The progressive complexity of mental representation is the basis for changes in human cognitive development. Evaluation of its external manifestations as graphic representation in drawings could be an instrument to understand changes in cognitive development and representational complexity. The aim of this study is to evaluate the appearance and role of the indicators used by children to represent moving figures in their drawings. This allows us to know the continuum from its non-manifestation to full expression through the vectorial interrelationships of the graphic indicators in each of the ages studied. Participants were n = 240 children from 5 to 8 years old; their drawings of two moving figures were analyzed, applying the polar coordinate technique. Results show a map of interrelations among the graphical movement indicators and changes in the drawing elements in an increasing continuum of complexity and the roles conferred to figures sketched. The conclusion is that changes evaluated in drawings can interactively reflect mental representation, and they could promote its transformation. The applied transfer of the results to education is discussed, in order to optimize the representational complexity and cognitive development. Understanding human development and the successive emergence of competencies is exciting, because it allows us to grasp the complexity of the processes involved in the organic base (the brain), from which the human mind progressively emerges, along with the progressive knowledge of the world, the resolution of tasks, language and decision making, among other skills.One of the most promising current interdisciplinary approaches to investigate and understand cognitive development is neuroconstructivism , a frameThe internal representations of physical and social reality built from the beginning of life are progressively modulated and expressed through external representational systems such as drawing or writing, which allow us to manifest what is known about the environment, while being influenced by them. Therefore, representations about the world are dependent on the environment they model , while tOne way to study mental representation is through the external manifestation of this internalized reality, and a child’s drawing is the first notation that allows it, showing how and what is known about reality. Despite the fact that movement is an inherent possibility of objects and situations that the newborn preferentially captures, allowing an object and its movements to be identified, as well as its shape and position ,4,5,6, tThese initial graphic representation modes of forms (configurative) and actions (dynamic) interact with each other, expressing events as continuous processes in time and space. With their development, children represent their thinking about shapes and movements through a series of drawings, or in one, and sometimes with functional dependence between the description of the movement and the description of the form, a reflection that their representation is composed by coding various aspects of the object or event, represented in different axes or vectors. Other times, it is the result of knowledge about how to represent them .The significant representation of movement in children’s drawing emerges between the ages of 5 and 6 ,10, implAmong the existing qualitative studies, those carried out ,13 standRecently, the development of drawing has been related to executive functioning and its core components , highligThe results indicate that children from 4 to 6 years old are capable of drawing differences in the activity of the figures, adding new distinctive characteristics from ages 6 to 10, which could be facilitated by instructions from ages 7 to 9 ,24. WithOn the other hand, ref.  found thThe changes in drawing involve three resources: the availability of external models, the endogenous changes in mental representations and the theory of the graphic representation of inexperienced children . This suConceptual and procedural flexibility can emerge earlier than expected . ThroughIn summary, drawing is a complex skill that involves biomechanical, graphomotor, perceptual, cognitive and social developmental skills  and is tThus, the study of the emergence and development of movement in children’s drawing is an instrument that allows us to evaluate the graphic representational processes as indicators of the changes in the child’s cognitive development, a functional reflection of the transformations in their mental representation of reality, especially between 5 to 8 years of age. Therefore, capturing the signs of movement in a continuum of changes and transformations will allow inferring the underlying representational mental restructuring ,35.In accordance with the above, the general objective of this work is to evaluate the differences in the objective indicators used by children from 5 to 8 years of age to represent movement in drawing activities, through the analysis of polar coordinates that will allow knowledge of the continuum from its non-representation towards full representation, as well as evaluating the appearance and role of movement indicators that establish the step between the two through the vector representation of the associations between them, in each of the ages under study.Participants were drawn by non-probabilistic intentional sampling among students from the second year of Early Childhood Education to the third year of Primary Education. The final sample was composed of N = 240 participants with typical development, distributed according to the age range of the study from 5 to 8 years, with n = 60 participants per age group. A total of 240 drawings were collected, with a total of 480 characters analyzed.wolf and rabbit, have their own movement, characterized by the escape of the rabbit, chased by the hungry wolf. ; (b) n = 12 categories that comprise different positions-orientations and (c) n = 49 microcategories, such as body and external indicators.To capture the movement in the drawings, a coding instrument consisting of a mixed system of field formats and category systems was adapted ad hoc; all category systems met the requirement of completeness and mutual exclusivity ,38, confRegarding the quality control of the data, both Cohen’s kappa coefficient and the generalizability study revealed that the reliability was optimal, and a highly significant goodness of fit was estimated regarding the validity of the coding instrument. This confirmed the consistency of the instrument . Due to The administration was carried out in each school group  during school hours. The administration interval ranged between 60 and 75 min. As the procedure, the story was told, focusing on the aspects of movement, and at the end the children were asked to draw it. For all participants, parents provided written informed consent in order for their child to participate in the study. Participants were informed of the confidentiality of their responses and of the voluntary nature of the study. No incentive was provided for their participation. The investigation was in accordance with the Declaration of Helsinki.The proposed observational design was Nomothetic/Punctual/Multidimensional . It was The analysis of polar coordinates was proposed by Sackett ; it alloTo carry out a polar coordinate analysis, a lag sequential analysis must be previously performed , and theFor each analysis of polar coordinates, the proposal of a focal behavior is required, which is assumed, according to the study objectives, as the generator or initializer of a series of connections with the other categories, called matching or conditioned behaviors. In this study, given the breadth of the observation instrument, multiple polar coordinate analyses were carried out, specifying the respective focal and conditioned behaviors.sum statistic proposed by Cochran [The polar coordinate analysis complements the prospective (forward feeding) and retrospective (backward feeding) perspective, allowing us to know the relationships between focal behavior and conditioned behaviors. Therefore, the analysis is based on both perspectives. Sackett  ingeniou Cochran , providi Cochran , the sumsum values. In addition, we applied the same procedure  to obtain the retrospective Zsum values. In both cases, we applied the binomial test between conditional probabilities (from the coding of the drawings) and expected or unconditional probabilities (random effect). We applied this to the obtained adjusted residual values , considering the criterion behavior of the sequential behavior and the conditional behaviors in positive lags to obtain the prospective Zsum values obtained, the length and angle of each of the vectors are found, which allow graphing the interrelation between the focal behavior and each of the conditioned behaviors. The length of vectors is the distance between the origin  of coordinates Zsum and the intersection point, which corresponds to sum corresponding to the focal behavior and Y to the conditioned behavior, as well as the angle, whose trigonometric function of the sine arc is Arc sin =From the ZThe interpretation of these vectors is carried out taking into account their angle and, consequently, the quadrant in which they are located, which indicates the nature of the interrelation between the focal behavior and each conditioned behavior, and taking into account their length, which indicates the presence or absence of strength  of the association between focal and conditional behaviors.sum can have a positive or negative sign, so the “game” of signs when combining the prospective and retrospective values for each focal behavior will determine in which of the four possible quadrants  the vectors corresponding to each of the conditioned behaviors will be located, in accordance with the following provision:Each prospective and retrospective ZQuadrant I (+ +). The focal and conditional behaviors activate each other. Angle: φ = (0 < φ < 90). Quadrant II (− +). The focal behavior inhibits and is activated by the conditional behavior. Angle: 180 − φ = (90 < φ < 180).Quadrant III (− −). The focal and conditional behaviors inhibit each other. Angle: 180 + φ = (180 < φ < 270). Quadrant IV (+ −). The focal behavior activates and is inhibited by the conditional behavior. Angle: 360 − φ = (270 < φ < 360). Ultimately, all the vectors corresponding to each of the conditioned behaviors in relation to the focal behavior considered can be drawn, as well as the selection of the significant or very significant ones, as has been done in this study. Thus, a powerful statistical technique is incorporated that allows to methodologically solve those of the observation instrument.https://jairodmed.shinyapps.io/HOISAN_to_R/ access on 30 June 2019).The analysis of polar coordinates is carried out using the free program HOISAN 2.0  (Universp < 0.001) between focal and conditione behavior).The results report stable patterns of behavior (or graphic indicators) in the representation of movement in the drawing between the selected focal behaviors and the rest of the behaviors collected in the observation instrument as macrocategories, categories and microcategories. Given the number of behaviors and the profusion of significant relationships, the focal behaviors with the most significant vectors were selected, which allows grasping the underlying representational processes through external graphic indicators of changes in children’s cognitive development.  age, considering the highest number of significant relationships in each of the study categories; (b) who is the most active character in the drawn story.static predominates with the rabbit and the movement macrocategory predominates with the wolf in the drawing. Within the static macrocategory, the relationships between the graphical indicators of movement that are mutually activated predominate; in the indication macrocategory, the focal activates and the conditioned one inhibits; in the movement macrocategory, the focal inhibits and the conditioned one activates.At 5 years of age, the macrocategory static, the character with the highest number of significant vectors is the rabbit, with six significant relationships. In the behavioral map estimated from the focal behavior vertical-front crossed arms (evfbcr), it is observed that the relationship of prospective and retrospective mutual activation with three conditioned behaviors predominates  , and the conditioned one is inhibited (ihpcficecg).movement, it is also the wolf that reports the most significant relationships between the graphical indicators. The most represented relationships are retrospective activation and prospective inhibition between the focal behavior vertical-front face profile (mvfcp) and the conditioned ones .In the representation according to the macrocategory static and indication in the rabbit and the macrocategory of movement in the wolf. Relationships in which focal and conditioned behavior are mutually activated predominate in the three macrocategories of static, indication and movement, as reflected in vertical-front dropped arms (vfbc) is mutually activated, with five conditioned behaviors . In the representation of the macrocategory indication, the rabbit is the character with the most reported indicators; the focal behavior with the most significant relationships is static body indicators with scribbles (ivficecg), with two conditioned behaviors: one relationship with mutual activation with (ivficecg) and the other with mutual inhibition with (ivpcficecg).At 6 years, the graphic representation of the predominant movement (plus significant vectors) is that of movement, it is still the wolf that presents the most significant relationships for focal behavior horizontal profile face front ears in the air (mhpcfoa), whose greatest representation occurs between the relationships in which both behaviors are mutually activated prospectively and retrospectively .Regarding the representation through the macrocategory of movement macrocategory, significantly and mutually activating the relationships between focal and conditioned behavior. On the other hand, when the graphic representation is made according to the macrocategories of static and indication, the focal and conditioned behaviors mutually inhibit each other. The character with the most significant relationships is the wolf , but the one with the most significant vectors is the relationship in which both mutually inhibit each other . In the graphic representation using the indication macrocategory, the wolf offers more significance between the focal behavior horizontal profile face front static body indicators with scribbles (ihpcficecg) and the conditioned behavior (ihpcficecg), which mutually inhibit each other. On the other hand, in the graphic representation using the movement macrocategory, the greatest number of significant vectors appears in the rabbit drawing between the focal behavior vertical arm stretched out in front (mvfbea) and the conditioned behaviors, with mutual prospective and retrospective activation with five conditioned behaviors .movement macrocategory. Statistically significant relationships are reported with a predominance in which the focal and conditioned behavior are mutually activated, which denotes that at this age the child has a greater number of resources to graphically express movement.Finally, at age 8, the predominant graphic representation is through the static and indication, there are no significant relationships between behaviors (or graphic indicators), indicating their marked decrease as a means of representation. The character with the greatest statistical significance in the graphic indicators within the movement macrocategory is the rabbit, who acquires the greatest prominence in the drawing of history, with the predominant focal behavior of vertical front arm joint flexion (mvffba) and with a high incidence of prospective and retrospective mutual activation, with five conditioned behaviors .static macrocategory predominates in the rabbit, with behaviors that are mutually activated, while the indication and movement macrocategories have less presence; they appear only in the wolf and are activated and inhibited between them. At 6 years of age, the three macrocategories of study are mutually activated; the participants draw more in static and indication, but at the same time there is an increase in graphic representation through the macrocategory of movement compared to the previous age. On the other hand, at age 7, there is a predominance in the drawing of the movement macrocategory, followed by the indication one; a mutual inhibition between static and indication and a mutual activation in the movement macrocategory is verified. At 8 years of age, the graphic representation appears mostly through the movement macrocategory, not presenting significant relationships in those of static and indication; in the movement macrocategory, focal and conditioned behavior are mutually activated.As can be seen, at 5 years, the Consequently, the evaluation of these graphic indicators shows that there is a change in the role of the characters in the story, depending on the age of the participants.movement and indication in the rabbit, at 7 and 8 years it is the rabbit that takes an active role, eliciting more movement in the wolf.As can be seen in These results show that it is possible to evaluate changes in the graphic representation of more flexible movement and according to the role of the characters in a story, through a sequence in the drawing that reflects transformations in the graphic representation of greater activity among the characters, according to the role of persecutor  or flight (at an older age). The production of signs in the drawing, with interaction of complex focal behaviors, provoke indicators of more elaborate graphic behaviors, which lead to increased flexibility in the representation of the movement with age, introducing new, more complex graphical indicators that also establish statistically significant relationships that trigger other behaviors.The results obtained offer resources to evaluate the presence and meaning of graphic indicators in children’s drawings through the way they draw movement, which can reflect changes in mental representation from 5 to 8 years old and, therefore, their derivations for learning.On the one hand, the results obtained corroborate that the need to represent movement in the characters of a story leads children to develop new resources that progressively transform their graphic scheme ,44. Likestatic indicators  through to the increase of its representation with indicators of indication, until those of movement predominate, accompanied by a change to a greater mutual activation in the macrocategories in which the child has more strategies to draw; that is, at 5 years they predominate in static, at 6 in indication and at 7 and 8 in movement.Specifically, the graphic representation of the movement follows a continuum from the predominance of its representation with face profile at 5 years to face front profile at 6, while at 7 and 8 the focal behaviors that elicit the most movement are the modification of the limbs but with more elaborate strategies by older children; specifically, at 7 years it is arm stretched out in front, the one that causes more infrequent conditioned behaviors at younger ages, such as curvature of the arm, which at age 8 became arm joint flexion as the most complex behavior evaluated in the drawings. Consequently, the graphical indicators that cause a greater representation of movement follow a growing trend of development, becoming progressively richer. This allowed us to verify which are the behaviors of graphical representation of movement that promote and facilitate the increase of movement indicators, influencing the representational changes in each of the study ages, which facilitates a differential practical application according to the moment of development.On the other hand, another interesting question derives from which are the indicators of the graphical representation of movement that promote relationships with other indicators at different ages because they allow evaluating the continuum of the transformations that take place and the introduction or the passage to other more complex indicators, flexibly; that is, what is the macrocategory that appears as the focal behavior that promotes more significant relationships with other conditioned behaviors (or graphic indicators), giving rise to more elaborate ones? According to the results, the progression goes from drawing the These results are consistent with previous studies that postulate that the arms and legs are the elements in which the greatest degree of modification is observed through more diverse solutions and that the inclination of the trunk or the flexion of the limbs of the figure to express movement are the most difficult indicators in their graphic representation ,25,30. Iindication and movement macrocategories in the profile position of the characters, in contrast to the horizontal position for the indication macrocategory. On the other hand, the front orientation in the drawing is significantly related to the representation of the static and movement macrocategories, while in the indication macrocategory it is the representation of the profile face front; this is in accordance with the results of [Another contribution of the evaluation is to know which categories of graphical indicators facilitate a better graphical representation of movement. It is interesting to note that at 5 years of age the representation predominates in the sults of  regardinsults of ,28 postuFinally, the results suggest that these transformations in the graphic representation of movement are conditioned by the content of the story, as the characteristics of the characters differentially motivate children to represent the characters with more or less movement, according to age.Specifically, at 5 and 6 years of age, the youngest draw more movement for the wolf, the figure that chases, and at 7 and 8 years it is the rabbit that runs away who is represented with more movement, corroborating the postulates of other authors such as  regardinAmong the conclusions, it stands out that drawing the movement of characters facilitates or is related to the representational change of reality, since the need to graphically express an action encourages the modification of the method that children use to draw movement ,31. ThisTherefore, evaluating the changes in the representation of movement in children’s drawings is a key aspect in the study of the acquisition of new mental representations and has important practical consequences, but it is not enough to know the isolated data of a certain behavior . For itsThe results point to statistically significant differences that support showing which are the transformations in children’s drawings as well as the adjustments in the graphic representation of movement that can indicate progress in the management of internal representations. This is thanks to the changes that reflect external representation procedures, in accordance with neuroconstructivist postulates on cognitive development, and the role of partial representations facilitating more complex changes determined by proactivity and progressive specialization .In summary, this work opens a path for didactic application for the evaluation and facilitators of representational transformations in children’s drawings from 5–6 years of age that, functionally, can promote the redefinition of internal representation, that is, cognitive change on the knowledge of reality and its organization.In conclusion, this study has made it possible to know the behaviors that act as antecedents and consequences to decipher the how and why of changes in the representation of movement in children’s drawings, allowing us to go beyond the isolated data of the differences that occur depending on the age of a certain behavior; this allows its practical application by training the behaviors that promote changes to influence the restructuring of mental representation.


Short, animated story-based (SAS) videos are a novel and promising strategy for promoting health behaviors. To gain traction as an effective health communication tool, SAS videos must demonstrate their potential to engage a diverse and global audience. In this study, we evaluate engagement with a SAS video about the consumption of added sugars, which is narrated by a child (a nonthreatening character), a mother , or a physician .This study aims to (1) assess whether engagement with the sugar intervention video differs by narrator type  and trait proneness to reactance and (2) assess whether the demographic characteristics of the participants  are associated with different engagement profiles with the sugar intervention video.In December 2020, after 4013 participants from the United Kingdom completed our randomized controlled trial, we offered participants assigned to the placebo arms  the choice to watch the sugar intervention video  as posttrial access to treatment. We measured engagement as the time that participants chose to watch the 3.42-minute video and collected data on age, gender, education status, and trait reactance proneness. Using ordinary least squares regression, we quantified the association of the demographic characteristics and trait reactance proneness with the sugar video view time.Overall, 66.43% (n=1047) of the 1576 participants in the 2 placebo arms voluntarily watched the sugar intervention video. The mean view time was 116.35 (52.4%) of 222 seconds. Results show that view times did not differ by narrator  and that older participants  watched the sugar video longer than younger adults . View time remained consistent across education levels. Participants with low trait reactance (mean = 119.3 seconds) watched the intervention video longer than high-trait-reactance participants (mean = 95.3 seconds), although this association did not differ by narrator type.The majority of participants in our study voluntarily watched more than half of the sugar intervention video, which is a promising finding. Our results suggest that SAS videos may need to be shorter than 2 minutes to engage people who are young or have high trait proneness to reactance. We also found that the choice of narrator  for our video did not significantly affect participant engagement. Future videos, aimed at reaching diverse audiences, could be customized for different age groups, where appropriate.German Clinical Trials Register DRKS00022340; https://www.drks.de/drks_web/navigate.do?navigationId=trial.HTML&TRIAL_ID=DRKS00022340RR2-10.2196/25343 Engaging the public in the care and maintenance of their own health constitutes a longstanding challenge for health communicators, health educators, and public health agencies worldwide ,2. InnovAs with all persuasion strategies, optimal engagement with SAS videos may be limited by a motivation to reject the health message—a phenomenon known as reactance . As a thIn a recent study, we investigated whether a child narrator reduced reactance to a SAS video about the consumption of added sugars . In the In this study, we investigate the role of trait reactance proneness and demographic factors in voluntary engagement with the sugar intervention video narrated by the child, the mother, or the physician. The participants (n=1576) are those who were initially randomized to the content placebo (the sunscreen SAS video) or the placebo (the earthquake SAS video) arms in the main trial and who were then offered the intervention video as posttrial access to treatment . We defiThis was a randomized controlled trial (RCT) with posttrial access to the treatment stage . In the Both trials (main and post) were hosted and run on the Gorilla platform (Cauldron Science Limited)  and partThe Gorilla algorithm randomly assigned participants to the 5 arms in the main trial and to the 3 intervention arms in the posttrial stage. Since the recruitment took place on the Prolific platform, it was not possible to identify or link data back to the participants. Participants responded to the survey questions and submitted their responses anonymously through the Gorilla platform. Both the study subjects and the investigators had no knowledge regarding the allocation status of the participants.All participants underwent a process of informed consent on the Prolific platform. The consent form explained the purpose of the study, the risks and benefits of the research, and how to contact the study investigators. By clicking the link, participants agreed to participate in our study and were redirected to the Gorilla platform, where additional information was given. Participants could leave the research study at any time.Here, we provide some basic details of the main trial to give context to our posttrial study. Further details of the main trial and its procedures can be found elsewhere .At the beginning of the main trial, participants were asked to answer demographic questions about their age, gender, and highest educational attainment. Participants were then randomized to the sugar intervention arm, the content placebo arm, or the placebo arm, where they watched a SAS video from start to finish.The sugar intervention video was narrated in English, with a duration of 3 minutes and 42 seconds. Its aim was to boost knowledge about the health consequences of consuming added sugars -30. The For this study, participants who were randomized to the content placebo video or placebo video were then given the option to watch the sugar intervention video . Participants could watch the sugar video or end the study without watching the sugar video. If participants chose to watch the sugar video, they were asked on the next page to click the Play button or click the Finish button at any time to end the survey. The participants were informed that they would not be compensated for the additional time taken to watch the sugar video.The primary outcome of this study was participant engagement, measured as the total time (in seconds) spent watching the SAS sugar video. We also collected data on the participants’ age, gender, and educational status. We further considered the role of the participants’ propensity toward reactance and its effect on view time. To measure trait reactance proneness, participants answered 11 questions based on the Hong Psychological Reactance Scale . The queTo quantify the participants’ engagement, we used the graphical experiment builder in Gorilla that records a timestamp whenever a new screen is displayed. In our case, Gorilla registered the moment when the participant reached the instruction screen of the final task as the first timestamp, the moment when they entered the video screen as the second timestamp, and the moment when they ended the experiment as the third timestamp. Gorilla also recorded loading delays of more than 10 seconds.engagement time as the difference between the third timestamp and the second timestamp. The resulting variable was reported in seconds between 0  and 222 . We used 5 ordinary least squares regression models to investigate which sociodemographic factors and narrator’s voice were associated with engagement time. Model 1 included narrator, a categorical variable that equaled 1 if the participant was randomly assigned to watch the sugar video narrated by the preadolescent daughter, 2 if the narrator’s voice of the video was the mother’s, and 3 if it was the physician’s. Models 2-4, respectively, added age, gender, and education completed, which were all categorical variables. We included each categorical variable nonparametrically in our model as a set of dummies. Model 5 added the participants’ trait reactance proneness mean score, which is a continuous variable between 0 and 5. The methodology for calculating the participant’s trait reactance proneness mean score is described in the study protocol [Participants who spent less than 3 seconds on the video screen were grouped together with participants who did not watch the SAS video. Among participants who chose to watch the SAS video, we quantified the length of time spent watching the sugar video. We defined the dependent variable protocol .We dropped observations that had missing values and performed all statistical analyses using Stata software version 14.2.P values stem from chi-squared tests and provide evidence that the randomization was successful.Between December 9, 2020, and December 11, 2020, we recruited 4159 participants for the main RCT. The main trial design is shown in P<.001, P=.07, A total of 1047 (66.43%) of the 1576 participants chose to watch the sugar video. Among these participants, the average time spent watching the sugar video was 116.35 (52.4%) of 222 seconds. To see view time as a function of trait reactance proneness for the child, mother, and physician narrators, adjusted for education level, please see In this web-based RCT, we assessed participant engagement with a SAS video about added sugar consumption. We hypothesized that participants with higher levels of trait reactance proneness would watch the SAS video for a shorter period and that younger participants (aged 18-24 years) would have higher engagement with the sugar intervention when compared with older participants (aged 25-59 years). Overall, 66.43% (1047/1576) of the participants voluntarily watched the sugar intervention video with an average view time of 116.35 (52.4%) of 222 seconds. We observed that participants with low levels of trait reactance proneness watched the video longer, whereas contrary to our expectations, older participants watched the intervention video longer than younger participants.As stated, our results show that the majority of the 1576 participants chose to engage with the intervention video and watched, on average, more than half of the video. In recent years, an ever-increasing number of offerings, including high-budget entertainment productions, have competed to occupy our leisure time. The degree of voluntary engagement seen in this study, despite a comparatively low-budget, SAS health video, underscores the potential for this health communication modality. The engagement documented in our study also far exceeds patient engagement with print-based health communication materials distributed in health care settings . In 1 suWe examined the role of trait reactance proneness on participants’ view time, which has been shown to be an obstacle to successful health promotion campaigns . BecauseIn the main trial, we investigated the role of the narrator on reactance to the sugar video. Since previous studies have shown that individuals may perceive doctors as coercive or overly directive , we firsSince the SAS video was designed for rapid distribution on social media channels, we expected higher participation from younger participants (aged 18-25 years). Surprisingly, we found that older people (ages 25 years and more) watched the video, on average, longer than younger participants. This result might be explained by the perceived vulnerability among older adults, that they are more likely to suffer from health problems that are associated with an excessive consumption of added sugar. Furthermore, longer viewing times in older adults might also be connected to differences in information processing or the perceived seriousness and involvement in the study. Younger participants  are less risk averse and more accustomed to engaging with extremely short forms of content ,39. AnotA key strength of this study was the use of an RCT design, which allowed us to reduce any systematic differences and bias through randomization. In addition, the use of an online recruitment platform helped us reach a large sample size, ensuring the quality and reliability of the results. We are not aware of any other study that had such a large sample size and used a similar experimental approach to examining participant engagement in the field of public health. Arguably, this posttrial stage of our RCT enabled us to capture participants’ voluntary willingness to watch a SAS video without any financial compensation. Although this condition is similar to the real world, we acknowledge that participants’ responses may have been affected by their awareness of being in a scientific study and that their actions were being recorded for scientific purposes. Nevertheless, outside of a scientific study setting, we report anecdotal evidence of willingness to engage in our sugar intervention video. After our RCT, the child-narrated version of the video was posted on the creator’s (author MA) YouTube channel, where it reached 3700 views in the first 48 hours after its release.Our study had several limitations. Given the online setting of our study, we were not able to determine whether participants actively watched the intervention video (it may have been playing in the background while the participant was engaged in other activities). Given the posttrial phase of our study, we were only able to evaluate the role of demographic factors and trait proneness reactance on participant engagement with the sugar intervention video. We acknowledge that other factors could have affected the time that participants spent watching the sugar intervention video, such as the perceived threat of the message, the perceived threat to health, the perceived risk of adopting an alternative behavior, and anger and negative cognition toward the sugar message see . In futuSAS videos demonstrate potential for engaging diverse audiences and thereby enhancing the distribution of health education messages. Designed to be emotionally arousing and culturally neutral, SAS videos can facilitate public health efforts to promote healthy behaviors and meet audiences where they are across the media landscape. The evidence from this study demonstrates promising engagement with the SAS health messaging modality, across diverse audiences. As these audiences spend increasingly more time online, the need for innovative approaches to engaging them also increases. Even the most accurate and clear health messages have little value if they fail to reach their target viewers. For this reason, researchers and health communicators of the future will need to understand how to optimally engage their audiences and research in this field should be a high priority.


Background: Previous work has indicated that pubertal timing and parenting styles are associated with adolescents’ drinking behavior, but studies on the relationship between the above three variables are lacking. Methods: Participants were 1408 Chinese adolescents aged 11–16 years old (46.52% girls). The data emphasized pubertal timing, parenting styles, drinking behavior, and socioeconomic and demographic characteristics of the adolescent and his or her family. Results: Early pubertal timing was related to drinking behavior; however, parenting styles played a moderating role. For male adolescents, father emotional warmth, mother rejection, and mother emotional warmth moderated the relationship between early pubertal timing and drinking behavior. For female adolescents, mother rejection, mother emotional warmth, and mother over-protection moderated the relationship between pubertal timing and drinking behavior. Conclusions: Parenting styles that include emotional warmth, rejection, and over-protection appear to influence the negative outcomes associated with early pubertal timing, and may be useful in reducing adolescents’ drinking behavior. Puberty is the transition from childhood to adulthood. As a critical developmental milestone, puberty is notable for its rapid and near-simultaneous transformation across biological, social, and psychological domains. As physical appearance matures, individuals often necessitate a reorganization of identity and self-perception . PubertaPubertal timing is influenced by both genetic and environmental factors . The majContextual amplification theory posits that the interaction of contextual factors (including family environment) and pubertal timing will affect the risk of problem behaviors among adolescents. This theory holds that the family environment plays a moderating role between pubertal timing and externalized problem behavior, and emphasizes the interaction between the family environment and pubertal timing. Family environment, as an important contextual factor for adolescent development, can be regarded as both a risk factor and a protection factor . If the Existing research indicates that early pubertal timing and parenting styles might influence drinking behavior in youth. Adolescence is a time of vulnerability and adjustment, when impulse control is still relatively immature. The risk of adolescence drinking is positively associated with authoritative, disengaged, or harsh parenting; parental provision of alcohol; and favorable attitudes towards alcohol use and drinking/misuse . On the Evidence suggests that cultural norms might influence the relationship between parenting styles and behavior problems in youth ,29. ExamThere were gender differences of the relationship between pubertal timing and adolescent drinking behavior. Girls who mature early are twice as likely to try drinking as those who mature with average timing or relatively late. Girls who mature early had a higher rate of drunk behavior than girls who mature with average timing or relatively late. Association with deviant peers is the intermediary variable between girls who mature early and drinking, whereas parental monitoring is the protective factor . HoweverWe recruited a total of 1408 adolescents, all of whom were between 11 and 16 years old. A cluster sampling method was performed to choose classes from eight middle schools in Changsha, Yueyang, Hengyang, and Huaihua in the Hunan province of China, totaling 1540 students as potential participants. There were no immigrants in the sample.Demographic information for the study was obtained by questionnaire questions, including age, gender, grade, school, residential address, parental marital status, parents’ education level and occupation, and number of siblings.Pubertal timing was measured by the Pubertal Development Scale (PDS). This scale is a noninvasive self-report measure of pubertal development. It consists of five items: age at menarche, breast growth in girls, deepening-voice and facial hair growth in boys, body hair growth, and growth spurt and skin changes  in both genders. Response options were: “not yet started” (1 point), “barely started” (2 points), “definitely started” (3 points), or “seems finished” (4 points). In addition, females were asked about menarche; either no (0 point) or yes (1 point). A higher PDS total score indicates earlier pubertal timing among peers. This scale has good validity and reliability, with Cronbach’s α ranging from 0.68 to 0.83, and in this study, it was 0.681. Chan and colleagues  translatParenting style was measured using the Short-form Egna Minnen av Barndoms Uppfostran for Chinese (s-EMBU-C). This scale was translated and revised from Egna Minnen av Barndoms Uppfostran (EMBU)  by JiangDrinking behavior was measured using the Adolescents’ Drinking Behavior Surveillance System, which refers to the Youth Health Risk Behavior Surveillance System (2005). It has 3 items: the first item was “How many days have you drunk more than 1 glass in the past 30 days?”; the second item was “How many days have you drunk more than 5 glasses in the past 30 days?”; The third item was” How many days have you been drunk in the past 30 days?”. The answers were: (1) never; (2) 1–2 days; (3) 3–5 days; (4) 6–9 days; (5) 10–19 days; and (6) more than 20 days. Responses were categorized into “no” (response 1) or “yes” . This categorization method was shown to be effective in revealing adolescents’ drinking situations in the existing study .Prior to study participation, all participants gave written informed consent, including written parental consent. The study was approved by the Ethical Committee for Scientific Research in the Hunan Normal University. Surveys were conducted in June 2021. Student participation in the survey was voluntary. Surveys were administered during class time by the research staff. To ensure confidentiality, all questionnaires were completed anonymously. Participants were told that if they were uncomfortable with the answers, they could choose not to respond to the questionnaire or any of the questions on the questionnaire.All analyses were conducted in SPSS version 22.0 . Respondents who answered “yes” in the first item (drunk more than 1 glass in the past 30 days) are considered as “tried drinking individuals”; those who answered “yes” in the second item (drunk more than 5 glasses in the past 30 days) are considered as “heavy drinking individuals”; whereas those who answered “yes” in the third item (have been drunk in the past 30 days) are considered as “drunken individuals”. Twelve groups were identified based on gender and age. Three perceived pubertal timing groups were defined, consistent with prior descriptions in the literature: Early (>1 SD above the mean for the same age and sex peers), Average (within 1 SD from the mean), and Late (>1 SD below the mean) . Table 1Firstly, descriptive statistics were used to report the frequencies. Secondly, chi-squared tests and Pearson correlations were used to investigate individual differences in main variables and the association between pubertal timing, drinking behavior, and parenting styles. Finally, hierarchical linear regression analyses were examined to investigate the direct predictive effect of pubertal timing and parenting styles on adolescent drinking behavior, and parenting style as a moderator of the association between pubertal timing and adolescent drinking behavior. Before testing possible moderation effects, pubertal timing scores were centralized  .All data were reported by the adolescents in the current study, and to estimate the common method variance, we used Harman’s single-factor test . Factor n = 503), whereas 64.28% of them came from rural areas (n = 905).Complete data were available from 1408 students (753 boys and 655 girls), resulting in a 91.43% response rate. In terms of demographic data, 35.72% of the participants came from the city (n = 1408), as well as pubertal timing differences in drinking groups. During the month preceding the study, among boys, the tried drinking rate was 32.01%, the heavy drinking rate was 13.55%, and the drunken rate was 7.84%. Among girls, the tried drinking rate was 23.51%, the heavy drinking rate was 7.02%, and the drunken rate was 3.36%. Moreover, there were gender differences , grade differences , and hometown differences  within the different levels of drinking. χ2 boys = 6.94, p < 0.05; χ2 boys = 23.58, p < 0.001; χ2 boys = 12.80, p < 0.01; χ2 girls = 22.19, p < 0.001; χ2 girls = 31.01, p < 0.001; χ2 girls = 14.49, p < 0.01).A higher PDS total score indicates earlier pubertal timing among peers. There are four levels of the adolescents’ drinking behavior in the past 30 days: “0” indicates there is no drinking behavior at all; “1” indicates one type of drinking behavior ; “2” means two drinking behaviors; and “3” means three drinking behaviors. Therefore, a higher score indicates more drinking behaviors .Bivariate correlations among primary study variables are reported in Hierarchical linear regression analyses were conducted to evaluate the moderating effects of parenting styles  between pubertal timing  and adolescents’ drinking behavior.β = 0.18, p < 0.001) than for those with a low level of mother rejection  than for boys with a high level of father emotional warmth and mother emotional warmth  than for girls with a low level of mother rejection and mother over-protection  and low mother emotional warmth groups , PDS can significantly and positively predict girls’ drinking behavior (β = 0.10).Among girls, as shown in behavior . HoweverThe current study investigates parenting practices as a moderator between early pubertal timing and adolescent drinking behavior. The results show that adolescents’ early pubertal timing correlates with more drinking behaviors, which is consistent with the previous studies ,32,40. TBy exploring the moderation relationship, we identified several explanations for the pubertal-timing–adolescent-drinking association, so we can speak more directly concerning the different perspectives on changing family contexts. We found that for different genders, the mechanism of parenting styles regulating the relationship between puberty timing and adolescent drinking behavior is different.For boys, paternal emotional warmth and mother rejection moderated the effects of pubertal timing on alcohol use. High paternal emotional warmth could lower the drinking risk in early developing boys, whereas high mother rejection may increase drinking risk in them. This study verified that paternal emotional warmth is an important psychological resource for boys to deal with incidents and social pressure, and the emotional connection with parents and important others can buffer the negative impact of disadvantages to a certain extent. Father emotional warmth felt by boys has a very special significance. On the one hand, it is because fathers play an irreplaceable role in the growth of boys, and affect gender roles, moral development, deviant behavior, social adaptation, and so on . On the In female adolescents, mother rejection, mother emotional warmth, and mother over-protection moderated the relationship between pubertal timing and drinking behaviors. Results from simple slope testing show that a low level of mother emotional warmth increases female adolescents’ drinking behavior, regardless of their pubertal timing status. In Chinese traditional culture, compared with fathers, mothers are more responsible for providing love and warmth to their children, and girls feel their mothers’ emotional warmth more than boys . Hence, Through analyzing the differences between gender and location, it is found that girls’ drinking behaviors are significantly less than that of boys, and the drinking behavior of rural students is significantly higher than that of urban students, which is consistent with the existing results in China . This reRural students have significantly more drinking behaviors than urban students. One reason might be that there are more left-behind children among rural students , and theSeveral of our results are consistent with previous studies. First, the current study shows that compared to on-time pubertal timing adolescents and late pubertal timing adolescents, adolescents with early pubertal timing reported a higher drinking rate ,30. SecoOur findings should be interpreted in light of a few limitations. First, this study adopts PDS to measure pubertal timing. Although self-assessment of PDS is a well-known, reliable, and valid measure of pubertal status , it coulIn summary, the findings from this study show that parenting style is a moderator of the association between pubertal timing and Chinese adolescents’ drinking behavior. Future research should continue to unpack the specific influence factors. Subsequent research should also move toward more specificity in the effect of alcohol use on future mental health. Ideally, future research may benefit from repeated adolescent reports over time as a longitudinal study, in order to explicitly examine within-individual change. Further establishing these lines of research will inform the development and dissemination of parenting interventions that directly address the needs of at-risk adolescents, and aid in reducing the impact of early pubertal timing on adolescents’ developmental outcomes.Based on prior research and the present results, it may be worth considering variations in pubertal timing and parenting styles for alcohol prevention. Schools, clinical institutions, and parents should realize that pubertal timing is not just an indicator of advanced cognitive, neurological, or social development or maturity. Early pubertal timing teenagers may be exposed prematurely to risks, and thus, need support from parents and other caregivers. Emotional connection with parents or other significant people is essential, which can help reduce the risk of problem behaviors ,60. This


In different interpersonal offense situations, ED has different effects on forgiveness. In the severe offense situation, the forgiveness level of high-ED individuals was significantly lower than that of the low-ED individuals, p = 0.023, partial η2 = 0.144; in the mild offense situation, the forgiveness level of high-ED individuals was significantly higher than that of low-ED individuals, p = 0.029, partial η2 = 0.140. The results showed that different levels of ED have no consistent effect on forgiveness in different interpersonal offense situations; high ED hinders individual forgiveness in serious offense situations but can promote individual forgiveness in mild offense situations.Forgiveness, as an important content in the field of morality, means that the offended person overcomes the negative emotion, cognition, and behavior toward the offender and replaces it with positive emotion, cognition, and behavior. Based on the theory of the limitation of psychological resources, ego depletion (ED) will lead to the weakening of self-regulation function, thus making some immoral behaviors, which is not conducive to individual forgiveness. In order to explore the influence of ED on individual forgiveness in different interpersonal offense situations, this study used the Stroop task to manipulate the level of ED and used imaginary situations to distinguish offending situations. We found that the level of forgiveness in a serious offense situation was significantly lower than that in a mild offense situation,  In real life, interpersonal offenses occur from time to time. The occurrence of offenses and the coping strategies of both sides are not only interpersonal problems but also moral problems. For example, forgiveness requires the offended to reduce revenge motivation, increase benevolence motivation, and replace negative feelings with positive emotions . As a suForgiveness can not only relieve anger, anxiety, depression, and other negative emotions, but also promote the generation of positive emotions and improve life satisfaction . It is nEgo depletion is a concept based on the theory of limited psychological resources. Based on Freud’s theory of personality structure, Baumeister et al. defined the ED as the decrease of the ability or willingness of self-participation in volitional action due to the previous exercise of will. From this point of view, any self-regulation behavior, whether it is the need to set appropriate goals, plan, implement goal-oriented behavior, evaluate the goal progress of a person, or resist the temptation to promote the implementation of long-term goals, should cause ED . Based od = 0.62), indicating the objectivity of ED effect, after controlling for the influence of publisher bias, So far, there has been a debate about the nature and stability of ED  were randomly recruited at Nanjing Normal University of China, with homogeneous variables critical to the study. Participants with a history of neurological and psychiatric disorders, who were receiving psychoactive drug therapy that could change cognitive ability, were excluded from the study. All participants had a normal or corrected-to-normal vision and normal hearing. The study was approved by the local ethics committee of Nanjing Normal University and all participants gave their written informed consent for the study and were paid for their participation.In this task, “red,” “yellow,” “blue,” and “green” were written in four colors: red, yellow, blue, and green. Then, by controlling the proportion of consistent and inconsistent color words in the Stroop task, participants had different degrees of ED . AccordiParticipants in the high ED read three serious imaginary situations and participants in the low ED read three mild imaginary situations : (1) serThe 120 participants were randomly assigned to the high-ED group or the low-ED group to complete the above Stroop task and fill in the operation check questions of ED. Before completing the Stoop task, the ED test did not actually differ between the two groups. Then, they were asked to immediately read the randomly assigned interpersonal offense situations, imagine, and complete the follow-up measurements. The response time and accuracy as well as the forgiveness score were recorded and submitted to a two-way ANOVA with an offensive situation as a within-subject factor (serious and minor) and ED as a between-subject factor (high and low). Using the Greenhouse–Geisser epsilon correction factor, we corrected degrees of freedom.t-test showed that the high-ED group reported higher ED than the low-ED group, t(118) = 3.665, p < 0.001, d = 0.473 (t(118) = 2.678, p = 0.008, d = 0.346], put in more energy , and felt more energy loss . In addition, the reaction time was longer . These data showed that the proportion control of consistent and inconsistent color words in the present Stroop task effectively manipulated the degree of ED.After completing Stroop task, the independent sample  = 0.473 . Among tt-test showed that the participants in the serious offense situation were more hurt than those in the mild offense situation, t(118) = 2.407, p = 0.018, d = 0.311, revealing that the present different interpersonal offense situations were effectively manipulated.For the test of offensive situation, the independent sample Forgiveness level consists of positive cognition, positive emotion, and positive behavior toward the offender. As shown in F < 1, but the main effect of an offensive situation was significant, F = 21.772, p < 0.001, partial η2 = 0.158. Importantly, we found significant two-way interactions between ED and an offensive situation, F = 10.175, p = 0.002, partial η2 = 0.181. Further analysis revealed that the forgiveness score of the high-ED group was significantly lower (29.5 ± 9.39) than that of the low-ED group (35.6 ± 9.63) in a severe offense situation, F = 5.286, p = 0.023, partial η2 = 0.144, whereas in a mild offense situation, forgiveness score of the high-ED group was significantly higher (44.4 ± 11.46) than that of the low-ED group (38.4 ± 10.94), F = 4.893, p = 0.029, partial η2 = 0.140.Ego depletion and an offending situation were used as independent variables and forgiveness as dependent variables. The main effect of ED was not significant, The purpose of this study was to explore the effect of ED on forgiveness, and to examine the different effects of ED on forgiveness in different interpersonal offense situations. In this study, the Stroop task was used to manipulate the degree of ED in the laboratory context, and the level of aggression was manipulated by imagining the situation and substituting the subject into the offending situation. Stroop task is the most commonly used paradigm in the study of ED e.g., . ImaginiThe present results showed that the main effect of ED on forgiveness was not significant, whereas the main effect of an offending situation on forgiveness was very significant, revealing that the level of forgiveness in a mild offense situation was significantly higher than that in a serious offense situation. The interaction effect of ED and an offending situation on forgiveness was also very significant, showing that in the serious offense situation, the higher the degree of ED, the lower the level of forgiveness, however, in the mild offense situation, the higher the degree of ED, the higher the level of forgiveness.Consistent with the results of this study in the context of a serious offense, many studies supported that ED can reduce the level of forgiveness . HoweverSeveral explanations could account for the present fact that individuals with high ED are more likely to forgive minor offenses. The first is that the higher the ED is, the less contemplation of offense is. Therefore, compared with low-ED individuals, individuals with high ED may have less negative cognition of offensive behavior. However, when the degree of ED is not high, people still have enough self-regulation resources. They may over-analyze the offense and convince themselves that forgiveness is unnecessary. Therefore, in the situation of slight offense, high-attrition individuals are more likely to forgive than low-attrition individuals, which may be because they are too tired, but they are not willing to waste energy on such trivial matters because of the minor offense. Second, It is widely accepted that self-regulation consists of two stages, one is to suppress destructive impulses and the other is to participate in constructive impulses, both of which require independent self-control. There was evidence that severe ED may impair the ability of a person to participate in both stages of self-regulation, whereas slight ED may only affect the ability of the second stage . AlthougFinally, the “sticking anchor” hypothesis may also provide an explanation for the results of this study. ED weakens central executive control and increases sensitivity to salient cues. In other words, ED enhances the influence of external cues (anchors) on behavior . Pitesa It is noteworthy that in this study, according to Baumeister’s framework , ED is rThis study explored the influence of ED on individual forgiveness level in different interpersonal offensive situations using the Stroop task to distinguish the offensive situations. We found that the level of forgiveness in a serious offense situation was significantly lower than that in a mild offense situation. In different interpersonal offense situations, ED has different effects on forgiveness. In the severe offense situation, the forgiveness level of high ED individuals was significantly lower than that of the low-ED individuals; in the mild offense situation, the forgiveness level of high-ED individuals was significantly higher than that of the low-ED individuals. The results showed that different levels of ED have no consistent effect on forgiveness in different interpersonal offense situations; high-ED hinders individual forgiveness in serious offense situations but can promote individual forgiveness in mild offense situations.The original contributions presented in the study are included in the article/supplementary material, further inquiries can be directed to the corresponding author/s.The studies involving human participants were reviewed and approved by Nanjing Normal University. The patients/participants provided their written informed consent to participate in this study.YZ and YY: data collection and the draft. LZ and YY: design and revised the manuscript. All authors contributed to the article and approved the submitted version.The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.


The reference years were compared with regard to the volume of drinking, heavy episodic drinking, having had an accident and quarrelling while drunk. The prevalence of drinking declined in both age groups during the study period. The rate of decline was somewhat higher among year 9 students. In 2018, the prevalence of drinking was the same for year 11 students as it was for year 9 students in 2005. The volume of drinking was lower among year 11 students in 2018 than year 9 students in 2005. No differences were observed for heavy episodic drinking. The decline in drinking has caused a displacement of consumption so that today’s 17–18-year-olds have a similar drinking behaviour to what 15–16-year-olds had in 2005.To examine and compare trends in drinking prevalence in nationally representative samples of Swedish 9th and 11th grade students between 2000 and 2018. A further aim is to compare drinking behaviours in the two age groups during years with similar drinking prevalence. Data were drawn from annual surveys of a nationally representative sample of students in year 9 (15–16 years old) and year 11 (17–18 years old). The data covered 19 years for year 9 and 16 years for year 11. Two reference years where the prevalence of drinking was similar were extracted for further comparison, 2018 for year 11 ( Youth drinking has been declining for two decades in Sweden ,2. This We know from previous studies that the declines in drinking have occurred across all socio-demographic groups . In SwedThe consequences of the declines in youth drinking also remain unclear; a delayed age of onset should be associated with reduced drinking later in life . One stuSeveral studies have shown contemporary and concordant changes in parenting practices and have shown that these changes are associated with the decline in drinking ,21,22. TThis study aims to examine and compare trends in alcohol consumption among Swedish 9th graders and Swedish 11th graders using nationally representative school surveys to see if trends show similar developments for these two age groups. A further aim is to compare the drinking patterns and self-reported harm in the two age groups to examine if there has been an upward shift in drinking habits as a result of the declines in youth drinking.Data on youth alcohol consumption was retrieved from a database collected by The Swedish Council for Information on Alcohol and other Drugs (CAN). CAN have conducted school surveys of alcohol consumption among year 9 students (15–16 years of age) annually since 1971. Since 2004, they have also conducted surveys with year 11 students (aged 17–18 years). The samples are nationally representative of students in the two grades. The sampling, conducted by Statistics Sweden, uses a stratified approach to ensure that all regions in Sweden are represented. School class rather than pupil is used as the unit when drawing the sample, i.e., if a class is drawn, then all students in that class fill in the questionnaire. The response rates in year 9 vary between 90 and 83% and, for year 11, between 86 and 80% . The sur(1)‘Have you ever had a drink containing alcohol?’—those reporting zero drinking occasions were categorised as non-drinkers.(2)A quantity and frequency scale for the last twelve months. These questions were asked separately for each beverage type  and then summarised into a measure of overall drinking in litres of 100% alcohol during the last twelve months.(3)Heavy episodic drinking (HED) was measured by the question: ‘How often do you drink alcohol corresponding to at least half a bottle of spirits or one bottle of wine or four large bottles of strong cider or four cans of strong beer during one drinking session?’. The response categories were ‘some times per week’, ‘some times per month’, ‘about once a month’, ‘a few times per year’, ‘more seldom’ and ‘never’. This was dichotomised into monthly or more often = 1 and less than monthly = 0.(4)Alcohol-related harm was measured using the question: Have you ever experienced any of the following problems due to your drinking of alcohol? Quarrel/Accident or injury. The response options were ‘Never’, ‘Once’, ‘twice’ or ‘three times or more’ and were dichotomised into 0 = Never and 1 = once, or more than once.The alcohol questions used in this study consisted of:n = 5423) and data from 2018 for year 11 (n = 4878). Detailed data on drinking were extracted for the two years. These were then used to compare the two years with respect to all the measures of drinking. In the final sample, 49.8% were female. Descriptive comparisons were made between the two years. Differences were tested using chi-square and t-tests. The significance level was set at p < 0.05 for all analyses. Cluster robust standard errors were used to control for the respondents being nested within school classes.In the most recent survey available to us (2018), the prevalence of drinking among 11th graders was 72.5 per cent, we then scanned the trend for the 9th graders to find a suitable year for comparison. In 2005, the prevalence of drinking among 9th graders was 71.8 per cent, and this year was then chosen as our reference year for further comparison. Data from 2005 was used for year 9  . FurtherIn 2018, Swedish year 11 students had the same drinking behaviours as year 9 students in 2005. The declines in youth drinking have shifted drinking to later in life so that today’s 17–18-year-olds drink about the same as 15–16-year-olds did twelve years ago. The long-term importance of this needs to be studied further.


Video games are expanding exponentially with their increased popularity among users. However, this popularity has also led to an increase in reported video game addiction. There may be consumer engagement–related factors that may influence video game addiction.This study aims to empirically examine the impact of the dimensions of consumer video game engagement on video game addiction. The dimensions are dedication, absorption, conscious attention, social connection, enthusiasm, and interaction. We utilize the uses and gratifications theory to study the video game engagement dimensions as potential factors through which gamers feel gratified and engaged in video game playing. Additionally, this study incorporates the cultivation theory to investigate how video game engagement factors trigger video game addiction.A two-step process was applied for data analysis on valid cases of 176 gamers aged 15-25 years: video game addiction was specified and validated as a reflective-formative construct, and hypothesis testing was later performed using the WarpPLS on valid respondents.P=.08 and interaction with P=.49, which did not significantly contribute to video game addiction.The analysis uncovered 2 dimensions of video game engagement: social connection with This study offers unique insights to a myriad of stakeholders, mostly psychologists and psychiatrists, who routinely prescribe behavior modification techniques to treat video game addiction. Video games are one of the most popular forms of leisure activities, especially for youth (as well as other age groups) across the world . The vidThe literature on video game engagement has identified various factors that affect video gaming addiction. Studies on demographics have identified that males, young age, singles (relationship), etc are more likely to develop video game addiction . IncreasLikewise, the phenomenon of video game engagement has been investigated in different studies across multiple application areas. For instance, Abbasi et al  reportedThe purpose of this study was to expand the existing research by evaluating video game addiction from the lens of video game engagement. Our primary focus in this study was to evaluate whether different dimensions of consumer video game engagement play a role in predicting video game addiction. Our study will contribute to the literature in a number of ways. First, prior studies have not accounted for engagement factors that lead to addiction ,28,29. OWe explored the theoretical framework informing our understanding of the different dimensions of consumer engagement and video game addiction. Different theories associated with motivation, communication, and media were used to establish the theoretical framework for this research. This research takes its theoretical underpinning from the Cultivation Theory and UGT ,34.The principle of UGT was coined in the early 1940s. This theory came into the light to answer some questions raised concerning traditional mass communication. This theory emphasizes that media is used to satisfy a user’s various needs, which motivates them to use that media ,36. This. Sherry et al [UGT consists of 3 constructs: (1) achievement, (2) enjoyment, and (3) social interaction. Achievement in the context of gaming can be defined as the yearning to achieve power and rewards as well as the desire to perform better in comparison to other gamers . Sherry ry et al  found thry et al . In contry et al  are inclry et al . Enjoymery et al , and it ry et al . Social ry et al . Similarry et al . Thus, UThe explanation of mass media as cultivation was introduced by Gerbner . The CulThe Cultivation Theory provides a wide lens through which long-term effects of media can be examined. The Cultivation Theory has mostly been applied to traditional forms of media such as television. Aligned with the Cultivation Theory assumptions with respect to television , this theory posits that through continuous exposure to the video gaming world, player’s views of his real-world will become more similar to that of his gaming world . For thaThe massive popularity of video games has significantly changed the gaming industry as it is one of the most booming entertainment businesses . SeveralConsumer engagement is the interaction between a customer and an organizational entity through different channels whereas engagement in consumer game-playing is a concept that signals task-oriented consumer behavior in the game setting . Video gengagement is a multidimensional concept comprising of 3 dimensions: (1) cognitive, (2) emotional, and (3) behavioral. Researchers also accentuate that different dimensions of consumer engagement are interrelated [Previous studies deem engagement as a multidimensional construct that comprises of subconstructs such as immersion ,71, presrrelated . For insrrelated  identifiBouvier et al  identifiAbbasi et al  report mVideo game addiction and video game engagement were previously used interchangeably . HoweverDedication is the affective commitment of players toward video games . Kallio H1: Dedication positively predicts video game addiction in a video game player.Absorption is defined as the degree of involvement and immersion in a given activity . CsikszeH2: Absorption in video games significantly predicts video game addiction in a video game player.Conscious attention is the attention and time allocated toward a given activity -100. ConH3: Conscious attention predicts video game addiction in a video game player.Social connection is the relationship people have with other individuals or groups . Web-basH4: Social connections significantly predict video game addiction in a video game player.Enthusiasm is defined as the extent of eagerness and interest toward a given activity ,112. EntH5: Enthusiasm significantly predicts video game addiction in a video game player.Interactions reflect the degree of involvement that individuals and other entities have in virtual game settings. So et al  report tH6: Interaction positively predicts video game addiction in a video game player.This study was quantitative and cross-sectional. This approach is relatively fast in obtaining responses to develop or validate new theories . FollowiThis study was carried out among gamers who play in gaming zones   or in orWhile collecting the data, we carefully recruited gamers who played Counter Strike–Global Offensive, PlayerUnknown’s Battlegrounds, Call of Duty, and Fortnite and proceeded for data collection. Using the self-administered approach, we distributed 250 questionnaires and 190 were returned. We assessed the data quality and removed incomplete and biased responses  . FinallyThe structural equation modeling approach was applied for analysis, which is a well-rounded multivariate statistical analysis approach ,127. StrIn the measurement model’s assessment, first, the reflective constructs were assessed in which the construct’s outer loadings, Cronbach alpha, composite reliability, and convergent validity were evaluated. According to the criteria, the outer loadings should be greater than at least 0.40, the Cronbach alpha value should be greater than .70, the composite reliability should be greater than 0.70, and the convergent validity should be greater than 0.5 ,128. TheAdditionally, the discriminant validity was evaluated applying the Fornell and Larcker (1981) criterion. The criterion suggests that the square root of the average variance extracted of each dimension must be larger than its corresponding correlation coefficient. Heterotrait-monotrait ratio of correlations is another criterion that is the most recent and recommended validity test to assess the discriminant validity for reflective constructs . The hetTo create the second-order formative construct, that is, video game addiction, we employed the two-stage approach of Becker et al  to calcut value and calculated the predictive relevance, that is, Q2 and R2 coefficient value for the endogenous constructs [P=.04, and t statistics of 1.76 with 2f=0.056. Hence, H1 was supported. For H2, the results revealed a significant impact of absorption on the consumer video game addiction with B=0.215, P=.002, and t statistics of 2.98 with 2f>=0.113. For H3, the results were supported with B=0.166, P=.01, and t statistics of 2.27 with 2f=0.079. For H4, the hypothesis was also supported with B=0.220, P=.001, and t statistics of 3.05 with 2f=0.118. For H5, the analysis results revealed that the relationship between both the constructs was insignificant with B=0.107, P=.08, and t value of 1.44. Hence H5 was rejected. Similarly, interaction with consumer video game addiction was also insignificant with B=–0.003, P=.49, and t value of 0.04. We also calculated the R2 and Q2 for the endogenous construct, that is, video game addiction, which resulted in R2=0.409 and Q2=0.413. Our results showed that the study model has sufficient explanatory capacity and predictive relevance. PLS-SEM analysis was conducted in 2 stages comprising the measurement model and structural model assessment. Once the reliability and validity of the reflective and formative constructs were ensured, researchers recommended evaluating the structural model through path coefficients, effect size, nstructs ,29,128. In this study, we intended to empirically test the theoretical model illustrating the different dimensions of video game engagement, that is, (1) dedication, (2) absorption, (3) conscious attention, (4) social connection, (5) enthusiasm, and (6) interaction in a digital game, that predict consumer video game addiction. The underlying constructs were supported by theoretical underpinnings from the Cultivation Theory  and UGT Previous research suggests various personal, emotional, and psychological needs that contribute to overindulgence in video gameplay ,134. It H1 showed the relationship between dedication and the resulting video game addiction. The results supported that there is a positive relationship between the 2 constructs. They showed that dedicated players (and attached) to the gameplay for long hours put in more energy, commitment, and loyalty than casual players ,137. H2 Social connection and interaction were hypothesized to positively affect video game addiction . However, both the constructs had no significant relationship with video game addiction. These results seem to contradict the prior literature ,140-142.The results of this study contribute to the understanding of the Cultivation Theory in the context of video games, that is, video game addiction . While tThis study offers valuable insight for practitioners in game development, psychology, and social policy as well. First, an understanding of why consumers continue to use games up to the point of addiction can highlight factors that help make games engaging. This can be used to cultivate brand loyalty as game developers roll out updates of their games. Moreover, the insignificant correlation between social connections and video game addiction will help developers understand how social bonds may not facilitate engagement for specific regions such as Pakistan, in this case. At the same time, this information can also be used to curb factors that turn repeated or prolonged usage into a harmful addiction. This can help game developers ensure that they are producing games conducive to healthy usage to meet health care and social concerns. Similarly, these findings can be used by mental health practitioners who aim to find treatment solutions for video game addictions. By understanding the aspects of video game play that leads to addiction, these practitioners may be better able to prescribe changes to playing behavior and patterns to reduce addiction. In terms of policymaking, this study helps policymakers understand what aspects of video game playing lead to the development of problematic real-life behaviors that are considered unhealthy or are discouraged.This study seeks to examine the individual effect of different dimensions of video gaming engagement on video game addiction. The findings of our study add value to the existing literature. The factors that lead to video gaming addiction can be empirically stated through the findings of this study. This research also provides valuable insights into the consumption pattern of video gamers. Future research directions could involve incorporating the psychographic mechanisms as moderators such as personality traits, values and attitudes, interests, lifestyles, and gender in understanding video game addiction . Additio


Chronic Low-Grade Inflammation (CLGI) is a non-overt inflammatory state characterized by a continuous activation of inflammation mediators associated with metabolic diseases. It has been linked to the overconsumption of Advanced Glycation End-Products (AGEs), and/or macronutrients which lead to an increase in local and systemic pro-inflammatory biomarkers in humans and animal models. This review provides a summary of research into biomarkers of diet-induced CLGI in murine models, with a focus on AGEs and obesogenic diets, and presents the physiological effects described in the literature. Diet-induced CLGI is associated with metabolic endotoxemia, and/or gut microbiota remodeling in rodents. The mechanisms identified so far are centered on pro-inflammatory axes such as the interaction between AGEs and their main receptor AGEs (RAGE) or increased levels of lipopolysaccharide. The use of murine models has helped to elucidate the local and systemic expression of CLGI mediators. These models have enabled significant advances in identification of diet-induced CLGI biomarkers and resultant physiological effects. Some limitations on the translational (murine → humans) use of biomarkers may arise, but murine models have greatly facilitated the testing of specific dietary components. However, there remains a lack of information at the whole-organism level of organization, as well as a lack of consensus on the best biomarker for use in CLGI studies and recommendations as to future research conclude this review. Diet plays a role in the induction and progression of Chronic Low-Grade Inflammation (CLGI) which has been associated with metabolic diseases such as obesity and diabetes . Some foThe clinical differentiation of CLGI is still a matter of significant debate. The main biomarkers currently used in the diagnosis of inflammation, such as C-reactive protein (CRP), are not specific to CLGI. Hence, many studies in recent decades have attempted to define CLGI biomarkers in humans and rodent models, including the proposition that clusters of biomarkers may best define the state . While CAlthough centered on diet-induced CLGI in murine models, we begin our review by considering the essential concepts of acute and chronic inflammation in order to clearly define CLGI. Thereafter, those CLGI biomarkers currently explored in the literature are presented so as to demonstrate their use in such studies, their diversity, and their limitations, and to frame the current understanding of diet-induced CLGI. The corresponding literature on diet-induced CLGI is then reviewed, including dietary AGE consumption and obesogenic diets, to elucidate the current directions in CLGI research and explore the multiple, concurrent events which shape CLGI in rodent models. Firstly, we will explore the effects of immoderate consumption of AGEs on CLGI promotion. In the following sections, the effects of high-calorie diets on CLGI and their implications for adiposity, and the neuroinflammation associated with appetite control will be presented. Findings on gut microbiota remodeling, metabolic endotoxemia, and CLGI initiation will also be discussed. Finally, perspectives on CLGI research gaps that remain to be filled will be addressed.Inflammation is part of the body’s innate and adaptive immune defenses. It comprises a series of cellular and chemical signal barriers which aim to control and conquer endogenous and exogenous stimuli  and trauma-related damage . InflammBeyond the difference in duration between AI and CI, the degree of inflammatory response also determines whether inflammation becomes pathological. Under a non-overt inflammation scenario, a chronic, but low-grade inflammatory mechanism comprehends excessive metabolic stress correlated to the rise of circulating levels of inflammation signals . Both CICompared to the chronic but severe inflammation present in arthritis or Crohn’s disease , metabolThe discovery and elucidation of the CLGI process was an important step in the comprehension of diseases currently considered to be global public health concerns . The term “low-grade inflammation” was first used in the 1980s with reference to histologic samples from schizophrenic patients in which increased glial fibrils were observed , and to Screening for systemic effects of inflammation has demonstrated that several other organs are implicated in CLGI . In the More recently, some evidence appears to suggest that the gut microbiota also plays a critical role in CLGI progression, following remodeling as a result of nutritional imbalances. The consumption of increased quantities of fats and/or carbohydrates has been demonstrated to modify the composition of the microbiota and promote permeability of the gut–mucosal barrier ,30. A reAlthough the terms “Low-Grade Inflammation” or “Chronic Low-Grade Inflammation” are used interchangeably in the literature, we here take “chronic” to be a compulsory requirement for the low-grade inflammatory stimulus to promote some sort of pathological effect. Thus, based on the extensive literature currently published, CLGI can be formally defined as a pathological state lacking overt inflammation, but characterized by continuous and unresolved activation of inflammation mediators. It results in increased production of cytokines, reactive oxygen species, macrophage infiltration, adipocyte imbalance, or vascular damage; these effects are associated with metabolically active tissues such as adipose tissue, skeletal muscle, and the liver, implicating CLGI in metabolic diseases ,31. Age-Estimating CLGI via different biomarkers could pave the way for its early detection. But aside from the key discoveries in recent decades describing the expression patterns of some CLGI biomarkers which have cemented its pathophysiological functions, the diagnosis of CLGI remains to be defined from a technical perspective. While biomarkers of CLGI have been identified, their use is hampered by, on the one hand, a lack of basal values, and on the other, detailed knowledge of their levels in a pathological context. A cluster or panel of biomarkers could best describe CLGI, and in the following section we present the biomarkers currently under investigation, with a brief description of those from human studies, and a focus on murine models.Susceptibility to, and the diagnosis, prognosis, and treatment of several diseases have all benefitted from fundamental and clinical research discoveries of biomarkers. In essence, a biomarker is a physiological, physical, molecular, or elemental indicator of a normal or pathogenic process or response. Biomarkers of CLGI so-far investigated are molecules at the local  or systemic  levels. However, as we shall see, the commonalities between the different inflammation statuses  complicate the use of a single diagnostic biomarker specific to CLGI. Cytokines, adipokines , and chemokines are important signals of inflammation but the occurrence of these biomarkers per se cannot distinguish one type of inflammation from another. In humans, along with the numerous CLGI causes, which inevitably lead to modulation of biomarker expression, a considerable inter-individual variation exists according to age, body weight, eating habits, smoking, or alcohol consumption . With soA recent systematic review of inflammation biomarkers reported that the major inflammation signals currently being explored in human intervention studies are CRP, cytokines (notably IL-6 and TNF-α), adhesion proteins such as VCAM-1 and ICAM-1, and the MCP-1 chemokine . CRP, foWhen it comes to CLGI research in rodents, a similar range of biomarkers to that in human studies is observed. The ensemble of the biomarkers explored in the literature is presented in Despite the fact that we have not attempted to be exhaustive in this review, significant diversity can be observed among the molecular biomarkers of inflammation listed in Among the publications listed in A further issue in the research of some CLGI biomarkers is the differences in the expression of certain molecules across publications. For example, the CLGI-induced disruption of adhesion molecules such as ICAM-1 and VCAM-1 is reported to result in their overexpression by different publications investigating high-fat diets (HFD) or AGE consumption ,48,49. BAdvanced Glycation End-Products (AGEs) are the result of non-enzymatic, post-translational reactions between reducing carbonyls and protein-amino groups, nucleic acids, or aminophospholipids . The forAGEs have a close relationship with inflammation and oxidative stress which is mediated by RAGE, their eponymous receptor which is part of the immunoglobulin superfamily and participates in immune surveillance in the lungs, liver, vascular endothelium, monocytes, dendritic cells, and neurons, to name only the major locations identified so far . RAGE isdAGEs have been proposed as key factors in triggering inflammation in both healthy and diabetic individuals . Among tfood). In wild-type animals receiving dCML, a dose-dependent increase in expression of VCAM-1 was observed, both histologically and in mRNA expression, while RAGE expression was increased significantly only at the protein level. The RAGE knockout animals were apparently protected from an increase in these inflammation triggers, and no significant VCAM-1 expression increase with dCML dose was reported in this genotype [Protein-bound CML is a high-affinity RAGE ligand ,84. The genotype . Such a genotype  reportedgenotype . In animgenotype . The potgenotype  comparedgenotype . Chatziggenotype  reporteddb/db mice (more insights on the dietary modulation of gut microbiota and permeability are discussed ahead) [food produced a significant change in glucose metabolism, followed by increased expression of pro-inflammatory cytokines IL-1β, IL-17, TNF-α, and a decrease in anti-inflammatory cytokines IL-10 and IL-6 over 22 weeks treatment. The influence of dietary MG-H1 on gut microbiota was evidenced in reduced butyrate-producing species such as Candidatus Arthromitus and Anaerostipes sp. in animals receiving higher levels of MG-H1 [Similar to observations in animals fed HFD, dAGEs may also play a role in remodeling of gut microbiota. Evidence from experiments on rats and C57BL/6 mice demonstrated that dietary MG-H1 had a pro-inflammatory effect as well as remodeling gut microbiota ,75. Dietd ahead) . Regularof MG-H1 . From thof MG-H1 ,49. PrevAn analytical approach employing CML isotopes has demonstrated that dCML accumulates primarily in the kidneys, but also in the ileum, colon, and lungs in a RAGE-independent manner . RAGE isA striking characteristic of dAGEs is their interference in the physiology of multiple organs and tissues. In addition to their influence on the lungs, wound healing has also been shown to be disrupted by dAGEs, especially when associated with diabetes . DiabetiHowever, a question that remains to be answered concerns the reversibility of the several physiological effects of AGE consumption as previously presented in this topic. A recent study published by Dongen et al. (2021)  demonstrThe underlying role of inflammation in obesity has been discussed for over 20 years ,92. The Obesogenic diets have been shown to increase CVD risk in humans as well as comorbidities classically associated with being overweight . A closeIt appears that under a chronic consumption of an HFD, adipose tissue promotes an increase in systemic cytokine production. Heijden et al.  observedA significant limitation for the understanding of the real effects of diet-induced CLGI is confounding factors such as the variable quality of fat among the different commercially available diets for animal experiments. It appears that not only the duration of the exposure to an HFD is important, but also its composition. Benoit et al.  hypothesReporting similar findings on the effects of macrophages in adipose tissue, some recent studies have demonstrated the role of macrophage infiltration in the hypothalamus. As stated above, the hypothalamus is a fundamental actor in appetite control, and its proper function is therefore required to maintain energy homeostasis . RemarkaThe gut microbiota is an important functional unit established in the gastrointestinal system (GIS) that has co-evolved to participate in the regulation of host homeostasis, in addition to its direct role in digestion . The colDiet is a major environmental factor in the remodeling of the gut microbiome  Table 4Table 4. A considerable body of work has addressed the effects of HFD in reshaping the gut microbiome and in metabolic endotoxemia. Cani and colleagues  were theOther consequences for gut homeostasis have been observed in DIO experiments in mice. Food fermentation by the gut flora plays a fundamental role in the production of metabolites such as short-chain fatty acids (SCFAs). Propionate, butyrate, and acetate are important SCFAs that play anti-inflammatory and immunoregulatory roles in the gut . ButyratConsidering the relevance of LPS to CI triggers, a cornerstone of the investigation of CLGI is the use of subclinical doses of LPS to mimic metabolic endotoxemia in a murine model ,131. In In addition to these findings, subclinical doses of LPS have been shown to affect the liver and adipose tissue. In male ApoE knockout C57BL/6J mice, the simultaneous administration of super-low doses of LPS with administration of an HFD resulted in the development of nonalcoholic fatty liver disease (NAFLD) steatohepatitis, followed by intense leukocyte infiltration and sustained expression of p38 mitogen-activated protein kinase (MAPK) , a molecResearch aimed at elucidating inflammatory patterns in the murine gut can therefore rely upon measures of the cytokines TNF-α, IL-6, IL-1, NF-kB, and IL-1β levels in animals receiving fat-rich diets, together with a temporal increase in systemic LPS and modified F/B ratios. Investigations which analyze these patterns may prove to be powerful predictive tools of CLGI. More recently, another useful metabolic inflammation biomarker has received attention in studies of intestinal microbial dysfunction mediation. Lipocalin-2 (LCN2) is a glycoprotein secreted by several cell types but was initially identified in activated neutrophils . LCN2 isBased on the data presented in this review, the involvement of diet in the induction and progression of CLGI has been clearly demonstrated in murine models. Since multiple factors which contribute to CLGI initiation probably occur simultaneously , a better understanding of the interaction of inflammation biomarkers in different organs and tissues would help to elucidate key biomarkers of CLGI, as well as identify the most susceptible among them, pinpointing the potential physiological implications. The murine models described in this review have shed significant light on CLGI, particularly the importance of local (tissue level) measurements of CLGI biomarkers. The use of murine models is also helping to illuminate CLGI crosstalk among different organs due to the ease of sample collection, preparation, and analysis compared with other animal models or clinical studies. Indeed, significant advances have been made in the attribution of the physiological effects of CLGI, and the identification of potential biomarkers induced by target compounds such as dAGEs and dietary lipids in these models. They have enabled the study of direct effects of key dietary influences on animal physiology, but some limitations on the translational use of future biomarkers in clinical applications between murine models and humans may arise . In the future, the current use of qualitative or semiquantitative techniques for CLGI biomarker analysis should give way to more extensive and specific analytical techniques, such as proteomics, transcriptomics and metabolomics, that could drive research on both screening and quantification of CLGI biomarkers in the whole organism.From the nutritional perspective, strategies for the prevention of CLGI are required to reduce the impacts of several metabolic diseases, as well as to promote healthy aging. A balanced diet is often recommended to maintain good health , and eviLastly, current research on diet-induced CLGI has highlighted the utility of simultaneously examining several different inflammation biomarkers. Ongoing research has confirmed the involvement of several cytokines and other inflammation biomarkers in both the initiation and progression of CLGI, but their use for the prediction, and/or determination of CLGI still lacks consensus. We remain some way from defining a clinical diagnostic test for CLGI, but future CLGI treatment may target important receptors such as TLR4 and RAGE for the prevention of CLGI initiation, and diagnostics may rely upon the recent evolution of non-invasive biomarkers . With respect to the prospection of CLGI biomarkers, candidates should be systematically investigated to fill gaps in the whole-organism picture of inflammatory responses in different organs and tissues. From the diagnostics perspective, biomarker research should integrate current knowledge on the use of multiple biomarkers able to predict CLGI more robustly.The overconsumption of AGEs  and obesogenic foods leads to several physiological effects which contribute to the onset of CLGI, and their study has contributed greatly to our understanding. Several different classes of biomarkers have been reported as important, but the levels of cytokines such as TNF-α and IL-6, as well as chemokines such as MCP-1 and adhesion molecules , are repeatedly cited as potential biomarkers in CLGI research in murine models. However, progress in this field can be only made with more robust analytical protocols. Particular attention should be paid to the quality and homogeneity of the dietary regimes employed, the simultaneous analysis of multiple organs under the same dietary protocol, and establishing both normal and pathological levels of key biomarkers already identified. Metabolomics studies that include multiple CLGI biomarkers have potential in this regard and offer the possibility of defining clusters or panels of biomarkers capable of specifically targeting this subtle, multi-layered and complex inflammatory process.