respondents declined. The questionnaire completion took approximately 60–70 minutes on average. Responses to the open-ended TB diagnostic and treatment practices were evaluated against recommendations in the NTP guidelines to determine correct and incorrect responses. Different open-ended responses were coded, analyzed, and presented as frequency and proportions. Non-NTP providers were subsequently sensitized after the test, followed by revision of the test.Trained independent data entry clerks first entered the data into Microsoft Excel. Data collected were then categorized, coded, and cleaned before being imported into SPSS version 22 for additional statistical analyses. In addressing the research objectives, we applied descriptive statistics to summarize the sociodemographic status and described the proportion of participants with different TB diagnostic and treatment practice responses. Incorrect and correct practices were presented using frequency and percentages based on provision of the NTP guidelines.Ethical approval was obtained from the Ethical Committee of the Lagos State University Teaching Hospital. Permission was also received from the LSTBLCP. All study participants gave their informed consent. All information from participants was kept anonymous in conformity with the ethical guidelines.The majority of participants were private for-profit providers (139 [91.4%]); women (89 [58.6%]); general practitioners (58 [38.2%]); and aged 20–34 years (56 [36.8%]) . Fifty-sOverall, non-NTP providers reported prescribing 23 different anti-TB combination regimens . Of thesThe majority (63 [58.3%]) of the 108 respondents reported treating TB patients for 6 months per the NTP guidelines . HoweverNon-NTP providers in Lagos used 8 different tests to diagnose TB: AFB; chest X-ray; sputum microscopy, culture, and sensitivity; GeneXpert; Mantoux; full blood count; erythrocyte sedimentation rate; and QuantiFERON-TB . A high Our objective was to highlight TB diagnostic and treatment practices among non-NTP providers in Lagos, Nigeria. Our findings show that non-NTP providers reported diagnosing TB using 8 different diagnostic tests. The most common method was AFB used by 39.8% of respondents. A study from rural Pakistan also reported the use of 3 different tests  by non-NTP affiliated facilities to diagnose TB. The study added that non-NTP providers relied on clinical judgment and chest X-rays for TB follow-up.Non-NTP providers relied on clinical judgment and chest X-rays for TB follow-up, which raises concern about the use of inappropriate TB diagnostic tests not approved per the NTP guidelines.–,Non-NTP providers in Lagos reported treating TB using 23 different drug combinations. Studies from Nigeria and India found much higher numbers of drug combinations, 45–85 and 102, respectively, that were inappropriately prescribed as TB treatment regimens.Five of the regimens reported in our study contained streptomycin, which has been excluded from the list of first-line anti-TB drugs in Nigeria due to its high resistance.,,,Only 32.4% of respondents in this study reported prescribing appropriate first-line TB regimens per the NTP guidelines. This is lower than the 60% of private practitioners found in the Philippines–,We found that only 58.3% of private non-NTP providers reported placing PTB patients on a standardized 6-month anti-TB regimen as recommended by the NTP, while the remaining 41.7% self-reported overtreating (>6 months) or undertreating (<6 months) TB patients. Private non-NTP providers from India also failed to manage TB for the appropriate 6-month recommended duration.Considering the public health impact of poor-quality diagnostic and treatment services among non-NTP providers, policy makers and program managers should consider designing innovative approaches and rapidly scaling up engagement of these providers, strengthening their capacity, and monitoring their adherence to TB management guidelines. Urgent attention is needed to improve the quality and reach of the PPM program among non-NTP providers. On-the-job mentorship, direct observation of practices, and regular supervision could improve their TB diagnostic and treatment practices. These interventions should take into consideration the busy schedule of non-NTP providers and their desire for incentivization. In addressing the quality of TB care provided by non-NTP providers, innovations aimed at regulation such as linking annual facility accreditation with quality of care should be deployed. Future research should complement the type of survey we conducted with qualitative research to gain deeper insight into the reasons for the TB diagnostic and treatment practices among private non-NTP providers.On-the-job mentorship, direct observation of practices, and regular supervision could improve the TB diagnostic and treatment practices of non-NTP providers.This study is cross-sectional and relied on self-reported TB diagnostic and treatment practices of non-NTP providers rather than actual practice through direct observation or simulation. It is not uncommon to have discrepancies when self-reported practices are subjected to methodologies that seek to unravel actual provider practices. Furthermore, the risk of social desirability bias could lead to overreporting of TB case management practices. However, the study has contributed to the body of knowledge on diagnostic and treatment practices among non-NTP providers in Nigeria, documenting recent evidence of minimal progress and making recommendations to address quality issues. The foundation and evidence generated will provide strategic guidance while engaging non-NTP providers in Nigeria and other settings under the National PPM Roadmap.Our study revealed that a large number of non-NTP providers in Nigeria did not follow NTP recommendations in their TB diagnosis and treatment. Many providers used non-NTP-approved TB investigations to diagnose TB and prescribed inappropriate TB regimens. Non-NTP providers also subjected TB patients to either overtreatment or undertreatment. These findings have negative implications for TB case notification and the spread of DR-TB strains in Nigeria. Since private-sector providers will continue to attract a large number of patients in urban settings, their successful engagement by the NTP is critical to addressing the TB notification gap and the menace of DR-TB in Nigeria.


Nearly 65%-95% of chronic kidney disease (CKD) patients have hypertension. Calcium-channel blockers are the first-line drugs for the treatment of hypertension, including hypertension with diabetes. This study aims to estimate the effect of an L-type calcium channel blocker (CCB), cilnidipine, on the renal function of hypertensive patients. Randomized control trials were selected from PubMed, Embase, Google Scholar, China National Knowledge Infrastructure (CNKI), Science Direct, Elton B. Stephens Company (EBSCO), Springer, Ovid, Cochrane Library, Medline, VIP, and Wanfang databases (from the date of databases' establishment till January 2022). Data were independently evaluated following the Cochrane risk-of-bias tool. The changes in serum creatinine (SCr), urinary protein excretion (UPE), urinary protein/creatinine ratio (UPCR), and estimated glomerular filtration rate (eGFR) before and after treatment, in percentages, were extracted for the meta-analysis. The mean difference (MD) and a CI of 95% were determined using RevMan 5.3 software. A total of 11 studies were analyzed. The standardized mean difference (SMD) between cilnidipine and L-type CCBs was -0.022, suggesting a reduced SCr with cilnidipine. For UPCR, the SMD value is 1.28. Although cilnidipine reduced UPCR in all four studies, the L-type CCBs reported a slight increase in UPCR. For eGFR, the SMD value was found to be 0.693. Cilnidipine had a more favorable effect on eGFR when compared to the L-type CCBs.While cilnidipine had similar effects on SCr to that of L-type CCBs, cilnidipine showed greater improvement in UPCR, UPE, and eGFR values. Hypertension is a continuous and genuine threat to public health. Most patients with chronic kidney disease (CKD) also suffer from hypertension, showing a close association. Hypertension is a risk factor for deterioration of kidney function, resulting in end-stage renal disease (ESRD) . CKD, inCalcium-channel blockers (CCBs) were considered first-line treatment for hypertension, including in patients with diabetes. CCBs being potent vasodilators, are particularly effective in reducing peripheral resistance. Dihydropyridines like amlodipine, nifedipine, and felodipine are currently the most frequently used CCBs. Cilnidipine is a derivative of dihydropyridines and possesses the property of blocking both L-type and N-type calcium channels that are present on peripheral nerve endings inhibiting calcium release in sympathetic nerves and release of norepinephrine (NE). Sympathetic stimulation in the renal afferent and efferent arterioles increases resistance and decreases renal blood flow. Renal ischemia will cause further sympathetic activation, releasing pressor substances, such as NE and renin, leading to aggravated hypertension. Therefore, hypertension and CKD can cause mutual deterioration, and the therapeutic outcomes of hypertension are closely related to renal function.2+ channels are classified into six subtypes: L-, N-, P-, Q-, R-, and T-  for 10 of the 11 studies which were randomized trials. Unfortunately, due to the lack of availability of the full text of the Chinese article by Cao BQ et al. [The risk of bias was assessed using the Revised Cochrane risk-of-bias tool for randomized trials (RoB 2)[Figure DiscussionWe included 10 RCTs and one retrospective study of high quality in the present investigation to compare the effects of L/N-type CCBs and L-type CCBs on renal functions. The results of our analysis showed that while there were no significant differences in SCr changes between the cilnidipine group and L-type CCB group, the UPE and UPCR were decreased in the cilnidipine group when compared with the L-type CCB group and an increase in eGFR with cilnidipine.Both UPE and UPCR are indicative of urinary protein quantitative diagnosis. Higher values suggest an immense protein leak from the renal vessel wall compromising renal function. The leaked proteins destroy the Sertoli cells in the glomerulus, resulting in glomerular sclerosis (GS). Urinary protein is closely related to not only chronic renal failure but also independently expedites renal damage and has a negative impact on the cardiovascular system. Therefore, in addition to blood pressure control, proteinuria control is critical in treating hypertension. Cilnidipine appears to be effective in reducing proteinuria or preventing its progression ,17. IncrCompared with the L-type CCBs, the L/N-type CCB cilnidipine could significantly lower the UPE and UPCR without increasing SCr or decreasing eGFR, indicating that it was advantageous in improving kidney function in addition to its role in the treatment of hypertension .FurtherFigure Additionally, when analyzed, there was no evidence of significant publication bias.Our study had its own set of limitations. As it is an observational study, it cannot replace large-scale, multi-centered randomized trials but merely summarise and analyze the existing data. Furthermore, as the trials included were open-labeled, there is a possibility of biases. We considered the sample size in the trials to be quite small. As patient enrolment standards varied from trial to trial, there was heterogeneity among the data. This meta-analysis included only a few studies and more RCTs on a larger scale with long-term follow-up are desirable to confirm these findings further.We found that cilnidipine was more effective in reducing proteinuria or preventing its progression and had similar effects on SCr and eGFR in hypertensive patients in comparison to L-type CCBs.


Cor triatriatum sinister is a rare congenital anomaly characterized by the left-sided triatrial form of the heart. Diverse theories have been proposed regarding its formation, and the failure of incorporation of the common pulmonary vein into the left atrium (LA) during embryogenesis is the most widely accepted theory. Accordingly, cor triatriatum sinister may be associated with pulmonary venous obstruction and post-capillary pulmonary hypertension in the setting of restricted fenestration. A high proportion of patients with cor triatriatum sinister also have an associated secundum atrial septal defect. Pre-capillary pulmonary hypertension, which is unusual in patients with small atrial septal defects (<2 cm), is probably not as rare as some reports indicate, especially when combined with complex comorbidities. The conventional treatment strategy of atrial septal defect closure in patients with pulmonary hypertension, whether associated with cor triatriatum sinister or co-existing multiple cardiac anomalies, involves simultaneous repair with other cardiac surgical procedures. To the best of our knowledge, there is no reported clinical experience of percutaneous atrial septal defect closure in the literature. Herein, we present the case of an elderly female with pulmonary hypertension and coexisting cor triatriatum sinister, secundum atrial septal defect, and multiple cardiac anomalies. Despite optimal medical therapy, the biventricular failure deteriorated, and clinical stabilization could not be achieved. Transcutaneous atrial septal defect closure was then performed. Subsequent investigations showed an initial improvement (perhaps due to elimination of the left-to-right shunt) from this intervention, but the long-term impact did not appear favorable, likely due to multiple uncorrected cardiac anomalies. To the best of our knowledge, this is the first clinical report showing that partial treatment of combined pre- and post-capillary pulmonary hypertension by eliminating the pre-capillary component may have an initial benefit; thus, total surgical correction should be considered a definite therapeutic strategy unless contraindicated. Pulmonary hypertension (PH) due to left heart disease (PH-LHD) caused by elevated left-sided filling pressures is the most common etiology of PH. PH-LHD is further classified into two subsets according to the presence of a pre-capillary component [combined pre- and post-capillary PH (Cpc-PH) or isolated post-capillary PH (Ipc- PH)] . Cpc-PH A 62-year-old woman with long-term PH, valvular heart disease, atrial fibrillation (Af), and atrial flutter (AFL) on amiodarone, spironolactone, and valsartan/hydrochlorothiazide was admitted to the intensive care unit because of progressive dyspnea and bilateral lower limb edema for over 2 weeks. On physical examination, she was found to have bilateral basal rales, orthopnea, and grade IV bilateral lower-limb edema. The clinician-assessed New York Heart Association functional classification (NYHA class) was Grade III-IV. Chest radiography revealed an enlarged cardiac profile and lung congestion , Panel AThe RHC data ostensibly fulfilled the criteria for pre-capillary PH . However2) for it to be correctable, > 4.6 WU (PVRI > 8 WU.m2) for it to be not correctable, and between 2.3 and 4.6 WU (PVRI 4–8 WU.m2) to require individualized evaluation, which was the case in our patient. In patients with a 1.5-cm isolated ASD, who are likely to be asymptomatic, the magnitude of the left-to-right shunt with multiple structural anomalies and arrhythmia remains unclear, for it is unknown whether the left-sided filling pressure is also increased (p < 0.001), which is nearly equal to that of our patient (PAPm:36 mmHg). ASD closure may block the left-to-right shunt, but the long-term effect of the absence of decompression for irreversible PH  or pulmonary vascular resistance index (PVRI) . The ESCncreased . Recentlncreased . The optsible PH  warrantsTranscutaneous closure has significant benefits in ASD patients with PH owing to its minimal invasiveness and low complication rates. However, if a patient is undergoing other cardiac surgeries, the surgeries are typically performed together. CTS is a rare congenital cardiac anomaly in which a fenestrated fibromuscular membrane subdivides the LA into two chambers. When the fenestration is small, the obstruction mimics mitral stenosis, which may further aggravate Af  and incrThe serial quantitative echocardiography demonstrated normalized hyperdynamic left ventricular ejection fraction (from 78.34 to 58.73%) and functional class. Concerning the absence of sepsis or any other form of non-traumatic shock, ASD-related significant systemic pulmonary shunting might be a reasonable explanation for hyperdynamic left ventricular ejection fraction. The severity of aortic regurgitation represented by the left ventricular volume seemed unchanged compared with that before ASD closure. Notably, the left atrial volume increased one month following percutaneous ASD closure. With multifactor such as poorly controlled atrial fibrillation/flutter or perhaps worsened mitral regurgitation, making it hard to differentiate from effect after ASD closure. It seems that the rate of worsening heart failure, as represented by NT-pro BNP , is slowThe original contributions presented in this study are included in the article/supplementary material, further inquiries can be directed to the corresponding author.Written informed consent was obtained from the participant/s for the publication of this case report. Written informed consent was obtained from the individual(s) for the publication of any potentially identifiable images or data included in this article.W-JT and K-SH collected the clinical data and help complete the manuscript. I-HT analyzed and interpreted the patient data regarding the right heart catheterization and was a major contributor to writing the manuscript. T-CS and K-WC performed the diagnostic and therapeutic intervention procedure and made critical revisions to the manuscript. K-YW designed the research and made critical revisions to the manuscript. All authors read and approved the final manuscript.


Housework may provide a sustainable form of physical activity for older adults and improve health and survival outcomes. Longitudinal studies on associations between housework status over time and health outcomes are lacking. We aim to assess the longitudinal association of intensity and duration of housework with frailty and mortality outcomes.N=2996) and heavy housework (N=3022) were available at baseline  and follow-up at 3 to 5 years later, . Median time spent per week on light (≥420min/week) and heavy (>0min/week) household activities at baseline and follow-up were used to categorise individuals into three groups (i) consistent low levels of housework at both baseline and follow-up, (ii) inconsistent high levels of housework at either baseline or follow-up and (iii) consistent high levels of housework at both baseline and follow-up. Baseline and follow-up frailty index >0.10, and all-cause, cancer and cardiovascular mortality from mean 9.5 years follow-up to March 31, 2021. Effect estimates were adjusted for socio-demographics, nutritional risk, lifestyle and other physical activities.Among 3270 community-dwelling prospective cohort study participants, aged ≥55 years, data on light housework (Overall, participants had mean [SD] age, 66.9 [7.8] years; 1916 [62.7%] were female. Participation in high levels of light and heavy housework consistently over time was associated with decreased odds of prefrailty/frailty at follow-up,  and  respectively, in the older group aged ≥65, compared to participants with consistent low levels of housework at baseline and follow-up. Sex-stratified analysis revealed an association between regular heavy housework participation and lower prevalence of prefrailty/frailty at follow-up in older men but not women . Regular participation in high levels of light housework was associated with 41% lower risk of all-cause mortality  in women but not in men, and 54% lower risk of cardiovascular mortality .Regular participation in above average levels of light housework is associated with decreased odds of prefrailty/frailty in older adults aged ≥65 years, and all-cause mortality in older women. Heavy housework participation is associated with decreased odds of prefrailty/frailty, especially in older men aged ≥65. Housework may be a meaningful occupation for older adults and should be encouraged for health and wellbeing.The online version contains supplementary material available at 10.1186/s12877-022-03591-6. Regular physical activity mitigates the risks of adverse health outcomes associated with age, including frailty, functional disabilities and mortality , 2. EarlCompared to younger adults, older adults have higher prevalence of insufficient physical activity , 11, andHousework tasks account for a significant proportion of self-reported physical activity and are a large part of everyday activities in older people, especially among women . HousewoHowever, longitudinal studies of the effects of changes in housework status over time, on frailty and mortality outcomes from large population studies are scarce. In this study, we assessed the duration and frequency of light and heavy housework performed by community-dwelling older adults in Singapore at both baseline and follow up  and examined their associations with frailty, and mortality outcomes (mean 9.5 years follow-up).We analysed data in the Singapore Longitudinal Ageing Study (SLAS-2), an ongoing observational prospective cohort study of ageing and health transition among middle-aged and older adults in Singapore. Participants were aged ≥55 years at baseline and able to self-ambulate, excluding individuals who were unable to participate due to severe physical or mental disabilities. In the SLAS-2 cohort, 3270 residents in South-West Singapore were recruited from 6-Mar-2009 to 11-Jun-2013. Follow-up visits and assessments were conducted approximately 3–5 years later, from 16-Jan-2013 to 24-Aug-2018 for SLAS-2. Mortality from mean 9.5 years of follow-up was determined up to 31-March-2021. Details of methodology of have been described in earlier papers . Ethics At baseline and follow-up, participants were asked specific questions on frequency and time spent on light and heavy household tasks, according to the Longitudinal Ageing Study Amsterdam PA questionnaire (LAPAQ) . Light hCumulated Deficits Frailty Index at baseline and follow-up was derived from 98 possible deficits, across multiple systems and levels, including self-rated health, falls, hearing impairment, unintended weight loss, obesity, polypharmacy, activities of daily living  instrumental activities of daily living , metabolic diseases, history of medical conditions , depression, and other mental disorders , 31. ForDates of death were completely obtained from computerized national record linkage with the National Death Registry through the Singapore National Registry of Diseases Office and all-cause, cardiovascular and cancer mortality were determined.Demographic data included age, sex, ethnicity and marital status; socioeconomic status was assessed by housing status  and education, categorised according to none or primary (≤6 years of schooling), secondary (7–10 years) and tertiary (≥11 years) levels. Body weight and height were measured, and body mass index (BMI) was calculated. Baseline nutritional status was assessed using the Nutrition Screening Initiative , and theCategorical variables are presented as numbers (percentages), and continuous variables are presented as mean (SD). Baseline differences between high and low light and heavy housework groups were examined using Mann-Whitney U test for continuous variables, and Chi-square test for categorical variables. Binomial logistic regression determined the odds ratios (ORs) and 95%CI of associations between housework groups and prefrailty/frailty at follow-up. No issues with multicollinearity were detected using tolerance and variance inflation factors. Cox regression that satisfied the proportional hazard assumption was performed to calculate hazard ratios (HRs) and 95%CI of associations between housework groups and mortality. Estimated HRs were adjusted for age, sex, ethnicity, socioeconomic status (housing type), education, brisk walking and sports activities at baseline, nutritional risk, smoking, alcohol, marital status, and ORs were adjusted additionally for baseline prefrailty/frailty status. Sub-group analyses by age (<65 years and ≥65 years) and sex were examined for prefrailty/frailty outcomes, while sex-stratified analyses were reported for mortality outcomes. Similar logistic and cox regression models were used to determine associations of changes and baseline duration (hours per week) in light and heavy housework, walking and sport activities, with prefrailty/frailty and all-cause mortality outcomes.N=490) and loss to contact or refusals. The latter included 1664 or 55.5% of participants for light housework status at follow-up and 1705 or 56.4% of participants for heavy housework status at follow-up. Follow-up loss of participants for frailty outcomes included 1615 or 53.9% for light housework group and 1627 or 53.8% for heavy housework group. The follow-up outcomes were complete for long-term mortality. Multiple imputation was performed using Multivariate Imputation by Chained Equations (MICE) package (version 3.12.0) , regardless of sex eTable .P trend=0.027] but not in men  , 9.6 SD 2.3) and 9.9 (SD 2.0) respectively. Compared with a consistent low level of light housework at both baseline and follow-up, participation in high levels of light housework showed a 43–64% lower mortality risk in crude analysis. Participation in a high level of light housework at both baseline and follow up showed a 43% lower mortality risk after adjusting for age, sex and ethnicity  and 42% lower mortality risk in the fully adjusted model   of heavy housework, we observed that regardless of sex, heavy housework at either baseline or follow-up was associated with 29% lower mortality risk in the fully adjusted model , compared to participants who did <60 min/week of heavy housework at both baseline and follow-up eTable .In fully adjusted models, regardless of sex, similar trends of association were observed for both cancer and cardiovascular mortality, although the risk estimates were statistically significant only for high levels of light housework at both baseline and follow-up associated with 54% lower risk of cardiovascular mortality   to become prefrail/frail at follow-up. This is in agreement with a previous longitudinal study in older Chinese adults which showed that housework participation at baseline was independently associated with lower risk of incident physical phenotype of frailty at follow-up . We usedNotably, the associations between high levels of heavy housework and decreased frailty were most strongly evident in older men but not in women. A previous cross-sectional accelerometer study also showed that moderate-to-vigorous physical activity was more consistently associated with frailty in older men than women . While tAmong the younger group of older adults aged 55–64 years, regular participation in heavy but not light housework was associated with lower odds of prefrailty/frailty. Systematic reviews and randomized controlled trials have also shown that compared to low-intensity exercises, exercise interventions of moderate-to-high intensity were more effective in improving physical function and disability among frail older adults , 42. OurIn this study, consistently engaging in high levels of light housework over time was associated with lower risk of all-cause and cardiovascular mortality in older adults, especially in women. In contrast, an earlier study showed that compared to those who did not engage in any housework, participation in heavy but not light housework at baseline was associated with reduced all-cause mortality and cancer deaths in older Chinese men but not women . Yet, inThis study extends upon earlier findings by showing that light housework consistently performed over time is associated with favourable survival outcomes in older persons. These findings have important implications for policy and practice, as housework accounted for a significant proportion of self-reported moderate-to-vigorous-intensity physical activity among older adults, resulting in more older adults meeting physical activity guidelines through housework than recreational activities , 16. It This population-based cohort study recruited a large sample of community-dwelling older adults and demonstrated, for the first time, the impact of housework participation over time on subsequent frailty and mortality. As it is possible that housework activities could change over time, potentially influencing the effect estimates, we measured housework activities at both baseline and follow-up. This is a strength in this study. Inaccurate reporting of housework exposure due to recall bias associated with self-reported information was ameliorated by grouping participants with consistently below average (reference group) and consistently above average housework exposure (third group) at both baseline and follow up. On the other hand, the middle group of housework exposure represents a heterogeneous group of individuals, which included those with inconsistent recall of housework participation. In addition, those who reported above average (high) housework at baseline and below average (low) housework at follow-up may represent those with declining health, while those who reported housework exposure vice versa, may represent those who became more active. We considered sub-grouping this middle category of those with improving or reducing housework exposure, as such analysis may provide more granular information on their associations with subsequent adverse health outcomes. However, such multiple sub-grouping of housework exposure over time is also problematic. Granular information on the proximity between baseline and follow up in transition of housework exposure was limited by the 3 to 5 years follow up interval. For example, a participant who reported above average (high) housework at follow-up may have done so for only a short while prior to follow-up interview, and this might not provide meaningful observations about its association with subsequent health outcomes. We additionally used changes in housework duration from baseline to follow-up, in hours per week as a continuous variable, and such sensitivity analyses support a robust association of housework with favourable health outcomes.Although the LAPAQ used in this study is valid and reliable, we are unaware of earlier studies that have validated the housework subscale . The medParticipants who consistently engaged in high levels of housework are likely to be a self-selected group with higher functional ability, and conversely, their peers with declining function tend to not engage in housework activities. In this study, we found that regardless of the level of housework participation, ~70% of older adults engaged frequently in brisk walking and ~7% in sports, suggesting similar functional ability between high and low housework groups. Our data show that indeed other forms of physical activity including sport participation might be beneficial in reducing risk of frailty and mortality in older adults. While it is crucial that older adults engage in sustainable and meaningful physical activities, such as sports, depending on preferences, abilities and needs, housework may be an important form of physical activity that should not be ignored.In this cohort study of community-dwelling older adults in Singapore, regular participation in above average levels of light housework over time was associated with 39% decreased odds of prefrailty/frailty, 42% lower risk of all-cause mortality, especially in women, and 54% lower risk of cardiovascular mortality. Consistent heavy housework participation over time was associated with 44% decreased odds of prefrailty/frailty, especially in men. Older adults should be encouraged to participate in housework as a meaningful occupation to continue, even with advancing age, to sustain health and wellbeing.Additional file 1: eTable 1. Associations of participation in housework dichotomised by MET min/week with prefrailty/frailty at follow up. eTable 2. Associations of participation in housework dichotomised by MET min/week with all-cause mortality. eTable 3. Associations of participation in housework dichotomised by top quartile duration (min/week) with all-cause mortality.


Introduction: Computational modeling of cardiac mechanics and hemodynamics in ischemic heart disease (IHD) is important for a better understanding of the complex relations between ischemia-induced heterogeneity of myocardial tissue properties, regional tissue mechanics, and hemodynamic pump function. We validated and applied a lumped two-compartment modeling approach for IHD integrated into the CircAdapt model of the human heart and circulation.Methods: Ischemic contractile dysfunction was simulated by subdividing a left ventricular (LV) wall segment into a hypothetical contractile and noncontractile compartment, and dysfunction severity was determined by the noncontractile volume fraction (Results: Simulation of 20% of Conclusion: We successfully used a two-compartment model for simulation of the ventricular pump and tissue mechanics in IHD. Patient-specific optimizations using regional myocardial deformation estimated the  Computational modeling of cardiac mechanics and hemodynamics in ischemic heart disease (IHD) is important for better understanding of the complex relations between ischemia-induced heterogeneity of myocardial tissue properties, regional tissue mechanics, and hemodynamic pump function. Spatially detailed three-dimensional models based on the finite element method (FEM) are most frequently used for simulation of myocardial infarction (MI) and its effects on cardiac geometry, tissue mechanics, and electrophysiology. While many studies have successfully used FEM models for investigating the pathophysiology and potential treatment of MI , complexReduced-order modeling approaches with sufficient spatial and physiological details to accurately simulate global and regional tissue mechanics are important for patient-specific simulation of MI . The CirIn this study, we presented and tested a modeling approach for MI-induced myocardial contractile dysfunction, which is integrated into the CircAdapt modeling framework. Following previous observations by A brief description of the CircAdapt model components, which are most relevant for this study, are provided as follows. For further details on the CircAdapt model, we referred to previously published validation studies . ThereafThe CircAdapt computational model of the human heart and circulation is a closed-loop lumped-parameter model that simulates beat-to-beat hemodynamics and mechanics of the heart and blood vessels . The modPassive myocardial tissue behavior is described by the parallel elastic element, which captures both extracellular and intracellular structures. Therefore, total passive stress The extracellular matrix stress Here, In a combined experimental and modeling study, Sf,act . Since tSf,act  is appliSf,act . In thisectively . Compareectively , where tThe calculated strain For the two-compartment model, the sarcomere length In line with the study of We hypothesized that acute ischemia and subsequent reperfusion could realistically be simulated by manipulation of the tive dog   and circulating biomarkers in patients with myocardial infarction) cohort. This was a prospective study on first-time MI patients, approved by the local ethics committee (METC: NL45241.041.13) and in accordance with the Declaration of Helsinki. Patients in this study were included after an acute MI, when urgent revascularization was performed. From the measured cohort, we selected patients with narrow QRS (<120 ms), who had a minimum infarct size of 10% of the LV wall mass and a minimum relative LGE percentage of 25% in at least one myocardial AHA segment.Echocardiography was performed at the baseline  and at the 6-month follow-up using a commercially available system . LV volumes and ejection fraction (EF) were acquired by Simpson’s biplane method. Focused loops of the apical four-chamber view, two-chamber view, and three-chamber view were stored for post-processing (GE EchoPAC version 203). Speckle tracking deformation imaging of the LV was performed in 18 segments according to current clinical standards while blinded to the MRI results .At a median of 6 months after primary MI, all patients underwent contrast-enhanced 1.5 Tesla cardiac magnetic resonance (CMR) imaging . LGE image acquisition was performed 15 min after administration of 0.2 ml/kg gadobutrol , using prospective ECG-gated sequences of the short axis views from the base to apex, with 5 mm slice thickness. Images were analyzed off-line using Philips ISP9 software . Using the RV insertion points to the interventricular septum as anatomical landmarks, the heart was subdivided into 16 segments according to the model of the American Heart Association (AHA) , excludi−4, meaning that within one iteration, all parameters changed by less than 1% of the width of their MC sampling domain, or a maximum number of 1000 iterations was reached.To estimate the t) = 2 ms. MSPSO was performed in MATLAB 2019a . Simulations ran in parallel on an AMD Ryzen Threadripper 3970X.The CircAdapt model used in this study has been published before in more detail . To reduConstructed ESPVRs for the one- and two-compartment simulations of LV acute regional ischemia are shown in Simulated LV pressure-segment length loops and corresponding strain patterns at the baseline , the 6 months . At the In this computational study, we used the CircAdapt model of the human heart and circulation to test the ability of a lumped two-compartment model to realistically simulate the effects of ischemia-induced contractile dysfunction on ventricular pump and myocardial tissue mechanics. The modeling approach was first evaluated on the level of global LV mechanics by constructing ESPVRs at the baseline and during acute regional ischemia using simulations with a two- and one-compartment modeling approach. Then, simulated regional strains and pressure-length loops for increasing degrees of contractile dysfunction were compared with existing gold standard myocardial deformation measurements in dogs with acute and prolonged ischemia followed by reperfusion. Finally, patient-specific optimizations were performed to estimate the noncontractile volume fraction Constructed LV ESPVRs at baseline and during acute regional ischemia using both a one- and two-compartment modeling approach demonstrated that was used ; Table 1was used . In their kECM . When ine of 20% . QualitaSimulated strain patterns and LV pressure-segment length loops for ectively , 5. Whild kECM . This reressures . Adding reported , an acutreported . The datstunning . While istunning , which aOur simulations of prolonged ischemia and subsequent reperfusion demonstrated that erfusion ; Table 3erfusion . The occerfusion . At the xpansion . HoweverThe parameter ollow-up , suggestollow-up . Increasstunning . Increasmodeling  and clinmodeling  of straimodeling  and thermodeling . From thThe experimental measurements of fterload , this asfterload . FurtherWe successfully used a two-compartment model for simulation of ventricular pump and myocardial tissue mechanics in ischemic heart disease. Patient-specific optimizations using regional myocardial deformation successfully estimated


The relations of the variety and quantity of different sources of dietary insoluble fibers and hypertension remain uncertain. We aimed to investigate the associations between the variety and quantity of insoluble fibers intake from six major food sources and new-onset hypertension, using data from the China Health and Nutrition Survey (CHNS).Twelve thousand one hundred thirty-one participants without hypertension at baseline from CHNS were included. Dietary intake was measured by three consecutive 24-h dietary recalls combined with a household food inventory. The variety score of insoluble fiber sources was defined as the number of insoluble fiber sources consumed at the appropriate level, accounting for both types and quantities of insoluble fibers. The study outcome was new-onset hypertension, defined as blood pressure ≥ 140/90 mmHg, or physician-diagnosed hypertension or receiving antihypertensive treatments during the follow-up.During a median follow-up of 6.1 years, 4252 participants developed hypertension. There were L-shaped associations of dietary insoluble fibers derived from vegetables, beans, tubers, and fruits with new-onset hypertension; a reversed J-shaped association of whole grain-derived insoluble fiber with new-onset hypertension; and no obvious association of refined grain-derived insoluble fiber with new-onset hypertension. Therefore, refined grain was not included in the insoluble fiber variety score calculation. More importantly, a higher insoluble fiber variety score was significantly associated with lower risks of new-onset hypertension .There was an inverse association between the variety of insoluble fibers with appropriate quantity from different food sources and new-onset hypertension.The online version contains supplementary material available at 10.1186/s12916-023-02752-7. Hypertension is a major cause of the cardiovascular disease (CVD) and all-cause mortality worldwide . The preRecently, there has been growing interest in studies of nutrients and the risk of hypertension , 5. DietTo address these essential knowledge gaps, the current study aimed to evaluate the prospective associations between the variety and quantity of insoluble fibers intake from six major food sources  and new-onset hypertension in general Chinese adults., using data from the China Health and Nutrition Survey (CHNS), a national health and nutrition survey in China.The study design and major results of the CHNS have been reported elsewhere –15. In bA prospective open cohort study design was employed in our current study based on 7 rounds of CHNS data from 1997 to 2015. As shown in Additional file http://www.cpc.unc.edu/projects/china). The study was approved by the institutional review boards of the University of North Carolina at Chapel Hill and the National Institute of Nutrition and Food Safety and Chinese Center for Disease Control and Prevention. Each participant provided written informed consent.Data and study materials that support the findings of this study can be found on the CHNS official website  were used to calculate nutrient intakes of each participant. It has been validated that 24-h dietary recall could accurately assess energy and nutrient intake –19. The We calculated 3-day average intakes of dietary macro- and micro-nutrients in each round in the analyses. To represent long-term dietary intake and minimize within-person variation, all values of each nutrient in the analyses, if not specified, were presented as the cumulative averages, using all results from baseline to the last visit before the date of new-onset hypertension, or using all results during the follow-up among participants without new-onset hypertension. Moreover, in our current study, total insoluble fiber was divided into specific sourced fibers. Food sources constituting these subtypes are presented in Additional file Seated BP was measured by trained research staff using a mercury manometer and an appropriate-sized cuff, following a standard method at each study survey after the participants had rested for 5 min. The BP of the same arm was measured three times in a quiet and bright room. The mean SBP and DBP of all measurements were used in the analysis.2).Demographic and lifestyle information was available through questionnaires, including age, sex, smoking status, occupations, education levels, and living regions. Calibrated equipment was used to measure body height and weight following a standard operation procedure. Body mass index (BMI) was calculated as weight (kg) divided by height squared , the last survey round before the participant’s departure from the survey, or the end of the latest survey (2015), whichever came first.Population characteristics were presented as mean (standardized deviation [SD]) or proportions for continuous and categorical variables, respectively. Differences in population characteristics by the quartile of dietary total insoluble fiber intake were compared using ANONA tests or Age-stratified Cox proportional-hazards models were used to estimate the association of variety score of insoluble fiber sources, intake of total insoluble fiber, and insoluble fibers from different food sources  with new-onset hypertension, without and with adjustments for sex, BMI, SBP, DBP, smoking, alcohol drinking, urban or rural residents, regions, education levels, occupations, physical activity levels, self-reported physician-diagnosed diabetes, dietary intakes of sodium, potassium, protein, fat, and carbohydrate. Moreover, mutual adjustments for intakes of other sources of insoluble fiber were further included for the association between insoluble fibers from different food sources and new-onset hypertension. The Schoenfeld residual test was used to test the proportional hazards assumption, and no clear evidence of violation was detected. We also used restricted cubic splines with 3 knots  to investigate the potential nonlinear relationship of total dietary insoluble fiber and insoluble fibers from different food sources with new-onset hypertension with the adjustments for the covariates mentioned before.2, niacin, copper, and zinc were further adjusted. Second, dietary intakes of refined and whole grains, vegetables, beans, tubers, and fruits were further adjusted. Third, BMI trajectory classes, which were estimated by the R package lcmm, were further adjusted. Fourth, total insoluble fiber intake was estimated by multiple source methods (MSM) [A series of sensitivity analyses were conducted. First, dietary intakes of vitamin A, vitamin Bds (MSM) . Fifth, P value < 0.05 was considered statistically significant. All statistical analyses were conducted using R software .A 2-side Of the included 12,131 participants , a total of 4252 (35.1%) participants developed new-onset hypertension.2, niacin, copper, and zinc (model 2); dietary intakes of refined and whole grains, vegetables, beans, tubers, and fruits (model 3); or BMI trajectory (model 4) did not substantially change the results . That is, for each above insoluble fiber, there is a window of consumption (appropriate level) where the risk of new-onset hypertension was lowest. However, there was no obvious association between refined grain-derived insoluble fiber and new-onset hypertension.Figure Similar trends were found when assessing different sources of insoluble fiber intakes as categorical variables. Accordingly, the appropriate levels (g/day) of specific sourced insoluble fiber associated with the lowest risk of new-onset hypertension were mentclass2pt{minimSince there was no obvious relation of refined grain-derived insoluble fiber with new-onset hypertension, the refined grain was not included in the calculation of variety score of insoluble fiber sources. As such, if a participant consumed one of the 5 major food sources  of insoluble fiber at an appropriate quantity during the entire study period, he/she will get one point, with a maximal score of 5.2, niacin, copper, and zinc (model 3); dietary intakes of refined and whole grains, vegetables, beans, tubers, and fruits (model 4); or BMI trajectory classes (model 5) did not substantially change the results  Fig. . FurtherP value of the interaction for fat intake was < 0.05, because of multiple testing and similar directionality of the associations in different subgroups, the clinical implications of these interactions still should be further investigated  and the risk of new-onset hypertension were found in all the subgroups. Although the In this large, prospective cohort study among general Chinese adults, we reported an L-shaped association between dietary total insoluble fiber and new-onset hypertension. In addition, there was no obvious association of refined grain-derived insoluble fiber with new-onset hypertension, while a reversed J-shaped association of whole grain-derived insoluble fiber and L-shaped associations for insoluble fibers from vegetables, beans, tubers, and fruits, with new-onset hypertension. Moreover, a higher variety score of insoluble fibers was significantly associated with a lower risk of new-onset hypertension.A previous meta-analysis of 18 RCTs reported that an increase in total fiber intake had no significant impact on BP . AnotherOur study provides some new insights. First, there were non-linear relations of dietary total insoluble fiber and dietary insoluble fibers from different food sources with new-onset hypertension, including a reversed J-shaped association for the whole grain-derived insoluble fiber, and L-shaped associations for the total insoluble fiber, and insoluble fibers from vegetables, beans, tubers, and fruits. That is, when these foods-derived insoluble fiber intakes were relatively low, there were negative correlations between intakes of foods-derived insoluble fiber and hypertension risk; however, when intake exceeded certain thresholds, the risks of new-onset hypertension will increase or reach a plateau. More importantly, we found that there was no obvious association between refined grain-derived insoluble fiber and hypertension. The potential mechanisms by which insoluble fiber lowers blood pressure may include reduced inflammation levels , 29 and Second, we first found that there was a significant inverse association between the variety score of insoluble fiber sources and new-onset hypertension. More importantly, the removal of any one kind of fiber from the insoluble variety scores could not substantially change our findings. The possible explanation may be that the role of dietary fiber not only depends on the amount of intake but also its food sources. Since not all fibers from different food sources behave in the same way, fibers from a diverse range of sources, with differences in fiber structure and activities, may offer diverse functional characteristics and thus provide better health benefits. However, the detailed mechanisms still need to be further investigated in future studies.There are some limitations needed to be mentioned. First, although a broad array of covariates had been adjusted in the regression models, the possibility of residual confounding cannot be excluded. For example, CHNS only collected information about self-reported physician-diagnosed hypertension, diabetes, asthma, and CVD but not kidney diseases at baseline. Therefore, we could not examine whether baseline kidney diseases may affect our findings. However, among those with blood sample measurements, further adjustments for creatinine concentrations did not substantially change our findings. Second, the neutral detergent fiber method is a reliable analytical tool for measuring insoluble fiber. We could not calculate the amount of soluble fiber intake. Third, our study only included insoluble fibers from 6 major food sources in Chinese adults. Fourth, since the detailed sampling information was not provided by CHNS, summary statistics like prevalence and incidence should be treated with caution. Finally, our study was conducted in the Chinese population, whether the findings can be extrapolated to other populations needs further investigation. Therefore, the results need further confirmation.In summary, our study suggested that there was an inverse relation of the variety of insoluble fibers with appropriate quantity from different food sources  and new-onset hypertension in general Chinese adults. If our results are further confirmed, these findings support that the intake of an appropriate quantity of insoluble fibers from various food sources plays an important role in the primary prevention of hypertension.Additional file 1:Figure S1. Flow chart of study participants. Figure S2. The relationship of total dietary insoluble fiber intake with new-onset hypertension*. Figure S3. The relationship of total dietary insoluble fiber intake estimated by multiple source method with new-onset hypertension*. Figure S4. The relationship of total dietary insoluble fiber intake with new-onset hypertension after excluding those with physician-diagnosed hypertension or receiving antihypertensive treatment. Figure S5. Forest plots of the relationship of specific-sourced dietary insoluble fiber intake with new-onset hypertension. Figure S6. The association between variety score of dietary insoluble fiber sources and new-onset hypertension further adjusted for serum creatinine*. Table S1. Characteristics of the participants with and without blood pressure data. Table S2. Food sources of dietary insoluble fiber intake. Table S3. Sensitivity analysis for the association between total dietary insoluble fiber intake (g/d) and new-onset hypertension. Table S4. The association between total dietary insoluble fiber intake (g/d) in different waves and new-onset hypertension. Table S5. Sensitivity analysis for the association between variety score of insoluble fiber source and new-onset hypertension. Table S6. The association between variety score of insoluble fiber source and new-onset hypertension after the removal of any one kind of insoluble fiber from the insoluble fiber variety score. Table S7. Stratified analyses of the association between the variety score of insoluble fiber source and new-onset hypertension.