With the increasing offer of fertility treatment by a largely privatised sector, which has involved the proliferation of treatment add‐ons lacking evidence of effectiveness, In‐Vitro Fertilisation (IVF) patients are expected to make informed choices on what to include in their treatment. Drawing on interviews with 51 individuals undergoing fertility treatment, this article explores patients’ approaches to medical evidence interpretation and its role in their decisions to include add‐ons. While most IVF patients share understandings of what counts as medical evidence, our findings show how their approaches also differ. Our analysis focuses on how patients negotiate the notion of medical evidence and its relation to other forms of experience or knowledge. We present four different approaches to evidence in IVF: (1) delegating evaluations of evidence to experts; (2) critically assessing available evidence; (3) acknowledging the process of making evidence; and (4) contextualising evidence in their lived experience of infertility. We suggest that patients’ choice to include add‐ons is not due to a lack of information on or understanding of evidence, but rather should be interpreted as part of the complexity of patients’ experiences of infertility. Medical sociology literature has shown that infertility is a social process that needs to be understood within sociocultural contexts  delegating evaluations of evidence to experts; (2) critically assessing available evidence; (3) acknowledging the process of making evidence; and (4) contextualising evidence in their lived experience of infertility.In the last three decades, the concept of patient choice has gained popularity not only among insurance‐based health systems, where choice is traditionally institutionalised, but also among publicly funded national health systems , aiming at offering clinicians the best available evidence about the most adequate treatment for patients  and CAM therapists , are re‐elaborated and rearticulated in patients’ perspectives. In the case of fertility care, similar contrasting ontological and epistemological approaches emerge inside the same professional community  that was distributed on relevant online social media. In this survey, participants were given the option to leave their contact details to be contacted for further research participation. These interviews were conducted either over the phone, at the participant’s home or in a café setting, depending on the participant’s own preference.This article draws on interviews with 51 IVF patients, which includes 40 women who were going through IVF, 10 male partners and one female partner. At the time of the interview, 26 participants were undergoing or about to start IVF treatment, 15 were pregnant or had pregnant partners, and 10 had one or more children from IVF. Participants were aged between 29 and 47, with a mean age of 36. The recruitment of IVF patients and partners from across England took place through two routes that enabled us to include a range of patients who were undergoing NHS‐funded treatment, privately funded treatment or a combination of both. Firstly, 31 participants were recruited by research nurses at three participating NHS fertility clinics and interviewed on‐site at these clinics. Secondly, 20 participants were recruited via an online survey , the UK Health Research Authority (REC Ref 17/EM/0218) and locally at the participating fertility clinics. All interview participants were given written information and the opportunity to ask questions about the study before providing written consent to participate in the research. Each interview participant was offered a voucher of £20 for their participation. All identifiable information about participants and the participating fertility clinics has been removed from this article to preserve their anonymity.Interviews lasted between 30 and 80 min, giving a total of around 40 h of interview recordings, which were professionally transcribed verbatim. The transcripts were coded and analysed following an abductive process  delegating evaluations of evidence to experts; (2) critically assessing available evidence; (3) acknowledging the process of making evidence; and (4) contextualising evidence in patients' lived experience of infertility. Considerations about evidence were raised not only in relation to add‐on tests or treatments in IVF but also in other contexts such as the impact of hormones on cancer risk, the side effects of treatment on the health of IVF babies and the effectiveness of nutritional supplements to improve patients’ reproductive health. Although all these articulations of evidence were included in the analysis process, in this article, we focus here on participants’ decision‐making processes in relation to IVF treatment add‐ons.A large group of participants preferred to delegate evaluations of evidence in IVF to medical professionals. This generally meant that they preferred to follow the advice of their clinic or consultant in relation to treatment decision‐making. Their trust in professionals was often closely attached to an understanding and belief that professionals will only ever act in the patient’s best interest and that their clinic would never offer anything that might cause harm. Patients in this category often had reservations about exploring treatment options beyond the perceived basic, standard or routine IVF procedure, unless there was a very strong case  for doing something ‘differently’. Sometimes, this could be a consideration about the cost of add‐ons and their affordability or it could be a strategy for limiting the number of options in an attempt to remove some of the burden of making the ‘right’ decisions. Some of the male partners expressed reservations about directing the treatment, given that it primarily takes place on the female body.I’d rather just not know, I’d rather just trust kind of what people are telling me. And if they were worried then I should be worried kind of thing. So I didn’t really, no, I didn’t really look things up. But then I think if, because everything went so smoothly and so quickly that I didn’t really feel like I needed to. Maybe if it hadn’t then I would have been googling.The following quote is typical of participants in this group. In this quote, the participant emphasised that she would not research optional treatments and their evidence‐base in favour of following the clinic’s treatment recommendations. In addition to this, she also noted how following the guidance of her clinic involved a kind of emotional calibration. The ‘people’ that this participant refers to in this quote are the fertility professionals at her clinic:Notably, this participant was pregnant from her first embryo transfer at the time of the interview and had not been a fertility patient for as long as many of the other participants. Her reflection on whether she would do more independent research into treatment options (‘googling’) if she had been in treatment for longer reflects a tendency within the participant group for patients to become increasingly involved in directing their treatment if they had experienced several failed attempts.I went in trying not to get too personally, it sounds silly, trying not to get personally involved, I tried to keep it quite clinical almost as well, just go in and go right, please tell me, you’re the expert, I’ll trust you, so. I felt like I did kind of trust them and just kind of hoped that it worked. And certainly, when the other consultant spoke to us and she offered us those three extra things , again for me they sounded logical and again I was sort of just kind of hopeful and I hadn’t done much research into what they were. I just kind of trusted them I think. She was very friendly. Very nice.The following participant also articulated her approach to decision‐making as grounded in a relationship of trust with the consultant and the clinic. She explained how she felt most comfortable in following the guidance of the clinical team and specifically made a point of not researching treatment options but accepting the course of treatment that was recommended for her:Disengaging from the responsibility of making treatment decisions can offer a strategy for maintaining distance from the emotional strain of decision‐making. The previous participant described this as an attempt to keep the treatment process ‘quite clinical’ and thus not become ‘personally involved’. She explained how starting treatment felt like a relief from the strain of trying to conceive previously: ‘Once I was in the IVF process there was a sense of I can relax a little bit, I am with experts and with the top people […] I could put my faith and my trust in them. And I think I did almost completely.’ She noted that she was aware of the limited evidence‐base to support these ‘three extra things’, which she paid for as part of a self‐funded cycle of IVF, but she reiterated throughout the interview that she was willing to follow the advice of the clinical team.Another group of participants engaged in what we have termed critical evaluations of evidence. These participants saw themselves as playing a key and active role in assessing the available evidence for treatments that were offered to them, which would often involve doing extensive research drawing on a wide range of (mainly) online resources. The focus and outcome of critical evaluations of evidence varied between participants. Some would reject any additional treatment that was not supported by RCT. Others would emphasise a small but good‐quality evidence‐base or state that if a treatment is based on ‘sound science’ but has simply not been through enough testing, then this can be sufficient to justify its use. This group of participants would often adopt medical concepts and terminology to evaluate and reflect on evidence in IVF, and potentially use this to challenge suggestions or decisions made by fertility consultants.Participants who approached evidence critically would often draw on their professional knowledge or skills in assessing the evidence for a particular procedure, whether this was being able to navigate the scientific literature or through their familiarity with certain treatments from working in a medical or health‐care profession. One participant noted how their work shaped their ability to critically examine research studies: ‘I guess I’m a bit sceptical about, you know, working a bit with data in my job, you know, I know that it’s possible to make things swing one way or the other and it depends on, you know, the number you have. It depends on the studies.’ . In this case, critically evaluating evidence is extended to include evaluating the reliability of the studies and study methodologies that produce evidence.I think working at university has got benefits and that would be able to access peer reviews, we both work at universities so we’re used to doing that kind of research. So we’re quite well skilled to look. So we’d been doing a lot of research and looking up information from the start.Others were able to access peer‐reviewed articles through their professional work or network, such as an affiliation with a university. Access, in this context, refers both to the ability to physically access journals and articles that might otherwise only be available behind paywalls, but it also captures the ability to interpret and evaluate scientific writing, methods and research. The following participant and her partner, both of whom worked at a university, had been through multiple rounds of failed transfers by the time of the interview, which meant that there had been time for them to become increasingly invested and detailed in their learning:The consultant has suggested that we look at an endometrial scratch prior to the cycle starting. And when we first had a conversation with him there was some evidence to say that it might help, it might not, but there was no randomised trial. Since then, about a week later, the new study came out from New Zealand and that was that.(Same as above)She went on to describe how their consultant had recommended endometrial scratch, a procedure carried out before an IVF cycle where the lining of the womb (the endometrium) is ‘scratched’ using a small sterile plastic tube to make it more receptive to an embryo implanting. This add‐on has an amber light on the HFEA traffic system HFEA,  as thereThis participant saw the report of this study Whereas some participants perceived RCTs as the definitive source of evidence to support a treatment, a critical approach did not always mean that participants would disregard any treatment that was not supported by similar forms of high‐quality evidence. This approach could also involve risk calculations or evaluating whether there is ‘enough’ evidence to support a particular test or treatment. It could also involve questioning the feasibility or definition of evidence in IVF. The following participant had read a book that offered advice for how to improve egg quality through lifestyle changes, such as nutrition and reducing exposure to environmental toxins, and she reflected on the evidence base for these recommendations:By drawing on the widely familiar and accepted recommendation in the UK for women to take folic acid during early pregnancy and the pre‐conception stage NHS, , the predefinition of evidence in IVF. These participants had a strong awareness of the many aspects of reproductive biology and IVF that are still unknown within the medical sciences, and they accepted therefore that there may be some experimental aspects to IVF as a whole as well as their individual treatment. For example, one participant situated her willingness to try unproven treatments against a view that ‘the whole thing [IVF] is a bit of a scientific experiment’. Closely connected to this view was an emphasis on innovation, exploration and the development of knowledge in reproductive medicine, which we refer to as the ‘making’ evidence in IVF. This could sometimes involve reflections on the significant barriers to creating high‐quality evidence in IVF, such as the difficulties in coordinating multiple clinics or recruiting a sufficient number of study participants Sometimes, participants’ reflections on the making of evidence in IVF were grounded in their own experiences of participating in a research trial as part of their fertility treatment. These participants often perceived themselves as having a personal role in advancing the field of reproductive medicine. For example, one stated that: ‘medicine doesn’t advance unless you try things.’ Participants in this group often reflected on the unknown qualities of IVF and infertility more generally, and how medical research is needed to address significant gaps in knowledge and understanding. This view was often underpinned by experiences of receiving an ‘unexplained infertility’ diagnosis, as demonstrated by the following participant:Participants in this group generally placed high value on the potential for them to contribute to knowledge creation and recognised that any outcome of the trial, which the previous participant refers to as ‘negative information or positive information’, is still a valuable contribution.Some participants had considered including treatment add‐ons that, at the time of the research, were in the initial stages of testing, such as the effect of natural killer cells on embryo implantation. Participants often situated the use of immunological tests and treatments—which are rated red in the HFEA traffic light system (2022)—as controversial based on the reading they had done as well as potential discussions with their own consultants.[The] theory is that natural killer cells, which are in your blood, all over your body and work to attack viruses and infections, actually if you’ve got too many of them they can attack the embryo because half of it is a foreign body because half belongs to the male and I think that’s the issue. So if the killer cells are too high they, well, they believe that in women where the killer cells are too high, too many of them, that you’re attacking the healthy embryo […] I think it’s quite controversial, I think some people are very opposed about it, [they] think it’s not accurate, so it’s a theory.The following participant, who was preparing for further treatment after four unsuccessful embryo transfers, reflected on the theory of natural killer cells testing:This participant’s emphasis on the ‘theory’ of natural killer cells and the ‘belief’ that is driving investigations in this area constitutes this field of knowledge as uncertain. In the absence of any other explanation for why the embryos transferred had not implanted beyond unexplained infertility, the theory of natural killer cells holds an explanatory potential that is appealing.Some participants situated their understanding of evidence in the wider context of their lived experience of infertility. Although few detailed this contextualisation explicitly, many interviewees inferred the need to consider their interpretation of evidence and effectiveness in relation to their own circumstances and histories. In this way, certain treatments ‘made sense’ to participants for a variety of reasons that are not readily captured within a medical evidence‐base framework.I’m sure it was through one of those sorts of [online] forums that somebody had said about, like their clinic had recommended taking this low grade aspirin, and I just thought well, actually it kind of makes sense, you know, it thins the blood. It was like 75 mg or, it was a tiny, tiny little aspirin. And it really was something where I thought, you know what, if I’m not allergic to it and it’s not really going to cause me any harm, it’s like taking it for a headache, so yeah, that I chose to do.When patients are called to make choices about treatment in conditions of high uncertainty, as often there are no known causes of infertility and there is a generalised lack of evidence to support treatment  and normalising its use for common ailments (‘it’s like taking it for a headache’). She also noted how the potential benefit of aspirin ‘makes sense’ based on her existing knowledge and understanding of how this medication works (‘it thins the blood’) and thus improves blood circulation.I’ll give my example because me and my missus were married for eight years before we had a child. Now let’s say we were married for twenty years and we didn’t have a child and then you came up to us and said listen, there’s this new revolutionary medication which will help you but there are these side effects. Now depending what those side effects are and you said listen we haven’t tested it properly on everyone like it’s been 80% tested, it’s safe, there’s a 20% chance it might not be safe and you might have these side effects. The fact that we’ve been married for twenty years and we hadn’t had a child and this could be our last chance, maybe we would be willing to take that risk.Patient decision‐making about treatment was often influenced by their experience of infertility, and patients re‐negotiated notions of medical evidence, uncertainty and risk of potential harm on the basis of their personal circumstances. The following patient reflected on how the length of involuntary childlessness contributes to the re‐alignment of possible benefit versus risk:It’s difficult because like the steroids, obviously they could do harm, but I felt like the dose that I was on it was, you know, there was a risk but I felt like it was a risk I was willing to take […] I knew some of the side effects of the steroids, you know, I knew the risks but I took a cal‐, you know, that was my risk, I took it.Comparing and reflecting on different treatments, risk categories and types of evidence in light of patients’ lived experiences of infertility was common among patients. The following participant described her evaluation of risk when deciding to pursue, and pay for, the controversial immunological treatment discussed above in the form of steroids:As demonstrated in the previous quote, contextualising evidence in the lived experience of infertility could sometimes involve taking known risks in treatment. This participant had been through several failed cycles of IVF, including miscarriages, which likely shaped her willingness to pursue a riskier treatment option. She recognised that steroids are not supported by rigorous evidence that they improve chances of pregnancy, and that they may even be harmful, but she claimed this risk as one she was willing to take.As discussed above, several notions have been introduced to conceptualise patient informed choice in the age of evidence‐based medicine. However, all these notions tend to privilege biomedical over other forms of knowledge ; Formal analysis (supporting); Funding acquisition (lead); Methodology (lead); Project administration (lead); Supervision (lead); Writing – original draft ; Writing – review & editing . Josie Hamper: Conceptualization (supporting); Data curation (lead); Formal analysis (lead); Investigation (lead); Writing – original draft ; Writing – review & editing .


Atopic eczema (AE) is a chronic inflammatory skin condition, affecting 5% to 20% of people worldwide . While tThe review  extracteOverall, there was scarce evidence supporting the use of supplements for treating AE. However, given that many of the included studies were either underpowered or of low quality, evidence was insufficient to claim all supplements are completely ineffective. Nevertheless, the authors advised against further research without a stronger rationale—to the exclusion of fish oil, for which pooled data from 2 small studies suggest it may improve subjective daily quality of life in people with AE . Further, there was insufficient evidence to recommend any oral supplements as treatment, with the exclusion of probiotics [In a 2018 review of probiotics, vitamins, oils, and traditional Ayurvedic agentsobiotics . Meta-anOverall, this review highlights the limited evidence that exists for the use of nutritional supplements in AE. At present, the most effective “natural” modality for AE is topical emollients . Future


Similarly, individuals with sufficient eHealth literacy showed a higher likelihood of having more teeth  compared to the inadequate eHealth literacy group controlling for age, gender, income, and education. Individuals with problematic eHealth literacy exhibited a tendency towards lower odds of irregular brushing , although this result was marginally significant. In contrast, individuals with sufficient eHealth literacy had significantly lower odds of irregular brushing frequency  compared to the inadequate eHealth literacy group. Conclusion: The findings suggest a positive association between eHealth literacy and oral health outcomes. Improving eHealth literacy may have implications for promoting better oral health behaviors and outcomes.Objective: This cross-sectional study aimed to investigate the association between electronic health  literacy and oral health outcomes, including the number of teeth and brushing frequency. Methods: A total of 478 participants were included in the study and assessed for their eHealth literacy levels. Demographic variables, including age, gender, income, and education, were collected. The participants’ number of teeth and brushing frequency were also recorded. Multiple regression analyses were performed to examine the relationship between eHealth literacy and oral health outcomes, adjusting for sociodemographic variables. Results: The study sample consisted of both males (66.5%) and females (33.5%), with a mean age of 31.95 years. Among the participants, 16.95% were classified as having inadequate eHealth literacy, 24.06% had problematic eHealth literacy, and the majority (59.00%) demonstrated sufficient eHealth literacy. There was a significant association between eHealth literacy and oral health outcomes. Individuals with problematic eHealth literacy had a higher likelihood of having a greater number of teeth (RR = 1.12, 95% CI: 1.05–1.20,  As the focus of healthcare has shifted from treating illnesses to preserving health, health promotion has emerged as a societal issue that affects individuals in general as well as healthcare professionals . During In the field of dentistry and oral health, the concept of health literacy has gained importance and has been integrated into oral health literacy (OHL), which encompasses various tools and resources ,10. ReseIndividuals who possess greater expertise and competence in accessing eHealth information tend to be more effective at managing their own health and adopting healthier behaviors. This suggests that the ability to access and use eHealth resources, such as online health portals, mobile health applications, and other digital tools, can facilitate a more informed and engaged approach to healthcare . ThroughOver the past few decades, Saudi Arabia has undergone rapid socioeconomic development and related lifestyle modifications, but the prevalence of poor oral health in Saudi Arabia is still rising . UnderstStudy Design and Sample: This was a cross-sectional study that was conducted at the Taibah University College of Dentistry Hospital in Madinah, Saudi Arabia, in 2023. The patients included in the study were Arabic-speaking individuals aged 18 and older who sought dental treatment at the hospital and voluntarily agreed to participate. Potential participants were approached during their scheduled appointments to assess their interest and eligibility for participation. Convenience sampling was employed, where patients were selected based on their availability and willingness to participate. We adhered to the STROBE  guidelines in preparing and reporting the findings of this manuscript [Ethical Considerations: The study was approved by the Institutional Review Board of Taibah University (TUCDREC/O10323) and followed the guidelines of the Declaration of Helsinki. Each participant signed a consent form. Full confidentiality of the collected information was provided to the research participants.eHealth Literacy: eHealth literacy was the main explanatory variable of this study. The validated Arabic version of the Electronic Health Literacy Scale (eHEALS) questionnaire was used to assess participants’ perceived ability to find, evaluate, and use electronic health information . The queOutcome Variables: Oral health was the main outcome of this study. We had two oral health outcomes: the number of teeth and brushing frequency. The number of teeth was assessed through a clinical examination using the WHO method . A trainCovariates: The covariates of the study were the sociodemographic variables that were included in the analysis to adjust for potential confounding factors, these included age, gender, education level, and income. Sociodemographic data were collected through a self-administered questionnaire based on the Saudi General Authority for Statistics classification system. Income was measured by asking participants about their monthly income in Saudi Riyals. The income variable was categorized into four groups: “less than 2500SR”, “2500-4999SR”, “5000-9999SR”, and “More than 10,000SR. The education variable reflects the educational attainment of the study participants. It was divided into four categories: “No education”, “less than 6 years”, “7–12 years”, and “University or higher”.Data Analysis: First, the variables of the study were summarized across the eHealth literacy groups  using means and standard deviations for continuous variables and frequencies and percentages for categorical variables. The relationship between eHealth literacy and oral health outcomes (number of teeth and brushing frequency) was then examined using negative binomial regression and logistic regression analysis, respectively. in the logistic regression, the brushing frequency was dichotomized into an “irregular brushing” category, which refers to individuals who do not engage in daily tooth brushing, and a “regular brushing” category, which includes individuals who brush their teeth at least once a day, or twice or more a day. In addition, the demographic variables  were included as covariates in these analyses to adjust for potential confounding. The magnitude of the association between eHealth literacy and oral health was presented as adjusted incidence rate ratios with corresponding 95% confidence intervals for the negative binomial regression analysis, and an adjusted odds ratio with corresponding 95% confidence intervals for the logistic regression analysis. The statistical analysis was performed using Stata version 17 software, which was developed and distributed by StataCorp LLC .The sample consisted of 478 participants who were assessed for their eHealth literacy levels. In general, the study sample consisted of both males and females, with males accounting for 66.5% of the participants and females accounting for 33.5%. The participants’ mean age was 31.95 years (SD = 12.1). The age range of the participants varied from 18 years to 71 years. In terms of education, the sample included individuals with varying levels of educational attainment. The majority of participants had completed either 7–12 years of education (38.7%) or university or higher education (55.0%). Regarding income, the majority of participants fell into the “less than 2500SR” category, accounting for 53.1% of the sample. In terms of oral health, the mean number of teeth was 26.45, and regarding brushing frequency, the sample was divided into three categories: individuals who did not brush their teeth (9.6%), those who brushed once a day (46.7%), and those who brushed twice a day (43.7%). Among the participants, 16.95% were classified as having inadequate eHealth literacy, 24.06% had problematic eHealth literacy, and the majority (59.00%) demonstrated sufficient eHealth literacy. When comparing the eHealth literacy groups, there were significant differences across the study variables. The inadequate eHealth literacy group was older and exhibited lower levels of education, lower income, a higher proportion of males, fewer teeth, and lower brushing frequency compared to problematic and sufficient eHealth literacy groups .p < 0.001), indicating a greater likelihood of having a higher number of teeth compared to those with inadequate eHealth literacy. Similarly, individuals with sufficient eHealth literacy exhibited a higher IRR of 1.14  compared to the inadequate eHealth literacy group after adjusting for sociodemographic variables, suggesting a positive association between eHealth literacy and a greater number of teeth [p = 0.054), indicating a tendency towards lower odds of irregular brushing compared to those with inadequate eHealth literacy, although this result was marginally significant. Similarly, individuals with sufficient eHealth literacy had significantly lower odds of irregular brushing with an OR of 0.24  compared to the inadequate eHealth literacy group after adjusting for sociodemographic variables [In the regression analysis, after adjusting for age, gender, income, and education, individuals with problematic eHealth literacy had a higher rate ratio (RR) of 1.12  plays a crucial role in determining health outcomes, including oral health . Higher The results of this study have important public health implications. Firstly, they highlight the significance of eHealth literacy in relation to oral health outcomes. Improving eHealth literacy among the population can empower individuals to access, understand, and effectively utilize online health information, leading to better oral health management and behaviors . SecondlThe integration of eHealth literacy assessment into routine oral health screenings and the implementation of personalized interventions in clinical practice have important implications for improving oral health outcomes. By assessing patients’ eHealth literacy levels, healthcare providers can identify individuals who may need additional support in accessing and utilizing online health information ,46. AsseThis study has several limitations that should be acknowledged. First, the generalizability of the findings may be limited as the study was conducted at a single center, the Taibah University College of Dentistry Hospital, and the sample may not represent the broader population. Second, the cross-sectional design prevents establishing causality or determining the direction of the relationship between eHealth literacy and oral health outcomes. Third, reliance on self-reported measures introduces the potential for recall bias or social desirability bias. Despite efforts to adjust for confounding factors and address potential biases, there may be unmeasured confounders influencing the associations. One important limitation to consider, particularly in relation to the eHEALS tool, is the reliance on participants’ reading proficiency. Since the eHEALS questionnaire assesses individuals’ eHealth literacy, which involves understanding and interpreting health-related information online, it is crucial that participants possess a certain level of reading ability to provide accurate responses. This reliance on reading proficiency introduces the potential for biases, as participants with varying levels of literacy may interpret the questions in a different way or struggle to accurately report their eHealth literacy levels. Therefore, it is essential to recognize the impact of participants’ reading proficiency on the validity and reliability of the eHEALS tool and its potential influence on the study findings. These limitations emphasize the need for further research involving diverse populations, multi-center settings, longitudinal designs, and comprehensive assessments to strengthen the evidence base and enhance our understanding of the relationship between eHealth literacy and oral health. Despite these limitations, the study has notable strengths. These include the comprehensive assessment of eHealth literacy, oral health status, and oral health behaviors among a specific patient population, the adjustment for sociodemographic factors in the analyses, and the use of rigorous statistical methods to examine the associations. Additionally, the clinical observation of tooth count outcome in our study added considerable strength to our findings, as it provided an objective measure of oral health status. These strengths contribute to the validity and reliability of the findings and provide valuable insights into the relationship between eHealth literacy and oral health outcomes.Further research directions in the field of eHealth literacy and oral health can enhance our knowledge and guide future interventions. Future studies should evaluate the effectiveness of eHealth literacy interventions, exploring different approaches and comparing their impact on oral health outcomes, as most of the studies published to date have not examined oral health ,57. LongIn conclusion, this study sheds light on the association between eHealth literacy, oral health status, and oral health behaviors among patients visiting Taibah University College of Dentistry Hospital. The findings highlight a significant association between eHealth literacy levels and a higher mean number of teeth and a lower likelihood of not regularly brushing teeth. These results emphasize the importance of improving eHealth literacy among individuals to enhance oral health outcomes. Overall, these findings have significant public health implications, suggesting the need for targeted interventions to enhance eHealth literacy and promote oral health among the population.


The National Clinical Excellence Awards (NCEAs) in England and Wales were designed, as a form of performance-related pay, to reward high-performing senior doctors and dentists. To inform future scoring of applications and subsequent schemes, we sought to understand how current assessors and other stakeholders would define excellence, differentiate between levels of excellence and ensure unbiased definitions and scoring.Semistructured qualitative interview study.25 key informants were identified from Advisory Committee on Clinical Excellence Awards subcommittees, and relevant professional organisations in England and Wales. Informants were purposively sampled to achieve variety in gender and ethnicity.Participants reported that NCEAs had a role in incentivising doctors to strive for excellence. They were consistent in identifying ‘clinical excellence’ as involving making an exceptional difference to patients and the National Health Service, and in going over and above the expectations associated with the doctor’s job plan. Informants who were assessors reported: encountering challenges with the current scoring scheme when seeking to ensure a fair assessment; recognising tendencies to score more or less leniently; and the potential for conscious or unconscious bias in assessments. Particular groups of doctors, including women, doctors in some specialties and settings, doctors from minority ethnic groups, and doctors who work less than full time, were described as being less likely to self-nominate, lacking support in making applications or lacking motivation to apply on account of a perceived likelihood of not being successful. Practical suggestions were made for improving support and training for applicants and assessors.Participants in this qualitative study identified specific concerns in respect of the current approaches adopted in applying for and in assessing NCEAs, pointing to the importance of equity of opportunity to apply, the need for regular training for assessors, and to improved support for applicants and potential applicants. An inclusive sample of key informants were interviewed, which included Advisory Committee on Clinical Excellence Awards (ACCEA) subcommittee assessors  and representatives of professional organisations such as Royal Colleges and those representing particular groups of doctors.Interview guides were appropriately and comprehensively informed by the project’s initial literature review, the aims of the research and feedback from a dedicated public advisory group.Despite initial expressions of willingness to participate in the study, we were unable to recruit many non-white key informants or those from younger age groups.We carried out our research alongside a national consultation held by ACCEA which resulted in the move to Clinical Impact Awards and was not known to the research team during the research.Payment systems for doctors can have significant impacts on staff recruitment and retention, quality of care, and costs, and efficiency within a health system.ACCEA advises health ministers on award allocation following a national competition and assessment process. Despite its prominence, longevity and associated use of public funds, there has been relatively little research into the scheme. Commentators have questioned the scheme from a health economics perspective, including the underlying incentive structure and more recently a study used theoretical frameworks to explore the intrinsic and extrinsic motivations of the medical profession in relation to CEAs.6In relation to the assessment processes, earlier analysis of historical data showed that the arrangements for assessing applications were defensible, depending on the level of reliability judged to be required in the assessment process.In 2021, ACCEA, launched a national consultation to inform revisions to the awards scheme. A core part of the revised scheme was to adopt a scoring system that is robust, equitable, able to distinguish between levels of excellence, and aligned with ACCEA’s overall goals. Our independent study was commissioned to support this ambition. In addition to quantitative analysis of data from applications to ensure assessor reliability, qualitative enquiry allows deeper understanding of the views and experiences of assessors of applications. In informing a revised scoring scheme for the NCEAs, it is important to understand the views and experiences of current arrangements among assessors and other key stakeholders. In 2022, the CEAs have been updated to ‘clinical impact awards’ although just one round of applications, scoring, and awarding has been completed under these revised arrangements.Semistructured interviews were conducted with key informants of the NCEAs scheme, between July and August 2021. Reporting of this study is guided by Standards for Reporting Qualitative Research.11We sought to recruit up to 25 key informants, to include a sample of current ACCEA subcommittee assessors , applicants, representatives of professional organisations and other key stakeholders. We purposively sampled informants on the basis of current membership of ACCEA subcommittees in England and Wales or through membership of relevant national organisations such as Royal Colleges or groups representing doctors. Current ACCEA subcommittee assessors were invited via email invitation from the ACCEA main committee on behalf of the research team. Representatives of national-level organisations and bodies were identified in consultation with the ACCEA main committee and invited via email from the research team. Replies were directly to the research team to prevent the ACCEA main committee from knowing who had replied. From those who expressed interest, we purposively selected a range of individuals to maximise variation in terms of profession, gender and ethnicity. Participant’s identity was kept entirely confidential within the research team and not disclosed to any external agencies or bodies, including funding bodies and ACCEA.Two semistructured interview topic guides were developed; one for use with assessors, and one for use with representatives of professional organisations and other stakeholders. The topic guides were informed by a review of literature, the research team’s knowledge of the NCEA scheme, regular liaison meetings with the main committee for ACCEA, and input from a project-specific patient and public involvement group. We piloted the topic guides with a previous assessor, known to the research team. Both topic guides were organised into three sections, reflecting the aims of the study: (1) role and experience in relation to assessing and applying for CEAs; (2) ‘excellence’: what should be rewarded and how should excellence be defined and (3) equity within the application and assessment process. Interviews lasted up to 1 hour and were conducted via online platforms (Microsoft Teams or Zoom) or on the telephone according to interviewee preferences.A patient and public advisory group provided written and verbal feedback on the interview topic guides and on initial analysis of the interviews. Resulting changes made to the interview guide included providing a list of current assessment domains and a description of the current scoring scale for key informants.Interviews were audio recorded and transcribed. Transcripts were checked by BMT and anonymised. Interview transcripts were analysed inductively with a reflexive thematic analysis consisting of six recursive phases.In a reflexive thematic analysis, the coding process is unstructured, which meant that codes evolved to capture the researchers’ deepening understanding of the data and research area. During the six phases of analysis, BMT reflected on her assumptions surrounding the data and research area and how they might shape analysis. Professional characteristics of the core research team were also reflected on during the final analysis and write up stages, to ensure that such characteristics did not inappropriately shape findings. The results presented in this paper focus on the findings relating to how clinical excellence is defined and considerations of equity in scoring. Detailed comments made around the numerical scoring scales informed subsequent stages of research.Twenty-five key informants were interviewed. Most were ACCEA subcommittee assessors (n=14), others held dual roles as assessor and representative of professional organisation (n=6) or were solely representative of professional organisation (n=5). Six key informants reported holding an NCEA, and one participant reported being unsuccessful in application. A near equal proportion of interviewees were female (n=12) and male (n=13). Despite concerted efforts to recruit a diverse ethnic sample through purposive sampling, most key informants were of white ethnic background (n=19). A small number of informants were of other ethnic backgrounds . Nearly all informants were aged 45 years or older (n=24). Eleven potential key informants, who had expressed an interest in being involved in the interviews, did not respond to further invitations to participate.Our inductive reflexive thematic analysis generated three overarching themes around how interviewees defined clinical excellence, differentiated between levels of excellence and discussed definitions for and scoring of excellence that are unbiased. The overarching themes and their subthemes explore how: (1) ‘Clinical excellence’ is multifaceted, and a range of behaviours and activities should be rewarded; (2) Assessors develop their own personal strategies to guard against bias and perceived challenges with the current scoring scheme and (3) There are perceived inequities for marginalised groups of doctors surrounding producing evidence and due to the self-nomination process. A number of subthemes were also identified .Informants’ views on what constitutes clinical excellence appeared to be related to their current role as a medical professional, and/or past experiences as patients of the NHS.Nearly all informants reported that clinical excellence means demonstrating going over and above job expectations and the expectations of their colleagues, in terms of hours worked, taking on additional and more senior tasks, and relieving workload of colleagues:…to be able to really demonstrate what do I do that’s over and above. My job plan says this, my contract says that, actually I have excelled in the way that I have delivered on my contract … .Some also argued that doctors should not be further rewarded for activities that they are already being remunerated for:A lot of these posts such as clinical director or divisional director are renumerated at quite a high level so divisional director is getting paid 30 thousand pounds in our hospital on top of their NHS salary. So I don’t feel that… should carry weight in terms of clinical excellence award because they’re already being paid for that… .Many informants explained that making an exceptional difference to patients and the NHS constitutes clinical excellence and should be rewarded, being a perceived fundamental aim of the NHS and those working within it. A marker of excellence included patient preferences to be treated by certain doctors:‘I want to go and see this doctor for this disease,’ because the care that they give or the team that delivers that care is just brilliant and they’re fabulous. We want to reward that—that’s clinical excellence. .Many informants explained the importance of outlining the impact of excellence, such as on patients, their colleagues and the NHS overall. Some informants noted that as this is an NCEA Scheme, national and international impact of activities or otherwise beyond local impact should be demonstrated and rewarded:I think clinical excellence should be where people are… really showing that excellence at the regional or national level. .But others noted that excellence demonstrated at local level should not be overlooked:And if you read the definitions of national it doesn’t have to be national it can be anything outside of your immediate Trust, so you could be applying for a national award because you’ve influenced the Trust next door. .In assessing clinical excellence, many informants described the importance of recognising the context or setting through which excellence is achieved. Challenges for applicants were reported in respect of generating research excellence in non-university hospitals, or within specialties that offered less time and fewer resources to undertake research, such as emergency medicine and radiology:… the man or woman sitting in District Hospital X where they’re struggling just to manage the volume of work, and they cannot score particularly highly in domain four (research and innovation) because they just don’t have the time, whereas the individual who’s got half their week as an academic can get big publications. .Key informants who were assessors explained how they had developed personal strategies to assess clinical excellence and to try to ensure fairness. Strategies appeared to be in response to assessors’ experiences, and the written applications themselves. These informants did not specify that such strategies were recommended or guided by ACCEA, but were rather strategies that they had personally developed.Assessors described obtaining examples of relevant job plans to tackle the diversity of specialties and job roles in applications that were assigned to them. Lay assessors, and occasionally other assessors, suggested that their lack of knowledge about the typical working day of some specialties, especially with sometimes limited details provided under the job plan section, made it difficult for them to assess what constitutes a contribution that was ‘over and above’. They, therefore, sought information about the job role in focus:I know a little bit because we’ve got a big neurosciences centre… But I’m merely a lay person and I’m judging someone’s form on neuroscience, because what do I know? So, if the Societies give me a leg-up and support me that helps. .In assessing awards, informants reflected on the subjectivity of the process. Informants who were assessors described maintaining a ‘hawk’ or ‘dove’ assessment style to address unconscious bias, and that being aware of one’s own potential biases and performance as an assessor was important to diffuse issues with subjectivity:If you were a hawk you need to be a consistent hawk. You can’t be a hawk for one person and a dove for another… .Many noted several factors that could shape one’s perception and expectation of excellence, such as the assessors’ own job, life experiences, protected characteristics and whether the applicant is a current award holder.:I do four days of [speciality], 7am to 7pm… So my standard is really very high because of what I do for a living… .Assessor-informants described modifying scores to reflect application structure and content, when applicants’ presentation of material was particularly difficult to read. Examples included the use of undefined acronyms, variable use of bulleting and the use of excessive and poorly focused sentences and presenting the same evidence in multiple domains or presenting evidence in the incorrect domains:… abbreviations …Sometimes they bother to explain them earlier and sometimes they don’t…If you’re marking them and it’s all bullet-points, it’s pretty easy to scan through, but often you don’t get a sense of a journey or a development. Whereas if it’s all dense text, it’s much more difficult to read through…. .Informants also emphasised the importance of considering several sources of excellence evidence presented, and that assessors need a comprehensive overview of applicants’ excellence, in terms of role and contribution, from the applicants’ emic perspective, as well as the etic perspective of colleagues and patients, in order to fairly score:All evidence submitted says this person is a wonderful person you know they’re really good at their work… so yes if it was obligatory that we had to have citations from a number of different people then that would make it better. .Some informants suggested that citations from Royal Colleges were not entirely helpful and sometimes overlooked, as they were generally positive, and not all applicants were a member of a College.Key informants discussed a variety of inequities within the assessment scheme, which were suggested to be underpinned by long-standing inequities in the NHS. Informants explained that such inequities act as a perceived barrier to being successful in the scheme and thus discourage doctors from applying.Informants from various clinical specialties reported that there are difficulties for certain specialties to generate suitable evidence, such as in pathology, anaesthesia and emergency medicine, where doctors may not be able to generate appropriate evidence for all domains as easily as doctors from other specialties:Radiologists sit in a dark room looking at pictures and don’t have that much contact with many patients—so how do you assess how their patient benefit is, and how they get quality feedback from a patient who may never have seen them? Anaesthetists have a similar sort of problem… .Other informants suggested that it is difficult for service-focussed doctors, especially those working in district general hospital settings, to generate as much research evidence as academic-focussed doctors working in university teaching hospitals. Some informants also explained that there is a general assumption among doctors that most of these awards are given to doctors working within some specialties, such as surgery; potentially dissuading doctors from other specialties from applying.Many informants also reported time challenges for less than full-time applicants to generate evidence, because of the perception that they are unable to go over and above their work hours, or to take on additional tasks, and thus have restricted opportunities to develop evidence across all five domains, unlike full-time applicants, who were suggested to be able to do this:…because you’ve only got a 0.8 whole time equivalent contract, and so what you’re delivering at your baseline appears to be lower than what someone who’s on a full-time contract delivers, and then you’ve got to then not only bridge that gap, but also then go over and above, and I think that’s really difficult to demonstrate. .Eight informants explained that there are gender and ethnic disadvantages incurred through the self-nomination process of the scheme. Male and female informants, and informants from a variety of ethnic backgrounds, explained that female doctors and doctors from ethnic minority groups are less likely to recognise their excellence and to self-nominate themselves for an award; and when they do so, their presentation of material is sometimes seen as too modest:I think another one from somebody who is not British, for example, and there is a very different way of writing, there’s a very different way of expressing themselves, sometimes a lot more modest. You look at the difference between a female applicant and a male applicant and how they present their evidence. .It was suggested that female doctors and doctors from ethnic minority groups do not always feel comfortable taking credit for team effort in a self-nomination process application:As an ethnic minority person, you do suffer from imposter syndrome unlike say my white colleague who might have done half the things that I did but are absolutely fine in going there. Secondly, if you’re a female, then it’s even worse because you never really reach that stage where you think that you’re good enough until somebody tells you. .Informants from a range of specialties and backgrounds explained that there is widespread penalisation for teamwork in the application. Informants explained that the narrative nature of the application focused on the applicant only, and that mentioning too much teamwork could be costly:You can spend a lot of time writing things: ‘I did this, I did that.’ Or was it, ‘We did this or we did that, or was I part of the team that did this?’ and what’s more powerful. I think that plenty of folks are less good at taking the credit for stuff than others… .Nearly all informants provided practical suggestions which might be considered in relation to improving the scoring process and equitability of the scheme. Many suggested the need for advertising the scheme more broadly, such as through members of ACCEA visiting trusts to talk about the scheme to underrepresented specialties and groups of doctors, and allocating champions within trusts to encourage applications. Many also recommended that ACCEA should create support materials for prospective applicants, such as videos about how to collect evidence, or whom to approach for advice on applications. Finally, some informants advised that for assessors; more frequent training, contact and information about the range of specialties for assessors, would improve their contribution.Our qualitative study suggests that assessors and members of professional organisations believe that excellence must constitute going ‘over and above’ the expectations of job plans, be related to service to the NHS, and demonstrate benefits to patients. The interviews further highlighted that assessing whether an applicant has demonstrated such excellence in their clinical practice could be challenging, given that often limited job plan information is provided to assessors. Assessors in our study emphasised the subjective nature of assessment and explained that they may develop their own personal strategies to guard against their own potential biases, and against challenges encountered with assessing the evidence presented. Such strategies did not necessarily correspond with ACCEA assessor guidelines.Concerns have previously been highlighted regarding potential inequities in the CEA scheme relating to disparities in the number and success of applications by ethnicity, gender and clinical specialty of applicant.To our knowledge, this is the first qualitative exploration of the views and experiences of current assessors and representatives of professional organisations, about the process of assessing applications for NCEAs. We have examined how the NCEAs are viewed in terms of the meaning of clinical excellence and the behaviours that should be rewarded, along with the processes through which assessors assess applications and ensure fairness, as well as the potential negative influences of specialty, gender, ethnicity and part-time working on applying. We achieved a good gender and professional role balance among informants to ensure that a range of views and experiences were captured.Despite initial willingness to participate in the study, we struggled to recruit many non-white key informants, as well as doctors from younger age groups. Furthermore, during the recruitment process we did not collect information on some other protected characteristics such as disability, and nor did we capture the views of representatives of employer organisations. It is, therefore, possible that we omitted to capture some extant definitions of clinical excellence, experiences with scoring and reflections on inequities important to some groups, organisations and individuals. In addition, it should be noted that the majority of key informants had experience of scoring as subcommittee members and were likely to be invested to some extent in the NCEA Scheme. The language used in interviews such as ‘over and above’ and ‘outstanding’ reflected some of the languages used in ACCEA policy and guidelines.In consultation with ACCEA, these findings are being used to inform the development of a revised scheme, anticipated to run from 2023 to 2024, which will aim to be more understandable and practical for assessors and applicants, and will provide clear guidance on carrying out a valid, an equitable assessment of applications. The practical suggestions from informants around advertising the scheme, supporting applicants and supporting assessors are also being explored by ACCEA.Future research could involve further qualitative interviews to explore the views and experiences of assessors and applicants with the revised NCEAs scheme around the practicalities, and equitableness of the scoring process, as well as the fairness of providing evidence for the application. Further interviews could also explore whether new training materials developed by ACCEA to support prospective applicants to apply have, as intended, reduced potential barriers for marginalised groups of doctors.4The NCEAs represent a significant opportunity for senior doctors and dentists in England and Wales and use a considerable amount of taxpayers’ money. Our study suggests that current assessors and representatives of professional organisations are supportive of the NCEAs in being able to reward clinical excellence. The findings are, at the time of writing (Spring 2023), in the process of informing future scoring and assessment of applications. Our findings also point to the broader importance of equity of opportunity to apply, and the importance of regular training for scorers and support for applicants.


Health literacy is strongly associated with health inequality among persons with deafness, and hypertension (HTN) is the most prevalent chronic disease among persons with deafness in South Korea. Despite its importance, research regarding the health literacy levels of persons with deafness with HTN in South Korea is lacking. This study aimed to comprehensively assess the health literacy levels of persons with deafness with HTN in South Korea, including linguistic, functional, and internet health literacy.In this descriptive cross-sectional study, 95 persons with deafness with HTN were recruited through facilities associated with the deaf community. From August 2022 to February 2023, data were collected through face-to-face surveys attended by a sign language interpreter and online surveys. The data were analyzed using descriptive statistics and Spearman’s correlation.Approximately 62.1% of the participants exhibited a linguistic health literacy level corresponding to less than that of middle school students, and the total percentage correct of functional health literacy was 17.9%. Each domain of internet health literacy was low. Significant correlations were found between some aspects of health literacy.The study’s findings highlight the low health literacy levels across various facets among persons with deafness with HTN in South Korea. Based on these findings, several strategies are suggested for developing HTN self-management interventions for persons with deafness. This study contributes to the foundational understanding of health literacy among persons with deafness with HTN in South Korea and provides valuable insights and guidance for developing HTN self-management interventions. The World Health Organization estimates that approximately 460 million people have hearing loss worldwide; the number is projected to reach 700 million, or one in ten people, by 2050 due to global population growth and aging , 2. AmonHealth literacy refers to "people’s knowledge, motivation and competences to access, understand, appraise, and apply health information in order to make judgments and take decisions in everyday life concerning healthcare, disease prevention and health promotion to maintain or improve quality of life during the life course."  Low leveHypertension (HTN) is a well-known chronic disease associated with an increased risk of premature mortality . PreviouIn the case of HTN, self-management, such as healthy diet, weight control, and regular exercise, plays a crucial role in effectively controlling blood pressure (BP) . HoweverFirst, it is necessary to understand the health literacy level of persons with deafness with HTN . VariousWhile a few studies have assessed the level of health literacy in the general deaf population, they relied on sign language versions of a single health literacy tool , a singlTherefore, this study aims to comprehensively assess the health literacy level of persons with deafness with HTN in South Korea before development of HTN self-management programs specifically tailored for this population. Various tools were utilized to measure different aspects of health literacy, including linguistic, functional, and Internet health literacy.This is a descriptive cross-sectional design study to identify the levels of linguistic, functional, and internet health literacy of persons with deafness with HTN in South Korea.This study targeted persons with deafness with HTN using facilities associated with the deaf community, such as institutions affiliated with the Korea Association of the Deaf, welfare centers, and churches. The inclusion criteria for the study were: (a) age ≥ 18 years, (b) registered as deaf in accordance with the Korean Disabled Persons Welfare Act, (c) use of sign language or lip-reading, and (d) diagnosed with HTN by a physician for at least 6 months. The six-month time period was selected based on the findings of a previous study targeting patients with chronic diseases; the duration was set at six months, the time it takes for patients to recognize the disease and develop self-care skills . The excData collection was conducted from August 2022 to February 2023. Before initiation, we contacted the individual in charge of each facility related to persons with deafness to explain the purpose of the study and requested their assistance. As some participants may have felt apprehensive about face-to-face surveys due to COVID-19, face-to-face and online surveys were conducted to enable participants to choose their preferred method. For the face-to-face survey, a sign language interpreter was present at the participants’ request to explain the research and consent procedure. After obtaining written consent for participation in the study, a questionnaire was provided. Since reading comprehension was also being measured , sign laThe demographic characteristics included gender, age, education level, subjective economic status, living arrangement, and religion. Subjective economic status was assessed by asking about difficulties in providing food, clothing, and shelter, with response options ranging from "very difficult" to "difficult" or "not difficult." Living arrangement was determined by asking about the individuals’ cohabitants. For disease-related characteristics, HTN-related information  and deafness-related information  were measured.Linguistic health literacy was measured using the Korean Health Literacy Assessment Tool-2 (KHLAT-2) , developFunctional health literacy was assessed using the Short Form of the Korean Functional Health Literacy (S-KFHLT), which was abbreviated by Kim . The KorInternet health literacy was measured using the DHTL-AQ tool . This toThis study was approved by the Institutional Review Board of the authors’ affiliations . All researchers completed training in understanding persons with deafness through the Seoul Regional Health & Medical Center for Persons with Disabilities (North). Researchers provided sufficient explanations to the participants about the purpose and study procedure, the protection of human rights, and the guarantee of data anonymity. Moreover, during the face-to-face survey, the participants’ characteristics were considered, such as wearing a transparent mask that showed the shape of their lips or having a sign language interpreter present so that the participants did not feel uncomfortable during the study. The researchers also provided a comprehensive explanation of the study to the sign language interpreters, to enable them to convey accurate information to the participants. Additionally, to ensure consistency in interpreting the study information, only two sign language interpreters were utilized. Throughout the entire process, COVID-19 quarantine guidelines were followed.p-value < 0.05 was considered statistically significant.The participants’ characteristics and the measured variables were described using descriptive statistics such as frequency, percentage, mean, and standard deviation. Additionally, in the case of variables, the percentage awareness or percentage answered correctly for each item was calculated together according to the characteristics of the assessment tools. Normality was confirmed using the Kolmogorov–Smirnov test. Spearman’s correlation was conducted to analyze the correlation between variables, because each aspect of health literacy was not normally distributed. For statistical analysis, SPSS version 26.0 software  was used, and The results presented in The level of internet health literacy among the participants is shown in p = 0.010) and application use  in internet health literacy. In the case of functional health literacy and internet health literacy, a significant correlation was found between each domain, and the correlation coefficient (rho) ranged from 0.412 to 0.656. (p < 0.001).We aimed to conduct a comprehensive assessment of the health literacy level of persons with deafness with HTN in South Korea, and the level was generally identified as low. Based on these findings, several suggestions were provided on how to approach the planning of HTN self-management interventions for persons with deafness when considering their health literacy.First, in linguistic health literacy, 62.1% of the participants had a level equivalent to less than that of middle school students for the general population, even though more than half of them completed high school or higher education. These findings agree with those of a previous study indicating that the health literacy of persons with deafness is at risk regardless of their education level . Additioth among middle-aged general hospitalized patients [Upon examining the items of linguistic health literacy in this study, it was observed that commonly used items in daily life were highly recognized by the participants. Interestingly, among these items, arthritis, a disease name, had the highest recognition rate. This finding differs from a previous study that ranked arthritis 13patients . This dipatients , and thepatients —suggestiIn the numeracy domain, one aspect of functional health literacy, percentage correct regarding medication-related questions, “Check drug expiration date,” “Medications to be taken on an empty stomach: 1 h before meals,” and “Medications to be taken on an empty stomach: 2–3 h after meals,” were ranged from 14.7% to 21.1%. These results were lower compared to a previous study involving older hearing people with an average age of 67.7 years, where the percentage ranged from 59.4% to 83.8% . MoreoveThe percentage of correct responses for questions related to consent for colorectal polyps’ resection, specifically "Things to be notified of before the examination" and "Complications related to the examination," were found to be the lowest among all functional health literacy items. This finding is consistent with a previous study focused on older hearing people . The preLooking at the overall score of internet health literacy, it was approximately 25% level, with digital critical literacy scoring even lower at around 15%. A previous study focusing on persons with deafness of various age groups mentioned their frequent reliance on the internet for obtaining health information . HoweverAnother interesting aspect of internet health literacy is that the percentage awareness of ICT terms was lower than the percentage correct of ICT icons. Particularly, when considering items that were commonly asked in both domains, it was found that approximately half of the percentage correct of ICT icons for Bluetooth and QR codes appeared as awareness of ICT terms, whereas URL accounted for only one-fifth. This may be due to the widespread use of Bluetooth in IoT (Internet of Things) technology  and the This study possessed several limitations. First, most participants engaged in face-to-face surveys; however, caution is required in generalized interpretation as there may be potential differences depending on whether face-to-face or online surveys were conducted. Second, to maintain accuracy and consistency in data collection, we educated sign language interpreters about our research and utilized only two sign language interpreters. However, as the researcher did not directly communicate in sign language and instead interacted through a sign language interpreter, there could have been some distortion in the delivery of the research explanation and progress. Third, the participants in this study were recruited through convenience sampling, which may restrict the generalizability of the findings. In particular, as many participants were older individuals, the results of this study may be influenced by characteristics common to this age group. Additionally, the measured health literacy levels in this study may have been lower than actual levels because most participants had comorbid conditions known to lower health literacy . Lastly,This study was conducted to comprehensively evaluate the health literacy level of persons with deafness with HTN in South Korea. The findings revealed low levels of linguistic, functional, and internet health literacy among the participants, with significant correlations observed between certain aspects of health literacy. Based on these findings, several strategies have been proposed for the development of HTN self-management interventions for persons with deafness. These strategies include using simple words, incorporating short phrases and visual materials, enhancing medication-related content, improving functional health literacy and digital critical literacy simultaneously, and familiarizing persons with deafness with the digital environment. However, it should be noted that the measured health literacy levels in this study may have been influenced by confounding factors such as older age and comorbid conditions. Nonetheless, this study serves as a foundational contribution to the understanding of health literacy among persons with deafness with HTN in South Korea. Additionally, it provides valuable insights to guide the development of HTN self-management interventions for persons with deafness.


Vaccinium oxycoccos L. berries growing in the Čepkeliai State Strict Nature Reserve in Lithuania. Studies were carried out on the phytochemical composition of cranberry fruit samples during the period of 2020–2022. Anthocyanins, flavonols, chlorogenic acid and triterpene compounds were identified and quantified using UPLC-DAD methods, and proanthocyanins were determined using spectrophotometric methods. The content of identified compounds varied, as reflected in the total amounts of anthocyanins (710.3 ± 40 µg/g to 6993.8 ± 119 µg/g), proanthocyanidins (378.4 ± 10 µg EE/g to 3557. 3 ± 75 µg EE/g), flavonols (479.6 ± 9 µg/g to 7291.2 ± 226 µg/g), chlorogenic acid (68.0 ± 1 µg/g to 3858.2 ± 119 µg/g), and triterpenoids (3780.8 ± 98 µg/g to 7226.9 ± 224 µg/g). Cranberry fruit samples harvested from open oligotrophic wetland habitats contained higher levels of anthocyanins, anthocyanidins, flavonol glycosides, and proanthocyanidins. The highest levels of triterpene compounds were found in the cranberry fruits harvested in the spring of the following year after the snowmelt. The use of principal component analysis showed that cranberry plant material harvested in October and November had higher levels of bioactive compounds.This study was carried out to analyze the accumulation patterns of anthocyanins, proanthocyanidins, flavonols, chlorogenic acid, and triterpene compounds in fruit samples of  The number of wetlands is declining worldwide, and their ecosystems are fragile: more than 50% of specific types of wetlands in parts of North America, Europe, Australia, and New Zealand were destroyed during the twentieth century . DestroyIn the reserves and strict reserves located in the territory of Lithuania, human visitation and economic activities are strictly limited. Phytochemical studies into cranberry fruit are important as they determine the optimum time for harvesting cranberries and provide research-based recommendations for their rational harvesting. The results of research and the implementation of recommendations based on research data would allow the Lithuanian Reserve Authorities to set time limits for the issuing of permits for the harvesting of cranberries by the population in protected areas, justify the procedure for issuing permits and optimize the use of natural resources for the population. The ripening of cranberries results in the accumulation of the highest levels of biologically active compounds, and thus studies on the qualitative and quantitative composition of the cranberry fruit are important for assessing the quality of raw plant material.Vaccinium oxycoccos fruits are rather fragmentary ..46].V. oxycoccos fruit samples  was consistent with the triterpenoid composition established in fruit samples of V. oxycoccos in the present study [Ursolic acid was the predominant acid in the cranberry fruit samples, accounting for 76.8% ± 2.0% of the detected triterpenoids . Klavinsnt study .V. oxycoccos fruit samples harvested during the 2020–2022 plant growing season  was detected in the samples harvested from the oligotrophic wetland habitat (site C) in the spring of the following year, after the snowmelt (21 April 2021). The levels of triterpene compounds in the fruits harvested from this habitat were not discernibly statistically different from the total levels of triterpene compounds of cranberry fruits harvested from the oligotrophic wetland habitat (site D) or the mesotrophic wetland habitat (sites A and B) in the spring of the following year, after the snowmelt (21 April 2021). The lowest levels of triterpenoids (4054.9 ± 101 µg/g) were established in the cranberry fruits harvested from the oligotrophic wetland habitat (site D) in November. These were not discernibly statistically different from the levels of triterpene compounds established in the cranberry fruits harvested from the oligotrophic wetland habitat (site E) in November.p > 0.05) from those established in most of the cranberry fruits harvested in August–November (The study of the composition of triterpenoids in cranberry fruits harvested in 2021 showed that the maximum observed levels of triterpene compounds (7226.9 ± 224 µg/g) were established in cranberry fruits harvested from an oligotrophic wetland habitat (site C) in the spring of the following year, after the snowmelt (23 March 2022). The levels of triterpene compounds in the cranberry fruits harvested from this habitat were not discernibly statistically different from the total levels of triterpenes in the fruits harvested from the mesotrophic wetland habitat (site B) the following spring on 23 March 2022 or from the oligotrophic wetland habitat (site C) on 31 August 2021. The lowest total level of triterpenes (5346.1 ± 139 µg/g) was established in cranberry fruits harvested on August 31 from an oligotrophic wetland habitat (site D). The levels of triterpenes in the fruits were not discernibly statistically different  was found in cranberry fruit samples harvested in November from a mesotrophic wetland habitat (site A). The quantitative composition of triterpene compounds detected in the fruit samples harvested from this habitat was not discernibly statistically different from that detected in the cranberry fruit samples harvested from the mesotrophic wetland habitat (site B) in October and November, from the oligotrophic wetland habitat (site D) in August, or from the oligotrophic wetland habitat (site E) in November. The lowest triterpenoid content (3780.8 ± 98 µg/g) was detected in cranberry fruit samples harvested on August 31 from a mesotrophic wetland habitat (site A).The amount of triterpene compounds in cranberry fruit samples harvested from the Čepkeliai State Strict Nature Reserve wetland habitats in August–November in different years (2020–2022) varied less than the content of phenolic compounds did (the coefficient of variation was 10.76%). Šedbarė et al. in their study found a similar variation (10.52%) in cranberry fruit samples harvested at the Kamanai and Žuvintas State Strict Nature Reserves .The Čepkeliai State Strict Nature Reserve is an area on the south-eastern edge of Lithuania . The cliChanges in the composition of biologically active compounds during cranberry fruit development and ripening are determined using genetic factors , environWe established trends in terms of the higher or lower levels of some compounds in cranberries harvested from different wetland habitats. The model in Sphagnum magellanicum, Sphagnum angustifolium, Polytrichum strictum, and Sphagnum capillifolium grow, which means that cranberries are exposed to direct sunlight for longer periods during the day. This creates favorable conditions for the biosynthesis of biologically active compounds in the fruit and influences the ripening process. Zhou et al. found that exposure to sunlight increased the total anthocyanin content of cranberry fruit by 75.3% in 24 h and by 87.2% in 48 h compared to a control sample kept in the dark [The oligotrophic habitats (sites D and E) are located in the higher part of the Čepkeliai wetland, where lower plants such as the dark . Daryanathe dark .p < 0.05) and proanthocyanidin content . Similar results have been obtained in studies of other fruits of the genus Vaccinium [Cranberry fruits of smaller weigh grew in oligotrophic-type (sites D and E) bogs. Consequently, smaller-weigh fruits accumulated a higher concentration of biologically active compounds. Correlation analysis revealed a significant negative correlation between fruit size and flavonol content , dihydroflavonol 4-reductase (DFR), anthocyanidin synthase (ANS), and chalcone synthase (CHS). In turn, this increases the anthocyanin content of the fruit [Most of the cranberry fruit samples harvested at the end of August and the beginning of September were located in the negative area of principal component II. The harvested samples showed higher levels of proanthocyanidins and flavonols and low levels of anthocyanins. In the coordinate plane, the points of the cranberry fruit samples harvested in late September, October, and November were scattered in the positive area of principal component II. These samples contained the highest levels of anthocyanins, while the levels of flavonols, chlorogenic acid, and proanthocyanidins also remained high. The most significant changes in the quantitative composition of anthocyanins and anthocyanidins were found during fruit ripening . Karppinhe fruit . The antThe samples harvested in spring, after the snowmelt, were located in the area of negative values of principal components I and II. These cranberry fruit samples showed a decrease in the amounts of anthocyanins, flavonols, proanthocyanidins, and chlorogenic acid, while their levels of triterpene compounds were the highest.As the quantitative composition of biologically active compounds changes during the ripening stage of cranberries, it is important to perform studies on the phytochemical composition of cranberry raw material in order to provide consumers with cranberry fruit raw material with a high commercial value and a known qualitative and quantitative composition. The highest levels of anthocyanins were found in samples of ripe cranberries. Anthocyanin levels varied depending on the period of fruit preparation and the characteristics of the types of habitats. The detected quantitative changes in flavonols, proanthocyanidins, and chlorogenic acid were lower than those in anthocyanins. Routine studies on the qualitative and quantitative composition of biologically active compounds in cranberry raw material would allow for the monitoring of the composition of cranberry raw material and its preparations and the prediction of their biological effects ,59.O-glucoside , quercetin-3-galactoside, quercetin , myricetin, quercetin-3-rhamnoside, quercetin-3-α-l-arabinofuranoside, quercetin-3-α-l-arabinopyranoside, oleanolic acid, ursolic acid, α-Amyrin, β-Amyrin, corosolic acid, and maslinic acid  were used as standards for the identification of the compounds. Acetone, methanol, acetonitrile, hydrochloric acid, and 4-(Dimethylamino) cinnamaldehyde) were purchased from Sigma-Aldrich . Ethanol 96% (v/v) was purchased from AB Stumbras . Formic acid was bought from Merck .All the chemicals used in the experiments were of an analytical grade. Cyanidin chloride, cyanidin-3-galactoside, cyanidin-3-glucoside, cyanidin-3-arabinoside, peonidin chloride, peonidin-3-arabinoside, peonidin-3-glucoside, peonidin-3-galactoside, myricetin-3-galactoside, malvidin-3-galactoside, malvidin chloride, malvidin-3-arabinoside, delphinidin-3-galactoside , quercetin-3-Vaccinium oxycoccos L.) were harvested from five different places in the territory of the Čepkeliai State Strict Nature Reserve in 2020–2022 . Freeze-drying was performed in a lyophilizer . The samples were freeze-dried at a pressure of 0.01 mbar and at a condenser temperature of −85 °C. The dried samples were ground using a Retsch GM 200 electric mill . The moisture content of all cranberry fruit samples was measured using the European Pharmacopoeia method [v/v). When the procedure was performed using an effective ultrasonic power of 565 W and an ultrasonic frequency of 80 kHz at room temperature, the duration of ultrasonic extraction was 15 min. After the extraction, the prepared cranberry extracts were filtered into a 20 mL volumetric flask. Three extraction replicates were performed for each sample. The prepared cranberry extracts were stored at −20 °C for further analyses.An ultrasonic device  was used for an ultrasound-assisted extraction procedure. For the extraction of anthocyanins, proanthocyanidins, and flavonols, 1 g of lyophilized cranberry fruit powder was mixed with 20 mL of 70% ethanol acidified with 1% hydrochloric acid (v/v) acetone. When the procedure was performed using an effective ultrasonic power of 1130 W and an ultrasonic frequency of 80 kHz from 22 ± 1 °C to 60 ± 1 °C, the duration of ultrasonic extraction was 60 min. After the extraction, the prepared cranberry extracts were filtered into a 10 mL volumetric flask. Three extraction replicates were performed for each sample. The prepared cranberry extracts were stored at −20 °C for further analyses.For the extraction of triterpenoids, 1 g of lyophilized cranberry fruit powder was mixed with 10 mL of 100% (m/v) in ethanol–hydrochloric acid at 9:1 (v/v)). The blank was the DMCA solution without the extract. Optical density was measured with a spectrophotometer at 640 nm after 5 min. A standard curve was established beforehand with a (–)-epicatechin (µg/g (–)-epicatechin equivalent (EE) dry weight and a calibration equation of 𝑦 = 0.7021𝑥 + 0.0138. R2 = 0.9994.A spectrophotometer  was used for spectrophotometry analysis. Proanthocyanidins were measured with DMCA (4-(dimethylamino)cinnamaldehyde) . Twenty Phenolic compounds and triterpenoids were identified using a Waters ACQUITY UPLC chromatograph  equipped with a photodiode array detector . The compounds were separated on a reverse-phase, 100 × 2.1 mm, 1.7 µm-particle-size ACE C18 analytical column . Samples of the three cranberry fruit extracts were filtered through a filter with a pore size of 0.22 µm  into vials and injected into the UPLC system with a 1 μL volume injection. The data were collected using the Empower 3 (Waters) Software. The quantity of each compound was calculated using the calibration curve of the external standards. Concentrations were expressed in µg per g of dry weight.The analysis of anthocyanins and anthocyanidins was performed using the validated technique previously described by Vilkickyte et al. . The colThe analysis of flavonols and chlorogenic acid was performed using the validated technique previously described by Urbstaite et al. . The colTriterpenoid analysis was performed using the validated technique previously described by Sedbare et al. . The colThe data were statistically analyzed using SPSS Statistics 21  and Microsoft Excel 2016  with a 5% significance level for variation analysis. The Kruskal–Wallis one-way ANOVA test was used to determine differences in the content of the identified compounds between cranberry samples. The data of the quantitative analysis were analyzed by applying principal component analysis (PCA). The means and standard deviations of the three independent evaluations were calculated.Studies on the qualitative and quantitative composition of bog cranberry fruit samples provide new insights into the variation in the composition of anthocyanins, proanthocyanidins, chlorogenic acid, triterpenic compounds, and flavonols in cranberry fruit. These data are valuable for determining the optimum time for cranberry harvesting, for investigating the influence of different wetland habitats on the quantitative composition of bioactive compounds, for assessing the quality of cranberry fruit, and for evaluating the use of quality cranberry fruit raw material for food and health purposes.The phytochemical composition of the cranberry fruits growing in high wetlands varied over the three-year period (2020–2022), but the overall patterns of change in bioactive compounds showed that the highest levels of bioactive compounds were concentrated in the oligotrophic habitats (sites D and E). These are located in the higher part of the Čepkeliai marsh, where the plants are lower and where they are exposed to direct sunlight and climatic conditions that enhance the biosynthesis of flavonoids. The most significant changes in anthocyanin content during ripening, with peak levels reached in October–November (when the fruit are fully ripe), resulted in a balanced content of bioactive compounds in the cranberry fruit samples.