The purpose of this study was to describe the social support networks and daily support interactions of cancer-affected individuals, including young adult (YA) and LGBTQIA+ survivors and care partners.via social media for a pilot study testing a novel online method for collecting prospective, daily social support interaction data (N=28). All participants were aged 18+; survivors had a current or recent cancer diagnosis and were engaged in treatment and/or services; care partners were identified by the survivors. Enrollment also purposefully targeted YA and LGBTQIA+ survivors. Social network data (up to 10 members) were assessed at baseline. Daily online surveys assessed support interactions between participants and specific network members over 14 days. Descriptive statistics summarized data and explored between-group  differences in social network characteristics  and support interactions (support source and type).Participants were recruited at two United States cancer centers and There were no significant differences between YA and non-YA participants on any measures. LGBTQIA+ participants’ support networks were less dense , less cohesive , more centered on the participant , and included more LGBTQIA+ members . LGBTQIA+ participants reported having more interactions with LGBTQIA+ network members  and received significantly more of all types of support from LGBTQIA+ vs. non-LGBTQIA+ members. LGBTQIA+ participants also reported receiving more appraisal support than non-LGBTQIA+  including more appraisal support from relatives .Important information related to support access, engagement, and needs is embedded within the everyday contexts of the social networks of cancer-affected people. Individualized, accessible, and prospective assessment could help illuminate how their “real world” support systems are working and identify specific strengths and unmet needs. These insights would inform the development of more culturally competent and tailored interventions to help people understand and leverage their unique support systems. This is particularly critical for groups like YA and LGBTQIA+ survivors and care partners that are underserved by formal support services and underrepresented in cancer, caregiving, and social support research. Social support, a social determinant of health that influences a range of outcomes , is a crYoung adult YA, aged 18-39) –13 and L-39 –13 aBoth YA and LGBTQIA+ groups also share characteristics that impact access to and engagement with formal support services such as lower income and financial stress, inadequacy of insurance, less traditional family and kinship systems, and lack of access to culturally competent care, increasing risk for unmet support needs. YA and LGBTQIA+ survivors have also reported feeling excluded from typical formal support services that have been largely developed with older, heterosexual, and cisgender patients living within traditional spousal relationships centered in nuclear, biological family structures; these services are not seen as relevant to their relationships and experiences , 25. YA Cancer-affected individuals, particularly those in underserved groups, rely on their informal social systems for support , 26. In Relatively little research, however, has examined the social support networks of YA and LGBTQIA+ cancer-affected individuals , 31. YAsThe purpose of our study was to pilot an individualized, prospective, observational approach to assess characteristics of the personal social support networks and patterns within daily support interactions of a sample of cancer survivors and care partners focusing on YA and LGBTQIA+ individuals. To do so, we developed a novel online method combining social network assessment  and prospective daily interaction diaries  and we report on the development, feasibility, and acceptability of these methods elsewhere . Here weWe employed a prospective cohort design. All study activities were reviewed and approved by institutional review boards for the protection of human subjects at both study sites. This study was determined to be exempt by the University of Utah IRB (#00119352) and the Advarra IRB .via community partners’ social media channels. Rolling recruitment occurred between August 2019 and May 2020. As our primary aim was to pilot test the feasibility of our methods within hard-to-reach populations  and provide proof of concept for prospective assessment of complex social network and support data, the small sample size and use of purposive sampling methods were acceptable strategies   or a carAt baseline, participants completed a demographic survey in REDCap  and an iDemographic data included cancer-related role (survivor or care partner), age, racial identity, Hispanic/Latinx ethnicity, sexual orientation, gender, cis- or transgender status, relationship status, highest level of education, and income.Each participant completed an individual baseline interview with a researcher in which an eco- mapping technique was used to elicit egocentric social network information. Participants were asked to identify up to 10 people in their social network they considered to be important sources of support related to their cancer experience . For each person, participants provided the following data: First name or initials, age, gender, whether the member was LGBTQIA+, the participants’ primary relationship to the network member, length of time known, closeness of the relationship between the participant and each network member, and whether/how specific network members were connected with other network members.via text or email to an online survey presenting a list of their network members and were asked to select which members they had interacted with during the last 24 hours. For each network member selected, participants were then asked to focus on one interaction with that member during the past 24 hours and provide the following information about that focal interaction: the purpose of the interaction (free text response), whether the interaction was perceived as supportive , the type of support the interaction represented for the participant , and perception of helpfulness of the interaction . Only interactions perceived as supportive (yes vs. no/not mean to be) and rated as at least somewhat helpful (≥ 2 Likert rating) were included in analysis.Based on participant preference, first names or initials of network members were then incorporated into brief daily REDCap surveys assessing characteristics of participants’ interactions with the identified members  of their support network. Each day for 14 days, participants received a link Study data from both sites were merged, and all study data were reviewed and checked for consistency and errors. Missing data analysis was conducted to assess the pattern of missingness for the baseline psychosocial measures; multiple imputation was used to impute missing data after missing completely at random was confirmed. Descriptive statistics were used to summarize baseline and daily interaction data using both SPSS (version 27) and R software. UCINET  softwareParticipants’ support networks had a mean of six members  and represented a mix of relatives  and non-relatives . Between-group comparisons showed no significant differences in network size/number of network members.There were no significant differences between YA and non-YA support networks composition or structure. We examined the total number of reported support interactions overall and with unique network members for each participant, focusing on relationship type (relatives vs. non-relatives), LGBTQIA+ status (LGBTQIA+ vs. non-LGBTQIA+ network members), and on the number of support interactions for each type of perceived support .Participants reported a mean of 41.79 support interactions overall during the two-week period  and a mean of 27.8 interactions with different network members . There were no significant differences between YAs and non-YAs for number of interactions of any specific support type  overall, or when examining support type by source (relative or non-relative.)While not statistically significant, LGBTQIA+ participants reported more daily interactions with non-relatives than with relatives overall  are integrated within survivors’ and care partners’ existing social networks (or not), including interactions between timing and types of support, service use, and wellbeing. The social support systems of cancer-affected people are inherently unique and—for YAs and people in minoritized populations like LGBTQIA+–may not be well-reflected in the expectations and operations of established formal services. For example, routine clinical care may hold implicit expectations of a hetero-normative network more traditionally seen in research on older adults, in which a spouse or adult child is available to provide outpatient care to patients. Those whose networks do not conform to this standard may not only experience feelings of alienation, but may be missing critical support for their care.Developing a working understanding of more diverse social support landscapes is therefore important for clinicians as well as researchers. Clinicians can be mindful of expectations for support required for patients and caregivers to participate effectively in treatment and facilitate connections to inclusive formal resources when additional support is needed. Across healthcare systems, more tailored, less generic patient-centered clinical and support services would be particularly impactful for groups like YA and LGBTQIA+ who report feeling alienated by normative care models that do not acknowledge their individual contexts and experiences.Researchers should focus on developing personalized interventions that boost cancer survivors’ and cancer care partners’ self-efficacy in accessing and leveraging social support to meet everyday challenges. This is especially critical for underserved populations, including people who are YA and LGBTQIA+ cancer survivors or care partners, who may be even more reliant on their personal social networks who feel disconnected from typical, formal support resources, and whose support systems may look different than those represented in the cancer literature. Finding ways to better coordinate holistic, high-quality cancer care is a national priority . ConductThere were a number of limitations to this study. The descriptive and exploratory nature of our analyses limits the generalizability of our findings. A small sample size and purposive, non-probability sampling may have increased the risk of selection bias. There was a wide age range within the LGBTQIA+ group which may be contributing to the differences we found, although we verified that groups did not significantly differ by age. While grouping individuals of diverse sexual orientations and gender identities together in a single LGBTQIA+ group is often necessary due to small numbers of participants in these groups, it confounds important between-group differences that are relevant to understanding cancer- and minority-stress related support needs; this is compounded by the lack of representation of transgender and gender diverse participants in most studies, including this one. Finally, our data collection period spanned August 2019-May 2020 and the onset of the COVID-19 pandemic in the US slowed our study enrollment considerably, leading us to close recruitment before enrolling an equal number of LGBTQIA+ and non-LGBTQIA+ participants.Every cancer-affected individual’s social support system is unique. Both structural and functional aspects of social support networks–network characteristics and patterns of interactions within these networks—are likely to influence survivors’ perceptions of support, appraisal of stress, capacity to cope, and ultimately their well-being. These influences may differ from person to person and by groups affected by differing social determinants of health . RelatioWe sought to examine the personal social support networks of cancer survivors and their care partners in two groups—YA and LGBTQIA+ cancer survivors—that have been under-represented in survivorship, caregiving, and social support research and who subsequently report unmet support needs. We further sought to contextualize this by studying the survivor-care partner dyads in relation to their personal support networks. This study provides proof of concept for this strategy, and suggests that there may be important aspects of YA and LGBTQIA+ survivor cohorts in the structure and function of their personal support networks. Next steps include adapting all data collection methods for online access, repeating the protocol with a larger sample over a longer period of time, and modeling how social network characteristics and daily interaction patterns predict changes in perceived stress, support, and mental health outcomes.kristin.cloyes@nurs.utah.edu.A limited de-identified data set is available on request. Requests to access the datasets should be directed to The studies involving human participants were reviewed and approved by University of Utah IRB, and the Advarra IRB Moffitt Cancer Center. The patients/participants provided their written informed consent to participate in this study.KGC and MR conceptualized this study and acquired project funding. KGC developed the methodology for data collection. KET, REM, and KJM coordinated project administration. J-WG developed the plan for formal analysis. KGC, J-WG, EJC, SCC, and SEW performed data analysis. KGC wrote the original draft. All authors contributed to the article and approved the submitted version.This study was supported by a Dick and Timmy Burton Foundation Pilot Grant Award, University of Utah College of Nursing, Moffitt Cancer Center Adolescent and Young Adult Program with support from Swim Across America and the Bay Area Advisors, K01NR016948 (J-WG’s effort), T32NR013456 (KJM’s effort), NINR F31NR018987 (SEW’s effort). The REDCap application reported in this publication was supported in part by the National Center for Advancing Translational Sciences of the National Institutes of Health under Award Number UL1TR001067 for period 5/1/13–3/30/18 and UL1TR002538 for period 4/1/18-2/28/23.The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.All claims expressed in this article are solely those of the authors and do not necessarily represent those of their affiliated organizations, or those of the publisher, the editors and the reviewers. Any product that may be evaluated in this article, or claim that may be made by its manufacturer, is not guaranteed or endorsed by the publisher.


Ultrasound (US) is currently the standard approach for the initial evaluation of fetal anatomy and maternal conditions during pregnancy since it facilitates a real-time examination and is widely available and cost-effective.Magnetic resonance imaging (MRI), due to its capabilities, can greatly improve the diagnostic performance of US during pregnancy ,2. The advances made in MRI techniques have overcome the technical difficulties of imaging a structure that is affected by both fetal and maternal motions.In recent years, MRI has become a useful element in the decision-making process for fetal abnormalities and maternal diseases in pregnancy, proving to offer unequivocal advantages over ultrasound ,2,3.The added value of MRI-based imaging is three-fold, and leads to the following: (a) an improvement in diagnostic accuracy by adequate morphological examination, (b) the detection of additional anomalies, and (c) in addition, MRI has the potential to provide information regarding renal and pulmonary functions.Fetal MR imaging using fast and ultrafast pulse sequences assists in acquisition of high-quality images regardless of maternal body habitus, fetal position, or amniotic fluid index. Fetal MRI is also not hampered by the acoustic shadowing from fetal pelvic bones, thereby facilitating multiplanar imaging and a better differentiation of kidneys and pelvic organs compared to US, especially late in pregnancy.MRI can improve the management of many high-risk pregnancies such as those complicated by PAD, placental abruption, or acute abdominal pain; upgrades the counseling in different clinical conditions including a trial of vaginal birth after cesarean section or CMV infection; is useful in the recognition of the developing fetal anatomy and in the detection of subtle fetal abnormalities or complex lesions; and may guide therapy, particularly when perinatal intensive care and surgery are considered or when delivery is expected to present unique challenges ,3,4.Moreover, MRI offers a promising noninvasive method by which to interrogate multiple facets of placental development and function and to investigate the pathophysiology of severe disorders such as intrauterine growth restriction (IUGR) and preeclampsia (PIH) ,4.MRI provides excellent resolution, anatomical detail, multiplanar acquisition, and permits 3D reconstruction in normal and pathological settings .With the advent of rapid sequences and short acquisition times, the use of fetal MRI has evolved exponentially. It has become key in the optimization of prenatal counseling, as it often refines or modifies the US based prenatal diagnosis, thereby altering the management of the pregnancy. MRI is particularly helpful in evaluating complex fetal abnormalities ,3.The role of fetal MRI is to add metabolic and functional studies, address the challenge of objectively detecting diffuse white matter lesions and early damage with the help of DWI and ADC mapping, and to visualize abnormal white matter tracts with prenatal tractography. Functional MRI can be a useful tool for evaluating blood oxygenation in human fetuses to monitor high risk fetuses and sensorial fetal activity ,5.Arterial spin labeling (ASL) and/or intravoxel incoherent motion (IVIM) have also been used to measure placental perfusion in pregnant women. ASL or IVIM could overcome the limitation of contrast agents as these imaging techniques do not require the use of an exogenous contrast agent .Although the use of Gd-based contrast agents in pregnant women is currently very limited, DCE-based techniques remain a robust method to measure the in vivo perfusion of organs and our study paves the way and provides a benchmark for future developments in placental perfusion studies .Functional placental MRI reveals a range of placental changes, associated with inflammatory processes that have been confirmed on subsequent histology. It shows promise as a tool to noninvasively identify inflammation in vivo, and could therefore assist in determining the optimal timing for interventions designed to prevent fetal injury, such as antenatal corticosteroids and magnesium sulfate and the need for delivery and/or in utero transfers where indicated ,5.It is hoped that MRI will permit a noninvasive, longitudinal estimation of the renal function. However, there are still many challenges to overcome, such as its validation and determining its technical limitations, as well as the need for compensation for both maternal and fetal motion and models that account for rapid changes with gestational age. This will require new tools for advanced image registration, segmentation, and model-fitting, which can only be developed through close cross-disciplinary collaboration and the sharing of data and software (5).In conclusion, MRI provides a morphological and functional evaluation of fetal and placental diseases and these joined data can provide an early diagnosis and better management in many conditions.


Avoidable disability associated with depression, anxiety, and impaired cognition among older adults is pervasive. Incentives for the detection of mental disorders in late life include increased reimbursement, reduced cost, and less burden for patients and families.Mental health problems in the elderly are major public health issues around the world. Thai older adults who experience mental illness rarely seek care from mental health specialists; rather, they tend to seek help from a general physician. Primary health care is, therefore, an important setting for the detection of mental health symptoms and subsequent treatment. We describe the design and implementation of a mental health care model in the Thai primary care system. Initial results of screening for behavioral and emotional problems are reported.This work is intended to explore mental health conditions in Thai elderly people to provide of identifying and non-pharmacological treating psychiatric conditions in the Primary care unit. The instruments used in the survey, which consists of twelve symptoms found in the elderly, developed into an online program to suit pandemic conditions.In an effort to document mental health problems in the primary care system, 4,854 veterans (mean age 68) from 46 provinces across Thailand were screened for multiple mental health symptoms. The sample divided into 1,701 males (35%) and 3,153 females (65%).While screening for depressed mood is now common in primary care, we found it useful to screen for specific symptoms of depression in older persons  in a primary setting.No significant relationships.


In1998, the Boston Birth Cohort (BBC) was initiated at Boston Medical Center (BMC) in response to persistently high rates of preterm birth  in the US population and the longstanding profound PTB disparity among Black, Indigenous, and people of color (BIPOC). The BBC encompasses two linked study protocols: The PTB Study serves as the baseline recruitment in the BBC. It aims to address fundamental questions about the causes and consequences of PTB. The study oversamples preterm babies using a case/control study design, in which cases are defined as mothers who deliver a preterm and/or low birthweight baby . Controls are enrolled at a 2:1 control/case ratio and matched by maternal age (±5 years), self-reported race and ethnicity, and date of delivery (± 7 days for case delivery). From inception, it was designed as a comprehensive gene-environmental study of PTB. As a natural extension, the Children’s Health Study, under a separate but linked Institutional Review Board protocol, is a longitudinal follow-up study of the participants who were recruited at birth in the PTB Study and who continue pediatric care at BMC. This linked model allows for investigation of early life origins of pediatric and chronic disease in a prospective cohort design. The BBC is one of the largest and longest National Institutes of Health–funded prospective birth cohort studies in the United States, consisting of 8733 mother-child dyads enrolled in the PTB Study at birth, and of those, 3592 children have been enrolled in the Children’s Health Study, with a median follow-up of 14.5 years. The BBC mirrors the urban, underresourced, and underrepresented BIPOC population served by BMC. A high proportion of BBC children were born prematurely and had chronic health conditions  in childhood. The BBC’s long-term goal has been to build a large, comprehensive database  and biospecimen repository to elucidate early life origins of pediatric and chronic diseases and identify modifiable upstream factors  to improve health across the life course for BIPOC mothers and children. This article focuses on the rationale, study design, and scope of data collection of the Boston Birth Cohort (BBC). In a subsequent article, we will highlight major scientific discoveries in the BBC as the result of the past 20+ years of research efforts across multiple organs/systems and scientific disciplines.The BBC was initiated in 1998 at Boston Medical Center (BMC) in response to persistently high rates of preterm birth  in the overall US population and the longstanding profound PTB disparity among Black, Indigenous, and people of color (BIPOC). In each year since, nearly a half-million babies have been born preterm. Despite intensive research and intervention efforts, the PTB rate has remained high and, at present, affects one in 10 babies in the US and one in seven BIPOC women. Worldwide, 11% of infants are born preterm, and 1 million infants die annually due to PTB.,4PTB is a major cause of neonatal and infant morbidity and mortality with lifetime health consequences for children both in the US and worldwide. In 1998, when the BBC was initiated, the rate of PTB in the US rose to 11.6%, following a rise from 11.0% to 11.4% from 1996 to 1997. In 2021, for the first time in 6 years, the US PTB rate declined slightly from 10.2% in 2019 to 10.1% in 2020, except among BIPOC mothers whose rate increased from 14.25% to 14.36%.PTB represents a longstanding and profound health disparity in the US. In 1998 and still today, 20 years later, the rate of PTB among BIPOC women (14%) has been about 50% higher than the rate among White women (9%). and because of the significant heterogeneity and complexity of biological pathways that could lead to PTB.,9One major obstacle in preventing PTB is our incomplete understanding of its causes and underlying mechanisms. This knowledge gap has been partly explained by the fact that PTB is a complex trait determined by multiple environmental and genetic factors,–12 age,–15 education,,17 income,,19 nativity, malnutrition,,22 stress,–25 social support,,27 smoking,–30 and air pollution.–34 A history of prior PTB,36 and a woman having been born prematurely herself appear to be the strongest risk factors identified to date. An early study showed that the combination of these two factors significantly increased the risk of PTB or low birthweight (LBW). However, these risk factors still only explain a small fraction of PTB in the overall population and do not appear to drive the PTB disparity among BIPOC women.Early studies on PTB were largely focused on identifying sociodemographic, environmental, and clinical risk factors, of which a number have been recognized, including maternal race and ethnicity,–41 However, lack of representation of BIPOC in genetic studies can lead to misclassification of benign vs. pathologic genetic variants and create or exacerbate health disparities in historically underserved populations. From a health equity perspective, even though BIPOC women have the highest rates of PTB, the majority of US birth cohorts that have included GWAS have primarily been conducted in White European populations.–45 Meanwhile, the realization that traditional genetic factors cannot explain the development of heterogeneous, multifactorial health outcomes like PTB has shifted interest toward gene-environment interactions (G×E). Despite their promise, there is a lack of adequately powered studies on the role of G×E interactions in PTB among all populations. Studies conducted in the BBC have provided strong evidence to support this direction.,38,46–50While the importance of genetic susceptibility in PTB has been recognized and multiple genetic variants have been linked to risk of PTB, neither candidate genes nor genomewide association studies (GWAS) have been able to pinpoint genetic loci that could help to explain a substantial portion of PTB.A more profound realization is that the lack of birth cohort studies conducted among historically underrepresented and understudied BIPOC may largely explain our limited understanding of the causes and health disparity of PTB. The BBC’s focus on BIPOC women and children and the interconnections between environmental exposures and genetics are crucial steps toward understanding the etiology of PTB and addressing the persistent disparity of PTB.As illustrated in Figure  to more thoroughly address the complex and multifaceted nature of minority health and health disparities in BIPOC through the examination of contributions across different domains of influence within a life course perspective  and at different levels of influence  within those domains. Table In 2015, the BBC adapted the research framework of the National Institute on Minority Health and Health Disparities A long-term goal for the BBC has been to build an adequately powered, comprehensive database, and biospecimen repository that allows for investigation of the causes and long-term health consequences of PTB, and for elucidation of early life origins of pediatric and chronic diseases and the health disparity among BIPOC mother-child dyads enrolled in the BBC. Ultimately, the findings from the BBC will inform clinical and public health practice and policies, including evidence-based primary prevention of PTB and early interventions for children born preterm to mitigate adverse long-term health consequences.As our understanding of PTB and its impact on life-long health evolved along with the emergence of cutting-edge biomedical advances in science and technology, so did our vision for the cohort. As a result, the BBC encompasses two linked study protocols: the PTB Study and the Children’s Health Study, as illustrated in Figure The Preterm Birth Study Study serves as the first time point of recruitment and represents baseline recruitment in the BBC. We use a case/control study design, in which cases are defined as mothers who deliver a preterm (<37 weeks gestation) and/or LBW baby . Controls are enrolled at a 2:1 control/case ratio and matched by maternal age (±5 years), self-reported race and ethnicity, and date of delivery (± 7 days for case delivery).–50,52–57 Over time, we have expanded our research from maternal/fetal genomics to epigenomics–60 and metabolomics,,62 and have identified deoxyribonucleic acid methylation alterations and metabolites associated with PTB.The PTB Study was designed to perform a comprehensive genetic-epidemiologic analysis of PTB and to dissect biological pathways leading to PTB by examining the role of maternal versus fetal genes in each pathway to increase our understanding of genetic and environmental determinants of PTB.–66 These findings are in line with the theory developed by David Barker that chronic degenerative conditions of adulthood may be triggered by circumstances decades earlier including PTB and LBW.,68 That theory, now named the Developmental Origins of Health and Disease  and otherwise known as early life epigenetic programming, points to exposures in utero or during early childhood that program dysfunctions that appear later in life.–73 These observations motivated further expansion of the BBC in 2004 to conduct postnatal follow-up of the BBC study population as the Children’s Health Study. This allows for investigation of early life origins of pediatric and chronic disease in a prospective cohort design.–65,74–89As a natural evolution of the BBC PTB Study, the Children’s Health Study, initiated under a separate but linked Institutional Review Board (IRB) protocol, aims to conduct a longitudinal follow-up study of the mother-child pairs who were recruited at birth in the PTB Study and who continue pediatric care at BMC. Early studies produced evidence that while PTB manifests at birth, its effects continue across the life course.All participants in the BBC are recruited at BMC in Boston, MA, the largest safety-net hospital in New England. BMC serves approximately 65% of Boston residents who are concentrated in neighborhoods with the highest level of health disparities. More than half of BMC patients reside in disinvested, economically depleted neighborhoods and receive health care coverage through government payers such as Medicaid, the Health Safety Net, and Medicare.We identify potential participants for the PTB Study by tracking daily births and admissions to the postpartum floor at BMC. The inclusion and exclusion criteria include the following: any woman admitted to the postpartum floor who delivers a singleton live infant and meets our case  or control (full-term ≥37 weeks with birthweight ≥2500 grams) definition. A small percentage of women (<1%) with pregnancies that involve in vitro fertilization, multiple gestation, chromosomal abnormalities, or major birth defects; or women who delivered as the result of major trauma are excluded from the study. Women who do not understand English, Spanish, or Haitian Creole, the three primary languages of the BMC patient population for which we have language-specific IRB-approved consent forms, are also excluded.Multilingual and culturally diverse Research Assistants (RAs) meet with eligible mothers at the maternal bedside during her postpartum hospital admission 24 hours after a vaginal delivery and 48–72 hours after Cesarean section to assess interest in participation. This timing was chosen to allow for maternal recuperation from labor and delivery (L&D). After determining eligibility, the RA explains the study in-depth and obtains written informed consent. Once consent is obtained, the RA administers a questionnaire interview and collects a maternal blood sample. The RA also retrieves cord blood and placenta that were obtained by the L&D nurses at delivery and stored in a designated refrigerator in L&D for study collection.Beginning when a PTB Study child is at least 6 months of age, we invite the mother-child pair to expand their study participation to the Children’s Health Study to be longitudinally followed from birth (through linkage) to age 21. We delay recruitment until the infant is at least 6 months old to allow the mothers time to establish pediatric care and adjust to the demands of caring for a newborn. The inclusion/exclusion criteria include the following: past participation in the PTB Study and biological mother. Biological mothers who have lost permanent legal custody of their children are excluded because they are unable to provide consent for their children.RAs approach mothers at BMC during check-in to their own or their child’s medical appointments to assess interest in participation and determine eligibility. After an in-depth discussion of the study protocol, written informed consent is obtained from the mother at recruitment and the child at age-determined intervals as required by the BMC IRB for minimal risk studies involving children. Biospecimen collection and protocol measurements also are completed at age-determined intervals. When procedural changes are made, all participants are reconsented. In 2020, the IRB eliminated child assent and replaced it with Parental Permission Consent.Recruitment into the PTB Study is ongoing. Enrollment in the Children’s Health Study is dynamic; we are both actively recruiting and prospectively following children born over the past 2 decades. Due to the rolling enrollment in the Children’s Health Study, the length of follow-up varies, with a median length of 14.5 years. Many mothers who participated in the PTB Study but did not initially establish pediatric care at BMC in infancy return to BMC for care in childhood and are eligible for recruitment.Relevant to both the PTB Study and the Children’s Health Study, a growing number of children who were recruited during our earliest enrollment period are now aged 18+ years . Beginning in June 2019 through an IRB amendment, we query if a newly recruited mother-infant dyad in the PTB Study is a third-generation BBC participant. These mothers may “opt-in” to allow yearly electronic health record (EHR) surveillance for herself and her newborn until age 18. We also received IRB approval to reconsent the mother and the age 18+ child to continue participation over their lifetime, with an emphasis on yearly health data collection from the EHR. We hope to follow the children into adulthood and the mothers into middle and late adulthood.As of June 30, 2021, 8733 mother-newborn pairs have been enrolled in the PTB Study, including 4134 (47.34%) BIPOC; 2479 (28.30%) Hispanic; 1065 (12.20%) non-hispanic white; 214 (2.45%) Asian American Pacific Islander; and 841 (9.63%) who did not identify with a race or ethnicity category. Race and ethnicity were self-reported by the mothers during the questionnaire interview. To enhance statistical power to study PTB, the BBC oversampled infants who were born preterm . Of the 8733 mother-infant dyads, 3592 children from the PTB Study have been enrolled into the Children’s Health Study. Key characteristics of the mother-infant dyads recruited at birth and subsequently recruited into the Children’s Health Study are presented in Table The BBC has received initial and annual continuation review and approval by the IRBs of BMC and Johns Hopkins University. Because we ask several sensitive questions during the maternal interview, in addition to standard Health Insurance Portability and Accountability Act protections, we obtained additional protections of confidentiality. Initially, we obtained a Certificate of Protection under Massachusetts General Law, C11, Section 24A: Reduction of Morbidity and Mortality within the Commonwealth; this protection has since been replaced with a Certificate of Confidentiality granted by the National Institutes of Health CC-HO-11-15. RAs emphasize these added protections to assure mothers of the high level of confidentiality protections to minimize concerns about disclosing sensitive information for research purposes.The BBC has a rich data repository that is unprecedented in studies conducted with participants who have been historically underrepresented in research.http://links.lww.com/PN9/A7.Our data contain key phenotypes, genetic, microbial, and biological samples collected at multiple time points from birth through early adulthood. Current data collection in the Children’s Health Study focuses on the children’s transition from mid-childhood to adolescence and young adulthood and on the mothers’ transition to middle age. A summary of the data collection scope and timing intervals is shown below in Table In-person maternal questionnaires administered 24–72 hours after delivery, collect baseline information on maternal environmental exposures pre- and post-conception and the mother’s previous birth outcomes. Newborn gestational age is calculated based on the last menstrual period or early ultrasound (<20 weeks gestation). Maternal health is assessed through maternal self-report and EHR abstraction before and during pregnancy for the presence of hypertensive disorders ; diabetes ; intrauterine infection, genitourinary infection, past reproductive history and outcomes, and use of illicit substances (blood and urine toxicology screening during pregnancy and at delivery on both mother and neonate) including alcohol use  and smoking (ever and in each trimester of pregnancy). A modified food frequency questionnaire that focuses on consumption of fruits, vegetables, fiber-rich foods, dairy, pasta, breads, cereal, meat, eggs, nuts, seeds, tofu, shellfish, fish, coffee, teas, juices, and soda is administered to assess average daily intake during pregnancy. To assess stress in pregnancy, we administer the Perceived Stress Scale-10, a 10-question classic stress assessment used because of its brevity, reliability, and validity across language groups. We follow the mother and infant’s postpartum course through EHR review until both are discharged from hospital care. The RA abstracts clinical variables from the EHR.The RA administers yearly questionnaires to assess child health with an emphasis on nutrition, asthma and allergies, development, and pubertal timing. We administer three developmental screening questionnaires: the Modified Checklist for Autism in Toddlers is administered beginning when the child is age 16–30 months. The Social Responsiveness Scale (SRS)-2 (Pre-school version) is administered at age 30–47 months followed by the SRS-2 (School Age) at age ≥48 months. The Social Communication Questionnaire (SCQ) is administered at age ≥30 months. The Autism Diagnostic Observation Schedule, Second Addition (ADOS-2), is a semi-structured, standardized assessment instrument that includes a number of play-based activities and social situations and is designed to obtain information in the areas of communication, reciprocal social interactions, and restricted and repetitive behaviors associated with a diagnosis of autism spectrum disorder. The ADOS-2 is completed on children who failed the SCQ with a research score of 11 or greater and is administered and scored by an ADOS-trained Developmental and Behavioral pediatrician. A self-administered Pubertal Development questionnaire is administered at age 6 years and is conducted yearly. We measure the body composition of both mother and child using the Tanita Body Composition Analyzer BF-350 scale . The RA also measures maternal and child waist circumference. Waist circumference measurements are taken with a soft cloth tape measure in cm just above the hip bone in a horizontal plane around the abdomen at the level of the highest point of the iliac crest. Before reading the tape measure, the RA ensures that the tape is snug but does not compress the skin and is parallel to the floor. The measurement is made at the end of a normal expiration. Measurements are recorded at 2 separate intervals after asking the mother and/or child to take a breath and exhale. Spirometry and impulse oscillometry (IOS) and pulmonary function tests (PFTs) are performed on a subset of children beginning at age 3 and 6 years, respectively. Due to funding limitations, we eliminated PFT and IOS administration in 2015. We also performed Radioallergosorbent (RAST) testing. Diagnostic testing for specific immunoglobulin E (IgE) to eight common food allergens  was completed by Quest Diagnostics, a Clinical Laboratory Improvement Amendments Certified Lab . RAST results with specific IgE >0.35 kU/L were reported to both pediatric primary care physicians and mothers and entered into the EHR. Due to reduced funding, we eliminated RAST testing in 2016. We schedule childhood study blood draws to align with physician-ordered blood draws and piggyback on our study blood collection by providing additional study tubes to the pediatric phlebotomist for research analysis. Children provide a yearly urine specimen when able.Maternal and child EHRs are reviewed each year to assess clinical variables including weight, height, blood pressure, lab work, sick visits, hospitalizations, diagnostic tests, medications, and International Classification of Disease (ICD) codes. In 2017, BMC incorporated an SDOH screening tool called THRIVE. Responses are entered in the EHR dashboard that automatically assigns ICD-10 codes. We can access responses to questions about homelessness, food and housing insecurity, inability to afford medications, lack of transportation, educational aspirations, utility bill concerns, and caregiving issues, as documented by providers during routine outpatient healthcare visits outside of the study encounters. With the integration of community health care data into Epic’s EpicCare (Care Everywhere), we can access BMC-affiliated community health center healthcare utilization outside of BMC to complete collection of clinical data, thereby reducing any missing outside healthcare utilization from our rolling recruitment strategy. Using Fisher Scientific Sterile Transport Swabs, the maternal oral cavity is swabbed in six locations . Meconium is collected from infant waste.Trained RAs draw maternal venous blood at the bedside. We collect a maximum of 10 mL ethylenediaminetetraacetic acid maternal and cord blood. L&D nursing staff collect study cord blood at delivery from all newborns through venous umbilical cord milking. For ribonucleic acid (RNA) analysis and stabilization, we use PAXgene Blood RNA tubes and collect an additional 2.5 mL of maternal whole blood and cord blood on a subset of mothers and newborns (incubated for at least 2 hours at room temperature). Maternal venous, cord, and childhood blood is centrifuged (1430 g at 0°C for 13 minutes) and fractionated into plasma, white blood cells, and red blood cells. Fresh placentas are sectioned in 2 × 2 cm on both maternal and fetal sides containing decidua basalis tissue, membranes, and a small piece of the distal umbilical cord, and stored in −20° freezers. For any recruited participant whose placenta is examined by the hospital pathologist for gross and histopathological review, we code the pathological findings into predominantly eight categories, in line with the classification proposed by Redline.In childhood, we collect venous blood (K2EDTA) at five time points: age 9–12 months, 2–3 years, 4–5 years, 6–7 years, and 10–15 years. RAST blood is collected in 6-mL red-top  tubes. To ensure maximum efficiency of sample use, each fractionated sample is divided into small aliquots and biobanked. Children provide a yearly urine sample of at least 10 mL collected in bisphenol A-free sterile specimen containers as a sensitive and noninvasive source for measurement of a range of environmental pollutants and renal function. All biospecimens are stored in −80° freezers pending analysis.We have examined maternal and child health outcomes along the following organs/systems. This list will expand with ongoing investigations in the BBC.Prenatal, perinatal, and birth outcomesAllergy, asthma, and upper and lower airway conditionsCardiometabolic outcomesNeurodevelopmental outcomesPubertal developmental outcomesA more detailed description of phenotypes and a list of the BBC publications by organs/systems will be summarized in a subsequent publication.We intentionally chose BMC as a single recruitment site for a multitude of reasons. BMC is the medical home to our participants anchored within a large academic medical research center. This allows for optimization of resources and uniform and comprehensive repeated clinical data collection within a single medical system and EHR platform.The conduct of clinical studies also requires robust research infrastructure support, which we can leverage through additional clinical resources, specifically the presence of a study office centrally located in the pediatric clinic along with a continuous EHR query system that began in 2002. Our foremost strategy has been to eliminate, as much as possible, the logistical barriers for mothers to participate in the study. We align study visits with regularly scheduled medical visits across multiple clinical outpatient departments, thereby reducing maternal and child burden by eliminating the need to travel to BMC specifically for study visits.Along with primary care clinics, the multiple specialty care clinics and patient-focused programs at BMC increase the number and frequency of outpatient visits attended overall. This allows for multiple opportunities to engage with participants outside of yearly well-child visits and offers flexibility for the mother and child to complete the protocol across multiple encounters, further reducing their time burden while maximizing data collection. With a single recruitment site and central location for comprehensive pediatric health care services including inpatient, emergency department, primary care, and subspecialty clinics, we can be nimble and pivot our research team to a specific clinic where participants have the greatest number of appointments, thereby focusing our resources to maximize initial recruitment and engage and retain recruited participants.We have determined that the most important retention strategy is to be flexible and cognizant of maternal time constraints to complete the study procedures in a single session. We include an option for “deferment of procedures” in the informed consent to allow participants to complete questionnaires and measurements over several encounters. The RA can assess in real-time if a specific clinical care visit has been long or if the mother is rushed and defer approaching her for study activities until the next visit. This approach accounts for our considerably small withdrawal rate and highlights the advantages of our integrated study presence in the pediatric clinic.BMC established an EHR query system in 2002. With IRB approval and in collaboration with BMC Information Technology, we developed a weekly computerized query report using patient appointment scheduling to identify participants eligible for or recruited into the Children’s Health Study. By providing the medical records of recruited PTB Study mothers and children, a query can be run each week to output those participants with a scheduled appointment in the pediatric or other ancillary clinics. The data manager further refines the appointment list against the recruitment log file to provide a weekly recruitment list. Additionally, within the EHR system, we conduct real-time monitoring for canceled appointments and, conversely, for when a participant has “checked in” for their appointment.Clinical variables are obtained from the Clinical Data Warehouse (CDW), a repository of BMC’s patient EHR data including legacy  and community health center data. We provide the medical record numbers of recruited participants in the PTB Study and Children’s Health Study to the CDW Senior Data Manager with updates on recruitment at 6-month intervals.Due to concerns about low literacy among BMC mothers, most questionnaires  are read aloud by the RAs. This reduces time and missing data. Since our transition to the research electronic data capture (REDCap) system, we can simplify the presentation of the questionnaires by using the program’s branching logic and voice recording the questions allowing a playback feature for mothers, if needed.Our study office is equipped with a PlayStation, a television, children’s movies, handheld electronics, and I-pads. In general, performs child measurements while the second RA completes maternal questionnaires and measurements. The RAs are also familiar to providers and administrative staff and able to assess wait times, allowing some study procedures to begin while a participant is waiting for their medical visit to start.We also periodically conduct information sessions with clinical providers about the Children’s Health Study’s research goals, as we understand clinical staff are instrumental in their assistance as trusted sources of information about research participation.A study information board hangs in the pediatric clinic hallway with information about the study, pictures of the Pulmonary Function testing and Bioelectric Impedance Analysis equipment along with photographs of RAs, their names, what languages they speak, and a brief biography. As a result, many study mothers and children come to the study office to ask if they are due for any measurements since they are in the clinic and waiting for or finishing their appointment. This is also helpful information for clinicians who rotate through the pediatric outpatient clinics.We provide a small gift card incentive after protocol completion in the PTB Study and at each yearly completed study visit in the Children’s Health Study. Taxi vouchers are provided if a participant arrives before their medical appointment to complete study procedures specifically for study purposes.In March 2020, all in-person non-COVID-19 and safety-related research activities were suspended at BMC. With IRB approval, we administered questionnaires to BBC participants electronically using REDCap or over the telephone, adding two newly developed COVID-19 hardship questionnaires. The first COVID-19 questionnaire was designed to assess the acute impact experienced within the first 6 months of the stay-at-home order issued by the City of Boston on March 10, 2020. This questionnaire assessed COVID-19 positivity rates and testing rates, household composition, missed healthcare appointments, experiences of food insecurity, and significant events . As COVID-19 pandemic restrictions continued in Boston, we administered a second COVID-19 questionnaire to assess the longer-term impact of the pandemic, especially regarding health care visits, school disruptions, caregiver stress, use of telemedicine, loss of employment, housing and food insecurity, and attitudes toward COVID-19 vaccines. Additionally, through weekly EHR surveillance, we queried the incident risk of COVID-19 positive mothers and children in the BBC and followed their health outcomes and symptomology.In essence, COVID-19 not only changed the way the study team interacted with the cohort but also impacted the cohort’s health outcomes, which glaringly highlighted the consequences of health inequities among populations living in low-resource, marginalized communities who make up a large proportion of the essential workforce. The BBC is well-positioned to examine the intersectionality and joint impact of biological factors, SDOH, and COVID-19 on the long-term physical, social, and emotional health of the mothers and children in the BBC, which, in turn, will inform clinical and public health preparedness and policies to minimize adverse consequences due to current and future pandemics.In addition to the common strengths associated with prospective birth cohort design, such as temporal, dose-response relationships and the ability to study comorbidities, control for time-dependent covariables, and conduct longitudinal data analyses, the BBC has the following unique strengths:Largest, longitudinal birth cohort study of US urban BIPOC women and their children from low-resource communities who bear a disproportionally high burden of social adversities and disparate health outcomes including PTB, but who have been severely underrepresented in PTB research.Participants were and continue to be recruited from a single-site medical center using uniform systems including a long-standing, single hospital EHR across time and essential clinical, laboratory, and computational infrastructures to ensure that clinical data are comprehensive and complete.By utilizing a wide range of informatics, a diverse study staff, and a study design that embeds study visits alongside clinical visits, through the two linked studies of the BBC, we have successfully recruited and retained participants from birth to age 21 and are approved to reconsent for lifetime follow-up.We have a comprehensive collection and archive of extensive epidemiological and clinical data including SDOH and maternal, placental, newborn, and childhood biospecimens.Application of cutting-edge biomedical advances in science and technology in the fields of genetics, epigenetics, and metabolomics while also addressing SDOH among BIPOC women and their children living in urban and low-resourced communities. While the collection of genetic, epigenetic, and metabolomic data is not unique, it is rare for such data to be obtained in an understudied and underrepresented BIPOC population. In doing so, the BBC helps to ensure that all women and their children can equally benefit from scientific and technological advancements.,94 which can for the first-time integrate key contributors of PTB including genome, epigenome, metabolome, health inequities, and environmental factors with maternal, placental, and fetal triads in a single study. This positions the BBC to apply current and future biomarkers, identified in the populations most likely to benefit from them, to prevent PTB and improve health outcomes. Figure Due to exponential advances made in science and technology since 1998, we now use a life-course-biopsychosocial framework,Both a strength and a limitation of the BBC are that it is conducted in a predominately BIPOC population; while findings from the BBC may not be generalizable to other populations, the findings apply to those most impacted by PTB and its long-term consequences. A potential limitation is that, although mothers have preferred having questionnaires read aloud to them, reading questions aloud may have inadvertently produced social desirability bias in their responses.Furthermore, the unique features of the BBC stated above overcome many of the limitations of most existing birth cohort studies, which struggle with limited sample sizes, fragmented data, longitudinal retention, and lack of multilevel multidimensional data to bridge biology with SDOH. Missing data and attrition/loss to follow-up are still threats to this and any longitudinal studies. There is also the challenge of describing such a dynamic long-term study like the BBC, largely due to the complexity that underlies its seamless operation. This includes significant ongoing IRB policy changes related to retention and tracking that have impacted the cohort in important ways.The BBC is also uniquely positioned to address the lack of BIPOC representation in biomedical research, and even more so in research that uses advanced biotechnology such as multi- omics. The BBC, with its extensive biorepository, along with extensive and longitudinal collection of epidemiological and clinical data, offers an unprecedented opportunity to gain a deeper understanding of the underlying causes and mechanisms of the persistent disparity in PTB; to provide critically needed evidence to inform public policy, social reform, health services organization and delivery, and clinical and public health programs; and, ultimately, to improve individual and population health for BIPOC and for all society.We are indebted to the BBC mothers, children, and families for their ongoing participation. We would like to thank over 100 investigators ranging from faculty and postdoctoral fellows to students and research assistants who worked with us over the past 20+ years and brought tremendous energy, diversity, ideas, and talent that was so vital to our recruitment and retention success. We are indebted to the L&D nursing staff for cord blood collection, and the support of the clinical departments in Pediatrics, Family Medicine, and OB/GYN. We appreciate timely EHR data retrieval by Linda Rosen at the BMC CDW. The CDW service is supported by the Boston University Clinical and Translational Institute and the NIH Clinical and Translational Science Award (grant UL1TR001430).The Institutional Review Boards (IRBs) of Boston Medical Center and Johns Hopkins Bloomberg School of Public Health approved both study protocols of the BBC. We continually assess RA training, informed consent administration observations, retrain periodically, and perform numerous data quality checks.https://www.ncbi.nlm.nih.gov/). Investigators interested in learning more about the BBC and how to obtain BBC data can contact us at BBCcontact@bmc.org. Our team will review specific data requests during monthly team meetings. For general inquiries, we will respond as quickly as possible.Our goal is to make the BBC data available to investigators, while at the same time respecting the confidentiality of our participants and ensuring the integrity of the data. A subset of the data including maternal and child genotypes and phenotypes from the Preterm Birth Study is available under controlled access request at: Genome-Wide Association Study of Preterm Birth—NCBI ; the Health Resources and Services Administration (HRSA) of the U.S. Department of Health and Human Services (HHS) grants ; and the National Institutes of Health (NIH) grants .XW designed and initiated the BBC and has been the principal investigator of the BBC since its inception; CP, GW, XH, SR, LF, SC, BB, WK, CY, WGA, and XW conducted research; and CP, TB, and XW wrote the article. All authors have contributed to and reviewed the article and approved the final article for submission. CP, WGA, and XW had primary responsibility for final content.None declared.


Psychotic experiences (PE) are common in the general population, in particular in childhood, adolescence and young adulthood. PE have been shown to be associated with an increased risk for later psychotic disorders, mental disorders, and poorer functioning. Recent findings have highlighted the relevance of PE to many fields of healthcare, including treatment response in clinical services for anxiety & depression treatment, healthcare costs and service use. Despite PE relevance to many areas of mental health, and healthcare research, there remains a gap of information between PE researchers and experts in other fields. With this review, we aim to bridge this gap by providing a broad overview of the current state of PE research, and future directions. This narrative review aims to provide an broad overview of the literature on psychotic experiences, under the following headings: (1) Definition and Measurement of PE; (2) Risk Factors for PE; (3) PE and Health; (4) PE and Psychosocial Functioning; (5) Interventions for PE, (6) Future Directions. Psychotic experiences (PE) are common phenomena in the general population . Here PE are discussed under 6 headings; (1) Definition and Measurement of PE; (2) Risk Factors for PE; (3) PE and Health; (4) PE and Psychosocial Functioning; (5) Interventions for PE (6) Future Directions.Greater awareness and inclusion of PE in healthcare research and clinical practise is an important step in expanding this field, and a general overview of PE research may be a valuable step to this goal. In this narrative review we aim to cover a broad range of subjects but, where possible, the information is synthesised from systematic reviews of the area . Both are forms of subclinical psychotic symptoms, and share common symptomology ’ in  studies  PE are transient,  met criteria for overt psychosis    & migrant status and PE indicate that there are differences based on EMS, with high discrepancies between groups. One meta-analysis found certain EMS groups showed higher PE in certain regions  is associated with higher rates of PE  of cross-sectional designs of included studies.Trauma such as sexual, physical, or emotional abuse increases risk of PE . However a second study failed to find these differences   meta-analysis observed individuals with PE showed a 2-fold increase for mental health service use compared to healthy controls  found that the presence of PE was associated with a 5 year median shorter lifespan , finding the intervention led to a reduction in PE. Two other samples, with significantly smaller samples, found traditional in-person CBT reduced PE frequency and impact (Maddox et al., However, to date there have been very few interventions focused primarily on PE. Soneson et al.  were unaFuture direction for measurement: More focus should be placed on the different types of PE, to elucidate their potentially divergent trajectories and psychopathologic significance. This will require more extensive clinical characterisation of PE. Development of such tools are growing, the SOCRATES assessment of perceptual abnormalities and unusual thought content by (Kelleher & Cannon, Secondly, the criteria used to define PE should have an evidence based in clinical outcomes. One key way this can be clarified is by studies which consider the psychosis continuum, measuring not only within distinct categories but cross-spectrum differences (DeRosse & Karlsgodt, Future direction for analysis. A significant number of risk factors, and a modest number of protective and mediating factors, have been identified to date. However, knowledge of the mechanisms which underlie these events is unknown. It is likely that a number of factors interact on multiple-levels. It is possible that more advanced statistical techniques, such as network analysis or machine learning algorithms, may mimic this type of interactive environment better than the current techniques.PE has a significant association with psychopathology (Gin et al., Future directions for PE treatment: While PE does not predict poor outcomes, it has the potential to be utilised as an early marker for mental disorders. This could be valuable as an early screening tool to identify vulnerable individuals outside of clinical services, as demonstrated by (Knight et al., The study of PE is a rapidly growing area of research, which has faced some significant difficulties in unifying definition, assessment and research. We hope this review has offered some clarity to the area, and provided a substantive overview on PE, their risk factors and outcomes, with the hope that future research may be a more unified body that can continue to push forward in this promising field.


The current review aims to summarize published research on nutrition transition patterns (depicting changes in dietary consumption) in European populations over the last three decades (1990–2020), with a focus on East-West regional comparisons. Pubmed and Google-Scholar databases were searched for articles providing information on repeated dietary intakes in populations living in countries across Europe, published between January 1990 and July 2021. From the identified 18,031 articles, 62 were found eligible for review (17 from Eastern and 45 from Western European populations). Overall, both in Eastern and Western Europe, there have been pronounced changes in dietary consumption patterns over the last three decades characterized by reductions in average reported intakes of sugar, carbohydrates and saturated fats and increases in reported fruit and vegetable consumption. There has also been a tendency toward a reduction in traditional foods, such as fish, observed in some Mediterranean countries. Overall, these data suggests that European countries have undergone a nutrition transition toward adopting healthier dietary behaviors. These processes occurred already in the period 1990–2000 in many Western European, and in the last decades have been also spreading throughout Eastern European countries. Firm conclusions are hampered by the lack of standardized methodologies depicting changes in dietary intakes over time and the limited coverage of the full variety of European populations. Future studies based on standardized dietary assessment methods and representative for the whole range of populations across Europe are warranted to allow monitoring trends in nutrition transition within and among European countries. The recent decades have been characterized by dramatic changes in the economic and social outlook of Europe . IncreasEnvironmental, political, social, educational and economic circumstances have all played a major role in the epidemiological transition . DietaryPreviously, Grigg  publisheTo depict dynamics linking nutritional patterns with the socio-demographic and epidemiological shifts, the concept of “nutrition transition” has emerged as a theoretical framework outlining nutrition changes over time, between and within populations , 18.While the nutrition transition phenomenon was extensively explored in various countries across the globe, e.g., Asia, Africa, the Middle East, and Latin America –21, therTo address these gaps, we aimed to collect and summarize published research on nutrition transition patterns in European populations over the last three decades (1990–2020) with a focus on East-West regional comparisons.The present narrative review is based on the general framework of narrative reviews proposed by Ferrari  and compA literature search of the PubMed and Google-Scholar databases (January 1990 to July 2021) was conducted using the following combination of terms and text words . Each of the above 1 to 4 key words were combined with the words: Europe, United Kingdom, and the names of each of the 27 European Union member states, i.e., Austria, Belgium, Bulgaria, Croatia, Republic of Cyprus, Czech Republic, Denmark, Estonia, Finland, France, Germany, Greece, Hungary, Ireland, Italy, Latvia, Lithuania, Luxembourg, Malta, Netherlands, Poland, Portugal, Romania, Slovakia, Slovenia, Spain, and Sweden. Additionally, article bibliographies and gray literature sources were searched for relevant publications. Publications accessible in full text were selected for the review.Studies were included based on the following criteria: (1) studies providing information on dietary intakes over time ; (2) studies reporting on populations living in any one of the 27 countries, members of the European Union by the date of last literature search (July 2021) and the UK, as it was a member of the EU for the 29 of the 30 years period; (3) studies reporting on adult populations, i.e., 18 years and older.The exclusion criteria were: (1) studies focused on specific population subgroups based on age, gender, ethnic group etc. such as children, adolescents, pregnant women, elderly; (2) studies reporting only behavioral data ; (3) food safety research studies; (4) studies providing only data on physical activity or body composition with no reference to diet; (5) studies reporting on factors affecting dietary intake and habits and not actual intake; (6) studies on associations between diet and various health outcomes without data on dietary intakes; (7) studies reporting on specific or clinical nutrition models and narrow aspects of diet, such as specific food groups or nutrients e.g., fats, vitamins, etc. and not whole of diet; (8) studies reporting on consumption in specific circumstances only, such as diet consumed away from home; (9) economic research studies ; (10) dietary/nutritional intervention or methodological studies.The process of study selection, including identification, screening, eligibility, and inclusion is illustrated with a flowchart presented in Data extraction was performed by four reviewers  using a predefined data extraction table. The following information was extracted: (1) Country; (2) First author and year of publication; (3) Study design; (4) Time period of the study; (5) Level of data; (6) Number of participants; (7) Age range; (8) Method of dietary assessment. Any discrepancies in the data extraction were discussed and resolved by consensus among the reviewers.The following information depicting nutrition transition dynamics in the respective European region and individual countries was specifically extracted denoting intakes of specific micro- and macronutrients, and food groups including: (1) “carbohydrates,” incl. bread, bakery products, cereals, rice, pasta, flour, potatoes, potato products; (2) “saturated fatty acids”, incl. animal lipids, butter, added lipids (if no other data); (3) “sugars,” incl. sugar, sugar products, honey, chocolate, and other confectionary”; (4) “fruits and vegetables”; and (5) “fish,” incl. fresh, frozen, canned, fish products. Furthermore, data was extracted according to predefined time periods (decades): (1) 1990–1999; (2) 2000–2009; (3) 2010–2019, and also extracted based on country (categorized into each of the 28 European Union countries). Eastern and Central European countries (referred shortly as Eastern European countries) included those that joined the EU after 2004, characterized by political and economic transition (shifts from non-market to market economies) in the last 30 years. These include the following 11 countries: Bulgaria, Croatia, Czech Republic, Estonia, Hungary, Latvia, Lithuania, Poland, Slovakia, Slovenia and Romania. Only Eastern European EU member states were included in the search due to the recognition that in these countries efforts were concentrated on direct measures to harmonize requirements, including nutritional, and, later, on the establishment of an “internal market.” Subsequently, a concerted shift in emphasis necessitated a greater emphasis on food safety harmonization. Hence, the legislation in Eastern European EU countries was adapted to the EU regulations and the choice for stratification was based on the attempt to standardize the group of participants. The remaining 17 countries included Western European countries traditionally characterized by market economies and representing the initial EU member states.The identified studies were evaluated according to the theoretical framework proposed by Popkin , 24 cateThe final literature search resulted in identification of 62 articles depicting dietary changes in 26 European countries. The main characteristics of the selected studies: name of country and first author, year of publication, time period of study, number of participants, age-range of participants, and method of dietary assessment, are presented according to East vs. West European region in Overall, the number of studies conducted in Western European populations was greater, with 45 articles reporting data from 16 Western European countries  was characterized by a lower number of records as compared to the previous two decades. The evidence was especially scant for Eastern Europe.Dietary data methodologies used across studies were predominantly based on national household budget survey data, which was the methodology utilized for 9 out of 10 Eastern European countries and for 12 out of 16 Western European countries. The majority of the publications were based on large national representative samples. Food balance sheets or other routinely collected data from official institutions were used if there were no other sources of information for specific countries and time periods. Most of the included studies provided dietary assessment as population averages with a small number of exceptions including Denmark , GermanyThe majority of studies provided information on selected nutrients, foods and food groups as proxy indicators of the dietary intakes in the studied populations. Among these, we identified saturated fatty acids (SFA), carbohydrates, sugar, fruits and vegetables and fish as the five most commonly assessed dietary indicators with measurements over the studied time periods. Overall, a trend of reducing the SFA consumption in the period between 1990 and 2009 could be observed in the majority of Western European countries . Malta aSimilar trends with a stable decrease in SFA intakes across all decades could be observed in the majority of the Eastern European countries. Among these, the Czech Republic, Slovenia and Romania (for the period 1990–2000) provided an exception with an overall increase in the SFA consumption over the years.The consumption of carbohydrates was also found to follow a decreasing pattern across all decades in the majority of countries, both in Western and Eastern Europe . The conThe consumption of sugar decreased in the majority of the Western European countries (11 out of 16 countries) . NeverthA decreasing trend of sugar consumption was not so explicit in the Eastern European countries, particularly in the period between 1990 and 2000. However, a tendency of decreasing sugar consumption could be observed for the second decade (2000–2009), except for in Slovakia.There was no consistent trend in fruit and vegetable consumption across European countries during the first decade (1990–2000), with half of the countries both in Eastern and Western Europe reporting an increase in intakes, with the remaining half reporting either stable or decreased intakes . During There was a trend of increasing fish consumption reported in Western European countries in the period between 1990 and 2000 . HoweverTo allow a comparison of the European transition patterns with global trends to be made, we operationalized the available data on reported dietary intake changes to approximate the nutrition transition patterns according to the pre-defined criteria by Popkin . OverallTo depict the shifts between pattern 4 to pattern 5, we evaluated whether three or more of the following dietary changes have been observed in each country: (1) reduced sugar intake; (2) reduced refined carbohydrate intake; (3) reduced saturated fat intake; (4) increased fruit and vegetable intake; (5) increased fish intake. In Eastern Europe, only two countries (Hungary and Slovenia), experienced the positive changes toward pattern 5. For four more countries  there is some evidence for a beginning transition but not sufficient to be classified as such. For the rest of the countries the data is either lacking or revealing stable, albeit unfavorable trends.In this narrative review, we provided a summary of published research depicting nutrition transition patterns in Europe over the last three decades (1990–2020) with a focus on comparisons between Eastern and Western European countries. Our literature search resulted in identifying 62 studies eligible for review, among which 17 reported data from Eastern European countries and 45 reported data from Western European countries. To our knowledge, this is the first review that aimed to summarize data on changes in dietary intakes in European populations covering the last three decades characterized by dynamic political, economic and socio-demographic transition between and within European countries. This period has been particularly challenging to Eastern and Central European countries which experienced dramatic societal and political transition after the fall of the Berlin Wall with inevitable consequences to public health.Our results reveal that there is an overall tendency of increased consumption of healthy foods, i.e., fruits and vegetables and fish, and a decreased consumption of unhealthy nutrients and foods, i.e., SFA and sugar and sugary products. Contrary to the overall transition toward healthier dietary patterns, several Mediterranean countries traditionally characterized by high intakes of fruits and vegetables, showed reversed trends with lowering fruits and vegetable intakes in the recent decades.Another registered positive trend across most of the European countries was the consistent decline in SFA consumption, starting already before the 1990's . It is aThe increases in fruit and vegetables consumption was another positive trend evidenced for half of the European countries. These positive changes are still not overcoming the generally low consumption of fruits and vegetables, for many of the countries. This indicates a need for increasing production and reduction of cross-national availability disparities, through targeted support of countries that lag behind. The estimates of the GBD match closely with our qualitative investigations. The positive trends in fruit and vegetable consumption in Europe have partially been found in the USA where increased consumption of whole fruit, but not of total fruits was reported .The only negative dietary aspect that we describe is the continuous wide scale decrease in complex carbohydrates consumption in all European countries (Western and Eastern) which was discussed also by the GBD study . The GBDThe trend toward healthier dietary patterns were obvious in Western European countries since the first studied decade (1990–2000), whereas, in Eastern European countries these pro-health nutrition trends have been emerging only in the two more recent decades (2000–2010 and 2010–2020).The current evidence suggests that there have been positive changes in diet/nutrition in the Western European countries since the 90's that largely coincided with trends observed in Eastern European countries, albeit showing a tendency to be occurring at a later time period. This phenomenon was especially pronounced for changes in sugar consumption, where most of the Western countries experienced declining trends from the beginning of 1990s, whereas in Eastern European countries sugar consumption started to decline after 2000s. These results were similar to those reported in studies in the USA where sugar consumption started to decline from the middle of the 90's mainly as a result of reduced amount of soft drinks consumption .A positive mild increase in fish consumption has been registered among two thirds of the Western European countries in the 90's. Eastern European countries lagged behind with relatively stable low levels of fish consumption between 1990 and 2010. These results are in line with the results from the GBD study . These rThe results from the current review should be interpreted with caution taking into account the variety of methodological approaches for dietary intake assessment used in the studies and the lack of studies systematically evaluating the dietary changes over time across various study populations across Europe. For food and macronutrient intake analysis, we utilized mostly data reported from household budget surveys that exist for many, but not all European countries. Most of the surveys have been standardized using same data collection procedures .There is a lot that can be done on both European and national levels to strengthen the observed positive changes where progress has already been made and also to further stimulate the lagging nations. Efforts and resources need to be directed toward data gathering in a systematic comparable way on individual level through regular representative dietary surveys reported in a standardized / unified way. Wide-scale population level primary prevention can be initiated through both nutrition education, designed to facilitate voluntary adoption of nutrition—related behaviors conducive to health and well-being, and through control of consumers' access to highly processed foods rich in sugar, salt, trans and saturated fats. These preventive actions should include policies toward production and equal access to fruits and vegetables, fish and fish products.In relation to the nutrition transition process throughout the countries of the European union, the limited available evidence suggests that 12 of the 26 six studied countries are advancing toward the last, pattern five of the nutrition transition theory. The process has started with a more than a decade earlier in Western compared to the Eastern European countries. However, we might question whether these too broadly defined patterns, depicting global tendencies developing over large time spans are of practical importance for the discussion of the European situation. The specific  situation in Europe is characterized with a huge diversity of populations and dietary patterns requiring more advanced tools/instruments to allow drawing of a more precise yet standardized evaluation of the nutrition dynamics across and within countries. Recently Popkin and Ng (2021) suggested that it is not inevitable for low and middle income countries experiencing transition toward pattern 4 to reach the same high levels of consumption seen in high-income countries, and the associated negative health impacts . Europe This narrative review has several strengths. It adds to the evidence from published studies –16 and iBased on the current review, we observed that European countries seem to have undergone a nutrition transition in the previous three decades, shifting toward healthier dietary behaviors. These processes occurred already in the period 1990–2000 in many Western European, and in the last decades have been also spreading throughout Eastern European countries. Whilst not the predominant outcome, less healthful dietary changes such as moving away from traditional diets i.e., less consumption of fish, were identified in some Nordic and Mediterranean countries. Firm conclusions on trends in dietary changes are hampered by the lack of standardized methodologies depicting changes in dietary intakes over time and the limited coverage of the studied European populations since only those that provided dietary survey data were included in the review. Future studies based on standardized dietary assessment methods and representative for the whole range of populations across Europe are warranted to allow monitoring trends in nutrition transition within and among the European countries.KA conceived the idea of this review paper. KD, RP, NU, TK, SN, GH, and CE conducted the literature search. KD, RP, NU, and GH performed the extraction of the data. KA, KD, and RP wrote the review. All authors provided critical comments, read, and approved the final version of the manuscript.This work was partly supported by The German Federal Ministry of Education and Research (BMBF) (Grant No. 01DS19002).The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.All claims expressed in this article are solely those of the authors and do not necessarily represent those of their affiliated organizations, or those of the publisher, the editors and the reviewers. Any product that may be evaluated in this article, or claim that may be made by its manufacturer, is not guaranteed or endorsed by the publisher.


Theoretical and empirical studies indicate that a lack of transparency and highly complexity makes it difficult for patients to navigate healthcare systems. This requires the competence to access, understand, appraise, and apply information about the healthcare system, its organizations and proceedings, i.e., navigational health literacy. Since little is known about navigational health literacy, partly due to a lack of measurement tools, a new instrument measuring navigational health literacy was developed as part of the Health Literacy Population Survey Project 2019-2021 (HLS19). It was applied in national health literacy surveys of the three German-speaking countries Austria, Germany and Switzerland among others. The empirical findings obtained in the three German-speaking countries and further perspectives on the topic will be presented and discussed in the workshop.The workshop on navigational health literacy has three key objectives: 1) It gives an overview on the newly developed instrument for measuring navigational health literacy in HLS19, its development and validation; 2) it aims to discuss the distribution of navigational health literacy among the Austrian, German, and Swiss population and to highlight barriers and challenges for patients regarding navigation health literacy; and finally 3) it proposes steps to promote and strengthen navigational health literacy.The workshop is designed to enhance the understanding of navigational health literacy and to propose future scenarios and steps for action to develop and implement better health literacy outcomes. By the end of the workshop, participants– will have discussed the methodological approach for measuring navigational health literacy;– will have heard of current data and developments regarding navigation health literacy in Austria, Germany and Switzerland;– will have exchanged ideas and sustainable strategies to strengthen healthcare systems by developing navigational health literacy.The four panelists will give short presentations on: HLS19, navigational health literacy research, the newly developed instrument measuring navigational health literacy in HLS19, key findings of their respective national health literacy surveys, and recommendations and current navigational health literacy initiatives in their countries. In a panel discussion, the panelists and workshop participants will discuss the presented findings and recommendations as well as the need for action regarding implementation strategies, hands-on initiatives, and sustainable solution approaches.• Navigating healthcare systems and related information proves difficult for major parts of the general population.• There is a need of health literate healthcare systems and organizations reducing the demands placed on patients by providing guidance and support.Doris SchaefferBielefeld University, Bielefeld, GermanyLennert GrieseBielefeld University, Bielefeld, GermanySaskia De GaniCareum Center for Health Literacy, Zürich, SwitzerlandRobert GrieblerAustrian National Public Health Institute, Vienna, Austria


Here, to help inform the discussion of ships as possible vectors of SCTLD, we provide an overview of the current state of knowledge about ships and their potential to transfer organisms in the greater Caribbean, focusing in particular on ballast water, and outline a set of recommendations for future research.Stony coral tissue loss disease (SCTLD) is a troubling new disease that is spreading rapidly across the greater Caribbean region, but the etiological agent(s) and the mechanisms(s) of spread are both unknown. First detected off the coast of Miami, Florida, major ocean currents alone do not explain the pattern of spread, with outbreaks occurring across geographically disjunct and distant locations. This has raised concerns by researchers and resource managers that commercial vessels may contribute as vectors to spread of the disease. Despite existing regulatory and management strategies intended to limit coastal marine invasion risks, the efficacy of these measures is still unresolved for ship-borne microorganisms, and disease transport  Stony coral tissue loss disease (SCTLD), a lethal coral disease first reported off the coast of Miami-Dade County, Florida in September 2014 , has sprAs with many other coral tissue loss diseases , the etivia ballast water (BW), biofouling (BF) of BW tank walls and on exterior submerged surfaces, bilges, fish holds, fishing gear, and anchor chains , which transport cargo and people, as potential vectors for pathogens as a possible cause SCTLD, focusing particularly on BW, and we do not explore other means by which ships can transport organisms or recreational vessels. We provide a brief overview of BW and relevant United States and international regulations on BW management. We then summarize current efforts to evaluate ships as a potential vector for SCTLD. Finally, we provide recommendations for future research to address key knowledge gaps. We intend this perspective piece to inform research and management strategies on the potential for ship-mediated spread of SCTLD.3 of BW into United States waters  for each arrival. These reports identify, for every tank of BW discharged, the location and date of all BW sources, discharges, and BW management methods applied.Under United States Coast Guard (USCG) regulations, all ships that are capable of carrying BW and bound for ports or places in the United States are required to submit a BW management report to the National Ballast Information Clearinghouse  was originally used by ship masters to reduce the amount of sediment buildup in ballast tanks. This practice was then adopted to reduce transport of coastal organisms. Initial guidelines were disseminated by governments and the International Maritime Organization (IMO) , 1997. UBallast water exchange is conducted in the open ocean either by continuously pumping three full tank volumes of water through each tank or by pumping out the original water until the pump loses suction, and then refilling. BWE replaces coastal BW or organisms with open ocean water, reducing the concentration of coastal organisms in BW tanks but not eliminating them . Such reSimilar regulations have been established internationally by the IMO  under th3; fewer than 10 organisms between 50 and 10 μm per mL; and fewer than 1 colony-forming unit (CFU) of Vibrio cholerae (serotypes O1 and O139), 250 CFU of Escherichia coli, and 100 CFU of enterococci per 100 mL. These limits are largely achieved through use of ballast water management systems (BWMS). Treatment with a BWMS is more effective for meeting concentration-based discharge standards than conducting BWE  to evaluate BW as a potential SCTLD vector. Subsequently, EPA established a collaboration with USCG and the Smithsonian Environmental Research Center to evaluate BW discharges and shipping patterns within the context of SCTLD spread. Additionally, the Naval Research Laboratory and the National Oceanic and Atmospheric Administration (NOAA) Atlantic Oceanographic and Meteorological Laboratory are collaboratively investigating the degree to which SCTLD-exposed water can remain infectious, and the efficacy of UV treatment.Appearances of SCTLD at geographically distant locations, and first reports near ports , has invUnited States BW management data and Caribbean-wide SCTLD report information are being used in projects to evaluate BW as a potential vector for SCTLD. However, such analyses are correlative and often do not yet consider other possible mechanisms or interactions. Correlations between disease incidences and ship movements or BW discharge are useful, but not sufficient to definitively identify ships as vectors. Importantly, given the extensive maritime traffic in the Caribbean, including both ships and recreational vessels, we urge caution in drawing conclusions based on apparent correlations, in the absence of experiments demonstrating causation.A preliminary analysis in 2019, including >36,000 BW discharge and management records in the NBIC, spanning Sep 7, 2013–Aug 6, 2020, detected no clear relationship between BW discharges and SCTLD occurrence in United States waters, since sites with SCTLD varied in BW discharge histories, including some with no reported discharge.Following these initial results, on September 6, 2019, at the request of NOAA, USCG, in collaboration with EPA, issued a Marine Safety Information Bulletin MSIB; , advisinThe MSIB, as a rapid communication, avoided the significant administrative timelines associated with new regulations; however, it has not appreciably decreased the potential risk of transporting coral pathogens to United States locations in the greater Caribbean through the discharge of unmanaged BW. The increasing use of BWMS to treat BW prior to discharge is expected to significantly reduce the risks of pathogen transport, but efficacy of treatment methods against organisms causing SCTLD needs to be directly tested. If BW is identified as a contributor to SCTLD spread, mitigation may need to include approved treatment systems, and depending on the efficacy of such, new regulations for BW management.via ships to other geographic regions. It is therefore imperative that we understand whether the disease can be transferred via ship BW and/or BF, and under what circumstances. While SCTLD warrants such attention due to its significant impacts, it also provides an important model to understand the broader risk associated with microorganism transfers.Stony coral tissue loss disease continues to spread across the greater Caribbean and there are indications that Pacific corals may also be susceptible to the disease , prompting concern about pathogen movement While ships clearly have the potential to spread pathogens, understanding the likelihood of ship-mediated spread of SCTLD remains challenging given the unknown etiology of the disease. While successful treatment with antibiotics suggests the pathogen(s) may be bacterial , we cannvia ships. As with BW, the flux of BF organisms is potentially large, given the cumulative surface area that arrives from other bioregions to United States waters alone  mean that a significant proportion of BW flux among ports within the region will remain unmanaged until existing ships operating in the region reach their United States and Convention discharge standard compliance dates. Additional interim best management practices, and/or emergency measures, to reduce the transport of SCTLD by these otherwise exempted ships should be considered.via BW and BF, at a large geographic scale; however, their roles in the dynamics of this disease are still not clear. We recommend continued focused research on these possible mechanisms of spread, in concert with ongoing efforts to understand disease etiology and ecology. We also encourage collaborations that bring together experts in ships/shipping, water disinfection, and coral disease.While efforts are underway to understand the potential pathways by which SCTLD spreads geographically, no definitive connection between any transport mode and disease outbreaks has yet been verified. It is reasonable to recognize ships as potential vectors for transmission of SCTLD, Sup.