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This stage comprises multiple case study design to explore in-depth community engagement and trust in healthcare for Gypsy/Travellers . The unit of analysis is the approach to engagement between health services and Gypsy/Traveller communities within a locality. Each case study involves interviews, focus group discussions and documentary analysis. Four case studies will be selected purposively to reflect the diversity of Gypsy/Travellers communities, different approaches to community engagement, and examples of good practice regarding maternity, early years’ or child dental health services (identified through the realist synthesis and online consultation). Three case studies will be in England and one in Scotland to reflect the larger population of Gypsy/Travellers in England and to meet the funders’ remit of advising policymakers in England. The selection of a case study in Scotland strengthens the methodology because there are differences between healthcare structures and remuneration in England and Scotland that could be significant. | study | 99.94 |
Overall, the case studies will include English/Romany Gypsies, Irish Travellers, Scottish Gypsy/Travellers and Eastern European Roma migrants. They will be conducted in two phases of six months. Lessons learned from the first two case studies, for example approaches to recruitment or revisions to interview topic guides, will inform the conduct of the second two case studies. | other | 99.9 |
Our purposive sample strategy is designed to reflect the diversity of Gypsy/Traveller populations living in the UK. We aim to recruit mothers who live in permanent housing, and in authorised and unauthorised sites, and those following a nomadic lifestyle. Where the mother wishes, we will include other family members in interviews Health practitioners will be recruited purposively to include those working in maternity, early years’ and child dental health services. Finally we will include key informants from civil society organisations that are involved in community engagement activities with Gypsy/Travellers. See Table 1 for an overview of the proposed numbers of participants and data generation methods.Table 1Target numbers of participants in case studiesParticipantsData generation methodEach case studyTotal across four case studiesMothers of pre-school childrenFace-to face interviews8–1232–48Health and social care practitionersFocus group discussion6–824–32Telephone interviews2–48–16Key informants from civil society organisationsTelephone interviews2–48–16 | study | 99.9 |
The case studies will include analysis of documents, sourced through NHS and civil society organisations, websites, social media and from the research participants, related to methods and activities used by health services and civil society organisations to engage Gypsy/Travellers. | other | 99.9 |
There are challenges in recruiting participants from marginalised communities. In each case study we will identify relevant civil society organisations, community workers, local authority or NHS frontline health and social care workers as gatekeepers who can identify potential participants. Leeds GATE will facilitate recruitment through their networks. We are developing relationships both for circulating the online consultation (stage two) and facilitating recruitment to case studies. We will liaise with individuals and organisations working with Gypsy/Travellers with whom we have established links and who are familiar with research process through a previous study . The Stakeholder Advisory Group will identify additional organisations and specialist services to enahnce recruitment. The gatekeepers will facilitate recruitment of health and social care practitioners and key informants from civil society organisations. | other | 99.44 |
We will conduct semi-structured, face-to-face interviews. The interview topic-guide will focus on perceptions of trust, views, experiences and awareness of maternity, early years’ and child dental health services including barriers to service use, experiences of community engagement activities, and suggestions for ways of improving services. | other | 99.75 |
We will conduct focus group discussions with telephone interviews as a contingency for those unable to attend a focus group . The topic guide will include participants’ experiences of service provision for Gypsy/Traveller communities, barriers to providing quality services, organisational context, examples of good practice in terms of engagement and developing trust with Gypsy/Traveller communities and cost implications. | other | 99.9 |
The locations of interviews and focus group discussions will be negotiated with participants. All interviews and focus groups will be audio-recorded with the participants’ written consent and transcribed for analysis. Where necessary, interviews with participants from Eastern European Roma backgrounds will be undertaken by a bilingual researcher who will transcribe and translate the audio-recording. | other | 99.9 |
We will analyse data thematically, informed by the evaluative framework derived from the realist synthesis in stage one. The research material from each case study will be analysed and reported independently before comparing similarities and differences across case studies . We will analyse diverse participant experience to avoid essentialist interpretations based on particular cultural groups . NVivo 10 Software will be used to manage the data. | other | 98.7 |
Costs incurred by health and social care services will be estimated for each approach identified and represented as per family/per individual depending on the nature of the cost. All potential sources of costs will be identified, for instance cost of a visit from an appropriately trained practitioner. Cost data will be drawn from systematic review evidence and standard costing sources . Although the results will only provide a conservative estimate of the costs associated with each approach, such knowledge is important to guide decision-making and future trials. If data is sufficiently rich, a theoretical cost-benefit analysis could be included using real life experiences of Gypsy/Travellers to estimate the potential benefits through cost savings. | review | 99.8 |
The findings of the three completed stages of the research (reviews, online consultation and case studies) will be synthesised, using a triangulation protocol , to draw up a list of approaches to community engagement for enhancing Gypsy/Travellers’ trust in mainstream services. This will be done at the data interpretation phase . A ‘convergence coding matrix’ will be created to display the different sets of findings informed by the evaluative framework developed from the realist synthesis. | other | 94.5 |
Two cross-sectoral workshops will present the draft policy options/recommendations to diverse stakeholders. This approach ensures that options/recommendations culminating from research reflect the realities and constraints of policy and practice . Furthermore, the workshops will create a community of interest for dissemination. Up to 40 stakeholders will be invited to attend (or nominate a deputy) including: representatives from civil society organisations; frontline maternity and early years’ health services and children’s dental health services staff, service managers and commissioners, national and local policymakers, representatives from Local Authorities, and members of the User and Stakeholder Advisory Groups. Detailed field notes along with materials from the groupwork and plenary sessions, will be synthesised and included in the final report. | other | 99.9 |
Workshop participants will consider:the importance, acceptability, feasibility, replicability and sustainability of recommendations;barriers to and positive strategies for implementation of recommendations;possible consequences and costs of different policy options;how policy and practice options might work in different healthcare settings (e.g. mental health, adult dental services) and for other vulnerable populations (e.g. vulnerable migrants, homeless). | other | 99.9 |
It would not be possible to undertake this study without the involvement of Gypsy/Travellers. The study team includes the Chief Executive Officer of Leeds GATE, who is hosting the User Advisory Group whose involvement will include: input to the evaluative framework derived from the realist synthesis; development of participant information sheets and consent forms; advice on recruitment, topic guides for interviews and focus group discussions; interpretation of findings, and dissemination activities. In each case study location, we will identify two members of the local Gypsy/Traveller community to advise on the conduct of the research and any local issues of relevance, for example access, recruitment, and locally-tailored participant information sheets. We will support members of the User Advisory Group and local case study community members through two advocacy-training events in the first and second years of the project. The participatory events will bring together community members, researchers and members of civil society organisations. | other | 99.6 |
The main output will be a report detailing: a) an evaluative framework of Gypsy/Travellers’ engagement with health services; b) recommendations for policy and practice on how to enhance trust and improve the acceptability of health services to Gypsy/Travellers; and c) evidence on which to base future implementation strategies including estimation of costs of policy options. To increase impact, we will disseminate widely through written summaries, social media, and academic and professional conferences and publications. This will include: to Gypsy/Travellers communities led by the User Advisory Group; to research participants, and more widely through the network of civil society organisations developed from the online consultation and stakeholder workshops. Short articles will be written for magazines/newsletters. More detailed summaries will be prepared for health and social care organisations and disseminated to relevant professional organisations. | other | 99.9 |
This multi-component study seeks to explore ways of improving the uptake and delivery of health services and thereby reducing health inequalities for Gypsy/Travellers who are marginalised in the UK and across Europe . The multi-method approach will combine data from a variety of perspectives including Gypsy/Travellers, health professionals and civil society organisations to provide policy recommendations to enhance trust and improve the acceptability of health services to Gypsy/Travellers | other | 70.0 |
Although we have chosen to focus on maternity, early years’ and child dental health services as exemplars of mainstream health services, the findings may have resonance for other health services. Issues of trust and engagement are likely to be determinants of differential uptake of health services for other marginalised populations such as homeless people and refugees/asylum seekers. Thus, our findings may have broader application. The robust methods of public and patient involvement will help to ensure that the research is conducted ethically. The involvement of stakeholders, particularly through the workshops will increase the likelihood that final recommendations reflect the realities and constraints of policy and practice. Through the online consultation and our approach to selecting the case studies we aim to provide best practice guidance. | other | 99.2 |
Our study has several challenges and limitations. Trust and engagement are terms with multiple meanings. We planned the detailed literature reviews to develop theoretical understanding of these concepts which can then be explored in case studies and workshops. We anticipate that the explanatory framework will address different meanings of trust and engagement especially when these might differ between Gypsy/Traveller populations and health services. Within the constraints of the time and funding we are limited to four case studies which will be selected on the basis of good practice. This may reduce our ability to reflect on lessons-learned from approaches that have not worked. By the very nature of the marginalisation and discrimination experienced by Gypsy/Travellers in UK society, it is likely that recruitment to our study will be challenging and require multiple approaches. The ability of the researchers to develop trusting relationships first with gatekeepers and then with participants will be critical to the quality of the findings. We may not be able to recruit those who are most vulnerable e.g. those who do not engage with civil society organisations and/or those living in unauthorised encampments. Health professionals who participate are likely to be those who have an interest in this population group and therefore may not represent all mainstream practitioners. Despite these caveats, our study will add to the evidence-base of what works to increase trust and engagement between marginalised populations and mainstream health services. | review | 98.5 |
Plant viruses, the simple obligate intracellular parasites with small genomes, rely entirely on host machineries for their life cycle including replication, intracellular (cell-to-cell) and systemic movement (Nelson and Citovsky, 2005). Virus infections pose serious threats to agriculture and cause huge economic losses. Despite encoding only a limited number of proteins, numerous interactions of viral RNAs/proteins with host factors have puzzled the plant virologists for over a century and the complexity of these interactions is just becoming understood. | review | 99.8 |
Plants have developed two major strategies to counteract virus infections: resistance (R) gene-mediated, and RNA silencing-based defenses. In addition, the mutation in essential genes for viral infection also causes plant resistance against viruses, called recessive gene-mediated resistance. These approaches have been used in crop protections and have shown significant economic impact (Abel et al., 1986; Whitham et al., 1996; Baulcombe, 2004; Kang et al., 2005; Wang and Krishnaswamy, 2012). | review | 99.8 |
This Research Topic combines 13 publications, including 9 review articles and 4 research articles, covering almost every aspect of plant-virus interactions. The featured in-depth topic reviews in various sub-fields provide readers a convenient way to understand the current status of the related sub-fields and the featured research articles expand the current knowledge in related sub-fields. | other | 99.9 |
Not unexpectedly, vast majority of the papers in this Research Topic are related to gene silencing but with totally distinct emphasis. Khalid et al. summarizes the applications of various small RNA based genetic engineering (SRGE) in crop protection, focusing on the technology evolution and successful cases in different crops. Andika et al. reviews the current information on the molecular aspects of antiviral RNA silencing in roots, with emphasis on the interactions between host antiviral defense and soil-borne viruses. The distinctive characteristic features of RNA silencing in roots relative to shoots are summarized. Moon and Park review how the RNA silencing pathway cross-talks with the resistance (R) gene-mediated defense. Several components involved in host RNA silencing mechanisms have recently been shown to be required for R gene-mediated defense. It seems that it is a common phenomenon that miRNAs or siRNAs regulate R-gene mediated resistance through targeting R genes for cleavage in plants (Moon and Park). It is plausible that the cross-talk between these two defense pathways is to maximize the efficiency of defense responses against viral infections (Nakahara and Masuta, 2014). Huang et al. summarize the various scenarios of host- and pathogen-derived sRNAs or pathogen-induced host sRNAs in regulating host resistance/susceptibility or pathogen virulence/pathogenicity. | review | 99.9 |
The zigzag model (Jones and Dangl, 2006) presents a classic view of the interactions between plants and non-viral pathogens. Ding (2010) considered dsRNA as the Pathogen-associated Molecular Patterns (PAMPs) of viral pathogen and RNA silencing (or RNAi) as a form of PTI against viruses. Recently, Mandadi and Scholthof (2013) further integrated these concepts into current plant-virus interaction models. In this model, dsRNAs produced during virus infection are regarded as viral PAMP; RNAi-mediated antiviral defense is analogous to PAMP-triggered immunity (PTI); viral suppressors of RNAi (VSR) such as coat proteins (CPs), movement proteins (MPs), and replicase are regarded as avirulent (Avr) factors or effectors; R gene-mediated viral resistance is considered as viral effector-triggered immunity (ETI). Moon and Park and Gouveia et al. review how this model is shaped in details. In addition, Gouveia et al. reviewed the recent progresses in antiviral immune receptors and co-receptors involved in antiviral innate immunity in plants and describe the NIK1-mediated antiviral signaling, which is specific to plant DNA viruses and relies on transmembrane receptor-mediated translational suppression for defense. It remains to be seen whether this is an exception or a common viral defense mechanism used by plants. | review | 99.9 |
Recessive resistance is conferred either by a recessive gene mutation that encodes a host factor critical for viral infection or by a mutation in a negative regulator of plant defense responses, possibly due to the autoactivation of defense signaling. Eukaryotic translation initiation factor (eIF) 4E and eIF4G and their isoforms are the most widely exploited recessive resistance genes in several crop species (Kang et al., 2005). Hashimoto et al. thoroughly review the recent advances in recessive resistance studies not just limited to eIF4E and eIF4G. | review | 99.9 |
The disturbance of chloroplast components and functions is largely responsible for the chlorosis symptoms that are associated with virus infection. Chloroplast is not only the organelle that conducts photosynthesis but also the site for the biosynthesis of SA and JA, two major phytohormones that play roles in disease and resistance. Zhao et al. review the different aspects of chloroplast during plant-virus interactions, particularly focusing on the interactions between chloroplast and viral proteins that underlie the interplay between chloroplast and virus. Liu et al. review the major advances that have been made recently in identifying both the virulence/avirulence factors of Soybean mosaic virus (SMV) and mapping of SMV resistant genes in soybean. A special focus is given to the progress made in dissecting the SMV resistant signaling pathways using virus-induced gene silencing (VIGS). Romay and Bragard review the latest progress in plant antiviral defenses mediated by genome editing systems (GES). TALEN and CRISPR-Cas9 have been applied to generate resistance against plant viruses in the families of Geminiviridae and Potyviridae. Interestingly, the newly developed CRISPR-Cas systems using new versions of Cas9 proteins, capable to cleave ssRNA molecules, can be applied to target RNA viruses (Sampson et al., 2013; Abudayyeh et al., 2016). One advantage of genome editing is that the transgenes can be removed via segregation after editing. Some genome-edited crops have already been made available without being restricted by the US Department of Agriculture (Waltz, 2016). The other advantage of genome editing is that multiple alleles or genes can be edited simultaneously. | review | 99.9 |
Application of next generation sequencing (NGS) technology in small RNA profiling has significantly impact on the studies of plant-virus interactions. Li et al. investigate profiles of the Cucumber green mottle mosaic virus (CGMMV)-derived siRNAs (vsiRNA) in infected leaves and fruits of L. siceraria using NGS. The vsiRNA patterns of abundance, origination and polarity, hotspot distribution, GC content and 5′ terminal nucleotide are compared between the infected leaves and fruits. The similarities and distinct differences are revealed by this analysis. Co-infection of none-coding satellite RNAs (sat-RNAs) usually inhibits replication and attenuates disease symptoms of helper viruses. However, Xu et al. reveal that co-infection of none-coding satellite RNAs (sat-RNAs) of Beet black scorch virus (BBSV) enhances the replication and the symptoms of BBSV on N. benthamiana possibly through competitively occupying or saturating host silencing machinery. Fang et al. narrow down the functional domains of 2b protein of Cucumber mosaic virus (CMV) for dsRNA binding and Argonaute (AGO) interaction. Their findings demonstrate that the dsRNA-binding activity of the 2b is essential for virulence, whereas the 2b-AGO interaction is necessary for interference with RDR1/6-dependent antiviral silencing in Arabidopsis. Alpha-momorcharin (α-MMC) is a type-I ribosome inactivating protein (RIP) in Momordica charantia. Yang et al. provide evidence that α-MMC plays a positive role in the resistance against CMV in M. charantia and the antiviral activities of α-MMC may be achieved through up-regulating JA and ROS signaling pathway. | study | 97.9 |
We hope that this Research Topic helps readers to have a better understanding of the progresses that have been made recently in plant immunity against viruses. A deeper understanding of plant antiviral immunity will facilitate the development of innovative approaches for crop protections and improvements. | other | 99.25 |
The decreasing size of semiconductor features and the increasing structural complexity of advanced devices have placed continuously greater demands on manufacturing metrology, arising both from the measurement challenges of smaller feature sizes and the growing requirement to characterize structures in more than just a single critical dimension.1,2 These changing requirements have dramatically altered manufacturing metrology, both in terms of the available technology and its method of application. | other | 99.9 |
In the area of scanning electron microscopy (SEM), there has been a shift from the basic edge operators used in the 1990s to increasingly sophisticated imaging models and the increasing use of tilt SEM to reconstruct three-dimensional (3-D) representations of the surface.3,4 The past two decades have also seen the prodigious rise of scatterometry or optical critical dimension (OCD) metrology for in-line process control.5–7 Despite steadily increasing demands on the accuracy of the required models, both SEM and scatterometry continue to be widely utilized for process metrology. | other | 97.44 |
For reference metrology, critical dimension atomic force microscopes (CD-AFMs) remain well utilized, despite the demand for ever smaller, stiffer, and more robust tips. Furthermore, within the past decade, a new form of tilt AFM, with imaging capabilities similar to CD-AFM, has been introduced and is gaining acceptance in manufacturing support.8,9 An alternative implementation of CD-AFM based on the vector approach probing method has also been developed to enhance measuring flexibility as well as to reduce tip wear.10 Finally, the past decade has also witnessed the dramatic rise of interest in critical dimension small angle x-ray scattering (CDSAXS) as a potential reference metrology.11,12 | review | 99.7 |
Perhaps most dramatically, the realization that no single metrology technique will be suitable for all measurement goals has given rise to the concept of holistic and hybrid metrology, in which the results of multiple metrology methods are systematically combined so as to leverage the strengths of both and to lower the ultimate uncertainties.13,14 | other | 99.9 |
In general, the limitations of CD-AFM tend to be lower throughput relative to SEM and OCD, and it has image artifacts resulting from the tip sample geometrical and mechanical interaction. For reference metrology purposes, however, throughput is of secondary concern to the need for accuracy, and this, in turn, is largely dependent upon improvements in tip fabrication, characterization, and tip scanning control algorithms. | other | 99.75 |
The persistent challenge for CD-AFM technology has been keeping pace with the need for smaller tips. When CD-AFM was initially developed, the ability to image a 0.5-µm trench was technologically relevant.15 The requirements for current technology are nearly a factor of 50 smaller. This has resulted in a steady evolution of CD-AFM tips toward smaller widths, but the need to maintain the lateral stiffness of tips has also meant that these tips had to be shorter. Smaller tips were even more susceptible to damage than larger ones, so there has also been development of nonsilicon CD tips, specifically those of high-density diamond-like carbon.16 | review | 97.4 |
Due to the stiffness and wear-resistance of carbon nanotubes (CNTs), there has also been an ongoing interest in the use of CNTs as AFM tips.17–23 Indeed, there are now some commercial vendors of CNT tips. However, there have been significant issues surrounding both manufacturing and using CNT tips. Specifically, the growth or attachment of CNTs to AFM tips and cantilevers has been a challenge to the fabrication of CNT tips, and the flexibility and resultant bending artifacts have presented challenges to using CNT tips. | review | 99.44 |
CNT tips have several potential advantages over silicon-based tips: (1) significantly larger Young’s modulus by approximately a factor of five, (2) much greater wear resistance, and (3) a geometrical advantage over conical silicon tips in that wear of cylindrical CNT tip would not necessarily degrade its lateral resolution.18 Additionally, CNT tips will buckle under excessive compressive loading. This characteristic has the advantage of reducing sample damage, but brings with it the disadvantage of buckling-related imaging artifacts, as will be illustrated later. | study | 99.94 |
Given the much greater prevalence of conventional AFM relative to CD-AFM, most of the research into CNT tips has involved conventional AFM. The ability to image near-vertical sidewalls is the central feature of CD-AFM, and this geometrical requirement means that the constraints on the CNT orientation for a useful tip are even greater than for conventional AFM tips. However, there has been progress in the application of CNT tips to CD-AFM by a number of researchers.22,24 The considerably greater wear resistance of CNT tips has also been demonstrated in this context. | study | 99.8 |
In most cases, the goal of CNT tip fabrication has involved the use of straight CNTs. A cylindrical probe such as a vertical CNT can measure near-vertical sidewalls that are not re-entrant. However, for purposes of imaging vertical and re-entrant sidewalls, a tilted or bent CNT could be useful. Simply tilting a straight tip (or tilting the sample) carries a significant cost in terms of required geometrical clearance around a target feature. A vertical CNT tip with an intentional bend near the end offers the advantage of sidewall access but with much less stringent clearance requirements. Such a tip would allow access to sidewalls of one orientation. A more generally applicable solution would thus be a vertical CNT tip with lateral protrusions in both directions, thus more closely resembling the functional structure of silicon CD-AFM tips. | other | 78.75 |
In conventional AFM imaging, two distinct and significant artifacts have been observed in the use of CNT tips: divots and ringing. These artifacts are thought to be related to CNT bending, adhesion, and stiction, and are affected by the operational parameters of the AFM.20 Generally, these effects are more problematic for longer and thinner CNTs. This is similarly the case for CD-AFM applications of CNT tips. | study | 99.94 |
Approaches such as antiadhesion functionalization of the nanotube and the development of new AFM modes compatible with slender and flexible tips could also extend the duration and scope of CNT tip applicability. As we will show advances in CD-AFM scan algorithms for second- and third-generation instruments have increased compatibility with the CNT tips relative to first-generation tools. | study | 98.94 |
An elegant example of using CNT tips to optimal advantage was demonstrated by Watanabe et al.25 These researchers leveraged the high lateral compliance of CNT tips by incorporating the bending behavior into a unique imaging mode that could measure vertical sidewalls with a straight and vertically mounted CNT tip. This innovative work helped set the stage for a more recent investigation of CNT snap-in behavior on vertical sidewalls using a second-generation CD-AFM.26 In the future, similarly creative ways of using the behavior of very small tips to advantage will likely become increasingly important at the frontier of CD-AFM metrology. | study | 99.44 |
Since the early 2000s, the Korea Research Institute for Standards and Science (KRISS) has invested considerable effort in the controlled fabrication of CNT tips.21,23 Progress by KRISS in the precise control of CNT orientation, length, and end modification, using manipulation and focused ion beam processes, has allowed the implementation of ball-capped CNT tips and bent CNT tips for CD-AFM. Because the National Institute of Standards and Technology (NIST) has experience with CD-AFM metrology, the two organizations began collaborating during the mid-2000s on the application of CNT tips for CD-AFM metrology, and the initial results of this collaboration were published.27 | other | 99.4 |
In our initial effort, we used two different generations of CD-AFM instruments to evaluate ball-capped and bent-type CNT tips by imaging line/space gratings and a programmed line edge roughness specimen. We concluded that these CNT tips are capable of scanning the profiles of these features including re-entrant sidewalls, but there remain important challenges to address, including tighter control of tip geometry and careful optimization of scan parameters and algorithms for using CNT tips. | study | 100.0 |
This paper describes those initial results in detail and the current status of the effort as well as our plans. The primary emphasis here is to identify and examine the artifacts that may occur in CD-AFM imaging using CNT tips. The remainder of this paper is organized as follows. In Sec. 2, we describe two types of CNT tips developed by KRISS. The fabrication of these probes is described in Sec. 3. In Sec. 4, we show the measurement results. Our conclusions are summarized in Sec. 5. | study | 93.2 |
Figure 1 shows the types of CNT tips that we have developed at the Korea Research Institute of Standards and Science (KRISS) for new CD-probes. These are especially designed for dense lines where the tips should enter narrow trenches to probe the vertical sidewall surfaces. One is ball-capped (“B-tip” for short) and the other is bent (“J-tip” for short). The dimensions that we use to specify them are also illustrated. | other | 99.9 |
It is worth observing that probes with these general shapes are useful in coordinate measuring machine (CMM) metrology and stylus profilometry at larger length scales. If such tips can be implemented for AFM, then metrologists will be able to enjoy similar probing capabilities at the nanometer scale. | other | 99.9 |
The B-tip will provide similar advantages for AFM as the ball probe does for CMM metrology. It has a form that can enter the narrowest trenches or holes and probe both sidewalls. The extent of overhang or the degree of re-entrance that it can probe, however, is not as large as for the J-tip. The J-tip, on the other hand, is designed to probe one sidewall only, and cannot image the opposite one. It does, however, have a more effective geometry for imaging the bottom corner region—since the end is oriented at nearly normal to the local surface at the corner transition region—and in lithometrology applications, this region is of considerable interest. The J-tip provides a small vertical edge height (VEH), equal to the end radius of the CNT. This might be an advantage for some applications if the radius can be measured a priori. The J-tip may also be useful for experimental line-width measurement procedures in which two images taken in opposite sample orientation are stitched together to form a composite image.28 | study | 53.03 |
The functional geometry of CD-AFM tips is typically parameterized in terms of several metrics that help to quantify the expected performance and limitations of the tip for specific measurements. For our purposes here, we follow the most common convention, as described by Dahlen et al.29 The three metrics we will emphasize here are: (1) the tip width, which determines the smallest trench that can be measured, (2) the VEH, which limits the bottom portion of the sidewall that can be observed, and (3) the maximum overhang, which determines the limit of undercut or re-entrance of a sidewall that can actually be observed. | study | 99.75 |
For purposes of comparison between silicon CD tips and our CNT tips, we can derive the same types of tip metrics from the design dimensions of the CNT tips. For the B-tip, the tip width is 2rB, the overhang is rB − d/2, and the VEH is rB, where rB is the radius of the ball and d is the diameter of the CNT shaft. For the J-tip, these dimensions are lt sin θt + d/2, lt sin θt − d/2, and d/2, respectively, where lt is the length of the bent portion of the CNT, θt is the angle of bending, and d is the diameter of the CNT shaft. For B-tips, a typical value of d is 40 nm, and a typical value of rB is 30 nm. For J-tips, a typical value of lt is 200 nm, and a typical value of θt is 30 deg. | study | 100.0 |
It has been previously discovered that a focused ion beam (FIB) can align, bend, and straighten free-standing CNTs attached at one end to a substrate.30 Subsequently, it was discovered that sufficiently thin and high aspect ratio probes can be reproducibly treated the same way regardless of material composition.31 We also found that while the aligned CNTs were being irradiated by a parallel FIB from the top, a metal ball is formed at the CNT top end through ion beam-induced deposition (IBID). Since these processes are quite simple and are already described in the references, we do not discuss them in detail in this paper.23 By modifying the FIB process for straightening CNT tips on the manipulator, we have easily fabricated a B-tip as well as J-tips for CD-AFM as shown in Fig. 2. | study | 100.0 |
At the present time, the arc discharge-grown technique provides the best-quality CNT for probes, with diameters ranging from 10 to 40 nm. In order to fabricate unique shapes for CD probes, the CNT is first attached to a base tip so that the protrusion can be well aligned and have suitable length. | other | 99.44 |
There exist several methods reported so far for the fabrication of CNT tips. Each method has its own strengths and drawbacks. The simplest method is to attach a CNT directly to the base AFM tip manually using an acrylic adhesive while observing with an optical microscope.17 The method presents difficulties for accurate manipulation because an individual nanotube is not discernable with an optical microscope. A more sophisticated and expensive method is manufacturing in a vacuum chamber while viewing the individual nanotubes via a real time SEM image.32 Nanomanipulators installed in the SEM enable the manipulation with nanometer-level resolution. In contrast to the manipulation technique, some laboratories grow CNTs directly on AFM tips through chemical vapor deposition (CVD).19 With the CVD method, one can fabricate CNT tips on a wafer scale but some key issues not yet resolved include reproducible control of the length and growth direction of CNT. The FIB modification process described earlier can be applied to all CNT tips no matter how they are made, attached or directly grown, as long as they are not too poorly oriented. | review | 96.75 |
Until now, the method of using nanomanipulation in an SEM chamber is considered to produce the most accurate CNT tips. The mounting of the CNT is performed with the manipulator installed in an SEM, where a CNT is placed on the rear surface of the pyramidal silicon AFM mother tip, and then is glued using electron beam induced deposition of hydrocarbon. While the manipulation has sufficient resolution in the horizontal plane, normal to the e-beam direction, the vertical position cannot be distinguished within 1 µm or so because of the large depth of field of the SEM image. This makes impossible the precise 3-D manipulation of the CNT and AFM tip in space, resulting in a wide distribution of CNT attachment angles. One can improve this method by enabling the rotational motion of either or both the AFM tip and the CNT, with respect to the axis of the AFM tip, achieving an angle alignment precision as small as about 10 deg.33 | study | 99.9 |
Our fabrication of CNT tips consists of two separate steps: mounting of the CNT onto the AFM mother tip using manipulation in an SEM and the subsequent CNT modification using FIB. The procedure is shown in Fig. 2. CNT tips fabricated by manipulation in SEM are usually misoriented as made, so they are aligned in the FIB system through the ion beam bending (IBB) process. Thus processed, a CNT tip acts as a normal straight CNT tip, and the CNT itself maintains its elasticity as can be checked with a bending test in SEM.34 Using this process, we can change a “bad” tip to a “good” tip and a “good” tip to an “optimized” tip. The subsequent modification of CNT tips for CD-AFM starts with this straight form. It is noteworthy, however, that although IBB improves the tip geometry, ion bombardment is believed to introduce defects in nanotube structures, so minimization of dose is recommended. It is equally important to have a good nanotube tip prior to the IBB process. IBB-aligned CNT tips are then bent further to make the J-tip by irradiating the CNT end not masked by the cantilever, since the exposed part aligns opposite to the FIB direction whereas the unexposed part remains as is. Alternatively, FIB aligned CNT tips may be formed into B-tips by depositing platinum at the end using IBID. The organic platinum molecule adsorbed on the CNT is dissociated, and the platinum atoms form a ball at the top end of the nanotube while minimizing the surface energy. As the ball increases in size, it masks the CNT below, like an umbrella, so that the total increase in the shaft thickness is not significant. | study | 100.0 |
The optimum bending angle for a J-tip is dependent upon the desired application, since the geometry of the J-tip involves an inherent trade-off between performance on horizontal surfaces and vertical sidewalls. A bending angle of 90 deg might be optimum for imaging vertical sidewalls, since the tip would be normal to the surface. However, this would increase the geometrical clearance requirements of the tip in narrow trenches, and it would result in a blunt tip–sample contact region on horizontal surfaces, along with a corresponding impact on resolution. | other | 99.8 |
In terms of tip fabrication, with the cantilever mask, we cannot simultaneously control the angle and length of the bent CNT, which requires the employment of an independent mask. There is, however, still some flexibility to control the bending angle by controlling the FIB irradiation time. | other | 99.9 |
A complete description of CD-AFM principles and operation is outside the scope of this paper. However, the basic distinction between CD-AFM and conventional AFM is that CD-AFMs use two-axis (lateral and vertical) sensing of the tip–sample interaction and position control. In conventional AFM, the sensing of the tip–sample interaction is essentially limited to the vertical axis. When the two-axis tip control algorithm is combined with flared tips, it is possible to scan near-vertical and even re-entrant sidewalls. | study | 66.3 |
NIST has been working with different implementations of CD-AFM technology since the early 2000s and has experience characterizing the performance and uncertainties of three different CD-AFM instruments. One of the major goals of this effort has been the application of CD-AFMs as reference measurement systems for traceable dimensional metrology.35–37 The measurements described in this paper were primarily obtained on two CD-AFMs: (1) CD-AFM135 operates using a displacement measuring interferometer to detect the z-axis motion of the cantilever and (2) CD-AFM236 operates using a variation on the optical lever method to sense the cantilever motion. CD-AFM1 is thus capable of operating with lower vibration amplitudes than CD-AFM2. However, the larger cantilever vibration of CD-AFM2 means that it is potentially more robust against tip sticking. A logistical side note is that CD-AFM2 is not owned by NIST but belongs to a collaborating organization and is installed at their facility. However, its performance and uncertainties were characterized by NIST, and NIST personnel were permitted access to the instrument at the time of these measurements. Subsequent to our initial efforts, some results were also obtained using CD-AFM3, a newer instrument that is installed at NIST.37 CD-AFM3 has a more advanced tip control algorithm for scanning which can potentially reduce some imaging artifacts of CNT tips. | study | 99.94 |
In the following discussion, we elaborate on four experimental results that we have obtained by employing B- and J-tips in CD-AFM1 and CD-AFM2. For each measurement, the tip and sample geometries are given, and then the 3-D image and profiles are shown with short descriptions. The CNT tip-sample interaction is complicated and challenging to describe in general terms. More detailed models are being considered, but are beyond the scope of this paper. | study | 100.0 |
First, Fig. 4(a) shows the geometries of the platinum B-tip and the grating sample scanned in CD-AFM1. Figure 4(b) shows the resultant CD-AFM1 image composed of nine traces. The trace in front is for the tip moving to the right, the second trace is for the tip retracing and moving to the left, and so on. The measured profiles exhibit a slight re-entrance, consistent with the actual profiles, which indicates that the tip is functioning in concert with the two-dimensional feedback to track the actual sidewall. Due to the scale of the image, the sidewall re-entrance is not obvious, but it turns out to be ~10 nm, as observed both by silicon CD tips and CNT tips. More details on this sample are given in the Appendix, but our main goal here was the evaluation of CNT tip performance and not measurement of the grating. The length of each trace or scan line in Fig. 4(b) is nominally 4 µm, and each trace is offset by ~170 nm from the next one. The lines connecting the ends of the traces are not real but are just artifacts due to different numbers of adaptive sampling points in a trace and the plotting software used. This plotting artifact also appears in the rest of the CD-AFM1 and CD-AFM2 images in this paper. | study | 100.0 |
Figure 5 is the plot of one of the profiles from the image in Fig. 4(b). It has four typical artifacts found in CD-AFM profiles obtained with CNT tips. Artifact A in Fig. 5 is readily apparent. It is the rounding of the top corner, mostly or partly due to dilation from the interaction of the ball and the top corner. Artifact B is that the sampling interval is not uniform. This is because CD-AFMs operate using an adaptive scan mode, in which data are only taken when the surface sensing signal meets the condition set by the system. When the tip and sample are undergoing an abnormal or unstable interaction, such as that involved with flexing and sticking of the CNT tip, there will be significant portions of the profile for which there is no recorded data. In contrast, a typical CD-AFM flared tip shows more uniform sampling throughout most of the profile. Artifacts C and D are regarded as CNT tip-sample sticking either within or out of the range of modest control. The backtracking of the data as the tip scans up the sidewall (Artifact C) is extensively found in CD-AFM1 profiles, while artifact D is a rather typical distortion appearing in the profile when tip jumping occurs. | study | 100.0 |
Figure 6(a) shows the geometries of the J-tip and the same grating sample as in Fig. 4. Figure 6(b) is the CD-AFM1 image obtained. The length of the trace is nominally 5 µm, and each trace is offset by ~250 nm from the next. The trace and retrace are quite different, each having different artifacts, indicating that the tip operation was abnormal. To look more closely at the artifacts, both the trace and retrace profiles are shown in Fig. 7. | study | 100.0 |
Artifact E, as shown on the left of Fig. 7, is the result of feedback oscillation when the leftward foot of the J-tip is in contact with left tip corners of the grating. In normal operation, that part of the profile should have a rounded shape. More difficulty occurs in artifact F where the tip going down the sidewall begins to flex/buckle, and the cantilever keeps going, producing the apparent trenches (false height contrast), until the CNT relaxes to its undistorted shape at the point G. In the retrace, there are large feedback oscillations, artifact H, shown in the right of Fig. 7. These occur when the tip is scanning down the sidewalls, and it is expected that the vertical portion of the CNT is in contact with the sidewall as a whole. Additionally, the artifacts B and C that were observed using the B-tips (Fig. 5) are also apparent in the J-tip profiles shown in Fig. 7. | study | 100.0 |
Those various profile artifacts either do not appear or are much smaller if standard flared silicon CD-AFM tips are used. This fact strongly suggests that the root cause is the slenderness/flexibility of the CNT, which results in tip flexing and tip-sample sticking during scans. These tip behaviors are not completely controlled by the AFM control algorithms, which were not originally developed for such flexible tips. CD-AFM2 has a more advanced tip control algorithm than CD-AFM1, so the performance of J-tips on CD-AFM2 was generally better than on CD-AFM1. However, since the instrument is located at a non-NIST facility, we used different tips and samples with CD-AFM2 than with CD-AFM1. Some of the results obtained using a J-tip with CD-AFM2 are shown in Fig. 8. | study | 100.0 |
Figure 8(a) shows the geometries of the J-tip and the grating sample. Figure 8(b) shows the image obtained with CD-AFM2 and is composed of five traces and five retraces, alternately. The length of the trace is 10 µm, and each trace is offset by 200 nm from the next one. At a glance we can see that the image is much cleaner than the earlier images. One of the profiles is shown in Fig. 9(a). The apparent sticking-related artifacts C and D are not seen anymore, except for nonuniform sampling intervals. This is because the abnormal signal is treated properly so that the empty points do not distort the measured profile. Assuming similar interactions of the J-tip and the grating, we can conclude that the scan algorithm for dealing with such interactions has superior performance in this instrument. For comparison, another CD-AFM2 image of the same grating but with the less flexible I-tip (i.e., a vertical and straight CNT tip) is shown in Fig. 9(b). Note that this grating has non-re-entrant sidewalls with an outward slope of about 85 deg. The sampling is quite uniform in the more densely spaced data points. Therefore, another possible conclusion is that the remaining issue of nonuniform sampling with the J-tip is still due to nanotube slenderness. This nonuniform sampling could be addressed by either stiffening the CNT or by more sophisticated control of the tip–sample interaction. | study | 100.0 |
Apparent sidewall angles (SWA) were extracted from the measured profiles [Fig. 9(a), tip moving leftward] and were calculated using offline analysis software. The middle band of the sidewall (from 25% to 75% of the feature height) was determined for each edge and then the sidewall slope was determined from a linear fit to this segment of the edge. These results were averaged for all of the left and right edges in each scan line, and then averaged over all of the scan lines in each image. Table 1 shows the results of this SWA analysis for the J-tip scan shown in Fig. 9(a). The right edges of the features, which are in contact the end of tip foot, exhibit a larger apparent SWA than the left edges which contact the tip on the opposite side of the foot. Table 2 shows the apparent SWA extracted from a profile of the same grating imaged using an I-tip. The observed standard deviation of the SWA is relatively larger for the J-tip than for the I-tip, which means that the measurements using the J-tip were less stable. In contrast, the results obtained using the I-tip show symmetric SWA in the measured profile as well as better stability. | study | 100.0 |
Another performance test we ran was to scan a programmed line edge roughness (LER) sample with CD-AFM2 using a J-tip. This type of LER sample was originally developed for testing CD-SEM measurements of LER during lithography development and optimization.38 The actual feature sidewalls are normally close to vertical, and may also be slightly re-entrant depending upon the details of the etch for a given sample. More discussion is included in the Appendix, but the primary characteristic of the programmed LER features is a periodic variation in linewidth having different spatial frequencies and amplitudes on different targets. | study | 99.7 |
A J-tip image of the LER sample taken using CD-AFM2 is shown in Fig. 10, along with the SEM images of the J-tip and schematics of the tip and sample geometries. The actual image is composed of 25 traces and retraces, and it is shown in both top-down and perspective views in Fig. 10(b). The length of each scan line is 10 µm, and each scan line is offset by 20 nm in the slow scan axis. The image shows that the performance of the tip during scanning was reasonably stable, and this is further seen in the extracted profile from the image shown in Fig. 11. The apparent rounding of the left edge is due to the tip–sample dilation. Since the leftward foot of the J-tip has a height which is comparable to the pattern height, most of the apparent left sidewall is a mirror image of the bent side of the J-tip. There is also no discernible difference between the trace and retrace profiles which was problematic for much of the CD-AFM1 data. | study | 100.0 |
Using FIB processes that enable the geometrical modification of straight and aligned CNT tips, it is possible to fabricate CNT tips that are tailored for CD-AFM applications. Some examples developed by KRISS are the platinum ball-capped (B-tip) and the bent CNT tip (J-tip), which can reach re-entrant sidewalls and enter very narrow trenches or holes. The B-tip geometry more closely resembles the functional geometry of conventional CD-AFM tips and so is more generally applicable than the J-tip. However, as discussed more in the Appendix, the J-tip may be useful for cases of sidewall re-entrance exceeding 10 nm, which is the approximate limit of most conventional CD-AFM tips. Using two different instruments, KRISS and NIST evaluated the performance of these two tip types for CD-AFM metrology, and the initial results were promising. | study | 99.94 |
Since our first experiments in this area, there have been improvements in CNT tip fabrication methods, both in general and specifically in terms of the performance of the system at KRISS. Implementing analog control of the nanomanipulation in the SEM has improved the accuracy of CNT mounting compared to the previous digital control system. Consequently, the subsequent step of FIB alignment is no longer necessary. We have also implemented a new method of CNT cutting that uses electron beam etching instead of electrical cutting. As a result, the cutting precision has been improved by about an order of magnitude: from 300 nm down to 30 nm. | study | 99.94 |
There have also been improvements in CD-AFM technology since our initial work. Specifically, tip scanning and control algorithms show improved stability and performance on instruments such as CD-AFM3.We are currently conducting experiments on newer CNT tips using this instrument. A preliminary example of some of these results is included in the Appendix. | other | 99.8 |
In our continuing work, we plan to test CNT tips of these types with dimensions optimized for more challenging samples, including different materials and narrower trenches. Using the flexible fabrication techniques described here, we also plan to develop new kinds of nanoprobes that can address CD and LER measurements for current technology nodes. Although our fabrication method is not compatible with the requirements of mass production, we believe that a demonstration of effective tip geometries will motivate the development of alternative wafer-scale production techniques by other laboratories and will enable the advancement of CD-AFM capability. | study | 99.9 |
There is considerable evidence from systematic reviews for children and adolescents that eating breakfast is associated with a reduced risk of becoming overweight or obese and a reduction in body mass index (BMI) [1, 2]. For example, Swiss children regularly consuming breakfast showed better motor functional skills and were less overweight . For schoolchildren, breakfast plays a positive role in maintaining cognitive function during the morning . Furthermore, English children who regularly consumed breakfast had a more favorable type 2 diabetes risk profile and Greek schoolchildren showed an inverse association of breakfast consumption with HOMA-IR (homeostasis model assessment of insulin resistance index) . In obese children and adolescents, skipping breakfast is correlated with higher levels of blood glucose, triglycerides and very low density lipoprotein cholesterol . Finally, in Canadian children and adolescents, breakfast consumption is positively associated with nutrient adequacy . | review | 99.9 |
In a recent study, we identified skipping breakfast as one of the modifiable influencing factors for developing abdominal obesity in primary schoolchildren . This finding is supported by a study of Alexander and colleagues who were able to demonstrate that higher visceral adiposity was associated with skipping breakfast in overweight Latino youth . Abdominal obesity is more and more recognized as the most risky kind of obesity, as it is strongly associated with the majority of non-communicable diseases (NCD), the world’s number one killer [11, 12]. Furthermore, a remarkable number of persons who are normal weight according to BMI definition, are abdominally obese and e.g. for subjects with coronary artery disease, those who are normal weight but abdominally obese carry the highest risk of mortality . Concerning children, a meta-analysis revealed that BMI fails to identify excess adiposity in over a quarter of the affected children . A longitudinal study comparing BMI and waist circumference in children concludes “Children appear to be getting fatter and the additional adiposity is being stored centrally which is not detected by BMI” . Those children with abdominal obesity already have a lower health related quality of life, more days of absence at school and more visits to a physician . | study | 99.94 |
According to the literature, the frequency of breakfast intake decreases with age in children and adolescents [1, 8, 17]. Systematic reviews report associations of skipping breakfast in youth with lower socioeconomic status, lack of physical activity, frequent use of screen media, higher energy intake, unhealthy eating habits and other unhealthy lifestyle factors such as smoking and alcohol use [1, 17]. All in all, girls were more likely to skip breakfast than boys [1, 17]. | review | 99.9 |
Our study was embedded in the outcome evaluation of the health promotion program “Join the Healthy Boat”. This program includes health promotion in the curriculum of grades one to four at primary school and combines behavioral and environmental components. Children are empowered to make healthy choices in terms of physical activity, consumption of sugar sweetened beverages, and use of screen media. The aim of the present study is to look at factors that are associated with skipping breakfast in schoolboys and -girls in order to improve preventive and health promoting measures and to help respective multicomponent interventions to reach their goal of promoting healthy weight in children. | study | 99.94 |
The health promotion program “Join the Healthy Boat” was based on the successful “URMEL ICE” project (Ulm Research on Metabolism, Exercise and Lifestyle Intervention in Children), to the author’s knowledge the only school-based prevention program in Germany with proven cost-effectiveness . | other | 99.9 |
The present study was embedded in the baseline-measurements of the outcome evaluation of the school-based health promotion program “Join the Healthy Boat” in the state of Baden-Württemberg, Germany, in the year 2010. The “Baden-Württemberg Study” followed a cluster-randomized design with a waitlist control group. A more detailed description of the study can be found elsewhere . | study | 99.94 |
All children in classes of teachers who agreed to participate in the outcome evaluation were eligible (3,159 pupils). Parents of 1,968 first and second graders in 84 schools (5.4 – 9.9 years old), 62% of all eligible children, gave their consent for participation in 2010. Response rate for parental questionnaires was 87% at baseline. Data from direct measurements at schools or from parental questionnaires were available for 1,943 children at baseline. Parents gave information on their health behavior and their socioeconomic background, as well as on the health and lifestyle characteristics of their children. | study | 100.0 |
The parental education level was assessed and determined according to the CASMIN (Comparative Analysis of Social Mobility in Industrial Nations) educational classification . CASMIN classifies tertiary level as higher educational levels (e.g. academically-oriented university education), while secondary level includes a range from intermediate vocational qualification to full maturity certificates (equals 12–13 years of school in Germany), and primary level comprises inadequately completed general education to basic vocational qualification. Family education level was defined as the highest level of two parents or the level of a single parent who mainly cares for the child. For analyses, family education level was dichotomized into tertiary versus intermediate and elementary level. Household income was assessed in several categories according to the German KiGGS survey (German Health Interview and Examination Survey for Children and Adolescents) and dichotomized for analyses at a threshold of €1,750. A migration background was assumed if at least one parent was born abroad or at least one parent had mainly spoken a foreign language during the child’s first years of life. | study | 100.0 |
Questions about children’s behavior were taken from the validated questionnaires of the German KiGGS survey . Answers were offered on a 5-point Likert scale for frequency of consuming soft drinks, frequency of playing outside (nearly every day, 3–5 times a week, 1–2 times a week, less than 1 time a week, never), and time spent with screen media (never, about 30 min/day, about 1–2 h/day, about 3–4 h/day, more than 4 h/day). Variables were dichotomized for analyses (soft drinks > 1/week, playing outside > 60 min/day, screen media > 1 h/day). Information on the frequency of participation in club sports were retrieved in an open question and results were dichotomized for analyses (> 1/week). Parents gave information on the frequency of breakfast before school for their children on a 4-point scale, the results were subsequently dichotomized for analyses (never, rarely vs. often, always). Furthermore, parents stated how many days a week their children were physically active on a moderate to vigorous level (starting to sweat and/or get out of breath) for at least 60 min a day, as recommended by the World Health Organization (WHO) . Results were dichotomized for analyses at the median (physically active ≥ 4 days/week ≥ 60 min/day). Lastly, parents were asked whether they were smokers, and they rated their health awareness on a 4-point scale, the latter variable being then dichotomized for analyses (not at all, little vs. strong, very strong). | study | 100.0 |
Trained staff conducted the anthropometric measurements of the children according to ISAK-standards . The children’s height was measured to the nearest 0.1 cm (Stadiometer, Seca®, Germany), and body weight to the nearest 0.1 kg using calibrated and balanced portable digital scales (Seca®, Germany). Waist circumference (WC) was measured midway between ileac crest and lower costal arch to the nearest 0.1 cm using a flexible metal tape (Lufkin Industries Inc., Texas, USA). The children’s BMI was calculated as weight divided by height squared [kg/m2]. Excess weight and obesity were defined at or above the 90th and 97th age- and gender-specific BMI percentiles according to German reference data . Waist- to-height ratio (WHtR) was calculated as the ratio of WC and height in centimeters, participants with a WHtR ≥ 0.5 were then categorized as abdominally obese . Because there was some doubt the WHtR threshold of 0.5 was sensitive enough, a lower threshold (0.47 for girls and 0.48 for boys) as proposed by Nambiar et al. , correlating with the 95th percentile for %body fat, was added. | study | 100.0 |
Parental BMI was calculated with self-reported weight and height data from the questionnaires, and categorized as overweight (BMI ≥ 25.0) and obese (BMI ≥ 30.0), according to the international classification of the WHO . Parental WHtR was calculated as self-reported WC divided by height in centimeters and abdominal obesity was defined as WHtR ≥ 0.5 . | study | 99.94 |
Missing data are a frequently occurring problem in observational studies, possibly leading to biased results . Therefore, potential significant baseline differences between cases with and without missing values for the full regression model were examined. | study | 99.94 |
Differences between boys and girls, as well as between participants with and without missing values, were tested for their statistical significance. Depending on scale level and distribution of the data, the Mann–Whitney-U test or t-test for continuous data and Fisher’s exact test for categorical data were applied. The significance level was set at α = 0.05 for two-sided tests. These analyses were carried out using the statistical software packages IBM SPSS Release 21.0 for Windows (SPSSInc, Chicago, IL, USA). | study | 99.94 |
To identify a possible clustering effect of data in schools, the intraclass correlation coefficient (ICCLogit) for a generalized linear mixed model with binary outcome was calculated according to Eldridge et al. . Depending on the magnitude of the ICCLogit, the appropriate regression analysis, a logistic or a generalized linear mixed model, was conducted subsequently, considering the variables described above. A closer examination of decisive factors for target groups and target behaviors was realized in two sub-models. These analyses were performed with the statistical software R Release 3.2.5 for Windows (http://cran.r-project.org/). | study | 100.0 |
Primary school children who took part in this research had a mean age of 7.1 ± 0.6 years, 51.2% of them were boys. Table 1 shows the baseline characteristics of the participants. Significant differences between boys and girls occurred in anthropometric variables where boys had a slightly higher waist circumference but were less frequently at or above the 95th percentile for %body fat. They also had a different distribution of WHtR with a lower variance and range than girls. Boys more often played outside and reached higher levels of physical activity. Girls more often skipped breakfast than boys.Table 1Baseline characteristics of participants in the Baden-Württemberg Study (2010)MissingBoysGirlsTotalValues(n = 995)(n = 948)(n = 1,943)Child characteristics Age, years [m (sd)]7.09 (0.64)7.06 (0.63)7.08 (0.64) Migration background, n (%)297255 (30.9)270 (32.9)525 (31.9) BMIPERC, [m (sd)]5048.78 (27.87)49.14 (27.92)48.96 (27.89) Overweight, n (%)5054 (5.6)54 (5.9)108 (5.7) Obesity, n (%)5049 (5.1)34 (3.7)83 (4.4) Waist circumference, [m (sd)]5555.98 (5.83)***a 55.16 (5.90)55.58 (5.88) WHtR, [m (sd)]550.45 (0.04)*0.45 (0.04)0.45 (0.04) Abdominal obesity, n (%)5573 (7.5)85 (9.2)158 (8.4) ≥ 95th percentile for %body fat, n (%)55128 (13.2)***a 211 (22.9)339 (18.0)Parental characteristics Single parent, n (%)26582 (9.7)95 (11.4)177 (10.5) Tertiary family educational level, n (%)215262 (31.8)261 (32.5)523 (32.1) Household income ≤ €1,750, n (%)452101 (13.4)106 (14.4)207 (13.9) Overweight/obesity (mother or father), n (%)332532 (65.0)542 (68.3)1074 (66.7) Abdominal obesity (mother or father), n (%)974405 (82.7)407 (85.0)812 (83.8) Smoking (mother or father), n (%)270309 (36.9)319 (38.2)628 (37.5) Health awareness (mother or father), n (%)343541 (67.4)539 (67.6)1080 (67.5)Health and lifestyle characteristics Skipping breakfast, n (%)23689 (10.4)**134 (15.8)223 (13.1) Soft drinks > 1/week, n (%)241219 (25.6)197 (23.3)416 (24.4) Playing outside > 60 min/day, n (%)296615 (73.8)***515 (63.3)1130 (68.6) Physically active ≥ 4 days/week ≥ 60 min/day, n (%)320260 (31.7)***177 (22.1)437 (26.9) Club sports > 1/week, n (%)662338 (52.0)338 (53.6)676 (52.8) Screen media > 1 h/day, n (%)250173 (20.4)146 (17.3)319 (18.8) NOTE. m mean, sd standard deviation, BMI body mass index, BMIPERC BMI percentiles, WHtR waist-to-height ratio aMann–Whitney-U test, *p < 0.05, **p < 0.01, ***p < 0.001 | study | 99.94 |
Unadjusted, crude odds ratios (OR) for skipping breakfast for all variables in the subsequent generalized linear mixed regression models are illustrated in Table 2.Table 2Crude OR for independent variables taken into account in the generalized linear mixed regression model for skipping breakfastMissingCrudeValuesOR95% CIChild characteristics Female gender2361.62(1.22; 2.16) Age > 7 years2811.04(0.78; 1.37) Migration background3033.60(2.67; 4.84) Overweight4712.02(1.18; 3.43) Obesity2861.94(1.03; 3.66) Abdominal obesity2902.51(1.63; 3.88) ≥ 95th percentile for %body fat2902.20(1.58; 3.07)Parental characteristics Single parent2712.45(1.68; 3.58) Tertiary family education level3210.34(0.22; 0.50) Household income ≤ €1,7504573.48(2.46; 4.94) Overweight/obesity (mother or father)3381.89(1.33; 2.67) Abdominal obesity (mother or father)9781.16(0.66; 2.03) Smoking (mother or father)2762.60(1.94; 3.49) Health awareness (mother or father)3490.70(0.52; 0.96)Health and lifestyle characteristics Soft drinks > 1/week2442.78(2.07; 3.73) Playing outside > 60 min/day3010.67(0.50; 0.90) Physically active ≥ 4 days/week ≥ 60 min/day3260.62(0.43; 0.90) Club sports > 1/week6671.03(0.72; 1.48) Screen media > 1 h/day2562.97(2.18; 4.04) NOTE. N = 1,943. OR odds ratio, CI confidence interval | study | 99.94 |
In the bivariate analysis, female gender, migration background, variables of overweight and obesity, single parenthood, lower household income, parental overweight and obesity, parental smoking, one or more soft drinks per week, and screen media use exceeding 1 hour per day had higher odds for skipping breakfast. On the other hand, tertiary family education level, parental health awareness, playing outside more than 60 min per day, and physical activity of more than 60 minutes on 4 days and more per week showed lower odds for skipping breakfast. The ICCLogit of skipping breakfast was 0.045, indicating that 4.5% of the total variance is due to clustering of data in schools. This would lead to differences in the ORs between a logistic regression model and a generalized linear mixed model. Therefore, the model presented here is the generalized linear mixed model for binary outcomes, which accounts for the clustering of data in schools. Table 3 shows both the results of the full model and of sub-models for groups and behaviors for targeted preventive measures.Table 3Generalized linear mixed models for skipping breakfast, full and sub-models for target groups and behaviorsFull modelSub-model target groupsSub-model target behaviors(n = 1,441)(n = 1,515)(n = 1,612)OR95% CIOR95% CIOR95% CIMigration background2.39***(1.68; 3.40)2.81***(2.02; 3.91)Tertiary family education level0.55**(0.35; 0.85)0.42***(0.28; 0.64)Single parent2.17**(1.33; 3,54)2.13**(1.34; 3.40)Female gender1.53*(1.07; 2.18)1.43*(1.03; 1.99)≥95th percentile for %body fat1.51† (0.99; 2.24)1.47† (1.00; 2.17)Soft drinks > 1/week2.41***(1.70; 3.44)2.49***(1.81; 3.43)Physically active ≥ 4 days/week ≥ 60 min/day0.71(0.47; 1.07)0.64*(0.44; 0.93)Screen media > 1 h/day1.91***(1.31; 2.79)2.48***(1.77; 3.46) NOTE. OR odds ratio, CI confidence interval†p < .10; *p < .05; **p<. 010; ***p < .001 | study | 99.94 |
A higher level of physical activity and tertiary family education level showed lower odds for skipping breakfast. On the other hand, migration background, single parenthood, female gender, percentage of body fat at or above the 95th percentile, and frequent soft drink and screen media consumption had higher odds. | study | 87.6 |
Further sub-models were calculated for boys and girls, they are depicted in Table 4.Table 4Generalized linear mixed models for skipping breakfast, sub-models for boys and girlsSub-model girlsSub-model boys(n = 767)(n = 758)OR95% CIOR95% CIMigration background2.51***(1.60; 3.93)3.63***(2.10; 6.28)Tertiary family education level0.36**(0.17; 0.74)Single parent2.95***(1.64; 5.31)≥95th percentile for %body fat1.56† (0.97; 2.52)Soft drinks > 1/week2.12**(1.33; 3.38)2.88***(1.68; 4.94)Physically active ≥ 4 days/week ≥ 60 min/day0.55† (0.29; 1.04)Screen media > 1 h/day2.62***(1.60; 4.31) NOTE. OR odds ratio, CI confidence interval†p < .10; *p < .05; **p<. 010; ***p < .001 | study | 99.94 |
The sub-model for girls showed higher odds for migration background, single parenthood, percentage of body fat at or above the 95th percentile, and frequent soft drink and screen media consumption. In the sub-model for boys lower odds were found for a higher level of physical activity and tertiary family education level. | study | 99.94 |
Participating children with missing data, significantly, more often had a migration background, lower results in the 6 min run test, and they differed in all anthropometric measurements from the ones with complete data. Participants with missing data had significantly higher BMI percentiles, more often were overweight and obese, and more often had a higher waist circumference and a higher WHtR. They also were more often abdominally obese and more often had a percentage of body fat at or above the 95th percentile than their counterparts. Finally, their parents were significantly more often single parents, less frequently had a tertiary educational level and more often a household income at or below €1,750. | study | 100.0 |
The study shows that migration background, living with a single parent, female gender, having a percentage of body fat at or above the 95th percentile, the consumption of soft drinks and high levels of screen media use are positively correlated with children skipping breakfast. Reaching high levels of physical activity and tertiary family education level are negatively correlated with skipping breakfast. Accordingly, interventions that influence the reported target behaviors as well as those that are tailored to the identified target groups are necessary. Behavioral changes can be addressed in all kinds of interventions at different levels. Differences between boys and girls should be taken into account according to the gender distribution in the respective target group. | study | 99.94 |
First, parents should be informed about the importance of a healthy lifestyle and health-conscious behavior, such as responsible media consumption, sufficient physical activity, little or no soft drink consumption and most of all the importance of a regular breakfast. Furthermore, parents should be supported in their essential function as a role model for their children and demonstrate healthy breakfast habits. Therefore, interventions should synergistically promote children’s health and involve their parents in order to be successful . At an organizational level, teachers could inform parents about the need for regular and healthy breakfast for children at parents’ evenings because there are positive effects of breakfast frequency and quality for both parents and children . | other | 99.9 |
Some of the identified family-related factors for skipping breakfast are non- or hardly modifiable, like migration background, family education level and single parenthood. Despite these difficult socioeconomic circumstances (e.g. poor housing, living and working conditions, worries, uncertainty) in which parents have to bring up their children, many of them may be aware of the importance of a healthy lifestyle but lack the necessary resources to implement it. The most promising way to reach children from families with these traits runs via settings like schools or kindergarten. The latter should offer regular breakfast at the start of a school or kindergarten day. In this way, all children are reached and skipping breakfast can be avoided. When developing measures for targeted prevention, there should be a special focus on the needs of the target groups identified in this study. Families in difficult socioeconomic circumstances need to be supported and provided with financial assistance for the payment of breakfast and/or other healthy meals at school. Thus, policy makers and intervention developers have to note that there are low-threshold and easily accessible opportunities required for reaching deprived target groups. Not least, policy makers should support healthy eating habits in schools and kindergartens at all times. | other | 99.7 |
Although the importance of breakfast consumption to young children’s health is generally known, there is an increasing prevalence of children skipping breakfast [34, 35]. Food behaviors established in childhood are often continued into adulthood . Therefore, it is necessary to identify the determinants of skipping breakfast. Based on these determinants, interventions for preventing skipping breakfast and promoting healthy dietary behaviors among children can be developed. | other | 87.4 |
The parental role in the development of children’s healthy breakfast behaviors is not questioned . Pearson et al. report in their review on family correlates of breakfast consumption that parental breakfast intake is associated with the breakfast intake of their children . Furthermore, they found out that living in two-parent families also has a positive influence on children’s and adolescent’s breakfast consumption . The research from Wendy & Campbell also shows that children with single parents are more likely to skip breakfast than those with two parents . These findings confirm the results of the present study that also found evidence for a relation between family structures and skipping breakfast. Therefore, it is important to consider family structures of the children when designing programs to promote healthy breakfast behavior’s. | review | 99.9 |
Associations between parenting and children’s breakfast consumption were found for permission to skip breakfast and parental self-efficacy of skipping breakfast which were negatively associated with children’s breakfast consumption . Another study by Fugas et al. shows further reasons for skipping breakfast: lack of time, not being hungry in the morning and feeling unwell at the time of having breakfast are identified as explanations for skipping breakfast before going to school . Similar to our findings that girls are more likely to skip breakfast than their male peers, other studies showed that breakfast consumption was more frequent among boys [42, 43]. This result could be explained by the likelihood that even young girls care more about their appearance and a slim figure . A further study found out that adolescent boys and girls are more likely to skip breakfast if they perceived that their mothers often skip lunch . Equal results are available for girls skipping breakfast with regard to their best friend’s meal skipping behaviors. On the contrary, those who reported exemplary maternal healthy eating behaviors were less likely to skip breakfast . These findings underline the importance of interventions to address parents, children and their peers simultaneously. | study | 99.94 |
The investigations of Keski-Rahkonen et al. and Utter et al. show an association between skipping breakfast and having a higher BMI [43, 46]. Research on breakfast intake and abdominal obesity parameters are rare. Alexander et al. report that eating breakfast was associated with lower visceral adiposity in overweight Latino youth, aged 10 to 17 years . In a survey of Iranian children and adolescents aged 6 to 18 years the percentage of abdominal obesity in breakfast skippers was almost 5 percentage points higher than in non-skippers . A French study in primary schoolchildren showed that those who regularly eat breakfast had the lowest waist circumferences . | review | 89.2 |
There are many studies showing a positive relationship between skipping breakfast and a low socioeconomic status [42, 49]. In the present study, children with migration background were more likely to skip breakfast than their counterparts and a tertiary family education level was positively associated with having breakfast. | study | 100.0 |