It results in greater healthcare needs in the community, including more frequent access to GP services and increased needs at home. Recent estimates suggest that the health and social care cost of malnutrition in both adults and children in England alone exceeds £19 billion, and half of this expenditure is due to people >65 years.Older patients as a group are particularly at risk, and it is a common misbelief that weight loss is an inevitable part of the ageing process. Malnutrition exacerbates the age-related decline in muscle mass and strength, leading to sarcopenia, which can contribute to frailty.,2National Institute for Health and Care Excellence (NICE) guidelines recommend that GPs screen patients on registration and when there is cause for any clinical concern.6,current weight status using body mass index;unintentional weight loss — there is evidence that a weight loss of 5–10% can produce physiologically relevant changes in body function;acute disease effect producing or likely to produce no nutritional intake for >5 days.The MUST was developed by the multidisciplinary Malnutrition Advisory Group of the British Association for Parenteral and Enteral Nutrition (BAPEN).2Each parameter is scored on a scale of 0–2. Based on the score, the patient is defined as belonging to a low (0), intermediate (1), or high (≥2) risk of malnutrition group. Those identified at medium or high risk should have a nutrition management care plan devised using the malnutrition pathway.Despite these recommendations, it would appear that malnutrition has attracted little attention in primary care, and screening using validated tools is not routinely included in care planning for over-75s. The reasons for this could include lack of knowledge and training within primary care; a focus on overeating and obesity as the major health need for the population; lack of leadership or ownership from GPs who perhaps regard this as a role for practice nurses or dieticians; lack of resources; funding pressures; and an over-burdened clinical agenda.32). Of the 12 underweight patients, only one (8%) had a MUST score undertaken and four (33%) had documentation of receiving dietary advice; three (25%) had been referred to a dietician and four (33%) were prescribed ONS. Within this group, there were high rates of primary care consultations, with an average of 12 nurse contacts/year, due largely to high rates of pressure sores and ulcers in these patients. These data are consistent with other reports that show patients are not being adequately screened for malnutrition using validated tools (such as MUST), and clinical management could be better.Two authors undertook a retrospective review in their own practice, which is a small GP surgery in Dorset with a relatively high population of older people, with 539/3797 (14.2%) registered patients >75 years. It is an accredited ‘Dementia Friendly’ surgery, and is a teaching practice with high Quality and Outcomes Framework ratings and good patient satisfaction ratings. Of the 539 patients, there were 411 (76%) who had a BMI recorded in the last 2 years, and 12 (3%) of these patients were underweight , and commissioners need to consider incentives,http://www.malnutritiontaskforce.org.uk/) and BAPEN (http://www.bapen.org.uk/).To date, there have been a number of initiatives to address the problem of malnutrition such as the work undertaken by the Malnutrition Task Force  toolkit. Materials are free to download.12


Prestrobilurin A, formed via benzoate and cinnamate, has been identified as the first enzyme free intermediate in strobilurin biosynthesis. via a linear tetraketide, primed with the rare benzoate starter unit, itself derived from phenylalanine via cinnamate. Isolation of a novel biphenyl metabolite, pseudostrobilurin B, provides evidence for the involvement of an epoxide in the key rearrangement to form the β-methoxyacrylate moiety essential for biological activity. Formation of two bolineol related metabolites, strobilurins Y and Z, also probably involves epoxide intermediates. Time course studies indicate a likely biosynthetic pathway from strobilurin A, with the simplest non-subsubstituted benzoate ring, to strobilurin G with a complex dioxepin terpenoid-derived substituent. Precursor-directed biosynthetic studies allow production of a number of novel ring-halogenated analogues as well as a new pyridyl strobilurin. These studies also provide evidence for a non-linear biosynthetic relationship between strobilurin A and strobilurin B.The strobilurins are important antifungal metabolites isolated from a number of basidiomycetes and have been valuable leads for the development of commercially important fungicides. Isotopic labelling studies with early and advanced intermediates confirm for the first time that they are produced  Many other strobilurin analogues have been isolated from other basidiomycetes. Structural variations include oudemansin A 4 from Oudemansiella mucida in which the central 9/10 double bond of the triene system has formally had methanol added,5 from Flaviolaschia sp. which contains a methyl enol ether6 from a Petrula sp. containing a hydroxymethyl.e.g. strobilurin G 7 from Bolinea lutea.8 in which the methoxyacrylate substituent of strobilurin A has been replaced by a methyl 3-hydroxy-propionate moiety has also been isolated from B. lutea.9Strobilurins are a group of bioactive metabolites produced by various fungi.The key β-methoxyacrylate toxophore targets the Qo site of complex III of the mitochondrial electron transport chain and prevents ATP synthesis.2 and 3 with the aim of increasing photo-stability and selectivity. Thus, compounds such as azoxystrobin 9 (Syngenta) and Kresoxim-methyl 10 (BASF) are among the most widely used fungicides worldwide, used as effective treatments against a broad range of destructive fungal plant pathogens.11 and cyrmenin A 12 from the myxobacteria, Myxococcus fulvus and Cystobacter armeniaca respectively.The biosynthesis of the strobilurins, particularly that of the β-methoxyacrylate toxophore, remains obscure despite the fact that the strobilurins and analogues are amongst the most commercially important fungal metabolites known. Early labelling studies on mucidin were consistent with a polyketide produced from a benzoate starter, itself derived via phenylalanine, extended by successive condensations with three malonates, and a C-methylation from S-adenosyl methionine (SAM).13C]-acetate suggested that rearrangement of an originally linear polyketide chain occurs. B. lutea has been described as the only ascomycete to produce the strobilurin/oudemansin family of metabolites.1713C]-acetates, [methyl-13C]-methionine, [2H8]-, [3-13C]- and -phenylalanines, supplemented to cultures of S. tenacellus and B. lutea resulted in the production of isotopically enriched strobilurin A 2 Sorangium cellulosum)Feeding studies using singly and doubly labelled -cinnamate both as the free acid 23 and its SNAC thiol ester 24. SNAC thiol esters have been commonly used in studies of polyketide biosynthesis to mimic the thiol ester linkage of co-enzyme A and acyl carrier protein (ACP) and are usually incorporated into biosynthetic pathways more readily than the parent carboxylic acids.23 was incorporated significantly more efficiently (85%) than the SNAC thiolester 24  have a trans-acting stand-alone ER domain15–17 shown in 16 and 17 to cultures of B. lutea. To aid metabolite analysis they were synthesised with a fluorinated phenyl ring as fluorine has been demonstrated to be a useful tracer for biosynthetic studies.Z,4E isomer of 2-methyl-5-phenylpenta-2,4-dienoic acid 26 and its SNAC thiol ester 27  15.Both precursors 18  to H-5. The 19F NMR spectrum shows a signal at –114 ppm as a double, double, doublet with the same coupling constants  with the correct molecular ion ([M + H]+ 280 Da) for the trideuterio-labelled analogue of 3-fluorostrobilurin 36 to indicate intact incorporation of 30. The structure was again confirmed by full NMR analysis. The 19F NMR spectrum was identical to that previously obtained for 36, as was the 1H NMR spectrum except for the absence of the signal at δ 1.98 ppm for the three protons of the 14-methyl. This confirms that tetraketide 17 is indeed the final enzyme-bound product of the strobilurin PKS.Z isomer 33 was also synthesised and fed as a 5 : 1 mixture with the 2E isomer. A small incorporation into 36 was observed, but this is likely to have been due to the small amount of E-isomer present in the fed mixture.‖The 2As the trienoic acid bilurins  as discuer of 30  with a t18 (thus named prestrobilurin A) to strobilurin A is proposed to proceed via epoxidation and rearrangement to give aldehyde 21, enolisation to 22 and methylation forming the β-methoxyacrylate moiety  we observed a minor peak eluting after strobilurin B 3 with a molecular ion [M + H]+ 291 Da with a 37Cl isotopic peak at 293 Da. We purified this metabolite by preparative HPLC, and isolated 0.8 mg of pure compound for NMR characterisation. Signals for a 3-methoxy-4-chloro-phenyl ring as in strobilurin B 3 were evident, but those for the triene side chain were absent, being replaced by signals consistent with the presence of a second 1,2,4-trisubstituted aromatic ring. COSY and HMBC correlations  with UV characteristics typical of strobilurin A and B. These were isolated and their structures 41 and 42 determined from their mass spectra and full NMR analysis  of 8–30% with 2-fluorostrobilurin 48 consistently the poorest yield. The 3,4 and 3,5-difluoro-analogues 50 and 51 were formed from the corresponding benzoates, and feeding 3-fluoro-4-methyl- and 3-fluoro-4-methoxybenzoates gave the corresponding fluorostrobilurins 52 and 53. Feeding of nicotinic acid gave the novel 3-aza-strobilurin A analogue 60 and supplementation of the medium with KBr produced the bromo-analogue 4-dechloro-4-bromostrobilurin B 56. Other attempts to introduce halogens, e.g. by supplementation with chloride, bromide or iodide, or by adding chloro- or bromobenzoates gave only trace amounts (by LCMS), at best, of alternatively halogenated compounds. Similar results were observed in feeding a range of aromatic analogues to squalestatin-producing cultures of Phoma sp.However, feeding of 2-, 3- and 4-fluorobenzoate/cinnamate gave the corresponding fluorostrobilurins B. lutea F23523, feeding of 2-fluorocinnamate gave an interesting result. Production of strobilurin A 2 was completely inhibited, the fermentation giving strobilurin B 3 along with about 50% 2-fluorostrobilurin B 48, 10% 2-fluorostrobilurin G 59, and about 1% 2-fluorostrobilurin H 57 (Fig. S636, 4-fluorostrobilurin B 55 and 4-fluorostrobilurin C 58. Finally 4-fluorocinnamate gave strobilurin A 2 along with 4-fluorostrobilurin A 49 only with no strobilurin B, presumably fluorine at C-4 inhibiting oxidative hydroxylation.With 7 Fig. S6. All str61 was chemically synthesised (Scheme S1B. lutea it was rapidly metabolised (Fig. S762. The formation of 62 can be rationalised as summarised in 63. Concerted decarboxylation and dehydration to triene 64 followed by epoxidation and hydrolysis gives diol 62, whose structure was established by 1D and 2D NMR analysis (Fig. S8The inhibition of strobilurin A production with 2-fluorocinnamate reflected the result of another experiment. The simple triketide analogue Scheme S1 as a potd Fig. S7 to give s Fig. S8.3 production remains unaffected but no strobilurin A 2 is detected. Time course experiments (Fig. S961 is rapidly converted to the diol and that the diol itself is responsible for inhibiting strobilurin A production. In both these experiments, feeding acid 61 and 2-fluorocinnamate, strobilurin B production is unaffected. This strongly suggests that the pathways to strobilurin A 2 and strobilurin B 3 are different and that strobilurin A 2 is not converted directly to strobilurin B 3, so that the pathways must diverge at an early stage. On feeding -cinnamate to cultures inhibited as above, no restoration of strobilurin A 2 production is observed, but strobilurin B 3 is produced and labelled from the precursor. This suggest that in these experiments, incorporation post-benzoyl CoA into strobilurin A is being inhibited. This suggests that benzoyl CoA may first be hydroxylated to 3-hydroxybenzoyl CoA before elaboration into the strobilurin B pathway (In this experiment, strobilurin B s Fig. S9 clearly  pathway .et al.18. The potential role of cinnamate as both the precursor to the starter unit and an assembly intermediate in its own right has been clarified. Prestobilurin A 18 undergoes oxidative rearrangement to form the core β-methoxyacrylate moiety, but no direct evidence for the process has yet been observed. However, indirect evidence for the intermediacy of an epoxide in the key rearrangement to form the methoxyacrylate toxiphore has been obtained here via the isolation pseudostrobilurin B 39 which is likely formed via the common epoxide intermediate 37. Precursor-directed biosynthesis experiments demonstrated that a wide range of mainly fluorinated starter units can be tolerated by the PKS to provide several halogenated strobilurin analogues. Finally and unexpectedly, the production of strobilurin A 2 can be selectively inhibited with no effect on strobilurin B 3 biosynthesis. This suggests that they are produced by parallel pathways and that strobilurin A 2 is not an intermediate to strobilurin B 3. Further work on the genetic and molecular basis for strobilurin biosynthesis is underway and will be reported elsewhere.The strobilurins and analogues are amongst the most commercially important fungal metabolites known. Despite this their biosynthesis has been relatively little studied since the initial work of Nerud Full experimental details are supplies in the ESI.There are no conflicts of interest to declare.Supplementary informationClick here for additional data file.


Serum visceral proteins such as albumin and prealbumin have traditionally been used as markers of the nutritional status of patients. Prealbumin is nowadays often preferred over albumin due to its shorter half live, reflecting more rapid changes of the nutritional state. However, recent focus has been on an appropriate nutrition-focused physical examination and on the patient’s history for diagnosing malnutrition, and the role of inflammation as a risk factor for malnutrition has been more and more recognized. Inflammatory signals are potent inhibitors of visceral protein synthesis, and the use of these proteins as biomarkers of the nutritional status has been debated since they are strongly influenced by inflammation and less so by protein energy stores. The current consensus is that laboratory markers could be used as a complement to a thorough physical examination. Other markers of the nutritional status such as urinary creatinine or 3-methylhistidine as indicators of muscle protein breakdown have not found widespread use. Serum IGF-1 is less influenced by inflammation and falls during malnutrition. However, its concentration changes are not sufficiently specific to be useful clinically as a marker of malnutrition, and serum IGF-1 has less been used in clinical trials. Nevertheless, biomarkers of malnutrition such as prealbumin may be of interest as easily measurable predictors of the prognosis for surgical outcomes and of mortality in severe illnesses. Malnutrition has a substantial clinical and socioeconomic significance; it increases rates of complications in hospitalized patients and healthcare-associated costs. Its prevalence has been estimated in hospitals of Western countries to be 30–50% and in long-term care facilities up to 85% depending on the definition and the type of population studied ,2,3.One of the problems of diagnosing malnutrition is the lack of a unified definition and of standard methods for screening and diagnosis. Malnutrition results from a mismatch of nutritional requirements with intake. In many malnourished patients, there is an associated disease-related inflammation, resulting in a complex interplay between the two. Inflammation influences both, requirements and intake. It promotes malnutrition and adverse outcomes by provoking anorexia and by altering metabolism with elevation of resting energy expenditure and by increasing muscle catabolism .The appreciation that inflammation plays a major role in the pathophysiology of malnutrition is often lacking, and many clinicians assume that weight loss is the single most important criterion for a malnourished state. This has led to frequent underrecognition of the condition . The purpose of this review is to review the published literature on the role of laboratory biomarkers as a tool to diagnose malnutrition, to assess nutritional risk and to monitor nutritional intervention.About half of all published risk scores of malnutrition use serum laboratory markers such as visceral proteins, and others do not .Results of these screening tests vary considerably, as shown in a Greek study in elderly subjects . These aA consensus committee of the European and US nutritional societies (ESPEN and ASPEN) proposed three sub-definitions of malnutrition. “Starvation-related malnutrition” is present when there is chronic starvation without inflammation; “chronic disease-related malnutrition” is defined as a condition when inflammation is chronic and of mild to moderate degree, and “acute disease or injury-related malnutrition” occurs when inflammation is acute and of severe degree . The crip < 0.001) and concentrations of albumin (p < 0.001), hemoglobin (p < 0.001), total cholesterol (p < 0.001), prealbumin (p < 0.001) and total protein (p < 0.05) among subjects at high risk of malnutrition assessed by MNA were significantly lower than those with low risk. Similar results were observed for malnutrition identified by SGA and NRS 2002. When patients with acute illnesses were included, the predictive value of albumin and prealbumin was distinctly reduced, confirming the conclusion that they are more markers of inflammation than of malnutrition. The authors concluded that BMI, hemoglobin, and total cholesterol were useful markers of malnutrition in older adults. A meta-regression published recently  assessedVisceral proteins are mostly synthesized in the liver. Poor protein and energy intake, impaired liver synthetic function as well as inflammatory status result in low circulating levels of visceral proteins. During inflammatory states and increased production of acute-phase proteins the liver reprioritizes protein synthesis, and lowers as a mirror visceral protein synthesis to a degree which correlates with the severity of the injury.Albumin is the most abundant protein in human serum. It has been used for decades as an indicator of malnutrition in patients in clinically stable conditions . Serum There is a clear relationship between serum albumin concentrations and all-cause mortality in elderly subjects . In patiOther studies also found this protein to be a good predictor of surgical outcome ,27. Comp3 and serum albumin < 3.5 g/dL [When serum albumin as a biomarker for the differential diagnosis of unexplained weight loss (involuntary weight loss of more than 5 kg in the previous 6 months) was included in a study from Spain in 306 referred patients, a little more than one-third were ultimately diagnosed with a malignancy. Multivariate analysis found the strongest predictors of a neoplasm were age >80 years, white blood cell count > 12,000/mm3.5 g/dL .Albumin has been criticized as a player in nutritional assessment due to its lack of specificity and long half-life (approximately 20 days) . Serum aPrealbumin, also named transthyretin, is a transport protein for thyroid hormone and is synthesized by the liver and partly catabolized by the kidneys. Serum prealbumin concentrations less than 10 mg/dL are associated with malnutrition .The use of prealbumin has been advocated as a nutritional marker, particularly during refeeding and in the elderly . The maiPrealbumin levels may be increased in the setting of renal dysfunction, corticosteroid therapy or dehydration, whereas they can be decreased during physiological stress, infection, liver dysfunction, and over-hydration .An algorithm that uses prealbumin has recently been proposed as a practical guide to help the clinician to stratify general medical and intensive care patients by risk of complications and outcome . PrealbuAn increase in the C-reactive protein/prealbumin ratio in medical intensive care unit patients has been associated with mortality , and a lSeveral publications reported a role for prealbumin in predicting prognosis  in various clinical conditions such as gastric cancer , lung ca2). The authors concluded that serum visceral proteins are not predictive of nutritional deprivation and should not be used to guide nutritional therapy in this group of patients.A systematic review assessed the role of albumin and prealbumin in otherwise healthy subjects who were severely nutrient- deprived due to poor access to food or unwillingness to eat, mostly due to anorexia nervosa . The stuThis acute-phase reactant is a transport protein for iron. It has a relatively long half-life (approx. 10 days), and has also been used as a marker of the nutritional status  It is inDuring iron-deficiency the levels of transferrin are elevated whereas they are decreased in iron-overload states. Serum transferrin increased in parallel to prealbumin during nutritional intervention in critically ill children . Serum lThis is a low molecular weight protein with the physiological role to transport retinol from the liver to target organs. It represents the visceral protein with the shortest half-life (approx. 12 h) . AccordiCreatinine is the end product of creatine which consists of 3 amino acids and is mainly present in muscle. Provided that renal function is intact its excretion reflects creatinine production which in turn is a mirror of skeletal muscle turnover. Each mmol of creatinine in urine is derived from 1.9 kg skeletal muscle . The dis3-methylhistidine is a component of muscle fibers and is not reutilized by the body. Its urinary excretion reflects the amount of fat-free mass and it can be used as a measure of the rate of muscle protein breakdown. It is less dependent on renal function than creatinine; it is often expressed per mmol of urinary creatinine . Both asAs can be seen in 3 (reference range 2000–3500) [The local inflammatory response to a s.c. injection of an antigen is impaired during severe malnutrition. At the same time, maturation of lymphocytes may be reduced in malnourished patients so that total circulating lymphocyte concentration falls to less than 1500/mm00–3500) .These abnormalities can be taken as supporting evidence for protein-energy malnutrition, however, they are not specific and insensitive, and concomitant diseases and a severe stress reaction may also have an effect. Both markers respond slowly to correction of the nutritional status. These reasons limit their use as diagnostic tools for malnutrition.IGF-1  is a ubiquitous growth factor, and the circulating form is mainly produced by the liver. Pituitary growth hormone stimulates its release. Its serum half-life is short (approx. 24 h), and it is largely bound in plasma to binding proteins (mainly IGF BP 3). Fasting lowers plasma IGF-1 levels more than 4 fold and IGF-1 concentrations increases during nutritional repletion. A correlation between energy intake (and less so of protein intake) and plasma IGF-1 concentrations has been reported . IGF-1 lDecreased serum leptin concentrations combined with elevated prothrombin time has been reported in malnourished hospitalized patients with end-stage liver disease .Nesfatin-1 is an anorexigenic molecule and seems to play a role in appetite regulation and energy homeostasis. Serum nesfatin-1 concentrations have been shown to be increased in chronically malnourished but otherwise healthy children .Zinc is the most abundant trace element in man beside iron; it is present in all body tissues and fluids and is an essential component of many enzymes. Zinc deficiency has been associated with impaired taste and smell, reduced immunity and increased risk of pneumonia . In caseZinc deficiency is due to low intake of zinc-containing foods such as meat and to decreased absorption caused by intestinal malabsorption . AccordiLaboratory assessment of other trace elements such as iron is not specifically mentioned as part of current nutritional screening tools. This does not mean that in cases with clinical suspicion of micronutrient deficiency this should not be performed. The same can be stated for laboratory screening for vitamin deficiencies, in particular, those of vitamins A, B1, B6, B12, D, and folate.Dementia: Eating and swallowing problems increase the risk of malnutrition. According to a study from a memory clinic in the Netherlands, about 14% of community-dwelling subjects with newly diagnosed dementia were at risk of malnutrition [utrition . These aIn patients with dementia, the nutritional history may only be obtainable by asking family caregivers about appetite and weight change of patients. However, it is unknown whether nutritional information provided by family caregivers are reliable, and therefore biomarkers of malnutrition would be of particular interest.A recent study compared biochemical blood markers among patients with Alzheimer’s disease (AD), dementia with Lewy bodies (DLB), and frontotemporal lobar degeneration (FTLD) . A totalSarcopenia in the elderly: A clinical investigation performed in elderly persons supported the view that prealbumin levels are useful surrogate indicators of lean body mass (LBM). Compared to serum albumin and RBP, prealbumin showed the highest positive correlation with LBM [with LBM . In ordewith LBM . Ingenblwith LBM .A position paper from the International Society of Renal Nutrition and Metabolism (ISRNM) stated that serum biomarkers played a particular role in diagnosing malnutrition in patients with kidney failure . ProteinSerum prealbumin levels were positively correlated with body cell mass in pre-dialytic kidney patients . Serum bThe role played by serum biomarkers in diagnosing or monitoring malnutrition is controversial, particularly in more recent reports. This is explained by their relatively low specificity and by the fact that underlying diseases such as inflammation exert a major influence, particularly on serum visceral proteins. In addition, the role of biomarkers to guide nutritional therapy has not been studied in large randomized controlled trials. A recent randomized controlled multicenter trial in hospitalized patients with malnutrition might fill this gap in the near future . Neverth


Safety issues arise during the performance of activities as dementia advances. Occupational therapists collaborate with dementia clients and their caregivers to find solutions and strategies to prolong safe activity participation. Additionally, occupational therapists teach through demonstration showing engagement in specific activities may no longer be safe. We present the case of a 70-year-old male with mild dementia. His caregiver believes he needs to use a smartphone for safety during outdoors walking; the client’s enjoyed and valued occupation. This case report illustrates smartphone use may be difficult to learn for a person with mild dementia. It highlights the need for the caregiver and person with dementia to receive education together for best understanding. New technologies for community mobility such as outdoors walking are considered.  Healthcare professionals and caregivers may desire prolonging engagement in activities as long as possible for a person with dementia. Conversely, they may prematurely disengage a person for fear of danger to the person. This case report describes how an occupational therapist worked with a client having dementia and his caregiver by providing intervention to test continued independent outdoors walking by the person with dementia. The intervention strategy was to teach smartphone use. It is crucial to provide background information first on people with dementia becoming lost in the community while walking alone for recreation or transportation. We define occupational therapy as a profession that assesses people’s ability to engage in meaningful activities. Safety while performing activities takes precedence. We end with comments about technology and how smartphone use may not be an answer to independence in community mobility for people with dementia.Of the estimated 5.5 million Americans living with Alzheimer’s dementia in 2017, an estimated 5.3 million are age 65 and older and approximately 200,000 individuals are under age 65 and have younger-onset Alzheimer’s [Occupational therapy practitioners work not only with people with dementia, but also their caregivers and family members. Occupational therapy practitioners focus on the person’s remaining abilities. They use adaptations and modifications to maintain client activity participation for as long as possible, making them valuable members of the care team. Primary concern when teaching activity engagement is how safe the person is performing the desired activity . OccupatOccupational therapy practitioners use activity analysis in the assessment and intervention process. Activity analysis is defined as examining the typical demands of an activity, the range of skills involved in its performance, and how technology and the environment might be ascribed to enable performance. Occupational therapy practitioners have a unique and holistic perspective to activity analysis as a fundamental component of their practice. The occupational therapy perspective not only looks at how an activity might be typically done but how it is done and experienced by an individual ,5. Key tCommunity mobility is defined as “planning and moving around in the community and using public or private transportation, such as driving, walking, bicycling, or accessing and riding in buses, taxi cabs, or other transportation systems”  (p. S19)Unfortunately, community mobility may be dangerous for those with dementia. They may become disoriented in unfamiliar environments and later have difficulty finding their way in familiar environments . FunctioStudies indicate that all persons with dementia are at risk of becoming lost in the community whether driving or walking ,11,12,13Carl, a 70-year-old retired male was diagnosed with mild dementia. He reports having a limited external support system, as his closest family members are deceased. He lives in an adult care home and receives in-home occupational therapy services as well as outpatient occupational therapy services through a community-based day center. Carl’s in-home caregiver, Julia provides him with assistance in some activities such as laundry and meal preparation. He uses a ride service to attend outpatient therapy sessions. Carl no longer drives. However, he often walks in his neighborhood and enjoys frequenting the neighborhood park. Walking is his mode of transportation to this neighborhood park. Carl’s daily routine consists of self-care activities, reading, watching television, outdoor walks in his neighborhood, caring for his living quarters and attending a community day center for therapy services, which include occupational therapy and social engagement activities. He enjoys his relationships with the other day program participants as well as his relationship with his rehabilitation therapists.Julia requested Carl have a safety evaluation. She was particularly concerned Carl would become lost while walking to/from the neighborhood park. Although Julia reported no incidents of Carl wandering, she expressed her concern that he could possibly get lost while walking in the community. She frequently discouraged him from taking walks. Julia reported Carl frequently becomes confused using the television controls in his room. Carl reported frustration with his ability to keep track of his thoughts, stating “I can’t seem to get things done like I used to, but I have a lot of great ideas.” The occupational therapist administered the Trail Making Test . This asThe occupational therapist established goals with Carl and Julia to address his personal safety while walking in the community by introducing the use of a smartphone. Both believed it was worth trying despite Julia reporting Carl frequently becomes confused using the television controls in his room. In-home visits focused on teaching Carl to use his smartphone, one that is designed for older adults. These visits also provided Julia with verbal feedback and demonstration regarding his ability to use the smartphone. The therapist matched cognitive level to activity analysis of using a smartphone. The occupational therapist provided simple instructions to use a smartphone when walking outdoors. The simplest was to press the red button if he was lost or in danger. Julia’s phone number was programmed into the phone. It was hoped that Carl would be able to call Julia if he became lost on a walk.One of the greatest challenges Carl faced was the ability to error correct if he reached an unintended action on the phone. On multiple occasions, Carl expressed frustration with the small size of the phone keys. He was highly distractible during teaching sessions. Furthermore, the smartphone had features that confused Carl such as a text messaging button, camera, photo album, email, and brain games. Carl could not remember the purpose of emergency button.Julia observed the therapist working with Carl. The last home visit aimed to assess Carl’s use of his smartphone in his home environment as well as address any further caregiver concerns. During multiple attempts at making a call, Carl needed moderate cues from the therapist and completed a call independently on one occasion. The therapist informed Julia that after assessing Carl’s progress, his goals clearly needed to be modified in order to address the safety concerns in a different way. Julia and the therapist discussed the possibility of using a personal tracking device to prevent Carl from getting lost in the community. Julia expressed that she was grateful that they explored smartphone use as she wondered if it would be helpful and did not know how to teach Carl its use. She was not surprised that smartphone use would be challenging for him. Julia and the therapist discussed outstanding considerations such as whether or not Carl would remember to charge his phone and take the phone with him when in the community. Julia believed he might misplace the phone. Handling calls that were the wrong number or soliciting calls received may be challenging. Having the demonstration further resolved the importance of having an identification card and Julia’s phone number on it with Carl when he was walking in the community. She believed with the cold rainy weather coming Carl would stop going for community walks. Hopefully, she could find a companion to go with him or he would no longer desire this activity. They ended the session with Julia agreeing with the therapist’s advice: Julia would obtain a tracker device for Carl. This would alert her if he walks too far and identifies his location, which she stated would bring some peace of mind. Enabling independence may improve the quality of life for a person with dementia, but this can only be done when it is generally safe to do so ,15,16,17Prior to navigation technology and smartphones, some healthcare workers may have recommended the use of a co-walker as a viable solution to prolong outdoor walking for a person with dementia. Many walkers may enjoy the socialization of this strategy. However, some individuals may find having a walking partner an intrusion of private reflective time. Some people prefer the solitude for quiet time to enjoy nature.Thinking about this problem in a bigger perspective, research stresses the importance of intelligent design of community environments for individuals at risk for cognitive decline . DementiHowever, this land-use planning for dementia does not solve immediate needs for people with dementia and their caregivers’ concerns about safety. This brings reliance on technology. Although teaching the use of a smartphone may not be workable, other technology may provide some safety options. Rowe et al. describes a person who was lost 0.25 miles from his home for 6 days. The search for him required law enforcement, the use of a helicopter search, and the work of volunteers . WearingSometimes, the quest for independence versus safety drives healthcare professionals or caregivers to promote or discourage engagement in an activity without knowing if partaking is safe or not. This case report illustrates the safety risks of what may be taught for independent participation and what may become a safety hazard for those with memory impairments. Occupational therapists are in a unique position to demonstrate to caregivers and clients with dementia activities that may be dangerous when there is memory impairment. Demonstrating to both at once may yield best understanding. Having a variety of technology samples to teach may demonstrate best what choices need to be made for safety in the community and if this option is possible. The occupational therapy intervention did not change the client’s behavior as others have found . However


In: Elder K, Saitta B, Ducomble T, Alia M, Close R, et al. Ensuring access to affordable, timely vaccines in emergencies. Bull World Health Organ. 2019 Dec 1;97(12):851–53the author list and affiliations should read as follows:a Barbara Saitta,a Tanja Ducomble,b Miriam Alia,c Ryan Close,d Suzanne Scheele,a Elise Erickson,e Rosalind Scourse,e Patricia Kahnf & Greg Eldere“Kate Elder,a Access Campaign, Médecins Sans Frontières, New York, United States of America (USA).b Médecins Sans Frontières, Geneva, Switzerland.c Médecins Sans Frontières, Barcelona, Spain.d Perelman School of Medicine, University of Pennsylvania, Philadelphia, USA.e Access Campaign, Médecins Sans Frontières, Rue de Lausanne 78, Case Postale 1016, 1211 Geneva 1, Switzerland.f Médecins Sans Frontières, New York, USA.”


The Washington Post noted the rising violence in Rocinha, the largest favela in Rio de Janeiro, Brazil. With the headline “A Once‐Trendy Rio Slum Is Now ‘at War,’” it detailed how the “showcase shantytown in Brazil's showcase city” had become a conflict zone, with a fourfold increase in killings in less than a year  and I Love Paraisópolis —both produced and broadcast by the Brazilian television company Rede Globo. The two telenovelas became rather popular and soon provoked tourists to visit their locations. However, these tourism flows did not last very long. Tourism decreased in both communities, just as it had before in Rocinha and other favelas in Rio de Janeiro. In light of this scenario, how local residents of Complexo do Alemão and Paraisópolis perceive the use of their communities as filming locations and tourist attractions is worth analysis. Through this line of inquiry, we propose the telenovela effect: the scope of the telenovelas’ impacts (including their instigation of tourism) on location communities before, during, and after their releases. In this study, interviews with twenty individualsAs a response to this research gap, this article analyzes the use of the favelas Complexo do Alemão in Rio de Janeiro and Paraisópolis in São Paulo as filming locations and tourist attractions through the eyes of residents who are either directly or indirectly involved in these uses. These two communities were respectively depicted in the Brazilian telenovelas Since the first slum community was settled in Rio de Janeiro at the end of the nineteenth century, the favelas have had contradictory associations in the Brazilian and global popular imaginary. On the one hand, they are seen as zones of high criminality and violence, and on the other they are considered the birthplace of typically Brazilian cultural expressions. As Beatriz While these communities and their residents are shunned by Brazilian politicians and wealthy elites, they are hailed in other meaning‐making practices, namely media and tourism. Since 1992, when the first group of tourists visited Rocinha, the Brazilian favelas have been incorporated in the rising global phenomenon of slum tourism, which includes other poverty‐stricken areas such as Mumbai, Kibera, and South Africa's townships  196‐98. Film‐Induced Tourism 11). The favelas are a case in point: The Oscar‐nominated City of God  has been regarded as largely responsible for the establishment of these places as popular tourist spots in Rio . The film depicts the community of Cidade de Deus as “an artistically creative, convivial, and vital favela coexisting with the hell of the drug trade” .The connections between the media and tourism industries are evident in film tourism: “the visitation to sites where movies and TV programs have been filmed as well as to tours to production studios, including film‐related theme parks” . More than a shared spatial imaginary, the favelas have become a global trademark capable of hyping up any leisure enterprise, from hostels and restaurants to bars and parties. Devoid of any geographical marker or cultural specificity, the word “favela” in itself has been appropriated by, for example, an Asian restaurant in Sydney, Australia, and a techno club in Münster, Germany  and A Regra do Jogo (2015‐16). In Brazil, telenovelas are usually exhibited six times per week on free‐to‐air television, with three productions consecutively airing in standard time slots—at 6 p.m., 7 p.m., and 8 or 9 p.m. Their production rhythm is industrial, with a clear and segmented work division  and a strategic planning in terms of costs and target audience . For example, the writers could only implicitly suggest that Grego was a drug dealer. For Renata, this softer characterization was intended to avoid denigrating the favela's image on TV.In response to these critiques, Renata, who participated in the composition of the characters of When a telenovela … shows that in the favela there are moments of conflict, but there's also the guy at the bar who jokes around, who throws a party every now and then, that there are boys flying kites, the girls [sunbathing] on the rooftops, or the very nice people who live there, this automatically stimulates people to ask themselves if the favela is really that bad thing in the newspaper, or if it's really a spot to be explored like other parts of the city.In spite of these complaints about representation, both in Complexo do Alemão and Paraisópolis, the respondents at times also pointed out some positive outcomes of the TV productions. Jessica said that, although generally showing Complexo do Alemão in a very superficial way, the telenovela was also rather playful in dealing with the local scenery:I Love Paraisópolis challenged the common media representation of the community, especially in the news: “You get a lot more audience if you show in your newscast that there is a gunfight here … than if you show that we have a ballet school … that we have girls being considered for [the Russian ballet company] Bolshoi … [Crime] unfortunately still draws more attention.” According to Elizandra, then, even though the way the telenovela depicted Paraisópolis was still not ideal—in her opinion, the plot became too comic and, again, some characters too unrealistic—it was better than usual.Moreover, according to some respondents, the telenovelas gave at least some positive visibility to the favelas. According to the president of the Women's Association of Paraisópolis, Elizandra This resonates with what several other interviewees argued. The telenovelas seemed to bring positive affirmations of pride and self‐esteem among residents. As the community leader Gilson Salve Jorge—179 episodes spanning seven months—and the instability of the favelas, in terms of security, prevented this effect from being long‐lasting.In the interviewees’ view, the telenovelas never seemed to find an appropriate balance in the representation of Complexo do Alemão and Paraisópolis. While at times they repeated long‐standing stereotypes about the favelas, they also overly attenuated certain aspects of these places because of content restrictions related to the telenovelas’ timeslots. However, this flawed representation was still better than not being represented at all. The visibility given by the telenovelas to these communities renovated the sense of pride and belonging of their residents, even though, in Complexo do Alemão, the limited endurance of From the interviews it also appeared that, once the telenovelas were broadcast, they generated a sudden yet equally temporary interest in the favelas. According to former local tour guide Paulo Salve Jorge momentarily boosted the tourism that already existed in the community. The production inspired the creation of specific tours and souvenirs and was mentioned by tour guides, depending on the tourists’ interests. In Paraisópolis, however, the answers were more divided, with some interviewees noticing a temporary increase in tourists and others not perceiving any impact whatsoever.In terms of tourism, all respondents in Complexo do Alemão agreed that the telenovela The main point is the cable car. The cable car started to feature in newspaper headlines as a tourist attraction … But then that's it, in the period of the telenovela the big public [for tourism] was because of the telenovela. But then even after the telenovela ended, over time, the public that came talking about the telenovela gradually diminished, so [the reason] was more the cable car indeed.Part of the explanation of why the influence of the telenovela was either considered temporary or barely noticed in these favelas is that these productions were not the main factors for the rise of tourism in the first place. In Complexo do Alemão, the construction of a cable carIn Paraisópolis, interviewees cited the presence of local artisans and qualified tour guides, the urbanization of Paraisópolis, and the spread of the fame of favela tours in Rio to São Paulo as the main reasons tourism occurred. The telenovela itself was never mentioned. For the outsider tour operator Luis Nowadays, the influx of tourists is very small in both communities. When asked about what made tourism decrease again, respondents in Complexo do Alemão said it was the rise of violence, especially due to police operations, and the closing of the cable car. The end of the telenovela was considered important only because it coincided with other events—the beginning of the low tourist season, the upsurge in violence, and the increase of negative reports about the community in the media. In Paraisópolis, the end of the telenovela was never mentioned as a factor for the decrease of tourism. Outsider tour guides said that the increase of violence was the main problem. However, Gilson affirmed that the cultural circuit offered by the Residents’ Union continues to receive the same, albeit “not so expressive” number of visitors as always.There is potential here, but it doesn't depend … on a media strategy. I think Alemão has issues that go beyond this media strategy. While this security issue is not solved or partially defined, I think that everything remains too unstable. So even if the strategy is good and even if it works in terms of audience impact, I think it won't be long‐lasting.In general, the respondents were skeptical about the capacity of media productions to sustain tourism in their communities. When asked about what is needed for tourism to be successful again in Complexo do Alemão, interviewees mentioned the reopening of the cable car and the solving of the security issues that the community faces nowadays. In Paraisópolis, the need for more infrastructure both for tourists and locals—hotels, but more importantly, sanitation and paved streets—was considered the main factor. As Jessica sums up:Thus, any after‐effects of the telenovelas were deemed largely temporary. Investors apparently lost interest in these neighborhoods once the hype created by the TV productions lost momentum, and tourism entrepreneurs faced challenges that went beyond the popularity of the telenovelas—namely the closing of main tourist attractions and, most importantly, the rise of violence. Hence, trusting in media productions as a means of development in the favelas on their own is unfeasible. The limited period of exhibition of the telenovelas, together with the historical and structural issues that these communities experience, hinder the telenovelas’ power to sustain a positive image of the favelas that could potentially generate new business and tourism opportunities for their residents.According to the analysis of twenty interviews conducted in the two communities, we can say that in areas that have faced stigmatization and neglect for so long, media productions and related tourism practices are seen by locals as an opportunity for development, self‐expression, and empowerment—but they often fail to fully live up to these expectations.As our case studies have shown, most residents interviewed for this research wanted the telenovela crews to work together with the community in the production phase, to provide a more realistic representation of these neighborhoods during the broadcast period, and to leave a long‐lasting imprint in the favelas once the telenovelas ended. Ultimately, however, the outcome of the filming of the telenovelas was largely considered ephemeral: a temporary collaboration, a temporary pride, and a temporary boost in business and tourism.I Love Paraisópolis and Salve Jorge inaccurate: by toning down characters and repeating stereotypes, for example. Besides, the limited airing period of the telenovelas translated into an equally limited popularity and sense of self‐esteem, especially in Complexo do Alemão. In the end, the telenovela effect, that is, the scope of the telenovelas’ impacts before, during, and after their releases, was like a telenovela: short‐lived and fast‐paced. Thus, beyond the specific outcomes observed in this study, the term telenovela effect can potentially also be used to refer to the ephemerality of the effects that telenovelas—and arguably other media forms—have on their filming locations.One of the explanations for this is the telenovela genre itself. Its fast‐paced, cost‐effective style of production does not allow for an extensive filming period on location, restraining the possibilities of collaboration with the community. The timeslots of the telenovelas also restrict the type of content they can show, which resulted in the residents interviewed by this study deeming Hypothetically, though, the memory of a telenovela could still be preserved on the filming location—and continue to generate income for locals through tourism—as long as references to it are created. These might include the production of souvenirs (as done in Complexo do Alemão) and the heavy marketing of telenovela tours. However, this research has shown that such an endeavor might be unfeasible in the favelas due to the instability that these sensitive urban areas face: limited financial resources, waves of violence, and other adversities derived for the most part from governmental neglect. The second reason for the ephemerality of the telenovela effect, then, can be ascribed to the locations themselves. The favelas, and arguably other less advantaged territories, offer scholars and policymakers alike complexities and specificities for location filming and tourism that go beyond a successful media production. With this, we claim that the potential often attributed to media tourism in privileged contexts is not entirely applicable to areas such as favelas. As part of a larger project, this study is the first step toward a better understanding of the complexities of these territories. Further research can be conducted—in other sensitive contexts and with other media and tourism practitioners, that is, film commissions and governmental bodies—to provide a broader panorama of media tourism in less privileged areas.


The increasing availability of large cross-national datasets enables researchers to integrate micro and macro levels of relations between human values and behavior. Particularly interesting are interactions between personal and cultural levels which can demonstrate to what extent a specific behavior is affected by individual values and cultural context. In this study, we aimed to shed light on this issue by analyzing data on basic values and drinking behavior from 21 national representative samples of the European Social Survey (2014). The results of multilevel regressions showed that country-level effects of Openness to Change (vs. Conservation) or Self-Transcendence (vs. Self-Enhancement) were not significantly related to frequency of drinking. As expected, individual-level Openness to Change (vs. Conservation) was consistently positively related to drinking frequency, whereas Self-Transcendence (vs. Self-Enhancement) was not. Contrary to our hypothesis, there was a positive association between personal Self-Transcendence (vs. Self-Enhancement) values and frequency of drinking in countries putting higher importance on extrinsic motivations , while this link was less positive or even negative in countries valuing intrinsic motivations . Moreover, a marginally significant interaction between individual- and country-level Openness to Change (vs. Conservation) values supported the same counter-intuitive result. These findings challenge the widespread idea that more conservative societies attenuate the link between personal values and behavior. In contrast, self-affirmation and cultural rewards theories, as well as culture-specific value instantiations, may explain these results. This study shows that the value-behavior link differs across cultures, yet in a more complex way than was assumed so far. This opens up new possibilities for research on values and behavior in a cross-cultural context. The increasing availability of large cross-national datasets enables psychologists to integrate micro and macro levels of analysis. Particularly interesting are cross-level interaction effects which show whether the nature of a lower-level relationship depends on a higher-level variable. These kinds of cross-level interactions can illustrate to what extent the link between values and behavior changes as a function of context characteristics. Although personal values have been found to be associated with a large variety of behaviors, little is known regarding how culture shapes these relationships  of drinking is one of the dimensions of alcohol consumption. It is usually addressed in health research because of its consequences for mental and physical health. Another crucial dimension of alcohol consumption is the frequency of drinking, which is interesting from a social-psychological perspective, because it can serve as an expression of people's motivational goals. Furthermore, this relationship may be moderated by the cultural context, so studying it can provide further insight into the value-behavior link as a function of culture.To date, researchers have focused on socio-demographic and psychological factors, such as age and personality traits, as predictors of drinking behavior. The social context in which drinking behaviors are situated has been mostly examined at the meso-level, e.g., in the form of neighborhood characteristics that foster frequent drinking behaviors , intensity or quantity of drinking  and frequency of drinking, as well as quantity and frequency of heavy or binge drinking. These can be summarized by two overall dimensions: frequency of drinking and intensity of drinking or extent of drunkenness  enjoyment and sensation-seeking, (2) social motives, and (3) coping motives, related to anxiety and coping with stress  are positively related to alcohol consumption, and Conservation values  are negatively related. This is the case for assessments of drinking status used with adolescents in Mexico and Hong Kong  showed less consistent or non-significant associations with drinking behavior. Some studies showed that Self-Transcendence values were associated with abstinence  is positively related to the frequency of drinking at the individual level.Overall, it seems that Conformity and Tradition  are robust negative correlates of alcohol consumption, whereas Hedonism and Stimulation  are strong positive correlates. This is consistent with the findings related to the enjoyment drinking motive (see above), as enjoyment-seeking is a direct expression of Hedonism and Stimulation values. It is also reasonable from a psychological perspective: drinking is universally associated with enjoyment-seeking and approach motivations, but not compatible with values emphasizing self-control as well as avoidance and prevention of harm  value dimension, we did not hypothesize its relation to frequency of drinking at the individual level but merely explored the association.post-hoc with differences in cultural beliefs and norms  is positively related to the frequency of drinking at the country level.H3: The value dimension Self-Transcendence (vs. Self-Enhancement) is positively related to the frequency of drinking at the country level.Studies examining the cultural context of alcohol use mainly focus on differences between ethnic groups which are explained In the studies reviewed above, cultural values were examined in terms of having a direct effect on alcohol consumption. However, cultural values can also exert a cross-level interaction effect by changing the strength of the relationship between two individual-level variables. There is some indication that individual-level associations with drinking behaviors may not be the same across different cultures. Kuntsche et al.  reveal tFrom a theoretical standpoint, culture constitutes a powerful normative context that can provide a greater or lesser sense of legitimacy for acting in line with one's personal values. Moreover, a culture can directly reward or discourage specific behaviors. In other words, culture may moderate the value-behavior link by enhancing or attenuating it  has a stronger positive relation to frequency of drinking in cultures characterized by higher Openness to Change (vs. Conservation).Schwartz's  value thGiven the inconsistency of individual-level findings in regard to the Self-Transcendence (vs. Self-Enhancement) dimension, we did not formulate any hypothesis. However, following the extrinsic-intrinsic rationale presented above, we expected that value-behavior links may be stronger in cultures valuing Self-Transcendence than Self-Enhancement.We analyzed data from the seventh round of the ESS ” to “Very religious (10).” Depression was measured with an eight-item version of the Center for Epidemiologic Studies Depression Scale Radloff, . The iteWe employed multilevel regressions because the data is clustered within countries Hox, . The cluThe overall frequency of alcohol consumption varies substantially across countries . At the second stage, we entered all the control variables and tested their effects for differences across countries. Effects of gender and age were found to differ substantially across countries, so we included their random effects in all the subsequent models. At the third stage, we entered country-level values, random effects of individual-level values, and finally, interactions between individual- and country-level values. The results are listed in Table At the individual level, the Openness to Change (vs. Conservation) value dimension showed a strong positive association with frequency of drinking, even after including the control variables. This supported our hypothesis H1. At the same time, Self-Transcendence (vs. Self-Enhancement) did not show a fixed effect that was different from zero. Tables The control variables showed effects that were consistent with the literature: respondents who were male, older, more educated, and lived with a partner drank more often. Frequency of social encounters and higher levels of wellbeing  were also positively related with the frequency of drinking while religiosity was negatively associated with it. The interaction of age and female gender was significant and negative, indicating that the gender gap in frequency of drinking increases with age.At the country level, the multilevel results showed that the coefficients for both value dimensions were non-significant, indicating that hypothesis H2 and H3 were not supported. These results were replicated when conducting an analysis with the ten basic values and four higher-order values at the country level (see Tables p < 0.001). At the same time, the more conservative Bayesian information criterion slightly increased, indicating that the increase in model fit is not large relative to its increase in complexity. Nevertheless, the variance of random effects was significant, so we tested whether country-level values could explain the slope variance.Model M3 showed that the variance of random effects was significant for both value dimensions, as evidenced by the bootstrapped confidence intervals of these variances. A decrease in the Akaike information criterion (AIC) in models with and without random effects showed that including the random effects of the two value dimensions was a reasonable extension of the model. Likelihood ratio tests computed as the difference between deviances of these two models showed a significant increase in model fit . The interaction of individual Openness to Change (vs. Conservation) with country-level Self-Transcendence (vs. Self-Enhancement) was not significant. In contrast, the effects of Self-Transcendence (vs. Self-Enhancement) were significantly moderated by both country-level value dimensions. Even though there were significant cross-level effects, the pattern of results did not confirm our Hypothesis (H4), but showed trends that were opposite to what we expected, as illustrated in Figure Models M4 to M7 Table  tested iThe figure shows that the slope for individual-level Openness to Change (vs. Conservation) is more positively associated with frequent drinking in countries valuing Conservation compared to those countries endorsing Openness to Change. The effects of Self-Transcendence (vs. Self-Enhancement) even change their nature depending on the country-level value dimensions: in countries with higher Openness to Change or Self-Transcendence, the effects of individual-level Self-Transcendence (vs. Self-Enhancement) are negative while in countries with higher Conservation or Self-Enhancement they are positive.Looking at the interactions of the ten basic and the four higher-order values listed in the Supplementary Material Tables , S6, we The analysis using the four higher-order values further supports the identified pattern. In addition, it suggests that the interaction between individual- and country-level Self-Transcendence (vs. Self-Enhancement) is mostly due to individual Self-Enhancement and country-level Self-Transcendence. The analysis also shows a weak positive interaction of both individual Openness and Conservation with country-level Self-Transcendence, demonstrating more positive and less negative effects, respectively, in countries scoring high on Self-Transcendence. Overall, the specific interactions support the more general results for the value dimensions reported above, highlighting some minor specifics.The current study examined how values relate to the frequency of drinking and how this values-drinking behavior link may be moderated by culture across 21 European countries. We found some support for our hypotheses. As expected, the individual-level value dimension Openness to Change (vs. Conservation) was positively related to the frequency of drinking. This is consistent with previous research showing that individuals who value pleasure and enjoyment also exhibit more frequent drinking, whereas those valuing conformity and security drink alcohol less frequently  as well as Self-Transcendence (vs. Self-Enhancement) cultural values. This is consistent with the empirical evidence showing that individuals residing in countries that value Autonomy, Egalitarianism, and Harmony drink more frequently than individuals residing in countries that value Embeddedness and Hierarchy  values and frequency of drinking in countries putting higher importance on extrinsic motivations , while this link was less positive or even negative in countries valuing intrinsic motivations . The marginally significant and negative interaction between individual- and country-level Openness to Change (vs. Conservation) also supported this pattern.We suggest two possible mechanisms that could explain these findings. First, in countries that emphasize extrinsic motivation, social approval and rewards may be provided to more conservative individuals and to those who emphasize Self-Enhancement, so that they are encouraged to express their values in the form of less frequent drinking. Indeed, Conservation values directly involve conformity, whereas Self-Enhancement values involve conformism through motivation for social approval  in Openness to Change cultures. A possible explanation (though not an exclusive one) is that differences in the value-drinking links evolved due to different value instantiations (i.e., context-specific expressions of values, see Hanel et al., Overall, the evidence from our study challenged the general idea put forward in the literature that more “socially tight” cultures that emphasize extrinsic motivations place constraints on acting upon one's values—at least in the particular case of drinking frequency behavior. The opposite seems to be the case; these cultures seem to strengthen the link between personal values and frequency of drinking, or even transform it from negative to positive. In a way, this supports the findings of Kuntsche et al. , who shoOur study has some limitations. First, it is limited to one dimension of drinking, namely the frequency of drinking, which is more related to individual preferences, lifestyle, and cultural patterns of drinking, rather than to risky health behaviors and alcohol abuse. It is reasonable to expect that binge drinking or degrees of drunkenness have different correlates and distributions across cultures. Second, as mentioned above, the sample was limited to 21 European countries, and these countries were not selected randomly. This limits the generalization of the results to a larger set of countries. The relatively small sample size also underpowers country-level effects, restricting the inclusion of covariates at the country level and making them less precise than they could be in a larger sample. This might also explain why one of the cross-level interaction effects was only marginally significant. However, the overall pattern of results—also supported by the additional analyses reported in the Supplementary Materials—corroborates our interpretation of the findings. Future research with data from more countries could establish whether the effects of cultural values are reproducible outside Europe and whether they change after controlling for the relevant country characteristics, such as climate or prevalent religion. Third, causality between values and drinking behavior is not guaranteed in our study, as all the key variables were measured at the same time. It is possible that more frequent drinking leads to less stress or more emphasis on Hedonism values. However, as is the case with most behaviors, the direction of causality from values to behavior is more plausible (for a review, see Maio, Despite these limitations, the current study makes an important contribution to the literature. It is the first study to report cross-country differences in value-drinking links. It sheds light on how the value-drinking behavior link may be moderated by the cultural context. And, most importantly, it identifies a number of novel results suggesting a set of possible explanations that can shed more light on explaining drinking patterns across nations, taking into account not only individual characteristics but also the cultural contexts in which individuals live. Ultimately, this study suggests that the strength of the value-behavior link differs across cultures, yet in a way that is more complex than was previously assumed. This opens up new possibilities for research on values and behavior in a cross-cultural context.http://europeansocialsurvey.org. All the codes that produced models, tables, and figures are available at https://osf.io/94357.The European Social Survey data is freely available online on MR conducted the statistical analysis and wrote the first draft of the paper. C-MV suggested the idea of the paper, wrote Introduction, and contributed to the writing of all the other parts of the paper.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.


Evidence from behavior, computational linguistics, and neuroscience studies supported that semantic knowledge is represented in (at least) two semantic systems . It remains unclear whether, and to what extent taxonomic and thematic relations are co-activated. The present study investigated the co-activation of the two types of semantic representations when both types of semantic relations are simultaneously presented. In a visual-world task, participants listened to a spoken target word and looked at a visual display consisted of a taxonomic competitor, a thematic competitor and two distractors. Growth curve analyses revealed that both taxonomic and thematic competitors attracted visual attention during the processing of the target word but taxonomic competitor received more looks than thematic competitor. Moreover, although fixations on taxonomic competitor rose faster than thematic competitor, these two types of competitors started to attract more fixations than distractor in a similar time window. These findings indicate that taxonomic and thematic relations are co-activated by the spoken word, the activation of taxonomic relation is stronger and rise faster than thematic relation. The structure and organization of semantic knowledge are critical to nearly all aspects of human cognition such as object recognition, memory and language processing. Evidence from behavior, computational linguistics, and neuroscience studies supported that semantic knowledge is represented in (at least) two semantic systems . In the present study, we presented the two critical types of semantic competitors within a single visual display, with the aim to investigate whether the two types of semantic relations are co-activated. If this is the case, what is the relative strength and timing of taxonomic vs. thematic relations? Moreover, in previous studies, target objects were often co-present in the visual scene. When target objects are co-present in the visual display, most of fixations tend to shift toward these target objects, causing less fixations toward the other objects  participated in the experiment. They were undergraduate students from universities in Beijing, China, and were paid RMB 20 (about 3.5 US $) for their participation. All participants had normal or corrected-to-normal vision. This study was approved by the ethics committee of the Institute of Psychology, Chinese Academy of Sciences. We obtained written informed consent from the participants of this study.SD = 76). Each visual display consisted of four pictures of common objects, one taxonomic competitor, one thematic competitor and two unrelated distractors . The second rating asked participants to judge the taxonomic relatedness between word pairs, i.e., the degree of being in the same taxonomy. The third rating asked participants to judge the taxonomic relatedness between word pairs, i.e., the degree of connected via events or scenarios. All of the rating were based on a 7-point scale , each collected rating scores form different sets of 17 participants. We followed the instructions  used in ests see  on the rBesides, 40 filler trials were added. Each filler set consisted of four objects with no overlap in meaning and visual form. One of the four objects was randomly selected as the target word. In total, 304 pictures were used, 218 of which were selected from the data base developed by Liu et al. , and theEye movements were recorded using an EyeLink 1000 tracker . Experimental materials were presented on a 21-in. CRT monitor (Sony Multiscan G520) with a 1,024 × 768 pixels resolution and a refresh rate of 150 Hz. The eye-tracking system was sampled at 1000 Hz. The participants placed their chins on a chin-rest and leaned their foreheads on a forehead rest to minimize head movements. Although viewing was binocular, eye movement data were collected only from the right eye. Participants were seated 58 cm from the video monitor.Participants were first asked to familiarize themselves with the pictures by viewing them in a booklet, with the name printed underneath each picture. Subsequently, the eye tracker was calibrated and validated, and re-calibration was conducted whenever the error was >1° during the experiment. The participants performed this procedure by means of a nine-point calibration, and the validation error was smaller than 0.5° of visual angle on average. A drift check was performed at the beginning of each trial, and then a blank screen was presented for 600 ms. The visual display was presented 2,000 ms before the onset of the spoken target word. Spoken target words were presented to participants through a headphone . Participants were asked to listen to the spoken words and view the displayed pictures without performing any explicit task. The visual display disappeared 4,000 ms after the spoken word onset. Each participant performed 36 critical and 40 filler trials which were randomly intermixed, following 8 practice trials. Trials were presented in a random order, and the entire experiment lasted approximately 20 min.Four areas of interest were defined, each overlapped with one of the pictures, corresponding to a rectangle (350 × 250 pixels). We calculated the mean fixation proportions of taxonomic competitor, thematic competitor, and distractors over successive 100 ms intervals. p < 0.001) and linear  terms. Importantly, paired comparisons showed that both types of semantic competitors received more fixations than distractors . Effects on linear term were also significant, suggesting that fixation rose faster on both of the competitors than distractors  , a multilevel regression modeling technique using fourth-order orthogonal polynomials . Paired comparison between the two competitors showed significant intercept term, estimate = −0.082, p < 0.001, indicating more fixations on the taxonomic than the thematic competitor. The linear term suggested that fixations on taxonomic competitor rose faster than that on the thematic competitor . Moreover, other inflections on the time courses of taxonomic and thematic effects did not differ significantly, as suggested by the quadratic, cubic and quartic terms . Actually, during the preview period, fixation proportions on the four objects approximated the chance level 0.25 (see Besides the critical time window, we also calculated fixation proportions over successive 100 ms intervals during the preview period to test if there was any preference on the pictures caused by factors other than the spoken activation. We compared fixation proportions on the four objects in the same way as the first model in analysis of critical time window. The results suggested that fixation proportions on both of the competitors did not differ significantly from that on the distractors (taxonomic competitor: estimate = 0.011, 0.25 see .The present study examined the semantic representations invoked by a spoken word when the referent object was absent in the visual scene. Two types of semantic relations were compared, which are proposed as complementary systems and investigated widely (Mirman et al., The finding that the magnitude of taxonomic effect and the rise speed of fixations on the taxonomic competitor was greater than the thematic effect was consistent with findings with the previous studies in which target objects were presented in visual displays (e.g., Mirman and Graziano, What could be the reason for the similar start points of two effects, in contrast to an earlier thematic effect relative to a taxonomic effect previously found by Kalénine et al. ? DiffereOne of novelty in the current study was to adopt target-absent visual displays (Huettig et al., In the present study, taxonomic and thematic competitors were depicted within the same visual display and both attracted more fixations than the unrelated distractors. As we mentioned in the Introduction section, taxonomic and thematic relations are found to be dissociated both in behavioral and neural studies (e.g., Bonthoux and Kalénine, In conclusion, the present study suggested that taxonomic and thematic relations are co-activated by the spoken word, even when the referent object is absent from the visual context. These two relations are activated at similar time points, but the taxonomic effect is stronger and develops faster than the thematic relation in the processing of concrete concepts.All procedures performed in studies involving human participants were in accordance with the ethical standards of the institutional and/or national research committee and with APA regulations.PX, QQ, and XL inspired the idea of the study, designed the experiment, collected the data, conducted the data analysis, interpreted the results, and wrote the manuscript. WS provided the instruction to the execution of the experiment and data analysis. All authors agreed on the final version of the manuscript.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.