In response to an increased health burden from non-communicable diseases (NCDs), primary health care (PHC) is effective platform to support NCDs prevention and control. This study aims to assess Thailand’s PHC capacity in providing NCDs services, identify enabling factors and challenges and provide policy recommendations for improvement.This cross-sectional mixed-method study was conducted between October 2019 and May 2020. Two provinces, one rich and one poor, were randomly selected and then a city and rural district from each province were randomly selected. From these 4 sites in the 2 provinces, all 56 PHC centres responded to a self-administrative questionnaire survey on their capacities and practices related to NCDs. A total of 79 participants from Provincial and District Health Offices, provincial and district hospitals, and PHC centres who are involved with NCDs participated in focus group discussions or in-depth interviews.Strong health infrastructure, competent staff (however not with increased workload), essential medicines and secured budget boost PHC capacity to address NCDs prevention, control, case management, referral and rehabilitation. Community engagement through village health volunteers improves NCDs awareness, supports enrolment in screening and raises adherence to interventions. Village health volunteers, the crucial link between the health system and the community, are key in supporting health promotion and NCDs prevention and control. Collaboration between provincial and district hospitals in providing resources and technical support enhance the capacity of PHC centres to provide NCDs services. However, inconsistent national policy directions and uncertainty related to key performance indicators hamper progress in NCDs management at the operational level. The dynamic of urbanization and socialization, especially living in obesogenic environments, is one of the greatest challenges for dealing with NCDs.PHC centres play a vital role in NCDs prevention and control. Adequate human and financial resources and policy guidance are required to improve PHC performance in managing NCDs. Implementing best buy measures at national level provides synergies for NCDS control at PHC level.The online version contains supplementary material available at 10.1186/s12961-021-00791-1. Globally, non-communicable diseases (NCDs) contribute to 70% of total mortality each year . MoreoveVarious global health forums reiterate and foster commitment to prevent and control NCDs. For example, an Independent high-level commission on NCDs in 2018 ; the gloIn 2016 in Thailand, NCDs accounted for 74% of total mortality, with leading causes of cardiovascular diseases (23%), cancers (18%), chronic respiratory diseases (6%), and diabetes (4%). In 2016, there were 399 100 NCDs deaths, and 14% of the Thai population are at risk of premature death from NCDs Monthly meetings between the VHVs and PHC centre staff are mandatory for refreshing VHV’s knowledge and getting updates on national, regional, and provincial health policies and guidelines. For example, to minimize exposure to COVID-19 infection at hospitals, NCDs cases were shifted to PHC centres and medicines were delivered by post. VHVs also supported local quarantine of individuals travelling from high infection areas or who had exposure to confirmed COVID-19 cases. In the past few years, the Ministry of Public Health (MOPH) earmarked budget for capacity building of PHC for NCDs case managers through the training of trainers. Although the budget was interrupted, some district hospitals initiated a mini-refresher course for their staff members to be NCDs case managers.Within the province, all health facilities adhered to the clinical guidelines for case management and referral systems. Health professionals at PHC centres were well-qualified, and equity of health workforce density prevailed as the number of PHC staff was linked with the catchment population, regardless of the wealth of the province.Essential medicines for NCDs case management suggested by World Health Organization (WHO) Package of Essential NCDs Interventions  is intenSince the launch of the Universal Coverage Scheme (UCS) in 2002, the National Health Security Office (NHSO) contracted the district health systems to fund PHC centres and district hospitals for outpatient services using a capitation payment method. All medicines and vaccines at PHC centres are procured and supplied monthly or bi-monthly by professional pharmacists in district hospitals. This ensures uninterrupted supplies of quality medical products at PHC centres. The capitation budget is adequate to provide services.Since 2007, the NHSO has invested in the Local Health Promotion Fund (LHPF) at the sub-district level; it transfers 40 Baht per capita of catchment population in the sub-district, with an equal matching fund from the sub-district local government . The Fun“Paper media is outdated; we need secure funding for digital advertising media, we are able to mobilize resources from the Local Health Promotion Fund.” [L1]3.PHC service provisionIn addition to providing maternal and child health services such as antenatal care, family planning, immunization and child development clinics, PHC centres provided a wide range of screening and continued medication of well-controlled hypertension and diabetes, cervical cancer screening and follow-up for confirmed diagnosis of abnormal pap smear and treatment at provincial hospitals. Poorly controlled diabetic and hypertensive patients were referred to district hospitals. PHC centres also provided home visits for stroke, homebound and bedridden patients. All these services were mostly provided by postgraduate trained nurse practitioners. Some district hospitals with sufficient physicians, assigned physicians to work at large PHC centres.Local collaborations were initiated through multiple methods such as a Memorandum of understanding (MOU) between the Provincial or District Health Office and the local authorities (under the Ministry of Interior), or MOUs between the Provincial and District Health Office, District Health Coordinating Committee (DHCC), local nursing colleges, and private sectors. Some district or provincial hospitals had established NCDs committees, which comprise a multidisciplinary team.4.Monitoring systemsClear national commitment is reflected by the key performance indicators (KPI) through a Quality Outcome Framework by NHSO to monitor service provision of specific interventions, in which all public healthcare facilities must participate. Incentives were given when a facility reaches the targets. At the same time, national KPI on health were set by MOPH for which the regional, provincial and district targets were then agreed and translated into annual work plans, implementation and regular monitoring. District hospitals and PHC centres were required to achieve these NCDs targets, with financial incentives from NHSO if targets are reached. Inspection of the quality of services was continuously monitored by NHSO while Social Security Office (SSO) and Comptroller Generals Department (CGD) were less active. Further the MOPH Inspector Generals also monitored target achievements in their supervisory visits.For example, in the last 5 years a target was set for 80% of diabetic and hypertensive individuals to be screened for Chronic Kidney Disease (CKD); 90% of the Thai population aged 35–74 were to be screened for Diabetes Mellitus (DM) through fasting blood sugar and at least 70% of DM type two aimed to achieved HbA1c < 7%. A cumulative 80% of women aged 30–60 were to be screened for cervical cancer .PHC plays a critical role in mobilizing resources generated by the Fund to support priority health problems in communities, with full engagement by citizens and local governments . Most prOrganizational disintegration, policy incoherence, lack of harmonization and dialogues among national policy makers and ineffective communication of decisions and guidelines to the implementation level, in particular PHC, all resulted in confusion at PHC centres. The provider–purchaser model is split, which means MOPH is the main provider while NHSO, CGD and SSO are the main purchasers. Each organization set their own rules and regulations relevant to their missions and legal mandates. Even within MOPH, Departments develop guidelines of which some details may be slightly different. This then sometimes creates policy incoherence across organizations. This theme mainly analyses the incoherence of financial resources, confusion of policy communication and its duplication, limited human resources and data management. This theme reflects the reality on the ground. Three sub-themes emerged which included policy incoherence from the national to the local level, insufficient or inappropriate budget management and human resources for health, and challenges of health information systems, which are all listed below.Multiple MOPH Departments have their own NCDs-related responsibilities; lack of harmonization leads to duplications of data requests and reporting from the local level. Incoherent policy was evident in three different age groups for hypertension screenings  and responsibility lay in three different Departments. It should be noted that the Health Promotion Division of the Department of Health and the NCDs Division of Department of Diseases Control are both responsible for NCDs.Sudden discontinuity of policy caused programme interruption; for example, school and community-based behavioural modification projects were terminated after a few years of implementation. This led to confusion at the PHC centres. There were also unclear NCDs job descriptions in the Health Promotion Unit and the NCDs Unit in the Provincial Health Office. Clear job descriptions are essential to ensure synergies and avoid duplication of efforts.“NCDs quality standard comprises several indicators, but often without adequate budget allocation to fulfil these mandates. As a result, our performance will be marked in the red zone due to budget shortfalls.” [L7]Key informants raised the issue of conflict around budget allocation. The budget is transferred to the District Health Network , and usually the Director of the district hospital is the chair and the Head of District Health Office is the deputy chair of the network. Achieving targets of NCDs screening require major contributions by PHC centres, but they often lacked adequate budget, resulting in internal conflicts in the network. For example, PHC did not received adequate budget for screening HbA1C.“The heart of PHC settings should be health promotion and prevention, but currently our effort focuses on the treatments of NCDs, though these are the immediate needs of the citizens.” [L7]Some NCDs services once provided by hospitals are increasingly shifted to PHC centres. There is increased demand for achieving KPIs. Yet incentives did not match the increased workload shouldered by the PHC centre staff. There was no dental assistant to increase scope such as annual oral check-ups for school children and a lack of physiotherapists limits rehabilitation services and multidisciplinary home visits.Although the problem of data inaccuracy at the national Health Data Centre maintained by MOPH has improved, challenges remain. The variety of hospital software and information platforms led to the fragmentation of health data, despite efforts to harmonize and improve interoperability. Patient information was sometime entered and transferred manually, resulting in human errors.Non-MOPH public healthcare facilities such as those under the Ministry of Interior and Ministry of Defence have their own data systems, software and platforms, which are yet to be incorporated into the National Health Data Centre for monitoring service coverage and health outcomes.Urbanization and socialization rapidly transforms local contexts and bring on board challenges including lifestyles diseases. This is another concern raised by local PHC and echoed throughout the study.“People always choose the best option for themselves, therefore, easy access to PHC centres in their community are considered their best choice.” [L7]Rural PHC centres facilitate easy access to services and maintain good relationships with villagers and community leaders. Key informants confirm that patients prefer to seek health services from their local PHC centres rather than visiting over-crowded hospitals. Trust and interpersonal relationships within the community, built over years, influence people’s decisions to visit PHC centres.Greater challenges were echoed by key informants from urban PHC centres. Patients in urban areas, with various choices of private and public clinics and hospitals, often by-passed PHC centres. In addition, some private companies offered private insurance to employees who often used private hospital services. Coverage of NCDs screening and treatment outcomes by the private sector are unknown, as this information was not captured by the MOPH information system.Urban populations live in obesogenic environments, having more access to fast food, sweetened beverages and inadequate physical activity than their rural counterparts. Energy-dense foods are key risks to obesity and NCDs. Key informants also voiced that health promotion around smoking, alcohol, and physical activity is less effective if the population is not interested. Addressing commercial determinants of tobacco, alcohol and unhealthy diets through implementing WHO best buys measures is important, but beyond the capacity of PHC workers .“We have been discussing ‘Health Literacy’ for years without applying it in context. We should apply these principles instead of repeating our talk.” [L3]“We have performed so many services, but health behaviour is entirely on patients’ practices which closely link with their health literacy.” [H3]Many key informants suggested promoting health literacy through mass or local media and that the MOPH should monitor and take legal actions against the promotion of false-claim products related to NCDs. Promoting healthy diets through schools and community-based interventions requires parallel reforms for conducive food environments.Figure Figure Thailand achieved universal health coverage (UHC) in 2002 with the whole population covered by financial risk protection systems. The 9806 PHC centres in 7255 sub-districts nationwide provide the foundation for implementing UHC, as full geographical coverage contributes to equitable access to health services by all citizens , 29. In We estimated spending on PHC to be 40% of current health expenditure in 2017 and 38% in 2019  SpendingThe success of PHC depends on the availability of qualified nurses and other health professionals in every PHC centre, often recruited from local communities for training and home-town placement upon graduation. Implementing rural health workforce retention policies such as local recruitment and hometown placements, and financial and non-financial incentives results in higher rural retention . QualifiIn-depth interviews with key informants showed difficulties in recruiting adequate numbers of dental nurses in small PHC centres due to limited posts and lack of career paths. The MOPH recognizes the problems but solutions have yet to be decided. A study shows 72.8% of dental nurses resigned due to frustration and heavy workloads . HoweverPhysicians confirmed diagnosis and choices of medication for NCD patients in district hospitals. Patients with well-controlled symptoms were referred to PHC centres. PHC staff members especially professional nurses monitored adherence to treatment, provided follow-up repeat medication and referred poorly controlled patients back to district hospitals. Medicines distributed at PHC centres were managed and supplied by pharmacists in district hospitals. Health literacy information such as risks from tobacco, alcohol, high fat and salty diets and physical inactivity was provided to NCD patients and community members by the PHC workers with assistance from the VHVs who closely engaged with the community and monitored their behaviour.VHVs (1.054 million in 2020) are lay people in communities who are recruited to support PHC functions. Six 3-h modules are required for initial training of a new VHV  and a maWhen the COVID-19 pandemic peaked in March 2020, and the second half of 2021, VHVs played critical roles to monitor population mobility from high-risk areas and support home- and state-quarantine processes. Furthermore, VHVs are the key actors in identifying NCDs patients in the community, one of the priority targets for vaccinations, and in advising them to receive the COVID-19 vaccination, also ensuring that they have adequate NCDs medicines during the lockdown period. They also deliver NCDs medications to patients’ homes to prevent potential infection from spreading in the community and avoid patients coming into contact with large gatherings at PHC centres and district hospitals.VHVs are given digital blood pressure devices and blood strips and are trained by PHC centres to monitor blood pressure and blood sugar in NCD patients and report back to PHC centres regularly. Further, VHVs had monthly meetings with and training by PHC staff members at PHC centres. See Form 1 for a sample of a diabetic and hypertension screening form conducted by a VHV. In 2020, MOPH announced the ‘three doctors per family’ policy , which iThe Astana Declaration defines three mandates for PHC. First, meet people’s health needs through providing a comprehensive range of health services throughout the life course; second, address the determinants of health through multi-sectoral actions; and third, empower individuals, families and communities to optimize their health, and support people as co-developers of health and social services .Findings from this study confirm PHC can fulfil the first mandate on service provision and PHC centre health workers are fully trained for this purpose, including for NCDs. For example, 4 of 67 KPIs in 2020 were related to NCDs  and distAlthough countries in the WHO South East Asia region had integrated NCD management at PHC level, most of them are small scale such as in Indonesia, India, Sir Lanka, Maldives, Myanmar, Nepal and Timor Leste. Bangladesh is at the initial phase of piloting. Only Bhutan and Thailand had implemented NCD management at PHC level nation-wide .PHC is implemented with local government authorities through the DHCC creating spaces for multi-sectoral action. The DHCC supports law enforcement such as smoke-free public spaces, and legal sanction for violation of alcohol and tobacco sales to under-age children. PHC is also implemented through schools to promote healthy school lunches, and a ban on sugary sweeten beverages in schools .Despite this, challenges remain on addressing the fundamental determinants of health. PHC is not designed and does not have capacity to allow for implementation of WHO best buy interventions  which caA few limitations exist. First, only two selected provinces have participated in this study, and findings cannot be generalized to the national level. The equal number of health workforce by size of catchment population in the two provinces, rich and poor, cannot be generalized either, and national level secondary data does not allow us to ascertain this finding. Second, the majority of participants were from PHC centres and in-depth interviews were dominated by PHC staff perspectives. Third, the COVID-19 situation in 2020, which enforced physical distancing and limited travel, did not allow interviews with representatives from the community, healthcare providers, Civil Society Organizations, VHVs, NHSO and the national NCDs manager.Finally, the MOPH provides full scientific independence to researchers who are working in the MOPH. Hence, there is neither positive nor negative bias from the researchers’ side. However, field observation during in-depth interviews showed initial reluctance from key informants who were also MOPH civil servants to provide frank assessment. Upon ensuring confidentiality and rapport building, they then expressed the views frankly and constructively.From the 1970s onwards it took three decades by successive governments to achieve full geographical coverage of PHC centres and district hospitals in the 1990s. An average of three to eight staff members in small, medium and large size PHC centres can accomplish the PHC mandate to provide comprehensive health services throughout the life course, including NCDs interventions for the sub-district catchment population. PHC staff members are trained to perform these functions well, and are supported by adequate supplies of essential medicines. Over 1 million VHVs play critical roles in bridging between PHC centres and communities and supporting diseases surveillance in times of public health emergencies.Challenges remain to empower individuals and citizens to optimize their health, particularly in urban contexts. The PHC approach has limited capacity concerning multi-sectoral collaboration to address the social determinants of health as community-based interventions are not effective in implementing WHO best buy interventions. This study calls for improved coherence of policy and key performance indicators responsible by different departments in the MOPH prior to transcending to provincial, district and primary health care levels. This prevents unnecessary confusion and supports synchronized reporting by PHC centres.To empower citizens and address social determinants through multi-sectoral action on NCDs, synergies and national-level support is needed for interventions such as tax and price policies on tobacco, alcohol and sweetened beverages, control of advertising, enforcing smoke free environments, and the availability and marketing of alcohol.Additional file 1: Self-administered questionnaires.Additional file 2: Interview guidelines.


The use of tobacco amongst the youth of Pakistan is an increasingly concerning issue. Approximately 1,200 children between the ages of 6 and 15 start smoking each day.The medical community is well informed of the health hazards of smoking. With lung cancer being an indisputable consequence, tobacco-induced illnesses such as cardio- and cerebrovascular disease, chronic obstructive pulmonary disease and oral cancers are just a few of the other possible outcomes. Particularly for the youth, unique risks include lifelong addiction, sustaining a customer base for the tobacco industry. Pakistan has recently been identified as a business hub by British American TobaccoInterventions by health workers may be highly effective in individual smoking cessation efforts, with even a 3-minute counselling session resulting in benefits. Behavioural change and pharmacological interventions are also available. Beyond this, health professionals can involve themselves by building relationships with stakeholders and policy makers, speaking up or writing about the issue at hand. In Pakistan, however, where tobacco has become a cultural norm, physicians do not fully exploit this power to enable actionable change in tobacco uptake. Realizing their role as important societal leaders who can ‘denormalise’ tobacco use, particularly amongst youth, is critical.Pakistan is a signatory to the World Health Organization (WHO) Framework Convention on Tobacco Control (FCTC), supporting the implementation of comprehensive tobacco control programs through MPOWER. MPOWER employs the following strategies: Monitor tobacco use and interventions, protect people from tobacco smoke, offer help to quit tobacco use, warn about the dangers of tobacco, enforce bans on tobacco advertising, promotion and sponsorship, and Raise tobacco taxes and develop sustainable alternatives to tobacco growing. Yet the complex tobacco tax structure in Pakistan, providing economic favor to the tobacco industry, appears counterintuitive to this.A 10% increase in prices would reduce tobacco use in teenagers by 18%.Indus Hospital & Health Network has used the MPOWER framework to create ‘Voices Against Tobacco’ (VAT). This is a community-centric initiative aimed at supporting positive policy change and empowering Pakistan’s youth to take ownership of their health and future. VAT is a direct response to the need for a tobacco control coalition in Pakistan and the objective of this is simple - to provide a common platform for anti-tobacco advocates to amalgamate and support initiatives against tobacco use.VAT aims to invest in Pakistan’s youth by conducting capacity building exercises in school-based tobacco control training. VAT champions will then advocate for enhanced tobacco control measures amongst their communities and collect narratives on tobacco use, advertising and pricing. This will support galvanization of a strong group amongst the youth and project their advocacy efforts through multiple stakeholder engagement sessions and social media campaigns. Community outreach, along with a concurrent media campaign, will support national policy objectives including tobacco taxation, novel products regulation and sustainability of tobacco control through engagement with policy makers.Protecting the health, well-being and livelihood of Pakistani youth is of utmost importance, for their future and the future of the country. By synergizing multiple groups of value to tobacco control efforts, we can push for effective policy change and facilitate meaningful change in the current state of tobacco in Pakistan.


Mild Cognitive Impairment (MCI) is crucial to early detection and diagnosis of Alzheimer’s disease (AD). This work explores how classification features and experimental algorithms influence classification performances on the ADNI database. Based on structural Magnetic Resonance Images (sMRI), two features including gray matter (GM) volume and lateralization index (LI) are firstly extracted through hypothesis testing. Afterward, several classifier algorithms including Random Forest (RF), Decision Tree (DT), K-Nearest Neighbor(KNN) and Support Vector Machine (SVM) with RBF kernel, Linear kernel or Polynomial kernel are established to realize binary classification among Normal Control (NC), Early Mild Cognitive Impairment (EMCI), Late Mild Cognitive Impairment (LMCI) and AD groups. The main experimental results are as follows. (1) The classification performance in the feature of LI is poor compared with those in the feature of GM volume or the combined feature of LI and GM volume, i.e., the classification accuracies in the feature of LI are relatively low and unstable for most classifier models and subject groups. (2) Comparing with the classification performances in the feature of GM volume and the combined feature of LI and GM volume, the classification accuracy of NC group versus AD group is relatively stable for different classifier models, moreover, the accuracy of AD group versus NC group is almost the highest, with the most classification accuracy of 98.0909%. (3) For different subject groups, the SVM classifier algorithm with Polynomial kernel and the KNN classifier algorithm show relatively stable and high classification accuracy, while DT classifier algorithm shows relatively unstable and lower classification accuracy. (4) Except the groups of EMCI versus LMCI and NC versus EMCI, the classification accuracies are significantly enhanced by emerging the LI into the original feature of GM volume, with the maximum accuracy increase of 5.6364%. These results indicate that various factors of subject data, feature types and experimental algorithms influence classification performances remarkably, especially the newly introduced feature of LI into the feature of GM volume is helpful to improve classification results in some certain extent.Note that identifying  Alzheimer’s disease (AD) is an irreversible progressive neurodegenerative disease in the brain. Mild Cognitive Impairment (MCI), as a prodromal stage of AD, is the most challenging group, which can be divided into Early Mild Cognitive Impairment (EMCI) and Late Mild Cognitive Impairment (LMCI). It is well known that MCI has a high risk of developing into AD, thus identifying MCI is key to early detection and diagnosis of AD .In recent years, there has been great effort to identify pathological markers of AD and MCI so as to better computer-aided diagnosis or prognosis of them. With the rapid development of neuroimaging technology, various kinds of neuroimaging modalities including magnetic resonance imaging (MRI), positron emission tomography (PET), electroencephalogram (EEG) and cerebrospinal fluid (CSF) have been widely applied to the auxiliary prediction and diagnosis of AD –5. PartiAs well known that loss of nerve cells and synapses is common in MCI and AD patients, which results in the phenomenon of brain atrophy. The degree of brain atrophy can be effectively measured by gray matter (GM) volume. Some works in the literature have validated that gray matter in global and local brain regions is lost for MCI and AD subjects –16. ThroOn the other hand, there exist left and right asymmetry in brain structure and function which is termed as the phenomenon of lateralization. Ratnarajah et al. have studied the asymmetry of brain structural connection in normal newborns . IturriaThe structure of this work is as follows. Section 2 presents preparatory work and classification algorithm used in this work. The classification performances are illustrated in Section 3 in detail. Finally, conclusion and discussion are address in Section 4.In this section, some preparatory works for the classification experiment are firstly present, then the detailed experimental algorithm is illustrated.http://adni.loni.usc.edu/). The primary purpose of ADNI is to collect, validate and utilize data, including MRI and PET images, genetics, cognitive tests, CSF and blood biomarkers, so as to define the progression of AD  and , in which the default values are Cmin = -8, Cmax = 8, Gmin = - 8 and Gmax = 8. Besides the SVM classifier with RBF kernel, the tuning parameters for other classifier algorithms are selected to optimize the classifier accuracy. For SVM classifier with polynomial kernel, the turning parameters of degree, regularization parameter—C and the kernel coefficient–gamma are chosen as 3, 1and 0.5, respectively. The tuning parameter of minleaf for DT classifier is 3. For RF classifier, the number of trees is 500, the max depth of each tree is default for the small sample size. The tuning parameter k for KNN classifier is 1.In this section, the classification performances are presented in detail. They include binary classification results across six test groups, comparison of classification results between different subject groups and different classification algorithms, and comparison with other works in the literature.In this section, several classifier algorithms including RF, DT, KNN and SVM with RBF kernel, Linear kernel or Polynomial kernel are used to realize binary classification among NC, EMCI, LMCI and AD groups. The classification accuracies are outlined in Tables The classification accuracies of NC group versus LMCI group under different classification models are displayed in The classification accuracies of EMCI group versus AD group are depicted in The classification accuracies of LMCI group versus AD group are presented in In the following, firstly the classification performances between different subject groups are compared when fixing each classifier model. Then the classification performances between different classification algorithms are compared when fixing each binary subject groups. At last, the current classification performances are compared with the previous results in the literature.When fixing the SVM classifier with RBF kernel, linear kernel and polynomial kernel, RF classifier, DT classifier and KNN classifier, the classification accuracies for binary subject groups NC versus EMCI, NC versus LMCI, EMCI versus LMCI, EMCI versus AD, LMCI versus AD, AD versus NC are depicted in For each binary subject groups NC versus EMCI, NC versus LEMC, EMCI versus LMCI, EMCI versus AD, LMCI versus AD, AD versus NC, In the literature, there have been some results that identifying AD based on structural MRI. By extracting CSF and hippocampus volume on the AAL atlas, Ben et al. classified AD, MCI and NC group and obtained the accuracy of 87% for AD versus NC group . On the This work focuses on computer-aided diagnosis of AD and its prodromal stage including EMCI and LMCI. Employing the MRI images from ADNI dataset, the GM volume and LI based on AAL atlas are obtained. The classification feature containing GM volume in 64 different brain regions and LI for 15 different brain regions are firstly extracted by ANOVA and the Kruskal-Wallis test. Then, several classifier algorithms including RF, DT, KNN and SVM with RBF kernel, Linear kernel or Polynomial kernel are employed to realize binary classification among NC, EMCI, LMCI and AD groups. How the classification features and experimental algorithms influence the classification performances are explored. Using the 10-fold cross-validation method, the accuracies for binary classification are illustrated in Tables For different classifier models, the classification accuracy of NC group versus AD group is relatively stable especially in the feature of GM volume and the combined feature of LI and GM volume, which implies that the classification accuracy for AD versus NC is not dependent on these classifier algorithms. Moreover, no matter what classifier model is employed, the accuracy of AD versus NC is almost the highest across these binary classifications, with a best accuracy of 98.2564%. This indicates that the classification accuracies are affected by test groups, and a greater disease difference between groups is helpful to enhance classification accuracies.For different subject groups, the SVM classifier algorithm with Polynomial kernel and the KNN classifier algorithm shows relatively stable and high classification accuracies, while DT classifier algorithm shows relatively unstable and lower classification accuracies. This implies that the classification accuracies are influenced by classifier model.The classification performance in the feature of LI is poor compared with that in the case of GM feature i.e., the classification accuracies in the feature of LI are relatively low and unstable for most classifier models and subject groups. As the lateralization information is introduced into the original feature of GM volume, the classification accuracy for most binary subject groups is significantly improved, with a maximum increase of 5.6364%. However, the classification accuracies for some binary test groups are slightly decreased, including EMCI versus LMCI under DT classifier, SVM classifier with RBF kernel and Linear kernel, as well as NC versus EMCI under DT classifier, with a maximum decrease of 2.1111%. It can be seen that the feature of LI can effectively enhance the classification results for most test groups, which is helpful for early prediction of AD. When the disease difference between test groups is not striking , the prediction accuracy is slightly decreased by incorporating the LI. This may be due to the fact that when the boundary of the test groups is ambiguous, there is no distinct difference in brain lateralization, which makes the feature of LI can not play a positive role in classification prediction.The above results indicate that various factors of subject samples, feature types and experimental algorithms influence classification performance remarkably, especially the newly introduced feature of LI is beneficial to improve the classification performances when the disease difference between test groups is distinct. As known that MCI patients are a high risk population for AD. Early diagnosis and intervention can greatly reduce the risk of AD. This work proposes a technique to classify AD progression based on comprehensive samples including NC, EMCI, LMCI and AD groups. Here MCI is divided into fine stages of early MCI and late MCI, compared to a general stage of MCI in most previous works. In addition, one may wonder how is the classification performance if the four groups of NC, EMCI, LMCI and AD are simultaneously classified. Using the combined feature of GM volume and LI, our further experimental results illustrate that the classification accuracies for the four groups under different classifier of SVM with RBF, Linear, Linear kernel, RF, DT and KNN are 84.8714%, 85.2648%, 88.109%, 84.2595%, 84.2595% and 71.3448%, respectively. The classification accuracies of four group classification are relatively lower than those obtained in binary classification. As known that four group prediction will be much more clinically important and more exciting, meanwhile, two group classification might be easier and more powerful. Thus, these obtained results are believed to shed new perspective on neuroimaging data analysis, which provides diverse theoretical basis for clinical recognition and diagnosis of AD in different situations of two subject groups or four subject groups.At last, we want to point that besides the evaluation metric of classification accuracy there are some other metrics such as AUC, TPR and TNR to reflect the classification performance. Due to the various considered factors including three kinds of classification features, several kinds of classification algorithms and six groups of binary classification, this work only uses the evaluation metric of classification accuracy to study how classification features and experimental algorithms influence classification performance for simplicity. In addition, the data sample in this work consists of 203 structural MRI scans from 94 subjects. For the same subject, multiple images are collected at different time points. Although they may change over time, it is hard to control the dependence of different samples from the same subjects. Regretfully, multiple scans from the same subjects are treated as independent samples in this work. For the features selection, we extract the classification features using the 203 structural MRI scans by hypothesis testing methods . Then these 203 samples are split into training and validation sets by random divisions in the 10-fold cross-validation. Due to the randomness of sample selection, if one subject has multiple scans, some scans maybe divided into the training data and others maybe divided into the validation data. For the above two occasions there might be some shared information between training and testing dataset, which might lead to the over fitted classification results. These statements might be the limitation of the present results. In the future, we will increase the sample size and try to avoid the issue of overfitting by directly dividing different subjects into training and testing data with a ratio, performing variable selection and classification purely on training samples, and then test the results on the testing samples. On the same time, several evaluation metrics including AUC, TPR and TNR would be employed in combination to reflect the classification performance more thoroughly.


Background: Despite scientific evidence on prenatal physical activity and exercise, synthesized evidence is lacking on the provision of prenatal physical activity and exercise advice and counselling by prenatal healthcare providers. The scoping review seeks to fill this gap by synthesizing available literature on the provision of prenatal physical activity and exercise advice and counselling by prenatal healthcare providers to women during antenatal visits. Methods: The Preferred Reporting Items for Systematic Reviews and Meta-analyses (PRISMA) search framework for scoping reviews was applied to retrieve original research articles on the prenatal physical activity and exercise practices of healthcare providers with pregnant women, published between 2010–2020, and available in English. The search databases included Google Scholar, PubMed, Science Direct, Scopus, EMBASE, The Cumulative Index for Nursing and Allied Health Literature (CINAHL), BIOMED Central, Medline and African Journal Online. Studies that fulfilled the eligibility criteria were retrieved for analysis. Results: Out of the 82 articles that were retrieved for review, 13 met the eligibility criteria. Seven of the articles were quantitative, four qualitative, one mixed-method and one controlled, non-randomised study, respectively. Three themes emerged as major findings. Healthcare providers affirmed their responsibility in providing prenatal physical activity advice and counselling to pregnant women; however, they seldom or rarely performed this role. Major barriers to prenatal physical activity and exercise included insufficient time, lack of knowledge and skills, inadequate or insufficient training, and lack of resources. Conclusion: This review highlights salient features constraining the uptake of prenatal physical activity and exercise advice/counselling by prenatal healthcare providers in both community and clinical settings. Prenatal physical activity advice and counselling are key components to the promotion of physical activity adherence during and post-partum pregnancy; this requires adequate knowledge of physical activity prescriptions and recommendations, which are personalised and contextual to environment. Research is needed to examine the prenatal physical activity advice and counselling from prenatal healthcare providers on issues hindering effective delivery of the aforementioned in the context of promoting prenatal physical activity in clinical or community settings. Maternal physical activity and exercise are beneficial to health and the health advantages of prenatal physical activity are widely reported in the literature. The clinical relevance of prenatal physical activity practice is incontestable. Prenatal physical activity and exercise practice lowers maternal weight gain ,2; decreGenerally, there is growing interest in physical activity counselling as a form of preventive health and treatment . ScientiThe provision of prenatal physical activity advice and counselling is a challenge to prenatal healthcare providers. Therefore, this review seeks to answer two questions:What are the knowledge, attitude and practice of prenatal healthcare providers regarding prenatal physical activity advice and counselling?What barriers do prenatal healthcare providers encounter in offering prenatal physical activity advice and counselling?The objective of this scoping review was to synthesize published studies in order to assess the knowledge, attitude and practices of prenatal healthcare providers in offering prenatal physical activity and exercise advice and counselling to women during antenatal sessions; and to further identify and characterize barriers to prenatal physical activity counselling.https://osf.io/dp8wn) (accessed on 11 May 2021). The electronic search databases included Google Scholar, PubMed, Science Direct, Scopus, EMBASE, The Cumulative Index for Nursing and Allied Health Literature (CINAHL), BIOMED Central, Medline and African Journal Online. These databases were searched to retrieve articles published from prenatal healthcare providers’ perspectives on prenatal physical activity and exercise advice and counselling published from January 2010 to December 2020. The search was updated in March 2021. The search terms and key words used were: “Prenatal physical activity”, “Prenatal exercise”, “Pregnancy”, “Pregnant women”, “Prenatal care providers”, “Healthcare providers”, “Advice”, “Counselling”, “Knowledge”, “Attitudes”, “Practices” and “Barriers”. During the data sources search process, the articles were sorted by year of publication, and then, only the first 10 pages of the search were considered because of multiple similarities (duplicates) and unrelated articles . We included MeSH terms in the initial phase of the search strategy, but there was no improvement in the search and they were not utilized in the final search strategy.The Preferred Reporting Items for Systematic Reviews and Meta-analyses (PRISMA) Searches for scoping reviews  was seleAs this is a scoping review, the PCC (Population/Concept/Context) framework recommended by JBI  was utilThe exclusion criteria included non-peer-reviewed, other reviews , book chapters, editorials, letters, and conference abstracts; abstracts without full text, articles on experiences of pregnant women regarding healthcare providers’ advice on prenatal physical activity and exercise; articles published before 2010, and those not available in English.The PRISMA guidance on conducting and reporting scoping reviews selection process was utilized to search for articles. Scoping reviews summarise results of studies encompassing varying methodologies to identify gaps in the literature and to decipher knowledge about a phenomenon of interest . ApplyinThe titles and abstracts of the articles were screened independently by two authors (UBO and DTG) to ensure they met the eligibility criteria set for the study. The authors further performed a full text screening on the identified eligible studies from the title and abstract screening process. Based on the full text review of the selected articles, the data were further extracted in line with the objective of the study. The data were analysed applying a modified approach to thematic analysis . Given tThe search provided 82 articles. Of these, 61 articles were removed because of not meeting the eligibility criteria or being duplications. Out of the remaining 21 articles, a further eight were excluded because they were not original articles, and did not address the objective of the scoping review. Therefore, 13 articles  were included in the review for analysis. Two studies reported that the providers perceived that they have a role and responsibility in providing prenatal physical activity advice and counselling ,38,41. RRegarding providers attitudes to prenatal physical activity and exercise, two studies reported that providers believed exercise during pregnancy is beneficial ,35, whilOne study reported that prenatal care providers recommended exercise to their pregnant patients  and provSeveral barriers to prenatal physical activity and exercise are synthesised in this review . StudiesThis scoping review assessed the knowledge, attitudes and practices of prenatal healthcare providers in offering prenatal physical activity and exercise advice and counselling to women during antenatal sessions; and further identified and characterized the barriers to prenatal physical activity counselling. Studies on the perspectives of prenatal healthcare providers regarding physical activity counselling can inform about the unique needs of providers for appropriate interventions. Such studies are rare across countries. The review found that providers perceived that they have a role and responsibility in providing prenatal physical activity advice and counselling to pregnant women. However, the review also revealed that the providers have inadequate or no knowledge on various physical activity guidelines. This explains further why healthcare providers’ advice and counselling, in some instances, is limited and inconsistent with the then-current prenatal physical activity guidelines . PrenataThis review reveals prenatal care providers’ lack of knowledge about physical activity guidelines or recommendations during pregnancy as stipulated by specialised bodies and institutions such as the American College of Obstetricians and Gynaecologists (ACOG) , the WorThe review highlights that providers believed exercise during pregnancy is beneficial to the mother and the baby , and to Notably, this review highlights lack of time, and lack of knowledge and skills as the major constraining factors to prenatal physical activity counselling. A previous systematic review identified lack of time, lack of knowledge or training in physical activity counselling and lack of perceived success in changing patient behaviours as the three most cited barriers to physical activity intervention in the primary care setting . In anteThe review was limited to articles published only in the English language; therefore, the possibility of other published but relevant studies in other languages having been excluded cannot be ruled out. In addition, the review focused exclusively on prenatal healthcare providers . Therefore, the findings reported in this review cannot be extrapolated to other healthcare providers attending to women’s health. Notwithstanding these limitations, this scoping review is the first attempt to provide an overview of available evidence on prenatal physical activity counselling by prenatal healthcare providers from across multiple countries. Such studies are limited in developing countries, including Africa. The findings of this review call for concerted efforts in prenatal physical activity advice and counselling to promote the uptake of prenatal physical activity participation. This review underscores the need for prenatal care providers to prioritize the topic of physical activity and exercise during antenatal care in order to encourage pregnant women to engage in prenatal physical activity during pregnancy. Therefore, interventions to support prenatal care providers to play this key function of offering adequate counselling of physical activity pertaining to its importance, prescription and guidelines are crucial, in order to improve maternal and fetal health . More stThe findings of this scoping review highlight key salient points. Healthcare providers affirmed their responsibility in providing prenatal physical activity advice and counselling to pregnant women; however, they seldom or rarely performed this role. The most common barriers to prenatal physical activity counselling identified in this review are the lack of time and the requisite skill and training to advise or counsel pregnant women about prenatal physical activity during antenatal visits. Consequently, providers expressed the desire for training to improve their knowledge on prenatal activity advice or counselling. There is a need to prioritise physical activity counselling in maternal and clinical settings to encourage women to initiate and engage in physical activity during pregnancy for improved health outcomes. Prenatal care providers need time, knowledge and skill to perform this task effectively.


Despite substantial reductions in malaria burden and improvement in case management, malaria remains a major public health challenge in the Asia-Pacific region. Residual malaria transmission (RMT) is the fraction of total transmission that persists after achievement of full operational coverage with effective insecticide-treated bed nets (ITNs)/long-lasting insecticidal nets (LLINs) and/or indoor residual spray interventions. There is a critical need to standardize and share best practices for entomological, anthropological, and product development investigative protocols to meet the challenges of RMT and elimination goals.A systematic review was conducted to describe when and where RMT is occurring, while specifically targeting ownership and usage of ITN/LLINs, indoor residual spray application, insecticide susceptibility of vectors, and human and vector biting behavior, with a focus on nighttime activities.Sixty-six publications from 1995 to present met the inclusion criteria for closer review. Associations between local vector control coverage and use with behaviors of human and mosquito vectors varied by locality and circumstance. Consequently, the magnitude of RMT is insufficiently studied and analyzed with sparse estimates of individual exposure in communities, insufficient or incomplete observations of ITN/LLIN use, and the local human population movement into and from high-risk areas.This review identified significant gaps or deficiencies that require urgent attention, namely, developing standardized procedures and methods to estimate risk exposure beyond the peridomestic setting, analytical approaches to measure key human-vector interactions, and seasonal location-specific agricultural or forest use calendars, and establishing the collection of longitudinal human and vector data close in time and location. Massive scale up and substantial expansion of time tested interventions contributed to about 48%–75% decline in malaria incidence  and 60%–Anopheles species complexes, human behaviors, and the variable impact of vector control. Generally, effectiveness is high initially for community-based transmission scenarios and low in forest-based situations. In 2018, 3 high-burden Western Pacific countries accounted for 98% of 1 980 034 cases , and 2 countries in the South-East Asian region accounted for 98% of cases (India [85%] and Indonesia [13%]) ost NMCPs are unlikely to detect the emergence of behavioral resistance with their existing vector surveillance programs as only 31% of countries monitor the indoor-outdoor biting ratio with 34% tracking changes in peak biting time, the 2 most common expressions of behavior resistance” , it is iA. harrisoni (Minimus complex species) and A. dirus.to transfluthrin in Thailand, [Anopheles gambiae s.l. landings by at least 50% and 40% against Culex mosquitoes in the field. From the public health impact, the combined use of metofluthrin-impregnated spatial repellent devices and LLINs (Olyset Plus) reduced the infection rate in children as well as the number of pyrethroid-resistant vector mosquitoes in malaria-endemic villages in southeastern Malawi [Given the complete susceptibility  of field-collected populations of hailand, , there ihailand, , 175. San Malawi .The current review identified several areas of importance related to RMT. The first highlights the inefficiency of current measurement tools, which produce data often confounded by human and/or mosquito behavior and results in a misclassification of “residual” transmission. In situations where malaria is considered residual, as in Vietnam and Cambodia, primarily because of the very high population coverage of ITNs, the persistence of malaria transmission has moved from villages to farm plots and forested areas, often involving primary and/or secondary vector species , 45, 100The third aspect is night activities that may increase people’s contact with malaria vectors. Where data is available, a good understanding of human behavior is crucial for targeting context-appropriate vector control interventions across specific settings. Given the inherent heterogeneity of malaria transmission across different landscapes, it is imperative that data and information be “local” to identify the relative importance of specific activity categories and target groups based on the entomological, human behavioral, and epidemiological context. To do so requires a highly coordinated, interdisciplinary approach involving input from NMCP managers, social scientists, and public health entomologists to help prioritize and interpret data on the access to and use of ITNs and to clarify the gaps in protection.The fourth aspect is gender-related vulnerabilities and barriers for accessing malaria services that fuel persistent malaria transmission from cross-border or intraborder mobility of illegal migrants and indigenous populations. The available data suggest that outside forest communities, where entire families resides inside the forest, it is predominately younger males who are more frequently accessing the forest , 53, 177Another study highlighted poor ownership and use of ITNs among migrants in the Regional Artemisinin Initiative project areas of Myanmar, including identified barriers to their ownership and use . In mappIt is essential that social and gender determinants of ITN ownership and usage be explored in high-risk communities, and health communication messages should stress the need for everyone entering the forest or in nearby areas with malaria transmission to sleep under ITNs. The Malaria Matchbox  is a useIn the current review, various activity categories  are provThis review is limited by the possibility that studies that would have met inclusion criteria were not identified in the review process. Particularly, it did not consider factors (or possible “drivers” of transmission) that could influence transmission dynamics, such as changes in malaria receptivity and/or importation risk , including new land development, population movement associated with seasonal agricultural pursuits, periodic political, cultural or religious events, civil unrest, internally displaced populations, environmental parameters such as mean and/or total rainfall by location, and accessibility to malaria diagnosis and treatment. For example, from 2006 to 2016 in Cambodia, the number of confirmed malaria cases decreased 84% from 143 758 to 23 492 , while fGeographers have noted that the reduction in forest is directly related to the surge in economic land concessions, and that the annual rate of forest loss was between 29% and 105% higher in land concessions than in comparable land areas outside concessions . This prIn addition to identified constraints and limitations of available data (published or otherwise), it was not possible to compare study findings directly owing to differences in study design and methods. However, the general conclusions of the studies in this review unequivocally suggest that a majority of malaria vector biting occurs outdoors during early evening hours, before people retire indoors, followed by indoor transmission for unprotected individuals not using a bed net (treated or not). This is evident even in contexts where unadjusted human biting rates are higher outdoors than indoors. However, when viewing ITN users, we estimated that roughly half of the malaria exposure likely occurred outdoors in some settings, indicating a clear gap in protection.h,i) and users of LLINs  were consistently similar in Solomon Islands  and Myanmar  [A. dirus in GMS can exhibit similarly stereotypical nocturnal, indoor-feeding behavior, this is unusual among vectors found in Lao PDR  [A. maculatus and A. minimus, respectively) [Furthermore, estimates of the proportion of human exposure to Pacific and Southeast Asian malaria vector populations that occurs indoors for both unprotected residents (π ctively) . These vctively) .One of the most relevant indicators for understanding RMT is the protective efficacy of ITNs, defined as the proportion of human exposure to malaria vectors prevented by ITN use out of total exposure  . ProtectThe importance of human behavior for understanding malaria transmission dynamics cannot be underestimated, and yet, even with this commonly acknowledged link with persistent malaria, relatively few studies were identified that included specific human activities as risk factors. For those studies that have identified human factors, different methodological approaches were used across studies, greatly limiting the comparisons for this review.Here we have identified gaps/deficiencies that have been addressed by ESPT guidelines: (1) standard operating procedures and methods to best estimate risk exposure away from the peridomestic setting; (2) a standard analytical approach to measure human-vector interaction, which should account for outdoor sleeping as well as segments of the population that may spend most or all of the night away from home; and (3) collection of human and vector data close in time and location, and across time points , to reflect changes in vector and or human behavior between seasons as proposed by Monroe et al  and KillOur review identified the ESPT as a standard approach to validate the estimates used for collecting human behavioral and entomological data—an important next step for developing a more uniform understanding of RMT and risk factors in general for those vulnerable populations subjected to persistent malaria. Since linking human activities with entomological parameters of transmission is generally lacking, these parallel domains need to be carefully integrated if we are to make sound epidemiological sense of the transmission dynamics at work. Finally, only with a better understanding of the gaps in protection can other appropriate vector control interventions be introduced or developed, over time and across settings, to address these challenges. To do so must take into account the health systems enablers, such as capacity to maintain supply chains of necessary commodities, maintain high-quality, timely, and responsive heath information systems and develop human resource capabilities as well as adaptive capacity at the district to community level. This type of data will be needed to ensure access to and encourage use of LLINs and vector control products among at risk populations.In conclusion, perhaps the most important finding of this review pertains to the current state of the published research literature, which was limited at best. Standardized procedures and methods to estimate human exposure to mosquitoes indoors for unprotected residents at high vector control coverage within and beyond the peridomestic setting was not provided in 8 of the 14 survey-based studies included in this review. This omission rendered it impossible to reliably interpret the relative importance of the findings in the respective studies. Reliable interpretation of entomological and human behavioral data was often undermined by inadequate description of the study design and methods. Examples included the frequent failure to report how data were obtained . The omissions described above likely reflect that the focus of this review  was rarely a primary focus of RMT studies as identified by the search method. On the other hand, well-documented descriptive analysis of nighttime human activities and use of preventive measures were reported in 16 studies among 8 countries of interest: Cambodia (3 studies) , 62, 121Taken together, the omission of important data and information in many of the survey findings, the lack of a clearer understanding of RMT concept, and the dearth of dedicated mixed methods  seriously compromised the findings cited in this review. The seemingly clear patterns evident in the reviewed data and the recommended interventions should, therefore, be considered cautiously and highly tentative until greater numbers of well-designed studies are available in the literature. The current evidence-based review is not sufficient in scope or quality to reliably inform personal protection or preventative promoting interventions or broader community campaigns targeted at individuals who possess but do not (reliably) use mosquito nets or long-lasting hammock nets.


Although previous studies have reported weight bias among students and professionals in exercise science, physical education, kinesiology, and fitness instruction, predictors of weight bias in these professions have not been extensively reviewed.  The purpose of this scoping review was to explore the available literature on predictors of weight bias in exercise science students and fitness professionals to identify key concepts and research gaps. Findings. Six main themes were drawn from these studies including beliefs in the personal controllability of weight; sex differences; enrollment in a health sciences-related program; psychosocial and personal factors; knowledge of obesity; lack of personal history, family, or friend with obesity. Our scoping review highlighted diverse predictors of weight bias among exercise science students and professionals that warrant further study and intervention. PubMed and ERIC were searched from January 1990 to May 2019. Eighteen studies were included in this review. A thematic analysis was conducted.  Weight bias is defined as negative beliefs and attitudes toward people living with overweight or obesity . BeliefsWhile there is a lack of clearly defined approaches to reduce weight bias among healthcare professionals, a systematic review of weight bias reduction interventions identified preprofessional educational training in healthcare programs as one potential target . Since mWhile it is clear that weight bias is pervasive in students and professionals in the field of exercise science, we need a better understanding of the factors that predict weight bias in this field to avoid the propagation of weight bias and its negative consequences on patient adherence, health behaviors, and clinical outcomes. The purpose of this scoping review was to synthesize all available literature pertaining to the predictors of weight bias in students and professionals in exercise sciences. For the purpose of this paper, students in exercise science refer to students enrolled in undergraduate or graduate programs in exercise science, physical education, and kinesiology and professionals in exercise science include physical educators, fitness instructors, exercise physiologists, and exercise specialists. We used a scoping review methodology due to the diverse body of literature on this topic and large range of study designs and methodologies before considering undertaking a systematic review. This scoping review further aimed to identify knowledge gaps and future research directions in the field of weight bias among exercise and fitness trainees and professionals.We conducted a scoping review using the five-stage methodology outlined by Arksey and O'Malley . With thn = 2) were retrieved from the reference lists of pertinent studies that were identified in the personal libraries of the researchers.A literature search was designed and conducted in consultation with a health sciences librarian. PubMed and ERIC databases were searched on December 14, 2017, and again on May 8, 2019, using combinations of keywords and subject terms for weight, bias, health science students, and fitness professionals. Results were limited to articles published after January 1, 1990, and written in English or French. The complete search strategy for both databases can be found in the Appendix. Other articles  charted the characteristics of included studies in a table outlining title, authors, date of publication, country, study purpose, participant characteristics, methodology, and main findings. All authors verified the charted data for accuracy and the data are presented in The literature search conducted on May 8, 2019, resulted in 1310 unique articles (after 9 duplicate articles were removed). An additional two articles were identified from the reference lists from the researchers' personal libraries resulting in a total of 1312 articles. These 1312 articles were screened and assessed for eligibility based on the inclusion criteria. Of the 41 articles that were screened as potentially relevant, 18 studies met the eligibility criteria and were included in the scoping review .n = 11) and used a combination of implicit and explicit measures to assess weight bias . The rest of the studies measured weight bias through explicit measures only  or through other measures  such as Q-methodology and one-on-one interviews to explore personal constructs of body shape and weight.n = 12) sampled undergraduate students enrolled in exercise science (n = 3), kinesiology (n = 3), physiology (n = 1), kinesiology, health promotion, and recreation (n = 1), health sciences (n = 1), and health and physical education training programs (n = 3). Four of the 18 studies  sampled fitness professionals only which included personal trainers and fitness instructors (n = 1), health educators (n = 1), fitness center employees (n = 1), and physical education professors (n = 1). Finally, one study  sampled both exercise science students and fitness professionals, e.g., physical education and exercise science students and athletes.The majority of the studies . Two articles showed mixed results in ethnicity as a potential predictor of weight bias in exercise science students , 28; oneOne study by Fontana et al. evaluated the attitudes of professors in physical education departments toward individuals with obesity . The samThe present study is the first, to our knowledge, to gather the existing literature on predictors of weight bias in exercise science students and professionals. This scoping review provides a comprehensive summary of the overarching themes that emerged from the published studies that explored this topic. This comprehensive review helps identify predictors of weight bias that can serve as potential targets to address with curriculum changes and interventions aimed to improve training on the complexity of obesity and reduce weight bias in the early formative years before students become professionals in the field. However, since our scoping review focused on predictors of weight bias in exercise science students and professionals, suggestions for future research and interventions drawn from this paper can only be made about students and professionals in exercise science, kinesiology, and physical education fields.This scoping review identified many overarching themes that predict weight bias in exercise science students and professionals. Belief in the personal controllability of weight was found to be the most researched and consistent predictor of weight bias in our population of interest. There appeared to be sex differences in weight bias that warrants further study; enrollment in a health sciences-related degree or program; psychosocial and personal factors relating to philosophy and personalities; traditional knowledge of obesity focusing mostly on diet and exercise; and lastly, a lack of personal history, family, or friend with obesity. Future research studies are needed to better understand predictors of weight bias in other health and exercise science-related fields, understand the impact of curricula that is heavily based on lifestyle factors only such as diet and exercise on weight bias, and evaluate the impact of weight bias reduction interventions in undergraduate students and professionals in the field of exercise science, kinesiology, and physical education.


Combined acute and chronic hepatitis C virus (HCV) infection among persons <40 years of age was used as an outcome proxy measure for IDU. Local and statewide data sources were used to identify variables that are potentially predictive of high risk for HIV/HCV transmission that fell within three main groups: health outcomes, access/resources, and the social/economic/physical environment. A multivariable negative binomial regression was performed with population as an offset. The vulnerability score for each ZIP code was created using the final regression model that consisted of 11 factors, six risk factors, and five protective factors. ZIP codes identified with the highest vulnerability ranking (top 10%) were distributed across the state yet focused in the rural southern region. The most populous county, Cook County, had only one vulnerable ZIP code. This analysis reveals more areas vulnerable to future outbreaks compared to past national analyses and provides more precise indications of vulnerability at the ZIP code level. The ability to assess the risk at sub-county level allows local jurisdictions to more finely tune surveillance and preventive measures and target activities in these high-risk areas. The final model contained a mix of protective and risk factors revealing a heightened level of complexity underlying the relationship between characteristics that impact HCV risk. Following this analysis, Illinois prioritized recommendations to include increasing access to harm reduction services, specifically sterile syringe services, naloxone access, infectious disease screening and increased linkage to care for HCV and opioid use disorder.The current opioid crisis and the increase in injection drug use (IDU) have led to outbreaks of HIV in communities across the country. These outbreaks have prompted country and statewide examination into identifying factors to determine areas at risk of a future HIV outbreak. Based on methodology used in a prior nationwide county-level analysis by the US Centers for Disease Control and Prevention (CDC), we examined Illinois at the ZIP code level ( In 2014, Scott County, Indiana identified more than 200 cases of HIV linked to the injection of prescription opioids. In subsequent years Massachusetts identified an outbreak of 116 cases with HIV that occurred among people who inject drugs (PWID),The opioid crisis, which has disproportionately affected rural communities has laid bare the multiple population and environmental factors that underlay vulnerability to these infectious diseases  have examined multiple factors at the national level to identify areas at high risk of rapid HIV transmission  level indicators were collected from the 2013–2017 five-year average US Census American Community Survey, Illinois state-specific indicators from the CDC, and surveillance data related to HCV, sexually transmitted diseases and fatal and non-fatal opioid-related overdose from the Illinois Department of Public Health. Data were collected for 2017 and 2018 to mirror the methodology used by CDC  in individuals <40 years of age were included . This den = 1383). Some indicators were collected as counts and subsequently calculated as rates, per total population between ages 15–40 years  was reported as a cause of death; analgesic deaths were assigned as any drug overdose death in which prescription analgesics  were reported as a cause of death; opioid deaths as any drug overdose death in which any opioid drug was a contributing cause of death—includes the above four ICD-10 codes as well as T40.0 (opium) and T40.6 (other/unspecific narcotics). Non-fatal opioid-related overdose rates were collected from IDPH hospital and emergency department (ED) discharge data.Chlamydia, gonorrhea and syphilis cases were collected To better understand access to resources throughout the state, we included several treatment and intervention variables: 1) access to a pharmacy utilizing a naloxone standing order; 2) access to clinicians or clinics that can prescribe/dispense buprenorphine, methadone, or naltrexone; 3) and access to federally qualified health centers (FQHC). These systems were included within access to resources due to their ability to serve and engage the community . Covariates reflect place-based features of the Risk Environment Model that guide studies of the social determinants of HIV-related outcomes among PWID, recently extended and adapted to southern Illinois at the ZCTA scale Rhodes, . Covarian = 1383) due to using the ZIP code level approach, the number of indicators did not need to be reduced for analysis. Each variable was independently assessed for association with the outcome. To assess correlation between indicators, we developed a Spearman correlation matrix. The correlation matrix was calculated for pairwise complete observations and correlation plot was implemented with the proc corr package in SAS version 9.4 software .Given the large sample size . One variable was created as an overall sexually transmitted infection rate by summing values for the number of cases of chlamydia, syphilis and gonorrhea. All other predictors were not significantly correlated (<0.65) and therefore included in the model. The remaining predictors were used to model HCV infection in those under 40 years of age as a proxy for an HIV/ HCV outbreak. Vacant housing was excluded due to not being associated with HCV infection.2  = 1238.71, p ≤ 0.001]. Of these, one was health related: (1) overdose risk   (P ≤ 0.0001); (2) percentage Hispanic ; (3) percentage over 65 years of age ; (4) percentage disabled  and (5) percentage 15 to 24 years of age . Three of the indicators were economic: (1) poverty rate ; (2) log of per capita income ; and (3) risky jobs . Two variables were physical environment indicators: (1) mobile home  and (2) rental housing .An association was observed between 11 covariates and HCV detection incidence [χ 0.0001) . Five vaWhen using our vulnerability ranking, the ZIP codes with highest vulnerability were found to be distributed across the state yet focused in the rural southern region . Ten couWe identified communities at the ZIP code level across Illinois vulnerable to an injection drug use-related HIV outbreak using statewide data sources from 2017–2018. Our finer-scaled analysis illustrated more vulnerable regions compared to the national view, providing more precise indications of vulnerability below county scale. The CDC identified one county, Hardin County, as highest risk through their assessment (Van Handel et al., Illinois has often been referred to as a microcosm of the country, being representative of the national demographics related to age, race, education, and household income. While Chicago is the third most populous city in the US, nearly two-thirds of the state's 102 counties are rural. Disparities between large metropolitan and rural areas exist for a broad swath of health outcomes much as they do nationwide. While absolute cases of chronic HCV are correlated with higher population density, acute HCV incidence in the US has been increasing with a greater predominance in rural counties in association with the opioid epidemic (Zibbell et al., Prior analyses of Illinois public health surveillance data have demonstrated other demographic variables associated with increased risk of HCV, including white race, 25–64 age group and residence in rural counties (Jones et al., Higher income and lower percentage in poverty were protective factors, consistent with prior vulnerability analyses (Van Handel et al., The percentage of mobile homes and rental housing were independently associated with HCV risk suggesting that some aspects of the physical environment may impact disease vulnerability. These factors were not included in the nationwide CDC analysis, and were not significant in the county level analysis performed in Tennessee. Of note, in the South Dakota vulnerability analysis, the percent of mobile homes was associated with lower HCV infection rate in minority dominant counties, whereas in white dominant counties, this association was not significant. Given the known relationship between housing and health, this protective effect of race would be important to explore. In studies adjusted by race, homelessness and unstable housing has been shown to be associated with sharing used syringes among people who inject drugs, and higher physical health and mental health morbidity and mortality overall (Maness and Khan, The findings above reveal a greater complexity underlying the interplay between demographic, socioeconomic and environmental characteristics that impact HCV risk. In our previous work focused on a predominantly rural southern areas of the state, complex heterogeneities emerged as smaller spatial units were examined and aggregated based on common environmental typologies. In short, rural areas are not monolithic, and the ability to assess risk at the ZIP code level affords jurisdictions, the capacity to finely target relatively high-risk regions regardless of county lines and of state rankings overall.Additionally, broadening geospatial focus beyond areas of prevalent risk to those of increased vulnerability allows for more diffuse provision of preventive public health activities. State and local health departments may engage stakeholders such as community-based organizations, first responders and other health providers, to review high-risk ZIP codes that may or may not have been areas of concern based on previous service provision. Resources may be directed accordingly to build capacity and/or engage in field activities, such as disease screening as well as harm reduction services including sterile syringe provision, sexual risk reduction, and overdose education and naloxone distribution. The attention to prevention activities on vulnerable and potentially overlooked areas provides an important opportunity to expand investigation beyond active outbreaks as detected through traditional public health data, such as passive HCV and HIV surveillance, syndromic surveillance and overdose surveillance using emergency medical services and law enforcement sources.Our analysis has several limitations. Associations between the variables and HIV/HCV vulnerability should not be considered causal. HCV infection is known to be under reported, although it is unclear how this may vary across demographic and risk-related variables (Klevens et al., Our study updates prior, US-wide county level analysis of geospatial risk for HCV and HIV outbreak related to injection drug use with a fine-scale approach. We validated and extended previous findings to identify additional areas of vulnerability. Priority recommendations defined by the state as a result of the analysis include increasing access to harm reduction services, specifically sterile syringe services, naloxone access, infectious disease screening and increased linkage to care for HCV and opioid use disordercara.bergo@illinois.gov.The data analyzed in this study is subject to the following licenses/restrictions: confidential infectious disease reporting data. Requests to access these datasets should be directed to Cara Jane Bergo, MP and MK helped form this paper and the overall project. SH and JE helped allow data access and explore ways to implementation, also were consistent editors of the paper. CB worked on the analyses of this paper. All authors contributed to the article and approved the submitted version.The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.


The aim of this study was to evaluate adherence to Mediterranean diet (MeDi) and possible correlation of MeDi adherence and nutritional status parameters in Dalmatian kidney transplant recipients (KTRs). One hundred and sixteen KTRs were included in this study. Data about Mediterranean Diet Serving Score (MDSS), body mass composition, anthropometric parameters, clinical and laboratory parameters were collected for each study participant. The results showed 25% adherence to the MeDi in Dalmatian KTRs. MDSS showed association with higher serum albumin and phosphorus level and higher skeletal muscle mass. Also, significant association between diabetic status and MDSS was found. Adherence to olive oil intake suggested by the MeDi showed significant association with lower level of triglycerides and adherence to nuts suggestions was associated with lower level of fat mass. Following MeDi recommendations for consumption of other foods  were also associated with body mass composition parameters and laboratory findings. In conclusion, low adherence to the MeDi in Dalmatian KTRs raises high concerns. The results showed that MeDi can have favorable effects on nutritional status in KTRs. A structured nutritional approach is needed to enhance adherence to the MeDi and prevent possible adverse effects in this patient population. The Mediterranean diet (MeDi) has been recognized for its beneficial role in prevention and management of chronic diseases such as type 2 diabetes mellitus , hypertePatients suffering from chronic kidney disease (CKD) require special care when it comes to nutrition, and it can be challenging to prescribe nutritional therapy to this group of patients. However, adherence to the MeDi has been associated with reduction of cardiovascular risk, lower mortality risk, lower risk of CKD progression and lower levels of oxidative stress in patients suffering from CKD .Kidney transplantation (KTX) results in better quality of life and overall mortality, but these patients are still at high cardiometabolic risk, due to changes in nutritional status  and effeRecent studies have stated that adherence to the MeDi can be associated with lower risk of kidney function decline and graft failure  as well The main aim of this cross-sectional study was to evaluate dietary habits and adherence to the MeDi of kidney transplant recipients from Mediterranean region of Dalmatia (Croatia). In addition, we examined the correlations of MeDi adherence with nutritional status, body composition and transplanted kidney function.One hundred and fifty nine (159) kidney transplant recipients (KTRs) older than 18 years of age, with functioning kidney and no mobility difficulties, were included in this cross-sectional study conducted at the Outpatient clinic of the Department of Nephrology and Dialysis, University Hospital of Split, Croatia, between July 2019 and October 2019.Some exclusion criteria were included and a written informed consent was obtained in all the participants. The study protocol was approved by the Ethics Committee of the University Hospital of Split.Body composition was assessed using an MC-780 Multi Frequency Segmental Body Analyzer  for each study participant. The device uses a constant high frequency current flow and eight electrodes to determine electrical resistance of different tissues. The method is called bioelectrical impedance analysis (BIA). It is used to assess fat mass (kg), fat mass percentage (%), fat free mass (kg), visceral fat, muscle mass (kg), skeletal muscle mass (kg), skeletal muscle mass percentage (%) and body mass (kg). All patients were advised not to take any food or liquid at least 3 h before the measurement, to urinate just before the measurement and not to consume alcohol, eat or drink excessively nor to exercise in an excessive way at least one day before the body composition measurement . Height The Validated Mediterranean Diet Serving Score (MDSS) questionnaire was used to determine adherence to Mediterranean Diet (MeDi) considering the consumption of different foods and food groups (MeDi components) in time intervals per meal, day or week .The food is divided into fourteen food groups, and points are given according to the new Mediterranean food pyramid in the following way: Three points for fruits, vegetables, olive oil and cereals if consumed with each meal; Two points for dairy products and nuts if consumed daily; One point for the recommended number of servings per week is consumed for potatoes (≤3), legumes (≥2), eggs (2–4), fish (≥2), white meat (2), red meat (<2), sweets (≤2) and fermented beverages (1–2 glasses a day) .It sums up to a maximum MDSS score of twenty four (24), and the greater score implies greater adherence to the MeDi. Optimal cut-off point ≥13.50 was set to determine adherence or non-adherence to the MeDi . By thorough examination of patients medical records, data about existence and duration of primary chronic kidney disease, arterial hypertension, diabetes mellitus, cardiovascular events as well as time of kidney transplantation (KTX), type and duration of dialysis treatment before KTX were obtained. 2). A complete blood count was obtained using a hematology analyser  and intact parathyroid hormone  was measured by immunoassay analyzer .Regarding laboratory parameters, all study participants underwent usual peripheral blood sampling, and they were asked to obtain a 24-h urine sample on the same day of the body composition and blood pressure measurement. We collected data on levels of urea (mmol/L), creatinine (mmol/L), uric acid (mmol/L), serum albumin (g/L), phosphates (mmol/L), C-reactive protein , calcium (mmol/L), glucose (mmol/L), triglycerides (mmol/L), total cholesterol (mmol/L), low-density lipoprotein cholesterol (LDL) (mmol/L), haemoglobin (g/L), mean cellular volume (MCV), sodium (mmol/L), potassium (mmol/L), and eGFR using CKD-EPI  and logistic (dependent variable adherence to the MeDi with MDSS cut-off ≥14) regression analyses were performed to examine the effect of other measured parameters with greater adherence to the MeDi. Multivariate models included age, sex, time of kidney transplantation, and duration of dialysis treatment before KTX. In addition, logistic regression analyses were performed separately for each of the 14 foods or food groups to investigate which participants’ characteristics were associated with better adherence to the specific food group. Results of linear regression were provided as beta values (β) with standard errors (SE), while for logistic regression beta values were transformed into odds ratios (OR) with 95% confidence intervals (CI). Significance level was set at p-value < 0.05. All statistical analyses were performed using the free software environment for statistical computing R [Normal distribution for numerical variables was assessed by the Shapiro-Wilk test. In cases of normal distribution, data was described by mean and standard deviation (SD), while for cases of non-normal distribution, data was described by median and interquartile range (IQR). Categorical variables were described with numbers and percentages. To assess differences between groups, chi-square test was used for categorical variables, puting R .One hundred and sixteen (116) KTR patients were enrolled in this study. Only 29 out of 116 (25%) Dalmatian KTR were adherent to Mediterranean Diet pattern , with mean MDSS score being 10.57. There was no statistically significant difference between the group which is adherent to the MeDi (MDSS ≥ 14) and the group which is non-adherent to the MeDi (MDSS < 14) neither in general parameters regarding medical history, laboratory parameters, anthropometry nor body composition.When analysing adherence to the recommendations for each food group consumption separately, majority of KTRs followed recommendations on potato consumption , while 69.8% of KTRs stated that they consume sweets <2 times per week. Only 17.2% KTRs eats nuts daily as MeDi suggests. When it comes to olive oil and fish, only 32.8% of Dalmatian KTRs consume olive oil daily and 38.8% consume fish two or more times per week. Total adherence to the MeDi (MDSS score ≥14 implying good adherence) and adherence to the recommended consumption of food groups is shown in p = 0.012).Sex differences in adherence to the MeDi and its components are shown in Adherence to the MeDi and its components in different age groups of KTR patients are shown in Differences in MDSS adherence and adherence to its components according to the values of BMI are shown in In addition, when comparing adherence to the MeDi and its components based on the presence of different comorbidities , diabetes mellitus (DM), chronic kidney disease (CKD)) we found that adherence to MeDi suggestions of intake of fruits, vegetables and dairy were all higher in KTRs suffering from DM. Full table is shown in Statistically significant associations between adherence to the MeDi and measured parameters is shown in The complete table of univariate and multivariate linear and logistic regression of MDSS in KTRs can be found in Regression analyses of every food component of MeDi is shown in Daily consumption of nuts was associated with lower levels of fat mass (both in kg and %). Association between following dairy products recommendations and higher incidence of type 2 DM was found. Adherence to MeDi recommendations on eggs intake was associated with lower levels of BMI, WhTr, triglyceride levels, fat mass in percentage (%) and kilograms (kg). A graphical summary of the regression analyses is shown in In this cross-sectional study, designed to evaluate dietary habits of Dalmatian KTRs, we found very low adherence to the MeDi. To our knowledge, this is the first study that has evaluated MeDi adherence in KTRs in this region. Dalmatian kidney transplant recipients showed adherence to the Mediterranean Diet by only 25% despite living in the area where it has been traditionally consumed for centuries and is a part of UNESCO Intangible Cultural Heritage of Humanity . Other rOur results show no statistically significant difference in laboratory, antropometric nor body mass composition parameters between adherent and non- adherent to the MeDi group of Dalmatian KTRs. The possible explanation of these results can be the small number of KTRs adherent to the MeDi in our study. In contrast to our study, previous study from Oste et al.  found loWhen it comes to sex differences, there were no differences in adherence to the MeDi between male and female KTRs. Only significant diffefrence was noticed in higher adherence to alcohol consumption reccomendation in male KTRs. This fact could be explained by that the men in Dalmatia traditionally drink more alcohol, especially wine, than women .No statistically significant difference in adherence to the MeDi according BMI values, neither in MDSS or any food group besides borderline significance for sweets consumption in obese KTRs, shows an overeall poor dietary pattern in participants. Our results showed no differences in adherence to the MeDi in Dalmatian KTRs with present CKD vs. those without. It implies that our patients lack in needed nutritional support and that they are not aware of importance of nutrition being a part of treatment.The results of our study showed that adherence to the MeDi adjusted for the effects of age, sex, time since transplantation and duration of dialysis treatment prior to the kidney transplantation if expressed as total MDSS score was associated with higher skeletal muscle mass and was higher in participants with DM, while if MeDi was expressed as binary variable (adherent vs. non-adherent participants), we observed significant associations with higher serum levels of albumins and phosphorus.Our results showed that MDSS is predictor of serum albumin level in KTRs. Higher levels of albumin were associated with better long term posttransplantation outcomes in a study on 404 renal allograft recipients . Our resSignificance of following Mediterranean dietary pattern in KTR patients could be in maintaining a good nutritional status and in prevention of sarcopenia and protein energy wasting (PEW) both contributing to high cardiometabolic risk in this specific group of patients . FurtherThese results can be affected by intake of processed food, food additives and preservatives  which weSignificantly higher MDSS score was found in KTRs with DM. Diabetic KTRs in our study seem to be more aware of the fact that nutrition is the integral part of chronic disease treatment. Furthermore, our results showed higher incidence of DM in those KTRs adhering to MeDi reccomendations on fruit, vegetables and diary products intake.This could be the consequence of eating food with high glycaemic index (GI). Recent meta-analysis states that the added benefit of lower GI version of MeDi in DM prevention . This fiWhen discussing specific foods and food groups of Mediterranean diet we wanted to highlight the importance of olive oil, fish and nuts consumption in Dalmatian KTRs. Only one third of Dalmatian KTRs consume olive oil daily as MeDi suggests. Also, our results show that those patients who consumed olive oil following the reccomendations of MeDi had statistically lower levels of tryglicerides. Recent findings have highlighted the direct impact of olive oil on HDL levels ,34, whilOur results showed that 38% of Dalmatian KTRs consume fish >2 times per week, and most of them are aged between 18–40 years. The possible explanation for this findings could be that younger KTRs are more aware of helathy habits and find themselves in a better financial position, from where they are able to spend more money on specific groceries like fish. Older patients are mostly retired with low household income.Dalmatian KTRs are the least adherent to nut consumption recommendations where only 17.2% of them consume nuts daily. Although low adherence, it is a lot higher than in general population adherence to nut consumption reported by Relja et al. . Pre-traRegarding other components of the MeDi, fruits, vegetables, cereals, potatoes, eggs and dairy products showed signifficant associations with researched parameters in this population.Adherence to reccomendations of consumption of fruits with every meal showing association with lower phosphorus levels in Dalmatian KTRs could be explained by the fact that bioavailability of phosphorus from plants is low . Higher Furthermore, our results suggest association between lower LDL values and moderate intake of potatoes (three or less times per week) in Dalmatian KTRs. Consumption of cereals with every meal showed an association with lower levels of potassium in our study indicating favourable effects for KTR population. Interestingly, moderate consumption of eggs (2–3 times per week) as suggested by the MeDi showed associations with lower levels of BMI, WhTr, fat mass in kilograms and percentage as well as lower trygliceride levels indicating its potential impact on nutritional status improvement and lowering lipid parameters in KTRs.There are some limitations to this study. It is a single center, but largest urban center on the Adriatic coast, to where almost 2 million people gravitate. We also included relatively small number of participants in this study but due to the specificity and small number of target population it is a representative sample. Any causal or directional conclusions are halted by the cross-sectional design of the study. In this study we are lacking data on patricipants income, level of physical activity and intake of food additives and perservatives.The results of this sudy showed low adherence to the MeDi of Dalmatian KTRs. Surprisingly low adherence is noted for food traditionally and geographically available in this region such as olive oil, fish and nuts. MeDi can have favorable effects on undernutrition and prevention of obesity which is a purpose of nutritional care in post-transplantation period. These results point out a necessity of structured nutritional approach in this population of patients and also in different countries. Future studies, with a higher number of participants should be designed to investigate the impact of this intervention on long-term outcomes on nutritional status of KTRs.