Alzheimer's disease (AD) and Parkinson's disease (PD) are neurodegenerative disorders characterized by cognitive impairment and functional decline increasing with disease progression. Within non-pharmacological interventions, transcranial direct current stimulation (tDCS) might represent a cost-effective rehabilitation strategy to implement cognitive abilities with positive implications for functional autonomy and quality-of-life of patients. Our systematic review aimed at evaluating the effects of tDCS upon cognition in people suffering from AD and PD. We searched for randomized controlled trials (RCTs) into PubMed, Web of Science, and Cochrane Library. Three review authors extracted data of interest, with neuropsychological tests or experimental cognitive tasks scores as outcome measures. A total of 17 RCTs  were included. Compared with sham stimulation, tDCS may improve global cognition and recognition memory in patients with AD and also some executive functions  in patients with PD. Criticism remains about benefits for the other investigated cognitive domains. Despite preliminary emerging evidences, larger RCTs with common neuropsychological measures and long-term follow-ups establishing longevity of the observed effects are necessary for future research in applied psychology field, alongside improved clinical guidelines on the neurodegenerative disorders pertaining electrodes montage, sessions number, duration and intensity of the stimulation, and cognitive battery to be used. This pepars compacta of the substantia nigra, typical motor symptoms are characterized by resting tremor, rigidity, bradykinesia, and postural instability. Patients with PD show additional motor deficits including gait disturbance and motor complications, such as dyskinesia in the course of the disease  to PD dementia (PDD). Cognitive impairment is quite common in PD, affecting approximately 30–40% of the patients  , 40, 41,Our systematic review tried to bypass the aforementioned limitations and represents an update systematic review of RCTs evaluating the effects of tDCS upon cognition in AD and PD as a stand-alone technique  compared with sham  stimulation.Preferred Reporting Items for Systematic Reviews and Meta-analyses (PRISMA) Statement  or high-definition tDCS techniques; (2) other noninvasive brain stimulation techniques ; (3) studies recruiting individuals with neurological disorders different from AD and PD  or classified as having mild/major neurocognitive disorder and also psychiatric diseases and other relevant medical conditions that might interfere with cognitive functioning; (4) studies recruiting healthy older adults; (5) animal studies; and (6) manuscripts written in other languages than English.Studies from the literature search were selected if they met the following criteria: (1) assessing the effects of tDCS on cognitive functioning; (2) including patients with AD or PD selected by recognized international diagnostic criteria, i.e., NINCDS–ADRDA criteria for AD  and UK BQuality Assessment Tool for Quantitative Studies   first evaluated methodological criteria used by RCTs examining tDCS effects upon cognition in AD  and PD  patients Studies  developen = 305), we screened the titles and the abstracts of the remaining records and identified 19 articles for a full-text inspection. Two studies  scores was present among studies, with that of   by tDCS of the temporal cortex –52 whileIn patients with PD, executive efficiency was enhanced either thanks to the stimulation of DLPFC as a single brain area through variable sessions of treatment i.e., 1–10 sessions) at 1–2 mA of 20-min current stimulation  sessions, 61 or tTranscranial DCS was well tolerated by the patients even if some side effects were sometimes reported  e.g., , 54, 58], 5854, 5placebo) stimulation. Transcranial DC stimulation seems to ameliorate cognitive vitality of patients in relation to global cognition and recognition memory in AD and divided attention, verbal fluency, and reduction of sensitivity to interference in PD, respectively. From a neuropsychological point of view, criticism remains about potential usefulness of tDCS for working memory, processing speed and visual attention, visuospatial abilities and verbal learning performances while initial proof arises about language improvement after tDCS.This systematic review aimed to provide a comprehensive overview of the current knowledge about the effects of tDCS stimulation upon cognition for patients with AD and PD when compared with sham , tDCS delivery settings , concomitant pharmacological therapy and concurrent psychopathological symptoms, particularly depression and apathy not routinely evaluated except for some investigations represent confounding variables that make difficult to compare among studies [cf. ].In four cases , 59, 62,Some researchers , 53, 54 via the glutamatergic corticostriatal pathway, as shown in animal studies  and EEG activity, may offer supplementary information able to deeply investigate brain circuitry modulation. For example, mechanisms of cortical plasticity have been investigated in patients with AD by TMS protocols, such as theta brust stimulation (TBS) showing a clear impairment of long-term potentiation (LTP) cortical-like plasticity and a relative sparing of long-term depression (LTD) mechanisms in AD . There iThese observations could lead researcher to implement neurostimulation techniques exploring different sites of stimulation or to even consider multisites techniques that could give more insight on the correct parameters to be used. A recent area of interest is represented by an implementation of tDCS technique, namely, high-definition tDCS , a novel approach that uses smaller electrodes whose configuration can be optimized for targeting specific brain regions . Such a Given the relatively minor neurodegenerative changes, tDCS appears to be more promising in early phases of the disease, i.e., MCI due to AD and in the Parkinson's disease mild cognitive impairment (PD-MCI), as confirmed by preliminary investigations also when it is delivered alongside cognitive or physical training –88. AccoDespite emerging evidences, the larger RCTs are welcome in the next future for replicating preliminary results on patients with AD and PD and for measuring the effects on different outcomes beside cognition  allowing researchers to depict a more comprehensive analysis of tDCS potential.at-home rehabilitation strategy under supervision of therapists, in order to improve personalized medicine purposes [cf. (Cortical plasticity and connectivity result to be impaired in the neurodegenerative conditions and neurophysiological findings could provide more robust evidence about the implementation of tDCS protocols for these diseases. The optimization of tDCS protocols should also start from early response of the patient to the treatment. Future tDCS studies would also take advantage of computational models to ensure a calibration of the stimulation technique on specificity of the patient . Finallyses cf. –93]..at-home The original contributions presented in the study are included in the article/supplementary material, further inquiries can be directed to the corresponding author.DMC made the most substantial contribution in data conception, knowledge synthesis, acquisition, analysis, interpretation of data, and as well as manuscript writing. FC and RC were involved in checking for quality of the studies and risk of bias evaluation. UB and GC revised the paper for intellectual content. All the authors approved the final version of the manuscript.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.


While age friendly city (AFC) initiatives aim to build supportive physical and social environments for older adults, dementia-friendly initiatives (DFI) see the critical need of persons living with dementia (PWD) to be included in society. Given the close relationship between advanced age and dementia risk, communities facing challenges of aging and dementia will benefit from the integration of DFI and AFC. This study aims to summarize the differences between AFC and DFI practice and to identify integrative models for DFI and AFC based upon cases in the U.S.A and China. Qualitative interviews with 11 stakeholders from Massachusetts and Michigan of the U.S.A. and Beijing and Shanghai in mainland China were recorded via Zoom and transcribed for analyses in order to identify different integration models. A summary of differences and commonalities between AFC and DFI core values, key players, major activities, and outcomes is reported. Four practice models of AFC and DFI based upon case analyses were described as sequential integration, concurrent integration, sequential separation, and concurrent separation. Massachusetts’ model is unique in the support from the state government to integrate both from the beginning, and Michigan witnessed separate efforts between grassroots-based agencies and the state government. Shanghai model represents a sequential integration that includes DFI in local government’s long-term aging policy plan, while AFC and DFI in Beijing have a loose connection despite progress made for each initiative. Communities need to develop a practice model considering its local community needs, policy support, and sustainable resources available.


The purpose of this review is to summarize research articles that provide risk estimates for the historical and future impact that climate change has had upon dengue published from 2007 through 2019.Findings from 30 studies on historical health estimates, with the majority of the studies conducted in Asia, emphasized the importance of temperature, precipitation, and relative humidity, as well as lag effects, when trying to understand how climate change can impact the risk of contracting dengue. Furthermore, 35 studies presented findings on future health risk based upon climate projection scenarios, with a third of them showcasing global level estimates and findings across the articles emphasizing the need to understand risk at a localized level as the impacts from climate change will be experienced inequitably across different geographies in the future.Dengue is one of the most rapidly spreading viral diseases in the world, with ~390 million people infected worldwide annually. Several factors have contributed towards its proliferation, including climate change. Multiple studies have previously been conducted examining the relationship between dengue and climate change, both from a historical and a future risk perspective. We searched the U.S. National Institute of Environmental Health (NIEHS) Climate Change and Health Portal for literature (spanning January 2007 to September 2019) providing historical and future health risk estimates of contracting dengue infection in relation to climate variables worldwide. With an overview of the evidence of the historical and future health risk posed by dengue from climate change across different regions of the world, this review article enables the research and policy community to understand where the knowledge gaps are and what areas need to be addressed in order to implement localized adaptation measures to mitigate the health risks posed by future dengue infection.The online version contains supplementary material available at 10.1007/s40572-021-00322-8. Aedes aegypti and Aedes albopictus mosquitoes [According to the World Health Organization, an estimated 390 million (range 284–528 million) people worldwide are infected with dengue annually, 96 million range 67–136 million) of which present clinical manifestations [squitoes . Further6 millionsquitoes . Many fasquitoes , 16. Weasquitoes . Throughsquitoes –22. Sevesquitoes –29.Possessing an understanding of what epidemiological evidence currently exists on how climate change has historically impacted the risk of dengue infection, and how it may impact future risk, is important to understand so that future funding can be directed towards addressing knowledge gaps in order to better inform the development of localized health adaptation strategies. In this study, we synthesize recent literature assessing the historical and future health risk of dengue infections from climate change across all regions of the world.From April to June 2020, we searched the U.S. National Institute of Environmental Health Sciences (NIEHS) Climate Change and Health Literature Portal , which mStudy data, health and climate information, and key findings were extracted from each relevant paper and subsequently organized by continent, then alphabetical name of country, and chronological order of publication date. Studies providing historical health risk estimates are presented in Table A total of 654 studies (no duplicates) were initially retrieved for screening and assessed for possible inclusion. After exclusion of non-pertinent articles, 30 studies met the final inclusion criteria for providing historical dengue health risk estimates based upon changes in climate variables and 35 studies met the final inclusion criteria for providing future dengue health risk estimates based upon climate projection scenarios Fig. . Most stn=24), with Vietnam having the most studies from Asia (n=6). Air temperature (presented in units of °C), rainfall (in mm), and humidity (%) were the key climate variables , sunshine hours (n=3), sea surface temperature (n=3), atmospheric pressure (n=2), dew point (n=2), and normalized difference vegetation index . Statistical analysis involved dengue case data that ranged in length from 3 to 28 years on a frequency of daily, weekly, monthly, or annual aggregates that were either clinically diagnosed (n=16) or laboratory confirmed (n=14). In addition, 18 of the papers included an assessment of lag effects (between climate conditions and dengue cases) that ranged from a few days up to eight months. The studies that were ascertained, based upon the search criteria, developed health risk estimates utilizing a variety of advanced statistical models that included generalized linear models, Poisson and logistic regression, and semiparametric techniques including generalized estimating equations, many of which integrated additional approaches that encompassed negative binomial, nonlinear, or quasi-methods and the incorporation of lag effects. Furthermore, one study by Anno et al. (2015) notably utilized spatial statistical analysis. A summary of significant risk estimates for each study is presented Supplementary information .Nearly all of the 30 studies presenting risk estimates of health impact based upon historical data see Fig. were froFor developing health risk estimates for contracting dengue based upon changes in temperature , decrease (n=3), or no change (n=1) for future dengue infections  utilized climate projections from the Special Report on Emissions Scenarios (SRES) [n=5). Furthermore, 20 of the studies provided health projection estimates based upon historical infection data, while the remaining 15 studies provided infection potential estimates based upon changes in mosquito habitat. In terms of geographic focus, 10 of the studies provided global-level estimates, seven were in Asia, six in Australia, and the rest spread across the remaining continents (excluding Antarctica). Furthermore, the studies developing these future dengue case projection estimates utilized a variety of approaches that encompassed statistical, mechanistic, mathematical, and ecological models.Of the 35 studies providing health-related risk estimates for contracting dengue based upon future climate projection scenarios extending as far out as the year 2100, 20 studies indicated an increase in future potential for dengue infection, while the others indicated a mixed direction  , while os (SRES) , or a vaA. aegypti mosquitoes could expand northward in eastern North America as well as in South and East Asia, and southward in Africa and Australia, while also broadening the distribution potential in the interior region of South America and Central Africa [A. aegypti worldwide to contract in the strongly positive climate areas, while currently unfavorable areas, such as inland Australia, the Arabian Peninsula, southern Iran, and some parts of North America may become climatically favorable utilizing the SRES A1B and A2 scenarios. Interestingly, Messina et al. (2019) indicated similar potential expansion as the prior two studies mentioned utilizing the RCP 6.0 scenario, which is known to be similar to the SRES A1B scenario [For the 10 studies that provided only global-level estimates for changes in future dengue case (see Table l Africa . Similarscenario . From a scenario . Proestoscenario  and a 20scenario  indicaten=6). Most of these studies indicated an increase in potential transmission, with Kearney et al. (2009) demonstrating an interesting finding of increased habitat suitability throughout much of Australia by the year 2050, with changes to water storage practices in response to drought as having great influence upon this [Across the regions of the world, seven studies were conducted in Asia  were found to be focused upon the North American continent, with three studies projecting an increase in dengue infection [For the European continent, four studies were found, all of which showed increase in dengue potential, with three of the four studies providing estimates for all of Europe  were found focusing upon Brazil, Ecuador, and Latin America, all indicating a heavy geographic dependence for either the increasing or decreasing probability of contracting dengue  has a life cycle that can be impacted by rainfall and temperature . As tempn=16 studies), which can be conflated with other diseases that display similar symptoms to dengue. A key area of research requiring attention stemming from this revolves around understanding how climate change impacts the four different serotypes of dengue. Additional research is needed to further understand the risk of historical incidence and future projections of contracting dengue across different serotypes, as well as how this risk changes across different demographic groups and geographic areas. In addition to the health research needed in the realm of how climate change impacts dengue, an improved understanding is also needed around the health–economic impact. Improving upon the understanding of costs associated with the diagnosis and treatment of dengue symptoms can lead to a better understanding of how interventions can benefit from both a health as well as economic lens.From the studies reviewed for both historical and future health risk assessment, there are several key areas of research that would benefit from additional focus moving forward. Foremost, it is clear that the impacts of climate change can vary greatly based upon locale, thus impacting the probability of contracting dengue accordingly. Conducting localized health impact assessments (and developing subsequent projections) is needed at the sub-country level so that those in the health sector can develop geographically relevant adaptation measures. Based upon the studies found, more broadly, the European continent is in need of additional research for historical risk assessments, while the African continent is in need for research related to both historical assessments and future dengue case projections. Reviewing the studies revealed limitations, a key one being that many of the historical studies are based on clinical diagnosis  given that many countries, particularly low- and middle-income countries, may not have the capacity to continuously assess the scientific literature for updates on risk related research that will have great implications for how they allocate future resources towards the development of adaptation measures. Another action that may serve to advance the climate–health research agenda is to integrate frameworks similar to the US CDC’s Climate-Ready States & Cities Initiative  into howDengue is one of the fastest spreading infectious diseases known, and climate change is a key driver of this change. Possessing an understanding of how climate change impacts the potential for contracting dengue enables the health sector to design robust and localized adaptation measures that span high-level policy response, improved forecasting and early warning systems, resource planning and allocation for health facilities, and communicating with the public. This study provides an overview of the historical and future health risks posed by dengue from climate change and enables the research and policy community to understand where the knowledge gaps are and what areas need to be addressed in order to mitigate the health risks posed by future dengue infection.ESM 1(XLSX 16 kb)


Type 2 diabetes (T2DM) and hypertension are major health problems, with an undisputed growth burden in the past decades. When uncontrolled, both conditions have many consequences regarding health, wellbeing and health care costs. The basis for action to tackle T2DM and hypertension lies in raising awareness regarding the need for early prevention, timely diagnosis and effective treatment. Yet, the lack of supportive environments for healthy lifestyles, and the lack of access to quality health care means, makes design of public health initiatives imperative to promote sustainable lifestyle changes for all.Nutrition and Lifestyle for the Prevention of Type 2 Diabetes and Hypertension, aimed at gathering novel scientific knowledge regarding prevention or treatment of these diseases through modification of lifestyle behaviors and highlights the environmental and social factors that act either as facilitators or constraints.Although there are several options for drug intervention, lifestyle changes are still the cornerstone of both prevention and treatment. Several nutrients, food items and dietary and lifestyle patterns have proven effective in recent studies, and several mechanisms have been described to support the protective roles of such interventions on both T2DM and hypertension. However, regarding a holistic approach for the prevention and management of both health conditions, we are still at the beginning of discovering the most cost-effective initiatives for promoting sustainable lifestyle changes and ensuring equity and access to healthcare services for all. The special issue entitled Regarding T2DM, several meta-analyses, reviews, observational and intervention studies have highlighted the dietary and lifestyle modifications related to reduced risk. The review by Altobelli et al. , highligRegarding intervention studies, results from the large school and community-based intervention “The Feel4Diabetes Study”, targeting high risk families for developing T2DM, Manios et al., showed that an approach including counselling sessions for behavior modification was particularly successful by decreasing sugary food items and sedentary time, and increasing breakfast and fruit intake , conductAmong the observational studies published in the special issue, several interesting findings regarding dietary and lifestyle behaviors in various health ages and special population groups were highlighted. Among the three observational studies in adults, in the prospective study of Bennasar-Veny et al. , involviRegarding hypertension, three observational studies were published in the special issue. Starting with the baseline data of the PREDIMED study, Gallardo-Alfaro et al. , revealeIn the present special issue, several sociodemographic factors related to adherence and maintenance to a healthier lifestyle pattern in relation to T2DM and hypertension risk reduction are revealed. Results from the large school and community-based intervention “the Feel4Diabetes-study” targeting high-risk families for T2DM, showed that sociodemographic characteristics, certain perceptions, beliefs and attitudes, affected the outcome of the two-year intervention. Specifically, regarding glycemic indices , Moschonis et al. revealed that those who benefited most were males, younger people, and those with higher education, living in southern and eastern Europe, perceiving their body weight to be higher than normal . RegardiAnother important topic raised in the special issue by three articles was the use of telemedicine and electronic health programs. In this regard the umbrella review by Timpel et al. , which gFinally, an interesting topic highlighted in the special issue is the need for early identification and timely prevention for both T2DM and hypertension. In this regard the study of Kanellakis et al., developed two self-reported tools for early identification of insulin resistance and hypertension . Such toThe present special issue gathers novel scientific findings regarding diet, lifestyle and sociodemographic factors affecting T2DM and hypertension. These findings could support future public health initiatives aiming to deliver holistic and sustainable lifestyle changes for the prevention and management of these chronic health conditions, prioritizing health equity for all.


Cyberbullying is becoming prevalent among health care professionals and may cause a variety of mental health issues. Traditional and complementary medicine practitioners remain an important pillar of the health care system in Malaysia.This paper presents a study protocol for an online survey  that will collect the first nationwide representative data on cyberbullying behavior among traditional and complementary medicine practitioners in Malaysia. The objectives of the survey are to (1) evaluate the cyberbullying behavior among traditional and complementary medicine practitioners in Malaysia, (2) identify sociodemographic and social factors related to cyberbullying, and (3) evaluate the association between cyberbullying behavior, sociodemographic, and social factors.A snowball sampling strategy will be applied. Traditional and complementary medicine practitioners who are permanent Malaysian residents will be randomly selected and invited to participate in the survey (N=1023). Cyberbullying behavior will be measured using the Cyberbullying Behavior Questionnaire (CBQ). Data on the following items will be collected: work-related bullying, person-related bullying, aggressively worded messages, distortion of messages, sending offensive photos/videos, hacking computers or sending a virus or rude message, and threatening messages about personal life or family members. We will also collect data on participants’ sociodemographic characteristics, social factors, and substance abuse behavior.This cross-sectional descriptive study was registered with Research Registry . This research work (substudy) is planned under a phase 1 study approved by the Research Management Centre, Xiamen University Malaysia. This substudy has been approved by the Research Ethics Committee of Xiamen University Malaysia (REC-2011.01). The cross-sectional survey will be conducted from July 01, 2021, to June 30, 2022. Data preparation and statistical analyses are planned from January 2022 onward.The current research can contribute to identify the prevalence of workplace cyberbullying among Malaysian traditional and complementary medicine practitioners. The results will help government stakeholders, health professionals, and education professionals to understand the psychological well-being of Malaysian traditional and complementary medicine practitioners.Research Registry Unique Identifying Number 6216; https://tinyurl.com/3rsmxs7uPRR1-10.2196/29582 Adverse consequences of cyberbullying behavior in the workplace are well-documented ,2. The nThe prevalence of cyberbullying in the workplace has raised some serious global public health concern. A Swedish survey estimated the prevalence of workplace cyberbullying to be 9.7% , based oCyberbullying behavior has psychological effects on the affected individual, such as social anxiety , emotionThe World Health Organization has expressed concern with the prevalence of bullying among students and employees globally -23. ReceUsing the workplace Cyberbullying Behavior Questionnaire (CBQ), this study aims to provide the first nationally representative data on cyberbullying behavior among traditional and complementary medicine practitioners in Malaysia. Objectives of the CBQ survey are to (1) evaluate the cyberbullying behavior among traditional and complementary medicine practitioners in Malaysia, (2) identify sociodemographic and social factors related to cyberbullying, and (3) evaluate the association between cyberbullying behavior, sociodemographic, and social factors. In the following sections, we discuss the research design and methods and present an overview of methodological challenges, strengths, and limitations related to the study design and sampling strategy.This is a cross-sectional descriptive study performed using the Cyberbullying Behavior Questionnaire (CBQ and its short version [CBQ-S]), which was administered to traditional and complementary medicine practitioners in Malaysia. The questionnaire includes 32 questions see  in a cloIndividuals were selected for study participation according to the following inclusion criteria: traditional and complementary medicine practitioners working in the public and private sector in Malaysia; and currently practicing in any one of the practice areas recognized by the Ministry of Health Malaysia .All eligible participants will be contacted through official Facebook pages of the Malaysian Society for Complementary Medicine, Federation of Chinese Physicians and Acupuncturists Associations Malaysia, Malaysian Chinese Medical Association, TCM & Western Naturopathic Malaysia, Traditional Malay Medicine Association, Majlis Perubatan Homeopathy Malaysia, Association of Chiropractic Malaysia, Malaysia Osteopathy Association, and Malaysian Health Qigong Association.Individuals were excluded from study participation according to the following exclusion criteria: not traditional and complementary medicine practitioners in one of the recognized practice areas and practitioners who did not give consent.Using traditional sampling strategies to recruit hard-to-reach population faces several hurdles. In this regard, a snowball sampling method is valuable. It is a technique to find research participants with the help of name suggestions from a single participant: initially, 1 participant is identified and then a chain of participants related to the first one is identified. This remains one of the valuable sampling strategies in descriptive studies . We willTraditional and complementary medicine practitioners will be selected from both public and private sectors in Malaysia. The total number of traditional and complementary medicine practitioners in Malaysia is approximately 15,000 (data as of 2011) . HoweverAll data are stored in a password-protected electronic format on OneDrive cloud (Microsoft). To ensure participant anonymity, the survey will not contain any information that will personally identify the participants. The study results will be used for research purposes only. This study will be conducted according to the Declaration of Helsinki and the guidelines of the National Committee for Clinical Research . The stuParticipants will use SurveyMonkey to accept or decline participation. Participants will be invited via Facebook pages of medical associations. There will be a reminder every 2 weeks to follow-up on the status of the questionnaire with participants. The items in the questionnaire were chosen according to previous studies by Einarsen et al , Farley Descriptive statistics and exploratory structural equation modeling will be used to assess sociodemographic and social factors related to cyberbullying and evaluate the association between cyberbullying behavior, sociodemographic, and social factors. Statistical analysis will be performed using SPSS (version 26) and SPSS AMOS/ADANCO (IBM).This cross-sectional descriptive study was registered with Research Registry . This research work (substudy) is planned under a phase 1 study approved by the Research Management Centre, Xiamen University Malaysia, whose protocol has already been published . This suThis exploratory study will provide the first nationally representative data on workplace cyberbullying for traditional and complementary medicine practitioners in Malaysia. The data collected and analyzed will explore the relationship between workplace cyberbullying and social factors. A significant strength of the study is the use of a validated measurement tool (CBQ and CBQ-S), which is a combination of different instruments validated for different population groups (Swedish and American) . CompareCBQ and CBQ-S are specifically administered to evaluate cyberbullying behavior in the workplace. Understanding the prevalence of cyberbullying is the first step in the formulation of evidence-based interventions for promoting the mental health of both perpetrator(s) and affected individual(s). Our sampling strategy has both strengths and limitations. Participants will be conveniently selected from the Facebook pages of various professional associations of traditional and complementary medicine practitioners using the snowball sampling method . The surThe CBQ survey results will provide data to identify the prevalence of workplace cyberbullying among traditional and complementary medicine practitioners, identify a correlation between social factors and cyberbullying behavior, and guide the implementation of related interventions for traditional and complementary medicine practitioners in a Malaysian context. Data from this survey will help improve mental health strategies to promote mental health education among health care professionals.


Medical School Outreach Programming provides value to medical schools and the community by: (1) fulfilling medical school accreditation requirements, (2) creating pipelines to promote diversity in future healthcare professionals, and (3) providing medical students with opportunities for extracurricular community-level engagement. An Outreach Program initiated at a U.S. community-based medical school provides a medical student-led model with primary goals of improving college candidacy and healthcare career representation for underserved and under-represented minorities in the United States. The Outreach Program also promotes the personal growth and education of medical students. Medical School Outreach Programming functions to fulfill medical school accreditation requirements, create pipelines for talented, diverse future health professionals, and provide opportunities to engage medical students with opportunities for leadership, extra-curricular learning, and community engagement. Current accreditation standards pertaining to medical education programs leading to the Doctor of Medicine (M.D.) degree contain requirements for community service and/or service learning as designated by the Liaison Committee on Medical Education. The LCME explains these requirements in Functions and Structure of a Medical School . StandarThe primary aim of the Outreach Programming is to increase racial and ethnic diversity in the next generation of healthcare workers by creating pipeline programming for students in local public schools with interest in pursuing medical career pathways. Community-Based Medical Schools (CBMS) across the United States have a goal of incorporating medical students into the local social and medical communities in which their learning occurs . This tyThe program goals include:1. Create an enriched 6-12th grade pipeline within the local County Public School System to increase recruitment/retention of minorities and economically disadvantaged students with interest in healthcare education.2. Improve grade point averages in science to improve college and health professional school candidacy.3. Strengthen students desire to pursue a career in healthcare as measured by career decidedness surveys.Selection of participantsThe Outreach Program serves Title I Schools in the local community; these are schools in which children from low-income families, as determined by the federal poverty line, make up at least 40 percent of total enrollment .Students were provided information about the Outreach Program by their teachers and by medical students who visited local Title I schools. Students grade 6 through grade 12 submitted an online application for the Outreach Program. The application included demographic information as well as free-response essays to questions pertaining to their interest in Medicine and Healthcare. Teachers also provided recommendations for students. All students who applied to this program must have met the following eligibility criteria: (1) active enrollment in school, (2) a passing score on their respective grade-level state assessments and (3) a passing score on an internal assessment which includes two essays and an interview. Students were then selected based on teacher recommendation, application responses, and demonstrated interest in the program. The Outreach Program has a capacity to accommodate approximately 120 students from each grade level from local Title I schools. In the academic year 2018-2019, there were 1,175 total applications and 823 were selected (70%). These students were then scheduled by their school district bus system to meet at the CBMS campus twice weekly. The Outreach Program supports underrepresented and under-served minorities on their path towards Medicine. Students come from economically disadvantaged and diverse racial/ethnic backgrounds. Many students are eligible for free/reduced lunch, reside in homes where English is a second language, have parents who cannot navigate a path to higher education, and will be first-generation college students.Medical students are given opportunities to volunteer with the Outreach Program beginning in their first year of medical school. Medical students at the CBMS are able to sign up for volunteer shifts based on availability. There are also opportunities for leadership in the Outreach Program that medical students may apply for throughout their medical school career.Program overviewStudents who participate in the Outreach Program engage with biomedical science curriculum which includes college access/prep, mentoring and skill-building activities to enhance creativity, collaborative problem-solving, and self-directed learning. The healthcare-specific activities include medical simulations, dissections, labs, and in-classroom instruction created and led by the CBMS medical students and faculty. This programming enables students to learn biomedical concepts using robust hands-on activities, utilizing the same “high-tech/high-touch” state-of-the-art medical school facilities and curricular innovations used to teach nursing students, medical students, medical residents and first responders. Embedding the Outreach Programming over a longitudinal pathway provides educational, mentorship and enrichment opportunities for local 6-12th grade students, strengthens their confidence in the sciences and promotes retention and success along their educational and health career pathway [Students who participate in the Outreach Programming engage in in-classroom teaching at their respective middle/high school by medical students, in addition to activities on the medical school campus. These activities are aligned to local district curricula and are designed to support different learning styles. The Outreach Program curriculum components all directly mimic teaching techniques and strategies designed by the College of Medicine curriculum. Sample activities include: (1) students deepen their anatomy and disease knowledge through animal dissections and cadaver donor cases led by medical students in the Gross Anatomy Lab, (2) at the medical school simulation center, high-fidelity patient simulators interact with students who learn how to ask relevant medical history questions, obtain vital signs and listen to the heart and lungs for clues to help them determine their patient’s condition, and (3) Outreach Program Saturday Sessions provides longitudinal programming over 10 weeks where selected students learn specialty-specific medicine from healthcare professionals and engage in college preparatory workshops covering essay writing, interviewing, transition to college, and research and presentation skills. Medical students create and coordinate all aspects of Outreach Program Saturday Sessions and can volunteer for the program from their first year of medical school through residency.Outcomes were measured for the 2019-2020 academic year using pre-assessment and post-assessment surveys. 6th- and 7th-grade students took the Career Decision Scale (CDS) survey, the Quantum Healthcare Career Pipeline Survey, the National Science Foundation (NSF) STEM Semantics Survey, and the STEM Career Interest Survey (STEM-CIS). 8th through 12th graders took these four surveys and the Career Thoughts Inventory (CTI).Engaging medical studentsMedical schools across the United States can achieve effective outreach programming by engaging medical students directly in their formulation and implementation. At the currently discussed Community-Based Medical School, medical students are responsible for planning and implementation of Outreach Program activities. Four student leaders are selected for leadership positions each academic year in which their responsibilities include: (1) Determining activity dates through coordination of medical student, College of Medicine, and local County Public School District calendars, (2) Creation of anatomy lab and clinical skills activities and cases that augment the school district curriculum along with specialty activities, (3) Recruitment and training of medical student volunteers for Gross Anatomy Lab, Clinical Skills Simulation Center, and specialty activities, (4) Oversight of the activities including timekeeping and volunteer management.Medical student involvement is not only necessary for program functionality, it serves as a mechanism through which medical students are able to interact meaningfully with their medical school curriculum. In both clinical skills and anatomy lab clinical cases, medical students are required to condense and disperse information to make complex medical knowledge accessible to students spanning from sixth to twelfth grade. This material must be integrated with anatomy and physical exam skills during timed sessions which provides additional opportunities for medical students to identify gaps in their knowledge and hone their medical skills, while teaching middle and high school students appropriate medical techniques. Medical students also administer group problem-based learning (PBL) clinical cases which directly mimics the preclinical curriculum at the College of Medicine. In these sessions, medical students function in the role that medical school faculty hold in their own coursework and lead groups of Outreach Program students in PBL cases. Volunteer medical students are also given the opportunity to apply their medical studies to create problem-based learning cases pertaining to clinical skills and anatomy. Engaging with medical school coursework through these various mechanisms facilitates deep understanding and long-term retention of various challenging concepts that form the foundation of preclinical medical education -8. ApartIn addition to the formal curriculum, Outreach Programming provides medical students with opportunities to be informal mentors as part of the “hidden curriculum” built into the program. Program participants meeting with medical students many times during their secondary education and form mentoring relationships which extend beyond the program duration and into post-secondary education. An additional mentoring mechanism built into the Outreach Program permits pre-health undergraduate students to assist medical students in a new, informal pipeline from the local chapter of the American Medical Student Association (AMSA). Twenty-one AMSA students selected from the general membership of the local Chapter operated in supervised volunteer roles where they were trained in medical aspects related to program activities and transitioned to leading activities under supervision.During the 2018-2019 academic year, 54 different medical students volunteered a combined total of 470 hours and engaged with 823 educationally disadvantaged/under-represented minority middle and high school students through Outreach Programming  and career indecision (decrease). Graduating seniors showed an increased connection to the field of healthcare, feelings of confidence in their learning, and increased STEM career decision-making. The intervention showed effectiveness in retaining students in STEM in 9th-12th grade and provides a learning pathway to engender STEM-persistence.Under the Outreach Program umbrella, medical students also volunteer with Outreach Program Saturday Sessions. Forty-five individual medical students and residents have volunteered in this capacity and 122 out of 128 juniors and seniors matriculating from community high schools have completed the program (95% completion rate).Despite the changing demographics of the United States, medical school graduates by race and ethnicity have remained consistent over time. According to the most recent report by the Association of American Medical Colleges, underrepresented minorities in medicine have lower medical school acceptance rates than peer applicants, and the demographics of medical school matriculants and graduates demonstrate a substantial gap between the proportion of URM students in medical education and the general population makeup of the United States . AcceptaRacial and ethnic disparities extend beyond medical school acceptance rates and faculty demographics, with minority groups in the United States facing an inequitable risk of lacking access to care and suffering worse health outcomes from preventable and treatable conditions. One of the foremost strategies in reducing disparities is creating racial/ethnic diversity in the health-care workforce in order to improve the quality of care received by minority groups. Diversity in the health-care workforce has been well correlated with the delivery of quality care to minority populations .Dr. Paul B. Rothman, Dean of the Medical Faculty and CEO of Johns Hopkins Medicine, states:“This is not just about fairness-diversity in medicine has measurable benefits.Studies show that students trained at diverse schools are more comfortable treating patients from a wide range of ethnic backgrounds. When the physician is the same race as the patient, patients report higher levels of trust and satisfaction. The visits even last longer-by 2.2 minutes, on average. When patients enter our hospitals, they want to see staff members and physicians who resemble them.All of this matters if we are going to start chipping away at the troubling health disparities we see in this region ."Health profession pipeline programming targeting middle and high school students is critical to improving minority representation in healthcare, promoting access to higher education, and addressing community-level health disparities. Outreach Programming at Community-Based Medical Schools prepares middle and high school students in the community to successfully pursue careers in medicine through an innovative biomedical science curriculum developed and delivered by medical students, faculty and staff. The programs’ goals are to remove barriers to higher education for the diverse students of the local community and to inspire them to pursue careers in medicine or biomedical research. Pipeline programs will possibly serve to improve URM medical student disparities for the next generation of medical professionals. There are various mechanisms by which the program does this including providing education for college preparedness and pre-health professional track advising, teaching medical knowledge and skills, and creating opportunities for informal mentorship between medical and high school students. Through these mechanisms, we can expect that students will enter college and medical school with increased ability and confidence promoting success, retention and achievement.


Breast cancer is a leading cause of cancer-related morbidity and mortality in sub-Saharan Africa, a global region where opportunities for breast care of any type are extremely limited due to insufficient infrastructure, a paucity of clinical services and vast shortages of trained human resources.A team of Zambian and US gynaecologic and breast oncology experts and nurse-specialists made multiple visits (each lasting 5 working days) to the Democratic Republic of the Congo (DRC), over a 2-year period. During each of five week-long site visits, hands-on training of local Congolese health providers was conducted during which time they were taught clinical breast exam (CBE), breast and axillary ultrasound, ultrasound-guided core needle biopsy/fine needle aspiration (FNA) and breast surgery. Simultaneous with the training exercises, a new breast care clinic was established and operationalised, and existing surgical theatres were upgraded. All activities were implemented in a private sector health care facility – Biamba Marie Mutombo Hospital – in the capital city of Kinshasa.From April 2017 to August 2020, a total of 5,211 women were identified as having breast abnormalities on CBE. Ages ranged from 26 to 86 years; median age: 42.0 (±14.1) years. Ultrasound abnormalities were noted in 1,420 (27%) clients, of which 516 (36%) met the criteria  for ultrasound-guided core needle biopsy or FNA. Pathology reports were available for 368 (71%) of the 516 clients who underwent biopsy, of which 164 were malignant and 204 benign. The majority (88%) of the cancers were advanced (TNM stages 3 and 4). Surgical procedures consisted of 183 lumpectomies, 58 modified radical mastectomies and 45 axillary lymph node dissections. Clinical competency for diagnostic and surgical procedures was reached early in the course of the training programme.By integrating onsite training with simultaneous investments in clinical service and infrastructure development, the barriers to breast cancer diagnosis and treatment were disrupted and a modern breast care service platform was established in a private sector health care facility in the DRC. It is p020, brea: 48–53) , a direc: 48–53) , such seThis tragic, deplorable and inhumane circumstance finds its most concrete expression in fragile, conflict and violence affected societies, like the Democratic Republic of the Congo (DRC). The DRC is the world’s largest fragile, conflict and violence affected nation, and is home to a population of 89 million people, of which the vast majority (~70%) live on less than $1.90 a day . In a reOur major objective was to increase access to breast care services for women, as part of a broader effort to build a women’s cancer centre in the DRC. Our approach consisted of integrating training with service delivery and infrastructure development. As a first step, we convened a meeting with officials from the Ministry of Health of the DRC, at which time we presented our intentions, goals and approach. After receiving Ministry of Health (MOH) clearance, we proceeded with the educational, service delivery and infrastructure development activities, as planned.As part of the implementation strategy, a multi-sectoral consensus conference was held to assess and document the status of clinical breast examination (CBE), breast ultrasound, ultrasound-guided core needle biopsy/fine needle aspiration (FNA), surgery, chemotherapy, radiation and pathology services within the country, as well as the presence of any designated cancer care facilities and programmes. The results of the assessment highlighted the significant workforce, infrastructure and funding gaps in the public sector, across all areas of cancer control. Informed by this evidence, our team of US and Zambian oncologists and nurse-specialists worked collaboratively with a team of local Congolese physicians and nurses to design a training curriculum and determine the clinical infrastructure required to address the major aforementioned deficiencies. The designated site for implementation of the breast care service platform was the Biamba Marie Mutombo Hospital (BMMH), a private sector 150-bed general hospital with a public health care focus, located in the capital city of Kinshasa. Opened in 2007, patients are charged on a sliding scale and no one is turned away due to an inability to pay. Partnerships with other non-profit organisations and the generosity of private contributors help ensure the sustainability of the facility. The decision to implement training activities and clinical/surgical services within a private sector facility was based on recommendations put forth by the consensus conference. It was felt this approach could facilitate programme initiation and sustainability by circumventing many of the logistical problems present in the public sector, such as lack of personal security, bureaucratic inefficiencies, unreliable procurement systems and the potential for politicisation and militarisation of health services.A team of Zambian and US gynaecologic and breast oncology experts and nurse-specialists made multiple visits (each of 5 working days duration) to the DRC, over a 2-year period. The training activities occurred during each day of the 5-day visits, consisting of a combination of didactics and hands-on instruction, led by a US breast surgical oncologist (master trainer). Women attending the newly opened cervical cancer ‘screen and treat’ clinic at BMMH were asked about breast symptoms, and if present their willingness to have a CBE. Those answering in the affirmative underwent a CBE by the cervical cancer screening nurses, all of whom who had been crossed trained to perform CBE. If discovered to have abnormalities , they were immediately referred to the newly established breast clinic where they underwent evaluation by trainees. In accordance with the MOH-approved competency-based training curriculum, BMMH staff physicians, nurses and physician assistants were trained in the following areas: (1) breast self-awareness; (2) CBE; (3) smart phone and traditional breast ultrasound; (4) axillary node ultrasound for the evaluation of suspicious axillary nodes; (5) ultrasound-guided FNA and ultrasound-guided core needle biopsy of breast masses; and the surgeon only in (6) surgical treatment of breast cancer , (7) breast oncoplastic surgery and (8) palliative breast surgery.The curricula for breast imaging were designed for both smart and standard breast ultrasonography, adopted from courses taught by the American College of Surgeons . TraineeSpecific to the surgical procedures, preoperative video teaching sessions took place prior to each procedure. The various types of procedures were reduced to their most critical and difficult constituent parts, then taught through active bedside mentoring in the surgical theatre . Each teaching case consisted of the trainee performing the procedure under the guidance of the master trainer, with relevant questioning and explanation of the rationale behind each step performed during the procedure. Throughout each 5-day training period, the trainee was asked to perform, on his own, a mental narrative of the procedures several times a day, reviewing the rationale behind each step and mentally visualising potential intra-operative complications and corrective responses. Post-surgical debriefing of the operation was conducted consistently. Onsite clinical training was supplemented between visits with virtual clinical mentorship. Lumpectomies performed for cancer treatment were carried out on small lesions (<3 cm) with benign ultrasound findings of the axilla, and in some cases for larger malignant lesions in patients completely opposed to mastectomy. Patients who underwent lumpectomy for cancer were counselled on the higher risk of local recurrences due to the lack of radiation therapy facilities in the DRC –26. ModiWritten consent in the commonly used languages of English, French, Lingala or Swahili was obtained prior to clinical or surgical procedures, including biopsies. In case of illiteracy, oral consent was obtained. Every consent required a witness. The proficiency of the trainees was determined through direct observation of their skills in performing the various procedures by the US breast surgical oncologist. Clinical competency was defined as a trainee being able to perform any of the stated procedures correctly and independently, as judged by the master trainer.Targeted investments in equipment and supplies plus modifications of existing physical structures within the hospital were used to create the necessary clinic space and upgrade the surgical theatres in which training activities took place, and clinical services were simultaneously provided.From April 2017 to August 2020, a total of 5,211 patients were identified as having a breast abnormality on CBE . Ages raTwo patients had oncoplastic surgery and five underwent purely palliative resections for quality of life reasons, i.e., large lesions associated with significant pain, incapacitating their ability to ambulate and maintain hygiene.There were no reported complications with any of the diagnostic procedures. There were seven cases of wound dehiscences – seromas with small surgical site skin separation  – in our surgical population .Analysis of our results reveals that the majority of women evaluated with CBE were between the ages 30 and 49 years with a median age of 42 years . This isOf the 5,211 patients with abnormalities on CBE, 516 (10%) had findings that met the criteria warranting a biopsy. This number is in line with other reports from SSA that report positive findings on 10%–13% on breast ultrasound that require biopsy –31. Althn = 4,315 versus n = 5,211), had fewer patients with indications for biopsy 133/497 (27%) versus 516/1,420 (36%) and a lower yield of malignancies among those who were initially evaluated with CBE  2.3% versus  3.1%. Unlike our approach, they did not address skills transfer, infrastructure development or treatment [n = 516) on women initially evaluated with CBE is the largest reported from the continent of Africa [In an earlier breast cancer study in the DRC, participating women were initially investigated with CBE. Those in whom a palpable mass was detected were referred to the hospital where they received a mammography and ultrasound and – in case of suspicious findings – a core needle biopsy. Compared to our cohort, theirs was smaller  patients had early-stage disease . All hadConsistent with the current literature on breast cancer in SSA, the majority of our patients had advanced stage disease  and the On the fourth visit, the master trainer instructed the trainee how to perform oncoplastic resections utilising the Batwing technique . This isWe report the successes, challenges and preliminary outcomes of developing breast detection and treatment services in the first women’s cancer centre in the DRC. Implementing a breast care service platform at a private sector healthcare facility (BMMH) has provided access to care for symptomatic women. It has also allowed local Congolese health care providers the opportunity to accumulate experience in the diagnosis and treatment of breast cancer in one facility, thereby increasing their expertise. Local capacity now exists for the detection, diagnosis and surgical management  of breast cancer in Kinshasa, DRC. This established cancer care service platform can now be leveraged to build workforce capacity in the public sector through future public–private partnership training programmes.Our effort represents a clear demonstration of how to improvise in a resource-constrained setting in order to initiate cancer care services. Enhancement, expansion and perpetuation of this approach throughout the DRC and other SSA countries have the potential for improving breast cancer care throughout the African continent , 42 WhenFuture plans are to fully integrate pathology services (including immunochemistry) into the clinical care platform, recruit additional general surgeons and other healthcare personnel for training from the DRC and other Francophone African countries, expand the chemotherapy unit and establish more rigorous quality assurance systems. Establishment of a tissue bank and involvement in relevant research is also of critical importance to improving outcomes. These efforts will be carried out within the larger vision of developing BMMH into a regional centre of excellence for women’s cancer control.None of the authors declare any conflicts of interest.Funding for the initiative was provided by a generous grant from the Howard G. Buffett Foundation whose mission is to catalyse transformational change to improve the standard of living and quality of life, particularly for the world’s most impoverished and marginalised populations.


Young adults typically gain more dietary autonomy as they start college, though this can also present nutritional challenges; however, research on the generalizability of their dietary intake data is scarce. To address this representativeness concern, we compared food and nutrient intakes reported by college freshmen attending a large, diverse university to an age-matched sample from the National Health and Nutrition Examination Survey (NHANES). We studied 269 students 18–24 years old recruited through the Mason: Health Start Here (HSH) study, a population-based cohort study of college students. Diet was assessed using a diet history questionnaire (DHQ-III) and estimated with food source composition tables. The NHANES sample of 835 adults was the reference dataset. Reported dietary intakes were weighted and compared with national intakes via t-tests. We observed comparable energy, carbohydrate, fat, and protein intakes in both groups; however, the HSH cohort reported a higher density intake of most micronutrients than the NHANES sample. Differences between these samples in intake, mode of dietary assessment administration, and reactivity may help explain the differences detected. These results demonstrate that when appropriately contextualized in terms of methodology and potential sources of bias, single college studies can be useful for understanding nutrition in young adults more broadly.  Young adulthood is a period of increasing independence for the 40% of young adults enrolled in United States (US) colleges. Diet is a health behavior known to shift substantially in young adulthood, and can have considerable long-term health and other impacts. Previous research indicates that significant environmental changes through adulthood, such as leaving the parental home, entering employment, and changing educational status contribute to poorer nutrition . Young aDespite the increased attention being paid to the role of health disparities in health and disease, for which nutrition is a key risk factor, there has been little research on the validity of dietary assessments among college students ,5,6. A cHealth Starts Here study. This longitudinal cohort study of successive waves of first-time freshmen was launched in 2019 to improve understanding of the natural history and determinants of young adult physical health, mental health, and college completion. The two primary objectives of the current work were to describe the dietary intake of this college population, and to evaluate the representativeness of the dietary intake and nutrient composition of the cohort by comparing it to an age-matched sample from the National Health and Nutrition Examination Survey (NHANES).To add to the literature on young adults’ nutrition, we undertook the current study, which seeks to better understand the generalizability of food and nutrient intakes reported by college freshmen in the Mason: Health Starts Here (HSH) is a longitudinal cohort study of first-time freshmen at George Mason University (Mason); objectives of the study include examining nutrition and physical activity levels during the college years [Mason: ge years . The oveNHANES data was obtained from the National Center for Health Statistics ,18. NHANn = 53), unphysiologically low  reported mean daily dietary intake (n = 26), or unphysiologically high  energy intake (n =2).The study includes first-time freshmen at George Mason University who are 18 to 24 years old and able to read and understand English. First-time freshman is defined as students who are newly embarking on a four-year undergraduate degree. Participants were students from a variety of disciplines from each college, including Health and Human Services, Humanities and Social Sciences, Visual and Performing Arts, Sciences, and Engineering. In the pilot year (academic year 2019–2020), the study was advertised via email to students in selected courses with large numbers of freshmen enrollees, through flyers placed outside of classrooms, brief presentations to select classes and student organizations, and an online recruitment video on the study website. Three hundred and fifty students were recruited from the incoming freshmen population of 3,704. This study includes the results of the 269 participants after applying the following exclusion criteria: incomplete Dietary History Questionnaire (The Dietary History Questionnaire (DHQ) used was developed by the National Cancer Institute as an epidemiological research tool to assess total adult diet . DHQ is n = 19,225 in the total NHANES sample for those two cycles). The following exclusion criteria were then applied in this order (the number excluded at each stage is in parentheses): age less than 18 or greater than 24 ; not having completed a high school education (n = 401); unreliable dietary intake as classified by NHANES (n = 129); unphysiologically low dietary intake of <500 kcal daily (n = 12); unphysiologically high energy intake >5,000 kcal daily (n = 15); missing occupation information (n = 1); missing smoking information (n = 1); and, missing anthropometry data (n = 12). There were thus 835 individuals from NHANES who were similarly age and education matched to the HSH study.To compare with the HSH Cohort, NHANES data from the most recent two cycles available (2015–2016 and 2017–2018) were used  and the second via telephone 3 to 10 days after the first recall. Dietary intake data are provided as individual food files and total nutrient intake files. As not all participants completed the second 24-hour recall, data from the first 24-hour recall was included in this analysis.p < 0.05.Descriptive statistics are presented as means and standard errors for numerical variables, and frequencies and percentages for categorical variables. Two different assessment methods were used in order to more fairly compare nutrient intake across the cohorts, and given that and underreporting has been documented with food frequencies questionnaires . PercentA higher proportion of females participated in HSH than in NHANES . The majThe HSH cohort reported significantly lower energy intake per day than NHANES . For theGrain products were the greatest contributor to daily energy intake for both cohorts . Fruits Health Starts Here (HSH) cohort study at George Mason University with those reported by a nationally representative sample of similarly aged adults from the National Health and Nutrition Examination Survey. While NHANES has some limitations as a comparison group due to it having no specific questions about whether adult participants currently attend school, and uses a different dietary assessment tool, NHANES is the most comprehensive assessment of dietary intake in a study population designed to be representative of the US. These methodological differences provide important context for the comparison we performed.Generalizability is a major concern when it comes to the assessment of dietary intakes of volunteer college students in epidemiologic research ,15. As dIn order to more accurately compare nutrient intake across cohorts, we focused on nutrient density and percent contributions. We observed comparable energy and macronutrient intakes in both groups. However, the HSH cohort reported a higher density intake of almost all micronutrients than the national sample. We also found percent intakes of fruits, vegetables, and milk were higher in the HSH cohort than in NHANES, while intake of grains and meat was lower in the HSH cohort. Different intake, mode of dietary assessment administration, and reactivity between these groups may in part account for these differences.Regarding total energy and macronutrient intakes, we found lower intakes among HSH cohort participants than the national sample. Such widespread differences in dietary intake could be in part a result of temporal changes in lifestyle. College freshmen often face major challenges and undergo major adjustments in lifestyle when transitioning to a new, unfamiliar environment as they start college . In addiCompared to NHANES, this cohort of students had a significantly higher density of micronutrient intakes, which may in part be attributable to dietary supplements. US. college students consume more dietary supplements than the general population, and many consume multiple classes of dietary supplements, despite the lack of scientific evidence to back the benefits of supplement use, and the potential for adverse events . DietaryA possible reason for the observed differences in dietary intake between HSH participants and the NHANES sample is a combination of biases associated with selection (participation) or reporting (dietary assessment method). Although both HSH and NHANES focused on nutrition, the HSH study likely attracted more health-conscious college students, whereas NHANES is a cross-sectional study, a major component of the national dietary intake monitoring system. The NHANES recruitment strategies also preclude knowledge of participation and refusal rates. While the distribution of demographic characteristics within the two samples, including age and education, was corrected by the statistical weights, the distributions of other demographic characteristics remain divergent. NHANES consists of urban and rural adults of diverse socioeconomic status, while HSH participants are college students residing in urban areas who, while diverse, tend to have a somewhat higher socioeconomic status. Wide dietary disparities have been observed based on socioeconomic status and region of residency . In addiIn general, researchers advocate continued collection of self-reported dietary intake. It is an important part of the overall effort to develop better methods of tracking dietary intake at the population level to inform nutrition policies and conduct research on dietary associations with diseases ,24. The This study has some limitations to consider as part of the overall interpretation. Despite the benefits of an FFQ, a limitation of FFQs is underestimation and misreporting. Questionnaires that use portion sizes may be more likely to underestimate nutrient intakes . In addiNevertheless, the study has several strengths. Despite some disadvantages, cross-sectional studies with sufficient sample size to generate statistical power can be used to assess trends in nutrient intakes and yield useful information . AdditioWe observed that college students in this sample had lower energy intakes, which is likely explained by differences in dietary assessment methodology. However, when controlling for energy intake difference by evaluating nutrient density, the college students in this population consumed higher amounts of most micronutrients. This observation suggests that there may be something about the student experience that contributes to higher micronutrient intake. This corresponds to their higher intake of fruits and vegetables, as well as their consumption of dietary supplements. These factors may be relevant for considering ways to improve micronutrient intake in other populations. The broader utility of these analyses and interpretation illustrates that when appropriately contextualized in terms of methodology and potential sources of bias, studies of single college populations can be useful for understanding nutrition in college students more widely.


Public rental housing (PRH) for low-income families has been shown in several studies to be associated with poor health status and obesity. However, the causes of this health disparity are controversial, and the associations and pathways between PRH and obesogenic behaviors remain unknown. Using cross-sectional survey data of 1977 adults living in Hong Kong (aged or over 18) together with multi-source GIS-based environmental data, we examined the associations between PRH and obesogenic behaviors and the extent to which those associations can be explained by neighborhood food and physical environment. The unhealthy food environment, which relates with infrequent fruit and vegetables consumption, was calculated based on the relative density of fast food restaurants and convenience stores to grocery stores. The physical activity environment, which relates to physical inactivity and prolonged sitting, was assessed in terms of density of sports facilities and street greenery, separately. Regressions and mediation analyses show that PRH was negatively associated with physical inactivity directly and also indirectly via higher sports facilities density; however, PRH was positively associated with unhealthy diet largely directly and positively associated with prolonged sitting indirectly via less street greenery. We advanced the international literature of PRH health impact assessment and its environmental health pathways by providing evidence from the least housing-affordable city in the world. The findings provide planning implications in formulating a healthier PRH community for these low-income PRH households and mitigating health disparities induced by housing type. Public rental housing (PRH), one of the most effective housing solutions for low-income families, has been employed in many countries around the world to improve living conditions of those needy families. Goal 11 of the United Nation’s 2030 Agenda for Sustainable Development reflects the significance of inclusive and healthy cities: “making cities inclusive, safe, resilient and sustainable” [There is a systematic review of a total of 14 articles, including 4 prospective studies, 8 cross-sectional studies, and 2 retrospective cohort studies on the relationship between staying in PRH in Singapore and health status . SimilarFrom the perspective of the paradigm of traditional housing health research, both interior housing condition and external neighborhood environment could affect residents’ health . If PRH Therefore, more studies are needed to assess the short-term health impact of PRH residence, such as obesogenic behaviors, to help understand the pathways of the health disparities induced by housing type. Surprisingly, such research is scarce. A natural experimental study aimed to assess whether enhancing the physical and social environment could reduce obesity among PRH residents via improving diet and physical activity or not . From baIn Hong Kong, PRH is the primary housing solution to achieve the vision of helping all households gain access to adequate and affordable housing based on the Long Term Housing Strategy 2014), and it was introduced in 1954, after the Shek Kip Mei fire . Approxi, and it To fill the above gaps, this paper examined the associations and pathways linking PRH residence to obesogenic behaviors via food and physical activity environment among adults in a Hong Kong context. We used GIS-based environmental variables together with a representative cross-sectional survey data among Hong Kong adults from 2014 to 2015. Two aspects were analyzed with regression and mediation models: (1) associations of PRH with food and physical activity environment and (2) the direct and indirect associations from PRH to obesogenic behaviors via corresponding food and physical activity environmental exposures. This study aims to not only verify the association among PRH, food, and physical activity environments and obesogenic behaviors but also to highlight the importance of neighborhood environments in mitigating health disparities induced by housing type. The findings in this study advanced the international literature of PRH health impact assessment and its environmental health pathways in the context of a representative world city, which provided governance implications for healthy PRH communities.Generally, we assumed that PRH residence is associated with obesogenic behaviors via residential environment  could be derived from extensive literature on built environmental health ,19,20,21Next, we state the theoretical foundation and the logical inference of the former part  and the related hypotheses  in the context of Hong Kong. Many studies have explored the environmental determinants of residential satisfaction with PRH in many cities ,30,31. HThis study was conducted in Hong Kong, a special administrative region of the People’s Republic of China. As one of the most densely populated areas in the world, Hong Kong covers approximately 1080 square kilometers of land and had a population of 7,336,585 people at the end of June 2016, with 7,116,829 usual residents and 219,756 mobile residents . Hong KoThe housing problem is worsened due to a lack of housing land, and Hong Kong has been ranked the least housing-affordable city in the world for a decade since 2011 by an international housing organization, Demographia . An insuWe used a representative sample of 1977 Hong Kong adults (aged or over 18) derived from a two-stage stratified sampling design by geographical area and housing type. Survey data of the 1977 adults were part of the first wave of the Strategic Public Research (SPPR) project, “Trends and Implications of Poverty and Social Disadvantages in Hong Kong: A Multi-disciplinary and Longitudinal Study”  ,39. ThisMulti-source objective environmental data were also collected in this paper. To measure the local retail food environment, data on different food outlets were collected from Hong Kong’s Food and Environmental Hygiene Department . To measThe independent variable is PRH residence. Housing type of PRH was coded as 1 while housing type of non-PRH including subsidized sale flats and private housing was coded as 0.Three measures of environmental exposures (Retail Food Environment Index (RFEI), sports facility density, and street view greenness (SVG)) were used as potential mediators. ArcGIS 10.4.1 was used to construct objective environmental measures. The objective environmental measures were standardized with a mean of 0 and a standard deviation of 1. We defined each respondent’s neighborhood as the area within a 1 km of Euclidean circular buffer from their home, which was considered as a walkable distance. RFEI was adopted from our previous study to characterize the unhealthy food environment . It was https://www.lcsd.gov.hk (accessed on 12 December 2021). Sports facilities were defined as sports center, recreation grounds, water sports centers, swimming pools, or sports grounds [For characterizing physical activity environment, we used sports facility density and SVG. Data on sports facilities were collected from the Leisure and Cultural Service Department, Hong Kong ( grounds . We did https://github.com/mittrees/Treepedia_Public (accessed on 24 May 2020).Street greenery was characterized by SVG-derived street view images using an object-based images classification algorithm. For measuring SVG, we requested a series of images using the Google Street View application programming interface. Referring to the method used in previous studies, the sampling points along the road network were at 100-m intervals, and images were taken in 6 main directions  . The imaThree variables of obesogenic behaviors, including infrequent FV eating, physical inactivity, and prolonged sitting, were constructed as outcomes. Infrequent FV eating was defined as not having fruit or vegetables every day. FV consumption frequency data of respondents were collected in the cross-sectional survey. Respondents were asked “How many days a week do you usually have: (1) fruits and (2) vegetables”. Response options were continuous number from 1 to 7 (days). For analysis here, we dichotomized the outcome: infrequent FV eating (<7 days/week) and frequent FV eating (=7 days/week) since daily FV consumption is recommended by WHO.Physical inactivity was defined as lack of vigorous physical activities such as heavy lifting, digging, aerobics, or fast bicycling for at least 10 min at a time during the last week and lack of moderate physical activities such as carrying light loads, bicycling at a regular pace, or doubles tennis during the last week . Prolonged sitting was defined as over six hours of sitting on a weekday. Physical inactivity and prolonged sitting were assessed by the International Physical Activity Questionnaire short form (IPAQ short) . They weSocio-demographic variables and perceived environmental variables extracted from the cross-sectional survey data were covariates, including age, gender, marital status, subjective poverty (“Do you think you are poor now”), and monthly income  , educatiArea problems and accommodation problems were used to characterize the perceived community and housing environment. To measure perceived community environment, residents were asked 12 items in relation to the question “Do you think that any of the things are a problem in this area?”: poor street lighting or broken pavement; noise ; air pollution; lack of open public spaces; risk from traffic for pedestrians and cyclists; illegal parking; people being drunk or rowdy in the street/park; criminal activity; problems with communal areas ; rats or insects; and others (please specify). To measure perceived housing environment, residents were asked 12 items following the question “Do you have any of these problems with your accommodation?”: shortage of space; lack of privacy (within the household or between neighbors); too dark; not enough light; too hot in summer/too cold in winter; damp walls, ceilings, floors, etc.; poor ventilation; rats or insects; light pollution (too bright in the evening); and others (please specify). The number of area problems and the number of accommodation problems were summed for respondents.This study investigates the associations among PRH, food and physical activity environments, and obesogenic behaviors among adults in Hong Kong. As the objective environmental variables are continuous variables (Z-score) and the outcomes of interest are binary variables, we used the maximum likelihood method to estimate the parameters of our regression models. In addition, logistic regression was used since it is a useful analysis method for classification problems, and it often models a binary outcome or other two possible discrete outcomes. The statistical analyses were conducted using Mplus Version 8.3 (1998–2017 Muthen & Muthen). The statistical tests were two-tailed, with a significance level of 0.05. Unstandardized regression coefficients (B), standard errors (SE), 95% confidence intervals (CIs), and probability (P) were obtained.First, to test the associations of PRH with food and physical environment, we regressed RFEI, sports facility density, and SVG on PRH, controlling for socio-demographic and perceived environment covariates.p) was used to test the fitting degree of the models. If p > 0.05, the fit of the model is good. The direct and indirect effects via corresponding food and physical environments were calculated. The proportion of the effect that is mediated was calculated as indirect effect/(direct effect + indirect effect) and presented as a percentage. The Sobel test was applied to test whether the indirect effect was significant.Second, to test direct and indirect effects from PRH to obesogenic behaviors via food and physical environment, mediation analyses were conducted with several regressions based on the conceptual framework we developed in p < 0.05). The food and physical activity environment of PRH residence is significantly different from non-PRH residence. The obesogenic behaviors of infrequent FV eating and physical inactivity among residents in PRH are significantly different from those in non-PRH. Specifically, residents in PRH had significantly higher rates of infrequent FV eating and lower rates of physical inactivity than those in non-PRH.Non-parametric tests among PRH and non-PRH residences for environmental exposures and obesogenic behaviors were conducted to compare their distributions. Bold numbers indicate significantly different distributions with the non-parametric test  list three types of sports facilities including regional, district, and local sports facilities . Local sThirdly, PRH was positively associated with unhealthier food environment and negatively associated with street greenery indicating a worse food and greenery environment in PRH, which partially explained the significantly higher rate of infrequent FV eating and fully explained the non-significant but higher rate of prolonged sitting in PRH residents. These results also contribute the international review of PRH’s health impact and are consistent with the previously reported inverse association between PRH residence and poor health outcomes in developed Western societies and developed Asian countries such as Singapore ,5,6. AddThe findings in this study advanced international review in several ways including health impact assessment of PRH, environmental pathways linking PRH residence to health, and the association between residential environment and health outcomes. In addition, these findings contribute to the possible solutions of health disparities induced by housing type by improving neighborhood environment in health disadvantaged communities. Hong Kong has a rich experience in PRH governance. The PRH practice in Hong Kong provides a reference for other cities with housing problems. This is first study in Hong Kong linking PRH residence to health-related behaviors. More studies need to be conducted in Hong Kong and compared with other cities for creating a healthy and inclusive residential environment for low-income households.This study also had several limitations. First, we were unable to establish a causal association between PRH residence, neighborhood environment, and behaviors due to the cross-sectional nature of the study. In addition, the mediation analysis we used comes with several assumptions and considerations about causal mechanisms that might bias the estimation of mediation effects when one or more assumptions are violated  ,46. In fWe found that residing in PRH was associated with higher rate of infrequent FV eating and lower rate of physical inactivity in the context of Hong Kong. The associations between residing in PRH and obesogenic behaviors were mediated by neighborhood food and physical activity environments. More targeted interventional studies directed at PRH communities need to be carried out to address the health inequalities induced by housing type and understand the causal associations among PRH, neighborhood environment, and health outcomes. These will aid policy makers in formulating better policies to improve health for low-income residents living in PRH and mitigate their health disparities with residents living private housing.


A growing body of research suggests that greater perceived partner responsiveness- the extent to which individuals feel cared for, understood, and validated by their romantic partner- leads to longer, healthier, and happier life in adulthood, yet little is known about possible moderating factors between responsiveness and well-being. Using a longitudinal design, the current study tested the moderating roles of age and gender in association between perceived partner responsiveness and depression symptoms. The data for the present study came from the National Survey of Midlife in the United States (MIDUS I and II) which is a longitudinal study on health and aging. A life span sample of 2856 married or cohabiting individuals  completed measures of perceived partner responsiveness, depression, age, and gender in two waves (T1 and T2). The results showed that greater perceived partner responsiveness at T1 predicted lower depressive symptoms at T2 controlling for depressive symptoms at T1. This finding remained when controlling for potential confounders including demographics and health covariates. The moderation analysis demonstrated that participants’ age was not a significant moderator in the association between perceived partner responsiveness and depression. Yet, gender significantly was a significant moderator such that the association of perceived partner responsiveness and depression was significant for female but not for male participants. These findings can have implications for mental health and relational well-being.


Background: Interventions to change behaviour have substantial potential to impact positively on individual and overall public health. Despite an increasing focus on health behaviour change intervention research, interventions do not always have the desired effect on outcomes, while others have diluted effects once implemented into real-life settings. There is little investment into understanding how or why such interventions work or do not work. Methodological inadequacies of trials of behavioural interventions have been previously suggested as a barrier to the quality and advancement of behavioural research, with intervention fidelity acknowledged as a key area for improvement. However, there is much ambiguity regarding the terminology and conceptualisation of intervention fidelity and a lack of practical guidance regarding how to address it sufficiently, particularly within trials of complex behavioural interventions.Objectives: This article outlines specific issues concerning intervention fidelity within trials of health behaviour change interventions and suggests practical considerations and specific recommendations for researchers, with examples from the literature presented.Conclusions: Recommendations pertain to (1) clarifying how fidelity is defined and conceptualised, (2) considering fidelity beyond intervention delivery, (3) considering strategies to both enhance and assess fidelity, (4) making use of existing frameworks and guidance, (5) considering the quality and comprehensiveness of fidelity assessment strategies, (6) considering the balance between fidelity and adaptation and (7) reporting the use of fidelity enhancement and assessment strategies and their results. Suggestions for future research to improve our understanding of, and ability to, address fidelity in behaviour change interventions are also provided. It is well recognised that health behaviours such as smoking, diet and physical activity play a crucial role in influencing individual and population-level health and well-being outcomes. Accordingly, health behaviour change is a growing focus of research, with estimates of hundreds of trials of behaviour change interventions conducted each day globally. Despite this increasing focus, many of these trials have modest and variable effects  trial includes a multidimensional assessment of fidelity for two audit and feedback interventions to assess the extent to which fidelity contributes to observed outcomes (i.e. proportion of unnecessary transfusions)  in the aforementioned survey had never used a specific fidelity tool or framework, despite the fact that 68.9% (n = 182) had reported previously using strategies to assess and/or enhance fidelity within a trial setting  are also of the utmost importance. As such, selection of fidelity assessment strategies  often means balancing comprehensiveness with feasibility , and when they are conducted in relation to the main trial results, for example, without knowledge of trial findings, or subsequently integrated to illuminate the findings. Bova et al.  provide Intervention fidelity is an area of key methodological importance which needs to be improved in order to enhance the science of behaviour change. The aforementioned issues are not intended to be an exhaustive list, rather to create awareness of common issues of particular importance for improving intervention fidelity within trials of health behaviour change interventions. This article outlined specific issues concerning intervention fidelity within trials of health behaviour change interventions and provides practical recommendations to be considered by researchers in order to improve how fidelity is addressed (summarised in