Digital health has become a widely recognized approach to addressing a range of health needs, including advancing universal health coverage and achieving the Sustainable Development Goals. At present there is limited evidence on the impact of digital interventions on health outcomes. A growing body of peer-reviewed evidence on digitalizing last-mile electronic logistics management information systems (LMIS) presents an opportunity to estimate health impact.The impact of LMIS on reductions in stockouts was estimated from primary data and peer-reviewed literature, with three scenarios of impact: 5% stockout reduction (conservative), 10% stockout reduction (base), and 15% stockout reduction (optimistic). Stockout reduction data was inverted to stock availability and improved coverage for vaccines and essential medicines using a 1:1 conversion factor. The Lives Saved Tool (LiST) model was used to estimate health impact from lives saved in newborns and children in Mozambique, Tanzania, and Ethiopia between 2022 and 2026 across the three scenarios.Improving coverage of vaccines with a digital LMIS intervention in the base scenario  could prevent 4,924 , 3,998 , and 17,648  deaths in Mozambique, Tanzania, and Ethiopia, respectively over the forecast timeframe. In addition, scaling up coverage of non-vaccine medications could prevent 17,044 , 21,772 , and 34,981  deaths in Mozambique, Tanzania, and Ethiopia, respectively. In the base model scenario, the maximum percent reduction in deaths across all geographies was 1.6% for vaccines and 4.1% for non-vaccine medications.This study projects that digitalization of last-mile LMIS would reduce child mortality by improving coverage of lifesaving health commodities. This analysis helps to build the evidence base around the benefits of deploying digital solutions to address health challenges. Findings should be interpreted carefully as stockout reduction estimates are derived from a small number of studies. Digital health has become a widely recognized approach to addressing a range of health needs, including efforts to advance universal health coverage and achieve the ambitious Sustainable Development Goals. A growing number of normative agencies and partners are developing frameworks and methodologies to standardize economic evaluation and impact measures from digital health interventions, but at present there is limited quantitative evidence on the potential impact of digital interventions on health outcomes . MeasuriLives Saved Tool (LiST), a modelling program in the Spectrum software package that analyses how increases in the coverage of specific health interventions prevent additional deaths and affect mortality rates over time. LiST uses empirical evidence on the effectiveness of health interventions and proportion of deaths that can be averted by that intervention, referred to as the affected fraction [A limited but growing body of peer-reviewed evidence on the impact of digital health interventions on improved care delivery and coverage of health services and commodities presents an opportunity to estimate health impact –7. Thesefraction . LiST isfraction .The purpose of this research is to contribute to the evidence base linking digital health interventions, health system outcomes, and health impact estimates. This study specifically focuses on the estimated health impact from digitalizing last-mile electronic logistics management information systems (LMIS) with inventory management, stock level notification, and distribution functionality. In LMICs, paper-based systems requiring manual data entry of health information are common at the lowest levels of the health system. Digitalized last-mile LMIS can improve the supply and distribution of health commodities by automating the various steps in the supply chain thus reducing stockouts, waste and supply chain inefficiencies . Fig 1 dMozambique, Tanzania, and Ethiopia were selected as the geographies of interest given that they are all in sub-Saharan Africa, where some of the largest health disparities exist relative to other geographies. In addition, these countries are in different digital health maturity levels. Digital health market maturity impacts the pace and ability of digital health innovations to scale in a given geographic context. The maturity level for a given country was determined using a model that contains indicators for digital political and regulatory factors, digital literacy, and digital infrastructure . Each ofThis research contributes to the global body of evidence on the health impact of digitalizing last-mile LMIS and proposes a replicable method for digital health researchers to connect peer-reviewed literature on the impact of digital health interventions with the LiST model or other modelling tools.This study estimated national changes in newborn and child health interventions and associated health impact based on the implementation of a digitalized last-mile LMIS between the years 2022 and 2026 in Mozambique, Tanzania, and Ethiopia. Based on available evidence, the implementation of the digitalized last-mile LMIS is projected to result in improvements in coverage of select lifesaving commodities. The study calculated three scenarios  with different coverage improvement rates for each country and compared these to the status quo where there is no change in coverage for the medicines and vaccines of focus in this analysis.We conducted a literature review to identify secondary data sources and augmented this with key informant interviews with implementing partners to identify changes in intervention coverage of lifesaving commodities based on the implementation of a digitalized last-mile LMIS. We used source material from a variety of key documents to inform the research and data collection for this study: World Health Organization (WHO) guideline recommendations on digital interventions for health system strengthening , GSMA ScThe data gathered in the literature review informed the range of the expected magnitude of change in the coverage of an intervention  that would be expected to improve due to digital health . Based oBase (10%), optimistic (15%), and conservative (5%) coverage scenarios enabled the model to capture the range in absolutely effect size across studies identified in For baseline mortality rates, health status, and effectiveness of interventions, the model used LiST-generated data from peer-reviewed journals, the United Nations Population Division, the Demographic and Health Surveys Program, and the Multiple Indicator Cluster Surveys . Only thThe calculation for modelling lives saved from changes in intervention coverage in LiST is shown in The analysis compared the three scenarios of impact to a counterfactual of the status quo or no change in coverage for the medicines and vaccines of focus, from 2022 to 2026. Given that the literature review and key informant interviews revealed rapid (12-month) rollout processes for the digitalized last-mile LMIS, the model assumed a one-year timeline for scale-up to final coverage rate increases in base, optimistic, and conservative scenarios, and then held constant for the remainder of the forecast timeframe.In addition to variation in digital health maturity, each country varied in baseline population, health status, and coverage of interventions applicable for this analysis as shown in Scaling up coverage of vaccines over five years with a base scenario of 10% reduction in stockouts (conservative scenario of 5% reduction in stockouts–optimistic scenario of 15% reduction in stockouts) could prevent approximately 4,924 , 3,988 , and 17,648  deaths in newborns and children under five in Mozambique, Tanzania, and Ethiopia, respectively. Scaling up coverage of non-vaccine medications accounts for a greater share of the total lives saved impact and could prevent approximately 17,044 , 21,772 , and 34,981  deaths in newborns and children under five in Mozambique, Tanzania, and Ethiopia, respectively . VaccineThe non-vaccine interventions with the largest impact on under-five newborn and child mortality across all three geographies were treatment of neonatal sepsis and pneumonia and oral antibiotics for pneumonia . Across The health impact from scaling up vaccine coverage was much less than that from scaling up non-vaccine medicines . ScalingImplementing a digital health intervention with inventory management, stock level notification, and distribution functionality has the potential to reduce under-five child mortality by improving coverage of lifesaving health commodities. This finding was consistent across commodities and the geographies of Mozambique, Tanzania, and Ethiopia. However, there are many factors that contribute to the impact of digital health interventions. First, the underlying population and health status impacted the total potential effect size of improving stock availability: the healthier the population, the less change was possible due to improving access. In the countries included in this research, the analysis showed that increasing coverage of pneumococcal and DPT vaccines and commodities for sepsis, pneumonia, and diarrhea treatment have the greatest impact on health outcomes, in part because these interventions tackled some of the highest burdens of disease for these geographies. In addition, there are effective health interventions to prevent and/or manage these diseases, resulting in improvements in health outcomes. Second, geographies and commodities that had a high level of baseline coverage also had reduced potential effect size in the model. This is most telling when comparing results between non-vaccine medications and vaccines, with the former having consistently higher impact partly due to the consistently lower baseline coverage levels.There are several limitations to this work, the first being that the key inputs in the modelling are based on available published literature on the estimated impact of LMIS on improvements in commodity stock levels. The study leverages four studies with published data directly addressing changes in essential medicine and vaccine stock levels following implementation of a digitalized LMIS. These studies were limited to retrospective pre–post designs which do not control for other elements that could be occurring while the intervention is being implemented.A second important limitation is the assumption that reducing stockouts improves medical commodity coverage using a 1:1 conversion given there are many determinants for increasing coverage of lifesaving medical commodities. On the one hand this 1:1 relationship may be an overestimation because system and governance factors may also have an indirect influence on whether a patient receives a needed health commodity. For example, the infrastructure needed to support supply chains  have been shown to influence the level of commodity stockouts in LMICs . In addiOn the other hand, the model results may be an underestimation because reducing stockouts can increase trust in the health system, leading to a higher volume of facility visits and an increase in demand , 27. TheThis analysis builds on the limited evidence base for the impact and social return for digital health in LMICs. Without data on health impact, stakeholders and decision-makers lack the necessary information to guide investments and efforts to improve coverage of lifesaving commodities. When it comes to evidence for the impact of digital health interventions, more published research, including data collection and making data available in the public domain, should be a priority moving forward. The promising findings of this analysis highlight the need to expand digital health impact research for additional digital health interventions to inform investment decisions. One important next step will be to link impact analyses, like this, with costing information related to the implementation of relevant digital health interventions to develop a social return on investment estimation. For some digital health interventions listed in the WHO digital health classification, different types of impact measurements such as cost savings or time savings may be more appropriate to capture the value of different digital solutions. In addition to expanding the body of evidence for impact, understanding the linkages of countries’ digital health maturity and the magnitude of potential impact is an important next step for guiding investment decisions.S1 FigAbbreviations: LMIS, logistics management information systems.(TIF)Click here for additional data file.S2 Fig*In Tanzania, Vitamin A for measles coverage is already at 99%. Consequently, no additional lives saved could be modelled due to increase in coverage for this intervention. Abbreviations: ORS, oral rehydration solution; PROM, premature rupture of membrane; Trt, treatment.(TIF)Click here for additional data file.S3 FigAbbreviations: DPT, diphtheria-pertussis-tetanus; HiB, Haemophilus influenzae type B.(TIF)Click here for additional data file.S1 DatasetAbbreviations: AIM, AIDS Impact Model; ART, antiretroviral therapy; BCG, Bacillus Calmette- Guérin; DemProj, Demography model; DHS, Demographic and Health Surveys; DPT, diphtheria-pertussis-tetanus; FamPlan, Family Planning; HiB, Haemophilus influenzae type B; HIV, human immunodeficiency virus; LiST, Lives Saved Tool; ORS, oral rehydration solution; PMTCT, Prevention of Mother-to-Child Transmission of HIV; PROM, premature rupture of membrane; UNAIDS, Joint United Nations Programme on HIV/AIDS; WPP, United Nations World Population Prospects.(XLSX)Click here for additional data file.


Journal of Mother and Child/Medycyna Wieku Rozwojowego invite you to read the latest issue of our quarterly, the first in 2021. The topics discussed in this issue encompass health problems in preterm-born children and the effect of continuous supportive telephone counselling on improving breastfeeding self-efficacy; adverse birth outcomes in Ethiopia; and health complaints among Polish adolescents. Other topics include a clinical report of G6PD deficiency with Harilaou variant and an interesting original paper presenting a molecular analysis of large or giant congenital melanocytic nevi. Overall, we offer seven original articles.The editors of the This issue’s first article discusses a study carried out in a group of 43 children prematurely born from singleton, twin, and triplet pregnancies and assesses their functional development between the ages of 2 and 2.5 years. Interestingly, no relationship was found between the multiplicity of pregnancies and the functional development of premature babies born between the 32nd and 36th weeks of gestation. Contrarily, residence, lack of family support during childbearing, pregnancy type, short interpregnancy interval, current obstetric complications, and a number of antenatal care (ANC) visits were identified as determinants of adverse birth outcomes in Ethiopia. The authors of that study recommended improving family support, lengthening interpregnancy intervals through family planning counselling and provision, and ensuring the recommended number of ANC visits.Two other clinically significant papers on prematurity are also presented. One investigates the effect of continuous, supportive telephone counselling on improving breastfeeding self-efficacy in mothers with late preterm infants is one of these. In the second paper, Asfour and colleagues give a meaningful description of a previously unrecognized adverse drug effect associated with daptomycin administration. Monitor of alanine aminotransaminase and prothrombin time seem to require attention.Medication is the topic of another article as well. Over-the-counter (OTC) drugs are becoming increasingly popular, leading the authors to study the habits and knowledge of parents regarding the use of OTC antipyretics for their offspring and consider the demographic and socioeconomic characteristics of the families. The presented data seem quite worrying; thus Pyznar et al. suggest educating caregivers and building parents’ awareness that they should take an active role in their child’s treatment. According to the authors, “It would be useful to create generally available recommendations for home treatment.”We continue with another excellent original paper dedicated to adolescents’ health, describing the trend of subjective health complaints of Polish adolescents compared to peers in 30 other countries and ranking all countries on a new measure. The authors suggest the HBSC-SCL index as useful for monitoring change in adolescent mental health. The proposed method of ranking may allow a broader view of the differences and similarities between countries and help to identify those performing unfavourably against cross-country patterns.“Urban Health and Nutrition Day or Only Immunization Day?” is a must-read for anyone interested in the mission of Urban Health and Nutrition Day. One can learn the barriers and bottlenecks, as perceived by the community health workers providing this service in the selected city of Nagpur, Maharashtra, India.NRAS variant in codon 61 importance as frequent, recurrent genetic causes of large/ giant CMN. Finally, we recommend an interesting and detailed article not to be missed by any researcher involved in inherited enzymopathies: a new case of G6PD Harilaou variant in a Greek male neonate, who suffered severe intrauterine haemolysis and passed away 39 hours after birth.This issue also includes the first molecular analysis of large/giant congenital melanocytic nevi (CMN) in Polish patients, where the authors support the hypothesis of the We hope that the presented papers meet your expectations and encourage you to read future issues of our journal.Aleksandra Jezela-Stanek MD, PhD, Asst Prof Department of Genetics and Clinical Immunology National Institute of Tuberculosis and Lung Diseases Warsaw, Poland


In rural communities, there are gaps in describing the design and effectiveness of technology interventions for treating diseases and addressing determinants of health.The aim of this study is to evaluate literature on current applications, therapeutic areas, and outcomes of telehealth interventions in rural communities in the United States.A narrative review of studies published on PubMed from January 2017 to December 2020 was conducted. Key search terms included telehealth, telemedicine, rural, and outcomes.Among 15 included studies, 9 studies analyzed telehealth interventions in patients, 3 in health care professionals, and 3 in both patients and health care professionals. The included studies reported positive outcomes and experiences of telehealth use in rural populations including acceptability and increased satisfaction; they also noted that technology is convenient and efficient. Other notable benefits included decreased direct and indirect costs to the patient (travel cost and time) and health care service provider (staffing), lower onsite health care resource utilization, improved physician recruitment and retention, improved access to care, and increased education and training of patients and health care professionals.Telehealth models were associated with positive outcomes for patients and health care professionals, suggesting these models are feasible and can be effective. Future telehealth interventions and studies examining these programs are warranted, especially in rural communities, and future research should evaluate the impact of increased telehealth use as a result of the COVID-19 pandemic. Health care is increasingly becoming a technology-driven environment. Telehealth is a remote health care service delivery method and allows for real-time communication between a patient and health care provider . TeleheaTelehealth is a convenient approach for patients to access health care in the comfort of their own home. Kruse et al  conducteResidents of rural communities across the United States include some of the most vulnerable populations, including individuals with low socioeconomic status, Indigenous communities, children and older adults, and individuals with disabilities . People The literature assessing the effectiveness of telehealth practices remains ambiguous and many technology interventions are unverified. In rural communities, there are gaps in describing the design and effectiveness of technology interventions and best practices for preventing and treating specific diseases and addressing determinants of health. Synthesizing the current scope and application of telehealth is critical for guiding future interventions and policies. For this article, we defined telehealth as both telehealth and telemedicine and will include mobile health and digital health solutions: electronic health, telemedicine, artificial intelligence, electronic medical record/portal technology, videoconferencing, wearables and biosensors, and remote monitoring tools. The objective of this study was to review and evaluate literature published on the current applications, therapeutic areas, and outcomes of telehealth interventions in rural communities in the United States.For this narrative review, we searched PubMed MEDLINE from January 2017 to December 2020. Key search terms included , “rural” AND “outcomes.” Filters were applied to identify free full-text studies published in English over a 4-year period to include the most recent evidence available in this research area. We included randomized controlled trials, mixed methods studies, qualitative studies, post hoc analyses, and prospective and retrospective cohort studies. Included studies contained at least one type of telehealth service and one primary measurable outcome and were assessed in rural communities/settings. We excluded systematic reviews, meta-analyses, editorials, conferences, unpublished studies and abstracts, studies outside the United States, and articles that were missing criteria based on the Critical Appraisal Skills Programme criteria. The Critical Appraisal Skills Programme has developed a set of 8 critical appraisal tools to assess the quality of evidence-based research; they have been widely used in previous studies .To organize our review of the literature, we used Covidence, a review management tool, to conduct a review of titles and abstracts, and a full review of the articles. We used Covidence to exclude duplicate records. Both authors screened studies for relevance based on titles and abstracts. Both authors reviewed the full-text articles of relevant articles for study inclusion. Article discrepancies on study inclusion were resolved through formal discussion and consensus between the two authors. The Critical Appraisal Skills Programme checklists  were useA total of 38 eligible articles were identified, of which 15 reported telehealth intervention outcomes and were included. The therapeutic areas examined included mental health (n=3), HIV (n=2), reproductive care/women’s health (n=3), osteoporosis (n=1), orthopedics (n=1), acute ischemic stroke (n=1), cancer (n=1), substance use disorder (n=1), ophthalmology (n=1), and emergency medicine (n=1). The majority of the studies (n=9) analyzed telehealth interventions in patients, followed by health care professionals (n=3) and both patients and health care professionals (n=3). Of the patient-centered studies, two studies were specific to veterans, two to Medicare beneficiaries, and one to Medicaid beneficiaries. Of the nine studies that analyzed telehealth interventions in patients, three (33%) of them examined the feasibility and acceptability of telehealth. These studies demonstrated that internet, electronic adherence monitors, and telelactation are feasible and accepted in rural, underserved populations and improve access to care . The disA total of two studies examined the outcomes of telehealth use in Medicare patients with substance use disorder (SUD) and mental health disorders, designated as Tele-SUD and telemental, respectively. Huskamp et al  concludeThe outcomes of the other four patient-centered studies included patient satisfaction, diagnostic validation, design and demand, and prevalence, diagnosis, and type of service. The advantages of telemedicine visits found in these studies included the following: decreased indirect and direct costs, lower travel costs and travel times, similar patient satisfaction compared to onsite visits, and patient satisfaction among telelactation users -14. In aA total of three studies analyzed telehealth interventions in health care professionals and reported outcomes. Lewiecki et al  examinedAnother study examined the application and acceptability of a telemedicine intervention called HIV ECHO. Moeckli et al  showed aA total of three studies analyzed telehealth interventions in patients and health care professionals. Gilbertson-White et al  examinedAnother study examined the feasibility and acceptability of telelactation. The advantages of telelactation were as follows: convenient and efficient, provided a needed service in rural areas lacking breastfeeding support services, and increased maternal breastfeeding confidence . The barThis review of the literature indicates telehealth is used for a variety of disease states and rural populations across the United States. Health technology interventions are a critical component of health care services in rural areas; they decrease staffing costs, travel costs, and travel time, and increase the ability of residents to seek care  that they otherwise would not be able to access in remote locations. This review explored telehealth in a broad sense and included technology models for clinical use, education and training of health care professionals and patients, and preventive and primary care services. All of these included models have shown feasibility and acceptability in rural populations, validating their importance and potential to improve outcomes and access to care.Overall, the included studies reported positive outcomes and experiences of telehealth use in rural populations, including acceptability and increased satisfaction; in addition, the technology was considered convenient and efficient. Other notable benefits included decreased direct and indirect costs to the patient (travel cost and time) and health care service provider (staffing), lower onsite health care resource utilization, improved physician recruitment and retention, improved access to care, and increased education and training of patients and health care professionals.Disadvantages of telehealth interventions included having tele-visits with unknown providers and technological issues such as loss of connectivity and limited Wi-Fi access in rural areas. Several studies reported that comparative effectiveness outcomes between telehealth and traditional visits were not statistically significant; however, these studies also noted telehealth technology was well accepted and implemented in rural, underserved populations and described the importance of testing additional technology interventions in these populations to identify which telehealth programs are most effective.Feasibility and acceptability are the foundation for implementing new health technologies in any environment or setting. This validation shows that rural populations and underserved communities have the capability to implement telehealth, report satisfaction with telehealth interventions, and describe the interventions as both convenient and effective. Even in articles where telehealth programs did not show statistical significance, these programs have demonstrated feasibility and acceptability. Limitations often associated with technologies  were reported at low rates, much lower than common perceptions about using these technologies in rural communities. This shows these technologies can be implemented successfully and supports the extension of telehealth programs in rural communities throughout the United States.A key additional finding of this review regards the appropriate types of telehealth programs. Although these technologies have been verified, these studies consistently highlight the need to test various telehealth programs in specific communities to validate which models are most effective; for example, diagnostic telemedicine versus telehealth video calls will have greater benefits in different settings and populations. It is important that we go beyond the scope of feasibility and acceptability to make sure we use telehealth programs to their full benefit and effect. The benefits have been established but the possibility of expansion of telehealth programs does not rely solely on testing just one model for a population but finding which model fits the community the best.Additionally, while no articles with a primary outcome of telehealth use for COVID-19 met the criteria for inclusion in this review, the landscape of telehealth and digital health care has changed dramatically since the start of the pandemic. The acceptance of telehealth during the pandemic has accelerated to the point that many of the barriers to telehealth use may have disappeared. To our knowledge, no reviews have been published on this topic in PubMed MEDLINE. Future reviews should focus on the changes in and outcomes of telehealth use in rural communities across the United States due to the COVID-19 pandemic.The administrative regulations behind telehealth programs, especially in areas where reimbursement for telehealth programs is not enforced by the state, should be highly considered. Requiring insurance companies to provide telehealth services to their patients is key to providing access to health care services in rural communities. Rural communities lack the resources, staff, and expertise to be able to positively affect health care outcomes, health care quality, and health equity. This review highlights the need for additional telehealth program studies and research into long-term real-world outcomes. Evidence-based studies have the potential to establish significance and comparative effectiveness against traditional health care . Additionally, state, federal, and local policy should be updated to cover the use of these programs and provide grants and funding for researchers to implement and test these programs in rural, underserved communities to improve access and quality of care.There are several limitations to this narrative review. Publication bias is possible within this study as we leveraged only PubMed MEDLINE and omitted grey literature such as reports, government documents and releases, working papers, white papers, and evaluations. Searching additional databases would potentially provide additional articles to be in included in this review. Additionally, limiting our search time frame to the past four years excludes earlier publications and data on health technology interventions and outcomes; however, the objective of this review was to report the most recent information on telehealth programs as they have advanced and expanded greatly over the past several years. Lastly, this review only included rural communities in the United States and would not be generalizable to non-US territories or domestic, urban communities, and populations affected by COVID-19. This study is generalizable to rural, underserved populations and potentially to the clinical settings and specific therapeutic areas studied in the included articles.This review highlights the current scope of using telehealth interventions in rural populations across the United States. Telehealth models were associated with positive outcomes for patients and health care professionals, suggesting these models can be effective for continuing education and training in the workplace. The findings of this review are limited to rural, domestic communities and are concentrated in specific therapeutic areas of disease. The findings support the existing literature on the need to increase and validate telehealth interventions and further update and implement policies to increase access and provide high-quality telehealth programs. Future telehealth interventions and studies examining these programs are warranted, especially in rural communities, and future research should evaluate the impact of increased telehealth use as a result of the COVID-19 pandemic.


Disease-specific programmes  are directed, supervised and executed via single vehicle using dedicated health workers. In contrast, integrated programmes  aim to tackle the overall health problems on a wider front and on a longer-term basis through the creation of permanent multifunctional healthcare delivery institutions . SeveralThe National Vector Borne Disease Control Programme (NVBDCP) is a focal agency of the Government of India responsible for control of 6 vector-borne diseases, i.e., malaria, visceral leishmaniasis, lymphatic filariasis, dengue, chikungunya and Japanese encephalitis. NVBDCP is a vertical programme due to separate budgets, healthcare cadres, supply chains, health information systems, monitoring, and evaluation frameworks but partially embedded in the existing mainstream healthcare system of the country at the grassroot level, especially after the advent of National Rural Health Mission (NRHM).The verticality of the 3 programmes within NVBDCP is evident in terms of staff, infrastructure and operations. Despite some attempts at integration at district level, State Programme Officers (SPOs) are different for each disease, and separate infrastructures like Filaria units still exist in some states. Vector control activities like indoor residual spray (IRS)  and the use of larvicides  are done in an independent and disconnected fashion. The grassroots-level workers and Primary Health Centre (PHC) staff are the same for surveillance of all three, but the training programmes are segregated for each disease which does now allow practice of joint surveillance. Finally, the key aspect of surveillance in terms of data  are different and not shared. NVBDCP provides antimalarial drugs, insecticides and larvicides to the states. Operational costs of the implementation of the programme are borne by states. The implementation of the national programme is thus the responsibility of states. Similarly, for kala azar, the central government provides drugs, insecticides and technical support and the states bear implementation costs. Lymphatic filariasis programme is a centrally assisted programme including procurements of drugs for MDA and other operations.Despite the above verticality, the above programmes utilize the same network of healthcare delivery system in common areas of endemicity. The National Rural Health Mission was launched in 2005  and aimed at providing decentralised community-owned healthcare delivery system through grassroot workers like Accredited Social Health Activist (ASHA) and Anganwadi Worker (AWW). The Auxiliary Nurse Midwife (ANM) and Multi-Purpose Worker (MPW) were placed at subcentre and PHC level for execution of all the national programmes. The present control/elimination programmes of malaria, visceral leishmaniasis, and filariasis leverage on the existence of above-described delivery system. Thus, the human resources are common, although the program execution is totally compartmentalised.Some notable benefits include: (a) increased profile for high-priority vector-borne diseases in elimination mode viz malaria, lymphatic filariasis and kala azar; (b) it remains effective despite ill-equipped and weak public health systems; (c) an ability to cover neglected and inaccessible populations; (d) a positive side effect on health systems like strengthening surveillance systems and quality control of laboratories; (e) it allows for better monitoring and accountability via transparent governance arrangements; (f) it allows involvement of nongovernment organizations, civil society, philanthropic bodies, donors, partners, and other stakeholders; (g) enhancement of trust in health beneficiaries; and (h) it enables availability of resources including financial for other prevalent diseases ,7.The shortcomings of these vertical programmes are (a) the donor-driven programmes and global health initiatives  have created parallel systems of planning, functioning, information systems, monitoring, and evaluation frameworks influencing national policies adversely by diverting and deflecting the coordinated efforts of policy makers to strengthen health systems; (b) these deplete scarce human resources from mainstream health services especially for delivering time-bound activities like distribution of insecticide nets and mass chemotherapy for lymphatic filariasis; (c) they overburden the procurement and supply-chain management systems by unplanned overloading of the supply lines with diagnostics, drugs, or vector control products obtained from donor agencies. Usually, the existent systems are weak and not positioned to accept a huge influx and thus suffer temporary disruptions; (d) they fragment the health system by creating duplicate surveillance and other programmatic structures, thus making interprogrammatic coordination difficult; (e) they create negative spillover effects for the healthcare system by thwarting planned mechanisms for integration into mainstream health services, besides the potential of exclusion of nonparticipant/nonbeneficiary populations. For instance, provision of long-lasting nets to households with pregnant women and young children on a priority can make other residents feel left out; (f) the stakeholders with vested interests may obstruct reforms designed to integrate services, for example, an agency (funded by donors) that runs vector control operations like indoor residual spray would prefer to continue so as to justify its role and existence even if there is evidence of reduced effectiveness of the spray. Such an agency may also resist integration with other vector control operations for diseases although in the overall benefit of the national agenda. At times, stand-alone operations (as in the example above) may gather more visibility than integrated and merged programmes, and hence, these are sometimes preferred by private agencies; (g) they create differential pay and incentive structures  promoting neglect of routine work and may discourage staff in the general health system; (h) a top-down approach curbs initiatives by affected communities ,7., while being very important, display wide differences in their geographical areas, epidemiology, control measures, requirements of community engagement and therapies. In addition, these viral diseases lack definitive treatments, and we currently possess limited understanding of their pathology and progression. Hence we propose that for now malaria, visceral leishmaniasis and lymphatic filariasis be targeted for integration rather than all 6. Cross-disease integration of the 3 diseases, which are already rooted in the general healthcare system of the country, could be gainful. An integrated approach would be most suited for the following reasons and opportunities: (a) Diminishing burden: The malaria, kala azar, and lymphatic filariasis burden is shrinking and all are progressing towards elimination. With this other diseases like the current COVID19 pandemic would take priority for the policy makers. Joint elimination programmes of a common architecture would be far more cost-effective and may offer greater scope of scaling up [Coendemic areas: As shown in Augmentation of general healthcare services: The proposed merger would significantly raise access to the healthcare systems by community as febrile illness episodes constitute a large proportion of the morbidity profile of the 3 infectious diseases. Being screened for common causes of fever under one umbrella as part of a broader healthcare objective would be an advantage. It will save repetitive work, resources, and can provide continual comprehensive services. Further, epidemiological information will travel in a more cohesive manner; (d) Common challenges exist like insecticide and drug resistance, need for better diagnostics, and role of private sector which poses as a gap in the surveillance system. Synergy with nonhealth sectors such as agriculture, housing, urban and rural planning and public works is currently missing but needed for well-rounded elimination programmes of all 3 elimination programmes.In view of the above, it would be pragmatic for affected countries like India to devise a plan for a unified integrated control and elimination agenda. Integration can be defined here as amalgamation of the 3 disease-specific thrusts even beyond the concept of “integrated service delivery,” which focuses on providing health services in the same location by the same health workers . It rathGiven below are the strategies, their commonalities, and the feasibility of integration at an operational level –12. The Surveillance: Routine surveillance is through active (case detection by house-to-house visits) and passive surveillance . Different healthcare workers are engaged at various levels, namely health workers at primary level and above like ANM, MPW, medical officers and laboratory staff. Community volunteers like AWW and ASHAs also provide healthcare to the people at grassroots level. In addition, entomological surveillance and monitoring of insecticide resistance is commonly done for malaria and kala azar. Since the healthcare staff structures are same for the 3 diseases, surveillance mechanisms can be integrated and staff can be multitasked, thus conserving resources. As cases of malaria reduce and India aims at sustaining malaria control, near real-time surveillance and reporting will become more desirable. Epidemiological data from all partners and stakeholders including private sector, nongovernment organizations, philanthropic agencies, donors, military, railways, etc. will need to be collated centrally for comprehensive analysis and data-driven decision-making. One robust solution is the development of a digital dashboard platform where above data sets can be coalesced and made accessible for both research and public health experts. This envisioned dashboard can accommodate epidemiological data of all 3 parasitic diseases and can be visualised in real time for evidence-backed control actions. Efforts to make the surveillance near real time and holistic involving all stakeholders and using a digital platform have already been proposed [proposed . Reportiproposed .Diagnosis and management: Point-of-care tests are used for early detection of malaria and visceral leishmaniasis. The filarial test strip is used for lymphatic filariasis. However, for all 3 diseases, confirmatory laboratory diagnosis is done at a facility. The healthcare staff are trained for diagnostic tests in the field. Similarly, treatment is administered by healthcare workers in the community in case of malaria and to at-risk population of lymphatic filariasis in mass drug administration format. For kala azar, the treatment is facility-based since the current treatment is by single-day intravenous infusion. In addition, development of joint rapid diagnostic kits would indeed be very valuable. Multiplexed assays for the 3 infections, if available at point of care, or at the PHC would be very useful in addressing the “early detection” component of control programmes. Indeed, integration of research activities under the umbrella of disease elimination will be a visionary step wherein the operational gaps of the programme could be identified and solutions devised via prompt action-oriented research. In addition, asymptomatic carriers in all the 3 diseases are of concern both for the scientific community as well as for programme managers. Asymptomatic carriers may or may not progress to clinical disease, but these carriers do escape the surveillance systems as they do not report to the healthcare system. However, they do act as reservoirs of infection and likely fuel transmission of each disease. Therefore, it is important to develop and deploy diagnostic tools for asymptomatic carriers in the programmatic mode, especially when all 3 diseases are in elimination phase. Molecular tools suffer from the limitation of being resource intensive in terms of expertise and infrastructure required. However, there have been attempts at developing diagnostic tools as point-of-care tests or at least for PHC level tests. These inlcude LAMP for visceral leishmaniasis and TrueNat PCR tool for malaria. Detection methods for filariasis include night blood survey (which is inconvenient) and filarial test strip. For lymphatic filariasis, the triple drug in mass drug administration format  aims at achieving a rapid decline in microfilaria rate. However, it requires both high coverage and high compliance rate in the community. Hence, it is being gradually rolled out in the country in a phased manner. With a large number of endemic districts for lymphatic filariasis (256 districts), coverage will take considerable time. Hence, here again, the healthcare workers can be trained holistically for malaria, lymphatic filariasis and visceral leishmaniasis in context of diagnosis and treatment of the symptomatic and asymptomatic patients.Integrated vector management: The routine vector control tools of IRS and long-lasting insecticide nets (LLINs) for malaria are being proposed for visceral leishmaniasis. Lymphatic filariasis vector control benefits from both of the above interventions. In addition, larval source management is common to all 3 programmes. Improved housing conditions have the potential to benefit all vector-borne diseases owing to reduction in favourable conditions for vector breeding. Susceptibility of vectors to the commonly used insecticides needs to be routinely monitored for all 3 diseases. Success of vector control programmes also depends on the acceptance and correct usage of the available tools by the community. Appropriate use of LLIN, acceptance of IRS, larval source management, and/or use of personal protective products are prerequisites for successful vector control. Therefore, joint vector management programmes, co-opted for the 3 diseases, x be far more advantageous than segmented individual programmes.Communities: Encouraging community involvement for better healthcare is a vital and common element to the 3 programmes. Active community involvement via household visits, awareness camps, community and religious leaders, and drama and theatre are the usual strategies for malaria, lymphatic filariasis and visceral leishmaniasis. Since the latter 2 diseases have protracted clinical manifestations and are prone to delay in healthcare seeking by the affected, special efforts are made to raise the perception levels of the community. Morbidity management of lymphatic filariasis is the second pillar of elimination strategy (first being mass drug administration) and is deployed via healthcare workers. Thus, high levels of community engagement are essential for all 3 disease control programmes.Logistics and supply chains: Diagnostics, drugs and vector control products utilize the same logistical and transport infrastructure available under the national programme. The vast geographical areas in India pose a challenge to timely provisions. Presently, the overstretched and fragile supply chains need to cater to demands of the 3 programmes. Once consolidated under one umbrella, the pressure on the supply networks may ease, and delivery of essentials may become more efficient.Monitoring and evaluation: Performance of each of the 3 control programmes is assessed periodically although the basic indicators are broadly similar for each. An integrated framework can be envisioned that will accommodate assessment of all 3 simultaneously. Since the surveillance strategies and intervention components will be shared, the monitoring and evaluation can also be assimilated. Integration of this component will be resource efficient and will provide government updates of the 3 eliminable diseases in a broad overarching manner.Health Management Information System: The existing information networks for the 3 diseases comprise of data aggregation from peripheral level (PHC) to centre . The data collection and collation is paper-based and monthly. World Health Orgnanization recommends countries to switch to near real-time data transmission for timely evidence-based decisions. This holds true for all 3 diseases in elimination mode as timely information and data-backed interventions are crucial for the success of the programmes. Information systems, though fragmented and outdated at present, can be made cohesive and data collection can be integrated. Digital platforms would make the convergence of data generated in the 3 disease systems feasible and available for analysis, interpretation and action.As India marches towards the goal of elimination of kala azar (2021), lymphatic filariasis (2021), and malaria (2030), there is a need to reorient and reposition our programmatic structures. Their governance should aim to assimilate the 3 vertical, stand-alone programmes into a single horizontal, and integrated programme. Integration of data from all sources including the private sector and other government sectors is needed for complete information on disease burden and for data-driven decisions . It is a


For instance, while there are many studies of the coral holobiont response in single or limited-number multiple stressor experiments, they provide only partial insights into metabolic performance under more complex and temporally and spatially variable natural conditions. Here, we discuss the current status of coral reefs and their global and local stressors in the context of experimental techniques that measure core processes in coral metabolism  in situ, and their role in indicating the health status of colonies and communities. We highlight the need to improve the capability of in situ studies in order to better understand the resilience and stress response of corals under multiple global and local scale stressors.Coral reefs are declining worldwide due to global changes in the marine environment. The increasing frequency of massive bleaching events in the tropics is highlighting the need to better understand the stages of coral physiological responses to extreme conditions. Moreover, like many other coastal regions, coral reef ecosystems are facing additional localized anthropogenic stressors such as nutrient loading, increased turbidity, and coastal development. Different strategies have been developed to measure the health status of a damaged reef, ranging from the resolution of individual polyps to the entire coral community, but techniques for measuring coral physiology  Coral reef ecosystems are hotspots of biodiversity and productivity in the ocean  that exc2) and other greenhouse gases ] affecting global biogeochemical cycles, biodiversity, and human health , their interactive effects require addressing multiple stressor effects on physiological processes at the holobiont level if we are to comprehensively understand their impacts on coral communities. Some of these drivers have major effects , but there undoubtably are other interactions that can affect the resistance and recovery response of coral communities, factors critical for reef management and proactive preventative planning. However, our current understanding of coral stress responses is largely based on experimental manipulation studies in laboratory systems that are poor representations of their natural habitats. recently . The priThe concept of the coral as a “holobiont” was introduced in the 2000s, whereby the coral comprises not only the animal polyps but also the associated symbiotic organisms, including photosynthetic endosymbionts, bacteria, viruses, fungi, and protists . These hThe family Symbiodiniaceae includes several genera of dinoflagellates, which reside in the tissue of corals and other marine organisms . The corThis continuous loop is stable under normal conditions, but the symbiotic dynamics within the coral holobiont are changing rapidly in the Anthropocene . Tempera2/low pH on corals is highly variable, where it can stimulate growth and photosynthetic efficiency in certain Symbiodiniaceae species (2 had no measurable effect on net photosynthesis (gross photosynthesis – respiration) but decreased biocalcification rates (3−) or phosphate (PO43−) can stimulate both photosynthesis and respiration rates in corals, but not necessarily result in a concomitant increase in net biocalcification (3) may indicate increasing competition for dissolved inorganic carbon (DIC) between coral host and endosymbionts under conditions of high production. Adding further complexity to these responses, ammonia (NH4+) enrichment appears to support coral resistance to thermal stress, unlike enrichments of NO3−, which can lead to increased levels of reactive species and oxidative damage  foundation, which is determined largely by coral energy reserves and the need to maintain optimal chemical conditions in the calcifying fluid at the tissue/calcium carbonate interface. Hard corals build their skeleton of CaCO3 through the uptake of calcium and carbonate ions from seawater. The reaction occurs in the calicoblastic cells lining the surface where primary crystal secretion occurs  is more susceptible to dissolution than that formed by other biocalcifying organisms  that supports and regulate the general homeostasis and plasticity of the coral holobiont. But understanding these in situ observations of coral metabolism from published peer-reviewed scientific literature. We included cases involved in original research on direct  underwater measurements of metabolic rates on both coral individuals and coral communities. We excluded sample collections , laboratory experiments, and indirect measurements of metabolic fluxes .We conducted a literature review based on case studies of in situ metabolism” and “underwater,” excluding the keyword “collection,” in articles published between 1991 and 2020. The search yield  was scrutinized, and the literature was manually reviewed to fulfill our selection criteria described above. A final list of 55 studies was included for the analysis in this review  boundary layer; (5) SCUBA imaging; (6) benthic chambers; (7) submersible chambers; and (8) automated sensors. The database was further classified based on the system type ; measured parameters ; sampling frequency ; sampling scale ; aim of the study (monitoring and experiment); and environmental stressor considered . We ranked the database by publication year  by characterizing the abundance, character, and distribution of light-harvesting pigments  and fluorescent proteins (a sign of immune response and tissue repair) in corals and (ii) as an indicator of how efficiently these pigments are being used to generate energy for the coral, indicated by the photo-physiological status of the endosymbiont.in situ assessments of coral reefs, through the detection of chlorophyll and green fluorescent proteins wide spatial scales  to modify the fluorescence yields, generating multiple turnover for the reduction of PSII, allowing noninvasive chlorophyll fluorescence analysis, quantum yield, and ETR of coral endosymbionts. The introduction of an underwater version of this instrument  facilitated the direct observation of changes in coral health in situ conditions  but more intense light is used to generate a single turnover and reduction of the primary electron acceptor  have been developed to measure biogeochemical processes in both simple (sediments) and structurally complex  reef communities, allowing the in situ study of diverse habitats, such as corals, sediments, and seagrass meadows . Benthic chambers are well-suited to measure these essential parameters in situ . For exain situ . In anotin situ . A similin situ . Here, tin situ . However meadows . The intin situ responses of coral communities. Using a combination of in situ flow chambers and fluorometric techniques, 2 levels on coral communities in short-term experiments ] enables short-term (minutes) quantification of coral photosynthetic, respiration, and biocalcification rates combined with the ability to study the effects of flow and chemical manipulations . It is unclear at what stage these changes in water flow and bulk chemical conditions may begin influencing coral responses. The use of micro- and automated sensors for unenclosed measurements has been developed to help avoid these potential artifacts. These approaches are broadly separated into community-scale and individual coral or polyp scales.2 in the boundary layer  approaches were developed to avoid these potential issues, whereby sensors placed well above the coral interface make unobstructed measurements of vertical gradients in velocity, temperature, and chemical constituents on the open reef to calculate the flux of momentum, heat, and Ory layer . Use of ry layer .Porites spp., turf algae, and crustose coralline algae  in different habitats, including highly productive reef crests relative to reef slopes  method at the DBL and a multiparametric probe in a benthic chamber , althougin situ studies of coral responses in the natural environment (2 enrichment (FOCE) system was used to incubate coral reef communities at ambient pCO2 (393 μatm) and high pCO2 (949 μatm), and a decrease in daily NCC by 49% under high pCO2 was observed over a 21-day experiment, corresponding to 26% reduction in NCC per unit of Ωa  and complex  structures. Standardization of methods and replication of experimental studies would allow the simultaneous measures of coral health in different locations with the ability to compare the ecosystem functions. However, there are limitations to in situ methodologies. In the case of benthic chambers, there are restrictions to which substrate surfaces are suitable for study, and they are not well suited, even with enhanced flow capabilities, for longer-term monitoring of coral health. These restricted systems also have limited spatial footprints and thus may not adequately account for all benthic of pelagic components . In the case of DBL approaches, limitations include the needed maintenance and fragility of microsensors, which can limit deployments to shorter duration, or under more quiescent weather conditions.Laboratory-based studies have provided a strong foundation for understanding coral metabolism and the responses to stress, and they will continue to serve as a primary means of research under controlled conditions. However, the expanding role of 2, dissolved oxygen, pH, and chlorophyll a), able to cover spatial, vertical, and temporal observations  area to calculate the carbon fluxes for productivity and biocalcification estimates (in situ techniques, such as the application of flow respirometry approaches to estimate carbon fluxes over a small spatial scales and different substrate type within a reef, coupled with reef-scale methods that provide an integrative assessment of the temporal variability in coral productivity and growth (Co-deployment of multiple instrumentation approaches, from water chemistry and physics to coral physiology, will be needed to ensure both accuracy and logistic practicality in monitoring fluxes of Ostimates ; the movd growth .WD and JC: conceptualization, methodology, formal analysis, and resources. WD: investigation, data curation, and writing – original draft preparation. WD, JC, CC, JW, MW, and LC: writing – review and editing. WD and CC: visualization. LC: supervision. JW and LC: project administration and funding acquisition. 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.


This study aimed to explore food and nutrition related concerns during the post-lockdown period and their impacts on food shopping, preparation, and eating behaviors. Design: A cross-sectional study was conducted through online questionnaire. We collected data on food and nutrition related concerns, socio-demographic characteristics, and changes in dietary behaviors. Participants: A total of 2267 responses were received from people living in 31 provinces across mainland China and 1994 participants were included in the final analysis. Analysis: Linear and multinomial logistic regression analyses were performed to evaluate the association among food and nutrition related concerns, socio-demographic factors, and dietary behaviors Results: About 56% of participants reported moderate to high levels of concerns related to food and nutrition. Contracting the virus when dining out or through contaminated foods were the top two concerns, followed by overnutrition. Higher levels of concerns were found among people who were older, overweight, or obese, having lower income and education, and living in urban areas, or whose family contained vulnerable individuals. Compared with the pre-COVID-19 period, people who were more concerned about food and nutrition were more likely to report changes in their food purchases and consumption; they were also more likely to eat from individual plates, using serving chopsticks, and separating plates and utensils for raw and cooked foods during the post COVID-19 lockdown period. Conclusion and Implication: Food and nutrition related concerns during the post-lockdown period were prevalent and associated with changes in dietary behaviors. Preventative policies and nutritional guidance should be developed to address these concerns in order to reduce inappropriate dietary behaviors amid public health crises. The coronavirus disease 2019 (COVID-19)—caused by severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) (a novel coronavirus)—is responsible for the current pandemic threatening global public health ,4,5.Rising levels of concern, stress, and anxiety have sounded the alarm regarding public mental health during the pandemic ,7. A sysEating is an integral part of daily life. A balanced diet may enhance immunity, prevent excessive inflammation and weight gain and promote healthy gut microbiocidal composition to battle against infections ,20,21,22Despite a growing number of studies on the mental and behavioral impacts of COVID-19 lockdowns in the literature, research into concerns specific to food and nutrition and how they affect dietary behaviors post-lockdown is sparse. This study aimed to understand how COVID-19 related food and nutrition concerns shape food shopping, preparation, and eating behaviors through surveys conducted post-lockdown in mainland China.We conducted a cross-sectional survey through the Wenjuanxing e-questionnaire platform  in August 2020. This study is the second wave of a longitudinal nutrition study initiated in March 2020 (the first survey) . The curn = 264). Furthermore, participants living outside mainland China (n = 9) were excluded, resulting in a total of 1994 participants’ responses usable for subsequent data analysis.A total of 2267 Chinese residents responded to the survey. Our study participants were recruited from 31 provinces, covering most geographic regions in mainland China. We embedded attention checking questions  to determine the seriousness of respondents; we subsequently removed nonserious participants to improve data quality . These 12 food items originated from the Household Dietary Diversity Score (HDDS) developed to measure household access to food . ParticiFive questions pertaining to food and nutrition related concerns were asked to participants to rate their levels of concerns on five relevant issues: (1) contracting the virus through contaminated foods; (2) contracting the virus when dining out; (3) food supply shortage; (4) overnutrition; (5) undernutrition. We used the Likert scale and assigned one point to “not at all concerned”, two points to “slightly concerned”, three points to “moderately concerned”, and four points to “extremely concerned”. Total score ranging from 5 to 20 for each participant was calculated, ranked from lowest to highest, and then grouped into one of the three categories: low level of concern (level 1: 5–8), moderate level of concern (level 2: 9–11), and high level of concern (level 3: 12–20). Besides, we asked the participants to report perceived changes  in food consumptions and dietary behaviors, such as frequency of seafood consumption and eating out, in comparison to the same period last year (2019). Other eating and cooking related behaviors such as using serving chopsticks and cooking food thoroughly were also asked in the questionnaire and examined in this study.The questionnaire was filled in anonymously. Informed consent was required prior to the survey by clicking the “agree” option to confirm willingness to participate voluntarily in the survey. The online survey was conducted in full agreement with the national and international regulations in compliance with the Declaration of Helsinki (2000). This study was approved by Tsinghua University Health Research Center Ethics Committee (NO.THUSM/PHREC/2020400-004).p-values were obtained. In models adjusting for body mass index (BMI), only 1854 subjects who reported both valid weights and heights were included. We used BMI cutoffs for Asians  to determine participants’ weight categories. All statistical analyses were conducted using Stata version 15.1 . We considered a p-value less than or equal to 0.05 (≤0.05) statistically significant.Demographic characteristics were grouped into categories and presented as percentages by three levels of concerns (created by xtile function in Stata). We assessed associations among categorical variables using Chi-squared test. Simple and multiple linear regression analyses were applied to estimate the effects of food and nutrition related concerns on grocery shopping and food storage patterns, whereas simple and multiple logistic regression were applied to estimate those effects on eating and cooking behaviors. To model the effects of food and nutrition related concern on changes in food consumption and dietary behaviors, we used multivariate multinomial logistic regression in which the dependent variable consisted of three categories  and “no change” was selected as the base outcome. We also ran “testparm” and “test” to perform Wald tests on selected coefficients from which A total of 1994 participants were included in the final analysis. Most study participants’ ages ranged from 18 to 30 (>60%) with 37% identified as male and 83% living in urban areas . There wWe observed that in-person grocery shopping at local markets was the preferred method of purchasing/obtaining food among our study participants  followed by home storage  and online grocery shopping  in the most recent week. Though very few people relied on food distributed through community or government-based programs in the study sample, high level of concerns appeared to associate with an increase in obtaining food from these programs . A high Regarding the perceived changes in the frequency of food consumption and dietary behaviors compared with the same period in the previous year (2019), we detected an overall increasing trend for shopping food online and cooking and eating at home. Apart from that, many participants had reduced their consumption of seafood, raw food, and imported fresh produce . Study pIn this study—among the first reporting food and health related concerns—we observed that concerns exist in the Chinese population even in the post-lockdown era; we found strong associations between several socio-demographic characteristics and a higher level of concern. Moreover, people who were highly concerned about food, nutrition, and health during the current pandemic were more likely to report changes in their dietary behaviors including how or where foods were purchased and cooked, and the frequency of consumption. Results from our study warrant further investigations into the mental and behavioral impacts of the COVID-19 pandemic that are likely to extend beyond lockdowns for years after the pandemic is contained.Recent studies have acknowledged the exposure to COVID-19 related stressors and mental health deterioration as well as their impacts on dietary behavioral changes during lockdowns taking place in many countries ,29,30,31Stresses and concerns may associate with irrational and undesired eating behaviors such as overconsumption of calorie dense foods and extreme eating restrictions, leading to negative health outcomes ,33. HoweImportantly, our study identified several socio-demographic groups that were more vulnerable to experiencing high levels of food and nutrition related concerns during the COVID-19 pandemic. Older age, being overweight or obese, lower annual household income and educational achievements, and living in urban areas or with vulnerable individuals appeared to increase the level of concern pertaining to food supply, nutrition, and risk of contracting the virus through contaminated food or when eating out. About 34% of our study participants were overweight or obese. Obesity is associated with high levels of stress and concerns about nutrition and health and adverse medical consequences ,36. PeopDriven by the pandemic and public health measures for COVID-19 prevention and control, the demand for online food shopping, ordering, and delivery has surged worldwide, in particular in Asian countries like China and South Korea where online shopping has expanded and penetrated extensively . DespiteWe report that food and health related concerns have minimum impacts on people’s preference for the locations where they purchase or obtain foods  post-lockdown. Modification of habits and behaviors, in particular shopping behaviors, can involve multiple factors such as the built environment, availability and timing of information, and individual motivation, all of which contribute to the determination of behavioral change and formation of various lifestyles . FurtherOn the other hand, concerns about food, nutrition, and health may exert positive effects by promoting desired changes in eating and cooking behaviors. Most Chinese people grow up sharing meals with personal chopsticks—an ingrained Chinese dining tradition that shows intimacy around the table. Nonetheless, communal eating may accelerate the transmission of pathogens like coronavirus through saliva  and therMany studies have observed changes in lifestyle and eating behaviors during the pandemic lockdown but very few have explored differences in dietary intake and behaviors comparing the pre-COVID19 era and post-lockdown period as nations reopen and gradually recover from the pandemic. Our data show drastic reductions in the consumption of seafood, raw foods, and imported fresh and raw foods among the study participants compared with the same period last year . The earliest COVID-19 cases linked to the Wuhan seafood market and recent reports of coronavirus detected on packages of imported seafood might have caused public distrust and discouraged people from consuming seafoods ,45. FurtAlterations in food choices driven by food and health related concerns may impact individual health and societal well-being during a disease outbreak . SeafoodNoteworthy, similar exposures  may induce different behavioral responses and outcomes, partly attributable to variations in individual socio-demographic characteristics and other factors such as personal preference, past experience, and environments. We found that higher levels of concern were associated with both increase and decrease in the consumption of frozen food and purchasing food at farmers’ market or online. People who care and express more concerns about food, nutrition and health may tend to take actions or notice and recall their diet and dietary behavior better than those who do not, hence the increased probability of reporting a change (either decrease or increase). Likewise, Poelman and colleagues conducted a cross-sectional study among adults in Netherland and reported that overweight or obese people—a group of people often concern about their diet—were more likely to indicate following a less healthy diet and also more likely to indicate eating more healthily than normal weight people during lockdown. Similarly, certain food items such as chocolate and wine have been favored and consumed by people in increased amounts to improve mood, but disliked and avoided by people who decided to watch their weight and stay in shape during lockdown . InteresThis study has several limitations. First and foremost, it was cross-sectional study, relying on self-reports from participants, therefore making it difficult to establish the temporal and causal relationships between food and nutrition related concerns and dietary behavioral changes. The use of an online survey facilitated the distribution and reach of the survey, but it might also have excluded certain populations like those with limited access to the internet, elders, and people who were poorly educated. Moreover, due to the unrandomized nature of the multi-stage sampling method, selection bias may exist. We also noticed that the food shopping locations provided in the survey might not be all inclusive: “farmers’ markets” was not an option in our study survey, but some studies have included it in their questionnaires. Qualitative studies are still needed to understand how public health crises like the COVID-19 pandemic impact people’s perceptions and choices of various food shopping locations.Our study showed a high prevalence of food and nutrition related concerns during the post COVID-19 pandemic lockdown period and that these concerns were associated with increased probabilities of reporting changes in dietary behaviors including food preparation and consumption. Current dietary guidelines have limited capacity in addressing dietary concerns during a public health crisis and may lack the specificity to provide nutritional guidance for diverse populations. Several socio-demographic characteristics such as age, weight, and income are associated with higher levels of concern about food, nutrition, and health, suggesting the need for proper programs and policies to support vulnerable populations as well as lifestyle guidance to promote healthy eating. Behaviors and habits formed during lockdowns may continue to exist for an extended period. Both psychological and physical consequences of long episodes of lockdown as well as potential persistence of altered behaviors and their effects on individual and societal health in the post-lockdown and post-pandemic era should be further investigated.


Collectively, studies published during the past 15 years suggest the existence of significant endocrine  and neurofunctional alterations  as a result of fatherhood, as well as preliminary evidence of genetic variability accounting for individual differences during the postpartum period in fathers. No studies were so far published evaluating epigenetic mechanisms associated with the paternal brain, something that was also the focus of the current review. We highlight the need for further research that examines neuroplasticity during the experience of fatherhood and that considers both the interplay between hormones and simultaneous assessment of the different biomarkers ; data collection protocols and assessment times should also be refined.During the postpartum period, the paternal brain suffers extensive and complex neurobiological alterations, through the experience of father–infant interactions. Although the impact of such experience in the mother has been increasingly studied over the past years, less is known about the neurobiological correlates of fatherhood—that is, the alterations in the brain and other physiological systems associated with the experience of fatherhood. With the present study, we aimed to perform a scoping review of the available literature on the genetic, neuroendocrine, and brain correlates of fatherhood and identify the main gaps in the current knowledge. PubMed, Scopus, and Web of Science electronic databases were searched for eligible studies on paternal neuroplasticity during the postpartum period, over the past 15 years. Reference lists of relevant key studies and reviews were also hand-searched. The research team independently screened the identified studies based on the established inclusion criteria. Extracted data were analyzed using tables and descriptive synthesis. Among the 29 studies that met our inclusion criteria, the vast majority pertained to neuroendocrine correlates of fatherhood ( The transition to parenthood represents a transformative period, marked by diverse co-occurring biological, psychological, social, economic, and behavioral changes  as a result of our interactions with the environment, allowing for the adaptation to new circumstances and demands . A refleFurthermore, intrinsic individual genetic characteristics, such as subtle changes in the DNA sequence, called single nucleotide polymorphisms (SNPs), might contribute to differences in parental responsiveness. Indeed, studies with mothers show that variability in parenting styles can be moderated by polymorphic variations in target genes associated with affiliative and reward systems. Particularly relevant in this regard is the oxytocinergic pathway, which includes the oxytocin neuropeptide (OT) and the oxytocin receptor (OXTR). Generically, genetic variability in the OXTR gene has been associated with sociability, caregiving, and parenting , with paAlthough growing neuroimaging, molecular and hormonal-based literature has explored the neurobiological basis of parenthood, the majority of research has been conducted on human mothers during pregnancy or the postpartum period e.g., , and lesDiverse reviews on fatherhood focus on different correlates and measures, such as neuroendocrine e.g.,  and funcA. What is known about the molecular mechanisms (genetic and epigenetic) related to fatherhood?B. What is known about the neuroendocrine correlates of fatherhood?C. What is known about the neurostructural correlates of fatherhood?D. What is known about the neurofunctional correlates of fatherhood?Our review aim was too broad to be addressed by a systematic review; instead, it was thought to be better addressed by looking at the scope and nature of the research pertaining to the neurobiological correlates of fatherhood, while identifying research gaps  and assessed outcomes from infant birth to 1 year postpartum; assessed neuroendocrine , brain structural changes , brain functional changes , and/or molecular mechanisms (genetic and epigenetic) among fathers; and were written in English language. The limited timeframe (0–12 months) was selected based on the focus of the review .Psychiatric or neurological disorders (in both father and infant) and premature birth were excluded, as the focus of the review was on normative correlates associated with fatherhood. Older adults were excluded as well (>60 years old), given the existing negative association between age and structural alterations in healthy aging e.g., . We exclSearches were performed in PubMed, Scopus, and Web of Science electronic databases. Following the Joanna Briggs Institute methodology , a threek = 0.86, indicating almost perfect agreement.Screening was conducted in the Rayyan QCRI software , where aa priori, including the following information: author name, year of publication, study design, participant characteristics, methodology, and key findings. Individual data forms were constructed for the different measures available.The included reports were split across two teams of reviewers responsible for extracting data on different neurobiological correlates. FP and MS extracted structural and functional data, while JA, SM, and BP extracted data concerning neuroendocrine and genetic/epigenetic measures. The team cross-reviewed each other’s extraction. After comparing each reviewer’s charted data, disagreements were resolved through discussion and a third reviewer when needed as well. A data charting form was developed In accordance with scoping review guidelines , an asseThe selection process of sources of evidence was adapted from the Preferred Reporting Items for Systematic Reviews and Meta-Analysis flow diagram. After the removal of duplicates, 1,492 citations were reviewed. Of these, 1,426 were excluded based on the title and abstract. Of the remaining 66 full-text articles assessed for eligibility, 37 were excluded for different reasons, detailed in the Flow Chart in Details of each study are provided in cf. In the endocrine and molecular domains, 21 articles met the inclusion criteria cf. , of whicn = 13, cf. The majority of studies reported longitudinal quantitative data n = 13, . Seven oBesides controlling for the effect of time of day for hormone values, the majority of the reviewed studies included the following covariates in their models or examined potential correlations with those prior to data analysis: parent age ; educatiTo our knowledge, only two studies addressed the association between genetic variability in two different genes (CD38 and OXTR) and paternal behavior and endocrine changes. Specifically, Oxytocin. Only one study compared OT levels between fathers and non-fathers, showing that parents had higher OT levels than non-parents , which does not correlate with both saliva and plasma OT levels  when compared to the infant’s birth day  on day two postpartum (SD = 2.14) and 6 months post-partum . Furthermore, a greater father’s involvement in play and childcare at 2–4 months postpartum was associated with father’s greater basal CORT levels and reactivity to first time holding their babies at infant’s birth day  followed a longitudinal design . SamplesInfant stimuli were used across studies to evaluate fMRI responses, with two studies using auditory stimuli , other unknown matched infant (OTHER), as well as control stimuli DOLL; . Whole-bThe whole-brain study by Finally, in the whole-brain study by The study by Two studies observed associations between the hormone OT and neural responses. The study by In our scoping review, we identified 29 primary studies published between 2005 and 2020 addressing neurobiological correlates of fatherhood. Specifically, 19 studies were retrieved for neuroendocrine biomarkers, two for SNPs of candidate genes, one for structural neuroimaging, and seven for brain activity or functional connectivity. Overall, there seems to exist some evidence in favor of significant neuroendocrine and neurofunctional changes, as well as a role for genetic variability in the transition to parenthood in fathers. On the contrary, there was limited or non-existent research focusing on structural brain changes and other molecular mechanisms such as epigenetic modifications associated with fatherhood outcomes  during the postpartum period.via nasal administration also show that this hormone increases paternal caregiving behaviors such as touch, social reciprocity, greater physical proximity to the child, and readiness for social engagement  or examined potential correlations with those prior to data analysis, future research should consider other covariables that importantly impact parenting, such as the level of father’s investment in child’s care , as well as measures of relationship functioning and satisfaction. Indeed, both relationship effort and parental effort are thought to influence male parental care , with paDuring the postpartum period, endocrine regulation arising from parent–infant interactions may influence complex structural and functional changes in the brain, mediating caregiving responses. Differences in fathers’ hormonal levels during the postpartum period were found to be associated with neural activation to infant stimuli in several brain regions . OverallAlthough not in the scope of our review  and EU through the European Social Fund and the Human Potential Operational Program – IF/00750/2015. JA was supported by the Psychology Research Centre (UI1662), University of Minho, through an individual Research Fellowship (UMINHO/BIM-CNCG/2021/28), framed by the Multiannual Funding of R&D Units (UIDB/01662/2020), and supported by the Portuguese Foundation for Science and Technology (FCT)/Ministério da Ciência, Tecnologia e Ensino Superior (MCTES) through national funds (PIDDAC). RG, BP, and MS are supported by a Ph.D. Grant  and sponsored by the Portuguese Foundation for Science and Technology. AG-Á is supported by the Portuguese Foundation for Science and Technology [Individual Call to Scientific Employment Stimulus – 3rd Edition 2019 – 2020.02059.CEECIND]. AM, AS, and IS are also supported by the Psychology Research Centre (PSI/01662), School of Psychology, University of Minho, through the Portuguese Foundation for Science and Technology by the Portuguese State Budget (Ref.: UIDB/PSI/01662/2020). The Center for Research in Neuropsychology and Cognitive and Behavioral Intervention (CINEICC) of the Faculty of Psychology and Educational Sciences of the University of Coimbra is supported by the Portuguese Foundation for Science and Technology and the Portuguese Ministry of Education and Science through national funds and co-financed by FEDER through COMPETE2020 under the PT2020 Partnership Agreement [UID/PSI/01662/2013].The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.All claims expressed in this article are solely those of the authors and do not necessarily represent those of their affiliated organizations, or those of the publisher, the editors and the reviewers. Any product that may be evaluated in this article, or claim that may be made by its manufacturer, is not guaranteed or endorsed by the publisher.