The 1st is based on evidence, systematic observations made in order to establish objective facts and reach reliable conclusions. The 2nd is instead based on the author’s personal experience, knowledge, and understanding. Medical research, historically authority-based but now mainly evidence-based, is typically performed with samples, limited groups of humans or animals, or specimens thereof. The purpose, however, is ultimately to generalize the observations beyond what has been observed, to humans or animals in general. Understanding when an observation can and cannot be claimed as evidence is thus crucial for a successful researcher.One underlying problem is sampling variation, i.e., the characteristics of multiple samples from a population of biologically diverse individuals are known to be heterogeneous, and the heterogeneity means uncertainty when just one single sample is studied. The solution to this problem is to quantify the uncertainty.Statistical inference, especially concepts such as p-values and confidence intervals—both uncertainty measures—therefore plays an important role when presenting research findings. Unfortunately, methodological misconceptions are ubiquitous in medical research. A few examples will be discussed here.Most papers contain a statistics section that includes descriptions like “variables were compared using Student’s t-test“. Such statements are formally incorrect, because statistical tests are not performed to compare observed variables but to test hypotheses concerning the properties of an unobservable population that is represented by the observed sample. The difference may be subtle, bit it is important. The p-value, an uncertainty measure, is the calculated probability of drawing a sample at least as extreme as the observed, given that a specific null hypothesis is true. The confidence interval is another uncertainty measure, which describes the inferential uncertainty of a specific estimate as a range of plausible values.A tested hypothesis may be clinically relevant, but the p-value itself says nothing about clinical relevance. Nevertheless, many authors believe that p-values represent scientific importance. This is a common and serious mistake. A finding with p < 0.0001 may well be completely irrelevant. The relevance of a finding must simply be shown by means other than p-values.Furthermore, the clinical importance of a finding can depend on the effect of a studied factor. For example, the minimal clinically important difference (MCID) of VAS pain is usually defined as at least 10 VAS units, and if the effect of a treatment reduces pain by less than that, the treatment effect should be considered clinically irrelevant, even if p < 0.0001. To show that the estimated treatment effect is clinically important, a confidence interval can be used. A clinically relevant treatment effect would be indicated by a confidence interval excluding all effects lower than the MCID.Numerous published papers report, based on statistical non-significance, that studied factors show “no effect”, that compared groups “do not differ”, and that the outcomes of investigated treatments “are not different”. However, statistical non-significance does not indicate equivalence but uncertainty, and uncertainty is not evidence.contradictio in adjecto. If there actually were no difference  a test  would have produced a p-value of 1.0. The presented p-value therefore shows that there actually was a difference in the sample. The probability that this observed difference is false positive, only existing in the sample, is 7.9%, marginally less unlikely than the 5% traditionally required for statistical significance. The p-value does not say anything about the risk of a false-negative conclusion, i.e., erroneously claiming that no difference exists. This risk may be considerably higher.Moreover, a statement such as “there was no difference (p = 0.079)” is a In addition, a p-value says nothing about a study’s ability to detect clinically relevant differences. Referring to the previous example, an observed clinically relevant reduction in pain VAS of 20 units could well have been accompanied by p > 0.05. This would, with a 5% significance level, not be enough to claim that a clinically relevant treatment effect exists, but it would be a mistake to claim that the treatment had “no effect” on pain. The finding is simply uncertain, and this should be adequately reported.A more informative presentation of the result could include the confidence interval of the estimated reduction in pain VAS. This interval would have shown the plausible values of the estimated reduction in pain VAS, say that it was –10 to 50. The result could be interpreted in the following way: In spite of not being able to provide reliable evidence of a beneficial effect, the investigation indicates that a potential effect is unlikely to be worse than a pain increase of 10 units or better than a pain reduction of 50 units.As a further description of common p-value misunderstandings, a Table 1 fallacy can be considered. The table usually describes baseline values after randomization in randomized trials and characteristics at start of follow-up in observational studies. Many authors include p-values in these tables. Why? 2 arguments are often given: (1) to enable an evaluation of the success of randomization in randomized trials, and (2) to show what variables need to be adjusted for in observational studies.P-values are, however, irrelevant for both purposes. The purpose of randomization is not to generate similar groups but to prevent systematic errors, and confounding adjustment is about validity (bias), not precision .In summary, the current practice of (i) presenting research findings as “significant” without specifying whether this refers to practical importance  or to inferential uncertainty , (ii) presenting p-values as descriptive measures of practical importance, and (iii) claiming that statistical non-significance provides evidence of equivalence should be condemned. It demonstrates ignorance and an unsound inclination to replace scientific reasoning with p-values. In spite of all presented p-values, the actual content is not better than a subjective opinion. Good research provides objective evidence.Statistical Editoremail:jonas.ranstam@med.lu.seJonas Ranstam


A 63-year-old female presented with the complaint of lump in left upper quadrant of abdomen since two years which had gradually increased in size reaching up to umbilicus. It was associated with dull aching abdominal pain. Her vitals and initial laboratory investigations were in normal range. Her family history was insignificant. Contrast enhanced computed tomography (CECT) of abdomen revealed a grossly enlarged spleen with parenchyma greatly replaced by cysts of variable sizes, largest one measuring 72mm x 69mm x 69mm. Few cysts had peripheral discontinuous rim like calcifications . Splenectomy done via subcostal incision revealed a spleen weighing 1800 gram and measuring 28cm x 16cm x 9cm with irregular surface showing numerous cysts filled with serous and serosanguinous fluid . Normal architecture of spleen was replaced almost completely by cysts filled with proteinaceous fluid containing red blood cells. There was dystrophic calcification in the periphery of the cysts. The endothelial cells were diffusely positive for CD34 and factor VIII, focally positive for CD31 but not for CD8. The diagnosis of splenic hemangiomatosis was made. Splenic hemangiomatosis is extremely rare with unknown incidence and is most frequently seen in cases of diffuse angiomatosis. The imaging characteristics of splenic hemangiomas are non-specific. The differential for a cystic lesion of the spleen includes lymphoma, metastases, abscess, cyst, lymphangioma and hematoma. Due to poor specificity of imaging and the risks associated with percutaneous biopsy of the spleen, splenectomy is performed when definitive characterization of splenic lesions is needed.


Internet media may exacerbate public confusion and anxiety about COVID-19. New media health literacy (NMHL) is considered to play a protective role against health-related misinformation from the media for individuals to maintain their health. The current study aims to examine the relationship among Taiwanese adults’ NMHL, health status, anxiety, and prevention behaviors during the COVID-19 pandemic. This cross-sectional study was conducted through an online survey, and 342 responses were included in the analysis. The survey tools include Health Status, COVID-19-Related New Media Health Literacy, COVID-19 Anxiety, and COVID-19 Preventive Behaviors. The research showed that both functional and critical prosuming literacy had positive relationships with health status. Functional consumption literacy had a weak negative correlation with COVID-19 anxiety. Furthermore, critical consumption literacy had a positive relationship with COVID-19 preventive behaviors. Therefore, individuals’ health, anxiety, and prevention behaviors are affected by different aspects of COVID-19-related new media health literacy. Compared to their consuming media literacy, Taiwanese adults have insufficient prosuming media literacy in regard to COVID-19 health issues. In December 2019, novel coronavirus disease 2019 (COVID-19) was discovered and started to spread worldwide. On January 30, 2020, the World Health Organization (WHO) further defined the COVID-19 pandemic as a Public Health Emergency of International Concern (PHEIC), which caused a large amount of public concern and fear about the possibility of a pandemic ,5. Internet media can provide fast and critical guidance on important public health messages by raising awareness and promoting positive health behaviors, which can help reduce disease transmission . HoweverMedia health literacy, combining the concepts of media literacy and health literacy, is considered to play a protective role, protecting individuals from health-related misinformation from the media ,13. AlthMedia literacy is the ability to access, analyze, assess, create, and share media and to develop critical thinking to reduce vulnerability to negative media influences and enhance health outcomes ,15. The Chen et al. (2011) proposed a promising framework of new media literacy that contains four components: functional consuming (FC) literacy, critical consuming (CC) literacy, functional prosuming (FP) literacy, and critical prosuming (CP) literacy . FC liteMedia literacy is closely related to health literacy when the media become resources for health information . The comThe conceptual assumption of health literacy is different from that of media literacy. Health information is usually purposely produced by the health system, while mass media content is usually implicit and may promote or damage health. Therefore, the single concept of either health literacy or media literacy seems insufficient to explain how individuals master health information in the media context . BuildinAlthough few empirical studies have explored health and media literacy, media literacy is regarded as playing an important role in how individuals obtain health information through various forms of media and how they understand and use this information . Media lAccording to the survey , the proThe survey method of self-report scale has been adopted by many researchers  literacy framework ,17, and This cross-sectional study aims to develop the COVID-19-related New Media Health Literacy Scale and explore its relationship with health-related variables. According to the recommendations of Wu and Tu (2011) and Comrey (1973), the appropriate sample size for scale factor analysis is more than 300 ,29.Regarding the implementation procedures, as the Taiwanese government has recommended specific preventive measures during the pandemic, including precautions regarding close contact and touching, we designed an anonymous online questionnaire in the traditional Chinese language to invite potential respondents. Respondents completed the questionnaire through an online survey platform (Google Forms). We published the URL of the online questionnaire on social networks (Plurk and Facebook) and explained the purpose of the research in order to recruit interested users to fill out the online questionnaire. In addition, we invite users to forward information freely. On the front page of the questionnaire, we provided informed consent information, so that the respondents started to fill out the questionnaire only after agreeing to participate in the research. Gift certificates or the chance to win money was offered for their participation. The inclusion criteria of the participants included (i) having access to a smartphone and social networking sites, and (iv) a willingness to take part in the survey. The participants who did not entirely complete the survey were excluded from the final sample. The data collection was conducted over three days (from 25 to 27 April 2020). Finally, a total of 342 participants responded to the questionnaire . M = 4.17, SD= 0.79).Health status was measured by asking the participants how they felt about their overall health using a 5-point Likert scale with the options very good (5), good (4), moderate (3), poor (2), and very poor (1). This measure is a widely used, validated indicator of health in the field of social sciences . In thisThe COVID-19 NMHL Scale was designed to measure the participants’ critical and active access to and their analysis, evaluation, construction, creation, and sharing of new media information related to COVID-19. This scale was developed based on the new media literacy framework proposed by Chen et al. (2011)  and a th2 = 521.84, p < 0.001). The outcome of the EFA indicated a single-factor structure (α = 0.81), with factor loadings ranging from 0.74 to 0.84, and the explained variance was 64.25%.The COVID-19 anxiety measure was used to examine the participants’ complex emotional responses to potential COVID-19 infection, such as tension, fear, panic, and anxiety ; the sca2 = 538.13, p < 0.001). The outcome of the EFA indicated a single-factor structure (α = 0.82), with factor loadings ranging from 0.52 to 0.72, and the explained variance was 65.93%.The items used to measure COVID-19 preventive behaviors assessed the participants’ degree of personal health actions to prevent COVID-19 infection; the four measurement items were developed based on the relevant literature : (1) I This study followed the code of research ethics and conformed to the Taiwan government’s institutional review board rules for exempt review. We did not collect any relevant identifying information of the humans involved, and an anonymous design questionnaire was used in this study. The questionnaire instructions clearly informed the participants of the research purpose and their rights regarding joining or dropping out of this study. Four checkpoints are provided in the research design so that respondents can stop answering at any time: (1) From the invitation and introduction SMS/email link to the online questionnaire; (2) After reading the research purpose, respondents decided to fill in the questionnaire; (3) During online filling-in, respondents are noted to quit at any time if they would like to; (4) Upon completing the entire questionnaire, and finally confirm “Send”. Respondents were assured that their participation was voluntary, anonymous, and strictly confidential and that they had the right to refuse to participate in the study at any time without any penalty.All analyses were performed using Statistical Product and Service Solutions 22.0 (SPSS)  software. First, the KMO measure of sampling adequacy and Bartlett’s test of sphericity were used to assess the suitability of the data for factor analysis . We adopSD = 7.94) were included in the final analysis, and their ages ranged from 18 years old to 70 years old. Among the respondents, 146 (42.69%) were male, and 196 (57.31%) were female. Regarding their education level, 6.14% had a high school education, 72.81% had a university education, 20.17% had a master’s education, and 0.88% had a doctoral education.An overview of the frequencies of the demographic variables of the final sample (n = 342). A total of 342 participants with a mean age of 23.42 (p < 0.001), indicating that the items were appropriate for factor analysis. Therefore, we performed a principal component factor analysis using the varimax rotation method with Kaiser normalization. The COVID-19 NMHL Scale developed in this study is based on the refined frame-work of new media literacy proposed by Chen et al. (2011) . To defiFC health literacy referred to the ability to understand COVID-19-related content in the media and contained five items. CC health literacy referred to the ability to critically analyze COVID-19-related content and contained seven items. FP health literacy contained three items related to the ability to disseminate and produce COVID-19-related media content and process COVID-19-related media content across multiple modalities. CP health literacy contained seven items focusing on the ability to interact and participate critically in the context of new media and critically analyze COVID-19-related media content.M = 4.37, SD = 0.58). Among the FC literacy items, the participants reported the highest level of agreement that they knew how to find information about COVID-19 pm online media. The lowest score for the four aspects of new media literacy was found for CP literacy . Among the CP literacy items, the participants had the lowest level of agreement that they could edit COVID-19 content presented as digital information and put it on the internet.The descriptive statistics of the COVID-19 NMHL Scale are also presented in F = 885.92, p < 0.001, M = 1.90, SD = 0.89) was significantly lower than the scores of the other three aspects of COVID-19 NMHL. The FP literacy score  was significantly lower than the FC  and CC  literacy scores. The FC literacy score was significantly higher than the scores of the other three aspects of COVID-19 new media health literacy.In addition, the repeated-measures ANOVA showed significant differences among the scores of the four aspects of new media literacy  that the development of personal media literacy occurs along two continuums, one from consumer literacy to production literacy and one from functional literacy to critical literacy . ConsumiVirtue’s study (2020) showed a similar result; that is, when taking a web literacy test, college students self-reported that they were best at reading-related skills, especially basic reading skills . Howeverr = 0.57, p < 0.001). CC literacy and FP literacy had a moderately significant correlation . FC literacy and FP literacy had a small significant correlation . FP literacy also had a small significant correlation with CP literacy   [r = −0.09, p = 0.10) and CC  literacy.Finally, the Pearson correlation analysis results are presented in n, 1988) . HoweverThese findings indicate that the correlations between reading and writing are far from perfect. Reading and writing consist of both dependent and independent abilities, and independent abilities allow reading and writing not only to be learned separately but also to have large numbers of variables and a limited amount of shared variance ,37. Prosp = 0.005) and CP literacy . FC literacy was significantly negatively related to anxiety . CC literacy was significantly positively related to COVID-19 preventive behaviors . These findings suggest that individuals’ development into functional and critical prosumers who interactively and critically disseminate and produce COVID-19-related media content serves to maintain their good health status. Existing research indicates that prosumption capacity is the ability to integrate production and consumption and that prosumers can cultivate their ability to access, understand, and process health information while being able to manage their own health conditions [The results of the multiple regression analysis are presented in nditions .In addition, in this study, FC literacy had a weak negative correlation with anxiety. FC literacy is an ability to access media content and understand its textual meaning . IndividThere was a significant positive correlation between CC literacy and COVID-19 preventive behaviors, and CC literacy predicted COVID-19 preventive behaviors by approximately 12%. This finding suggests that CC literacy (understanding COVID-19 and accordingly making judicious decisions) is the key to success in adopting COVID-19 preventive behaviors. People who are considered to have high critical health literacy can analyze information critically to help use high-quality information and make informed decisions about health to better control life events and situations . Aller, This study had some limitations. As a result of individual subjectivity, the participants’ self-reports may not reflect their actual media health literacy. Furthermore, since the online survey in this study was distributed through social networks, this may exclude non-social network users, resulting in under-representation of the sample and coverage errors. The online questionnaire cannot assess the number and characteristics of rejected respondents, and may also cause non-response errors, which leads to the limitations of sample selection in this study.In addition, although in a statistical sense, media health literacy can predict health, including health status, anxiety, and health behavior, in a practical sense, these variables are related but not necessarily causally related. Therefore, other research methods, such as experiments or observations involving longitudinal data collection and analyses of variables, can be used in future research to further examine media health literacy and other related health variables. Another limitation of this study was that it did not investigate the participants’ experience with COVID-19, such as whether there had been suspected or confirmed cases in their residential communities, which may interfere with anxiety and healthy behaviors.Finally, it should be noted that the survey period of this study was conducted before Taiwan raised its pandemic alert to the third level, when the impact of the COVID-19 pandemic was not serious compared to other countries. Therefore, temporal and spatial background factors might mitigate or moderate the investigation of emotional attitudes and the measurement of COVID-19 MHL, which should be taken into interpretation of our findings.Creating a link between the framework of new media literacy and health literacy and the further development of the COVID-19 NMHL Scale to measure participants’ four types of related new media health literacy are the unique contributions of this study, which provide a crucial starting point and insight into this research field.The current study revealed that compared to their consuming media literacy, Taiwanese adults have insufficient prosuming media literacy in regard to COVID-19 health issues. The findings of this research have practical implications for health education practice. The study showed that media literacy advocacy should focus more on how to produce and criticize media content to support the ability of the public to actively and critically participate in new media platforms. That is, the education sector and the government should cultivate individuals’ ability to jointly explore and reflect on problems through collective participation, to detect various meanings of different COVID information, to show concern for and engagement in public issues through dialogue, and to achieve the goal of promoting their health.However, the study does not suggest that consumption literacy related to COVID-19 information is not important. Individuals’ health, anxiety, and prevention behaviors are affected by different aspects of COVID-19 new media health literacy. Therefore, implementing instructional programs that can enhance individuals’ different levels of health literacy may help reduce the health crisis caused by COVID-19, especially anxiety; maintain individuals’ good health status; and encourage individuals to adopt COVID-19 preventive behaviors.In this way, future programs can intervene and make individuals consumers and prosumers, nurturing the four levels of health literacy and encouraging them to be more committed to participating more actively and critically in the consumption and production processes of digital media. In addition, future studies can further corroborate the effectiveness of interventions to transform audiences from pure media receivers to producers with media citizenship.


Notwithstanding the increased risks from COVID-19 with age, COVID-19 vaccine literacy relative to health literacy for older family carers is lower on average, higher with increased provision of care, and more variable, resulting in a substantial proportion of older family carers with relatively low vaccine literacy. At this stage of vaccine rollout in Japan, family carers’ sources of information to inform COVID-19 vaccine literacy is distinct, including more national and local mass media versus less health and care professionals and informal networks, which indicates the importance of tailored health communication strategies to enhance vaccine literacyIn super-ageing Japan, COVID-19 vaccinations were starting to reach older people as of June 2021, which raises the issue of vaccine literacy. This study focuses on family members who work and also care for their older parents, as they are at risk of COVID-19 and also risk transmitting COVID-19 to the parents they care for and potentially influencing their parents’ vaccine uptake. Such family carers are central to the approach in Japan to achieving a sustainable and resilient society in response to ageing. Contrasting family carers’ COVID-19 vaccine literacy with their overall health literacy provides insights into their preparedness for COVID-19 vaccinations. The purpose of this study is to understand how vaccine literacy, compared to health literacy, varies across family carers and the sources of information they use. Through a cross-sectional online survey, family carers’ vaccine literacy, health literacy and their sources of information, including mass media, social media, health and care professionals, family, colleagues, friends, and others, were assessed. The participants’ ( Vaccinations are a central aspect of addressing the COVID-19 pandemic, with unprecedented rapid development of several vaccines and initial heterogeneous deployment across countries. The preventative collective benefit of vaccinations depends on individuals’ voluntary vaccination decisions. Indeed, in the context of the COVID-19 pandemic, understanding intentions to vaccinate . In turnIn the context of COVID-19, the importance of health literacy, in particular critical literacy necessary to deal with the uncertainty and complexity of the pandemic as well as the torrent of more or less accurate information, has been discussed ,5. With Thus, for specific instances of vaccination there is value in understanding overall health literacy as well as vaccine literacy . While tNotwithstanding the recognition of the importance of health literacy and vaccine literacy, to date there has been a gap in assessing both underlying health literacy as well as vaccine literacy. Indeed, a person’s health literacy provides a relevant baseline against which to compare their vaccine literacy in a specific instance: that is, relevant gaps in vaccine literacy are not only low levels of vaccine literacy absolutely but also relative to health literacy. Hence, this research aims to shed light on the differences between vaccine and health literacy in the context of COVID-19 vaccinations. Furthermore, distinguishing overall health literacy from specific vaccine literacy enables distinguishing of information sources used to address these literacies, which is important when considering potential interventions to address health and vaccine literacy. Given the increasingly severe impact of COVID-19 with age, super-aging Japan where the population aging rate is highest in the world with 28.4% over 65 in 2020  providesFurthermore, among adults, family carers who work as well as care for their parents are an important group to understand as they may influence vaccine decisions of their older parents whom they care for. Also, in the context of the highly transmittable COVID-19 virus, they indirectly connect their parents to other extended family members, work colleagues, friends, and neighbors. Importantly, their vaccination would be an important prevention for their parents. Considering such family carers, relative to past practices in which non-working daughters-in-law were the main carers for their parents-in-law, care is increasingly provided by male and female family members who also work, which is rapidly becoming the norm as aging of society progresses . At the n = 5000) drawn from the online research company database that is representative of the population at large. Among these, the inclusion criteria were for survey respondents who care for older parents and also work or are taking leave from work due to provision of care: this resulted in n = 329 respondents, among whom a substantial majority completed the survey with usable entries, in particular on their health literacy, vaccine literacy and sources of media and information used to understand COVID-19 vaccines, yielding a sample used of n = 292.The cross-sectional survey was conducted through an online research service company, running from 15 May–2 June 2021. The survey reached a random sample of adults aged 20–70 years old  to very well (=4) for each item.The difference in scores between vaccine literacy and health literacy was constructed: this difference for each individual can range from −3 to +3 , with a positive (negative) number indicating higher (lower) vaccine versus health literacy. The difference between vaccine and health literacy is of interest. The health literacy measure reflects individual aspects that motivate the need for health literacy, such as health conditions, and individual propensity to access and use health-related information in general, not only due to COVID-19 or COVID-19 vaccines, as well as individual interpretations of the scales. Thus, overall health literacy provides a useful individual baseline against which to assess individual’s current vaccine literacy: in the context of a crisis, whether individuals are addressing the need for COVID-19 vaccine-related information to a sufficient degree, in particular relative to their baseline health literacy. Thus, the main variable of interest in the analysis is the difference between the scores for vaccine literacy and health literacy.To understand what informs participants’ sense of vaccine and health literacy, participants were asked to indicate the main sources of information they used spanning information from media, health and care services, and personal connections. In particular, options included national and local versions of broadcast and print media, social media, podcasts, medical and care service staff and professionals, as well as family members, friends, colleagues, neighbors, and ‘others’ for participants to define. Furthermore, participants were asked to assess the overall usefulness and reliability of their information sources on a five-point scale, from not at all (=1) to very well (=5).The other variables describe aspects of the respondents’ individual, family and care context. These demographic and care-related variables are: age; household income; and hours of care provided to parents; gender; marital status (either married or not married); whether or not they have children; educational level; whether full-time employees or taking care leave; parental care needs, assessed based on the government scale of seven care needs categories, from needing light daily-living support to requiring full-time assistance; and distance from their parents, including whether living together, within walking distance, or a range of travel times from within 30 min to over 2 h away.t-test for continuous variables and chi-square test for categorical variables. This single-variable analysis was, finally, complemented by single-variable and multivariable regressions, assuming a normal distribution. The dependent variable was the difference in vaccine versus health literacy and the explanatory variables were the demographic and care-related variables. Turning to the media and information sources, the comparison of use of each media source to inform vaccine literacy versus health literacy was, as the variables are continuous, based on Student’s t-test. A p-value less than 0.05 was considered to indicate statistical significance for all analyses. The data were analyzed using STATA .To assess each of health literacy and vaccine literacy on the respective nine-item scales, the average of the four-point score was used. The hours spent in care was taken to be the mid-point of each of the six categorical ranges up to 35 h, and 35 h for those reporting above 35 h, and thus treated as a continuous variable. The continuous variables were: age; household income; and hours of care provided to parents. The categorical variables were: gender; marital status; children; education; whether full-time or on care leave; parental care needs; and distance from parents. First, the variation of the difference of vaccine and health literacy with age was assessed, as age is a key risk factor for COVID-19. To analyze the variation with age, three subgroups were constructed based on age and the difference in vaccine and health literacy: under the age of 50; over the age of 50 and with vaccine literacy higher than health literacy; and over the age of 50 and with vaccine literacy lower than health literacy. Next, the two subgroups of those over 50 were compared to understand for which variables are the subgroups distinctive: this was to identify what variables are associated with higher difference in vaccine versus health literacy. The variables across the two subgroups were compared using Student’s n = 292) comprises 44% women and 56% men, with mean age 53 years (9.1 standard deviation). Participants’ living arrangements with respect to their parents receiving care vary, including 55% living with or close by their care-receiving parents. Also, their care-receiving parents span the range of the official seven care needs categories, from needing light daily-living support to requiring full-time assistance [The sample of family carers for older parents who also work or are taking leave from work due to provision of care n = 2 comprisp = 0.004), with a 0.64 correlation. The mean scores across the nine items ranges for vaccine literacy from 2.55 to 2.84 and for health literacy from 2.69 to 2.94. The analysis compares individuals’ vaccine literacy versus their health literacy, as health literacy was asked about in general whereas vaccine literacy with respect to current COVID-19 vaccinations. Comparing the difference in score for vaccine and health literacy with participant characteristics reveals that as the age of participants increases, the difference between literacy scores decreases, with younger participants having on average higher vaccine literacy than health literacy whereas the opposite is the case for older participants; and the standard deviation increases, thus there is a greater variation across older participants  and not significant for health literacy. Considering the other variables, the difference between the two groups is almost significant for having children (p = 0.066) and significant for hours of care provided to parents (p = 0.018).To understand the increased variability with age in the difference in vaccine and health literacy scores, first, three groups are compared  in termsThese patterns of significance were analyzed through multivariable analysis with, as a dependent variable, the difference in vaccine and health literacy scores, and as independent variables the demographic and care-related variables in : age; gep = 0.03). There are, however, significant differences in the mix of sources used. For vaccine literacy the main sources that more than 20% of participants are using are (with multiple responses possible): national television (56%), social media (37%), doctors (35%), national newspapers (29%), local television (27%), family (24%), and local newspapers (20%). In contrast, for health literacy the main sources are: social media (47%), national television (46%), doctors (46%), family (30%), national newspapers (29%), care managers (27%), friends (27%), and local newspapers (21%). Overall, participants use for vaccine literacy, compared to health literacy, more mass media and less inter-personal sources, with the proportion of participants indicating as a source: 10% higher for national television (p < 0.001), 6% higher for local television (p = 0.01), 4% higher for local newspapers (p = 0.03), 9% lower for social media (p < 0.001), 11% lower for doctors (p < 0.001), 9% lower for care-managers (p < 0.001), 7% lower for friends (p < 0.001) and 5% lower for family (p = 0.03). Overall, the mix of sources for vaccine literacy versus health literacy is rated to be similarly useful (3.2) and slightly less reliable .Turning to analyze the sources of information used to inform vaccine literacy , the aveConsidering the three different groups , there are no significant differences in sources of information used. Thus, for those over the age of 50 the significant differences in vaccine literacy relative to health literacy are not explained by access to different sources of information. Also, the assessment of overall reliability and usefulness of these sources does not differ across these groups. Hence, the difference in vaccine literacy could be from how participants encode such information and how such information affects their actual actions. Considering the nine items to assess vaccine literacy provides an indication. For those over the age of 50 comparing higher versus lower vaccine literacy, while all nine items have statistically significant differences in average value, the two items with the largest magnitude difference in vaccine literacy relate to whether the participant will take action. One item asks whether participants have taken or will take action following the knowledge and information they received  and the other relates to whether through their information search they decide by themselves if they want to be vaccinated. Thus, the main difference between these groups would stem from their ability to decide to act based on the information accessed.The survey participants are drawn from family carers who work and provide care for their older parents. Thus, they are both in close contact with their parents as well as at the intersection of several social domains, including other family members, colleagues at work and community. Given that the risk from COVID-19 increases with age and social contacts are important in transmission of the virus, such a set of participants is fundamental to understand for COVID-19 vaccination. The results are that as participants’ age increases, however, vaccine literacy relative to their own health literacy decreases and, importantly, is more variable. By comparison, in surveys covering a broader population, not only family carers, the impact of age on willingness to receive a COVID-19 vaccination has been mixed, both positive and negative ,31, althFor family carers, the results are that as age increases there is a larger proportion of participants with vaccine literacy lower than their health literacy. Nonetheless, the risk of COVID-19 increases sharply with age, which would suggest the importance of higher vaccine literacy among older participants. As carers risk transmitting COVID-19 to the parents they care for and may be expected to influence their parents’ vaccine uptake, the relative gaps in vaccine literacy of some participants are of concern for potentially significant knock-on effects. At the same time, in response to the ageing of society, the approach in Japan to achieving resilient and sustainable social systems places emphasis on the continued involvement of such family carers. Interestingly, the findings are that those who spend more time caring for their parents, and those who have children, tend to have higher vaccine literacy. In contrast, neither physical proximity to their parents, including living together, nor the extent of care needed by their parents are associated with higher vaccine literacy. Rather, it is the extent of personal engagement in care that is associated with greater vaccine literacy. Evidence from a different broader sample survey across Japan points to the willingness to protect others as a motivation for intention to take-up COVID-19 vaccines . As for The information used to inform COVID-19 vaccine literacy is recognized as an urgent, critical aspect  and shouThe current increased use of mass media likely reflects the novel, fast moving dynamic of the virus and the desire to access credible sources : furtherAt present, relative to health literacy, there is less access to person-specific information, which may become more important as vaccine roll-out progresses. The distinct pattern of media sources, relative to health literacy, points to the importance of an integrated media approach to support community-wide vaccine campaigns. Furthermore, among family carers over the age of 50, those with higher vaccine literacy had particularly higher self-rating on items related to the propensity to act on the information received: hence, further research could address how campaigns to improve vaccine literacy could enable and support the transition to act on the information received  complemented by understanding of how to make the corresponding processes and systems  supportive of those with lower vaccine literacy.The online survey format necessarily has some limitations, such as participants needing to be registered with the survey company and internet users thus limiting external validity, although it does enable timely insights. Furthermore, there is an ability to address specific groups of interest, such as the family carers focused on that is an important group for vaccine roll-out due to their role in caring for their older parents. As all the respondents are Japanese (which reflects that 98% of the population in Japan is Japanese ), there Indeed, vaccine literacy is evidenced to have important marks of distinction relative to health literacy, including which personal and social characteristics impact vaccine literacy and what sources of information are most distinctively accessed. These findings support the call for further understanding on vaccine literacy solely and in combination with health literacy, not least during the current pandemic and, more generally, contribute towards achieving a sustainable and resilient society.


Coordination of return to work (RtW) is implemented in many countries, but a Cochrane review found no considerable effect on workers’ sick leave compared to usual care. The aim of the study is to analyse how the evidence from this review can be used for decisions about (de-)implementing RtW coordination in a country-specific setting, using Finland as an example.We conducted a systematic literature search and online survey with two groups of experts to compare interventions included in the Cochrane review to Finnish RtW practice using content analysis methods. We applied the evidence-to-decision (EtD) framework criteria to draw conclusions about (de-)implementing RtW coordination in Finland, including benefits, harms and costs of the intervention compared to usual care.We included seven documents from the literature search and received data from 10 of 42 survey participants. RtW coordination included, both in Finland and in the review, at least one face-to-face meeting between the physician and the worker, a workers’ needs assessment, and an individual RtW plan and its implementation. Usual care focuses on medical treatment and may include general RtW advice. RtW coordination would be cost-saving if it decreases sick leave with at least 2 days compared to usual care. The evidence in the Cochrane review was mainly of low certainty, and the effect sizes had relatively wide confidence intervals. Only a new, high-quality and large randomized controlled trial (RCT) can decrease the current uncertainty, but this is unlikely to happen. The EtD framework did not provide arguments for further implementation or for de-implementation of the intervention.Interventions evaluated in the Cochrane review are similar to RtW coordination and usual care interventions in Finland. Considering all EtD framework criteria, including certainty of the evidence and costs, de-implementation of RtW coordination interventions in Finland seems unnecessary. Better evidence about the costs and stakeholders’ values regarding RtW coordination is needed to improve decision-making.The online version contains supplementary material available at 10.1186/s12961-022-00823-4. In many countries, sickness absence from work has since long been recognized as a public health problem with serious negative effects on workers and their families, as well as on employers, government and the society , 2. In EWhile the Cochrane review includes the best available evidence and found RtW coordination and usual care similarly effective, it is yet unclear how the evidence can be translated to RtW practice and policies. Especially when studies do not find beneficial effects of an intervention, practice and setting can be perceived differently from what is evaluated in these studies, and results are not translated to practice . For exaThe aim of the study is to (i) analyse how comparable the interventions in the Cochrane review  are to RWe conducted a systematic literature search in MEDLINE using PubMed, webpages of Finnish research and government institutes, and reference lists of included studies  to collect data about the difference between RtW coordination and usual care for workers on sick leave in Finland  and corresponding themes  based on the description of interventions included in the review , the main outcomes (length of sick leave and number of workers returning to work), the setting (Finland) and the perspective from which the decision is being made (population perspective).For each framework criteria Table , we summAfter the assessment, we drew our conclusion in relation to (de-)implementing RtW coordination in Finland. We formulated a summary of the most important judgements that were influencing our decision.We included six publications that described the content and process of RtW coordination interventions in Finland. Publications were either recommendations and part of information and training material , 14, 15 We judged RtW coordination and usual care interventions in Finland and those evaluated in the Cochrane review  to be moIn both the Cochrane review and Finland, the main differences between RtW coordination and usual care were that usual care mostly focuses on medical treatment, does not provide an individual tailored RtW plan and does not include considerations of the work or the workplace implementing RtW coordination. Previous studies have shown the EtD framework a suitable tool to make policy decisions that consider the wider social and political environment. Various policy-makers and stakeholders have been involved in the development of the framework and its criteria , and guiWe used prespecified categories (e.g. participants or content of the intervention) and judgements  to compare interventions. However, judgements remained subjective. We did not predefine what constitutes as similar , and others might judge differently. To increase the validity of the results, two authors analysed the data independently and resolved disagreements via discussion.Routinely collected data on the quality of RtW coordination is missing, and publications on RtW interventions usually describe the ideal intervention. Empirical data on what really happens in practice are scarce. We used data from a systematic literature search including grey literature and interviewed experts in a survey to describe the (intended) content and process of the RtW coordination practice in Finland. We compared in detail the current practice in Finland to what has been evaluated in studies in the Cochrane review. We do not think that additional empirical data about Finnish practice would considerably change our conclusions about the similarities and differences between the interventions.We combined data from different sources and study designs, but data on stakeholders’ values, attitudes, barriers to implementation of RtW coordination, and costs is either missing or very limited. Future studies that show little support from stakeholders for the intervention could alter our findings and support de-implementation strategies of RtW coordination. On the other hand, large support from stakeholders could support better implementation of RtW coordination.Even though we do not know barriers to RtW coordination in Finland, our survey results show that coordination might not be implemented as recommended. Although our survey included a small number of participants, and results from bigger studies could alter our findings, it is questionable whether better implementation would achieve a larger decline in sick leave days. Other interventions might be better suited alternatives, such as changes in sickness certification policies or incentives for employers to improve RtW rates of their workers . We do nWe used the EtD framework to draw conclusions on whether to (de-)implement RtW coordination in Finland. While the approach is systematic, evidence-informed and transparent, policy-makers might come to different conclusions—for example, when considering a different context in a different country or when placing different importance on certain criteria, such as costs or preferences. However, our study applied a transparent and evidence-informed approach to decision-making that has not been used previously for occupational health and safety (OHS) decisions. Therefore, our case study might be especially useful for OHS decision-makers to help ensure that all important criteria are considered and that the best available evidence is used.We found RtW coordination practice in Finland similar to the interventions and participants evaluated in the review. Consequently, the review findings apply, and the research evidence needs to be considered in decisions regarding (de-)implementing RtW coordination in Finland. Considering all EtD framework criteria, including costs and certainty of the evidence, investment in de-implementation strategies or better implementation of RtW coordination interventions in Finland is currently not required.New studies evaluating the effect and the costs of the intervention based on better quality data would help improve the evidence base. Both would empower decision-makers to implement interventions that are clinically and economically worthwhile.We recommend that changes in RtW practices should be implemented as part of a controlled evaluation study, including detailed descriptions of the content of interventions and usual care. New studies need to be sufficiently powerful to detect small but clinically relevant effect sizes, such as 2 days of reduced sick leave. Given the popularity of RtW coordination, an RCT of RtW coordination in Finland would be difficult to realize.Decision-makers can use the EtD framework and its criteria as a tool to make transparent evidence-based decisions in OHS. We advise to call for a comprehensive cost–benefit analysis, an assessment of stakeholders’ values, and better-quality evidence on the effectiveness of coordination on time to RtW for Finland to better inform the decision-making process.Additional file 1: Table S1. Categories and themes for data extraction and analysis of RtW coordination interventions. Table S2. RtW coordination in Finland—Cost analysis factors and measures. Table S3. Search strategy and results April 2019. Table S4. Key characteristics of included trials in Vogel et al. 2017. Table S5. Survey results expert judgements (n = 10). Table S6. Description of usual care interventions included in the review by Vogel et al. 2017 according to main aspects of RtW coordination interventions.


Splenic arteriovenous torsion causes splenomegaly and ischemic necrosis of the spleen. The recommended treatment for wandering spleen with hypersplenism is considered to be splenectomy. Splenic arteriovenous torsion causes splenomegaly and ischemic necrosis of the spleen. The recommended treatment for wandering spleen with hypersplenism is considered to be splenectomy. Splenic arteriovenous torsion causes splenomegaly and ischemic necrosis of the spleen. The recommended treatment for wandering spleen with hypersplenism is considered to be splenectomy.A 35‐year‐old Japanese woman had been diagnosed with a wandering spleen 20 years ago. No symptoms such as abdominal pain were observed before the delivery of her full‐term infant. Contrast‐enhanced computed tomography (CE‐CT) was conducted post‐delivery. The patient's spleen was located in the middle of the abdomen (A). A few months post‐delivery, she began to have frequent left‐sided abdominal pain. CE‐CT showed that her spleen had enlarged and moved into the pelvis (B). There is no dislocation of pancreas. The splenic artery and vein were spirally twisted 1260° (C). A laparoscopic splenectomy was performed (D). No abdominal pain occurred post‐surgery. The weight of the removed spleen was 350 g.This was a rare case of wandering spleen with splenomegaly and abdominal pain due to splenic arteriovenous torsion after childbirth. Wandering spleen which moves from the left hypochondrium to other places in the abdominal cavity had been caused by the absence or laxity of splenorenal and gastrosplenic ligaments.The authors declare that there is no conflict of interest that could be perceived as prejudicing the impartiality of the research reported herein.Informed consent for publication and related images has been obtained from the patient.


Evidence from several longitudinal studies has established the relevance of the approach of evolutionary criminology to understanding and intervening with adolescent criminal offenders, seeking to halt the criminal behavior before its potential consolidation in adulthood. The aim of this study is to present the psychometric properties of the Criminal Engagement Severity Scale (EGED) to discriminate between transitory and persistent delinquency in Chilean adolescents of both sexes. The characteristics of the sample are revealed through descriptive analyses, and evidence of validity and reliability is provided that show its discriminant capacity using ROC curves and odds ratios, measures of internal consistency , intraclass correlation, and unidimensional statistics. The results indicate that the EGED adequately discriminates between transitory and persistent delinquency, so that its use in contexts of assessment and intervention with adolescent criminal offenders can be recommended, because it helps to determine the intensity of the intervention required. In recent decades, the assessment of criminogenic risks and needs has been an area of particular interest for professionals who intervene with offenders, making it an extended practice in prisons . Such asAlthough there are great differences among youth offender systems around the world, the general purpose is to control juvenile delinquency by reducing the risk of recidivism in the offender population and preventing its onset where there is no contra-normative behavior, protecting, in most cases, the fulfillment of child and adolescent rights.Evolutionary criminology integrates the evidence of longitudinal studies, generating theories to explain the criminal career and its traits, expressed in a large corpus of literature that addresses the biopsychosocial, criminogenic risks that lead to its persistence, as well as the factors that affects its desistance. DeLisi and Piquero  identifyBeyond the complementary theories, Marc Le Blanc ,7 offersLe Blanc  proposesThe instrument to be described in this article, the Criminal Engagement Severity Scale (EGED), distinguishes between criminal types as understood in Moffitt’s evolutionary taxonomy ,10. In tDifferent studies describe typologies differentiated within PD, being characterized, for example, according to low, medium, or moderate risk levels , or accoThe second group of offenders presents an antisocial behavior limited to adolescence, or transitory delinquency (TD), which has its origins in social processes and begins in adolescence and desists in adulthood ,13,19. TAlthough there is evidence of the difference between PD and TD, functional application of the differentiation criteria is problematic. Whitten, McGee, Homel, Farrington, and Ttofi  examinedThe distinction between adolescents who present TD and PD becomes relevant when defining intervention strategies; Bonta and Andrews’s risk principle  emphasizThe use of criminogenic risk assessment instruments has become widespread in many correctional institutions around the world ,26, althSeveral studies report that although the intervention programs have adopted the use of properly validated instruments, professionals do not necessarily design or perform interventions according the evidence they provide ,33,34, oA balance must be maintained between needs and the most appropriate strategies to provide the service. The situation described in the previous paragraph occurs, partly, due to the poor training of the teams and little offerings in the network to provide specific services  appropriately, among other issues. However, it may also be due to how the interveners configure their strategies, favoring non-criminogenic focuses to obtain a more effective impact in the intervention, according to the RNR principle of specific responsivity .Hamilton et al.  also recThe aim of this study is to contribute evidence of the psychometric properties of the EGED to evaluate the general criminal risk levels in adolescents involved in criminal activities, understood as severity of criminal engagement. Evidence is also sought of the capacity of the instrument to discriminate between the two most significant forms of delinquency at this stage, TD and PD, thus contributing a simple tool to guide decision-making on the intensity of the interventions required in each case, within the framework of criminal penalty defined for the adolescent. This is consistent with the indications of Andrés-Pueyo and Echeburúa , Vincentnd year of first cycle of secondary school in Spain), and 35.5% are in treatment for drug use.A total of 537 adolescents, 478 boys and 59 girls, participated in the study, all convicted under the Adolescent Criminal Responsibility Act in Chile. A total of 29.1% were incarcerated, serving their sentence or in preventive custody at the time of the assessment, 45.6% were on probation, and 25.3% were in precautionary measure programs, or were given alternatives to incarceration or ancillary penalties for drug use. The average age was 16.8 years at the time of the assessment, and 66.6% committed their first crime before the age of 13. A total of ninety-eight percent have a family income below EUR 424 per month (minimum wage in Chile was EUR 306), 59.2% have completed 8 years of schooling .To calculate the inter-rater reliability, 5 experts in youth justice and 5 professionals with at least 5 years of experience working with offenders were asked to assess the items in three categories according to whether they considered them essential or not to differentiate between PD and TD. Characteristics of the judges are described in The EGED corresponds to an adaptation of the “Grille de gravité de l’engagement criminel” used in the Centre Jeunesse in Montreal, Canada . It consPrecocity;Presence of criminal record;Volume of crimes over 12;Absence of tension during their actions;Presence of crimes that violated a person’s integrity;Presence of problematic alcohol or drug use, or both;Use of weapons or tools in the commission of crimes;Planned organization;Presence of criminal accomplices;Spends time with maladjusted peers or offenders;Utilitarian motivation to commit crimes;Destruction of objects during their actions.The EGED evaluates maladjusted behaviors associated with breaking the law and specific features of the commission of crimes. The instrument’s items are:The strength of the EGED is that it assesses the main static risks associated with persistent criminal behaviors in young people, determining an adolescent’s degree of criminal engagement, or adherence to a pattern of persistent criminal behavior. It synthesizes evidence that facilitates the decision or professional judgment on the type of delinquency an adolescent presents; when applying it, the emphasis is on the person who makes the assessment, who triangulates the data before scoring, consults two or more sources aside from the young person’s self-report, and considers the official criminal history and not the judicialized one. These sources of information can be people who have close knowledge of their life history and current situation , and documentation available about the young person .Given that the EGED is consistent with the RNR Model, it includes the principle of minimal risk; thus, it is suggested that when there is doubt in the assessment of an item, that it not be marked and the necessary investigation be performed to score with certainty, crossing several sources of information for completion only when this is clear, or agreed upon with the assessment team. Being an instrument of professional judgment, it is inadvisable to ask the young person the questions directly; this may prove misleading by not adequately contrasting the information. The items should be checked from the data collected (interviews and files), the observation of the young person’s behavior, and what light other applied instruments can shed at the same time. In this sense, it is recommended that more than one professional with knowledge of the case take part in its completion and, if feasible, that the work be conducted in a team, for example, in a case analysis meeting.The Risks and Resources Evaluation Report (FER-R) has been in use in Chile since 2001, with its initial version being applied for nine years in programs for adolescent offenders on probation, until arriving at the revised version FER-R 3.0. It uses structured professional judgments to assess criminogenic risks and social adaptation resources. The risk indicators are grouped into two large categories: (a) behavioral risks detected by the system and (b) psycho-social risks, evaluating previous behavior, school risk, relationships with maladjusted peers, family risk, drug abuse, and negative attitudes or tendencies; in the adaptation resources, active personal resources are recorded, such as interests, cognitive and social competences, and family resources. In addition, it records the frequency and progression of crimes and information about previous interventions. The FER-R yields a maximum of 39 points for recidivism risk on its total scale and 18 points for resources, and each subscale has its own maximum score. Both the total scale and the subscales provide evidence to design an intervention plan with intensity and focal points differentiated for each case.The FER-R has various psychometric studies with Chilean samples, conducted at different times ,42. It sThe Self-Disclosed Delinquency Scale (EDA) is a guided interview form based on the criminal categories formalized in the Adolescent Criminal Responsibility Act in Chile and operated by state institutions dealing with childhood . Its objThe administration is via guided interview, asking the adolescent about the frequency with which they have enacted each behavior, to reconstruct the history of the crimes they recognize having committed; only the frequencies of self-reported crimes are recorded, for each age range, otherwise the check box stays blank. During the assessment, support is offered in answering questions, and specific experiences are asked about, taking advantage of the discussion about the evolutionary development of the criminal activity in the adolescent’s life, which deepens the dynamics, producing a fuller understanding of the case. The reliability analyses indicate adequate internal consistency for burglaries and thefts (0.95) and assaults and abuses (0.79), and moderate internal consistency for other crimes (0.60), due to the diversity of behaviors it records.The Youth Level of Service and Case Management Inventory, Chilean Version YLS/CMI-CL is an adapted inventory of the French-Canadian version of the YLS/CMI, reviewed and complemented with a score guide  created 27 = 0.514, p < 0.001) and the concurrent validity with the MACI scales, where the correlations ranged from 0.21 to 0.44, with the Tendency to Substance Abuse Scale and Transgressor Scale being the ones with the highest correlations. To give evidence of its discriminant capacity, the recidivist and non-recidivist groups are compared using an ROC curve, obtaining a large effect size .The YLS/CMI-CL has 42 items, divided into eight subscales: Previous and current offenses, family situation and parental role, education and employment, relationships with peers, substance abuse, free time use, personality and behavior, and attitudes and tendencies. Each item is encoded as present or absent according to the data collected by the evaluator and cross-checked by at least 3 different sources, giving a final score between 0 and 42 points. According to this total score, the adolescents are categorized into four recidivism risk levels: low, moderate, high, or very high, contributing to a broad and detailed view of the risk factors, specific needs, and receptivity of each young person. It has undergone validation studies in multiple countries, and in Chile it has shown good indicators for its use with young offenders , with a To determine the critical items and their cut-off scores, the characteristics of the main predictors in the meta-analysis by Cottle et al.  for crimA group of young people “with no record” was determined, where they scored zero on the scale “Previous and current offenses” on the YLS/CMI-CL and on the “Impact of previous interventions” on the FER-R; those that scored one or more on both indicators were categorized as “with a record”. With these criteria, a difference was established based on evidence between groups that have characteristics inherent to the TD and PD. This decision made it possible to fix the cut-off point for the criterion of previous criminal record, because the FER-R scale used for the criterion does not admit the commission of any crime for its record, and that of the YLS/CMI-CL tolerates up to three previous judicialized offenses. This leaves a tolerance limit of only one crime as evidence of TD, which is why the commission of two judicialized offenses gives evidence of being PD.To determine the criterion of precocity, the age of criminal onset recorded in the FER-R was used for a total of 141 cases (5–18 years) of both sexes , and it was analyzed by segmenting the base, where the group with a record (N = 62) obtained a mean M = 13.00 and median Mdn = 13.00; thus, it was established as a cut-off point to determine PD an age less than or equal to 13 years, meaning the commission of a crime before 13 years is evidence of PD.To determine the criterion of volume of crimes, the total of self-disclosed crimes on the EDA (TTTD) was used, recorded for all the cases of both sexes in the sample , and an Mdn= 15.00 was reported on this variable in the group with no record. Because the variable presented an AS= 4.07, it was decided to use central robust estimators  as the lEvaluating the evidence of the estimators, it was decided to leave the cut-off point at 12 for being the lowest value observed; i.e., it was considered that 13 or more crimes are indicative of PD.Using the three previous criteria, the sample was distributed into two groups, including in the first group adolescents who presented (a) criminal beginning at 13 years or later; (b) maximum 12 self-disclosed crimes (as reported in the EDA); and (c) maximum one judicialization in addition to the current case, which would correspond to the TD group. Thus, they made up a group of 420 cases of PD and 107 cases of TD.The scores of both groups were compared for the remaining nine items, and it was observed that “absence of tension” also appears as a predictor of static risk, because the cases of PD that had the item marked  were proportionally much higher than in the other group . The odds ratio of marking the item in PD compared to TD was 7.16, 95% CI ; the decision to include it as a critical item was to support the professional judgment of PD, by accounting for the psychological dimension of criminal engagement.p < 0.01, 95% CI 0.94–0.99), which indicates a good discriminant capacity and a large effect size [Finally, with the scores on the continuous scale of the EGED (0–12 points) recorded for all the cases of both sexes in the sample , an ROC curve was calculated between the TD and PD groups, categorized according to professional judgment during the execution of the study, in which the data emerged, where the cases were described by the professional responsible under the supervision of the research team. The area under the curve was 0.97 , which is an estimation of the reliability between evaluators, and that indicates what proportion of their grades represents an underlying construct; for this, a two-factor mixed model was used with absolute agreement, where the average measures were interpreted according to Landers . The resThe result indicates that there is 81.1% agreement in the evaluation of the underlying construct among the judges.Because the EGED is a unidimensional scale, we can give evidence of it using the indicators given by the program FACTOR 10.9.02 ; to achiThe result of the parallel analysis suggests the retention of a single factor; the other indicators given correspond to that of Unidimensional Congruence (UniCo), the explained common variance (ECV) and the Mean of Item Residual Absolute Loadings (MIREAL), each with their corresponding value by item , described in Analyses of ROC curves for each item on the EGED were performed using the total score of the FER-R as a test variable; p < 0.01, 95% CI 0.87–0.95), which implies a large effect size.With the four criteria plus the cut-off point, the ROC curve using the total score of the FER-R as a test variable yielded an under the curve of 0.91  and persistent delinquency (PD).Regarding reliability, both the α and Ω coefficients are found to be adequate for this type of scale and there is no need to eliminate any items ,53. The With respect to the evidence of unidimensionality, an essentially unidimensional structure is recognized , both byFor the evidence of validity by item, the areas under the curve show values that go from 0.70 to 0.88, which are satisfactory for such instruments ,55.Considering these results, from a strictly psychometric point of view, the EGED presents evidence that validates its use in assessment contexts to structure intervention plans for adolescent offenders according to the severity of their criminal engagement. Generally, in the specialized literature, such instruments are recommended, which is also reflected in the increase in their use in intervention programs with adolescent offenders ,34; althAs for the criticisms previously mentioned in this article, regarding the need for training in the use of assessment instruments in a correctional context, the little correspondence between the needs assessed and the established intervention plans, and the use of non-validated instruments or with purposes other than that for which they are used, the EGED offers a robust predictive and discriminant power that constitutes evidence of support in professional decision-making in juvenile justice, in the design of intervention plans, and in the guidance for judicial measures and criminal sentences.The evidence indicates that the instrument has appropriate psychometric properties for its use in Chile; therefore, the authors advise that the instrument continues to be studied to perfect and hone its use in other social and institutional contexts and with specific populations.The purpose of the EGED is to determine the degree of criminal engagement to differentiate and adjust the intensity of the intervention properly. In an adolescent is more engaged in delinquency, the intervenor should differentiate that they had many opportunities to learn and reinforce previous (counter-normative) learning, and intervene using the strategies that best suit that young person.In the case of TD, the aim is to reduce criminalization and contact with the justice system, thereby avoiding iatrogenic interventions, and favoring a rapid social reintegration in normalized contexts, but with the support required to reduce risk behavior and avoid recidivism and new arrests.When distinguishing PD, the intensity of the intervention should be adjusted according to the offender’s involvement, following the principles of the RNR and their individual characteristics. This implies an adjustment in the frequency of intervention contacts in short periods of time, number of objectives to be addressed, variety of focuses, depth of the changes sought, and specificityof the support provided in the helping relationship; all this, regardless of the sanction determined by the court. In other words, the severity of the criminal engagement is directly associated to the intervention plans, not to the sanction; in no case should a relationship be established between EGED score and sanction, the relationship sought is between EGED score and intensity of the recommended intervention in cycles not exceeding 3 months.In general, then, EGED seeks to contribute to differentiate between the characteristics of young people: the greater the criminal engagement, the greater the counter-normative learning, so interventions should be adjusted to deliver a service that gives more opportunities to the young person and decreases their criminogenic risk.The limitations of this study and those of the instrument are similar to those for the other instruments used in the adolescent correctional context. The sample of women 10.56%) is very low, which may alter the validity results for this group; and the characteristics of the instrument have not been studied in an indigenous population in Chile either, representing 12.8% in the most recent census % is very.


The real estate sector plays a significant role in the economy of any country. However, many investors make irrational investments in the real estate market. Therefore, the purpose of this study is to assess the effects of regret aversion and information cascade on investment decisions while considering the moderating role of financial literacy and the mediating effect of risk perception in the real estate sector of developing countries. This research utilized a quantitative research technique, collecting data by distributing structured questionnaires to real estate investors, followed by convenience sampling. This study used both descriptive and inferential statistics to make the data more meaningful. SPSS 25.0 was utilized to interpret the data. Cronbach's alpha was used to test for internal consistency, while validity was checked through correlation. Confirmatory factor analysis (CFA) was applied to confirm that the items on the questionnaire are perfectly loaded on their construct. Furthermore, process macro, model 5, was used to investigate the moderation mediation. This work addresses a gap in the literature by studying financial literacy as a moderator and risk perception as a mediating variable in regret aversion bias and information cascade bias's relationships with investment decisions in the real estate sector. The results confirmed that financial literacy weakens the negative effect of behavioral biases (regret aversion and information cascade) on investment decisions. In addition, risk perception mediates the relationships between these cognitive biases (regret aversion and information cascade) and decision making. The effects of other behavioral biases in real estate and stock market contexts should be examined in future research. Behavioral finance assumes that imperfect information leads to irrational investment decisions. Behavioral psychology has provided new insights into traditional psychology by introducing new finance concepts such as financial knowledge, cognitive biases, and risk perception  by two Ph.D. faculty members of GC University and a group of real estate investors with MBA degrees. Item 4 of financial literacy and the second item of regret aversion were edited (Urdu language) so that respondents could better understand the items and eliminate common method bias. Regarding the general description of the sample, data were collected using a structured questionnaire and sent to 325 real estate respondents—that is, 325 questionnaires were distributed to different retail investors. Out of these 325 questionnaires, 287 fully completed questionnaires were received from respondents. Another 17 returned questionnaires were discarded due to incomplete information. The remaining 21 questionnaires were not received from respondents. Overall, the response rate was 88% .The convenience sampling method  was used to select the respondents, as this method provides the highest response level while saving resources and time . The validity of the measurement determines whether a tool can provide a measurement of a concept  reported in The results in The results show that the composite reliability value is >0.8. The results are in line with Hair et al.'s  recommenp < 0.048). Therefore, hypothesis 5 is supported.Hayes's  process p < 0.000). The results of the regression suggest that it moderates the relationship between regret aversion and investment decisions.These interaction terms were plotted +1/−1 SD from the mean of financial literacy. The interaction term between regret aversion and financial literacy is significant and positive. The values of financial literacy against coefficient and significance are . These interaction terms were plotted +1/−1 SD from the mean of financial literacy. The interaction term between information cascades and financial literacy is significant and positive. The value of financial literacy is significant . The results of the regression suggest that financial literacy moderates the relationship between information cascade and investment decisions . The results show that the interaction between information cascade and investment decision is significant . This result suggests that financial literacy strengthens the positive relationship between regret and investment decisions. Thus, hypothesis 5 is supported. The effect of the interaction term between information cascade and investment decision is also significant . This result suggests that financial literacy strengthens the positive relationship between information cascade and investment decisions. Thus, hypothesis 6 is also supported.The results also reveal the effect of the interaction term between regret aversion and investment decision  investment decisions based on their regret related to previous decisions. Shimanoff  cited reThis study also investigated the effect of information cascades on investment decisions. The process macro under regression analysis indicated that information cascades have a significant and negative effect on investment decisions. This result supports the study's third hypothesis: “Information cascades significantly affect investment decisions.” Information cascade bias refers to investors' lack of knowledge about the property, ignorance of specific information that they might have, and tendency to blindly follow the crowd. Alevy et al.  examinedAnother aim of this study was to investigate the mediating effect of risk perceptions on the relationships between cognitive biases and investment decisions. The results indicated that risk perception partially mediates these relationships. This result supports the hypothesis that “Risk perception mediates the relationship between regret aversion and investment decisions.” It also supports the fourth hypothesis: “Risk perception mediates the relationship between information cascade and investment decisions.”Moreover, Ishfaq et al.  stated tThe fourth study objective was to investigate the moderating effect of financial literacy on the relationship between regret aversion and investment decisions. The regression analysis under process macro indicated that financial literacy weakens the negative relationship between regret aversion and investment decisions. This result supports the hypothesis predicting a “Moderating role of financial literacy in the relationship between regret aversion and investment decisions.” A financially literate investor will reduce any ambiguity involved in an investment decision. Dimmock et al.  examinedFinally, this research investigated the moderating effect of financial literacy in the relationship between information cascade and investment decisions. The results of the process macro regression analysis indicated that financial literacy weakens the negative relationship between information cascade and investment decisions. This result supports the study's sixth hypothesis related to the “Moderating role of financial literacy in the relationship between information cascade and investment decisions.” Investors who rely on professional advice and consult with others tend to make profitable investments because they constantly learn from their advisers  and investment decisions. Moreover, risk perception partially mediates the relationships between cognitive and investment decisions. This research also explored the moderation effect of financial literacy in the relationships of regret aversion information cascade with investment decisions. In this study, correlation and regression were utilized to examine the relationships between variables. Behavioral biases were found to negatively affect investment decisions.Investors do not always act rationally due to different biases. According to Kumar and Goyal , variousRisk perception significantly mediates the relationship between behavioral biases and investment decisions. As Ishfaq et al.  stated, This present study proposed that behavioral biases negatively affect investment decisions of investors, both directly and indirectly, considering risk perception as a mediator and financial literacy as a moderator. Kumar and Goyal  explaineIn this study, we combine the theoretical fields of cognitive psychology and perception of risk along with financial literacy and investment decision literature. Thus, the study makes a theoretical contribution by providing further insights into the cognitive biases and decision-making relationship by exploring how decisions and performance of an individual investor are affected by regret aversion, information cascade, risk perception, and financial literacy. This study provides several practical implications for the government and real estate investors. For instance, the government should conduct seminars and workshops on financial securities knowledge and behavior for real estate investors to reduce biases in their investment decisions, thereby helping the real estate market prosper. Others propose that many investors invest in the real estate sector despite not having formed their own opinions about investing—instead, they blindly follow others. Therefore, investors should attend courses that teach them about the behavioral biases that influence investment decisions, thus enabling them to manage their financing in the real estate sector more effectively.The results of the study suggested that the investment strategy relying on fast and frugal rules would not result in better returns to investors. Based on our findings, researchers would like to suggest that investors should not rely on cognitive thinking while making investments, but conduct a proper analysis of investment opportunities, develop quantitative investment criteria, and establish investment objectives and constraints, base decisions on their financial capability and experience levels  instead of making investment decisions by using cognitive biases.Shefrin  stated tThis research has some limitations. The main limitation is related to the short study period. The behavior of an investor is influenced by political and economic conditions in addition to cognitive biases. However, the short study period did not permit us to analyze the effects of such conditions. Second, due to COVID-19, this study was conducted in metropolitan areas of developing economies. Third, this study was conducted using survey questionnaires, which are associated with several general problems. For example, respondents may be hesitant and provide biased responses, which could affect the results.The present study proposes several recommendations for future studies. First, this study could be done with time series data and compared with cross-sectional data. Second, as mentioned in the previous paragraph, this research was limited to metropolitan areas in a developing country. Therefore, future studies could be conducted across multiple cities or cities in developed countries. Third, a quantitative research technique was used in the present study. Therefore, a quantitative data collection method was used. In the future, qualitative research methods could obtain responses from investors through interviews to accurately describe the problems of interest. Thus, qualitative research should be conducted in the future. Fourth, other variables could be examined in future research, such as personality traits, social norms, investors' attitudes, and investor types, to improve the current understanding of financial investment decisions. Fifth, similar studies can compare the decisions of investors in the stock exchange, real estate, and commodity market sectors. Finally, similar studies can examine differences between short-term and long-term investment intentions.The original contributions presented in the study are included in the article/supplementary material, further inquiries can be directed to the corresponding author/s.The studies involving human participants were reviewed and approved by Riphah International University Faisalabad. Written informed consent to participate in this study was provided by the participants' legal guardian/next of kin. Written informed consent was obtained from the individual(s), and minor(s)' legal guardian/next of kin, for the publication of any potentially identifiable images or data included in this article.MI identifies the problem area and build a hypothesis and do working on the significance of study. MK contributes on the result and discussion chapter. All authors contributed to the article and approved the submitted version.The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.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.