Literature documents positive effects of religion and spirituality on health including improved cognitive function, quality of life, and well-being. Extant research suggests that persons living with dementia (PWD) are more likely to have spiritual needs and rely on others to support their spiritual well-being than those without dementia. However, spiritual care is absent or minimally present in dementia care. To effectively address spiritual needs of PWDs, accurate screening and assessment is critical. We conducted an integrative review of the current literature on measures of religion and spiritualty for PWDs by searching five databases  and identified 14 studies that were peer-reviewed original research articles focusing on assessment of religion/spirituality among PWDs and published between 2000-2020 in English. Most were conducted in Europe (n=7), included PWD in mild stage (n=68) from various settings, and were cross-sectional in design (n=8). Of a total of 17 measures identified, 6 were originally developed for the general population and then adapted for PWD, and only 3 were validated for PWD. A majority of the studies were limited in sample size, generalizability, methodological rigor, and measure validation. More research is needed using diverse samples and rigorous study designs to develop valid screening and assessment tools for this population. Improving religious and spiritual measures could greatly impact public health by improving quality of life for millions of individuals suffering from dementia and their caregivers who carry a heavy burden.


Hearing, vision, and dual (combined hearing and vision) sensory impairments  are common in older adults and associated with adverse health outcomes. However, it is not clear how sensory impairments impact healthcare utilization in older adults. This study aims to examine hospital, emergency department (ED), and home health care use amongst adults 65 and older diagnosed with HI, VI, and DSI in an urban academic health system. This secondary analysis  used a limited data subset of older adult primary care patients’ EHR data from a parent study examining medical complexity, healthcare use, and social vulnerability. Using logistic regression and controlling for participant demographics and comorbidities, results show HI, VI, and DSI increase the likelihood of having an ED visit  and a home health episode  compared to those without sensory impairment (SI). No significant difference was found in hospital use and home health use for DSI. This is the first known study to examine ED use for older adults with VI and DSI, and home health use for older adults with SI in the US. Findings suggest older adults with SI have greater utilization and dependence on healthcare services. Older adults with SI may benefit from outpatient assessments and interventions to mitigate risks of ED use. Findings also support research into the drivers of healthcare use amongst this population, financial implications, and intervention development to prevent avoidable healthcare use.


BAP1, CDKN2A/B, and the TERT promoter, which are associated with particularly aggressive tumor biology. Despite the evident clinical value, advanced molecular profiling methods are not widely incorporated in routine clinical practice for meningiomas.Meningiomas are the most common primary central nervous system (CNS) tumor. They are most often benign, but a subset of these can behave aggressively. Current World Health Organization (WHO) guidelines classify meningiomas into three grades based on the histologic findings and presence or absence of brain invasion. These grades are intended to guide treatment, but meningiomas can behave inconsistently with regard to their assigned histopathological grade, influencing patient expectations and management. Advanced molecular profiling of meningiomas has led to the proposal of alternative molecular grading schemes that have shown superior predictive power. These include methylation patterns, copy number alterations, and mutually exclusive driver mutations affecting oncogenes, including To assess the degree of concordance between the molecular profile of meningiomas and the histopathologic WHO classification, the current method of predicting meningioma behavior.In a two-year single-institution experience, we used commercially available resources to determine molecular profiles of all resected meningiomas. Copy number aberrations and oncogenic driver mutations were identified and compared with the histopathologic grade.TERT, CDKN2A/B, or BAP1 of which 6% occurred in grade 1 meningiomas.One hundred fifty-one total meningioma cases were included for analysis . Chromosomal analysis of 124 of these samples showed that 29% of WHO grade 1 tumor featured copy number profiles consistent with higher grade meningioma, and 25% of WHO grade 2 meningiomas had copy number profiles consistent with less aggressive tumors. Furthermore, 8% harbored mutations in Routine advanced molecular profiling of all resected meningiomas using commercially available resources allowed for identification of a significant number of meningiomas whose molecular profiles were inconsistent with WHO grade. Our work shows the clinical value of integrating routine molecular profiling with histopathologic grading to guide clinical decision making. Meningiomas, named for their cell of origin, are the most common intracranial central nervous system (CNS) tumors in adults representing approximately one-third of all primary adult CNS tumors –3. The WIn current practice, WHO grade and extent of resection are the most widely used metrics to predict tumor behavior and guide management of meningiomas , 7. MostA developing understanding of the molecular landscape of meningioma suggests that WHO grade alone may not provide an adequate prediction of tumor behavior, for surveillance or adjuvant treatment planning considerations. Several recent publications have proposed alternative grading systems that incorporate genomic and/or epigenomic data in order to better predict meningioma behavior, particularly targeting those that do not behave in concordance with their assigned WHO grade –14. ThesBAP1, CDKN2A/B, and mutations within the promotor region of the TERT genes (via vendor) enhancing their appeal  of the University of Oklahoma Health Sciences Center (OUHSC) (IRB protocol number 10195). All patients who underwent their index surgery with a histopathologic diagnosis of meningioma following CNS tumor resection from May 2019-April 2021 were included in the study. Patient data including demographics, tumor location, and history of prior resection were collected by retrospective chart review.th edition of the WHO Classification of Tumours of the CNS published in 2016 , posterior convexity , falcine/parasagittal, tentorial, tentorial sinus, peritorcular, intraventricular, or multifocal. Meningiomas were further classified based on their sublocation  . Summary statistics are reported as counts or proportions for categorical variables. For continuous variables  mean and standard deviation are shown in figures. Statistical analysis of copy number alterations and Ki-67 between meningiomas with high-grade and low-grade copy number variations were done by one-way analysis of variance (ANOVA) with Tukey’s NF2 gene, the most common genetic disturbance associated with meningiomas, were evenly distributed across grades and comprised approximately 40% of the total meningioma cohort. The common histopathologic subtypes were all represented in our cohort with meningothelial and transitional comprising the majority of grade 1 tumors  occurring in WHO grade 1 meningiomas  with an altered TRAF7 or AKT1 E17K with an altered TRAF7 . This is consistent with a recent report that applied advanced genomics to create a molecular grade with improved prediction of meningioma behaviour, with up to 32% of cases reclassified when molecular data were applied . There aIn recent years, the clinical impact of molecular data in the treatment and management of meningiomas has become evident. Numerous classifications that incorporate molecular data have been shown to improve the prediction of tumour behaviour for meningiomas. With the rapid advances in molecular understanding of meningiomas over the recent years, it will be important to determine how this information can be integrated in routine clinical settings and standardized nationally, in particular for institutions with limited resources, and to correlate this information with clinical outcomes.The original contributions presented in the study are included in the article/The studies involving human participants were reviewed and approved by Institutional Review Board University of Oklahoma Health Sciences Center. Written informed consent for participation was not required for this study in accordance with the national legislation and the institutional requirements.Study design and data analysis: AR, PP, and ID. Histopathologic grading, processing, and shipment of meningioma samples for advanced molecular profiling: JP and K-MF. Drafting of manuscript: AR and PP. Proofreading, finalizing, and approval of manuscript: all authors.The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.All claims expressed in this article are solely those of the authors and do not necessarily represent those of their affiliated organizations, or those of the publisher, the editors and the reviewers. Any product that may be evaluated in this article, or claim that may be made by its manufacturer, is not guaranteed or endorsed by the publisher.


This article explores the need for conceptual advances and practical guidance in the application of the GRADE approach within public health contexts.We convened an expert workshop and conducted a scoping review to identify challenges experienced by GRADE users in public health contexts. We developed this concept article through thematic analysis and an iterative process of consultation and discussion conducted with members electronically and at three GRADE Working Group meetings.Five priority issues can pose challenges for public health guideline developers and systematic reviewers when applying GRADE: (1) incorporating the perspectives of diverse stakeholders; (2) selecting and prioritizing health and “nonhealth” outcomes; (3) interpreting outcomes and identifying a threshold for decision-making; (4) assessing certainty of evidence from diverse sources, including nonrandomized studies; and (5) addressing implications for decision makers, including concerns about conditional recommendations. We illustrate these challenges with examples from public health guidelines and systematic reviews, identifying gaps where conceptual advances may facilitate the consistent application or further development of the methodology and provide solutions.The GRADE Public Health Group will respond to these challenges with solutions that are coherent with existing guidance and can be consistently implemented across public health decision-making contexts. Several GRADE outputs and project groups have specifically addressed public health topics and used examples from public health guidelines . At the Case study 1Case study 2Case study 3Case study 4This article reports the results of activities undertaken to identify some of the challenges relating to GRADE and public health guidelines, specifically through an initial stakeholder workshop and a scoping review. We propose priority areas for further consideration and explain the rationale for these choices. We present four case studies of public health guidelines and systematic reviews  to illus1.2Public health is concerned with “preventing disease, prolonging life, and promoting health through the organized efforts of society.” . Public In this context, the GRADE approach has strengths which are well recognized. GRADE's structured and transparent methods for integrating evidence into decisions have been tested and implemented by guideline developers worldwide. Previous research has reported the adoption and further development of GRADE methods in public health contexts . PreviouTo explore experiences of GRADE users and lay the foundations for a GRADE public health project group, guideline developers and systematic reviewers were invited to participate in a workshop on GRADE for public health at the Global Evidence Summit in Cape Town, South Africa, in September 2017. Twenty participants contributed to a facilitated discussion of challenges encountered when applying GRADE to public health topics. Participants reported issues with agreeing on critical outcomes, assessing certainty when the body of evidence includes findings from disciplines other than health, making appropriate use of nonrandomized studies, and addressing stakeholder concerns about weak or conditional recommendations. In addition, participants raised the issue of the broad range of stakeholders involved in public health decision-making and how to address the differences and competing interests that may arise when guidelines apply to sectors other than health. Further challenges in applying GRADE included the need to integrate the perspectives of different disciplines and professions in areas such as planning, housing, transport, and social security; the need to address competing policy priorities and resource considerations across governmental agencies and geographical boundaries; and the involvement of both public sector and commercial interests.The formation of the GRADE Public Health project group was subsequently approved by the GRADE Guidance Group in October 2017 with the overarching goal to advance GRADE methodology in the development of public health guidelines. The work of the GRADE Public Health Group builds on previously developed and in-development GRADE guidance and related research on topics including equity, complex interventions, modeling studies, nonrandomized studies (NRS), and environmental and occupational health . Here, w2We conducted a scoping review with the aim of investigating (i) experiences of applying GRADE within public health systematic reviews and guideline development and (ii) existing research activity in this area. We included peer-reviewed published research on experiences, barriers, and facilitators encountered in public health contexts in the adoption of GRADE. We did not include methodological or technical documents that reported only the methods and not the experiences or reflections of reviewers or developers. We searched Medline and Embase ; used the snowballing technique to identify additional relevant studies; searched the reference lists of included articles; and contacted experts in the field. We performed a narrative synthesis using thematic analysis to identify key issues and challenges reported in the literature. We then developed the analysis through an iterative process of consultation and discussion conducted with GRADE Working Group members electronically and at three GRADE Working Group meetings.3We identified nine studies  that spe•Complexity of public health interventions.•Choice of outcomes and outcome measures.•Ability to discriminate between different types of observational studies.•Use of nonepidemiological evidence.•GRADE terminology.•GRADE and guideline development process.Rehfuess and Akl gathered insights from 25 stakeholders in 12 organizations about their experiences and views of using GRADE in the field of public health . They grIssues relating to GRADE terminology included definitions of “quality of evidence,” the use of the term “observational study,” and different understandings of terms such as “low-quality evidence” and “weak recommendations.” Participants reported challenges relating to the methodological difficulties of systematically reviewing nonrandomized studies, applying GRADE criteria to narrative synthesis in the absence of a pooled effect estimate, difficulties with the evidence-to-recommendations process, and concerns about the resources required to implement GRADE methodology .•Heterogenous and complex interventions.•Paucity of trial data.•Selecting outcomes of interest.•Using indirect evidence.•Integrating values and preferences.•Considering resource use.•Addressing social and legal barriers.•Wording of recommendations.•Developing global guidelines.Five reports ,15,28,30Dedios et al. evaluated the methodological quality and implementability of guidelines produced by the WHO Department of Nutrition for Health and Development . They suTwo reports ,31 relatFinally, Burford et al. (2012) summarized the benefits and challenges when applying GRADE to Cochrane public health systematic reviews . These cThe studies identified in the scoping review range in publication date from 2011 to 2018. During this period, developments in GRADE methodology occurred that addressed many, if not most, of the challenges identified. For example, GRADE changed its terminology about the quality of evidence to be more flexible. Furthermore, GRADE had already altered the traditional evidence hierarchy by allowing a body of evidence from observational studies to be rated as high-quality evidence. In addition, articles have since addressed the use of GRADE in the absence of meta-analyses . Overall4To formulate an approach to addressing the issues identified through the scoping review, the GRADE Public Health Group organized the challenges into themes, mapped these to current GRADE Working Group activities, identified gaps, discussed and presented potential activities and outputs, and reached consensus on a program of work including publications, contributions to other project groups, and training. The project group also identified and discussed case studies through which the relevance and applicability of the five themes were explored and confirmed in a variety of public health contexts, including both systematic reviews and guidelines. The five key challenges are described narratively below. 4.1Many health guidelines are intended for multidisciplinary audiences, including different health professions, health care managers, health policymakers, patients, and carers. The Health in All Policies approach is arguably where this becomes most challenging, for example, when considering the health impacts of migration policy . In addi4.2Differences in perspectives and in cultures of evidence also translate into challenges in selecting relevant outcomes and agreeing which outcomes are critical to decision-making. For example, in transportation policy any recommendations about traffic management would ideally consider all relevant outcomes, including respiratory health, changes in physical activity levels, emergency admissions, and safety for vulnerable road users. However, transport policymakers might not view these outcomes as critical when weighed against traffic flow, commuting times, road traffic collisions, costs, provision of goods, or public opinion. Relatedly, challenges may arise when benefits are realized to a greater extent by communities than by individuals who receive treatment  . A furth4.3The interpretation of evidence for a given outcome needs to be informed by knowledge of what change in that outcome would make a meaningful difference in a given context. A change in a health outcome that might be deemed too small to be of importance to a patient may be perceived differently from a whole population perspective, where small effects in many individuals may be magnified to differences that are important for public health interventions and policy , as can 4.4In public health, where randomized studies are less common and often infeasible in comparison with other areas of health, some types of NRS may provide greater certainty than others when investigating the health effects of policy or social interventions. For example, natural experiment studies may address selection bias and confounding through designs such as ITS or regression discontinuity, which may support stronger causal inference than other observational designs such as cohort and case-control studies . Two rec4.5•Life-threatening situations.•Uncertain benefit but certain harm.•Potential equivalence of effectiveness in which one option is clearly more or less risky or costly.•Potential for catastrophic harm .As demonstrated in the scoping review, the predominance of “weak” recommendations in public health guidelines has been of concern to guideline developers and policymakers. GRADE has addressed this issue by changing the terminology . It is already recognized that public health produces several situations in which action may be strongly recommended despite low or very low certainty, including:Early strong recommendations in the context of very low certainty evidence emphasized that GRADE had recognized this problem . However[5The views sourced from a participatory workshop, a scoping review, and four case studies suggest that key public health-related challenges in application of GRADE methodology include the incorporation of stakeholder perspectives from outside the health sector; agreement on the interpretation and prioritization of diverse outcomes; definition and interpretation of thresholds for population health and nonhealth outcomes; assessing the certainty of evidence from diverse sources and NRS designs; and addressing implications for decision makers, including the presentation of strength of recommendations to ensure utility and acceptability for stakeholders.These challenges may be categorized into three different types, as per the different types of solutions that may be proposed. The first type of solution is to identify the training needs of public health guideline developers (and their stakeholders) in understanding and using the GRADE concept, i.e., as per existing guidance. As different disciplines or “cultures of evidence” come together in public health, it will take time to speak a common (GRADE) language. The second type of solution has to do with applying existing GRADE guidance, including current developments, to the public health context. As identified within the scoping review, most of the existing GRADE guidance, both on rating certainty of the evidence and moving from evidence to decision, is already applicable to the public health context but would benefit from translation and examples, so that its relevance to public health practice and policy can be more readily recognized and a population perspective can be consistently reflected in all steps. The third type of solution is to advance the GRADE methodology where existing guidance falls short, i.e., to develop new GRADE guidance where necessary and appropriate.•Further GRADE concept articles or guidance to address social determinants in public health systematic reviews and guidelines using GRADE, considerations when applying GRADE to population-level outcomes and criteria to assess certainty of interrupted time series.•The ongoing development and dissemination of detailed examples of the application of GRADE to public health topics in coordination with other GRADE project groups, including the NRS and EtD groups.•Adaptation of GRADE training materials for public health and public policy audiences.The GRADE Public Health Group has considered the challenges in the context of other GRADE outputs and project groups, as well as other ongoing research in guideline methodology ,70, withBy providing a single, carefully documented, rigorous, and transparent method of evaluating evidence, GRADE serves to increase the trustworthiness, implementation, and adaptability of systematic reviews and guidelines, while also helping to reduce research waste. It is therefore our aim to address and mitigate any barriers to using GRADE in public health and, through the work of the GRADE Public Health group, to build bridges and increase mutual understanding across the wide range of policy and research areas that intersect in the population health context.Michele Hilton Boon: Conceptualization, Methodology, Writing - original draft, Writing - review & editing. Hilary Thomson: Conceptualization, Writing - review & editing. Beth Shaw: Conceptualization, Investigation, Writing - review & editing. Elie A. Akl: Conceptualization, Methodology, Writing - review & editing. Stefan K. Lhachimi: Writing - original draft, Writing - review & editing. Jesús López-Alcalde: Writing - original draft, Writing - review & editing. Miloslav Klugar: Writing - original draft, Writing - review & editing. Leslie Choi: Writing - original draft, Writing - review & editing. Zuleika Saz-Parkinson: Writing - original draft, Writing - review & editing. Reem A. Mustafa: Methodology, Writing - review & editing. Miranda W. Langendam: Methodology, Writing - review & editing. Olivia Crane: Writing - review & editing. Rebecca L. Morgan: Writing - review & editing. Eva Rehfuess: Writing - review & editing. Bradley C. Johnston: Writing - review & editing. Lee Yee Chong: Writing - review & editing. Gordon H. Guyatt: Methodology, Writing - review & editing. Holger J. Schünemann: Conceptualization, Methodology, Writing - review & editing. Srinivasa Vittal Katikireddi: Conceptualization, Methodology, Investigation, Writing - review & editing.


Fisheries exploitation can cause genetic changes in heritable traits of targeted stocks. The direction of selective pressure forced by harvest acts typically in reverse to natural selection and selects for explicit life histories, usually for younger and smaller spawners with deprived spawning potential. While the consequences that such selection might have on the population dynamics of a single species are well emphasized, we are just beginning to perceive the variety and severity of its propagating effects within the entire marine food webs and ecosystems. Here, we highlight the potential pathways in which fisheries‐induced evolution, driven by size‐selective fishing, might resonate through globally connected systems. We look at: (i) how a size truncation may induce shifts in ecological niches of harvested species, (ii) how a changed maturation schedule might affect the spawning potential and biomass flow, (iii) how changes in life histories can initiate trophic cascades, (iv) how the role of apex predators may be shifting and (v) whether fisheries‐induced evolution could codrive species to depletion and biodiversity loss. Globally increasing effective fishing effort and the uncertain reversibility of eco‐evolutionary change induced by fisheries necessitate further research, discussion and precautionary action considering the impacts of fisheries‐induced evolution within marine food webs. Excavations from Vanguard and Gorham's coastal caves by Gibraltar convey the appetite of our closest relatives, Neanderthals, whose diet included marine mammals, seafood and fish , which became exceptionally abundant , increased, which has resulted in a collapse of scallop fishery  and self‐regulating processes  also tends to correlate with body size (Nordström et al., Intertwined changes in declining body size, shifting diet, survival probability, spatial distribution and behavioural changes induced by overfishing can considerably modify the ecological role of species, alter the trophic structure of communities and reduce the value of fisheries catches (Essington et al., 7Fisheries have become an integral part of marine food webs and have, along with climate‐induced changes, showed a considerable potential to modify the structure and function of ecosystems by gradually altering eco‐evolutionary processes (Audzijonyte, Kuparinen, & Fulton, Interestingly, although our trophic level within marine food webs is high, it does not exceed that of natural apex predators (Roopnarine, The time calls for embracing the responsibility in our functional role. Evolutionary changes in the life history of harvested populations and direct fishing impacts increase the probability of regime shifts within the ecosystems, and these might be hard to reverse (Conversi et al., We have no conflicts of interest to disclose.


Older adults with motoric cognitive risk (MCR) syndrome are at high risk of developing dementia. Although the definition of MCR is well recognized and consensus, previous studies did not reach an agreement on diagnostic criteria and measurement methods/tools for slow gait speed, which is one of four components of MCR diagnosis. The substantial heterogeneity in the methodology of slow gait speed diagnosis for MCR limits comparability and meta-analysis of studies.The study aims to conduct systematic and standardized integration for diagnostic criteria and methods of slow gait speed diagnosis for MCR based on previous evidence that may improve comparability between future studies.A systematic literature review will be undertaken by searching the following electronic databases : PUBMED, EMBASE, The Cochrane Library, Web of Science. Additional studies will be identified by checking the reference lists of included studies or relevant reviews, manually searching the internet search engine Google Scholar, and searching the authors' personal files, if necessary. Two researchers will perform data extraction independently, and discrepancies will be resolved by discussion, which will include a third researcher if requires. The paper selection will perform in duplicate. Finally, a narrative account will synthesize the findings to answer the objectives of this review.This is the first study on systematic and standardized integration for diagnostic criteria and measurement methods/tools for slow gait speed in diagnosing MCR. The findings of this study will be convenient for medical staff to examine the intended use and applicability of each instrument/tool for evaluating the gait speed, and provide insight into developing uniform guidelines for MCR.PROSPERO registration number: CRD42021232671. Over 50 million people were estimated to be living with dementia globally in 2019, and this number is expected to increase to 152 million by 2050  and motoric cognitive risk (MCR) syndrome , 4. MCR ®, G-WALK ®) was commonly applied to evaluate gait speed in most recent studies  A discrepancy of measurement tools: instrumented walkway with embedded pressure sensors  studies , 25, 26, studies , 20th lo studies , or ≥ 1  studies , 24, 29. studies , 30. It  studies , 32. In  studies , 33. TheThe diagnostic criteria and measurement methods/tools for MCR are constantly evolving. There are no current uniform guidelines for MCR diagnosis, which impedes clinical practice and comparability of research on MCR across countries. Therefore, uniform diagnostic criteria and measurement methods/tools for MCR are needed. Given the scanty of studies on MCR diagnosis and the significant controversy on the diagnosis of slow gait speed, this study will conduct a systematic review to explore the ways used to diagnose MCR cases in all studies, using Verghese's criteria. It will focus on the variation of operationalization in the diagnosis component of slow gait speed for MCR.This study aims to perform a systematic review and narrative synthesis of evidence on the methodology of measuring slow gait speed in diagnosing MCR.The protocol was registered with the International Prospective Register of Systematic Reviews (PROSPERO) database (registration number CRD42021232671)  on 22 FeNo patients or the public will be involved in this study.Any original studies reporting the diagnostic criteria and measurement methods/tools for participants with MCR will be considered for inclusion in the final analysis.Inclusion criteria will include the following: (1) The participant population included MCR; (2) Full text include MCR diagnostic criteria and measurement methods/tools.Exclusion criteria will exclude the following: (1) Not relevant; (2) Not in English; (3) Inadequate description of slow gait speed methodology; (4) The full text does not include diagnostic criteria and measurement methods/tools for slow gait speed; (5) Duplicate analyses conducted on the same cohorts with the same assessment methods of slow gait speed; (6) Commentaries; (7) Methodology papers; (8) Conference abstracts; (9) Full text not available; (10) Animal or laboratory studies. Protocols, editorials, and letters will be excluded, but relevant references will be screened.According to key terms from previous literature reviews and Medical Subject Headings (MeSH), the following electronic bibliographic databases will be searched : PUBMED, EMBASE, The Cochrane Library, Web of Science. The literature search will be limited to the English language and human subjects. A detailed search strategy of PUBMED was built  titles and abstracts, and (2) full texts of relevant articles in two separate stages. Any study not meeting the inclusion criteria will be removed, and two researchers will resolve the disagreements by discussion or by a third researcher. Neither of the two researchers will be blind to the journal titles, the study authors, or institutions. According to the PRISMA, we will present the diagram of the selection process  see Fig.According to the previously designed and standardized sheet, two researchers will independently perform the data extraction from each eligible study. We will conduct calibration exercises before starting the review to ensure consistency across reviewers. The following data will be collected in the included studies: publication information, including the first author's name, publication year; study characteristics, such as country, research type, measurement setting, total study sample size; participant information, like age, number of the target population, prevalence, and inclusion and exclusion criteria; and screening information of MCR: except for SCD, dementia, and capability of daily living, the screening method of slow gait speed will be critical information for collection. This study will extract the cut-off values of slow gait in different age groups based on the gender stratification of the participants, and the cut-off value with the highest frequency of use will be considered “the most common cut-off value” for slow gait to match the particular gender and age. In cases where a publication characterized subjects using different MCR criteria, these criteria will be extracted separately and treated as separate entries for analysis , the China Scholarship Council Foundation (No. 201908330251), Zhejiang Provincial Natural Science Foundation of China (No. LQ17G030002), the General Scientific Research Project of Zhejiang Education Department (Y201942543), and the Zhejiang Provincial College Students Scientific and Technological Innovation Activities–Zhejiang Xinmiao Talents Program (No. 2021R431031).The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.All claims expressed in this article are solely those of the authors and do not necessarily represent those of their affiliated organizations, or those of the publisher, the editors and the reviewers. Any product that may be evaluated in this article, or claim that may be made by its manufacturer, is not guaranteed or endorsed by the publisher.


Virtual care delivery within mental health has increased rapidly during the COVID-19 pandemic. Understanding facilitators and challenges to adoption and perceptions of the quality of virtual care when delivered at scale can inform service planning postpandemic.We sought to understand consistent facilitators and persistent challenges to adoption of virtual care and perceived impact on quality of care in an initial pilot phase prior to the pandemic and then during scaled use during the pandemic in the mental health department of an ambulatory care hospital.This study took place at Women’s College Hospital, an academic ambulatory hospital located in Toronto, Canada. We utilized a multimethods approach to collect quantitative data through aggregate utilization data of phone, video, and in-person visits prior to and during COVID-19 lockdown measures and through a provider experience survey administered to mental health providers (n=30). Qualitative data were collected through open-ended questions on provider experience surveys, focus groups (n=4) with mental health providers, and interviews with clinical administrative and implementation hospital staff (n=3).Utilization data demonstrated slower uptake of video visits at launch and prior to COVID-19 lockdown measures in Ontario (pre-March 2020) and subsequent increased uptake of phone and video visits during COVID-19 lockdown measures (post-March 2020). Mental health providers and clinic staff highlighted barriers and facilitators to adoption of virtual care at the operational, behavioral, cultural, and system/policy levels such as required changes in workflows and scheduling, increased provider effort, provider and staff acceptance, and billing codes for physician providers. Much of the described provider experiences focused on perceived impact on quality of mental health care delivery, including perceptions on providing appropriate and patient-centered care, virtual care effectiveness, and equitable access to care for patients.Continued efforts to enhance suggested facilitators, reduce persistent challenges, and address provider concerns about care quality based on these findings can enable a hybrid model of patient-centered and appropriate care to emerge in the future, with options for in-person, video, and phone visits being used to meet patient and clinical needs as required. During the COVID-19 pandemic, virtual care globally has become a foremost mechanism of health care delivery to maintain physical distancing measures, reduce personal protective equipment use, allow for redeployment of workers to COVID-19 programming, and meet public health recommendations . DefinedWhile virtual care was being offered in some settings prior to the COVID-19 pandemic as a potentially convenient and effective option for care delivery ,13, wideIn 2019, Women’s College Hospital, an academic ambulatory hospital in Toronto, Ontario, Canada, launched an institutional strategic initiative to systematically address common barriers to virtual care adoption and facilitate coordinated and widespread use of virtual care across the organization -18,20. TIn response to the COVID-19 pandemic, the Ontario provincial government introduced physical distancing, lockdown, and other public health measures . ProvincLiterature from other jurisdictions delivering mental health care virtually during COVID-19 speaks to facilitators, challenges, and perceptions of the impact of care quality -28. UndeWe used a multimethods approach to collect quantitative and qualitative data for this evaluation. Quantitative data were collected through aggregate utilization data of virtual (phone and video) and in-person visits prior to and during COVID-19 lockdown measures between December 2019 and June 2020, as well as through provider experience surveys with mental health providers. Qualitative data were collected through open-ended questions on provider experience surveys, focus groups with providers in the mental health department, and interviews with administrative and implementation hospital staff. Ethics approval was received from the Research Ethics Board at Women’s College Hospital under the Ethics Assessment Process for Quality Improvement Projects .This study took place at Women’s College Hospital, an academic ambulatory hospital located in Toronto, Ontario. Toronto is an urban city center with a diverse population of approximately 6 million people . ResidenData collection began alongside the implementation of the video visit pilot in December 2019. A purposeful sampling approach was used to email invitations to all providers in the mental health department to a focus group to discuss their experiences with video visits within the pilot project and identify opportunities for improvement. Two in-person focus groups were held in January 2020 (pre-COVID-19 pandemic), and provider consent was collected.Following the COVID-19 pandemic and associated lockdown measures in March 2020, 2 additional focus groups were held with providers in June 2020 after widespread uptake of virtual care that included both phone and video visits across the organization. All providers in the mental health department were purposefully recruited via email with the assistance of a clinical champion in the department. After obtaining consent, focus group participants were arranged into 2 groups, 1 with only physician participants and the other with nonphysician mental health providers , to enable tailoring of questions based on professional roles. Additional interviews were conducted with administrative staff in the mental health clinic and with staff responsible for overall virtual care implementation at the hospital. These individuals were recruited through purposeful and snowball sampling. All collected qualitative data were audio-recorded and transcribed.Alongside focus groups and interviews, a provider experience survey was launched in May 2020 (during the COVID-19 pandemic) at the organizational level to collect data on experiences with virtual care in a scaled context, including viewpoints of providers in the mental health department. The survey included closed and open-ended questions. Aggregate utilization data on the number virtual phone, video, and in-person visits from December 2019 (3 months prior to COVID-19 lockdown measures) to June 2020 (3 months post-COVID-19 lockdown measures) was also collected for the mental health department, as well as the overall hospital.General descriptive analysis was conducted on aggregate utilization data to understand virtual care utilization trends 3 months prior to and 3 months following the implementation of COVID-19 lockdown measures in March 2020. Similarly, quantitative data collected from surveys were analyzed using Stata SE Version 15 . Data coAdoption of both phone and video visits rapidly increased during the week of March 9, 2020 to March 15, 2020, which coincides with the announcement of COVID-19 lockdown measures and availability of new provincial physician billing codes for both modalities . Prior tA total of 7 mental health providers participated in the pre-COVID focus groups, and a total of 14 providers participated in the focus groups held during COVID-19 . Providers consisted of physicians, nurses, and social workers . A total of 3 administrative and implementation staff was interviewed. Of a total 34 providers from the mental health department, 30 providers  completed the provider experience survey (response rate of 88%). Interview participants provided significant insights on factors influencing their adoption and use of phone and video visits during the pilot prepandemic and at scale during the pandemic  of all provider survey respondents agreed or strongly agreed that the technology they used to conduct video visits was easy to use. Nevertheless, a few technical challenges were described by focus group and interview participants. One of the foremost challenges was the initial set up and MyHealthRecord registration for patients to be able to conduct video visits. Patients required education and support, especially those who had older devices or low technical literacy. This was mentioned both during the pilot phase and following scaled use during the pandemic. Other technology-related challenges were also described, including challenges during the pilot with audio, video freezing, and connectivity, which impacted the therapeutic quality of video sessions. To help with this issue, significant hospital staff were redeployed during COVID-19 to provide setup and troubleshooting support to patients. Once patients were registered on the platform and able to navigate the technology, less support was required. During the COVID-19 pandemic, rapid and scaled uptake of video visits and providers connecting to the hospital from home caused bandwidth issues, resulting in poor connectivity and lag during conducted video visits. For this reason, some providers switched to phone visits for their appointments until these issues were resolved. Phone calls continued to be an important modality to deliver care during the pandemic, as a backup when video visits were not functioning correctly, and when patients lacked access to video visit technology.Data from the provider survey indicated that 67% (20/30) strongly agreed or agreed that they spent the same amount of time on video visits as in-person visits during the pandemic. In contrast, only 30% (9/30) of respondents indicated that the amount of effort spent was the same as in-person visits, 43% (13/30) of respondents disagreed or strongly disagreed, and 20% (6/30) were neutral that the amount of effort spent was the same. Focus groups conducted during the pilot and during the pandemic revealed increased effort required for technology set-up and troubleshooting within video visits for themselves and patients. Providers also indicated increased administrative tasks required to conduct care virtually , which were easier to do when seeing a patient in-person. Additional effort was also required to ask for certain information  and help patients prepare for the appointments (eg. by inquiring if they had a private space to conduct the visit and remind them that they could not record sessions) not usually necessary during in-person visits. Lastly, providers described feelings of “Zoom fatigue” and burn out and mentioned that video visits required more concentration, energy, and adaptations to interpret visual cues in comparison to in-person visits.Key facilitators of video visit adoption and use were also described. These are included in the following sections.The preparation work that had occurred during the pre-existing pilot that was implemented 3 months prior to the pandemic was perceived to contribute to the rapid uptake of video visits in mental health during the COVID-19 pandemic. This included a high-touch, in-person training approach and elbow support offered to providers during the initial pilot of video visits. Similar training was also offered to patients for registration, onboarding, and troubleshooting. Since there had been significant operational planning, training, and testing in the pilot with the support of a strong clinical champion, interviewed staff felt that the department was well prepared and operationally ready to rapidly transition in-person appointments to video and phone at the onset of the pandemic. Additionally, 77% (23/30) of provider survey respondents strongly agreed or agreed that they had adequate training and resources to learn how to use video visits, and 73% (22/30) strongly agreed or agreed that they would have appropriate support if an issue were to arise with a video visit.Provider survey respondents indicated that, on a scale of 1 to 10 , they would recommend use of video visits to other providers at an average rating of 7.9  and phoPhysician providers expressed the value-add of having billing codes and available financial compensation for the delivery of video and phone visits, as phone visit billing codes were unavailable to providers prior to the COVID-19 pandemic. Video and phone visits were thought to be effective, and phone visits were particularly deemed valuable to deliver certain types of visits, such as follow-up assessments, more efficiently, as well as being used as a backup modality when video technology had issues during visits or when video visit technology was not accessible or feasible for use by patients. Having billing codes for both video and phone visits enabled providers to use these modalities flexibly in the delivery of care that enabled better tailoring to patient needs.Overall, 43% (13/30) of the mental health providers who completed the survey strongly agreed or agreed that they felt they could deliver the same quality of care using video visits as in person, and 43% (13/30) strongly agreed or agreed the same for phone visits. Mental health providers further described their perceptions of the impact virtual care had on quality of care both during the pilot and during the pandemic, which is described in the subsequent sections under the Institute of Medicine domains of quality care .Mental health providers had a wide range of perspectives on the choice of appropriate virtual care modality (phone or video) for different types of visits  that emerged during COVID-19 where both phone and video visit modalities were being utilized. In most cases, providers felt that quality of care during phone and video visits was inferior to that of in-person care. While providers felt phone and video visits were appropriate to maintain care during the pandemic, many preferred in-person care. Choice of virtual care modality was primarily driven by patient-centered decision making, based on patient preferences, availability and accessibility of technology, and clinical appropriateness. For example, providers described the suitability of providing virtual care to patients who had difficulty leaving their homes but shared that attending in-person appointments may have helped these patients clinically and did not know what the long-term clinical impact of not leaving home for these patients might be.Virtual care was considered to be sufficient, but not excellent, quality of care in comparison to in-person care both during the pilot and during the pandemic. It was considered necessary given the pandemic context, but also valuable for certain patients and circumstances . Many providers felt that a connection with the patient was harder to build virtually, especially for new patients, which had a direct impact on the therapeutic relationship. Additionally, providers suggested that conducting visits virtually did not allow them to conduct assessment of certain visual cues that would begin in the waiting room, such as patients’ body language, mannerisms, and anxiety levels. This was expressed more in the context of phone visits, but also for video visits, thereby bringing up provider concerns related to care quality. With scaled use, providers adapted how they delivered care through phone or video to promote effectiveness. For example, video visits provided the added advantage of assessing home environments and interaction with family members, while more follow-up questions were used over the phone to understand silences. Overall, only 27% (8/30) of mental health provider survey respondents strongly agreed or agreed that the quality virtually was similar to an in-person exam, while 80% (24/30) strongly agreed or agreed that their last video visit enabled them to sufficiently address the patient’s clinical need.Many providers expressed concerns regarding the accessibility of virtual care for certain patients both during the pilot and during scaled use in the pandemic. Patients’ inability to access technology or an internet connection or patients having the digital literacy to conduct virtual visits were highlighted. Moreover, patients with specific characteristics  were described as having more difficulties accessing and navigating the video visit technology and registration processes. In addition, some providers reported that patients had challenges accessing a private space where they could feel comfortable openly discussing their mental health concerns. Hospital staff described potential future strategies to ensure equitable access to virtual care, such as by offering devices or having private spaces with internet connection being made available at the hospital.This evaluation provides insights into provider and staff experiences with mental health virtual care delivery within a pilot phase prepandemic and in a more scaled phase of implementation during COVID-19. Utilization data demonstrated the slower uptake of virtual visits in the mental health department prior to COVID-19 lockdown measures in Ontario (pre-March 2020) and increased uptake of phone and video visits during COVID-19 lockdown measures (post-March 2020). Mental health providers and clinic staff highlighted persistent barriers to use at the operational and behavioral levels including required changes in workflows and scheduling, initial set-up, troubleshooting and other technology-related challenges, and increased provider effort. Facilitators at the operational, cultural, and system/policy levels included having pre-existing infrastructure and IT support to enable widespread uptake, physician billing codes, and provider and staff acceptance of virtual care. Much of the described provider experiences focused on perceived impact on quality of mental health care delivery, including perceptions on providing appropriate and patient-centered care, perceptions on virtual care effectiveness, and equitable access to care for patients.Results from this evaluation provide insights on alignment with the Quadruple Aim objectives, specifically on access to health care services and provider experiences. Results provide insights on provider experiences, particularly persistent barriers that can be improved to enhance use of virtual care when it is the best modality for the patient and as a complement to in-person care. For example, while 84% of all provider survey respondents agreed or strongly agreed that the technology they used to conduct video visits was easy to use, this contrasted with providers’ shared perspectives that they had ongoing challenges with technology, adapting virtual care into their clinical workflows, and the overall effort required. This might be because the technology itself was not difficult to use, but rather its integration within established clinical workflows was contingent on other individual, organizational, and policy-level factors to enable optimal efficiency ,42. CollThe strengths of this study are two-fold. First, we examined the experiences of mental health providers who had already been delivering care virtually prior to the onset of the pandemic, as well as during scaled hospital use of virtual care. This provided an opportunity to understand the experiences and perceptions of a group of providers who had extended training and exposure to virtual care delivery, enabling us to understand consistent facilitators and persistent challenges that remained despite an organizational approach to removing known barriers. Second, we used multiple methods to examine provider experiences and use of virtual care, including focus groups, surveys, and aggregate utilization data. We also collected data from implementation and administrative staff to gather overall perspectives on virtual care implementation and adoption. Lastly, this study provides insights into provider and staff experiences within a pilot and larger scale adoption of virtual care in mental health, providing initial evidence on barriers, facilitators, and provider and staff experiences with scaled use, filling a gap in the literature where reporting on evidence in pilots is the norm . LimitatAn ongoing concern among providers in this evaluation was the ability to establish therapeutic relationships during phone and video visits and impact on the quality of care, which contrasts with some studies establishing the effectiveness of mental health delivery through virtual care -47. HoweIn conclusion, this evaluation provides insights on provider and staff experiences with virtual care use prior to and during the COVID-19 pandemic, highlighting persistent barriers, consistent facilitators, and perceived impact to quality care delivery within mental health. We have elucidated challenges to virtual care adoption in other contexts such as changes in workflows, provider adaptations on how care was delivered, technology-related issues, and provider perceptions of quality of care. This work is being used locally as a basis to develop strategies to overcome these challenges and will likely be of use in other contexts. Initiatives underway locally include support provided for virtual care implementation, training, skill, knowledge and literacy development, and workflow adaptation. Future research can continue to explore the effectiveness of mental health virtual care delivery and explore strategies that can enhance quality care delivery including gaining an understanding of patient perspectives to complement this work. Future work of this group will focus on the therapeutic relationship and equity considerations in the use of virtual care that would be beneficial, especially incorporating patient and family caregiver perspectives to further understand facilitators, challenges, and perceived and actual impact on the quality of virtual care.


Mosquito-borne West Nile virus (WNV) is the causative agent of West Nile disease in humans, horses, and some bird species. Since the initial introduction of WNV to the United States (US), approximately 30,000 horses have been impacted by West Nile neurologic disease and hundreds of additional horses are infected each year. Research describing the drivers of West Nile disease in horses is greatly needed to better anticipate the spatial and temporal extent of disease risk, improve disease surveillance, and alleviate future economic impacts to the equine industry and private horse owners. To help meet this need, we integrated techniques from spatiotemporal epidemiology, eco-phylogenetics, and distributional ecology to assess West Nile disease risk in horses throughout the contiguous US. Our integrated approach considered horse abundance and virus exposure, vector and host distributions, and a variety of extrinsic climatic, socio-economic, and environmental risk factors. Birds are WNV reservoir hosts, and therefore we quantified avian host community dynamics across the continental US to show intra-annual variability in host phylogenetic structure and demonstrate host phylodiversity as a mechanism for virus amplification in time and virus dilution in space. We identified drought as a potential amplifier of virus transmission and demonstrated the importance of accounting for spatial non-stationarity when quantifying interaction between disease risk and meteorological influences such as temperature and precipitation. Our results delineated the timing and location of several areas at high risk of West Nile disease and can be used to prioritize vaccination programs and optimize virus surveillance and monitoring. Mosquito-borne West Nile virus (WNV) is the causative agent of West Nile disease in humans, horses, and some bird species ,2,3. TheSince introduction in 1999, WNV has infected more than 27,000 horses in the US, with mortality rates estimated between 30 and 50% and neurologic symptoms that include stumbling, aimless wandering, convulsions, inability to swallow, impaired vision, teeth grinding, hind limb weakness, paralysis, and coma ,17,18,19WNV was originally described from Uganda in 1937  and thenCulex) and avian reservoir host species [Although WNV readily infects horses, they are “dead-end” hosts  that do  species . Thus, w species ,38. Our Grinnellian niche), pathogen interactions with hosts and vectors (Eltonian niche), and the pathogen’s fundamental niche (Hutchinsonian niche) to quantify shifts in virus distributions due to access and transport by competent avian hosts [We place our analysis within the disease biogeography paradigm because our framework was derived from human epidemiology methods with risk estimates contingent on (horse) population incidence and disease exposure rather than environmental suitability, occurrence probability, or abundance as is standard for niche models ,39,40,41an hosts .Avian species in the Order Passeriformes serve as the principal WNV reservoirs ,50,51,52Although predicting risk of disease transmission in multi-host systems is an outstanding challenge in infectious disease ecology, an improved understanding of the evolutionary and phylogenetic aspects of host community assembly and composition may help garner insight into virus dilution and amplification effects at the community and landscape scales ,59. ViruOur study area encompassed the contiguous US which includes a geographic extent greater than 9.8 million kmon (CDC)  as a texThe number of sentinel animal, avian, and mosquito WNV detections reported to the CDC were also obtained for the study period . ArboNET is a passive surveillance system. It is dependent on clinicians considering the diagnosis of an arboviral disease and obtaining the appropriate diagnostic test, and reporting of laboratory-confirmed cases to public health authorities. Diagnosis and reporting are incomplete, and the incidence of arboviral diseases is underestimated. We combined these virus detection reports and then aggregated to the county and month of detection to create a WNV surveillance covariate.s and time t (month of year) followed a binomial likelihood with a mean To help account for variation in county surveillance and reporting, we generalized  the WNV surveillance covariate by estimating virus detection probability for each county and month using the following formula,The stimates ,67,68,69 package , with coMean monthly maximum temperature and total precipitation data for the US (2009–2018) were acquired from the PRISM Climate Group at a 4 km grid resolution  using thhttps://droughtmonitor.unl.edu/) (accessed on 2 July 2021) and averaged to monthly values. The US Drought Monitor produces categorical drought stages based on a combination of metrics: the Palmer Drought Severity Index, NOAA’s Climate Prediction Center Soil Moisture Model percentiles, USGS Weekly Streamflow percentiles, Standardized Precipitation Index, and expert opinion. Arranged from the least to most dry stage, the reported drought levels included No Drought, Abnormally Dry, Moderate Drought, Severe Drought, Extreme Drought, and Exceptional Drought.Weekly drought indices reporting the areal proportion of each county subject to six different drought stages were obtained from the US DroughtMonitor (https://birdtree.org/) (accessed on 2 July 2021). We further cross-referenced the species common to both eBird (US occurrences only) and the Jetz et al. [Several model covariates were developed to evaluate relationships between avian WNV host species and equine WND occurrence. To develop avian covariates, we cross-referenced US occurrences of Order Passeriformes (perching birds) documented in the Cornell Lab of Ornithology eBird database  with thoz et al.  phylogenz et al. . The Tolz et al.  databasehttps://scinet.usda.gov/) (accessed on 15 July 2021), extracted individual bird occurrences using the auk package [We cloned the entire eBird database to the USDA SCINet High-Performance Computing System  website. The tool facilitated the process of trimming the full, time-calibrated phylogeny to our Passeriform species pool (303 species) before sampling this subset from a pseudo−posterior distribution [http://beast.community/treeannotator) (accessed on 12 July 2021) and the BEAST 2 package [Eco-phylogenetic analysis was conducted by first extracting 1000 bootstrap replicate trees from the Global Phylogeny of Birds using tools available at the ribution . We then package . We used package  to calcu package , mean pa package ), and ev package . As prevDynamic and static versions of avian host WNV molecular prevalence were estimated by matching species-specific prevalence estimates  to the chttp://www.earthenv.org/ (accessed on 15 July 2021).To characterize typical land use and elevation by county, we obtained remote sensing data (GeoTiff format) from the Global 1 km Consensus Land Cover data set  and the https://www.census.gov/) (accessed on 10 July 2021)and the Small Area Income and Poverty Estimates (SAIPE) Program within the US Census Bureau [County-level data reflecting human population density, median household income, and the percent of the population in poverty were obtained from the US Census Bureau .Bayesian epidemiological models were constructed to estimate WND relative risk and disease caseloads for horses located in the conterminous US. Our statistical model was of the form,se cases . Howeverf(·) represents statistical functions included to assess temperature and precipitation as spatially variable disease indicators. Because relationships between WND and climate were assumed to vary by location, climate covariates were designed to provide location-specific coefficient estimates. That is, rather than estimating a single coefficient that reflects the association of WND to temperature nationwide, the model instead provided a separate, “local” coefficient for WND–temperature correspondence in each US County. The f(·) represents temperature  allowed for estimation of log risk using a number of random (non-linear) spatial and temporal effects as well as several fixed (linear) covariates of interest as potential risk indicators. The log-risk linear predictor can be represented as,In addition to the spatial covariates used to estimate SVCs, a separate spatial effect  among disease risk indicators (graph nodes) such that covariates from similar groups  were positioned in relatively close proximity whereas covariates from different groups were at distance . For exaSpatial and temporal smoothing of reported WNV detections from sentinel animal, bird, and mosquito surveillance produced monthly, county-specific estimates for WNV detection probability in the US . The WNVWe identified 303 Passeriform species common to both the Cornell Lab of Ornithology eBird database  and the Combining avian host phylogenetics  with birThe strength and importance of avian host community metrics in estimating WND risk differed by adopted species pool and the specific composition measure . CoefficInitial inclusion of temperature and precipitation climate variables as fixed model covariates  cases/100,000 horses. However, the distribution of WND risk exhibited a temporal trend that sharply increased between the months of June and August  and showAs expected, equine WND risk was not uniformly distributed across the US nor was it constant throughout the year. Nationwide risk patterns generally indicated that few locations were free of any disease risk during the July–October period, which was identified as the time of highest risk . HoweverOur analysis revealed that risk spatial and temporal heterogeneity was associated with a number of virus, avian host, and climatic factors. Perhaps the most intuitive indicator of disease was detection of the WNV itself, which was found to be the strongest risk correlate during network analysis  and a roConsidering the large geographic extent of our study area, temperature and precipitation were presumed to exhibit spatial non-stationarity with respect to disease risk and were modeled as spatially varying coefficients (SVC). Spatial non-stationarity describes ecological relationships that vary by geographic location or across spatial scales ,103. As Precipitation coefficients exhibited a spatial distribution  with incDrought demonstrated a dynamic relationship to WND in that non-drought conditions were associated with increased risk, but abnormal dryness and moderate drought had a suppressive effect on disease . As drouNetwork analysis of the WNV enzootic system indicated that WND risk was more closely associated with avian host phylogenetic community structure than climatic, land cover, or human demographic factors . PhylogeWhen applied as WND predictive measures , speciesOur study faced two major data limitations. First, the ArboNET data that served as a basis for analysis were voluntarily provided to the CDC by counties. As voluntary data, case counts and virus detections were subject to county-level surveillance, collection, and reporting biases. Although our temporally and spatially-explicit model framework aided in accounting for many data biases, it was likely not perfect. Second, data reflecting equine WNV vaccination practices are not systematically collected in the US and were therefore not available for model inclusion. We suspect that vaccination practices may explain some of the WND variation revealed in our study, but controlling for this variation is problematic in the absence of detailed vaccination information. We did choose to assess the influence of household income as a potential proxy of vaccination, under the hypothesis that horses located in relatively high income areas might be more protected from WND due to owners being able to afford more consistent vaccination. Although we found that WND risk decreased in areas with increased income , the linSince initial invasion by WNV in 1999, approximately 30,000 horses in the US have been affected by neurologic disease and hundreds more are infected by the virus each year. Because of this, research elucidating the drivers of equine WND is greatly needed to better anticipate the spatial and temporal distribution of disease risk, improve disease surveillance, and avoid future economic impacts to the equine industry and private horse owners. To help meet this need, we applied a disease biogeography perspective and evaluated spatiotemporal relationships among four components of the WNV system: horse hosts, mosquito vectors, avian reservoirs, and climatic and demographic factors. Our findings pinpointed the timing and location of several high-risk WND areas throughout the US and can be used to prioritize virus surveillance and monitoring. Our analysis identified drought as a potential mechanism for virus amplification and demonstrated the importance of accounting for spatial non-stationarity when quantifying interaction between disease risk and meteorological influences such as temperature and precipitation. We also quantified avian host community dynamics across a massive geographic scale to show intra-annual variability in host phylogenetic structure and demonstrate host phylodiversity as a mechanism for virus amplification in time and virus dilution in space. Lastly, we encourage other researchers to expand on our methods for improved understanding of disease systems and to work towards fuller integration of spatiotemporal epidemiology, eco-phylogenetics, and distributional ecology.


One of the strategic actions identified in the Global Action Plan on Physical Activity (PA) 2018–2030 is the enhancement of data systems and capabilities at national levels to support regular population surveillance of PA. Although national and international standardized surveillance of PA among children and adolescents has increased in recent years, challenges for the global surveillance of PA persist. The aims of this paper were to: (i) review, compare, and discuss the methodological inconsistencies in children and adolescents’ physical activity prevalence estimates from intercontinental physical activity surveillance initiatives; (ii) identify methodological limitations, surveillance and research gaps.Intercontinental physical activity surveillance initiatives for children and adolescents were identified by experts and through non-systematic literature searches. Prevalence of meeting PA guidelines by country, gender, and age were extracted when available. A tool was created to assess the quality of the included initiatives. Methods and PA prevalence were compared across data/studies and against the methodological/validity/translation differences.Eight intercontinental initiatives were identified as meeting the selection criteria. Methods and PA definition inconsistencies across and within included initiatives were observed, resulting in different estimated national prevalence of PA, and initiatives contradicting each other’s cross-country comparisons. Three findings were consistent across all eight initiatives: insufficient level of PA of children and adolescents across the world; lower levels of PA among girls; and attenuation of PA levels with age. Resource-limited countries, younger children, children and adolescents not attending school, with disability or chronic conditions, and from rural areas were generally under/not represented.There are substantial inconsistencies across/within included initiatives, resulting in varying estimates of the PA situation of children and adolescents at the global, regional and national levels. The development of a new PA measurement instrument that would be globally accepted and harmonized is a global health priority to help improve the accuracy and reliability of global surveillance.The online version contains supplementary material available at 10.1186/s12966-021-01155-2. Sustainable Development Goals (SDGs), [Global Action Plan on Physical Activity 2018–2030 to provide guidance to support the implementation of national multi-sectoral PA actions and set a specific target of a 15% relative reduction in the global prevalence of physical inactivity in adults and adolescents [The benefits of physical activity (PA) for the health and well-being of children and adolescents are now widely accepted by the international scientific community , 2. Spec (SDGs),  the WHO Over the past 20 years, several questionnaires and surveys –15 have Although national and international standardized surveillance of PA among children and adolescents has increased in recent years, challenges for the global surveillance of PA and lack of generalization of PA data between and across continents persist. For example, there are methodological inconsistencies across international PA surveillance initiatives and national PA prevalence estimates often differ from one surveillance initiative to the next –26. MoreThe aim of this paper is to review, compare, and discuss the methodological inconsistencies in children and adolescents’ PA prevalence estimates from available intercontinental PA surveillance data/studies. This paper also aims to identify methodological limitations, surveillance and research gaps, and propose recommendations for improvement.collected or compiled data from the year 2000 onwards;included multiple countries from at least two continents;focused on early years (0–4 years) and/or children and adolescents (5–17 years);early years, children, and adolescents of all ability/needs levels and health status;assessed/estimated PA using report and/or device measures ;dataset presents publicly available estimated prevalence of PA at national levels.To control for over-representation of physical activity surveillance initiatives limited to high-income country settings and to centre the discussion around the physical activity data most commonly referred to in major publications and generally used to inform public health institutions, intercontinental PA surveillance initiatives were identified by international experts and literature searches. The inclusion criteria for the initiatives were the following:inactivity estimates from Guthold et al. (2020) [Prevalence estimates of children and/or adolescents meeting moderate- to vigorous-intensity PA guidelines were extracted by country, gender, and age (or school grade) when available. The 2016 physical A tool was created to assess the quality of the included initiatives. A list of relevant criteria for the international surveillance of PA of children and adolescents was identified and agreed upon by the authors after reviewing existing quality assessment tools and a final tool created where a score of 0 = not met, 1 = partially met, and 2 = fully met. Two independent reviewers (SA and ET) used this tool to assign a score to each included initiative and a third reviewer (MST) resolved conflicts between the scores. Equal weighting was given in calculating the average scores.Finally, tables were created to contrast the methods and results across the included intercontinental PA datasets and to map PA prevalence against the observed methods/validity/translation differences.Eight intercontinental initiatives were identified as meeting the selection criteria. Their detailed description and characteristics are presented in Online Supplement Material 15 followed by the Marques et al. study (106 countries or territories across six continents), [Online Supplement Material inents),  the GSHSinents),  Xu et alinents),  the Globinents),  2017/201inents),  ISCOLE sinents), , 32 and inents), . Dependiinents), , 29, 33 inents),  Finland,inents),  Mozambiqinents), ; while tinents),  Italy, [inents),  Philippiinents),  China, [inents),  United Sinents),  and Cambinents), , 29. A dOnline Supplement Material For the quality assessment process, the percent agreement between the two independent reviewers was 78%. A total of 35 conflicts out of 160 scores (20 scores for each included initiative) were observed between the two independent reviewers before being resolved by the third reviewer. The final scores from the quality assessment of each included initiative are presented in Table Eight intercontinental PA surveillance initiatives were identified for children and adolescents with open access to their findings and/or data and ranged from 10  to 146  countrieSix of eight initiatives included only children and adolescents aged nine or above in their targeted study population , 31, 35.The HBSC study and the Global Matrix were the only surveillance initiatives with an established periodicity. The HBSC has occurred every four years since 1982  and the ,22).The representativeness of the data for each initiative is described in Online Supplement Material For ISCOLE and ICAD 1.0, national PA prevalences were estimated based entirely on device-based measurements and included fewer countries than other initiatives  , 35. TheAs described in Online Supplement Material Online Supplement Material within them. The Global Matrix 3.0 was informed by various types of data across countries including device-based measurement, self-report or proxy-report questionnaire, and expert opinion; and for each of these categories, the methods varied substantially in terms of instruments, analysis, age range, sample size, and representativeness of samples [In addition to inconsistencies between initiatives, some inconsistencies were also observed  samples . However samples . Similar samples , 29. SevOnline Supplement Material The most concerning finding from the work presented in this paper is that cross-country comparisons varied greatly across the included initiatives. Indeed, countries with the highest and lowest prevalence of PA differed depending on the initiative. For example, the USA had one of the highest levels of PA in Guthold et al. and Marques et al., , 29 but The scores from the quality assessment presented in Table The WHO Global Action Plan on Physical activity 2018–2030 emphasised the importance of understanding and addressing social inequalities in physical activity participation across the life spectrum [There was almost no PA data available at the intercontinental level for the early years (0–4-year-olds) and children below 10 years were underrepresented compared to adolescents (11–17-year-olds) across all initiatives. Assessing movement behaviours in children younger than 10 years is challenging at the population level as valid and reliable questionnaires are lacking for this age group,  and therAs shown in Table None of the initiatives presented in this review intentionally included children and adolescents with disability or chronic conditions. This specific population is not consistently excluded from PA surveillance initiatives; however, the data is rarely presented in a way allowing to determine differences in PA according to disability and chronic disease status. In addition, special disability schools are typically excluded from the sampling in physical activity surveillance studies. The global TEENS study was an international cross-sectional study aiming to identify the main factors associated with quality of life in 8 to 25 year-old adolescents and adults with type 1 diabetes, where PA information was collected from medical records . HoweverThere was generally less data available in LMICs and the data generally was of a lower quality . There are several international studies/surveys including several countries within a single continent, in particular for European countries –50 but aFinally, the majority of the data presented in this review were collected using self-reported questionnaires, highlighting the need for more international device-based PA data among children and adolescents. Furthermore, PA data from ISCOLE and ICAD 1.0 were collected in 2013 or before, with the exception of the ISCOLE data from Mozambique,  and thesThe authors recommend that national and international efforts be made to address the aforementioned surveillance and research gaps in future surveillance initiatives: they should include younger children, children from ethnic minorities and indigenous population, children with disability or chronic condition, children from urban and rural dwelling locations. In addition, analyses should be presented by gender, by household socioeconomic status, and by urban vs rural dwelling. More specifically, the authors recommend that future surveillance initiatives using report and/or device-based measurements should develop feasible and affordable methodologies to assess meeting the MVPA component of the new WHO guidelines . We also encourage future initiatives using self/proxy report measurement to have a comprehensive approach that assess all domains of physical activity for children and adolescents  for a better reflection of the reality of their life across the variety of geographic, economic and cultural contexts. This information will also be key for the development of relevant and efficient interventions/policies promoting physical activity. We recommend that large international questionnaire-based surveillance initiatives use standardised device-based measurement on a portion of each of their national samples to challenge or confirm the validity of their data and facilitate international comparisons. Finally, we recommend that future surveillance initiatives employ a sampling method with stratification across socioeconomic status and urban/rural settings when a nationally representative sample is not feasible.While there are no perfect PA surveillance methods for children and adolescents, this review has highlighted that the current state is discordant with its public health importance. International comparisons are study specific and vary widely. The recent publication of new WHO PA guidelines  for chilThis review is the first to compile and compare this amount of children and adolescent PA data, surfacing serious issues related to PA surveillance and highlighting inconsistencies, surveillance and research gaps. The authors of the present review consisted of an international panel of experts involved in many of the included initiatives  and other relevant initiatives with data not yet available  and from both high-income countries and LMICs. All of the experts were involved in all stages of this review to prevent bias for or against a specific included initiative or missing a major source of relevant data/findings.clear reporting of elements that were not necessarily relevant to all of the initiatives and presenting the PA prevalence by specific categories, rather than the actual quality of the initiatives; further refinement is warranted.A limitation is that a systematic review approach was not utilized, so it was potentially missing relevant studies, and not representative of the real geographic distribution of the available surveillance initiatives. However, our approach allowed us to focus uniquely on open access/public data/findings that are most commonly referred to in major publications and generally used to inform public health institutions. In addition, the methods adopted in the present work prevented the overrepresentation of international but European/high-income country only studies. As there were no quality assessment tool suitable for the evaluation of the initiatives included in the present work, a new quality assessment tool for international surveillance of PA of children and adolescent initiatives was developed by the authors. The interpretation of the scores across the included initiatives should, however, be interpreted with caution as this tool awards more points for The compilation and comparison of the intercontinental PA data presented in this review showed that estimated national prevalence of children and adolescents meeting PA guidelines varied significantly by surveillance initiative, however three findings were consistent across all the initiatives: the insufficient level of PA of children and adolescents across the world; the lower levels of PA among girls in comparison with same age boys; and the diminution of PA level with age. LMICs, younger children, children and adolescents not attending school, with disability or chronic conditions, and from rural areas were generally under or not represented. There are substantial inconsistencies across and within included PA surveillance initiatives, resulting in initiatives contradicting each other. Therefore, there is an urgent need for the development of a PA instrument/protocol that is globally accepted, validated, and utilized.Additional file 1. Characteristics of the included intercontinental initiatives.Additional file 2. Extracted national physical activity prevalence for children and adolescents by initiativeAdditional file 3. Summary of the characteristics of the datasets by world region for each included initiativeAdditional file 4. Extraction of physical activity questionnaire items, translation, validity, and reliability information for the GSHS and the HBSC surveys


Caring for a child born preterm places significant emotional and financial burdens on family relationships. This paper examines (a) the extent to which children born very and extremely preterm are more likely to experience parental change/caregiver instability than children born full term, (b) predictors of parental change/s for preterm infants, and (c) whether exposure to parental change/caregiver instability increases child neurodevelopmental risk. Data were collected as part of a prospective longitudinal study of 110 very preterm and 113 full-term born infants and their parents studied from birth to corrected age 12 years. At ages 2, 4, 6, 9 and 12 years, detailed information was collected about the frequency and nature of all parent/caregiver changes for 3–6 monthly intervals of each child’s life. At age 12, all children completed a comprehensive neurodevelopmental evaluation of their emotional and behavioural adjustment, cognition, and educational achievement. Results showed that children born very preterm were at increased risk of experiencing parental/caregiver changes, with this risk being greatest for those born extremely preterm. Neonatal medical complexity, family socioeconomic disadvantage, maternal psychological wellbeing, and child neurodevelopmental impairment were associated with a higher risk of parental change. Preterm birth and exposure to parental change/instability contributed additively to poorer child outcomes. Findings support the need for family-focused neonatal and postnatal care strategies for high-risk infants, to support parents as well as their infants to optimize child health and developmental outcomes. Becoming the parent of a premature infant is a highly stressful life event for families ,2. Not oFurthermore, these challenges and stressors do not end at the hospital door. Children born VPT are at high risk for a range of health and neurodevelopmental impairments including feeding, respiratory and other health issues, more frequent hospitalisations, cerebral palsy, cognitive delay, executive dysfunction, and emotional and behavioural adjustment problems ,9,10. CoThere is some research to support the adverse impacts of preterm birth on family functioning, including disrupted social relationships, parental coping difficulties and increased financial costs particularly during early childhood (see Treyvaud  for a ren = 6016) found that by age 2, parents of very low birth weight  infants were two times more likely than parents of higher birth weight (>1500 g) infants to have separated or divorced . Odds ratios and significance levels for the predictors in each model are presented in The overall binary logistic models were significant at every age  and parental instability  but no interaction effect . Examination of the effects for each of the dependent variables indicated significant effects of preterm birth and parental change on both inattention symptoms and hyperactivity symptoms . In addition to SDQ scores, we examined the impact of preterm birth and exposure to parental change on symptoms of attention-deficit/hyperactivity disorder (ADHD). We used a multivariate analysis of variance to predict the two dependent variables of inattention and hyperactivity from preterm birth and parental instability. The overall multivariate tests (Pillai’s Trace) indicated significant main effects for preterm birth  and parental instability  on full-scale estimated IQ scores, but no interaction between these predictors . Preterm birth and parental instability were both predictive of lower cognitive ability at age 12.To understand the impact of preterm birth on educational outcomes we ran an analysis of variance predicting WISC-IV full-scale estimated IQ from preterm birth and parental instability. There was a significant main effect of both preterm birth  and parental instability , but no interaction between these predictors . A similar pattern was seen for broad reading skills, with significant main effects for preterm birth  and parental instability  but no interaction effect . The results indicate an additive effect whereby children are doubly disadvantaged if they are born preterm and have a history of parental instability.To understand the impact of preterm birth on educational outcomes we ran analyses of variance predicting the outcomes of WJ-III broad math standard scores and WJ-III broad reading standard scores from preterm birth and parental instability. When predicting broad math skills, there was a significant main effect of both preterm birth [This paper examined the longer-term impacts of very preterm birth on the partner relationships of parents of children born very preterm. Specifically, we examined whether very preterm birth may increase the likelihood that children will experience parental change/instability over their first 12 years, and in particular whether risks varied by infant gestational age at birth. Further, we examined potential risk factors for parental change and assessed the impact of this parental change/instability on children’s outcomes at age 12, above and beyond risks associated with preterm birth itself.Results indicate that very preterm birth is associated with an increased risk of parental change/instability from birth to age 12 years. These changes included parental divorce and separation, formation of new parental partner relationships, and adoption or foster care. There was a general tendency for the risk of any and multiple parental changes to be greatest for those born EPT, or those at the lower limits of viability. While children born extremely preterm had higher rates of both any and multiple parental changes than children born full term, children born very preterm were more likely than FT-born children to experience multiple or high levels of instability . By corrected age 12 years, nearly half of our sample of children born extremely preterm had experienced at least one parental change, and nearly a third had experienced two or more parental changes.Consideration of the predictors of parental change within the group of children born either very or extremely preterm showed that, in addition to gestational age at birth, early neonatal medical complexity was associated with increased risk of later parental instability at ages 9 and 12, suggesting longer-term impacts. Research on the impact of medical conditions such as autism spectrum disorder and ADHD has shown an extended period of the risk of divorce, persisting beyond early childhood and into early adulthood . Our resWe found that low SES was a significant predictor of parental instability at all ages. This is consistent with previous research showing that instability is more common within low SES families . FamilieOur findings also confirmed previous research suggesting higher rates of parenting stress in parents of children born very preterm, as compared to those born at full term ,4. FurthCollectively findings suggest that children born at lower gestations, subject to a more complex medical course during their neonatal hospital stay, living in lower socioeconomic conditions, and with mothers experiencing symptoms of depression, anxiety, and/or parenting stress are most at risk of exposure to instability of parents/caregivers.Finally, we examined the combined effects of preterm birth and parental change/instability on children’s neurodevelopmental outcomes at age 12. For most outcomes assessed, our results indicate an additive effect whereby children were doubly disadvantaged if they were born very preterm and then experienced subsequent parental change/s.An additive effect  was found for symptoms of inattention and hyperactivity (as assessed by both the SDQ and the SWAN), cognitive ability, educational outcomes, prosocial behaviour, and overall behavioural difficulties on the SDQ. There was an effect of preterm birth but not parental instability on peer relationship problems, and there was an effect of parental instability but not preterm birth on conduct problems. This latter finding is consistent with previous research that has found an inconsistent or lack of association between preterm birth and later conduct problems .These findings show that the family psychosocial context, in terms of maternal mental health, caregiver stability, and socioeconomic status, has long-term implications for the developmental outcomes of children born preterm. Strains on inter-partner relations and family stability may be greatest in families caring for a medically and neurodevelopmentally complex child, and in a context of limited financial and mental health/parenting resources and parenting/mental health stress. Taken together, our findings suggest a negative feedback loop in many families of children born very preterm, whereby the medical burden of preterm birth contributes to family breakdown and instability, which in turn negatively impacts children’s neurodevelopmental outcomes.Our results thus highlight the need for family-focussed neonatal and postnatal care strategies to support parents as well as their infants to ensure optimal child health outcomes. Monitoring of family and environmental factors ought to be a key component of neonatal and long-term follow-up. This is important as strategies to prevent parental and familial instability following preterm birth, such as support and resources directed at parental mental health needs and supporting their interparental relationships, will help to protect children from experiencing compounded risk to their cognitive, educational, and behavioural development.Our research focused on parental change and therefore does not take into account other types of family instability or disruption that children may experience. The comings and goings of other household members such as grandparents, other adult relatives and non-relatives, or siblings may also impact family functioning and child outcomes, particularly when household members are frequently changing. We chose to focus on parental change as it is likely of primary importance to child developmental outcomes and also most likely to be impacted by preterm birth. We also did not differentiate between the types of parental instability when examining outcomes. There may be differential effects based on the type of change experienced  but we did not have a large enough sample to explore the specific patterns associated with each type of parental change.Finally, in our consideration of psychosocial family factors, we focused on mothers  and have not examined the psychological well-being of fathers. Further work is required to better understand the contribution of paternal factors to parental instability in the families of children born very preterm.Our results indicate that preterm birth is associated with an increased risk of parental change/instability over the first 12 years of life. The risk of parental change was greatest for those born extremely preterm, with EPT children being 1.7 times more likely than FT-born children to experience any parental change and twice as likely to experience multiple (2 or more) parental changes. Neonatal medical complexity, family socioeconomic disadvantage, maternal psychological wellbeing, and concurrent child neurodevelopmental impairment were also associated with an increased likelihood of parental change. Furthermore, preterm birth and exposure to parental change/instability both contributed negatively to outcomes  in an additive, rather than an interactive, manner. These findings support the importance of family-focussed neonatal and postnatal care strategies to support parents as well as their infants for optimal child health outcomes.