Rural consumption is crucial in promoting economic and social development in China’s economic slowdown. Integrating urban-rural residents’ health insurance has alleviated the financial burden of medical expenses for rural households and boosted rural household consumption. This study examines the effect of integrating urban–rural residents’ health insurance on the consumption patterns of middle-aged and older adult households in rural China. Our research provides a reference basis for improving rural healthcare security and enhancing the sustainable consumption capacity in rural areas.We employed a Propensity Score Matching Difference-in-Differences model (PSM-DID) to estimate the association between health insurance integration and household consumption using panel data from the China Health and Retirement Longitudinal Study (CHARLS) from 2013 to 2018. Furthermore, we employed a mediation model to analyze the influencing mechanisms.Our findings suggested a positive association between health insurance integration and survival consumption as well as total consumption among rural middle-aged and older adult households. The conclusion remained valid after endogeneity treatment, robustness and placebo tests. Furthermore, we found that the impact of health insurance integration is more pronounced for middle-aged, female, and high-income rural residents’ households. Integrating urban–rural residents’ health insurance raised consumption by reducing medical expenses and increasing health and life expectancy.Policymakers should deepen the rural medical and health system reform, improve the convenience of medical services for middle-aged and older adult families in rural areas, and improve the medical and life assistance mechanism for vulnerable groups in rural areas. Additionally, the local government should continuously broaden rural household income channels to promote upgrading consumption structure while improving overall consumption levels. The report of the 20th Party Congress highlighted the importance of building a unified national market, enhancing the reliability of domestic circulation, and strengthening the fundamental role of consumption in economic development . ConsumpTransforming rural households’ consumption potential into a consumption booster requires overcoming objective barriers, such as health shocks from disease risk that can erode human capital and increased individual precautionary savings to cope with future uncertainty. Lower income levels and higher rates of illness in rural middle-aged and older adult households result in a lack of capacity to cope with health risk shocks. This lack of basic medical coverage inevitably leads to increased precautionary savings and reduced consumption expectations. Establishing and improving the basic medical insurance system and reducing the financial burden of medical care for middle-aged and older adult rural families are crucial to boosting rural consumption in China. The Chinese government established the New Rural Cooperative health System in 2003 to reduce future uncertainty and increase consumption decisions by providing higher levels of protection for rural households. China’s three primary health insurance systems segmented by region, urban–rural areas, and population have resulted in unequal utilization of medical services between urban–rural residents and created complex problems in cross-province settlement, medical treatment in different places, and reimbursement management due to the non-portability of medical insurance benefits. In January 2016, the State Council of China issued the “Opinions on Integrating the Primary Health Insurance System for Urban and Rural Residents,” which proposed the basic principles and specific requirements for integrating the medical insurance system for urban and rural residents . IntegraThe policy of integrating health insurance for urban and rural residents has drawn significant attention from domestic academics due to its implementation and coordination in several provinces. Previous research can be divided into two categories. The first category has examined the direct effects of integrating health insurance for urban and rural residents, such as reducing the medical burden on rural residents , enhanciThis study has several potential contributions. Firstly, While previous research has predominantly focused on rural residents when examining the integration of health insurance for urban–rural residents, there has been limited investigation into the consumption patterns of older adult households in rural areas. Given that middle-aged and older adult households are more susceptible to health and economic risks, they may be particularly affected by health insurance policy reforms. This study systematically investigates whether integrating health insurance for urban and rural residents has a positive impact on consumption among rural middle-aged and older adult households. Secondly, previous research has primarily focused on reducing the financial burden of medical expenses and has yet to thoroughly explore the long-term consequences of health insurance system reforms on household consumption. This paper examines the impact of medical insurance system reforms on household consumption from two perspectives: reducing the financial burden of medical expenses and improving health expectations, and comprehensively assesses both short-term and long-term effects. Thirdly, our study combines the Difference-in-Difference (DID) method and Propensity Score Matching (PSM) to control for the influence of unobservable factors that individual characteristics and changes over time may cause. Furthermore, we test the model settings using multiple methods to ensure the accuracy of the estimation results.Keynes introduced the theory of consumption function in his book “The General Theory of Employment, Interest, and Money”1936) . This th36 . ThisAccording to the theory of precautionary saving proposed by Leland , individCampbell and Mankiw developed the λ hypothesis  by conduBased on the above discussion, this paper proposes the following research hypotheses:Hypothesis 1: integrating urban–rural residents’ health insurance benefits middle-aged and older adult rural households by increasing their survival, development, and total consumption.Hypothesis 2: integrating urban–rural residents’ health insurance increases the consumption of middle-aged and older adult rural households by reducing the economic burden of healthcare costs.Hypothesis 3: integrating urban–rural residents’ health insurance increases the consumption of middle-aged and older adult rural households by improving their expectations for future health outcomes.This article utilizes data from the China Health and Aging Tracking Survey (CHARLS), a large-scale interdisciplinary survey conducted by the National Development Research Institute of Peking University in collaboration with the China Social Survey Research Centre and the Peking University Youth League Committee. This survey gathered high-quality micro-data representative of Chinese middle-aged and older adult households and individuals, with approximately 20,000 respondents from 28 provinces, autonomous regions, and municipalities directly under the Central Government. This article utilizes CHARLS data for two primary reasons. Firstly, the survey questionnaire design draws on international experience from countries such as the United States and Europe and employs various sampling methods such as PPS. The questionnaire covers essential information on individuals and household structures, health insurance and healthcare utilization, and multiple types of income and expenditure structures. These features provide high-quality data support for investigating rural household consumption issues. Secondly, the four surveys cover the implementation cycle of the policy of integrating health insurance for urban and rural residents. The data set includes variables related to the New Rural Cooperative and basic health insurance for urban and rural residents, which are more suitable for the research needs of this paper. This study utilizes the two-period treatment of 2013 and 2018 to obtain balanced panel data, given that the initial survey in 2011 lacked a straightforward questionnaire design. The research population consists of rural middle-aged and older adult households. Only complete two-period data samples of participants in the New Rural Cooperative Scheme and urban–rural residents’ health insurance were retained, resulting in a final sample size of 12,378, including 1,690 samples in the treatment group and 10,688 in the control group.The dependent variable studied in this articles household consumption. This paper has established three indicators based on the questionnaire design and research needs. ①Survival consumption reflects the necessary consumption expenditures for rural older adult households to maintain their daily lives. To calculate the annual survival consumption, the expenses on food, clothing, communication, water, electricity, and fuel in the past month are multiplied by 12 months. ②Developmental consumption, reflects the expenditures made by rural older adult households to improve and enhance their quality of life. To calculate the total developmental consumption, the expenditures on tourism, heating, consumer goods and appliances, education and training, healthcare, beauty, and automobiles in the past year are added. ③The third indicator, Total Consumption, reflects the overall consumption situation of rural households. To calculate the total annual consumption of rural older adult households, the Survival and Developmental Consumption are added. Additionally, to eliminate the influence of changes in the price level, all consumption indicators in this paper were adjusted using the current year’s CPI index. The dependent variables were transformed using the natural logarithm to reduce research bias, resulting in three variables: Ln_Survival for Survival Consumption, Ln_Developmental for Developmental Consumption, and Ln_Total for Total Consumption.The explanatory variable under study in this article is Insur_Integration, which integrates the health insurance of urban and rural residents. This variable is obtained by processing the different types of medical insurance (Med_Insurance) in the questionnaire. To ensure accurate measurement, sample data from provinces that completed system integration as early as 2008 were excluded from the 2013 dataset. Only samples from participants in the New Rural Cooperative Medical Scheme were included. The previous DID model defined two groups of dummy variables as follows: policy dummy variables included those who participated in the New Agricultural Cooperative Scheme in 2013 and those who participated in urban and rural residents’ insurance in 2018, assigned a value of 1 as the treatment group while those who participated in the New Agricultural Cooperative Scheme in both 2013 and 2018 were assigned a value of 0 as the control group Additionally, the time dummy variable (Time) was assigned a value of 0 in 2013 and 1 in 2018, with 2016 as the policy implementation point.In order to control for the influence of other variables on the consumption of households in rural areas, this study refers to the research conducted by Ma et al.  and has Based on the previous analysis, two types of variables in this study affect the mechanism. Firstly, the integration of urban and rural resident medical insurance reduces the out-of-pocket ratio of health expenses for rural older adult households, thereby easing the economic burden of medical treatment. The primary measurement variable used is the “Proportion of medical expenses to total expenses” of rural residents in the CHARLS questionnaire, which is obtained by dividing medical expenses by total expenses. The second variable type involves rural residents’ improvement in future health and life expectations. The leading indicators for measurement are “health expectancy” and “future hope” as answered by rural residents in the questionnaire. Respondents’ answers to “Health_Expectancy” were scored 1–5 based on “almost impossible, unlikely, possible, very likely, and definitely, “respectively, with higher scores indicating better future health expectancy.” For “Future_Hope,” respondents’ answers of “very little or none, not much, sometimes or average time, most of the time” were scored 1–4, with higher scores indicating better life expectancy.i-th sample in period t; The gradual transition from the new rural cooperative to basic medical insurance for both urban and rural residents creates a quasi-natural experimental setting to investigate the impact of integrating medical insurance on the consumption patterns of middle-aged and older adult rural households. This study employs a double-difference-in-differences (DID) model to mitigate endogeneity issues arising from omitted variables or selectivity bias. Two sets of dummy variables are constructed to conduct the DID analysis: ① Policy dummy, comprising a treatment group affected by the policy and a control group not affected by the policy.② Time dummy, including two periods before and after policy implementation. By comparing the consumption differences between the two sample groups before and after the policy implementation, the study systematically evaluates the impact mechanism of integrating medical insurance on the consumption patterns of urban and rural residents. We constructed a basic DID model, as illustrated in The DID model is based on a natural experiment where the treatment and control groups are randomly assigned, meeting the requirements of a natural experiment. This study aims to estimate the average treatment effect using the formula presented in The empirical findings indicate that integrating health insurance for urban–rural residents improves the survival and total consumption of rural middle-aged and older adult households. Nonetheless, it should be noted that the decision of rural residents to participate in the urban and rural residents’ basic medical insurance program is not entirely random and is subject to various influencing factors. Consequently, it poses a challenge to ensure the similarity of fundamental characteristics in the standard DID method, and there could be significant variations between the basic characteristics of rural middle-aged and older adult residents in the treatment and control groups. This discrepancy may lead to the regression model not satisfying the assumptions of random selection, resulting in endogeneity issues. The PSM-DID model was subsequently validated. Using total consumption as an example, it is evident from the plots that there is a substantial difference in propensity score values between the treatment and control groups before and after matching . This obThe placebo test is a standard method for evaluating policy effectiveness by creating a sample of dummy policy implementation times or experimental groups to determine whether the policy effect is genuine. Based on the combined use of PSM-DID in the previous section, it can be concluded that integrating urban and rural health insurance benefits improves subsistence and total consumption. However, it is still necessary to account for the impact of other unobservable factors. Life-cycle theory posits a relationship between consumers’ income and the expected value of income at different stages of life, including childhood, middle age, and old age . The impThe integration of urban and rural health insurance has the potential to impact rural middle-aged and older adult household consumption through two pathways. Firstly, it can reduce the current medical out-of-pocket ratio for middle-aged and older adult rural households, increasing their relative income and current consumption levels. Second, it can raise the future health expectations of rural residents, leading to greater optimism in coping with future uncertainties and ultimately increasing household consumption intentions. This paper investigates how the integration of urban and rural health insurance affects the consumption of rural middle-aged and older adult households through three mediating variables: “Proportion,” “Health Expectancy” and “Future Hope.” This paper employs the mediating effect test developed by Wen and Ye  to analyBased on this, Step 3 in this paper is to include the three mediating variables of “Proportion,” “Health_Expectancy,” and “Future_Hope” in the regression model for analysis, as shown in This study utilized panel data from the China Health and Retirement Longitudinal Study (CHARLS) for 2013–2018 to analyze the impact of the integration of medical insurance policies on household consumption among middle-aged and older adult in rural areas. Firstly, the study indicates that integrating health insurance for urban–rural residents has increased survival consumption by 7.3% and total consumption by 7.0% in rural households. This finding is consistent with the conclusions of previous studies such as Chen and Zhang  and Bai The heterogeneous results of this study indicate that the integration of medical insurance for urban and rural residents has similar effects on the heterogeneity of survival consumption and total consumption. Institutional integration is beneficial for increasing the consumption levels of middle-aged individuals, women, and high-income households in rural areas. In contrast, its impact on the consumption of older adult individuals, men, and low-income rural households is not significant. This study suggests that the possible reason for these results is that although the integration of integrating health insurance for urban and rural residents reduces medical costs for older adult and low-income rural residents, their income uncertainty and medical economic risks remain high. As a result, their household consumption decisions become more cautious . In addiThe existing literature has yet to explore the mechanism through how integrating health insurance for urban and rural residents affects rural household consumption. This study primarily analyzes the mechanism based on the proportion of medical expenditure, health, and life expectancy, providing necessary complementary research. This study shows that integrating health insurance for urban–rural residents improve the consumption level by reducing the medical economic burden and improving health and life expectations. Firstly, rural older adult households are highly susceptible to economic and health risks, with a heavy burden of medical expenses. Integrating health insurance for urban and rural residents has improved the medical benefits for rural households, reducing the economic burden caused by health risks. This is beneficial for enhancing their consumption capacity. Secondly, integrating health insurance systems has reduced social risks for rural households, improved life expectancy, and increased consumer confidence. This finding is consistent with the research conclusions of Ma and Li . Lastly,This study systematically explores the impact of integrating health insurance for urban and rural residents on household consumption in rural areas by employing the DID and PSM-DID methods. The study uses panel data from the China Health and Retirement Longitudinal Study (CHARLS) conducted from 2013 to 2018. The research conclusions are as follows: Firstly, integrating urban–rural residents’ health insurance is associated with an increase in the survival consumption and total consumption of rural households. This conclusion remains valid after endogeneity and placebo tests. Secondly, the results also reveal heterogeneity, indicating that integrating urban and rural residents’ health insurance on the consumption of rural middle-aged, female, and high-income households is more significant for survival and total consumption. Thirdly, integrating urban and rural residents’ health insurance increases the consumption of rural older adult households by reducing their medical burden and improving their health and life expectancy. Generally, the mediating effect on survival consumption is more significant than on total consumption.This paper provides the following policy implications: Firstly, The government should further deepen the equity of the primary health insurance system. Integrating health insurance for urban and rural residents is essential to enhancing institutional equity and has positive policy effects. The government should enhance the institutional integration of healthcare coverage for urban and rural residents while relieving the insurance premium burden on older adult and low-income families in rural areas. On this basis, it is necessary further to deepen the reform of the medical and health system and promote the phased coordination of fundamental healthcare coverage at the provincial and national levels to narrow the disparity in accessing medical and health services between urban and rural areas, stimulate rural development-oriented consumption, and achieve common prosperity. Secondly, it is imperative to improve the convenience of medical services for rural older adult households and fully leverage the positive consumption externalities of medical security. This study demonstrates that integrating health insurance systems has enhanced the consumption level of older adult households in rural areas. Therefore, the government should coordinate medical and healthcare resources in rural areas and actively steer medical service facilities, funds, and talents to focus on rural and remote areas, helping to improve the expectations of consumers and the quality of life of rural older adult households. Thirdly, it is imperative to address the medical service needs of rural women, families with low incomes, and older adult groups. This study suggests that the positive impact of integrating health insurance for urban and rural residents on vulnerable groups, such as low-income populations in rural areas still needs to be improved. Therefore, it is crucial to prioritize improving the quality of life for these groups. Establishing and improving healthcare and life assistance programs for vulnerable groups in rural areas provides convenient and targeted medical services, mitigates the negative impact of health risks on the lives of target groups, and enhances confidence in consumption for these families. Fourthly, Income is one of the most critical factors influencing consumption. Therefore, the government should increase investment in infrastructure construction in rural areas, such as water, electricity, roads, and the Internet, and expand the scale of family-based farming and private income sources in rural areas.The original contributions presented in the study are included in the article/supplementary material, further inquiries can be directed to the corresponding authors.The studies involving humans were approved by Ethical review and approval were waived for this study, due to the data used in this article coming from the public database, with which all subjects involved are anonymous. The studies were conducted in accordance with the local legislation and institutional requirements. The participants provided their written informed consent to participate in this study. Written informed consent was obtained from the individual(s) for the publication of any potentially identifiable images or data included in this article.JW: Conceptualization, Formal analysis, Writing – original draft. QH: Data curation, Methodology, Writing – review & editing.


Health professionals and care partners of persons living with dementia have expressed that learning needs related to dementia care are a priority. There are currently a variety of training programs available in Ontario (Canada) to address aspects of dementia care, but no commonly accepted description of the core knowledge, skills, and abilities,  that should underpin dementia-related training and education in the province. The aim of this study was to review current evidence to inform the later development of competency statements describing the knowledge, skills and actions required for dementia care among care providers ranging from laypersons to health professionals. We also sought to validate existing dementia care principles and align new concepts to provide a useful organizing framework for future competency development. We distinguished between micro-, meso- and macro-level concepts to clarify the competencies required by individuals situated in different locations across the healthcare system, linking competency development in dementia care to broader system transformation. This review precedes the co-development of a holistic competency framework to guide approaches to dementia care training in Ontario. In Canada, approximately 25,000 individuals are diagnosed annually and nearly 690,000 Canadians are estimated to be living with dementia . Many CaThe National Dementia Strategy ; the University of Waterloo’s Murray Alzheimer Research and Education Program (MAREP) ; and, the educational programs and tools of Lakehead University’s Rethink Dementia program (see http://www.rethinkingdementia.ca/). In addition, there are a number of health care worker-focused training programs including: P.I.E.C.E.S™ Canada and the Gentle Persuasive Approach(c) developed by AGE Inc.; Indigenous focused materials developed by the Indigenous Cognition and Aging Awareness Research Exchange (I-CAARE) (see https://www.i-caare.ca/); and courses offered in community colleges and workplaces as stand-alone courses or as part of a variety of dementia education certificates available for care partners and for healthcare workers. Each course or training program has its own curriculum, learning objectives and approach to content design, contributing to variation in dementia care practice and in the experiences of persons living with dementia who receive care from others.Currently, there are a variety of forms of dementia education and training in Ontario, Canada. Examples include dementia webinars and care partner seminars offered by national, regional and local Alzheimer Societies and university-linked dementia education programs such as: McMaster University’s iGericare program  that should underpin dementia-related training and education in Ontario, Canada.Competency frameworks are used extensively in healthcare to coordinate health professional education and provide a systematic approach to the development, delivery, and evaluation of curricula. To our knowledge and through an extensive review of the literature we conducted, there is no comprehensive unified Ontario-wide framework that describes the competencies required for dementia care across all categories of carers.Developing a competency framework for dementia care may assist in translating emerging dementia research findings into both lay and professional dementia education programs by helping to identify desired learning outcomes. Such a framework, particularly when co-developed with persons living with dementia and their care partners, could aid in aligning educational efforts with the identified aspirations and goals of individuals who live with dementia. Our aim was to review current evidence to inform the development of competency statements describing the knowledge, skills and actions required for dementia care among care providers ranging from laypersons to health professionals. We also sought to validate a preliminary adaptation of an existing dementia care competency framework , and, ifDiane Bardsley (now Bardwell) was the Principal Program Lead, Dorset Clinical Commissioning Group, South West Dementia Partnership (UK) in 2011. Her competency framework  was seleThese principles are used as an organizing framework to synthesize the findings of our review.The research team sought to identify a broad range of knowledge, skills, and actions relevant to dementia care that spanned the lay to professional continuum. With few existing examples of dementia care competency frameworks noted in a scan of the literature, a scoping review method was selected to gather the current state of the literature in dementia care competencies more broadly, beyond the few available, published competency frameworks. We used Arksey and O’Malley’s five-stage framework  to guideThe second stage revolves around identifying and selecting relevant studies. A 13-years paper publication date time frame was set (2008–2021) with the associated rationale being that significant changes continuously occur in the field and study of dementia care. This time frame reflects the study start date of 2018, and an additional, later, scan of the literature to ensure completeness and currency followed. The need was to retrieve competency statements that would assist with the creation of the most current, and up-to-date competency framework. In addition, the articles needed to be written in the English language and published in scientific, peer-reviewed journals.The following electronic databases were searched: Cumulative Index to Nursing and Allied Health Literature (CINAHL), Medline, Scopus, and PsychINFO. All types of dementia were permitted in the search. The terms clinical competence, attitude, attitude of health personnel, judgement, competency/competencies, knowledge, and frameworks were searched in combination with the terms: caregiver, carer, family/ies, friend/s, spouse, healthcare/care provider, health professional, clinician, and staff (Diagram 1). For this search, the term ‘caregiver’ was included as it is more frequently used in the literature, despite the recent trend to prefer the term ‘care partner’ in everyday use. Our analysis reflects the term ‘caregiver’ to maintain consistency with the literature reviewed.1 Dementia/2 Alzheimer Disease/3 exp Dementia, Vascular/(6489)4 Frontotemporal Lobar Degeneration/or Frontotemporal Dementia/(3326)5 Lewy Body Disease/(2987)6 dement*.tw. 7 or/1–6 8 Clinical Competence/9 Health Knowledge, Attitudes, Practice/10 Attitude/or Attitude of health personnel/11 Judgment/12 (competency or competencies).tw. 13 (knowledge* or skill* or attitude* or judg?ment*).ti,kf. 14 (framework* or frame work*).tw. 15 or/8–14 16 Home Nursing/(8827)17 Family/18 Friends/(4449)19 Spouses/(9233)20 exp Health Personnel/21 exp Health Occupations/22 Patient Care/(9315)23 Primary Health Care/24 .tw. 25 or/16–24 26 7 and 15 and 25 (2753)27 limit 26 to English language (2543)28 remove duplicates from 27 (2336)Diagram 1. Combination of Search TermsA total of 6746 sources were retrieved using this search strategy and one additional record was identified during peer review; 2269 duplicates were removed, leaving 4478 sources for further review . The titThe fourth stage of Arksey and O’Malley’s five-stage framework  is chartOnly high-quality sources moved forward to the data extraction stage. A data extraction form was created to extract the following information from the included sources: full citation, location of where the study was carried out, aim/purpose of the study, setting, methodology, sample, whether persons living with dementia were included in the study, methods/data collection, data analysis methods, any information pertaining to framework for dementia care, results in relation to competency statements, strengths and limitations of the study, and relevance to the topic/research question and secondary question.The final stage of the scoping review framework is collating, summarizing, and reporting the results . The aimIncluded studies reflected a heterogeneous sample of study designs or article types. Of the 22 included articles, three used quantitative designs, including a non-randomized control trial , a crossThe included studies were authored or conducted in seven different countries, with the most produced in Australia .Figure 2Seven studies reflected the long-term care setting and seven were relevant to the community setting (note: one article addressed both long term care and community). The remainder reflected the hospital environment, or were not setting-specific, meaning they did not describe specific environments .Seven of the studies included either caregivers and/or persons living with dementia, of which three included caregivers only. The characteristics  of included studies are summarized .Table 2.The findings of the review were mapped to the 13 organizing principles described by A study by Five studies identified knowledge of dementia including causes, signs and symptoms  which arFour studies identified concepts related to the assessment and diagnosis of dementia, including providing evidence-based dementia care, and facilitating access to supports, services and disease management . AdditioFive studies identified concepts relevant to communication, including communicating effectively and therapeutically , and demEight studies included a variety of concepts related to supporting those who live with dementia to live well. Two studies identified macro or systems concepts such as living well across communities and groups, and facilitating choices within legal and ethical frameworks . Four stRecognising factors influencing the use of psychotropic medications  was discussed as an important concept related to this principle in Partnering and interacting with caregivers in studies by Four studies identified concepts related to fostering models of integrated health and social care that include a variety of health professionals and specialists, and that may cross organizational boundaries . AccordiA range of relevant concepts related to the context of care were noted. Dementia care workers require knowledge and skill in engaging with communities to deliver community-based and culturally appropriate care, as per Two studies identified competencies related to the provision of palliative care as relevant gerontological nursing competencies . SupportThree studies noted the importance of staff education to increase worker knowledge, confidence and/or self-efficacy . FurtherSeveral studies highlighted the knowledge, skills, and actions required of leaders to enable effective processes and practices in dementia care. Four studies identified leadership actions relevant to macro or meso infrastructure development, such as enabling access to technology , ensurinTwo studies offered insights relevant to evaluation in dementia care and identified several desired outcomes for persons living with dementia  and/or tOur review demonstrates good alignment between the current literature and prior work identifying principles for holistic dementia care. The results are summarized by principle .Table 4.Of particular note is the comprehensive work of Through our scoping review, we noted a robust body of literature that can inform competency development in several specific areas . In other instances, the current literature is limited . There were only a few references specific to providing culturally sensitive care  and none addressing the needs of sub-populations of individuals living with dementia . These gaps in literature suggest areas for development and further study of the knowledge, skills, and actions  required by a range of actors  to address the broad spectrum of needs and experiences in dementia care.The findings also suggest micro-,meso-and macro-level concepts that can shape the development of an overarching competency framework in dementia care. Micro-level concepts are those that could be carried out by individual actors, such as members of the lay public, family or friend caregivers, unregulated care providers and/or regulated health professionals. Such concepts include: communication skills; facilitation skills; knowledge about the signs and symptoms of dementia; partnering with persons living with dementia and care partners; and, supporting individuals experiencing responsive behaviours. Meso-and macro-level concepts are those expected of leaders and organizations and include concepts such as infrastructure, care models and workforce development. The distinction between micro-,meso-and macro-level concepts links to other work describing integrated care  and helpAll concepts identified during this review could be mapped to the 13 organizing principles drawn from The sixth optional stage of the Our initial search yielded 6746 articles, a volume that was somewhat challenging for our research team to review. More stringent search criteria may have eliminated the volume of articles returned but may have also caused us to miss some of those studies that provided valuable insights. We elected to err on the side of inclusivity as competency-based approaches to dementia care is an emerging area of study.This scoping review was conducted to identify current literature relevant to the development of a competency-based framework for dementia care that spans the caring continuum, from members of the lay public to healthcare professionals. We identified 22 articles and confirmed 13 foundational principles that can serve to focus future competency development and inform curriculum design in dementia care training for the lay public, persons living with dementia, care partners and health care professionals. There are also implications at meso and macro levels for health care leaders and policy makers related to potential enablers for effective dementia care, which can be a focus for future study.We anticipate using the results of this scoping review to inform the co-development of a holistic competency framework to guide approaches to dementia care training that is squarely focused on what matters most to persons living with dementia. We also anticipate this review will be of relevance to those interested in dementia care education across Ontario and in other jurisdictions.


Youth in the child welfare system (child welfare–involved [CWI] youth) have high documented rates of mental health symptoms and experience significant disparities in mental health care services access and engagement. Adolescence is a developmental stage that confers increased likelihood of experiencing mental health symptoms and the emergence of disorders that can persist into adulthood. Despite a high documented need for evidence-based mental health services for CWI youth, coordination between child welfare and mental health service systems to increase access to care remains inadequate, and engagement in mental health services is low. Navigator models developed in the health care field to address challenges of service access, fragmentation, and continuity that affect the quality of care provide a promising approach to increase linkage to, and engagement in, mental health services for CWI youth. However, at present, there is no empirically supported mental health navigator model to address the unique and complex mental health needs of CWI youth and their families.Using a randomized controlled trial, this study aims to develop and test a foster care family navigator (FCFN) model to improve mental health service outcomes for CWI adolescents (aged 12-17 years).The navigator model leverages an in-person navigator and use of adjunctive digital health technology to engage with, and improve, care coordination, tracking, and monitoring of mental health service needs for CWI youth and families. In total, 80 caregiver-youth dyads will be randomized to receive either the FCFN intervention or standard of care : 40 (50%) to FCFN and 40 (50%) to control. Qualitative exit interviews will inform the feasibility and acceptability of the services received during the 6-month period. The primary trial outcomes are mental health treatment initiation and engagement. Other pre- and postservice outcomes, such as proportion screened and time to screening, will also be evaluated. We hypothesize that youth receiving the FCFN intervention will have higher rates of mental health treatment initiation and engagement than youth receiving standard of care.We propose enrollment of 80 dyads by March 2024, final data collection by September 2024, and the publication of main findings in March 2025. After final data analysis and writing of the results, the resulting manuscripts will be submitted to journals for dissemination.This study will be the first to produce empirically driven conclusions and recommendations for implementing a family mental health navigation model for CWI youth with long-standing and unaddressed disparities in behavioral health services access. The study findings have potential to have large-scale trial applicability and be feasible and acceptable for eventual system implementation and adoption.ClinicalTrials.gov NCT04506437; https://www.clinicaltrials.gov/study/NCT04506437DERR1-10.2196/49999 The COVID-19 pandemic has further increased the number of youth entering the child welfare system owing to having lost parents or caregivers from COVID-19–related death ), 7% behavioral , 1% psychosis, and 3% deferred.Eligible participants will be youth aged between 12 and 17 years who have an active dependency petition with the local unified family court (newly filed or existing when the RCT commences), are referred to the FCMH clinic for services, have an involved caregiver or legal guardian who can consent and participate in the intervention, and whose family has mobile phone access. The exclusion criteria include youth and caregivers who are monolingual in languages other than English or Spanish, caregiver impairment that would preclude providing informed consent, and the lack of an available guardian for consent.Study staff will be embedded in the FCMH clinic setting to introduce the study and procedures to eligible families at the time that families meet with FCMH clinic staff . FCMH clinic staff will refer eligible families to meet with study staff. Interested youth and families will be separately assented or consented in a private place (FCMH clinic staff will not be involved). We will obtain a waiver of parental consent for referred youth.Participants will be randomized (using a computer-generated randomization tool) to either the FCFN intervention group  or the standard of care group  directly after consent and completion of the baseline assessment.This study was approved by the institutional review board at the University of California San Francisco (268565) and was conducted in accordance with the ethical standards of the Helsinki Declaration.Multiple sources of data will be collected, including electronic medical records (EMRs); mobile phone or web entry in the Fostering Connections web application; and self-reports from the FCFNs, youth, and caregivers . CascadeIdentification Percentage screened , percentage assessed (CANS), and percentage in needTime to screening, full assessment, and determination of need (number of days)Transition Percentage referred for treatment and percentage who initiated treatmentTime to referral and initiation (number of days)Retention Engaged in care (≥6 weeks of attendance)Continuing care Navigator background (foster care family navigator [FCFN])Age, race and ethnicity, education, training, and years in child welfare fieldNumber and types of contacts with navigator Video, SMS text messaging, in person, and telephoneFCFN intervention fidelity (FCFN)Developed as part of prior study proceduresTherapeutic Working Alliance (youth)Twelve-item Working Alliance Inventory , used inNavigation Satisfaction Tool, Part I  Evidence-Based Practice Attitude Scale-50 (FCFN)A 50-item scale , developBarriers to Care Questionnaire(youth and caregivers)A 39-item scale   that assMotivation for Youth’s TreatmentScale(youth and caregivers)A psychometrically valid 8-item scale  that youMobile health  feasibility or satisfaction Mobile phone type, mobile phone service interruptions, number of mobile phone numbers, most preferred types of SMS text messages, number of messages opened or read, and responsesUsability of mHealth intervention components or “system”: System Usability Scale A 10-item measure  widely uSociodemographics Race, ethnicity, sex, education, income, legal history, and placement typePediatric Symptom Checklist A 35-item measure of child emotional and behavioral problems that has been identified as a feasible method for the early detection of mental health difficulties  and inteUniversity of California Los Angeles Posttraumatic Stress Disorder Reaction Index for Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition An instrument that screens for exposure to traumatic events and the frequency of posttraumatic stress disorder symptom occurrence during the past month (ranging from 0=none of the time to 4=most of the time) ; items mBrief Symptom Inventory (caregivers)A 51-item measure of past week mental health symptoms Parent-Adolescent General Communication Scale (youth and caregivers)A scale that assesses positive and negative aspects of communication via 2 subscales (open family communication and problems in family communication) , with 5 Parental Monitoring Questionnaire (youth and caregivers)A 24-item measure of parental monitoring across 4 areas or subscales , with higher scores indicating higher levels of monitoring domains Youth and caregivers in both conditions will each complete the electronic study assessment at baseline and at 1, 3, and 6 months . Unless it is specifically noted, all of the following measures will be collected from youth and caregivers across both conditions. FCFN navigator measures are also included.We will collect EMR data that will include (1) percentage screened , percentage assessed , and percentage in need ; (2) time to screening, full assessment, and determination of need (number of days); (3) percentage referred for mental health treatment as well as percentage who initiated treatment; (4) time to referral and initiation (number of days); (5) whether the youth engaged in treatment (whether they had ≥6 weeks of treatment attendance); (6) number of total mental health treatment sessions completed; (7) sociodemographics ; (8) Child and Adolescent Needs and Strengths (CANS) screener and full assessment ; and (9) Pediatric Symptom Checklist score .The 12-item Working Alliance Inventory (WAI) , which wThe 12-item Navigation Satisfaction Tool (NAVSAT), Part I , addressThis 39-item scale  assesses perceived barriers to youth health care access . Items aThis is a psychometrically valid 8-item scale that youth and caregivers complete to measure intrinsic treatment motivation with the subscales of problem recognition and treatment readiness .The System Usability Scale (SUS)  is a 10-This 35-item measure of child emotional and behavioral problems  is widelThis 51-item measure will be used to rate the extent to which parents have been bothered in the past week by their own mental health symptoms .This 17-item measure assesses past 12-month quantity and frequency of alcohol and drug use and the perceived level of functioning and impairment associated with substance use (youth only) .This scale will assess the positive and negative aspects of general communication via 2 subscales (open family communication and problems in family communication) . Five itThis 24-item measure is designed to assess parental monitoring across 4 areas or subscales  . Higher This assessment consists of a semistructured interview that obtains information about service use for mental health problems across multiple sectors  . InformaThis instrument is used to screen for exposure to traumatic events and assess the frequency of occurrence of PTSD symptoms in the past month . We willWe will collect data on race, ethnicity, sex, education, income, legal history, and placement type.Data regarding the number and types of contacts between the FCFNs and youth and caregivers will be collected from the Fostering Connections web application .This 50-item scale was developed and validated with mental health service providers and assesses global attitudes toward the adoption of evidence-based practices .As part of intervention delivery, the FCFNs will rate the adherence to sessions  of youth and caregivers. The FCFNs will also complete their own feedback session forms after each of the six 60-minute sessions to document the occurrence of planned activities and content and the occurrence of additional activities , as well as any aberrant events.A subsample of 12 families or 24 participants (6 youths and 6 caregivers or 12 participants from each condition) will be invited to participate in an exit interview at the end of the 6-month intervention period to inform feasibility, acceptability, and satisfaction with the FCFN and standard of care  conditions. Each participant will be offered a US $40 gift card .Up to 5 FCFNs will be invited to participate in an exit interview at the end of the pilot RCT study phase to provide more detailed feedback on their experiences of delivering the FCFN intervention and to inform future trials. Each participant will be offered a US $40 gift card .Analyses will be conducted using SAS 9.4 (SAS Institute Inc) . PrelimiGLMM analyses of dichotomous outcomes  will include intervention (FCFN group vs control group) as a fixed between-participants effect. Cox regression analysis (PROC PHREG) will be used to compare the interventions on time-to-event outcomes  using a shared frailty model that accounts for clustering within pods. The potential mediators and mechanisms of change, measured longitudinally  only for FCFN intervention participants, will be initially examined for intervention impact using GLMMs that include a repeated within-participants time effect. The majority of the mediators are scaled variables, anticipated to have normal distributions, but final models and link functions will be chosen based on observed distributions. It will not be possible to test mediation without data from the control group. Therefore, we will identify potential mediators to be studied in the future trial by first determining which potential mediators change between baseline and month 1 or month 3 and then examining whether month 1 or month 3 values and changes between baseline and month 1 or month 3 are associated with cascade outcomes.We will examine potential moderators  of intervention impact by adding the potential moderators one at a time, given the modest sample size, to the models used to examine cascade outcomes and mediators. Analyses of cascade outcomes will include moderator × intervention interactions, and analyses of mediators will include moderator × time interactions.All individual interviews will be digitally recorded and transcribed verbatim. Interview facilitators will review the recording and write notes within 48 hours of each interview completion to construct an executive summary of the main discussion points and topics. Executive summaries have been used successfully in the work conducted by the principal investigator (MTS) to provide data quickly and provide evidence of whether discussion theme saturation is achieved. Key data from executive memos will be immediately entered into ATLAS.ti software , and the results will be presented to the investigator team. After the completion of the executive summaries and development of the FCFN intervention content, interview data will be analyzed according to inductive thematic analysis methods. An initial codebook will be developed based on the interview guides and corresponding transcripts. To improve reliability and to ensure adequate intercoder agreement, one of the authors (ED) and a clinical research coordinator will compare coding patterns and refine the codebook until consensus is reached and then generate memos to highlight connections between codes and subcodes. Quotations from participants will be compiled and concepts and relationships pertinent to core themes developed. We will seek out and compare unique themes relevant to the analytic subgroups  to capture important thematic group differences. Final codes and memos will be compared and combined into overarching themes and subthemes. Themes will be discussed, refined, and named for the final analysis. The principal investigator will provide guidance on coding and analysis at regular study meetings. ATLAS.ti software (version 7) will be used to facilitate the analyses.The study was funded by the National Institute of Mental Health on April 20, 2020. The trial is open and recruiting. We propose the enrollment of 80 dyads by March 2024 and final data collection by September 2024. After final data analysis and the writing of the results, the manuscripts will be submitted to appropriate journals for dissemination, with main findings published by March 2025.This study is a protocol for an RCT testing an empirically derived FCFN intervention with adjunctive digital health technology (the Fostering Connections web application) to support linkage to, and engagement in, mental health services among CWI youth. The FCFN intervention encompasses six 60-minute family-based intervention sessions designed to address barriers to, and build motivation for, engagement in outpatient community-based mental health services for CWI youth (aged 12-17 years). On the basis of prior literature on health navigator models delivered in community-based settings, we hypothesize that youth receiving the FCFN intervention will have higher rates of mental health treatment initiation and engagement than youth receiving FCMH clinic standard of care .The strengths of this study include the use of a randomized study design to maximize internal validity and scientific rigor as well as the use of empirically supported intervention models  that have been successfully implemented in community-based settings with diverse populations. The study also builds off prior community-engaged mixed methods work involving interagency collaboration, EMR data collection, and qualitative research  to develop and iteratively refine the FCFN intervention and study procedures to enhance scientific rigor and relevance. The study is also designed to maximize real-world implementation potential through the delivery of the FCFN intervention by existing staff at a community-based mental health clinic for CWI youth.Potential limitations and design considerations include a partnering clinic that does not serve a sufficiently large sample size of CWI youth to be the sole site for the next phase of the large-scale trial. However, our investigators have existing research partnerships with other nearby large northern California counties that would allow us to expand and conduct large-scale FCFN intervention testing with other mental health clinics serving CWI youth using the same design approach as the pilot trial. Furthermore, sample size limitations may limit the current potential to analyze outcomes by those receiving the FCFN intervention as part of in-home services versus out-of-home placement and other demographic variables . Placement type and stability are important to consider in terms of intervention impact; thus, we will descriptively explore how outcomes may differ according to these variables to inform the future larger trial.real-world intervention testing while also allowing for the measurement and observation of design feasibility and acceptability for a future large-scale hybrid 1 (efficacy or effectiveness) trial. Third and last, the incorporation of digital health tools will aid the navigation process  to ensure that CWI youth are receiving optimal care that navigators, outside providers, and other relevant CWI systems can measure. The inclusion of an established digital health platform (Chorus for the Fostering Connections web application) supports the navigation process by supporting bidirectional SMS text messaging, appointment reminders, and critical navigation document sharing to enhance communication across FCFNs and families. Taken together, such innovations will allow the study team to provide first-time empirically driven conclusions and recommendations related to the processes, strategies, and preliminary impact of a family mental health navigation model for CWI youth.This study intends to move the field forward in several ways. First, it will extend a recently developed services continuum of care framework for legally involved youth with substance use  and address the mental health service strengths, gaps, and needs of CWI youth, families, and systems. Second, the pilot trial design will provide an opportunity to engage community stakeholders and leverage existing staff resources for


Non-communicable diseases (NCD) pose a substantial global public health challenge, representing the leading cause of morbidity and mortality worldwide. This study investigates the progress and challenges in implementing NCD policies in Sudan. Document analysis following the ready your materials, extract data, analyse data and distil your findings (READ) approach, was utilized to review published literature and reports. Data from the NCD Progress Monitor showed that the percentage of NCD-related mortality had increased from 32% in 2015 to 54% in 2022. Sudan’s progress in implementing NCD policies has been slow and challenging; eight of the 19 NCD target indicators had never been fully achieved, and only five targets were fully achieved in the year 2022. However, these figures may be underestimated due to the lack of robust NCD information systems. Like many countries, Sudan faces challenges in implementing NCD policies, particularly those targeting healthy diets, medications and data management systems. This may be linked to the prolonged history of conflict, shortage of trained health personnel, limited resources and lack of robust NCD surveillance systems in the country. The ongoing devastating war and destruction of the healthcare system infrastructure in Sudan further intensified these challenges. Prioritizing NCD policies and programmes during the anticipated post-conflict health system reforms is crucial for enhancing NCD prevention and outcomes in Sudan. Non-communicable diseases (NCD) are the leading cause of death worldwide, accounting for approximately 71% of global deaths. Cardiovascular diseases account for 17.9 million deaths, followed by cancers, respiratory diseases and diabetes. NCD have become a major public health challenge for both low- and middle-income countries (LMICs) and high-income countries [LMICs are experiencing a double burden of disease, with a high prevalence of infectious diseases such as human immunodeficiency virus/acquired immune deficiency syndrome (HIV/AIDS), tuberculosis and malaria, as well as an increasing burden of NCD. This shift is due to changes in lifestyle, urbanization and the adoption of unhealthy diets and behaviours. In LMICs, NCD are responsible for 80% of premature deaths, and the economic burden of NCD is expected to exceed US$ 7 trillion by 2025 .In May 2015, the World Health Organization (WHO) released a technical note detailing its plan for reporting to the United Nations (UN) General Assembly in 2017 regarding the advancements made in fulfilling the national commitments outlined in the 2011 UN Political Declaration and the 2014 UN Outcome Document on NCD. [The NCD policies are focussed on behavioural and metabolic risk factors for NCD, including tobacco control, reducing harmful alcohol consumption, promoting physical activity and improving access to healthy diets as well as strengthening health systems to improve early detection and management of NCD , 7. EvalThe document analysis methodology was adopted to assess the implementation of NCD policies in Sudan. Document analysis is commonly used in health policy analysis studies , and forThe WHO Progress Monitor reports published in 2015 , 2017 1, 2020 1, and 202In addition, a thorough review of published literature and reports across the PubMed, Google Scholar and Google databases was conducted to identify and contextualize the challenges faced in implementing NCD policies and programmes in Sudan. Specific information related to the implementation of NCD policies, progress indicators and challenges were extracted, and a detailed analysis of the gathered information was conducted. The analysis involved categorizing the data, identifying patterns and trends, and critically evaluating the content to distil a coherent insight into the progress and challenges of NCD policy implementation in Sudan.Sudan’s progress in implementing NCD policies has been slow and challenging. Figure Drawing on the National Multi-Sectoral Action Plan for the Prevention and Control of NCD 2015–2020) in Sudan, the national target for premature mortality from NCD was to achieve a 25% reduction in overall mortality from cardiovascular diseases, cancer, diabetes or chronic respiratory diseases by 2020 (baseline 2014) . However015–2020 Policies concerning alcohol are strictly implemented in Sudan, aided by the Islamic community in the country, in contrast to many other countries where policies for alcohol reduction were the most likely to have been dropped . Sudan rAccording to the Progress Monitor reports, Sudan had not fully achieved the unhealthy diet reduction measures targets from 2015 to 2022. The targets for sodium intake, saturated fatty acids, marketing for children’s restrictions, and public awareness campaigns on physical activity had never been achieved (Fig. The current state of NCD policy implementation in Sudan is challenging. Despite the high burden of NCD in the country, several factors hindered the effective implementation of NCD policies:Sudan has limited financial and human resources for healthcare and disease prevention, which could make it difficult to implement comprehensive NCD policies and programmes . The oveSurveillance systems are essential for target setting, monitoring, planning, raising awareness, emphasizing political commitments and accurately estimating the burden of NCD and the effectiveness of interventions. However, surveillance and monitoring systems for NCD are weak in Sudan. A recent operational assessment of implementing the NCD kit in Sudan’s humanitarian environment revealed that no electronic Health Information System was in use, and no NCD-specific registers or tracing systems were employed. In addition, patient-held record-keeping practices and the unavailability of file retrieval technologies further hampered the evaluation of NCD data . PreviouEffective NCD policies rely on people’s understanding of the importance of healthy behaviours, regular screening and adherence to prescribed treatments and health recommendations. However, there are low levels of health awareness in Sudan. For example many individuals do not recognize the risk factors associated with NCD , which mThe political will to address NCD is lacking in some LMICs due to competing political priorities, a lack of awareness of the impact of NCD, and vested interests . The natThe prolonged history of conflict and the recent devastating war have posed formidable challenges to the NCD control programmes and policies in Sudan. The destruction of health infrastructure has resulted in limited access to healthcare services, including preventive, diagnostics and treatment services . MoreoveThis study encountered several limitations. Qualitative insights from stakeholders were not included due to the ongoing war, hindering a deeper understanding of the challenges faced. Additionally, access to the latest unpublished documents from the Federal Ministry of Health was restricted, limiting the study’s scope to only published documents and reports. Despite these limitations, the findings provide valuable insights into Sudan’s NCD policy landscape, emphasizing the urgent need for comprehensive reforms and international support.Sudan’s progress in implementing NCD policies has been slow and challenging, marked by a concerning rise in NCD-related mortality rates. Challenges such as limited financial resources, inadequate healthcare infrastructure and political instability have impeded progress on implanting NCD policies and programmes. Urgent actions are needed, including strengthening healthcare infrastructure, enhancing health literacy and instigating political commitment to prioritize NCD prevention and control. These efforts should be informed by comprehensive, updated national strategies that reflect global interventions and involve multi-sectoral collaboration.


Bipolar disorder (BD) is a disabling disorder with heterogeneous symptom profiles and trajectories. Like many other neuropsychiatric disorders, clinical decision making related to diagnoses and choice of treatment is based on clinical assessments alone, and risk prediction for treatment success or resistance at an individual level remains sparse. An enormous effort to add biological markers to this risk prediction is ongoing. The role of lipids in normal brain functioning is well established, and several hypotheses about the role of lipids in the pathogenesis of neuropsychiatric disorders, including BD, have been made. The frequent comorbidity between neuropsychiatric disorders and cardiovascular disease, the genetic overlap of risk genes for severe mental disorders and genes involved in lipid regulation, and the lipid-altering effects of antipsychotics and mood stabilizers indicate that lipids could hold promise as biomarkers for neuropsychiatric disorders, including BD. To date, reviews of lipid biomarkers in schizophrenia and major depression have noted caveats for future investigations, while reviews of lipid biomarker research in BD is missing. In the current scoping review, we present a comprehensive overview of trends in previous research on lipid biomarkers in BD. The current literature varies greatly in the phenotypes investigated and study designs, leading to divergent findings. Small sample size; potential confounders related to physical activity, nutritional status, and medication use; and cross-sectional designs were frequently reported limitations. Future research may benefit from pivoting toward utilization of newer laboratory techniques such as lipidomics, but consistent use of study methods across cohorts is also needed. Bipolar disorder (BD) is a severe mental disorder that often leads to lifelong impairment in function and cognition, as well as increased mortality and high rates of comorbidity , 2, 3, 4Lipids and lipid metabolism may play key roles in the pathophysiology of neuropsychiatric disorders, including BD. This is due to the great abundance of lipid species in the human brain, the close relationship between lipid metabolism and cardiovascular disease, and the lipid-altering effects of medication used to treat such disorders , 16, 17.Given the critical roles that lipids play in neurodevelopment and the normal functioning brain, molecular markers may significantly aid in the prediction and detection of neuropsychiatric disorders and their prognoses , 35, 36.Previous reviews have focused on lipid markers in other severe mental illnesses such as schizophrenia , 47, 48 The current scoping review was conducted in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA)–extension for Scoping Reviews checklist and guidelines for scoping reviews . The metA comprehensive literature search was conducted by an experienced academic librarian in the electronic bibliographic databases MEDLINE (Ovid), Embase (Ovid), APA PsycInfo (Ovid), and Scopus on September 9, 2022. The search consisted of a combination of terms relevant to the role of lipids in BD. Documentation and extensive details of searches are reported in All individuals diagnosed with BD according to any ICD or DSM classification system editions.Measurement of lipid levels in body fluids of patients as potential biomarkers.Any kind of lipid species measured in any phase of any BD type.•Non-English language papers.•Papers published before 1990.•Letters, editorials, comments, conference abstracts, case reports, and unpublished literature.•Animal and in vitro studies.•Studies in postmortem tissue and tissues that are not body fluids  because these are not applicable in clinical settings.•Studies that only measured molecules related to lipids, but are not lipids themselves, including molecules related to lipid peroxidation.•Studies that measured dysregulated lipid levels specifically as a result of medication.•Epidemiological studies that did not investigate associations between lipids and clinical correlates in BD.•Reports that assessed metabolic syndrome in BD without distinguishing between individual metabolic syndrome lipid parameters.•Reports that investigated associations between lipids and BD for reasons other than assessing lipids as potential biomarkers for BD, such as explaining the prevalence of metabolic syndrome in BD.The selection of reports was conducted in accordance with the PRISMA 2020 statement . With thThe main reviewer (JKH) performed the data extraction with items decided a priori, using a standard extraction form. Quality assurance was performed by MH. The data were charted using Microsoft Excel (Microsoft Corporation). Data items that were extracted included information about the publication , as well as study design, study aims, lipids and phenotypes investigated, relevant findings, and reported limitations. All data items are listed and described in Some simplifications were made during data charting. The study designs were charted by the study author’s reported study design, without performing further evaluation. We also did not chart data on findings that were not related to the lipids investigated or the relevant phenotypes. Regarding the findings in case-control studies between BD and other psychiatric disorders, negative results and results that were determined to be irrelevant were not charted. Similarly, under “Authors’ interpretation of outcomes,” we did not chart data on interpretations that were not directly relevant to the charted findings.Number of reports, number of cases included in studies over time, distribution of laboratory methods used, lipid parameters, and phenotypes investigated were selected for bar plots using the R package ggplot2 . The numThe process for the selection of sources of evidence is summarized in Both the number of reports published and sample sizes in these studies have increased steadily since 1990, with a particularly high rate during the last years . There wLipid parameters investigated as potential biomarkers of BD since 1990 are shown in Only 2 studies did not investigate blood  as the biological sample . One of A variety of different phenotypes of BD have been investigated in relation to lipid biomarkers . The mosSmall sample size, potential confounding effects, e.g., diet, physical activity, and medication use, and cross-sectional study design were frequently reported as study limitations. The limitations are fully summarized in The results of lipid biomarker research were heterogeneous overall and to some extent contradictory. The majority of studies investigated standard lipids  and lipidomics. Several studies investigated more than one phenotype, and for reasons of clinical relevance, we present the findings based on separate phenotypes. A full summary and detailed description of study results for standard lipids are presented in et al.  are routine markers in clinical practice and therefore are easily available. Demonstrating associations between BD and these lipid levels may therefore be of value when considering cost-effectiveness. There are several theories connecting these 4 lipids to the pathogenesis of BD, such as the cholesterol-serotonin hypothesis , 118 andHowever, the study of TC, TG, LDL, and HDL as biomarkers is challenging due to many possible confounders such as food intake, comorbid somatic disorders, and medication use. In fact, psychotropic drugs used to treat BD are known to affect lipid metabolism and may lead to altered lipid parameters ,123,124.et al. (Lipidomics and metabolomics are relatively new and promising approaches for discovering lipid biomarkers ,126. Theet al. . With thet al. , 134.Lipidomics is an effective way of investigating potential biomarkers because it requires miniscule amounts of biological sample and can detect and quantify thousands of molecules in a single analysis run ,136. ThiOnly 2 of the papers included in this review analyzed body fluids other than blood—one investigated urine lipid levels, and the other investigated cerebrospinal fluid levels. Although readily available for sampling, urine contains very small amounts of lipids in the absence of kidney disease, which may explain the lack of studies investigating urine lipids as biomarkers for BD . In the The high rate of comorbidity and heterogeneous symptom profiles has led to investigations of the development of new and improved diagnostic criteria and classification of symptoms based on pathophysiological state markers with better prognostic properties ,145. TheCritical appraisal of methods and full synthesis of results are beyond the scope of this review design, with the associated possibility that we included studies of poor method quality. Furthermore, the descriptive presentation of results of the large number of reports included could leave key points biased. Moreover, genetic studies that address causal inference with methods such as Mendelian randomization were not included. To address the research question of to what extent lipid biomarkers are currently found in BD, a systematic review could be beneficial. However, the divergent study methods and research gaps found in this review suggest that future efforts should focus on alignment of study methods and minimizing frequent limitations. An important strength is the comprehensive literature search in 4 separate bibliographic databases and inclusion of a large body of literature.The current scoping review of the literature on lipid biomarkers in BD shows a large increase in the amount of research that has been conducted during the last 3 decades, with developments in technology and growing knowledge in medical biochemistry. Moreover, the understanding of the role of lipids in pathophysiological mechanisms has even broader implications if the use of lipids as medication is thought to have potential psychopharmacological properties. Taken together, the results of the research on lipid biomarkers in BD vary greatly in terms of phenotypes investigated and study designs, leading to divergent findings. The reported limitations such as modest sample sizes; potential confounders like physical activity, nutritional status, and socioeconomic status; subjects taking medication; and nonlongitudinal study designs should be addressed in future research. The development of lipids as reliable prognostic and diagnostic biomarkers relies on consistent study methods across cohorts, with robust sample sizes, and the utilization of newer laboratory techniques such as lipidomics.


Despite extensive debates about the mental health impacts of the use of social networking sites (SNSs), including WeChat, the association and mechanisms between social interaction of WeChat use intensity and antenatal depression are unclear.We aimed to test the mediating roles of upward social comparison on social interaction of WeChat and rumination in the association between social interaction of WeChat use intensity and antenatal depression.A cross-sectional survey was conducted in four hospitals with the self-reported measures of social interaction of WeChat use intensity, upward social comparison on social interaction of WeChat, rumination, antenatal depression, and control variables. The mediation analysis was performed through Model 6 from the PROCESS macro 4.0 in SPSS 26.P=.54), but was significantly positively related to the attitude toward social interaction of WeChat (P=.01). The direct effect of attitude toward social interaction of WeChat use on antenatal depression was not statistically significant . The results supported an indirect relationship between attitude toward social interaction of WeChat use and antenatal depression via (1) upward social comparison on social interaction of WeChat ; (2) rumination ; and (3) upward social comparison on social interaction of WeChat and rumination in sequence .Results from 2661 participants showed that antenatal depression was unrelated to social interaction of WeChat use intensity (Our findings highlight the necessity of focusing on attitudes toward SNS use, and the importance of upward social comparison and rumination in understanding the effect of SNS use on antenatal depression. Antenatal depression is typically defined as a nonpsychotic depressive episode of mild to major severity that occurs during pregnancy . A meta-Considering the high prevalence and adverse effects of antenatal depression, it is necessary to explore the comprehensive influencing factors underlying the condition, which is conducive to early detection and further treatment of groups at higher risk of antenatal depression. A recent meta-analysis revealed that the main factors associated with antenatal depression include pregnant women’s demographic characteristics, psychosocial factors, health-related factors, lifestyle, and nutrition ; howeverSince the concept of “Facebook depression” was first proposed, which is a term to simply describe the positive association between time spent on SNSs and depression , the effToward this end, our research focused on investigating the relationship between the intensity of SNS use and antenatal depression, with the aim to further explore the underlying mechanisms from a new perspective by examining the mediating roles of upward social comparison and rumination.Upward social comparison refers to the process of comparing oneself to others who are considered to be superior . Upward A recent meta-analysis demonstrated that upward social comparison on SNSs is associated with higher risks of depression, which even exceeds the association for SNS use itself . This fiHowever, given that the key factor explaining the causal link between upward social comparison and depression is unclear, at this point, we can only recommend users to abstain from upward social comparisons while on SNSs. Such a recommendation seems futile, because experiencing upward social comparison on SNSs is an inherent part of the human condition. Thus, it is necessary to explore the mechanisms underlying the relationships between upward social comparison on SNSs and depression, including rumination.Rumination is defined as repetitive thinking about the causes and implications of negative events and/or the symptoms of negative moods . ConceptNotably, a wealth of evidence demonstrates that rumination is a risk and maintenance factor of depression. The Response Styles Theory provides explanations for the mechanisms between rumination and depression ,28. FirsIn addition, research demonstrates differences among the effects of different types of SNSs on individuals; therefore, it is recommended that researchers should clearly specify which SNS is being investigated ,29,30. GWe hypothesized that: (1) upward social comparison on social interactions of WeChat is an independent mediator, (2) and upward social comparison on social interaction of WeChat and rumination are the chain mediators linking social interaction of WeChat use intensity and antenatal depression see .Cross-sectional data were collected from October 2021 to January 2022 using Wenjuanxing (an online data collection platform) through a convenience sampling method. To control the effect of missing data, the questionnaire was designed to ensure that valid respondents need to complete all items before submitting using the features of Wenjuanxing. Therefore, there was no need to apply methods for handling missing data in our study.We recruited pregnant women from four hospitals in Jiangsu Province, China. Inclusion criteria were (1) having basic understanding and communication skills and (2) voluntary participation. Exclusion criteria were (1) suffering from or with a history of mental illness, (2) receiving psychotherapy or a psychological intervention, and (3) not users of WeChat.Participants completed the measures, including assessments of social interaction of WeChat use intensity as the independent variable, upward social comparison on social interaction of WeChat and rumination as the two chain mediating variables, antenatal depression as the dependent variable, and control variables. We assessed the social interaction of WeChat use intensity (independent variable) with the Facebook intensity scale . We chanUpward social comparison on social interaction of WeChat (mediator 1) was measured with the six-item Chinese version of the upward comparison subscale of Iowa-Netherlands Comparison Orientation Measure  . We shifRumination (mediator 2) was measured by the Chinese version of the 22-item Ruminative Response Scale with a 4-point Likert scale  . Higher Antenatal depression (dependent variable) was measured by the Chinese version of the 10-item Edinburgh Postnatal Depression Scale (EPDS) with each item scored on a scale of 0-3 . This scTo reduce other possible influences on our model, we considered control variables, which were not the variables of primary interest for this study. To reduce the possible influence of individual differences, demographic information such as education level , job , advanced maternal age or not , and family income  were considered. To reduce the possible influence of the respondents’ characteristics related to antenatal depression, we also controlled for psychosocial and obstetric variables such as quality of relationship with husband and mother-in-law , whether it is an unplanned pregnancy , living conditions , the main caregivers during pregnancy , gestational age , gestation , parturition , BMI , and experiences of abnormal pregnancies and labor .Ethics approval was granted by the Ethics Committee of Nanjing Maternity and Child Health Care Hospital . All procedures conducted in our study were in adherence with the ethical guidelines of the institutional and/or national research committee and the ethical standards of the Helsinki Declaration. Informed consent was obtained from all participants included in the study.As with all self-reported data, it is important to control and examine the potential common method variance. First, we took actions to minimize potential common method biases . To reduData analysis was carried out in IBM SPSS Statistics (version 26). Model 6 in the PROCESS macro for SPSS was used to examine the mediating roles of upward social comparison on social interaction of WeChat and rumination.We processed the data on the social interaction of WeChat use intensity as follows. First, we evaluated three independent aspects: time spent on social interactions of WeChat, number of WeChat friends, and attitude toward social interaction of WeChat use. Due to different item scale ranges, the eight items were standardized before creating the total scores of social interaction of WeChat use intensity. Therefore, a total of four aspects of WeChat use were considered.Descriptive statistics were calculated to summarize the characteristics of each variable, including mean, standard deviation, skewness, and kurtosis. Normality was considered adequate if absolute values for skewness and kurtosis were below 3.0 and 10.0, respectively ,42.We used Cronbach α to represent the internal consistency reliability. A Cronbach α over .70 is considered an indicator of satisfactory item homogeneity.t-test (2-tailed) or ANOVA to find the control variables that are significantly correlated with antenatal depression, which needed to be controlled as covariates in the following mediation analysis. The standardized coefficients and 95% CIs for direct, indirect, and total effects were calculated through the bias-corrected bootstrap approach (5000 resamples). If the 95% CI did not contain 0, this indicated statistical significance. Two-tailed P values <.05 were considered to be significant.First, we calculated Pearson correlation coefficients between social interactions of WeChat use, number of WeChat friends, attitude toward social interaction of WeChat use, social interaction of WeChat use intensity, upward social comparison on social interaction of WeChat, rumination, and antenatal depression. We then performed an independent The STROBE  checklist for cross-sectional studies was applied in our study see .There was no single factor emerging from the factor analysis and the variation explained by the first factor was 21.1% (<50%), demonstrating that there was no serious risk of common method bias in our study .Of the 2661 valid questionnaires included in the analysis, 689 women had an EPDS score above 9.5, indicating that 25.9% of our sample may have antenatal depression. Among all of the considered control variables, gestational age, education level, gravidity, parity, family income, quality of relationship with husband and mother-in-law, whether it is an unplanned pregnancy, living conditions, and job were significantly correlated with antenatal depression, and were therefore set as covariates.Attitude toward social interaction of WeChat use, upward social comparison on social interaction of WeChat, rumination, and antenatal depression were significantly correlated with each other, which met the statistical requirements for mediation analysis.t test, and P values for the linear regressions. P values for the linear regressions. The results showed that the direct effect of attitude toward social interaction of WeChat use on antenatal depression was not statistically significant , whereas attitude toward social interaction of WeChat use significantly predicted upward social comparison on social interaction of WeChat  and rumination . Upward social comparison on social interaction of WeChat significantly predicted rumination  and antenatal depression . In addition, rumination significantly predicted antenatal depression . These results indicated that the mediating effects of upward social comparison on social interaction of WeChat and rumination, and the chain mediating effect of upward social comparison on social interaction of WeChat to rumination were statistically significant among the influences of attitude toward social interaction of WeChat use on antenatal depression.This study established mediation models to analyze the relationship between social interaction of WeChat use intensity and antenatal depression. The results suggested that there are different relationships between the four aspects of WeChat use and antenatal depression. Attitude toward social interaction of WeChat use influenced antenatal depression through three paths: the mediating role of upward social comparison on social interaction of WeChat and rumination, and the chain mediating roles of upward social comparison on social interaction of WeChat and rumination. These findings reveal the complexities characterizing the relationships between WeChat use and antenatal depression.r=0.11-0.13) [First, there was no relationship between antenatal depression and hours spent on WeChat use found in our study. Although recent meta-analyses consistently claim that there exist small, positive associations between hours spent on SNS and depression (11-0.13) , these eSecond, from a simple quantity-centric view, we found that having more WeChat friends was negatively associated with antenatal depression. This is likely because more SNS friends provides individuals with richer social capital benefits , strongeFinally, we found that antenatal depression was not related to the social interaction of WeChat use intensity, but was positively related to attitude toward social interaction of WeChat use. This seems to be a novel finding of our study, because previous studies on the association between intensity of SNS use and depression did not separately probe into the effect of attitude toward SNS. We can explain this finding from two perspectives. On the one hand, it may be that individuals with antenatal depression tend to score high on attitudinal questions ,53. For The above distinct relations remind us that different aspects of SNS use should not be referred as “SNS use” generally. Only a fine-grained assessment can provide reliable information as to how individuals are influenced by SNSs.Previous research has shown that SNS use itself does not necessarily cause negative effects see . SimilarIn our study, attitude toward social interaction of WeChat use influenced antenatal depression through three paths: upward social comparison on social interaction of WeChat, rumination, and upward social comparison on social interaction of WeChat to rumination. First, attitude toward social interaction of WeChat use could increase risks of antenatal depression through increasing upward social comparison on social interaction of WeChat. This finding should come as no surprise as current evidence suggests that upward social comparison acts as a mediator between (subtypes of) SNS use and depression . Our stuFurthermore, after exposure to upward social comparison on social interaction of WeChat, rumination occurred, which could also increase risks of antenatal depression. This finding provides new insight to explain why upward social comparison on SNSs increases the risk of depression. Future research is needed to determine the characteristics of individuals that are most susceptible to rumination after upward social comparison on SNSs, which can help to implement preventive interventions targeted at this subgroup.An intriguing finding was that attitude toward social interaction of WeChat use could decrease the risk of antenatal depression by decreasing rumination. Previous studies found that compared to general SNS use (such as time spent on SNS), high dependence on SNSs has the special potential to build and maintain multiform social capital . Social Compared to upward social comparison on social interaction of WeChat, rumination has stronger ability to increase levels of antenatal depression. This is probably because compared to upward social comparison on social interaction of WeChat, rumination is a more constant risk factor of depression. It is clear that rumination is the trigger and maintaining factor of depression . HoweverThe cross-sectional nature of this study is a major limitation. Future studies should adopt longitudinal designs to explore potential causality. In addition, all of the questionnaires used in this study are based on self-reports. These results need to be verified and enriched by qualitative and/or experimental research to better understand how individuals are influenced by SNSs. Furthermore, this study only focused on the chain mediating roles of upward social comparison on social interaction of WeChat and rumination, omitting other meaningful variables, which need to be investigated through more studies. Finally, our study only demonstrates that upward social comparison on social interaction of WeChat and rumination can increase antenatal depression, whereas demonstrating the magnitude of these effects requires further research.In sum, our main goal is to explore the mediating role of upward social comparison on social interaction of WeChat and rumination between social interaction of WeChat use intensity and antenatal depression. The results of this study indicate that attitude toward social interaction of WeChat use  is associated with higher antenatal depression, which highlights that attitude toward SNS use should be valued and widely explored. Furthermore, the effect of attitude toward SNS use on antenatal depression depends on three pathways: the mediating roles of upward social comparison on social interaction of WeChat and rumination, and the chain mediating effect of upward social comparison on social interaction of WeChat and rumination. According to our results, intervention strategies focusing on lower upward social comparison and rumination may be helpful to reduce the risk of SNS use for depression. Moreover, it is assumed that SNS friends from an individual’s actual life  are beneficial to decreasing depression. Although these findings need to be validated by longitudinal or experimental studies, they are helpful for researchers, health care professionals, and the public to better understand the inherent relationship between SNS use and antenatal depression.