Per playing position; center and left back  showed the highest running pace in offense and mid-left; front center defender and outside right for the defense . In conclusion; profile differences existed among players’ position activity; both in offense and defense; which should be taken into account when designing specific physical training programsThe purpose of this study was to analyze the on-court demands of handball players during the European Handball Federation Champions League Final Four (VELUX EHF FINAL4) 2019 to define time–motion characteristics  both in offense and defense. Furthermore; we aimed to define position-specific demands and differences among them. Forty players from three teams were analyzed during the tournament using a local positioning system (LPS) for the first time in top handball. Players covered similar distances both in offense (1388.28 ± 2627.08 m), and in defense (1305.47 ± 5059.64 m) and remained on court for a similar average time (15.69 ± 8.02 min and 15.40 ± 8.94 min respectively). When locomotion activities were normalized according to the time they spent on court; significant differences were found for defense compared to offense in walking (+20%;  Handball is an Olympic sport, belonging to so-called team sports. It is characterized by fast transitions between offensive and defensive actions during the game with the ultimate objective of scoring a goal ,2. To thThe very nature of the game implies that players must be physically trained to maintain the game’s speed and intensity throughout a match ,6,7,8, wLikewise, it is important to note that the playing position, the game phase (offense or defense), as well as the team’s playing style can lead to big differences in each player’s physical demands. Therefore, the physical load cannot only be determined generally, but according to each player’s specific position on the court both in offense and defense ,6,10. AlThis necessity to understand handball’s physical characteristics has raised great interest among researchers who have studied these demands using different methodologies . The mos® and Kinexon® jointly developed the Kinexon® tracking system for handball players  in addition to a monitored ball, the iball, which has been recently validated [Notwithstanding, no method exists to date that allow one to accurately measure the physical and physiological demands of handball players during the competition. In order to overcome this gap, the European Handball Federation (EHF), Selectalidated  and usedalidated  and othealidated . This tealidated . With thDespite a great interest in understanding the requirements of high-level players, only a few studies have focused on analyzing the real demands of an elite handball competition in male handball ,13,17,18To the best of our knowledge, no study has been conducted considering in detail the two phases of the game, offense and defense, and analyzing all the playing positions by using a technology that allows load individualization and automation, a local positioning system (LPS). Better knowledge of on-court demands of handball players at the highest level is necessary to improve the individualization of physical preparation ,7,17,18.Thus, the aim of this study was to analyze on-court demands of handball players during the VELUX EHF FINAL4 to define time–motion characteristics  both in offense and defense, including position-specific demands and differences among them.Data were obtained from players participating in the VELUX European Handball Federation (EHF) Champions League Final Four 2019/20, held in Cologne (Germany). The teams that participated in the Final Four were FC Barcelona (Spain), Telekom Veszprém (Hungary), HC Vardar (The Republic of North Macedonia), and KS Kielce (Poland). Barcelona’s players were not included in the study because their sensors were not placed properly, causing interferences in the signal and thus unreliable data. Dainis Krištopāns (HC Vardar) did not wear the sensors during the games so his data were not available for the analysis either. Finally, 40 players were analyzed during both semifinals, the final championship game and the bronze medal game. Goalkeepers were excluded from the analysis as distance and motion characteristics do not reflect their performance needs. Anthropometric characteristics and the age of the players are presented in The players’ position data were collected through a Local Positioning System (LPS) , which has been recently validated  and usedThe LPS system was installed, calibrated, and checked for accuracy by a technician who worked for the manufacturer as follows: The exact position of the anchors in reference to the playing field was measured .The variables described next were measured based on position and speed data. The distances covered during the entire match , distances per minute during play and relative distance in established speed zones were computed. These zones were set as zone 1: standing (≤0.9 m/s), zone 2: walking (1.0–1.9 m/s), jogging 2.0–3.9 m/s), running 4.0–5.4 m/s), high-intensity running (5.5–6.9 m/s) and sprinting (≥7 m/s), in accordance with similar handball studies [.9 m/s, r.4 m/s, hWe also considered the distinction between offense  and defense , and classified the players by their positions according to handball nomenclature in offense  and defense . The descriptive analysis of the data included the mean, the range, the variance and the standard deviation.t-tests for independent samples, where appropriate. To determine the magnitude of each relationship, Cohen’s effect size (ES) was used with a modified classification  proposed for sports sciences [p < 0.05.Graphical, analytical and numerical studies were performed using our own developed programs. The Shapiro–Wilk test was performed in order to verify the normality of the data. Group differences were determined by variance analysis (ANOVA) followed by Games–Howell or Tukey post hoc testing, or Student’s sciences  and usedsciences . The pren = 66) and defense (n = 67) during the VELUX EHF Final 4 was 15.69 min (±8.02 min) and 15.40 min (±8.94 min), respectively. The total average distance covered per player during each game in offense was 1388.28 ± 2627.08 and 1305.47 ± 5059.64 m in defense. When comparing offense and defense with regard to the absolute distances covered  and jogging , as well as a tendency towards high-intensity running .The average time on court in offense  and jogging , as well as a tendency for total distance  and high-intensity running .When comparing offense and defense, significant differences were found in walking  and sprint distances (p = 0.045) between the different playing positions. However, the post hoc analysis did not show any statistically significant differences  between the different playing positions  and the front defender , as well as a tendency between the central back and the mid left .When the distance covered in each locomotion category normalized according to the time spent on court in different playing positions during defense was analyzed, the ANOVA showed significant differences only for high-intensity running  both in offense and defense, including position-specific demands and differences among them. Significant differences were found between offense and defense in the walking and jogging categories. In offense, significant differences were established in the high-intensity running category between LW and other playing positions. In defense, differences were also identified for CB in walking, and the FCD in sprinting when compared to other playing positions.Several studies have analyzed handball games differentiating intensity categories ,19,23,24For the analysis of the intensity at which the player moves across the field, the categorization proposed by Cardinale et al.  used forGlobally, players covered similar distances both in offense and defense. These results are in line with the study reported by Michalsik et al. , which a−1. This data normalization facilitates the comparison between studies and allows the coaches to dispose of a workload reference regarding locomotion activities.Other studies that analyzed men´s top national leagues showed greater covered distances than ours, ranging from 3157 m on average in the analysis of the German first division  to 3627 Regarding time spent on court, offense and defense presented average times of 15.69 min and 15.40 min, respectively. Summing up both phases, values were similar to those presented by Luig et al.  and Card−1 and 81 m·min−1, respectively), our results did not match those presented by Michalsik et al. [Regarding the average running pace values in offense and defense  that have the highest values during the defensive phase, showing high ES values. CBs have higher values in the covered distance for the walking category than those found for mid defenders. These results are consistent with the work performed by CBs during this phase, as they are the players who move depending on the area where the ball is directed, and these displacements are usually of low intensity. In the same line, when the locomotion categories were normalized according to the time spent on court, we observed that in the HIrunning category, CBs covered less distance than the ORs and FCDs, which indicates that CBs carried out most of their activities in the low-intensity categories.In the sprinting category, the highest covered distances correspond to the FCDs, which showed significant differences with the CBs and Mid defenders, with a large and very large ES. These data are consistent with the specific role of this player, who carries out his activities mainly in the front defense line, covering the central area of the defense, moving from side to side. Again here, as an application to training, coaches should differentiate training by specific positions, for example, by creating very intense tasks for FCDs and wings.To our knowledge, this is the first time that specific defensive playing positions have been analyzed, so these data cannot be compared. It provides a novel and in-depth knowledge of the real needs of this phase of the game.The total distances covered by each playing position are smaller, for both phases of the game, when compared to those reported by Michalsik et al. . VariatiOther studies have also analyzed the playing positions in men’s championships with senior high level players, but have neither differentiated the phases of the game nor analyzed each individual playing position. Some of these studies have also shown greater high intensity values by the wing players compared to the rest of the playing positions ,25.What A trend that can be observed in the available studies is that regardless of the category, procedure used, level of play or gender, all studies analyzing locomotion activities in handball have in common the differentiation of loads according to positions ,10,19,25Several limitations were found that made it difficult to discuss this study and compare it to others. The first is the small number of works focusing on the playing load in high-level men’s professional handball in final tournaments, such as the Velux EHF Final 4. Moreover, it is complicated to compare studies because of the lack of unified criteria to determine locomotion categories. It would be necessary and essential to standardize criteria so that they could be taken into consideration in future studies. Other limitations present in the work are related to the lack of development of multivariate analysis techniques. Additionally, only one championship has been analyzed, corresponding to a high performance level in the senior men’s category.Further studies will be needed to deepen our knowledge of handball’s total load through the individualized use of sensor technology (EPTS), which allows us to learn about the other previously mentioned parameters. In addition, it would be advisable to combine the advances in the physical understanding of the game with its impact on the game’s technical–tactical component. Furthermore, there is also a need for extending the analysis to other competitions, categories and gender.Offensive players covered longer distances in the jogging category and defensive players in the walking category. Profile differences existed among players’ position activity, both in offense and defense. In fact, more activity in high-intensity categories was found for wing players in offense. In the case of defense, it was the CB that covered the largest distances in low-intensity categories, and the FCD covered most of the distance in high-speed categories.−1) and repeated in a random way over time, with high active rest time between sets. For example, you can do integrated training with simulated game situations, where FCDs in offense and LWs in defense have greater involvement. Another possibility is to design tasks that raise the fatigue threshold at each position and phase to check their impact on the game. These integrated exercises can also include explosive resistance training that improves performance in decisive final actions such as 1v1, blocks, etc.Our findings suggest the need to differentiate the training load specifically for each position, and differentiate between the phases of the game, creating specific exercises, that is, very short work (less than 2 m of displacement) involving high-intensity movements (above 5 mIn addition, knowing the specific load of a top-level tournament will allow coaches to determine the maximum levels of physical requirements in elite handball and set them as references based on the category. Furthermore, knowing that the different demands for the playing positions are differentiated will allow coaches to individualize and plan their workouts accordingly, as well as consider it in the match load dosing and in players’ substitutions, for example, if possible, giving more rest to the LWs and the FCDs to maintain the level of intensity.At a high performance level, coaches should work to improve training control. The normalization of locomotion activity data allows disposing of a workload reference, in addition to facilitating the comparison between sessions. Very little information is available about the demands of the game in the different national leagues. Currently, the system is only being used in the German Bundesliga. The use of the system in the VELUX EHF Champions league would undoubtedly provide us with new relevant information about the highest competition among European clubs.In the future, studies could be carried out to analyze players’ rotations in offense and defense. In addition, future research should relate workload on the court to the workload outside the court, such as in the fitness room. Finally, it is also possible that the results obtained in this study are useful for the future design of more specific physical tests related to the demands of the game.


Scientific Reports 10.1038/srep28536, published online 23 June 2016Correction to: 1. In the original article, this paper should appear as Reference 41 and should be cited as follows. The first paragraph of the Discussion section,The authors neglected to cite a previous paper showing that the fling effect can appear very close to a very shallow, large slip. This paper is included below as Ref. 29,30 and it was also identified in the ground motion pulses of the Gorkha earthquake14. Since, in this effect, slip dislocation is assumed to directly ‘fling’ the near-fault ground30, the ground motion pulse produced by this effect should include the near-field term of the analytical solution31 (ref. 30). However, the near-field term decays rapidly for long distances in inverse proportion to the distance squared29. Therefore, although the ground motion pulses in the Kathmandu Valley could be characterized by a combination of the rupture directivity and fling step effects, rupture directivity is a key factor causing the large ground motion spread far to the east during the Gorkha earthquake. This is also confirmed by the regional acceleration duration in Fig. 1b and the teleseismic waveforms in Fig. 2.”“In addition to the rupture directivity studied above, the ‘fling step’ effect has been proposed as another contributor of long-period ground motion pulsesshould read:29,30 has been proposed as another contributor to long-period ground motion pulses at very near distances from a very shallow, large slip41. However, as the main part of the Gorkha earthquake was at a depth of 15 km and Kathmandu is located 10 km away from it, this effect would not be perceived there during the earthquake. The near-field term of the analytical solution31 can also contribute to near-fault ground motions, but it decays rapidly with distance in inverse proportion to the distance squared29. Therefore, although the ground motion pulses in the Kathmandu Valley could be characterized by a combination of the rupture directivity and near-field term effects, rupture directivity is a key factor causing the large ground motion that was spread far to the east during the Gorkha earthquake. This is also confirmed by the duration of regional acceleration demonstrated in Fig. 1b and the teleseismic waveforms demonstrated in Fig. 2.”“In addition to the rupture directivity studied above, the fling effectIn addition, all instances of the phrase “fling step” should be replaced with the phrase “near-field term”.As a result, the second paragraph of the Discussion section,31. The line source in Fig. 5 was modified with a length of 60 km, a seismic moment of 4.5 × 1020 Nm (Mw 7.7), and a rupture velocity of 3.1 km/s, to fit to the zone of largest slips in the north of Kathmandu . The results of this calculation in Fig. 8 show that, even in the near field, the rupture directivity effect is mostly larger than the fling step effect. However, in the waveforms in Kathmandu, the north–south component of the fling step effect is comparable to that of the rupture directivity effect. Therefore, in the north–south ground velocities observed by DMG , the first southward pulse arriving earlier was due to the fling step effect, because the effect includes contributions before the S-wave arrival. The second northward pulse corresponds to the rupture directivity effect. It is also noted from Fig. 8 that the shape of a fling step pulse is mainly controlled by constructive interference like a rupture directivity pulse.”“To compare the rupture directivity and fling step contributions to ground motions in the near field of the Gorkha earthquake, we calculated ground motions using the far- and intermediate-field terms, or only the near-field term of the analytical solution in an infinite mediumshould read:31. The line source in Fig. 5 was modified with a length of 60 km, a seismic moment of 4.5 × 1020 Nm (Mw 7.7), and a rupture velocity of 3.1 km/s, to fit to the zone of largest slips in the north of Kathmandu . The results of this calculation in Fig. 8 show that, even in the near field, the rupture directivity effect is mostly larger than the near-field term effect. However, in the waveforms in Kathmandu, the north–south component of the near-field term effect is comparable to that of the rupture directivity effect. Therefore, in the north–south ground velocities observed by DMG , the first southward pulse arriving earlier was due to the near-field term effect, because the effect includes contributions before the S-wave arrival. The second northward pulse corresponds to the rupture directivity effect. It is also noted from Fig. 8 that the shape of a near-field term pulse is mainly controlled by constructive interference like a rupture directivity pulse.”“To compare the rupture directivity and near-field term contributions to ground motions in the near field of the Gorkha earthquake, we calculated ground motions using the far- and intermediate-field terms, or only the near-field term of the analytical solution in an infinite mediumIn the legend of Figure 8,“The upper pattern and waveforms are due to fling step pulses produced by the near-field term.”should read:“The upper pattern and waveforms are due to the pulses produced by the near-field term.”These changes affect only the additional Discussion and do not affect any other parts of the Article including the conclusions. The Authors apologise for these changes.


P <0·2 in univariate analysis, with a logistic regression model and a backward elimination procedure. A partitioning of the population was realised. Eighty patients were prospectively enrolled. Thirty patients (37·5 %) had criteria for malnutrition. The need for intensive care unit admission  was similar in the two groups. Three patients who died (3·75 %) were malnourished. Multivariate analysis exhibited that low BMI , dyslipidaemia , oral intake reduction <50 %  and glomerular filtration rate  at admission  were associated with the occurrence of malnutrition. We demonstrate the existence of a high prevalence of malnutrition in a general cohort of COVID-19 inpatients according to GLIM criteria. Nutritional support in COVID-19 care seems an essential element.Recent European Society of Parenteral and Enteral Nutrition guidelines highlighted the interest of prevention, diagnosis and treatment of malnutrition in the management of coronavirus disease 19 (COVID-19) patients. The aim of our study was to evaluate the prevalence of malnutrition in patients hospitalised for COVID-19. In a prospective observational cohort study malnutrition was diagnosed according to the Global Leadership Initiative on Malnutrition (GLIM) two-step approach. Patients were divided into two groups according to the diagnosis of malnutrition. Covariate selection for the multivariate analysis was based on  It can evolve to pneumonia requiring hospitalisation up to severe acute respiratory distress syndrome managed in intensive care unit (ICU). Infectious respiratory diseases lead to malnutrition, which can worsen the prognosis,5. In COVID-19 population, studies have reported that about half of the patients describe olfactory and gustatory dysfunction–8. These disorders may contribute to a reduction in nutritional intakes. Li et al. showed a high prevalence of malnutrition (52·7 %) in a cohort of 182 elderly patients with COVID-19. Recent European Society of Parenteral and Enteral Nutrition guidelines highlighted the interest of prevention, diagnosis and treatment of malnutrition in the management of COVID-19 patients. However, to date there are no data about the prevalence of malnutrition in patients hospitalised for COVID-19.Coronavirus disease 2019 (COVID-19) caused by the severe acute respiratory syndrome coronavirus-2 appeared in China in December 2019 and is spreading worldwideThe aim of our study was to evaluate the prevalence of malnutrition in patients hospitalised for COVID-19.o 2020-A01237-32) (RC31/20/0165 NUTRI-COV) was provided by the ‘Comité de Protection des Personnes OUEST I’, France on March 2020. All patients were included in this observational study after verification of informed consent.This was a prospective observational cohort study (NUTRI-COV) conducted in Toulouse tertiary hospital from March to April 2020. Approval for the present study  age >18 years, (2) severe acute respiratory syndrome coronavirus-2 pneumonia  hospitalisation in wards or ICU, (4) without end-of-life decisions and (5) affiliated to the French national health care system. Patients were excluded if they were pregnant or if they refused to participate.et al. which finds a correlation between undernutrition and self-reported food intakes according to a simple analogical visual scale. For anthropometric data (height and weight), patients were weighed on admission. The height was retrieved from previous data if these data were available. When height was not reported during a previous stay, the patient declared his height or it was measured in case of impossibility to declare his height (intensive care).At admission, patients were examined by medical practitioner according to current recommendations who collected the following data: weight, BMI calculation, recent weight loss, daily oral intake self-reported during the week prior to hospitalisation ), self-reported factors influencing oral intake reduction and Nutrition Risk Screening 2002. For the food intakes, we used the self-evaluation food intake according to Bouette Factors that may influence oral intake were prospectively recovered on admission in the form of open-ended questions such as: ‘for what reasons did your oral intake decrease in the week prior to your hospitalisation?’ The following items were not proposed: anosmia, dysgeusia, asthenia and dyspnoea in order not to influence the patient. When the patient was unable to answer the questions , the family member who had been closest to the patient and the attending physician were contacted in search of these different elements and the patient questioned as soon as possible to refute or confirm the statements made by the family members when it was feasible., treatments and biological data were collected from the patient medical record including C reactive protein, albuminaemia, protidaemia, serum creatinine, glomerular filtration rate (Chronic Kidney Disease Epidemiology Collaboration (CKD-EPI) formula), lymphocyte count and D-dimers at admission. Data collection was done prospectively by a third-party physician not involved in the patient’s care.During the hospitalisation, daily oral intake was recorded by specialist dietitian. Demographic characteristics, co-morbidities, ICU severity score (Simplified Acute Physiology Score II).Malnutrition was diagnosed according to the Global Leadership Initiative on Malnutrition (GLIM) two-step approach defined by the association of one phenotypic criterion  and one aetiological criterion Due to COVID-19, it was recommended not to use conventional methods for assessing lean body mass in patients because of the risk of contamination for caregivers. All patients undergoing chest CT scan were assessed for an association between undernutrition and pectoral muscle area assessment of muscle mass. This index is not used in nutritional assessment and we wanted to study this index in a pilot way in undernutrition in ICU. There are no data on validity or reliability for pectoral muscle area in nutritional assessment.. Based on chest CT scans which were routinely performed as part of COVID-19 management, pectoralis muscle area was measured by a trained radiologist. For comparability, pectoralis muscle area was indexed to body surface area  (expressed in cm2/m2). The section used to evaluate the cross-sectional area of the pectoral muscle was selected by scrolling the scanner towards the pulmonary apex and identifying the first axial image above the aortic arch. The pectoral muscle area (cm2) corresponds to the combination of the area of the small pectoral and large right pectoral muscle measured manually using the region of interest (ROI) surface area measurement tool. Indeed, the muscle area is used in oncology and pneumology as a prognostic factor.To estimate muscle mass, the pectoralis muscle area was analysed; the pectoral muscle area is used in pneumology as a prognosis factorThe primary end-point of the study was the prevalence of malnutrition defined by the number of malnourished patients on the total number of studied patients.2 and/or >10 % non-volitional weight loss in 1 month and/or albuminaemia <30 g/l and/or Nutrition Risk Screening 2002 ≥ 5), pectoralis muscle index on chest CT scan and the association between malnutrition and outcome . In order to differentiate between severe malnutrition, we used the French recommendations of the Haute Autorité de Santé. These recommendations overlap with the GLIM recommendations but have the particularity of adding deep hypoalbuminaemia (<30 g/l) as a severity criterion. The severity of undernutrition influences the level of surveillance and nutritional management.The secondary end-points were the prevalence of severe malnutrition  or means and standard deviations. Categorical data are expressed as numbers and percentages.t test or Mann–Whitney for continuous variables and χ2 or Fisher’s exact test for categorical variables).To compare the different parameters, parametric and non-parametric tests were used as appropriate , the percentage of prediction of the model and its AUC. To highlight covariates associated with malnutrition, a partitioning of the population was represented using a Classification and Regression Tree analysis. The advantage of this multivariate analysis approach is to describe the means of distribution of the population in homogeneous groups according to the existence of malnutrition and the covariates selected from the multidimensional analysis.Covariate selection for the multivariate analysis was based on P ≤0·05 was considered statistically significant.Statistical analyses were conducted using SPSS® for Window version 24 (IBM Corporation). From March to April 2020, eighty patients were prospectively enrolled in the study. We have included all patients responding to the inclusion criteria for the given period in our hospital. No patients withdrew their consent or refused to participate.The baseline characteristics of the patients are shown in v. 85·5 (IQR 64–101) ml/min per 1·73 m2).Thirty patients (37·5 %) had criteria for malnutrition of which 21/30 (70 %) met criteria for severe malnutrition. The comparison between patients with malnutrition or not is presented in P = 0·026). Serum albumin concentration was 25 (IQR 17–29·3) g/l in the group without malnutrition v. 20·5 (IQR 18–25·5) g/l in the malnutrition group (P = 0·162). Hypoalbuminaemia (<30 g/l) was similar between the two groups (75·6 % (n 31) v. 91·7 % (n 22), P = 0·11), respectively, in the group without malnutrition in comparison with malnutrition group. Pectoralis muscle index was not different between the groups without malnutrition v. the malnutrition group (respectively 7·40 (IQR 5·81–9·3) v. 7·448 (IQR 4·88–9·64) cm2/m2, P = 0·644).Twenty-one (26 %) patients met criteria for severe malnutrition. Nutrition Risk Screening 2002 was more elevated in malnourished patients (5 (IQR 4–5)) in comparison with patients without malnutrition (4 (IQR 3–5))  was similar in the two groups, respectively 56 % (n 28) in the no malnutrition group v. 60 % (n 18) in the malnutrition group (P = 0·72). There was not statistical difference between mechanical ventilation duration, ICU and hospital lengths of stay between the two groups.The need for ICU admission (P = 0·0083), dyslipidaemia , oral intake reduction <50 %  and glomerular filtration rate (CKD-EPI) at admission  were associated with the occurrence of malnutrition in COVID-19 inpatients  presented malnutrition. Three patients who died (3·75 %) were malnourished. Multivariate analysis exhibited that low BMI  shows the most important variables in homogeneous groups according to malnutrition. The percentage of estimation of this Classification and Regression Tree analysis was 80 %. For example, patients with BMI ≤ 22·5 kg/m.To our knowledge, the present study is the first reporting the prevalence of malnutrition in patients hospitalised for severe acute respiratory syndrome coronavirus-2 pneumonia. It showed a high prevalence (37·5 %) of malnutrition in hospitalised patients with 26 % of severe malnutrition. However, we have probably overestimated the prevalence of severe undernutrition in our patients using hypoalbuminaemia as recommended by the French guidelines; we believe that this hypoalbuminaemia is more reflective of the inflammatory state of these patients and co-morbidities . The population of the study was overweight (median BMI 28·5 (IQR 25–31) kg/m2) consistent with numerous previous studies,20.Median albuminaemia was very low (24 (IQR 18–27) g/l) and pectoralis muscle area index was not associated with recent malnutrition. There was no association between recent malnutrition and the need for ICU admission. However, there were more deaths in the malnutrition group. The included population was comparable to recent publications of COVID-19 cohorts in terms of age, sex ratio diagnosed with the Mini Nutritional Assessment. The mean age of the population was 68·5 years old. Interestingly, in this younger cohort (59·5 (IQR 49·5–68·5) years old), we described more than one-third of malnourished patients (37·5 %). The diagnosis of malnutrition was based on international GLIM criteria, not specific to an elderly population and easy to use. All hospitalised patients got the aetiological criterion (pneumonia), the phenotypic criterion being based solely on a recent weight loss of 5 % in our overweight population.A recent Chinese publication found a high prevalence (52·7 %) of malnutrition in 182 elderly patients with COVID-19n 37) of the patients reported decreased food intakes with multiple reasons. They mentioned anorexia (27·5 %), asthenia (21·25 %), dysgeusia (27·5) and anosmia (20 %). Surprisingly, no statistical association was made between the self-reported importance of starvation and the existence of malnutrition. In a recent publication, Bouëtté et al. found an association between oral intakes <7/10 and the existence of malnutrition according to GLIM criteria in a population of general medicine practice patients,13. One first explanation of our results could be a lack of power for this criterion. Another explanation could be related to the inflammatory nature of COVID-19 malnutrition. In ninety-seven patients, Hedlund et al. found an association between hypoalbuminaemia, inflammation and outcome in patients hospitalised for community-acquired pneumonia. The authors argue that hypoalbuminaemia is explained by the inflammatory status more than their nutritional status.Concerning the weight loss and the importance of fasting, almost 46 %  were malnourished. One of them died after withdrawal of life-sustaining measures. The others, with extracorporeal life support, died from severe intracranial haemorrhage. Our study was not designed to analyse this association. Association between nutritional status and outcome is well knownet al. exhibited a small agreement between GLIM and European Society of Parenteral and Enteral Nutrition definition for malnutrition.NUTRICOV strengths are the prospective design of the study, which allowed for an exhaustive collection and the use of international tools (GLIM definition and Nutrition Risk Screening 2002). Therefore, this is the first study analysing malnutrition in a general population of COVID-19 inpatients. The limits are the declarative nature of some collected data . Another potential bias is the measurement of the height of prone patients in ICU, which is less reliable than a vertical measurement. This might have influenced our BMI calculations. We used GLIM criteria to define malnutrition. GLIM definition may lead to higher prevalence because of requiring fewer criteria in comparison with European Society of Parenteral and Enteral Nutrition definition. In a recent publication, Clark Severe acute respiratory syndrome coronavirus-2 is responsible for severe forms of pneumonia requiring hospitalisation. European Society of Parenteral and Enteral Nutrition recently suggests the existence of a nutritional risk and recommends to routinely check for malnutrition in COVID-19 patients to improve global patient care. We demonstrate the existence of a high prevalence of malnutrition (37·5 %) in a general cohort of COVID-19 inpatients according to GLIM criteria. Considering this high prevalence, nutritional support in COVID-19 care seems an essential element.


Despite social and economic development, the burden of malnutrition across the globe remains unacceptably high. A vital relationship exists between nutritional status, human capital, and economic standing. Malnutrition adversely affects the physiological and mental capacity of individuals; which in turn hampers productivity levels, making them and their respective countries more susceptible to poverty. A two-way link exists between malnutrition and poverty, creating a vicious cycle with each fueling the other. Malnutrition produces conditions of poverty by reducing the economic potential of the population and likewise, poverty reinforces malnutrition by increasing the risk of food insecurity. The aim of the paper is to describe the interconnection between malnutrition and poverty, and to highlight how both serve as the cause and consequence of each other. The paper also discusses ways to move ahead to tackle these issues in a parallel manner rather than in separate silos. Malnutrition relates to a deficiency, excess, or imbalance of energy and other macro and micro-nutrients. It comprises of varying degrees of under- or over- nutrition, which leads to changes in body composition, body function, and clinical outcomes. In other words, malnutrition is an all-inclusive term that represents all manifestations of poor nutrition and ranges from extreme hunger and undernutrition to obesity , 2. DespMalnutrition has long been linked to poverty as higher rates of malnutrition are found in areas with chronic poverty . The impThe World Bank has set the International Poverty Line at $1.90 per person per day using 2011 Purchasing Power Parity (PPP) conversion factors . TherefoSince the 1990s, it is estimated that the proportion of the world's population living in extreme poverty has declined by more than a half . In 2015To analyze the vital linkages between poverty and malnutrition; it is important to highlight the growing evidence that health outcomes including malnutrition are driven by social determinants of health i.e., the conditions and circumstances in which people live, learn, work, and even play have a significant impact on their health . This inA vital relationship exists between malnutrition and poverty. Poverty creates unstable and unfavorable conditions that may contribute to fueling the problem of malnutrition . People The deficiency of micronutrients or “hidden hunger” is an important component of malnutrition . MicronuBriefly put, the double burden of malnutrition and the importance of micro-nutrients should be recognized when analyzing the malnutrition-poverty cycle. There is a growing need to reimagine the concept of malnutrition and development experts and policy makers should make strides to account for the inherent complexities of both concepts in order to develop successful and sustainable nutritional strategies .The question that now arises is whether malnutrition is a cause or consequence of poverty and vice versa? To elaborate upon this, it is important to highlight the relationship of human capital with nutrition and poverty.Human capital is an integral asset of any country and the process of developing human capital begins from infancy and continues throughout the course of an individual's life . NutritiA vicious cycle exists through which both poverty and malnutrition fuel and reinforce each other . GloballIn order to progress socially and economically, there is an urgent need to recognize the burden of poverty and malnutrition and to take immediate steps to break the ongoing cycle. To achieve this target, it is important to understand what factors feed and reinforce it.The cycle of poverty and malnutrition appears to be intergenerational. Evidence suggests that malnourished women are at a higher risk of having malnourished children and this creates an intergenerational effect . It is iConsidering the inter-linkages described above between malnutrition and poverty, nutrition specific interventions need to be augmented with nutrition sensitive interventions in order to accelerate the progress of reducing malnutrition. Nutrition sensitive interventions are those that address intermediate and underlying causes of malnutrition and help to improve access to nutritious food, clean water and sanitation, education and employment, and health care etc. Large scale nutrition programs focusing on evidence based nutrition interventions should also target key underlying determinants of nutrition including poverty in order to enhance the coverage and effectiveness of nutrition-specific interventions. These include interventions in the sectors of agriculture, social safety nets, early child development, education, and women's empowerment. Women's empowerment is instrumental in not only improving malnutrition but general well-being . Hence, Nutritional interventions should be designed in an all-rounded, holistic manner. It would be fruitful to involve multiple stakeholders including health, education, agriculture, water, sanitation and hygiene, gender and economics. To ensure sustainability, nutritional interventions should be context-specific and should also be cost-effective since these issues concern low and middle income countries.Ending poverty in all its forms is the first of the 17 Sustainable Development Goals and ending hunger, reducing food insecurity and improved nutrition and agriculture is the second goal. Furthermore, at least 12 of the 17 goals contain indicators that are highly relevant to nutrition. Poverty and malnutrition are deeply interrelated, with each fuelling the other and hence it is imperative to tackle both issues simultaneously rather than in parallel silos. A two-way link exists, with both elements being the cause and consequence of each other. This vicious cycle remains a prime public health concern and immediate strides need to be made against it. For a sustainable improvement in nutritional outcomes, the battle against poverty and malnutrition has to be fought on all fronts, to achieve a healthier and more equitable society.All authors contributed to the study and the write-up.The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.


The present study looked at the extent to which 2-year-old children benefited from information conveyed by viewing a hiding event through an opening in a cardboard screen, seeing it as live video, as pre-recorded video, or by way of a mirror. Being encouraged to find the hidden object by selecting one out of two cups, the children successfully picked the baited cup significantly more often when they had viewed the hiding through the opening, or in live video, than when they viewed it in pre-recorded video, or by way of a mirror. All conditions rely on the perception of similarity. The study suggests, however, that contiguity – i.e., the perception of temporal and physical closeness between events – rather than similarity is the principal factor accounting for the results. Pictures and film are multifaceted objects that are used by adults to further the enjoyment and education of children from an early age on. In relation to the visual meaning that is conveyed, pictures appear to be self-explanatory, even “tautological”  and, thuTherefore, even perceivers who are less familiar with pictures, such as infants and some animals, can recognize a visually familiar object in a picture display without having former training in picture perception . Indeed,sign to characterize a kind of meaning relation in which one instance is directly experienced, e.g., perceived (an expression), while another instance is taken to be the focus of interest (a content). It is in this sense that we say that, from the point of view of the perceiver, a sign expression is differentiated from its content and/or referent  can be expected to be held constant between treatments. Our hypothesis is that indexicality has an impact on the perception of information about the external world, also in the case of media that are predominantly based on iconic relationships, and, irrespectively, of the perceiver having developed the habit to use sign relations or not. Indeed, it will be suggested that, in the particular case studied in the following, indexicality accounts at least as much for the results as iconicity.Another factor of importance for understanding semiotic resources , we will suggest, is the perception of indexicality, prevalent in experience of the lived world, and the rupture introduced to this contiguity following the use of certain media. This links to the possibility that the semiotic resources can be understood by means of the spatial situatedness of the semiotic resource at hand, in relation to the perceiver and the referent. Meaning-making thus also involves indexicality, including in the sense of contiguity . Indexicobject retrieval games described above, young children’s understanding of scale models or video as sources of information has also been tested  in a way that is not mere imitation . DeLoachn tested . In sum,4 months . Hence, 4 months . A possi4 months .suppression of distinctive features of the media can render their function as an information source more accessible, the opposite manipulation, which could be interpreted as enhancing the media and making the sign expression appear more unreal (and thus reduce iconicity), has also been shown to improve the performance among young children. When a scale model was put behind a clear plastic window, thus making it less accessible to interaction, the youngest children (24 months of age) improved their search of the real room  is a variable that matters in object retrieval games, altering iconicity is not a straightforward parameter for manipulating children’s success in retrieving a toy. Moreover, the suppression or accentuation of media characteristics, amounting to a modification of sign relations, clearly plays a part, as shown in some of the studies referred to above. The present study is involved with three varieties of iconicity in  temporally continuous visual signs, that is, in live streaming video clips, pre-recorded video clips, and mirror images. These meanings are compared to the direct perceptual experience of the same event. While all four kinds of visual meaning share some amount of iconicity, intuitively there is a sense in which the three kinds of signs are iconically different from direct perception of the actual world. In addition, the two kinds of video clips share more iconic properties with each other than either of them with the mirror image. Nevertheless, all four ways of conveying the information are identical, from the point of view of what we call higher order iconicity: they convey the same event. Moreover, all conditions rendered an identical visual framing of the scene , showing the hiding event with the similar cups and tokens, all from a frontal perspective. The two kinds of video share a kind of and indexical relations is vital for creating meaning in everyday experiences . Second, however, they differ with respect to conditions that make it possible to keep track of a contiguity to their reference objects in the here-and-now. Third, we do not expect children 2 years of age to grasp the sign relation in pictures; that is, we do not expect them to link a pictorial expression and a referent as being two related – but separate – instances of visual meanings. Hence, although 2-year-old children are expected to be familiar with watching video or television, and although they may well perceive a video projection as something different from reality experienced here and now, they do not necessarily use the abstract sign relation in order to link the two instances of meaning . On the In the experiment, 2-year-old children watched an attractive object being hidden under one of two cups. They witnessed this event in one of the following four conditions: directly through an opening in a cardboard screen, by means of live video on a computer monitor, by means of pre-recorded video on a computer monitor, or in a mirror. The children were then presented with the two cups they had seen and were stimulated to search for the object under one of them. According to our underlying assumption, these conditions pose different problems with regards to the way of employing the different semiotic resources for making the choices. Specifically, the general aim of the study was to assess contiguity as a variable for connecting visual meanings separated in time and space, independently of sign function. In the experimental situation, the children encountered two different categories of objects, that was, the cups in the video and the actual cups at the retrieval place, and yet it was hypothesized that, under certain circumstances, these objects could be perceived as being contiguous and thus potentially spatially and temporally continuous. Such media as allow for a presumed continuous perception of the target cup witnessed at the place of hiding and of its transition to the place where choices had to be made, may potentially facilitate the children’s access to the information needed for making correct choices. Perception of contiguity was expected to be afforded by live video and in the mirror condition. In live video and in the mirror trials the actual hiding events occurred at the same moment in time, though in appearance not in space, as the event exposed for viewing, just as in the direct perception.Maintaining clearly separated places for information and retrieval was crucial for the design of the test, since such a discontinuity demands a bridging operation in the form of perceiving contiguity, or a sign relation. The two places were expected to be clearly separate to the child, and therefore subjectively experienced as two different places and not confused as one and the same. At the same time, the two places were both within the child’s perceptual reach during the entire session. Moreover, although the two places were proximate, the child had to take a few steps and face different directions in the shifting of places see . The expNote also that the children never entered the experimenter’s space B in  where thnot expect 2-years-old children to have recourse to sign meanings in their perception of pictures, videos or mirrors  and the variations at the lower order levels of iconicity  was equal in live and pre-recorded video (filmed by the same camera projected on the same screen) and as equal as possible in the mirror reflection . Therefore, we expected the children watching the video or the mirror to be able to perceive under which cup the token was being hidden . In addi mirrors . The tas mirrors .The prediction was that the condition in which information stemmed from direct perception would be the easiest to master and consequently would generate most successful trials. Secondly, we expected performance in live video to be second best since it affords cues for contiguity close to those in direct perception. In contrast, the hiding and retrieval events in pre-recorded video are discontinuous, and thus they were predicted to be difficult for the children. Previous studies indicate that 2-year-old children are more successful in gaining information from live video than from pre-recorded video. In a retrieval game, children were shown to have more success finding the hidden toy when informed by an in-the-moment responsive on-screen person in a live video than from an on-screen person in a pre-recorded film, although this person also acted in a social child-friendly way , 2019. IWe did not have a specific expectation for the mirror image. The mirror image is distinct from ordinary perception. Even though the viewing angle can be subjectively adjusted in mirror perception, the continuity of the mirror image to the corresponding scene is disrupted (cf. the hiding event in this study). The mirror displays its object (cf. the hiding information) from a different direction than the place where the scene or act occurs in the real room. Moreover, the enantiomorphic nature of the mirror image implies a reversal of the directions within the scene. However, there have so far been too few studies about how 2-year-old children understand the mirror image as a source for visual information for any conclusion to be drawn. In a different research paradigm, following A total of 36 children participated, 22 of which were girls and 14 boys. Their mean age was 24 months and 18 days . They had been raised in Sweden and had no known developmental disorders. Caregivers reported normal visual acuity. The children were recruited from birth records and were randomly chosen from an address pool with caregivers who had agreed on being contacted for the purpose of the study. All participants lived in the south of Sweden at the time of the study.The experimental setup is illustrated in A 48 × 29 cm rectangular window was cut out of the screen 52 cm above the floor. The cut-out piece was used as a shutter when changing equipment between conditions in the test as described below. A mirror (40 × 255 cm) was placed on an easel (45 cm from the floor) at a distance of 215 cm from the child. A red colored light bulb attached to the top of the mirror could be turned on and off with a remote control. The mirror was covered under a white sheet when not in use , the child and the experimenter took their places, while the caregiver sat down right behind the child on the left side. At this point, the direct perception condition began. The experimenter caught the child’s attention with a hand puppet through the opening, and then placed two cups on a tray on table T1. Subsequently, the token was put in front of one of the cups (target cup), then the non-target cup was placed upside down, and finally the target-cup was placed upside down over the token and thus covered it from sight . ImmediaComfort trials were given by way of a new hiding at T2 if the child indicated frustration or disappointment , or when the child had chosen the non-target cup three times in a row. The comfort trials did not substitute for the eight test trials. After the last direct perception trial, the shutter was closed, and a monitor was put in the opening so that the child could no longer look into the experimenter’s space.Only one choice was permitted per trial. A child who did not find the token was immediately encouraged to witness a new hiding. The tray was taken back to T1, so that the child could see it being cleared. Given the children’s age, we were worried that having them endure all four conditions during one experimental session would be too much. Therefore, each child was exposed to one of six possible combinations of two of the three remaining conditions after the direct perception condition. As a result, the direct perception condition was done by all 36 children while each of the other three conditions was done by 24 children. The hiding procedure in the other three conditions was similar to the one in the direct perception condition, except that it was viewed indirectly from a media display as described below. Also, the children were once more given eight trials, and comfort trials were offered according to the procedure described above. The first condition started directly after the last direct perception trial, the first experimental condition followed, but the children were given a 5-to-10-min break with juice refreshment and picture book reading with their caregiver, before the last experimental condition began. The entire session took 30–35 min to complete, including the break. All sessions were recorded with a Panasonic HDC-HS700 camcorder.In this condition, a camcorder (Panasonic HDC-HS700) recorded the experimenter hiding the object under the cups. The camcorder was placed in the opening in the cardboard screen so that it had the approximate same viewpoint as the child. The recording was projected simultaneously to a 42-inch monitor (HP Compaq LA2205wg) which was placed in the opening of the cardboard screen and therefore blocked the view into the experimenter space. A trial started with one of the hand puppets appearing on the screen to catch the child’s attention. The experimenter’s shift from the attention-catching to the start of the hiding game was continuously visible to the child in live video. The camera was never turned off during the live video condition, and thus the child could watch the experimenter leaving and coming back.In this condition, the same 42-inch monitor was placed in the opening of the cardboard screen. Film clips, showing the hiding event, were projected on the monitor. The clips had been prepared in advance and their presentation was controlled by the experimenter from a computer placed in the experimenter’s space. Similar cups and tokens as in live video were used, and the trays had been prepared in advance in accordance with the order of the video clips. In order to emphasize that the event shown on the screen was not linked in time and space (as in live video) the stimuli were different in four aspects: (a) the attention-catching puppets were animated with sound effects, (b) the hiding event was recorded in a visibly different environment although projected from the same angle and visuospatial section (only showing the torso and the hand of the hider), (c) the hider was another person wearing other clothes than the experimenter, and (d) the monitor turned black when the hiding event was completed. As in the other conditions it was the experimenter who offered the choice between the real cups to the children.In all conditions but the mirror test, a sheet covered the mirror to preclude children using it to see what was happening at the other side of the barrier. This sheet was now removed, and the mirror remained uncovered throughout the full procedure in this condition. The experimenter faced the mirror frontally, using a remote control to switch on or off the red light on top of the mirror in order to direct the child’s (and the caregiver’s) gaze toward the mirror. The hiding took place behind the screen, at table T1B, as in the other conditions. A trial started with one of the hand puppets showing up in the mirror, after which the child could see how the experimenter hid the token under one of the cups, and then headed over to table T2. All children participated with enthusiasm in the direct perception trials, and the feedback from comfort trials encouraged the children to engage in new trials in cases where the actual testing trials were experienced as being difficult or uninteresting to the child. The scores are binary, i.e., the choice was either correct (the target cup) or incorrect . One session with mirror trials was interrupted after four trials, and the remaining trials were scored as incorrect. Moreover, due to technical error, the scores from one child were replaced with the scores from a supplementing child.X2 = 0.289, df = 3, p = 0.962). In the second step of the analysis we compared the random-intercepts model selected in the first step with a model that also included condition as a predictor. This comparison was significant  suggesting reliable differences in accuracy rates across the four conditions. In the third step of the analysis all six pairwise comparisons were tested statistically using generalized linear hypothesis testing. The results are displayed in The response accuracy in the four conditions was analyzed as a mixed-effects logistic regression. The analysis was performed in R version 3.6.2  using thp = 0.5), but those in the pre-recorded and mirror conditions do.As the results in Perceptual similarities with referent objects constitute the predominant qualities in iconic media such as pictures and video. Despite its prevalent role, however, iconicity does not have to be the single relational factor having an effect on meaning perception in iconic media. In this study we examine whether indexicality, in terms of contiguity, may play a significant role in determining young children’s ability to track information from perceptually iconic sign resources in order to solve a problem in real space. The children in the current study were most successful in choosing the target cup after having witnessed the hiding in either the direct perception condition or from watching live video. In accordance with our expectations, the number of successful choices in the direct perception condition also marginally significantly exceeded those in the live video. The scores for successful choices in pre-recorded video and mirror trials were, however, both low.Meaning grounded in similarity is fundamental for what we characterize as iconic signs. All the three tested media provide a realistic image of the visual world. Moreover, in all test conditions the hiding procedure was performed identically, allowing the child always to perceive the hiding from the same angle . Nevertheless, the children performed significantly better when receiving the information by watching live video than by watching pre-recorded video or by way of mirror images. Contingency factors were kept as similar as possible across the tested media. The video presentation did not respond to physical interaction  and there was no repetition of a single hiding trial. In order to avoid variations due to in-media social contingency across the media types the hider’s face was not shown in any condition and the experimenter remained silent (mute) across the hiding events in all conditions. Parents’ co-viewing followed the same instructions in all conditions. The stepwise introduction of the game in the pre-phase and base trials enabled an almost language-free training and game procedure. For the experimenter, words were only used at the retrieval place asking, “Where is the token, can you help me find the token?” and to engage in a new trial, “Shall we play it again?” Our interpretation is that variations in perception of contiguity, which was differently elicited in the trials, accounts for the difference in the probability of the children choosing the target cup.Live video was the test condition that elicited the perception of the transition from place B to C  most similar to direct perception; more so than pre-recorded video and mirror images. The mirror was the only condition where the occluder did not stand in the way for the children to keep track of the experimenter and the cups. Most obviously, mirror perception is enantiomorphic, giving rise to visual conversions to opposite forms and directions. Pre-recorded video, on the other hand, was the most discontinuous condition. Although pre-recorded video yielded visual information about the hiding of a token, it lacked informative cues to connect the video information with the retrieval of the object, because the procedure was recorded at an independent location, and there were no cues for the experimenter leaving the place which connected this event to the bringing of the cups to the retrieval place. Thus, it can be surmised that pre-recorded video provided fewer cues for a perception of contiguity than any of the other conditions. That the cups, and the location of the reward tokens, appeared identical on the screen and during the choice was apparently not enough for successful performance.The children performed less successfully in live video than they did in the direct perception condition. This accords with our predictions, that direct perception should be the easiest condition, i.e., the condition where the children retrieved the most tokens. Only in direct perception trials were the cups presented for the child perceptually unaltered across a trial (from perceiving the hiding to making the choice). According to previous studies, transference between 2D and 3D presentations make learning difficult for young children . Memory Some arrangements involving the different media were needed that may have affected the results. For instance, the mirror had to be adjusted to the physical spaces so that the visual frame of the hiding event was equal to the video projections . The distance to the hiding place and to the child, respectively, thus decided the position of the mirror. However, the mirror surface was proportionally the same size as the monitor, taking into account its position further away from the child. Considerations also had to be made to distinguish pre-recorded video from live video, from the point of view of the child, while keeping the visual information about the hiding constant. Arrangements were made to enhance features of pre-recorded film. First the attention catcher were animated pictures instead of the hand puppets in the other conditions, secondly, the assumption was that the difference in background (blue colored curtains) and a different person with different clothes  would be enough for the child to perceive the pre-recorded video as different from the situation here and now. This of course supposes a balance between obtaining the feature of the medium and keeping the higher order iconicity equal.The monitor was identically placed in both live video and pre-recorded video. The monitor fitted the opening in the occluder so that the directionality for perceiving the hiding event was kept constant with the direct perception trials. In live video, as opposed to recorded video, the hiding was depicted as occurring  at the identical physical space (B) as in the direct perception trials. In the shifts between conditions, a shutter was used to conceal the installation of the monitor, and the children seemed to react with surprise and joy as they encountered the screen when the shutter was removed again. They thus seem to have distinguished the monitor in both live video and recorded video. Furthermore, the monitor was within reach of the child, and several children touched the screen and some also tried to “click”, “sweep” or “scroll” on its surface as if trying out a touch screen. The children frequently commented on, and pointed at, the monitor. All in all, we take these actions as indications that the children did not mistake the video projections for a window-like perception. Moreover, no child was insistent in their “clicking” or “scrolling” the monitor’s surface. When there was no response from the medium the children changed behavior to pointing without touching. We take this as an indication that the children differentiated the media object . RemarkaThe children were not trained in live video interventions in advance  and wereThe children in this study were significantly more successful in retrieving the token when they were informed by means of live video than by seeing the event in a mirror. This result is intriguing. The continuity from the mirror perception allowed for an unbroken perception of the cups from the hiding place to the retrieval. Moreover, in a variation of the mark test  observedMirror images, however, cannot simply be equated with perceptual reality, as our study shows see also . Neverthmeaning forms the basic model of the concept of sign in semiotic theory. Observations on (at least) dual meanings in signs are also central to psychological studies of children’s meaning-making . More precisely, we wanted to investigate whether the perception of contiguity facilitated the linking of one instance of meaning to another  independently of meanings being conveyed by signs or not. Psychological studies  suggest The low probability for the children to find the token in the pre-recorded video condition or by means of observing the hiding via a mirror, as contrasted with the high probability of finding it in the live video condition, supports the assumption that 2-year-old children do not yet use the potential sign relation subsisting between the information gleaned from the media and the actual cups, but that they had to have recourse to the direct perception of contiguity in order to facilitate their retrieval of the right cup in live video.In addition, the current study demonstrates that a mirror image cannot simply be taken to be equivalent to direct perception – although it can momentarily be mistaken as such. Whereas the cups are never out of sight in the mirror, the image is both inverted and dislocated and therefore disrupts contiguity between the “mirror cup” and the “real cups”  is emphasized. Thus, it adds the semiotically informed concept of indexicality as a factor to understand pre-cursors to the development of sign use and young children’s perception of iconic media. The present study may be taken to suggest that the extent to which the continuity of ordinary perception is implemented in the experiment enters as a partially independent factor in the understanding of different iconically dominant semiotic resources.All datasets generated for this study are included in the article/The studies involving human participants were reviewed and approved by the Regionala Etikprövningsnämnden i Lund. Written informed consent to participate in this study was provided by the participants’ legal guardian/next of kin.On the basis on an original proposal formulated by GS, all authors contributed to the development, conception and design of the study. SL and TP piloted the study and organized the database. JW performed the statistical analysis and wrote sections of the manuscript (statistics). SL wrote the first drafts of the manuscript. All authors contributed to the manuscript revision, read 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.


VITAL Start is a video-based intervention aimed to improve maternal retention in HIV care and adherence to antiretroviral therapy (ART) in Malawi. We explored the experiences of pregnant women living with HIV (PWLHIV) not yet on ART who received VITAL Start before ART initiation to assess the intervention’s acceptability, feasibility, fidelity of delivery, and perceived impact. Between February and September 2019, we conducted semi-structured interviews with a convenience sample of 34 PWLHIV within one month of receiving VITAL Start. The participants reported that VITAL Start was acceptable and feasible and had good fidelity of delivery. They also reported that the video had a positive impact on their lives, encouraging them to disclose their HIV status to their sexual partners who, in turn, supported them to adhere to ART. The participants suggested using a similar intervention to provide health-related education/counseling to people with long term conditions. Our findings suggest that video-based interventions may be an acceptable, feasible approach to optimizing ART retention and adherence amongst PWLHIV, and they can be delivered with high fidelity. Further exploration of the utility of low cost, scalable, video-based interventions to address health counseling gaps in sub-Saharan Africa is warranted. Despite global progress in reducing the number of new HIV infections, mother-to-child transmission of HIV remains a critical challenge. Globally, nearly 160,000 children 0–14 years) were infected with HIV in 2019, with over half  of these infections occurring in Malawi and other countries in sub-Saharan Africa (SSA), primarily through vertical transmission of HIV ,4,5. years weUnfortunately, suboptimal maternal retention and adherence to ART remain significant global challenges to halting the HIV epidemic and eliminating vertical HIV transmissions ,7. It isSeveral barriers preventing optimal retention and ART adherence in Malawi and other countries in SSA have been identified in both quantitative and qualitative studies ,21,22,23Video-based intervention to Inspire Treatment Adherence for Life)—aims to improve maternal ART retention and adherence through behavior change by providing a VITAL Start at the critical teachable moment before committing to lifelong ART. The messages in the video are woven into an entertaining drama. Baylor-Malawi decided to create the video intervention because many of the barriers to maternal retention and ART adherence related to lack of information and empowerment of women to prevent vertical HIV transmissions, as well as to help standardize pre-ART counseling and overcome shortages of skilled healthcare workers that provide pre-ART counseling. The intervention can be delivered by lay health care workers and does not require as much healthcare worker time as the standard of care—pre-ART counseling delivered using flipcharts, as recommended by the Malawi Ministry of Health  …”[Participant 3026]“…I had fear because we were together with my husband (watching video); therefore, I thought that maybe we would have problems…maybe the marriage would end. ...; however, when we went home, it is when he reminded me that it’s time to receive/collect medication… Since then, I have been very happy…”[Participant 2087]VITAL Start met participant expectations and gave them hope. In addition to reducing fears, participants also reported that VITAL Start met their expectations, helped them to understand their situation better, and gave them hope that they could stay healthy and live normal lives despite being diagnosed with HIV. The video also dispelled myths about the health of people living with HIV. “…yes, it [the video session] met my expectations… it managed to help me to understand my status and also how I am supposed to live…”[Participant 2087]“…when I watched it, I was encouraged that I do not have any problems…”[Participant 1086]“…when I watched the video, it showed me that I am not very different from the people that are normal [those without HIV] … someone does not get sick frequently, therefore I thought that the only difference would be taking medication daily. Therefore, I saw that I am a normal person…”[Participant 2087]Post-video discussion reinforced the VITAL Start message: Some participants reported that the post-video sessions, which involved a sit-in with the counselor, complemented the video session well. Participants liked the post-video discussion because it echoed what they heard in the video and presented an opportunity to clarify any lingering issues. “…because, at first, they asked questions on a thing that I had not learned yet, and when I watched the video, it was like they (the counselor post-video) were repeating so that I should remember what I had watched…”[Participant 2087]A more believable story because of the use of relatable video settings: Most participants found the video setting relatable (use of common places like the market and people doing everyday activities)—which made the messages more believable, appropriate, and well-received,“…the video was shot well because at the market is where men work, they fix bicycles and buy things, the other place is at home, and the other place is the hospital where people receive counseling. The video showed all the places…”[Participant 2087]“…everything went well…”Feasibility was examined by asking questions about the suitability, practicability, and utility of the video. The women reported that VITAL Start was feasible given that they had a positive experience overall. Specifically, participants said that video instructions were clear, they did not encounter any challenges when using the equipment, and using the equipment was comfortable. They also valued the privacy of watching the video alone in a room given that clinics are crowded places and lack privacy. They appreciated that this arrangement prevented inadvertent disclosure of their HIV status. “…Everything seemed well. They told me what to do if it pauses, but it did not. I watched it very well up until I finished…”[Participant 1057]“…it was good because there was no other person who disturbed me when I was watching the video. I watched it freely…”[Participant 1093]“…I felt very sweet [an exaggerated expression of feeling good]…because if I was to watch it with someone else, my friend would have gone out and spread the bad news…so I was very happy because the things I watched, I was watching alone…”[Participant 2047]“…the most important message was adhering to medication…”Fidelity of delivery was assessed by invoking retrospectively whether key messages or concepts in VITAL Start were delivered as intended. The majority of the women were able to recall key messages from the video; three women (9%) were unable to recall all the key messages. Specifically, the women felt the video increased their ART related knowledge, improved their self-efficacy, and encouraged partner disclosure. Increasing ART knowledge: Participants reported positive messaging about ART in general, and also on the key counseling messages regarding HIV diagnosis and treatment. This included the benefits of ART for preventing vertical HIV transmissions and maternal health, the importance of adherence to prevent drug resistance, possible side effects, strategies to adhere to ART, and partner disclosure. “…they (in the video) were talking about the medication so that one should be well in her life …and life should go on well and the expected child as well. And if we stop taking medication, then the virus will wake up and get to the child, and the child will not be alright and later the child is born infected…”[Participant 3048]“…the most important message (from watching the video) was adhering to medication so that I can protect the child that I am expecting…”[Participant 3108]Improving self-efficacy or changing behavior: Participants reported the intervention helped establish adherence promoting behavior such as setting aside a specific time for taking the medicines, with the majority choosing to take the medicines around dinner time. Other participants reported selecting a safe and easy-to-remember location in the house to keep their medication. “…the ones I still remember are: I am supposed to go to the hospital to collect drugs in good time, on a scheduled day/the day you were told. One is not supposed to miss a dose, one is supposed to adhere to medication…”[Participant 2055]“…oh, this helped us in a lot of things: 1, about diet. 2, about taking medication. 3, taking care of oneself. Yah, it taught us a lot…”[Participant 2141]Encouraging partner disclosure: Participants also reported feeling that VITAL Start encouraged partner disclosure. Most participants reported that the video helped them to find a starting point for disclosing, as well as on how to say what they wanted to say.“…it (the video) encouraged me that I should not be afraid. At first, I was afraid that what am I going to do, and what do I do? But after watching the video to say, no you should not worry and I did not get worried; when I reached home, I started explaining (to my husband)… ”[Participant 1081]“…it (the video) helped me to have the courage that I should open up to my partner and also to a friend …”[Participant 2055]“So after watching the video, I saw that they have taught me ways of making him understand and how to approach my husband…”[Participant 1051]Recall challenges: Three participants had challenges recalling all the key messages from the video. For example, when asked what the main message was in the video, two participants said they could not recall the key messages. These participants, however, were still able to recall other messages. “…Ah, let us plan a day I should also go for HIV testing and counseling”The perceived impact of VITAL Start was assessed by understanding participants’ actions or behavioral responses after watching the video. Following the intervention, several actionable responses or behavioral changes emerged, including more women disclosing their HIV status to their partners, greater partner engagement, and more women feeling empowered. However, a handful of women still feared to disclose to their partners. Cue to action for partner disclosure: When asked to describe any actionable responses or behavioral change participants experienced as a result of the video intervention, actionable areas were disclosing their HIV status, partners going for HIV testing and counseling, and partner support in medication adherence. Some participants reported that they were pleasantly surprised by the overwhelmingly positive response and support they received from their partners after disclosing and asking their partners’ to get tested as well.“… so when I reached home after watching that video…I started asking him questions that “are you ready to go for testing?” He responded that “Yes I am ready”. “What if we are found positive, what will be your thoughts?” Then he kept quiet; he did not answer me. So the issue was continued in the evening that “What are your thoughts on that issue we were discussing?” He responded that “Whatever the case will be, I will accept it because I am not the first one…”[Participant 1081]“…eh, because my husband was refusing to get tested, so when I left here, I told him. So he said that “Ah, let us plan a day I should also go HIV testing and counseling.”[Participant 2122]“… He [my husband] asked me why I was taking time at the hospital, I explained. When I got home, he welcomed me happily. I told him I was not going to take the medicine. He asked if I had been counseled. I said I would take the medicine the following day. He responded that I shouldn’t do that but wake up. He woke up and handed me Super Shake. When I take medicine with water I vomit. So he opened the bottle and handed it to me and then what?... I drank it. Yesterday, he mentioned that it is unfortunate that today is Sunday, he would have loved to know his HIV status. Also, he encourages me every evening to take my medication so that we protect our unborn baby. This makes me happy…”[Participant 2142]“… When I was coming this morning, he was the one who readied me…”[Participant 2142]Lingering fears to disclose: While the video helped to alleviate the women’s fears around HIV status disclosure and made them feel prepared to disclose, four women (12%) could not disclose their HIV status to their partners. They were worried or unsure about how their partners would react if they disclosed their status. Despite these fears, some of the participants hoped that someday they would have the courage to disclose or wait until the day their partner is in a good mood.“…it is about the message; the person in the video told her friend while I have not yet told any friend, or even a relative. I will tell them in the future and I will tell my relatives how things are…I had intentions or thoughts [to disclose] because he is my husband; he is the one I would tell first. However, during that time, I was thinking about how I could make him understand…”[Participant 1051]“…it [watching the video] removed my fears, but I just didn’t know how to start [to disclose]. And when I see him, something bothers me, but what challenges me is how I am going to explain all these things…I believe that God will strengthen me so that one day I shall tell him…”[Participant 1057]“…I was scared because, for one to tell the partner [that they are HIV positive], that means you are close to him. Maybe if he told me that he will marry me after making me pregnant, then you can tell him…But if we were married, I would have told him to come with me and get tested…”[Participant 3025]“…To tell him… I will know a day how he will carry (conduct) himself, that day I will explain to him the truth, “I went to the clinic, they found me positive … this is the (clinic) book. But because of the way you behave (react), I was afraid to explain to you, but today this is it”…”[Participant 2123]Greater partner engagement: Participants who watched the video with their partners reported that it was very beneficial for their partners to view the video and that the video enhanced partner engagement.“…there were similarities (the video and my circumstances) when the man in the video refused to go to the hospital… my husband was telling me to wait, that he should find time to excuse himself at work, and when he did, we went [together]. While in the video, the husband refused to go… that video story relates to me….my husband is someone who has changed the way he talks from that day up until now; he is very loving than how he used to be in the past. It seems like the video taught him a lot of things… the way we stayed at home at first, we never chatted together; however, I now have enough time to chat with him when he calls me and sit and chat together. And I can see that things have changed in my life …until now…”[Participant 2087]Increasing empowerment: Some participants described how the video empowered them to take measures to ensure treatment adherence, including using times for news bulletins as a reminder.“…My procedure (routine put in place to help with adherence), I cannot forget to take the drugs because I am HIV positive, and I have drugs in the house…I cannot forget no matter how busy I may be. I can stop what I am doing. Taking drugs cannot take more than 30 min, it is not possible…”[Participant 1081]“…I like listening to the radio, so the time I have set for taking medication is 7 o’clock. When the time is 7 o’clock, I am supposed to go and take medication before I start listening to the news…”[Participant 1057]“…But if you could reach out to the people in these villages, we could all be liberated”Finally, the participants suggested aspects of the video that might be improved, modified, or expanded. They also suggested diseases and medical conditions, other than HIV/AIDS, for which a similar type of video might be used. These suggestions included using the video in communities, creating an audio version of the counseling that can be aired on radios, and developing a similar video for people with cancer or tuberculosis. The opportunity for improvement was examined by asking questions about whether there should be any modifications that would make the intervention more palatable, attractive, or valuable, and how a similar type of video intervention might be utilized for the benefit of other types/categories of patients and settings. Expanding to communities and using radio messaging: Some participants suggested that the video intervention should be expanded to communities, particularly among folks who do not make it to HIV testing sites. Reaching out to possible beneficiaries may involve the use of other media such as radio messaging:“Maybe the sick people who are in the villages who do not [want to] go to the hospital, those who do not want to know their status, those who may be visited and shown the video, perhaps they may be encouraged to get their blood tested…”[Participant 1057]“…if you could reach out to these patients in the villages. There are people in these villages who are afraid. But if you could reach out to the people in these villages, we could all be liberated…It is not everyone who went to school; some of us didn’t. When people hear the word hospital, it is a very frightening word. Transporting oneself there [the hospital] is a problem…A lot of people cannot manage to walk to get there; if you can be reaching out to them and counsel them, they could be happy people and very content.”[Participant 2142]“…you should even put it [the counseling] on the radio so that other people can also listen. Considering the people who have not tested for HIV, if they could listen to this message or if they could watch the video, it means it could change people’s lives…”[Participant 1093]“… It is not only HIV positive people who should watch this video, no. Any person who is HIV positive or negative…”[Participant 1093]Creating similar videos for people with long-term conditions: When probed on which other individuals are likely to benefit from a video intervention, some participants suggested patients with other long-term conditions, such as cancer:“…maybe cancer [patients], [people with] epilepsy; people can have video counseling since it shows everything very well…”[Participant 3026]“…such as those with TB (tuberculosis) and malaria…”[Participant 3025]Identifying effective, low-cost, and scalable interventions that can improve maternal retention and adherence, particularly in sub-Saharan Africa where the majority of people with HIV live, remains a priority in a global quest to achieve a HIV-free generation. However, finding such interventions has been challenging. This study explored the perceptions and experiences of PWLHIV who received VITAL Start—a video-based intervention to deliver ART information and education to prevent vertical HIV transmission to PWLHIV before ART initiation. Specifically, we sought to understand the intervention’s acceptability, feasibility, fidelity, perceived impact, and aspects of the intervention that might need to be improved. Participants  found the intervention highly acceptable—it helped to allay their fears and concerns about their HIV diagnosis and depicted the “way of life” for most of them. The women also reported that watching the video went well without any glitches, which suggests that the video was feasible. We also found that the fidelity of delivery was good, given that the women were able to recollect key messages and concepts from the video and reported that the video helped them to adhere to ART. Additionally, participants reported that the video had a positive impact on their lives as it gave them the courage to disclose their HIV status to their sexual partners who, in turn, encouraged them to adhere to ART and showed a willingness to undergo HIV testing and counseling. At the same time, the findings highlight opportunities to further optimize VITAL Start and expand the use of similar interventions in this setting. These opportunities include creating other videos to support or provide education to people with long term conditions and implementing the interventions in the communities, not only in clinics.Overall, these findings suggest that VITAL Start met its intended purpose and highlight the importance of creating video interventions including settings and characters with whom the targeted audience can identify. The women were satisfied with the video content; they could relate to the setting of the video as it was shot locally with characters plying typical trades and living a type of life that many people in Malawi and similar settings live. Thus, the women could map the video content to their circumstances by comparing and contrasting the characters represented. The post-video session with a counselor and the post-video script ensured that the key messages from the video were not lost. The video’s intended message included empowering women to be able to freely talk about living with HIV, teaching them the benefits of ART adherence, and how a reminder system could help ensure adherence. Some of the reminder systems reported included identifying common familial routines convenient for them to be taking ART, for example, mealtimes, a favorite program on television or radio, or just before bedtime. An additional take-home message was about encouraging the participants to disclose their HIV status to their loved ones who, in turn, would support them as needed. Indeed, what the women reported suggests that those who disclosed received support from the partners, including being encouraged to adhere to ART. Finally, the video delivery was convenient, with the participants saying the tablet was easy to use. Furthermore, they appreciated the privacy of individualized viewing and the use of headphones, which eliminated inadvertent disclosure of HIV status and the stigma associated with watching the video. While the fidelity of delivery of the intervention was good, we note that three women (9%) had difficulties recalling specific messages from the video, although this is not inconsistent with the literature ,37,38,39One of the aims of VITAL Start was to help PWLHIV disclose their status to their partners, and our findings suggest that nearly 90% disclosed—which compares favorably with reports from many studies in sub-Saharan Africa aimed to improve HIV status disclosure among sexual partners ,44, as wWe also highlight one unexpected positive finding—watching the video with a partner was rewarding as it increased partner engagement. This was somewhat unexpected because we have observed that men in Malawi do not often accompany their spouses to the clinics, and if they do, they (men) appear to pretend to be in a hurry. Although the video was designed to provide education on the prevention of vertical HIV transmission to PWLHIV and empower them to disclose their HIV status to partners, the finding suggests that interventions targeting women should keep both women and their partners in mind to optimize the intervention’s benefits.Overall, these findings reinforce emerging literature promoting the use of video interventions in healthcare. Video interventions have been used successfully in sexually transmitted disease clinics ,54,55,56It is worth noting that the current study, although largely exploratory, reports on four implementation outcomes , while the majority of studies that examine intervention implementation in healthcare, including the use of evidence-based interventions in HIV care, only report on a few outcomes; most only report acceptability . By repoThis study has several limitations. First, only about a quarter of eligible participants—those who received the VITAL Start intervention—returned for interviews, suggesting that our study might have suffered from selection bias. To better understand the nonresponses, we compared the characteristics of women who returned for the interviews and those who did not return to identify any selection bias issues. We found that the demographic characteristics of responders did not differ significantly from those who received the standard of care. Further, we compared the incidence of intimate partner violence—one of the post-intervention outcomes at month 1—among those who returned for the interviews and those who did not. We found that the incidence of intimate partner violence across three categories  did not differ significantly among participants who returned for the interviews and those who did not. This suggests that those who failed to return for the interviews did not do so because of negative or adverse outcomes post-intervention, for example, when disclosing status to a partner. Therefore, despite some women not returning for the interviews, there is no evidence of selection bias; our findings are thus still representative of not only the women who received the VITAL Start intervention but also the entire study cohort.The second limitation is that we were unable to stratify the analyses by the experiences of participants who watched the video with their partners and those who watched alone. This is because the number that watched the video with their partners was very small (3/34). Notwithstanding, participants who watched the video with their partners reported having a good experience and receiving partner support in ensuring that they adhered to ART. But as more data from the VITAL Start trial become available, this will be one area of further inquiry. Beyond what the participants reported during the interviews, we will look at whether verifiable outcomes such as ART adherence (measured by the concentration of tenofovir-diphosphate) and viral suppression among participants who watched the video with their partners differ from those of participants who watched the video alone.The third limitation is that our findings may not be generalizable to all PWLHIV in Malawi—a limitation inherent in qualitative research designs ,62,63. TA major implication of our findings is that the video intervention can help to improve overall service delivery, and this can be achieved in two ways. First, the video saves time; it requires much less time for direct interaction between the client and provider compared to the standard of care . The savTo eliminate mother-to-child transmission and, therefore, achieve a HIV-free generation, it is critical to find low-cost, easy-to-scale, and acceptable interventions that can increase ART adherence among PWLHIV and improve retention in HIV care. This qualitative study shows that a short video on ART and education to prevent vertical HIV transmission followed by a quick Q & A session is an acceptable, feasible, and impactful intervention to use among PWLHIV. The video intervention encourages HIV status disclosure to sexual partners and results in behavioral changes that impact ART adherence because it addresses the key issues in the ART cascade—from initial HIV diagnosis to achieving viral suppression. While considerations to scale up the intervention may have to wait until the effectiveness of VITAL Start compared to the standard of care is reported, our findings on the four implementation outcomes  of VITAL Start are nonetheless encouraging. The findings suggest that solutions to the problems facing the optimal delivery of ART and prevention of vertical HIV transmission may be within reach. This is particularly true for many countries in sub-Saharan Africa, where most people with HIV live; mother-to-child transmission of HIV is still high, and human resources shortages continue to hinder the delivery of healthcare services. Furthermore, as suggested by the participants, future research could focus on exploring the feasibility of expanding the video intervention to communities to benefit people with similar conditions who fail to come to the clinics for testing and treatment.