The local farmers of Central Punjab, Pakistan have been using indigenous grasses as vital components of ruminant diets, but little is reported about their nutritional potential. Hence this study investigated nutritive potential of a selection of ethnobotanically important fodder grasses. Multiple nutritional parameters , secondary metabolites  and in vitro digestibility values were determined. Furthermore, the legitimacy of ethnobotanical knowledge of local inhabitants about these grasses was also verified. The results suggested that majority (77%) of these grasses can be regarded as good quality fodders because of their high protein (169 g/kg) and good digestibility (457 g/kg) with moderate fibre (≤ 602 g/kg), lignin (≤ 50 g/kg) and secondary metabolites . Pearson correlation between nutritional parameters indicated that in vitro digestibility values were positively correlated with crude proteins  and negatively correlated with fibre , ADF, r = − 0.84 and ADL, r = − 0.82) contents. Moreover, a positive relationship was identified between ethnobotanical knowledge and laboratory findings for studied grasses. Spearman correlation test showed that ranking of grasses based on ethnobotanical preferences were highly correlated  with the laboratory results for CP (0.85), NDF (− 0.76), ADF (− 0.72) and ADL (− 0.62). The resilient complementarities between ethnobotanical preferences and nutritive analysis authenticate farmer’s traditional knowledge, which needed to be aligned with the corresponding scientific data. Farmers can use these findings for appropriate fodder selection and development of precise supplements for feeding ruminants within a sustainable and economically viable livestock industry for food security. Central Punjab refers to the alluvial planes that are surrounded by the two rivers i.e. Jhelum and Sutlej. This region is one of the biggest and most developed areas of Punjab, comprising one of the most extensive canal irrigation system frameworks in the world. This made it permissible for boosted agricultural output and an immense increment in arable land. Among agribusiness this land not only involves production of staple grains  but also plays a significant part to supply feeds ingredients for the livestock industry.The Punjab province is the most developed, populous, and prosperous region of Pakistan, representing about 60% (110 Million) of the country's total population. It has an area of 205,344 sq km and it is the 2nd largest province in area after Balochistan. This zone is playing a promising role in agricultural production. It contributes about 68% to the annual food grain production, whereas 51 million acres of land is cultivated and another 9.05 million acres are remained to be converted as a cultivable land in different parts of this province  at different stages of maturity was evaluated. This study declared the studied grasses as a suitable fodder to feed ruminant animals16.Though Harun et al.18, highlands of Baluchistan19 and the desserts of Cholistan20. Moreover, with relevance to Central Punjab, Pakistan we found limited nutritional data about ethnobotanically used fodder grasses. Sultan et al.21 evaluated the nutritional capacitances of ten commonly used irrigated grasses . Ahmed et al.22 also nutritionally investigated two traditionally used fodder grasses  of district Sargodha. In another study five indigenous grasses  of Faisalabad and Sargodha were subjected to proximate analysis and their order of preference was established on the basis of nutritional facts23. While these studies recommended many grasses as a valuable part of ruminant feed, they did not satisfactorily represent all the nutritional facts of a diversified range of ethnobotanically used fodder grasses in Central Punjab Pakistan.Nutritional evaluation of these ethnobotanically used fodders grasses is a global trend. However, in Pakistan only a few studies had been conducted in this regard and most of these studies were confined to Himalayan grassland1 to generate a nutritional database for the previously identified ethnobotanically used fodder grasses of Central Punjab Pakistan. We anticipate that this information and its subsequent use may help the herdsmen and range managers to determine the incorporation of suitable grasses in animal diets for an improved animal health and performance. Moreover, this study aimed to highlight possible complementarities between the fodder grass rankings based on ethnobotanical knowledge, preferences and nutritional compositions. The outcomes of this study could be used as a benchmark to exploit local fodders more efficiently as a nutritional resource to optimize animal production in an affordable and a sustainable manner.Therefore, the current research was conducted as an extension of our previous studiesEchinochloa crus-galli, whereas minimum moisture was found in Cenchrus setiger. It is well-known that dry matter (DM) and moisture contents have inverse relationship to each other. Therefore, the grass species with peak moisture content had lowest DM i.e. 202 g/kg and species with minimum moisture possessed the maximum amount of DM i.e., 664 g/kg. Moreover, the ash and organic matter (OM) contents also have reverse relationship among them i.e., minimum ash with greater OM and vice versa. Hence current nutritional results reported the lower ash values in Eragrostis minor (7 g/kg) with upmost OM content (993 g/kg). Whereas Setaria verticillata exhibited the greater ash content (115 g/kg) with lowest OM content (885 g/kg). In regards to the fat content, Acrachne racemosa expressed the maximum value (46 g/kg) while Agrostis gigantean showed the least i.e., 20 g/kg. However, the crude protein (CP) contents in grasses ranged from 41 to 164 g/kg. The lower CP was observed in Arundo donax while higher CP was observed in Eragrostis minor. Interestingly these two species (Arundo donax and Eragrostis minor) exhibited exactly inverse results for NDF. Eragrostis minor reported least NDF (429 g/kg) whereas Arundo donax showed the highest value (798 g/kg). This showed a considerable negative association between CP and NDF contents of grasses. However, in terms of ADF, Zea mays showed the smallest value (247 g/kg) and maximum value was observed in Setaria verticillata (603 g/kg). The utmost ADL content was reported in Arundo donax (153 g/kg) although undermost ADL content was in Brachiaria reptans i.e. 35 g/kg.The overall nutritional compositions of studied grasses are presented in Table Cenchrus setiger, Phragmites australis, Acrachne racemosa, Lolium temulentum, Apluda mutica, Tetrapogon villosus and Setaria verticillata. Conversely, the lowest values were recorded in Cenchrus ciliaris followed by Cenchrus pennisetiformis, Chrysopogon aucheri, Eleusine indica Chrysopogon zizanioides, Setaria viridis and Eragrostis minor.In this current research, the anti-nutrient contents presented considerable variations in total phenols (TP), total tannins (TT) and condensed tannins (CT) i.e. 35–153 g/kg, 21–132 g/kg and 12–85 g/kg, respectively (Table Eragrostis minor (660 and 661 g/kg respectively) whereas the minimum values were observed in Dactylis glomerata (175 and 179 g/kg respectively)  and in vitro organic matter digestibility (IVOMD) respectively. The highest IVDMD and IVOMD were observed in Cenchrus ciliaris, Cynodon dactylon, Apluda mutica, Setaria pumila, Saccharum spontaneum, Desmostachya bipinnata and Pennisetum orientale were found to be much higher in comparison to the values presented by Sultan et al.24 who analyzed some grasses from Northern regions of Pakistan. The probable reasons for this variation are disparities in the land geography, climate, soil composition and sampling times which can affect the corresponding nutritional variations in forages28. However, in comparison to the current study, Manzoor et al.23 and Sultan et al.21 reported lower DM values for some grasses  from the same geographical range. These lower values were possibly due to differences in soil fertility level, phenological states of grasses, and sampling or analytical procedures.As indicated in Table 29. This information can help us to use suitable forages for feeding animals to satisfy their mineral requirements with or without supplements. Conversely, high mineral contents in animal feeds may dilute the quantity of other available nutrients to animals. Moreover, if animal fed with excessively high mineral contents, these will not only affect the digestibility but also might cause the accumulation and crystallization which ultimately lead to urinary restrictions or infections. In the current study mean ash and OM contents were found to be within the satisfactory limits  of several tropical grasses around the globe. The ruminant’s protein demand varies according to its age or growth stage, such as the higher CP levels (150–160 g/kg) are especially good for lactating cows because during lactation amino acids demand is higher for additional metabolic functions and synthesis of milk protein37. Current results revealed that Dichanthium annulatum, Bothriochloa bladhii, Eleusine indica, Sorghum helepense, Cynodon dactylon, Zea mays and Eragrostis minor were especially good in this aspect because of their higher CP content. However, for non-lactating ruminants comparatively lower protein intake is recommended. Therefore, measurement of CP is a supportive tool in order to assure that animal is ingesting sufficient proteins as per its body requirement. As intake of excessive proteins or consumption of poor quality proteins are both economically detrimental29.This study found that out of 53 studied fodder grass, 40 species possessed fairly moderate to good CP range i.e. 169–95 g/kg. Generally, the upper limit of CP values in present analysis were found to be relatively higher than the maximum CP content of some previously studied grass species from similar zone38. Results showed that CP of Ottochloa compressa (72 g/kg) was at borderline; whereas remaining 12 grasses possessed CP lower than the critical value  of those grasses belonged to the high priority group (A) and three  were from moderate priority group (B) whereas rest of the seven grasses were from the low priority grass group (C). The presence of greater number of fodder grasses with lower CP in group C declares a supportive evidence for ethnobotanical knowledge of local inhabitants of the study area. The intake of this kind of protein deficient diet will not only result in the loss of appetite but also reduce the cellulolytic activity of rumen microbes which slow down the fibre digestion39. Low feed intake and poor digestion reduce the food efficiency which can cause underprivileged growth and development of livestock41. Therefore, for healthy animal productivity uninterrupted supply of CP is mandatory43. Although 77% of studied grasses showed sufficient levels of CP which recommend them as good protein sources for maintaining healthy livestock, they still cannot compete with high CP containing legumes45. The differences between grass and legumes for CP contents are quite significant; hence a blend of grass and legume in ruminant diet is more recommendable46.The recommended critical value for CP content is 70 g/kgmpressa 7 g/kg was48. It is negatively related to digestibility of feed, as lower the concentration of fibre in feed it become easier to digest which results in good energy value24. Fibre can be determined in terms of NDF and ADF contents but the NDF method is considered to be most reliable one for measuring the total cell wall a fibre contents in a feed29. Forage digestibility and ruminant’s consumption capacity largely influenced by its NDF content49. Its value in animal feed is quite critical and a feed is considered to be of poor quality if it has NDF above 650 g/kg50. The current study revealed the mean NDF value of 602 g/kg which is under the critical limit but 12 species i.e., Arundo donax > Dactylis glomerata > Digitaria longiflora > Heteropogon contortus > Cymbopogon jwarancusa > Setaria verticillata > Leptochloa panacea > Lolium temulentum > Enneapogon persicus > Apluda mutica> Acrachne racemosa > Apluda mutica > Aristida adscensionis had NDF above the critical value (650 g/kg). However, Ottochloa compressa exhibited the NDF values that were very close to the critical value of 697 g/kg. The grasses with more than the critical NDF value indicated reduction in voluntary feed intake and feed conversion efficiency but lengthier rumination periods51. Norton37 stated that NDF varying from 670 g/kg to 780/kg was considered to be high enough to limit DM intake and digestibility. The results predicted an interesting relationship between CP and fibre contents as indicated in Fig. Fibre is often regarded as the negative index of nutritive quality52. Lignin content is also negatively correlated with fodder palatability53 because it has negative affect on OM digestibility54. The average ADL content was reported as 382 g/kg. One of the significant reasons in preference of grasses by ruminants is their digestible cellulose and hemicellulose contents. The microflora of ruminant’s digestive is capable to efficiently digest cellulose and hemicellulose of grasses42. The mean cellulose and hemicellulose in studied grasses were reported as 317 g/kg and 220 g/kg, respectively. However, digestibility of cellulose is inversely proportional to the amount of lignin. As fodder matures its lignification increases with 100 g/kg which lessens the cellulose digestibility by about 60%. The lignin content in younger fodder is the 50 g/kg, which increases the cellulosic digestibility up to 80%55. The current results exhibited that 75% of species had lignin from 34 to 50 g/kg which represented their good cellulosic digestibility. However a few species with higher lignin content  negatively affected the cellulose digestion in ruminants. On comparison with previous studies relatively higher fibre values  were found in the findings stated by Rafay et al.20 and Sultan et al.24. The soil fertility and season of fodder harvesting are important influencing factors for variation in fibre contents58.NDF is also associated with other cell wall structural contents i.e., lignin, cellulose and hemicellulose62. The significant possible damages of secondary metabolites are such as reduction in immune function, growth and reproduction impairments, which ultimately leads to animal morbidity and mortality64. By considering these effects, quantification of secondary metabolites is appraised to be essential in order to make appropriate fodder selection65. According to reports, tannins at 60–120 g/kg DM in animal diet can lower the efficiency of animal digestive system and ultimately its productivity as well60. However, few other researchers reported that low levels of these secondary metabolites positively affected ruminant health67. Like condensed tannins between 20 and 50 g/kg DM are essentially required for efficient utilization of nitrogen and healthy weight maintenance66. On the basis of recommended acceptable ranges of secondary metabolites, the studied grass species had been categorized into three groups i.e. high (> 100 g/kg), moderate (50–100 g/kg) and low (< 50 g/kg). Figure 68. Moreover, sufficient tannin concentrations facilitate to increase the digestion proficiency, milk production, wool growth and animal’s ovulation rate69. Additionally, specific quantity of these secondary metabolites has positive ecological effects such as improvement of soil quality and nutrient cycles69. However, grasses belong to the high secondary metabolite category  are not considered good for ruminant’s health. Panhwar64 stated that the excessive intake of secondary metabolites (anti nutrients) could affect the digestibility of vital nutrients which not only lessened the palatability but could also be fatal. It had been reported that higher dosage of phenols may reduce the bone mineralization and could also cause disturbance in cholesterol or estrogen levels72. Whereas greater amounts of tannins could result in reduction of protein digestion and absorption which eventually depress the voluntary feed intake (VFI)74.Secondary metabolites like phenolics and tannins are known as anti-nutritional factors because of their negative effects on ruminant health especially if consumed in large amounts75. Kallah et al.76 and Megersa et al.77 suggested that on average 450 g/kg digestibility of forage/fodder was sufficient to maintain an optimal animal performance. The findings of Van Soest78 suggested that 400–700 g/kg digestibility for grasses were found in tropical and subtropical lands. Noguiera39 also acclaimed 400–527 g/kg digestibility for grasses. For more understanding, ethnobotanical grasses were further classified into 3 clusters i.e. high (< 450 g/kg), medium (400–450 g/kg) and low digestible grasses (> 400 g/kg)  exhibited significant positive relationship with each other.Evitayani et al49 described that forage digestibility was negatively influenced by NDF contents whereas Arif et al.83 argued about the positive influence of CP on digestibility values of fodder/forages. As mentioned in Table 85. These results were also concordant with the report of Van Soest47 who stated negative association between NDF and digestibility of various feeds. Lichtenberg and Hemken86 specified that DM digestibility was decreased by 3–4 units with per unit increase in lignin content. However, poor digestibility fodder grasses can be improved by adding urea supplements into an animal diet65. Some other studies also supported the fact that by addition of urea as a supplement can improve the digestibility of low quality forages88.Many factors influenced the digestibility of a particular fodder. Harper and McNeill89 supported this fact that low level of tannins resulted in good IVDMD of fodders. This is because those tannins in NDF and ADF firmly bound to cell wall and cell protein and thus resulted in lower digestibility values51. Whereas CT had also been notorious in order to lower the digestibility values54.Moreover, it also had been observed that digestibility was inversely proportional to secondary metabolite contents . As shown in Table 1  and ethnobotanical ranking groups of high, medium and low priority. Secondary metabolites analysis also showed an affirmative association with ethnobotanical knowledge. Crosstab analyses clearly declared that grasses ranked in high and medium ethnobotanical priority groups were comparable to low and medium secondary metabolites ranking groups Table . AdditioGrasses of Central Punjab Pakistan had been used as animal fodder for centuries but unfortunately little information about their nutritional worth was available. This study not only provided a nutritional profile of studied grasses but also made an attempt to validate the ethnobotanical knowledge of local inhabitants of Central Punjab Pakistan about these fodder grasses. It can be concluded that a strong positive correlation existed between ethnobotanical preferences of fodder grasses and nutritional facts of particular species. Nutritional results confirmed that those grasses which ranked superior by the local inhabitants of the study area also contained higher CP levels than those species which were ranked as inferior. Moreover, the grasses perceived for low palatability possessed great levels of structural fibres  and secondary metabolites (anti-nutrients). The Pearson correlation studies also showed that grasses with higher proteins had low fibre content and good digestibility. It can be summarized that good quality fodders were high in protein and digestible nutrients, but low in fibre and lignin. The strong complementarities between ethnobotanical preferences and nutritive analysis reflected the reliability of ethnobotanical knowledge of local farmers and shepherds. However, it is recommended to integrate these conventionally used fodders into modern feeding systems. The good quality grasses can be directly incorporated into ruminant diets whereas grasses with low nutritional quality can be improved by using biochemical processing before making either silage or hay or can be mixed with either good quality forages or supplements before feeding the animals. These results are valuable in making appropriate fodder selection and supplement development that will match livestock requirements which consequently can support economical livestock performance. However, further studies are required to evaluate their mineral composition; feed intake and animal’s ability to efficiently utilize these ethnobotanical feed resources for sustainable animal production in low to moderate animal input systems.1.The study was conducted in Central Punjab region of Pakistan which is regarded as the subtropical continental low land Fig. . Normall1. Representatives of collected fodder grass sample was taxonomically identified by using specimen identification guidelines in the herbarium of Lahore College for Women University, Lahore and the Quaid i Azam University, Islamabad. Moreover two online plant databases i.e. flora of Pakistan (http://www.efloras.org/index.aspx) and flora of India (https://sites.google.com/website/efloraofindia/) and various grass flora identification keys92 were also used in fodder grass identification process. However, remaining samples were washed to remove contaminants or dust particles, shade dried and finely ground . All the samples were kept inside airtight polythene bags until further nutritional analysis as described below.For sample collection the rural areas from Northern irrigated zone were actually targeted because of their reliance around feeding conventional grasses for raising their ruminant animals. As the literature reported, the grasses were more palatable before their maturity. Therefore, representative samples of each of the 53 specimens from different parts of the same field were collected at their pre bloom stage through repeated field visits during this study. These samples represented the same fodder grasses as previously reported by Harun et al.93. Nitrogen content was determined by the advance MACRO CUBE System and obtained nitrogen value was multiplied by 6.25 to estimate the crude protein (CP) contents of these samples. However, for fat analysis advance micro-digester (MARS6) was used. Whereas neutral detergent fibre (NDF), acid detergent fibre (ADF), acid lignin fibre (ADL) were done by adopting the methodology prescribed by Van Soest et al.48. Cellulose and hemicellulose contents were calculated by the formulae Cellulose = ADF-ADL, Hemicellulose = NDF-ADF48.Parameters like moisture, dry matter, ash, proteins, fat, were evaluated by following the standard methods of AOAC94. For the estimation of TP, TT and CT tannic acid and epigallocatechin gallate was used respectively to establish relevant standard curves.The selected secondary metabolites i.e. total phenols (TP), total tannins (TT) and condensed tannins (CT) that can affect the fodder quality were also estimated by using the methodology prescribed by Makkar et al.95 was adopted for digestibility test by using only the first stage of the 2 stage procedure. Rumen fluid (RF) was collected from 3 freshly slaughtered cattle (Aberdeen Angus breed) at a local abattoir  of Newcastle upon Tyne, UK. Equal volumes of these RF were pooled and then mixed with the pre warmed buffer solution in a ratio of 1:2 and kept at 39 °C in a water bath  in order to maintain anaerobic conditions. Moreover, carbon dioxide was flushed into this buffered RF (BRF) and pH was adjusted around 7. For the incubation 0.5 g of each ground fodder grass sample was put inside the 50 ml capacity polypropylene tubes and 40 ml of the BRF was also dispensed into each tube. These tubes were sealed with the rubber stoppers  and incubated in a water bath at 39 °C. The tubes were shaken manually few seconds thrice a day . After 48 h the tubes were taken out and placed inside an ice filled bucket to stop the on-going fermentation. Later on the tubes were subjected to centrifugation (accuSpinTM3R) at 2000 rpm for 10 min. The insoluble residues were washed, dried, weighed and then ashed before estimating In vitro dry matter digestibility (IVDMD) and In vitro organic matter digestibility (IVOMD). IVDMD of samples were measured by drying the washed residues at 80 °C whereas IVOMD was estimated by formation of ash in the furnace at 550 °C. The calculations were done by following the formulae mentioned below and a blank sample of BRF was used for correction in dry matter residue weight.The method of Tilley and TerryAfter obtaining laboratory results  the fodder grasses (n = 53) were ranked in descending order (high to low) according to results of each studied parameter. For each parameter, grass at rank 1 considered as most potential one whereas at rank 53 with the lowest potential. This ranking helped to correlate the laboratory findings with ethnobotanical preferences.The obtained data was computed in the excel sheets and graphical illustrations were made for data analysis. Correlation between CP, NDF, ADF, ADL, CE and HC were inferred by using Pearson correlation method  through SPSS version 23. Moreover, the Spearman’s rank correlation  was also used to examine possible relationships between laboratory results and ethnobotanical preferences of fodder and grazing grasses at P < 0.01. Crosstab method within descriptive statistics of SPSS was also employed for making comparisons between secondary metabolites based grass categories and ethnobotanical ranking of studied fodder grasses. Additionally, comparisons were made between In vitro digestibility based grass categories and ethnobotanical ranking of studied fodder grasses. Microsoft Excel was used to organize different data sets for creating trend lines and visual presentations.


In a survey evaluating technology use among school-goingindividuals from the United States of America and Australia, 96% of students had onlineaccess and used technology for various functions, especially video games. Thus, videogames have become the most popular multimedia entertainment for them.In addition to their entertainment and leisure capabilities, video games may havepotential as an education tool, especially in medicine. According to a survey withmedical students, 98% of them believed that technology should be better integratedwithin their medical curriculum, and 80% of them believed that video games can improvetheir education,4. As is wellknown, robot-assisted surgery is on the rise, and previous video game experience can beadvantageous for budding robotic surgeons.Most interesting of all, video games and surgical procedures share similar skills, suchas visuospatial skills and hand-eye coordination; therefore, video games can be avaluable tool for surgical training among medical studentsvs.non-gamers (< 6 hours of video game/week). Participants performed urethrovesicalanastomosis by virtual reality simulator on RobotiX Mentor™, which measuredperformance parameters, and answered a questionnaire for demographics and gamingexperience. Players significantly outperformed non-gamers in three of the 24 performancemetrics (P<0.05), and there was a trend towards better results forseven of the remaining 21 metrics. Previous video game experience > 6 hours/week maygive an advantage in simulated robotic surgery.In an observational study, 30 medical students and two interns with a median age of 25years were recruited and subsequently divided into groups according to their previousgaming experience - gamers (≥ 6 hours of video game/week) . Finding high-fidelity ways to teachsurgical skills to medical students is vital, as the acquisition of these skills beginsat this early point of training,8. An important point for furtherexploration is video game-based training (or VGBT) protocols with hardware and softwaretailored to surgical skill sets, especially among inexperienced individuals,8,9.Therefore, training curricula that include video games can help fine-tune the technicalinterface between surgeons and screen-mediated applications such as robotic surgery.Video games can be a practical teaching tool to help train surgeonsHowever, comprehensive and up-to-date systematic reviews are needed to confirm this.Methodological heterogeneity among included studies limits the ability to makeconclusive decisions; thus, future studies with long-term follow-up, larger samplesizes, results stratified by video game characteristics, and up-to-date technology areneeded to validate these preliminary results. Also, future studies testing thishypothesis are recommended to develop simulator programs for certification of roboticsurgeons.


The Coronavirus 2019 pandemic necessitated a rapid uptake of video-based interviewing within the personnel selection process in healthcare. While video-based interviews have been evaluated previously, we identified a gap in the literature on the implementation of video-based interviews and how they compare to their face-to-face counterparts.A scoping review was conducted to consolidate the available literature on the benefits and limitations of video-based interviews and to understand the perceived barriers associated with transitioning away from face-to-face interviews. A search strategy, developed in concert with an academic health sciences librarian, was run on Ovid MEDLINE, Embase, PsycInfo, and Cochrane Central. The search was performed on March 31, 2020, and updated on February 21, 2021. Studies that implemented and evaluated the impact of video-based interviewing in healthcare were included in our study. Review articles and editorials were excluded.Forty-three studies were included in our scoping review, of which 17 were conference abstracts and 26 were peer-reviewed manuscripts. The risk of bias was moderate or high in most studies, with only four studies having a low risk of bias. Both financial costs and opportunity costs associated with the selection process were reported to be improved with video-based interviewing, while no studies explored the impact on environmental costs. Technical limitations, which were not prevalent, were easily managed during the interview process. Overall, video-based interviews were well received by both applicants and interviewers, although most participants still reported a preference for face-to-face interviews.While video-based interviewing has become necessary during the Coronavirus 2019 era, there are benefits from a financial, opportunistic, and environmental point of view that argue for its continued use even after the pandemic. Despite its successful implementation with minimal technical issues, a preference still remains for face-to-face interviews. Reasons for this preference are not clear from the available literature. Future studies on the role of nonverbal communication during the video-based interview process are important to better understand how video-based interviewing can be optimized.This scoping review was registered with Open Science Framework.The online version contains supplementary material available at 10.1186/s13643-022-01959-8. Whether applying to medical school, residency programs, fellowships, or for the role of a staff physician, interviews play an important part of the selection process for both applicants and programs. The Coronavirus 2019 (COVID-19) pandemic, and the public health measures that have accompanied it, has necessitated a transition away from face-to-face interviews. This provides an opportunity to scrutinize the benefits and limitations of video-based interviewing as they compare to traditional face-to-face interviews.Face-to-face interviews come with both financial and opportunity costs that have been reported in previous studies –4. FinanThe environmental costs of face-to-face interviews have not been well-studied in the literature, but a recent emphasis has been placed on the impact of long-haul flights associated with traveling for interviews on our carbon footprint . In lineVideo-based interviewing presents an opportunity to continue with personnel selection by adhering to COVID-19 restrictions while addressing the aforementioned costs associated with face-to-face interviews. While previous studies have reported on their experience with video-based interviews and provided summaries of the current literature on the topic, a formal structured synthesis of the literature on video-based interviewing within healthcare does not exist –13. GiveThe aim of this review was to evaluate the extent of previous research on video-based interviewing as it applies to healthcare contexts. We sought to review the benefits and limitations of video-based interviewing and identify gaps in our current knowledge on the implementation of video-based interviewing. The research question that guided this scoping review was as follows:Within selection processes in healthcare, how do video-based interviews compare with face-to-face interviews in terms of costs, implementation, and candidate selection?A scoping review was conducted in anticipation of the heterogeneity of study designs available on this topic. We employed the methodology that has been previously outlined and subsequently refined , 15. FulInclusion and exclusion criteria that were developed to select studies that were in line with our research question are provided below. Studies that were not published in English or French were excluded due to translation services available. There was no limitation based on publication date.Involve applicants interviewing via video-based and/or face-to-face interviews ANDInvolve applicants applying to medical school, residency, fellowship programs, dentistry, pharmacy, nursing, or other healthcare-related fields ANDAny study design that involved the implementation of video-based interviews ANDAny method of data analysis, including quantitative and qualitative studies ANDAssess any outcome of interest including financial costs, environmental impact, or time investedInclusion criteria:Review articles OREditorials or expert opinions that do not describe a particular video-based interview that was implemented ORStudies that are not published in English or FrenchExclusion criteria:The results of our search were initially screened based on title and abstract by two independent reviewers . Cohen’s kappa statistic was determined following this to ensure inter-rater reliability before proceeding to the next stage of screening. Any discrepant studies by either of these reviewers were included in full text review. After initial screen based on title and abstract, the two reviewers  independently screened the full texts of the selected studies in duplicate. Any discrepancies following this were reviewed by a third independent reviewer (HM) who made the final decision on study inclusion. Reasons for exclusion after full text review were documented.DistillerSR  was used for the data extraction process. A standardized form was created on this platform and independently tested by two reviewers (RS and RH) on the initial 10 studies that were included. Following this, the data extraction form was modified to capture the range of methodologies and outcomes of the studies that were included in our scoping review. No further changes were made to the data extraction form after this modification, and the same standardized form was used on all included studies.Given the nature of a scoping review, no formal statistical synthesis of the study data was pursued. Study characteristics including geographic location, study methodology, discipline of authors, purpose of interview, and type of analysis are presented as descriptive data. In line with our aim to identify the benefits and limitations of video-based interviewing, outcomes from each study were also grouped thematically as they applied to financial costs, opportunity costs, environmental costs, technical limitations, impact on the rank list, and body language.Risk of bias assessment of each included article was performed using the Joanna Briggs Institute (JBI) critical appraisal tools by two independent reviewers  . Althougn = 19), letters to the editor (n = 7), did not involve applicants in healthcare fields (n = 3), did not have any measured outcomes (n = 8), or abstracts which full text was already included (n = 3). The search was updated on February 20, 2021, and 5 additional studies met inclusion criteria. Two additional studies were retrieved from review of the references of the included studies. As such, a total of 43 studies were included in our scoping review [A total of 3851 studies were retrieved from our search, after duplicates were removed. Following review of titles and abstracts by two independent reviewers, a total of 76 studies were selected for full text review (Cohen’s kappa = 0.84). Following independent full text review by two reviewers, a total of 37 studies were selected. These were reviewed by our third reviewer after which 36 articles were included. Reasons for exclusion after full text review included the lack of any video-based interview being implemented n = , lettersg review . A PRISMg review . A summaOf the included studies, 17 were conference abstracts and 26 were published manuscripts. Forty-two studies were conducted in the USA, while 1 was conducted in Australia.n = 1), anesthesiology (n = 1), general surgery (n = 1), pediatric surgery (n = 1), gastroenterology (n = 1), internal medicine (n = 1), orthopedic surgery (n = 2), obstetrics and gynecology (n = 2), family medicine (n = 2), complex general surgical oncology (n = 3), female pelvic medicine and reconstructive surgery (n = 1), maternal fetal medicine (n = 1), advanced gastrointestinal minimally invasive surgery (n = 1), and emergency medicine (n = 22).Twenty-nine studies included medical students applying to residency, 2 studies of students applying to medical/dental school, 2 studies of pharmacy students applying to their respective pharmacy residency, and 10 studies of residents applying to fellowship. Of studies involving medical residency or fellowship applications, disciplines included urology  . With thA total of 76% of applicants and 78% of interviewers were satisfied with the video-based MMI process. Similar to the face-to-face counterpart, the video-based MMIs involved seven questions with 2-min change over time between stations. The interview process was set up and overseen by five administrative staff and two IT staff. This study was the only study that explored the role of a video-based MMI as a replacement to the face-to-face counterpart. This one study demonstrated that the video-based MMI was an acceptable alternative to an in-person process.One-way video interviewing describes the process by which applicants submit answers to standardized questions in video format to be evaluated as part of the selection process. There were 24 studies that employed this method of video-based interviewing.Twenty-two of these studies evaluated the standardized video interview (SVI), an online unidirectional interview that was developed by the Association of American Medical Colleges (AAMC) and piloted with the Accreditation Council for Graduate Medical Education (ACGME)-accredited emergency medicine programs. Twelve of these studies were abstracts –49 and 1Overall, there were small correlations between SVI scores and other aspects of the application such as USMLE scores , facultyApart from the studies that assessed the AAMC’s SVI specifically, two other studies described their use of one-way video interviewing or asynchronous video interviews , 61. BotHigher scores on this one-way interview were correlated with higher in-person interview scores , 61. WhiOverall, results were ambiguous as to what the SVI was measuring and the value that should be attributed to it amongst other aspects of the emergency medicine selection process. Nonetheless, one-way interviews may hold some promise as an initial screen, but there is no evidence we found to demonstrate that it should replace a bidirectional interview.Eleven of the included studies discussed technical limitations of video-based interviewing , 36, 37.No studies reported any major concerns from a technical point of view that limited the use of video-based interviewing.Fourteen studies discussed the financial costs associated with the selection proces s, 37, 59.Overall, video-based interviewing was seen as a way to improve financial costs for all stakeholders, particularly for applicants in whom financial limitations impact their application process.Fifteen studies discussed the opportunity costs associated with the selection process , 58, 61.Two studies discussed that video-based interviewing was particularly beneficial for applicants that could not get time off work to attend face-to-face interviews  and for One study explained that the introduction of the SVI may have increased the time required for applicants to prepare for the interview itself . From a While one-way video interviewing may come at the cost of increased work for both applicants and interviewers, bidirectional video-based interviewing allows applicants to take less time away from personal or professional commitments and results in fewer disruptions for the programs themselves.None of the 43 studies discussed the environmental impact of interviewing in healthcare as it applies to personnel selection.Three studies discussed the role of body language as it pertained to video-based interviewing , 23, 33.None of the studies discussed the interpretation of body language and how this plays into applicant selection.There were 12 studies that assessed either the perceived or objective impact of video-based interviews on the rank list , 60, 61.Three studies reported from the applicants’ perspective that most applicants were comfortable ranking programs after a video-based interview , 30. OneFrom the interviewer perspective of determining the rank list, three studies reported that there was no significant difference of interview type on the ranking of applicants , 29.In terms of the SVI, one study reported the lack of any significant correlation between the SVI scores and rank list position , while aQuality assessment was completed for the 26 peer-reviewed manuscripts included in our scoping review. Using the JBI critical appraisal tools to evaluate each article, 11 studies were felt to have a high risk of bias, 12 with a moderate risk of bias, and only 3 studies with a low risk of bias. Most studies lacked a valid and reliable tool to evaluate applicant/interviewer perspectives on video-based interviews, did not assess or control for potential confounders, or had poor survey response rates. A summary of our quality assessment is provided in Additional file 3.Our scoping review summarizes the current literature and highlights major themes about video-based interviewing in healthcare. Overall, both financial costs and opportunity costs associated with the selection process were reported to be improved with video-based interviewing, while the impact on environmental costs has not been well explored in the current literature. Bidirectional video-based interviews were well received by both applicants and interviewers, yet a preference remains for face-to-face interviews. One-way video interviewing may be useful in select settings as a screening tool, but was not found to be a good replacement for bidirectional interviewing.Important features of video-based interviewing that were described by multiple studies included the use of a video tour of the facility/city, an informal video-based session with current trainees, and having a dedicated administrative person to help applicants and interviews navigate through the video-based platform. While technical limitations were anticipated, there were no major technical issues that limited the use of video-based interviews. The interpretation of body language in a video-based setting was not well explored.In the context of the social distancing measures necessitated by the COVID-19 pandemic, video-based interviewing has garnered recent interest across multiple disciplines within healthcare which were captured by our broad search strategy. Our search was also updated after its initial run to capture the influx of studies that were published since the start of the COVID-19 pandemic. Previous reviews have not been as structured or encompassing of video-based interviewing in healthcare as our scoping review , 63, andThe results of our review are in line with those from a previous literature review but also serve to highlight gaps in literature. Joshi and colleagues outlined benefits and drawbacks to video-based interviewing . SimilarAn important finding in our review was that despite studies reporting that applicants and/or interviewers felt that the video-based interview worked well, completing transitioning away from face-to-face interviews was not seen as a favorable option. From the results of our review, however, reasons for this are unclear. One of the challenges with assessing the reasons for this hesitancy may be the methodology of the available studies. While using surveys to quantify applicant and interviewer perspectives on video-based interviewing is helpful, it falls short in highlighting the thought processes that guide decision-making. It has been suggested that qualitative studies that use an inductive approach to data gathering may be more beneficial in such circumstances to get a better understanding of the reasoning behind our decision-making .Another aspect of video-based interviewing that was not well reported in the included studies is the role of body language and nonverbal communication. While the lack of body language was alluded to in three studies, quantifying the impact of body language on the video-based selection process has inherent challenges and has not been assessed in a healthcare context. In a study by Proost and colleagues from the organizational psychology literature, it was found that applicants are less attracted to organizations that use video-based interviews compared to those that use face-to-face interviews for their selection process . They exGiven the nature of the topic, the challenges associated with survey studies, and the inherent biases involved in the selection process, most studies had a moderate or high risk of bias. Additionally, analyzing perceptions around video-based interviewing comes with the challenge of measuring differing viewpoints in a reliable and valid way. We did not come across any validated measurement tool as studies developed and implemented their own surveys. While the goal of our scoping review was not to statistically synthesize data, we appreciate that collating the results of these heterogenous studies has its difficulties. Future research on developing an assessment tool to grade the quality of the interviews may prove helpful in standardizing the evaluation of interview processes.Our scoping review summarizes the available literature on the use of video-based interviewing in healthcare contexts and has highlighted important areas for further exploration. Video-based interviewing, while necessary during the COVID-19 era, provides benefits from a financial, opportunistic, and environmental point of view that argue for its continued use even after the pandemic. While video-based interviewing has been reported to be a feasible alternative to face-to-face interviewing, hesitancy remains to completely transition from face-to-face interview for reasons that are difficult to extrapolate from the currently available literature. In addition, the role of nonverbal communication and how this factors into decision-making is important to evaluate, as it will help to better understand the complex thought processes that underlie personnel selection in healthcare.Additional file 1:. Preferred Reporting Items for Systematic reviews and Meta-Analyses extension for Scoping Reviews (PRISMA-ScR) ChecklistAdditional file 2:. Database: Ovid MEDLINE(R) ALL <1946 to February 19, 2021>. Search StrategyAdditional file 3:. Table 2a: Risk of Bias Assessment for Cohort Studies. Table 2b: Risk of Bias Assessment for Randomized Trials. Table 2c: Risk of Bias Assessment for Quasi Experimental Studies. Table 2d: Risk of Bias Assessment for Cross Sectional Studies


The Swiss Youth and Media Act, which is about to enter into force, is an attempt to provide a legislative framework for video game use. Among other inclusions, the law intends to make providers more accountable by taking measures to protect minors from harm that can be caused by improper use of video games. However, it is a challenge to create a legal framework that can adequately regulate the evolving features of video games. Legislators must find a suitable regulatory approach which takes into account the fact that there is an increasing convergence between video games and gambling, particularly with the introduction of loot boxes. Moreover, there is a need for regulation, including the prohibition of misleading designs, the introduction of additional protection for minors, and the assurance of transparency of transactions. Appropriate policy legislation and consumer-protection measures are needed to protect people using these types of products, particularly children and adolescents. Further work should focus on assessing game characteristics to refine regulatory models to promote safe gaming. Based on experiences from the field of psychoactive substances as well as that of gambling, it is now a matter of developing a matrix of harm with elaborated categories: a tool that makes it possible to evaluate the potential harms of certain game design in an evidence-based manner. Today, 64.5% of the Swiss population plays video games at least several times per year . This stBased on the current state of knowledge, this viewpoint proposes to identify and summarize games (as a product) and the internal mechanisms that may pose a risk for problem gambling behavior. By describing different forms of video games and their inherent mechanics, the present viewpoint aims to ensure that appropriate legislation can be enacted through this means in Switzerland, as well as in other jurisdictions worldwide. By highlighting the possible harms that can result from the features of video games, a recommendation will be made as to how preventive aspects can be adequately considered in regulation. Moreover, by presenting what implications may result from these internal characteristics, it emphasizes the need for future research concerning the development of a valid assessment grid that would assist policymakers in refining government regulation of video game products. Notwithstanding the endeavors described, there is little epidemiological data available on gaming in the general population in Switzerland or elsewhere. A Swiss study from 2015 on “problematic Internet use”  reports that the prevalence in the general population over the age of 15 is 3.8%, with the most affected age group (15–24 years) having a prevalence rate of 11.2%  Table 1Table 1. While there can be many benefits associated with gaming , there aProblematic video game playing is multifaceted rather than a unitary phenomenon. As a result, multiple factors emerge in different ways and at different levels of analysis . The essence of this view is that no single level of analysis is sufficient to explain the emergence or maintenance of video-game-playing behavior . HoweverGenres are defined by the gameplay mechanics, for example battle royale (BR) games, first-person shooter (FPS) games, multiplayer online battle arena (MOBA) games, and real-time strategy (RTS) games. Video game themes are categorized based on how in-game visual contents look (are presented) [types are therefore used to classify video games based on the specific combination of electronic components or computer hardware  [Video games are complex art forms that combine elements of storytelling, graphics, sounds, game mechanics, and sometimes ubiquitous elements into digital artifacts . The preesented) . Video gesented) . Video g mobile) . Each of mobile) . The structure of video games depends also on the business model. Therefore, it is worth taking a closer look at the different business models, especially because the introduction of monetization strategies has changed traditional game design . On the Fortnite , players can spend real-world money to buy in-game “emotes” that allow them to express ideas and feelings via the movements of their in-game avatar [Games with a payment feature have increasingly raised concerns due to the psychological mechanisms that induce payment in such games. Attention is also drawn to the increasing problems of payments made by children, which, according to some authors, are a risk factor for the future onset of gambling addiction . Therefoe avatar . However, not all microtransactions in games are purely cosmetic. Players now also have the option of buying virtual items and bonuses that increase their chances of success in the game . These pDiablo Immortal, released at the beginning of June 2022 on iOS and Android, illustrates the problem. This free-to-play game (that is to say free at the beginning) puts loot boxes at the heart of its gameplay: it is indeed not possible to go beyond a certain stage in the game without buying loot boxes. The YouTube channel Bellular News [P2W games are thus defined as those video games that offer the possibility of spending money on content, items, or events that help the player to progress in the game. While the optional purchase of in-game items and events is a common feature of online games, P2W products are functional in that they give players a distinct advantage in the game and increase the likelihood of winning. More recently, however, P2W games have been criticized by both developers and players for both causing frustration and being perceived as unfair . A new plar News  estimatelar News . As participants in a for-profit industry, the objective of game developers and publishers is to create attractive and entertaining games. This implies that some vendors strive to produce games that will be played by as many players as possible for as long as possible, as this increases the game industry’s revenue streams. To achieve repeated play, developers use elements of game design based on psychological mechanisms such as variable reinforcement  that encourage long-term player investment . The litThe paradox is that microtransactions are not game mechanics in themselves but monetization tools (buying is not playing). Thus, the expansion of microtransactions in games raises some concerns that certain players  may be vulnerable to excessive spending or impulsive purchases. There is also a suggestion that some activities may provide a path to gambling and/or that some games are designed to resemble slot machines and have the same basic element of chance governing the distribution of in-game rewards. At the same time, there are concerns that some in-game purchase systems that use randomness, such as loot boxes, may contribute to excessive gaming behavior and psychological overinvestment in video games in general . AccordiIn April 2020, the Entertainment Software Rating Board (ESRB) and Pan-European Game Information (PEGI) introduced the Interactive Element of “In-Game Purchases (Includes Random Items)” and the Content Descriptor of “Includes Paid Random Items”, respectively. Both argued that these measures are intended to better inform consumers by flagging the random nature of certain in-game purchases Accordingly, these labels would ensure consumer protection. ,50. WhetFrom a public health perspective, the regulation of loot boxes and other microtransactions is highly pertinent, though it must of course acknowledge the commercial interests of game developers and the gaming industry. In addition, it will be important to take into account the tension between the conflicting interests of all involved parties . HoweverTo effectively address the above challenges, researchers need to understand and consider the characteristics and functioning of in-app purchases and gambling features, including how children are drawn in and which subgroups of players are most vulnerable. Thus, video games should be regulated according to classification systems that purport to relate to the harms and risks of each game. However, the methodology and processes underlying classification systems are generally not specified or made transparent, which reduces confidence in their accuracy and undermines health education messages . TherefoAnother key area of investigation is parental knowledge, as it enables effective prevention methods . HoweverReviews ,58 indicIn Switzerland, the legal draft of the Federal Act on the Protection of Minors in respect of Film and Video Games is still pending. The responsible commission decided in May 2022 to remove all regulation of microtransactions as well as a paragraph on prevention and media literacy promotion from the proposed draft. This does not seem consistent to us, given the situation as set out above and the previous debates. Admittedly, microtransactions are not game mechanics. However, the video game, as a consumer product, gives access to these microtransactions. If it is coherent to separate them from a semantic point of view, it would be unwise not to legislate for this facility. However, the consultation process has not been concluded yet.This viewpoint intends to summarize the evidence on the potential harm of certain video games (as a product) and internal mechanisms as well as inherent commercial technologies that may pose a risk for problem gaming behavior. It thus aims to inform policymakers who can use this contribution to develop adequate regulation. Given the prevalence of video games, it is surprising that they are barely regulated in Switzerland. The fact that the Swiss legislature now intends to regulate video games within the Swiss Youth and Media Act is therefore to be seen as positive. The Swiss Youth and Media Act should create a legal framework that protects children and adolescents from aggressive commercial techniques used by the video game industry. They must be protected from game design elements based on psychological mechanisms designed to encourage players to make long-term investments. The above explanations indicate that some video games can provide a pathway to gambling, as some games are designed to resemble slot machines and incorporate the same basic random choices for in-game rewards. What must therefore be emphasized at this point is that: children and adolescents should be restricted from accessing any mechanisms which fit a jurisdiction’s legal definition of gambling or which fulfil all the criteria of the psychological definition of gambling . FurtherEven if this point of view is obvious to everyone (or at least it should be), the regulation of the Youth Media Protection Act will remain a challenge. It appears that the model proposed in the draft law is based on the regulation of video content, which is not sufficiently adapted to the development and interactivity of the mechanisms of video games. However, the problem of loot boxes would be a clear risk factor amenable to regulation. The fact that Swiss legislators take rating boards such the Entertainment Software Rating Board (ESRB) and Pan-European Game Information (PEGI) into account is reasonable and important. From a prevention perspective, it would make sense if the expertise of youth media protection associations were also considered for the classification of the respective video games. In addition, to ensure compliance with youth protection regulations, test purchases are required. This obligation should be detailed at the legislative level. However, due to the difficulties in regulating purchases made online (and therefore at home), other strategies must also be explored, and in particular measures related to providing consistent and precise information. It is not possible to have an imprecise professional or political discourse on these issues.As a basis for regulation, large-scale, international, representative studies are needed to provide evidence on the prevalence and adverse health consequences of video gaming . FurtherBattle Royale (BR) game: A particular genre of video game that mixes survival and shooting games, based on the so-called “last man standing” mechanic.First-person shooter (FPS) game: Shooter video game centred on weapon-based combat in which the player experiences the action through the eyes of the character, from a first-person perspective. Free-to-play (F2P) game: Video game which can be obtained free of charge.Gaming disorder (ICD11): Characterized by a pattern of persistent or recurrent gaming behavior , which may be online  or offline, manifested by: 1. impaired control over gaming ; 2. increasing priority given to gaming to the extent that gaming takes precedence over other life interests and daily activities; and 3. continuation or escalation of gaming despite the occurrence of negative consequences. The gaming behavior and other features are normally evident over a period of at least 12 months in order for a diagnosis to be assigned. Loot box: In-game item or reward paid for with real-world money that contains randomized contents whose value is unclear at the time of purchase.Massively multiplayer online role-playing game (MMORPG): Role-playing game in which the player assumes the role of an avatar and takes control over many of its actions. This video game contains a social aspect, with players being able to interact with one another, and is characterized by a persistent world which keeps existing and evolving while the player is offline.Microtransactions: In-game payments for items or unlockable content made directly from real-world money or indirectly through the buying of virtual currency.Multiplayer online battle arena (MOBA) game: Strategy video game distinguished by two teams of players competing against each other on a battlefield with the objective of destroying each other’s main structure. Each player controls a single character with the aim of improving its abilities over the course of a game, thus contributing to the team.Pay-to-win (P2W) game: Video game that offers the player the possibility to spend money on content, items, or events which serve to advance the game.Real-time strategy (RTS) game: Strategy video game in which each player places structures and manipulates multiple units in order to secure areas of the map and/or attack their opponents’ assets. It usually features specific aspects such as base-building, resource-gathering, and indirect control of units.