health articles 2021

Healthy Living Guide 2020/2021

A digest on healthy eating and healthy living.

As we transition from 2020 into 2021, the COVID-19 pandemic continues to affect nearly every aspect of our lives. For many, this health crisis has created a range of unique and individual impacts—including food access issues, income disruptions, and emotional distress.

Although we do not have concrete evidence regarding specific dietary factors that can reduce risk of COVID-19, we do know that maintaining a healthy lifestyle is critical to keeping our immune system strong. Beyond immunity, research has shown that individuals following five key habits—eating a healthy diet, exercising regularly, keeping a healthy body weight, not drinking too much alcohol, and not smoking— live more than a decade longer than those who don’t. Plus, maintaining these practices may not only help us live longer, but also better. Adults following these five key habits at middle-age were found to live more years free of chronic diseases including type 2 diabetes, cardiovascular disease, and cancer.

While sticking to healthy habits is often easier said than done, we created this guide with the goal of providing some tips and strategies that may help. During these particularly uncertain times, we invite you to do what you can to maintain a healthy lifestyle, and hopefully (if you’re able to try out a new recipe or exercise, or pick up a fulfilling hobby) find some enjoyment along the way.

Download a copy of the Healthy Living Guide (PDF) featuring printable tip sheets and summaries, or access the full online articles through the links below. 

In this issue:

• Understanding the body’s immune system
• Does an immune-boosting diet exist?
• The role of the microbiome
• A closer look at vitamin and herbal supplements
• 8 tips to support a healthy immune system
• A blueprint for building healthy meals
• Food feature: lentils 
• Strategies for eating well on a budget
• Practicing mindful eating
• What is precision nutrition?
• Ketogenic diet
• Intermittent fasting
• Gluten-free
• 10 tips to keep moving
• Exercise safety
• Spotlight on walking for exercise
• How does chronic stress affect eating patterns?
• Ways to help control stress
• How much sleep do we need?
• Why do we dream?
• Sleep deficiency and health
• Tips for getting a good night’s rest

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Public Health

How health care in the u.s. may change after covid: an optimist's outlook.

John Henning Schumann

Many of the changes in health care that happened during the pandemic are likely here to stay, such as conferring with doctors online more frequently about medication and other treatments. d3sign/Getty Images hide caption

Many of the changes in health care that happened during the pandemic are likely here to stay, such as conferring with doctors online more frequently about medication and other treatments.

With more than one-third of U.S. adults now fully vaccinated against COVID-19, there's growing optimism on many fronts. A majority of states have either lifted health-related restrictions or have announced target dates for doing so.

Already, many clinicians and health policy experts are thinking about what the post-pandemic world will look like.

COVID-19 demonstrated that even in a behemoth industry like health care, change can come quickly when it's necessary. Patients understandably avoided hospitals and clinics because of the risk of viral exposure — leading to quick opportunities for innovation.

For example, the use of telemedicine skyrocketed, and many think it's an innovation that's here to stay. Patients like the convenience — and for many conditions, it's an effective alternative to an in-person visit.

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Telehealth tips: how to make the most of video visits with your doctor.

Dr. Shantanu Nundy , for one, is optimistic about the future of health care in the U.S. He is a primary care physician practicing just outside Washington, D.C., and the chief medical officer at Accolade, a company that helps people navigate the health care system.

Nundy has bold views, based on his current roles as well as prior positions with the Human Diagnosis Project , a crowd-sourcing platform for collaboration on challenging medical cases, and as a senior health specialist for the World Bank, where his work took him to Africa, Asia and South America.

He spoke with Shots about his new book , Care After Covid: What the Pandemic Revealed Is Broken in Healthcare and How to Reinvent It .

This interview has been edited for length and clarity.

You seem pretty optimistic about changes to U.S. health care because of the pandemic. What changes or new practices do you think are most likely to stick around?

I am optimistic. Health care has changed more in the past year than during any similar period in modern U.S. history. And it changed for the better.

Doctors and other front-line workers finally started meeting patients where they are: in the community (e.g., at drive-through testing and mass vaccination sites), at home (e.g., with house calls and even hospital-level care at home), and on their devices. Doctors and patients connected in new ways: In my clinic, which serves low-income patients in the Washington, D.C., area, I was given an iPhone for the first time for video and audio visits and found myself messaging with patients between visits to refill medications or follow up on their symptoms.

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Some of these changes will reverse as things get back to normal, but what won't change is the fundamental culture shifts. The pandemic magnified long-standing cracks in the foundation of the U.S. health care system and exposed those cracks to populations that had never witnessed them before. All of us — not just patients with chronic diseases or patients who live at the margin — have the shared experience of trying to find a test or vaccine, of navigating the byzantine healthcare system on our own.

The crisis also exposed just how inequitable the health care system is for Black and brown communities. The numbers don't lie — these populations died of COVID-19 at a rate much higher than their white counterparts. I'm hopeful these shared experiences and revelations have created the empathy and impetus to demand change.

Coronavirus Updates

Studies confirm racial, ethnic disparities in covid-19 hospitalizations and visits.

Your book envisions a care framework that will be "distributed, digitally enabled, and decentralized." Let's take them one at a time. What do you mean by "distributed care?"

"Distributed care" refers to the notion that care should happen where health happens, at home and in the community. We need to redistribute care from clinics and hospitals to homes, pharmacies and grocery stores, barbershops and churches, workplaces and online, where patients are on-the-go. This doesn't mean we should eliminate traditional health care settings. Hospitals and clinics will continue to play a major role in health care delivery, but for most people, these will become secondary, rather than primary, sources of care.

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The most obvious upside to distributed care is that it's more affordable. Without the overhead costs of expensive medical facilities, costs decrease. It also has the potential to be more effective and equitable. Our health is largely driven by our behaviors and our environment. By delivering it where we live and work, care can better address the root causes of poor health, including social isolation, poor nutrition, physical inactivity, and mental and emotional distress. Distributed care can also reach communities too far from the nearest clinic or hospital — or who are too distrustful to even step foot in one.

Racial Equity In Vaccination? Dialysis Centers Can Help With That

We already have digitally enabled care to some extent: We use apps, our medical records are electronic, and many of us have now used telemedicine to connect with clinicians. What is your vision of the future of "digitally enabled care?"

"Digitally enabled" refers to the idea that the right role of technology in health care is simply to increase the care in healthcare. ... For a glimpse of what's possible, I'll share my mom's experience during the pandemic. For 25 years, she struggled with Type 2 diabetes (and for the past 10 years, has been on insulin). But faced with all the reports of patients with diabetes having higher rates of COVID-19 complications, she signed up for a virtual diabetes service that was completely different than anything she had tried in the past two decades.

She was shipped a free glucose meter and weighing scale to send her data to her new diabetes care team. She downloaded a mobile app where she did video visits with her doctor — more frequently than she ever had in person — and 24/7 access to a health coach that she sometimes messaged with multiple times per day in the first few weeks of the program. She also was connected with another patient — a gentleman in Chicago who, like my mom, followed an Indian vegetarian diet — to exchange recipes with. The result: Within weeks, my mom lost over 10 pounds and safely got off of insulin. Nearly a year later, she still is.

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How do you envision future care that is decentralized? Will U.S. health care become more of a do-it-yourself industry?

"Decentralized care" refers to a model where decisions about care are in the hands of those closest to it, including doctors and patients.

But health care is highly centralized and heavily regulated, and what doctors can d o often comes down to what we can charge insurance companies for.

One example: I had a patient who was in and out of the hospital for heart failure. After one of these hospitalizations, I saw her in-clinic and learned that she didn't have a scale and couldn't afford one. Daily weigh-ins are critical for patients like her, as a few pounds gained can be an indicator of impending heart failure. So, I handed her a $20 bill from my pocket for a scale, and she was never admitted to the hospital again. If our health care system was decentralized, I would be able to get my patients the $20 piece of equipment they need instead of racking up thousands of dollars in expensive medical tests and hospitalizations.

With all of the innovation you foresee, will there be actual market-based competitive pricing reform, or will all of the whistles and bells just drive health care costs inexorably upward?

The type of innovation we need most is true "disruptive innovation." This is a term that gets thrown around liberally, but the real definition refers to products or services that dramatically lower prices and increase quality, much more so than those currently available.

I see two steps we must take to get there: First, we need to stop nibbling around the edges. Often, our solution to, say, Type 2 diabetes, is training doctors in better management or approving a drug that is 1% better (and 200 times more expensive) than what we have now. A truly disruptive innovation is what my mom used: a digitally enabled service that reversed her diabetes and got her off of insulin completely.

Second, we need to get out of our own way. Early on in the pandemic, when we finally allowed patients to test themselves for COVID-19, we still required a doctor to sign off on the test. Patients filled out a questionnaire and a doctor then needed to scan through dozens of forms an hour to approve or reject the test applications (these were almost always approved). That's crazy! Now, we've finally let doctors off the hook, and patients can walk into a CVS or Walgreens to pick up a rapid COVID-19 test over the counter.

What are some ways that your future vision could go off the rails and lead us toward a care system that is less open, less transparent or less patient-centered?

The biggest threat is the continued monopolization of health care. In many parts of the country, there are only one or two large health systems and a few options for health insurance. This drives up prices with little to no benefit for patients or doctors.

Will the lessons of COVID-19 make us more prepared, and our health care system more adept for the next global challenge?

Absolutely. The pandemic has created medicine's greatest generation. By shepherding this country through the crisis, an entire generation of doctors, nurses, pharmacists and administrators learned an entirely new set of skills: public communication, front-line innovation, data-driven decision-making.

An outside force — a new virus — accelerated much-needed change in health care, but the work is just beginning. The future of care is now on us.

John Henning Schumann is a doctor and writer in Tulsa, Okla. He hosts StudioTulsa's Medical Mondays on KWGS Public Radio Tulsa. Follow him on Twitter: @GlassHospital .

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Nih research matters.

December 22, 2021

2021 Research Highlights — Promising Medical Findings

Results with potential for enhancing human health.

With NIH support, scientists across the United States and around the world conduct wide-ranging research to discover ways to enhance health, lengthen life, and reduce illness and disability. Groundbreaking NIH-funded research often receives top scientific honors. In 2021, these honors included Nobel Prizes to five NIH-supported scientists . Here’s just a small sample of the NIH-supported research accomplishments in 2021.

Printer-friendly version of full 2021 NIH Research Highlights

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Advancing COVID-19 treatment and prevention

Amid the sustained pandemic, researchers continued to develop new drugs and vaccines for COVID-19. They found oral drugs that could  inhibit virus replication in hamsters and shut down a key enzyme that the virus needs to replicate. Both drugs are currently in clinical trials. Another drug effectively treated both SARS-CoV-2 and RSV, another serious respiratory virus, in animals. Other researchers used an airway-on-a-chip to screen approved drugs for use against COVID-19. These studies identified oral drugs that could be administered outside of clinical settings. Such drugs could become powerful tools for fighting the ongoing pandemic. Also in development are an intranasal vaccine , which could help prevent virus transmission, and vaccines that can protect against a range of coronaviruses .

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Developments in Alzheimer’s disease research

One of the hallmarks of Alzheimer’s is an abnormal buildup of amyloid-beta protein. A study in mice suggests that antibody therapies targeting amyloid-beta protein could be more effective after enhancing the brain’s waste drainage system . In another study, irisin, an exercise-induced hormone, was found to improve cognitive performance in mice . New approaches also found two approved drugs (described below) with promise for treating AD. These findings point to potential strategies for treating Alzheimer’s. Meanwhile, researchers found that people who slept six hours or less per night in their 50s and 60s were more likely to develop dementia later in life, suggesting that inadequate sleep duration could increase dementia risk.

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New uses for old drugs

Developing new drugs can be costly, and the odds of success can be slim. So, some researchers have turned to repurposing drugs that are already approved for other conditions. Scientists found that two FDA-approved drugs were associated with lower rates of Alzheimer’s disease. One is used for high blood pressure and swelling. The other is FDA-approved to treat erectile dysfunction and pulmonary hypertension. Meanwhile, the antidepressant fluoxetine was associated with reduced risk of age-related macular degeneration. Clinical trials will be needed to confirm these drugs’ effects.

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Making a wireless, biodegradable pacemaker

Pacemakers are a vital part of medical care for many people with heart rhythm disorders. Temporary pacemakers currently use wires connected to a power source outside the body. Researchers developed a temporary pacemaker that is powered wirelessly. It also breaks down harmlessly in the body after use. Studies showed that the device can generate enough power to pace a human heart without causing damage or inflammation.

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Fungi may impair wound healing in Crohn’s disease

Inflammatory bowel disease develops when immune cells in the gut overreact to a perceived threat to the body. It’s thought that the microbiome plays a role in this process. Researchers found that a fungus called  Debaryomyces hansenii  impaired gut wound healing in mice and was also found in damaged gut tissue in people with Crohn’s disease, a type of inflammatory bowel disease. Blocking this microbe might encourage tissue repair in Crohn’s disease.

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Nanoparticle-based flu vaccine

Influenza, or flu, kills an estimated 290,000-650,000 people each year worldwide. The flu virus changes, or mutates, quickly. A single vaccine that conferred protection against a wide variety of strains would provide a major boost to global health. Researchers developed a nanoparticle-based vaccine that protected against a broad range of flu virus strains in animals. The vaccine may prevent flu more effectively than current seasonal vaccines. Researchers are planning a Phase 1 clinical trial to test the vaccine in people.

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A targeted antibiotic for treating Lyme disease

Lyme disease cases are becoming more frequent and widespread. Current treatment entails the use of broad-spectrum antibiotics. But these drugs can damage the patient’s gut microbiome and select for resistance in non-target bacteria. Researchers found that a neglected antibiotic called hygromycin A selectively kills the bacteria that cause Lyme disease. The antibiotic was able to treat Lyme disease in mice without disrupting the microbiome and could make an attractive therapeutic candidate.

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Retraining the brain to treat chronic pain

More than 25 million people in the U.S. live with chronic pain. After a treatment called pain reprocessing therapy, two-thirds of people with mild or moderate chronic back pain for which no physical cause could be found were mostly or completely pain-free. The findings suggest that people can learn to reduce the brain activity causing some types of chronic pain that occur in the absence of injury or persist after healing.

2021 Research Highlights — Basic Research Insights >>

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Year in review: 2021's key global health moments, according to the WHO

In November 2021, the WHO’s global tobacco trends report found the number of people using tobacco had dropped by 69 million between 2000 and 2020. Image:  Unsplash/ Afif Kusuma

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Stay up to date:, global health.

• The pandemic might have dominated health headlines this year, but there have been lots of other stories on the World Health Organization’s global health agenda.
• From COVID-19 and malaria vaccines to falling tobacco use, and from dementia to diabetes, these are some of the WHO’s biggest health stories of 2021.

Health topped the news agenda once more in 2021, with ‘Covid vaccine’ the number one Google News search in the UK.

But there were other big health stories throughout the year - and some you might have missed, according to the World Health Organization (WHO).

1. COVID-19 vaccine and inequities

More than 8.85 billion vaccination doses had been administered by Christmas 2021, and the WHO had validated 10 COVID-19 vaccines as “safe, effective and high-quality”.

But only a quarter of the health workers in Africa had been fully vaccinated , according to the WHO, showing the divide in access between the developed and developing world.

In 2000, Gavi, the Vaccine Alliance was launched at the World Economic Forum's Annual Meeting in Davos, with an initial pledge of $750 million from the Bill and Melinda Gates Foundation.

The aim of Gavi is to make vaccines more accessible and affordable for all - wherever people live in the world.

Along with saving an estimated 10 million lives worldwide in less than 20 years,through the vaccination of nearly 700 million children, - Gavi has most recently ensured a life-saving vaccine for Ebola.

At Davos 2016, we announced Gavi's partnership with Merck to make the life-saving Ebola vaccine a reality.

The Ebola vaccine is the result of years of energy and commitment from Merck; the generosity of Canada’s federal government; leadership by WHO; strong support to test the vaccine from both NGOs such as MSF and the countries affected by the West Africa outbreak; and the rapid response and dedication of the DRC Minister of Health. Without these efforts, it is unlikely this vaccine would be available for several years, if at all.

Read more about the Vaccine Alliance, and how you can contribute to the improvement of access to vaccines globally - in our Impact Story .

In December, the WHO’s Director-General Dr Tedros Adhanom Ghebreyesus warned that “blanket booster programmes” risked prolonging the pandemic , as supplies going to rich countries meant greater opportunity for the virus to spread.

There was a huge effort to collaborate on vaccine access, led by the WHO. The ACT-Accelerator halved the cost of COVID-19 rapid tests for low- and lower-middle-income countries, while COVAX delivered more than three-quarters of a billion doses globally.

2. Humanitarian crisis in Afghanistan

Since August, when the Taliban took control of Afghanistan, the country has descended into greater poverty and, besides COVID-19, diarrhoea, dengue, measles, polio, and malaria are affecting the population.

The WHO sent 414 metric tonnes of life-saving medical supplies and helped to vaccinate 8.5 million children against polio.

The country is on the brink of famine, with 98% of Afghans without enough food to eat and a million children at risk of dying from hunger as the winter sets in, according to UNICEF.

3. Universal health coverage

The pandemic is likely to stall 20 years of progress towards Universal Health Coverage , the WHO and the World Bank found.

Even before COVID-19, having to pay for health services was pushing more than half a billion people into extreme poverty.

Childhood immunizations have been disrupted during the pandemic, with 23 million children missing out on routine vaccines in 2020. Services to screen for and treat diabetes, cancer and hypertension were disrupted in more than half of countries surveyed by the WHO between June and October 2021.

“We must build health systems that are strong enough to withstand shocks, such as the next pandemic and stay on course towards universal health coverage,” urged Dr Tedros.

4. Tobacco use in decline

In November 2021, the WHO’s global tobacco trends report found the number of people using tobacco had dropped by 69 million between 2000 and 2020.

There are now 60 countries on track to meet the voluntary global target of a 30% reduction in tobacco use by 2025 - up from only 32 countries two years ago.

5. Violence against women

A third of women - around 736 million - are subjected to physical or sexual violence by an intimate partner or sexual violence from a non-partner, the WHO reported in March 2021.

“Violence against women is endemic in every country and culture, causing harm to millions of women and their families, and has been exacerbated by the COVID-19 pandemic,” said Dr Tedros.

“But, unlike COVID-19, violence against women cannot be stopped with a vaccine. We can only fight it with deep-rooted and sustained efforts - by governments, communities and individuals - to change harmful attitudes, improve access to opportunities and services for women and girls, and foster healthy and mutually respectful relationships.”

6. Malaria vaccine

In October, the WHO recommended a malaria vaccine for children for the first time , after a successful pilot scheme in three African countries: Ghana, Kenya and Malawi.

RTS,S - or Mosquirix - is a vaccine developed by British drugmaker GlaxoSmithKline, which acts against P. falciparum, the most deadly malaria parasite globally, and the most prevalent in Africa.

Dr Tedros called it a "historic moment" and a "breakthrough for science, child health and malaria control", that could save tens of thousands of lives a year.

7. Diabetes in the spotlight

To mark the 100th anniversary of the discovery of the life-saving diabetes medicine insulin, the WHO launched a Global Diabetes Compact in 2021 to reduce the risk of diabetes and ensure access to equitable and affordable treatment.

In November, a report showed that insulin remained out of reach for many due to high prices, low availability and few producers dominating the insulin market.

“The scientists who discovered insulin 100 years ago refused to profit from their discovery and sold the patent for just one dollar,” said Dr Tedros. “Unfortunately, that gesture of solidarity has been overtaken by a multi-billion-dollar business that has created vast access gaps.”

Have you read?

3 of this year's most talked-about topics, explained, two years of covid-19: key milestones in the pandemic, who: what you need to know about the new malaria vaccine , 8. the state of dementia.

By 2050, there will be 139 million people living with dementia - more than double the 55 million people living with the disease today, the WHO estimates.

But only a quarter of countries have a national strategy for supporting people with dementia and their families, the WHO reported in September.

“The world is failing people with dementia, and that hurts all of us,” said Dr Tedros. “We need concerted action to ensure that all people with dementia are able to live with the support and dignity they deserve.”

9. Health and climate change

As world leaders prepared to gather in Glasgow for COP26, the WHO launched the Global Air Quality Guidelines , to show how air pollution damages human health.

The WHO and partners also presented a Health Argument for climate action report and an open letter signed by organizations representing two-thirds of the global health workforce.

It said: “The climate crisis is the single biggest health threat facing humanity. As health professionals and health workers, we recognize our ethical obligation to speak out about this rapidly growing crisis that could be far more catastrophic and enduring than the COVID-19 pandemic.

“We urge governments to live up to their responsibilities by protecting their citizens, neighbours, and future generations from the climate crisis. Wherever we deliver care, in our hospitals, clinics and communities around the world, we are already responding to the health harms caused by climate change.”

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COVID-19 Science Update released: October 1, 2021 Edition 107

The COVID-19 Science Update summarizes new and emerging scientific data for public health professionals to meet the challenges of this fast-moving pandemic. Weekly, staff from the CDC COVID-19 Response and the CDC Library systematically review literature in the WHO COVID-19 database external icon , and select publications and preprints for public health priority topics in the CDC Science Agenda for COVID-19 and CDC COVID-19 Response Health Equity Strategy .

Sign up for COVID-19 Science Updates

Section headings in the COVID-19 Science Update have been changed to align

with the CDC Science Agenda for COVID-19 .

PDF version for this update pdf icon [PDF – 1 MB]

Here you can find all previous COVID-19 Science Updates.

Health Equity

Natural History, Reinfection, and Health Impact

PEER-REVIEWED

Efficacy of the mRNA-1273 SARS-CoV-2 vaccine at completion of blinded phase external icon . El Sahly et al. NEJM (September 22, 2021).

Key findings:

• COVID-19 was 93.2% (95% CI 91.0-94.8) (Figure).
• Severe disease was 98.2% (95% CI 92.8-99.6).
• VE for preventing COVID-19 ≥4 months after the 2 nd injection was 92.4% (95% CI 84.3-96.8).

Methods : Clinical trial conducted among adults randomized to receive 2 doses of the mRNA-1273 (Moderna) vaccine (N = 15,209) or placebo (N = 15,206). Outcomes of COVID-19, severe COVID-19 illness, and SARS-CoV-2 infection were assessed ≥14 days after the 2 nd dose, as of March 26, 2021; median follow-up time was 5.3 months. Limitations : Key populations (e.g., pregnant women, children, immunocompromised patients) not included; low circulation of Delta variant during trial.

Implications : A 2-dose regimen of mRNA-1273 conferred substantial protection against symptomatic SARS-CoV-2 infection and severe COVID-19 illness in adults for at least 4 months.

Note: Adapted from El Sahly et al . Cumulative COVID-19 incidence among participants who received placebo or mRNA-1273 . The dashed vertical line depicts the beginning of the adjudicated assessment of outcomes. From the New England Journal of Medicine, El Sahly et al. , Efficacy of the mRNA-1273 SARS-CoV-2 vaccine at completion of blinded phase. September 22, 2021, online ahead of print. Copyright © 2021 Massachusetts Medical Society. Reprinted with permission from Massachusetts Medical Society.

Effectiveness of mRNA COVID-19 vaccine among U.S. health care personnel external icon . Pilishvili et al. NEJM (September 22, 2021).

• Severe symptoms or hospitalization were more likely among unvaccinated case participants than among partially or fully vaccinated case participants.
• VE was comparable across race and ethnicity, comorbidities, and age.

Methods : Case-control study conducted among 1,482 cases (had SARS-CoV-2 infection) and 3,449 controls (did not have SARS-CoV-2 infection, matched on test date and site) selected from healthcare personnel in acute care hospitals and long-term care facilities in 25 U.S. states, December 2020–May 2021. VE for the BNT162b2 (Comirnaty, Pfizer/BioNTech) and mRNA-1273 (Moderna) vaccines was calculated as 1–(matched OR). Limitations : COVID-19 testing practices varied across sites; vaccinated personnel may have accessed testing differentially than unvaccinated, potentially underestimating VE; persons with unknown prior COVID-19 could not be excluded.

Implications : BNT162b2 and mRNA-1273 vaccines prevented symptomatic COVID-19 among frontline healthcare personnel, regardless of demographic characteristics or underlying risk.

PREPRINTS ( NOT PEER-REVIEWED )

Real-world serologic responses to extended-interval and heterologous COVID-19 mRNA vaccination in frail elderly – interim report from a prospective observational cohort study external icon . Vinh et al. medRxiv (September 21, 2021). Published in The Lancet Healthy Longevity as Real-world serological responses to extended-interval and heterologous COVID-19 mRNA vaccination in frail, older people (UNCoVER): an interim report from a prospective observational cohort study external icon  (February 21, 2022).

• Antibody levels at 4 weeks after 2 nd dose did not differ between vaccine recipients of either heterologous or homologous vaccine regimens (Figure).
• Antibody levels by 4 weeks after 2 nd dose were comparable to those of previously infected individuals and did not differ by age, sex, or presence of comorbidities.

Methods : Real-world study among elderly long-term care facility residents in Québec (n = 185) who received 2-dose mRNA vaccines with an extended (16 week) interval between doses. Participants received homologous vaccination (2 doses of either mRNA-1273 [Spikevax/Moderna] or BNT162b2 [Comirnaty, Pfizer/BioNTech]) or heterologous (1 mRNA-1273 dose then 1 BNT162b2 dose) based on availability. IgG responses were measured. Limitations : Clinical outcomes were not evaluated; cellular immune responses were not measured.

Implications : Based on antibody responses, heterologous vaccination might be as effective as homologous vaccination among elderly persons receiving mRNA vaccine.

Note : Adapted from Vinh et al . Antibody responses to homologous ( MM: Moderna/Moderna , PP: Pfizer/Pfizer ) vs. heterologous ( MP: Moderna/Pfizer ) mRNA vaccines based on previous infection status. Top row (A1, B1, C1) no previous infection, bottom row (A2, B2, C2) previously infected. Antibody responses to receptor binding domain (A), S-protein (B), or N antigen (C). t1: baseline, t2: 4 weeks after 1 st dose, t3: 6–10 weeks after 1 st dose, t4: 16 weeks after 1 st dose, t5: 4 weeks after 2 nd dose. Licensed under CC-BY-NC-ND 4.0.

COVID-19 in the Phase 3 trial of MRNA-1273 during the Delta-variant surge external icon . Baden et al. medRxiv (September 22, 2021).  Published in NEJM as Phase 3 trial of mRNA-1273 during the Delta-variant surge external icon  (December 23, 2021).

• Reductions in the rate of infection were more pronounced in persons aged <65 years, but reductions in the rate of severe illness were more pronounced among persons aged ≥65 years.

Methods : Using data from the randomized Coronavirus Efficacy (COVE) mRNA-1273 vaccine trial, rates of COVID-19 and severe COVID-19 illness were assessed during July 1–August 27, 2021 in an intention-to-treat analysis. Outcomes among adult participants vaccinated earlier (July–December 2020; N = 14,746) were compared to those vaccinated more recently (December 2020–April 2021; N = 11,431). Limitations : Short follow up time (2 months).

Implications : During the months when Delta was the dominant COVID-19 variant, rates of COVID-19 and severe illness were lower among persons who were more recently vaccinated. Reevaluation after longer follow-up is needed.

Trajectory of COVID-19 vaccine hesitancy over time and association of initial vaccine hesitancy with subsequent vaccination external icon . Siegler et al. JAMA Network Open (September 24, 2021).

• Among participants hesitant to vaccinate at baseline, 32% reported receiving 1 or more vaccine doses, 37% reported being likely to be vaccinated, and 32% remained unlikely to be vaccinated at follow-up.
• Vaccine willingness at baseline was similar for Hispanic/Latino and non-Hispanic White participants (71% vs. 69%), but Hispanic/Latino participants had lower vaccination rates at follow-up (31% vs. 51%; Figure).
• Vaccination was confirmed with antibody test results (94.8% sensitivity; 99.1% specificity), suggesting self-reported vaccination status is a valid metric.

Methods : Cohort study of 3,439 U.S. respondents who completed surveys at baseline (August 9–December 8, 2020) and follow-up (March 2–April 21, 2021) to measure vaccine hesitancy, and who self-collected biological specimens to measure antibody response. Limitations : Follow-up period ended before vaccines were available to all respondents.

Implications : Vaccine hesitancy declined in this sample. However, differences in vaccination by socio-demographic characteristics pose challenges to overall vaccination coverage and achievement of health equity, and also suggest potential barriers to vaccination.

Note : Adapted from Siegler et al . Alluvial plot paths from hesitancy at baseline (August 9–December 8, 2020) to vaccination status ( vaccinated , willing , hesitant ) at follow-up (March 2–April 21, 2021) among a national, weighted sample of 3,439 U.S. respondents by race and ethnicity. Licensed under CC BY.

Two articles this week describe disparities in vaccination rates in Illinois communities. One article assesses the role of income and race/ethnicity in vaccination coverage; the other examines the impact of vaccination inequality on COVID-19 severity.

A. Social and economic inequality in coronavirus disease 2019 vaccination coverage across Illinois counties external icon . Liao. Scientific Reports (September 16, 2021).

• Among Illinois counties with higher income inequality, higher percentages of either Black or Hispanic/Latino populations were consistently associated with lower odds of full vaccination in the county (Figure).
• Among Illinois counties with lower income inequality, greater poverty among county residents was associated with lower odds of full vaccination in the county during March–April 2021 (Figure).

Methods : Ecological county-level analysis of socioeconomic factors and vaccination coverage in 51 Illinois counties in 3 waves on February 4, March 10, and April 3, 2021; data were stratified by county income inequality as calculated by median Gini index. Limitations : Study conducted during early phases of vaccination distribution; findings may not be generalizable to communities in other U.S. states.

Note: Adapted from Liao. Odds ratios (95% CI) of a county being fully vaccinated by county-level political affiliation, poverty, and race and ethnic composition, stratified by income inequality (upper half Gini indicates higher income inequality, lower half Gini indicates lower income inequality). Estimates adjusted for county population density, percent population aged ≥65 years, percent male, and percent uninsured. GOP = Republican. Licensed under CC BY 4.0

B. Consequences of COVID-19 vaccine allocation inequity in Chicago external icon . Zeng et al. medRxiv (September 23, 2021).

• The percentage of Chicago residents identifying as non-Hispanic/Latino Black was 80% in the least vaccinated ZIP codes and 8% in ZIP codes with highest vaccination coverage.
• 72% of deaths among Chicago residents in ZIP codes with the lowest quartile of vaccination coverage could have been prevented if vaccination coverage was similar to vaccine coverage in the highest quartile ZIP codes.

Methods : Ecological ZIP code-level analysis of COVID-19-associated cases, deaths, and 1 st -dose vaccination coverage (as of March 28, 2021) in Chicago, August 2020—June 2021. ZIP codes were grouped by (1) lowest quartile of vaccine coverage, (2) middle 2 quartiles, and (3) highest quartile. Limitations : Population characteristics of ZIP codes can be heterogenous; ecological design limits controlling for individual-level factors.

Implications for Liao and Zeng et al. : Communities in Chicago and other Illinois counties experienced unequal COVID-19 vaccine coverage. Reducing disproportionate morbidity and mortality from COVID-19 may require vaccination strategies that are informed by community social and economic needs.

Prior infection and age impacts antibody persistence after SARS-CoV-2 mRNA vaccine. external icon Fraley et al. Clinical Infectious Diseases (September 22, 2021).

• Higher antibody levels were observed among vaccinated healthcare workers (HCWs) with recent SARS-CoV-2 infection compared with vaccinated HCWs without prior infection (Figure).
• Among HCWs without prior SARS-CoV-2 infection, persons aged 18–49 years had higher antibody response at week 3 (2 nd vaccination dose) and week 28 (~7 months following 1 st vaccination dose), compared with persons aged ≥50 years.

Methods : Among 188 HCWs fully vaccinated with BNT162b2 (Comirnaty, Pfizer/BioNTech), antibody levels up to 28 weeks after the 1 st vaccine dose among HCWs with SARS-CoV-2 infection 30–60 days prior to vaccination were compared with levels among HCWs without prior infection. Limitations : Did not examine SARS-CoV-2 infection >60 days before vaccination.

Implications : Magnitude and duration of antibody response and protection from vaccination may be higher among those with prior SARS-CoV-2 infection and younger persons, which could inform ideal timing of booster vaccination.

Note: Adapted from Fraley et al. Antibody levels for SARS-CoV-2 spike subunit 1 (S1), spike subunit 2 (S2), and receptor-binding domain over time among vaccinated HCWs with a recent SARS-CoV-2 infection and those without prior infection . Week 0 = 1 st vaccination dose; week 3 = 2 nd vaccination dose; MFI = Median Fluorescent Intensity; *indicates p <0.05. Used by permission of the Infectious Diseases Association of America and Oxford University Press.

Assessment of a program for SARS-CoV-2 screening and environmental monitoring in an urban public school district. external icon Crowe et al. JAMA Network Open (September 22, 2021).

• 46 individuals were found to have SARS-CoV-2 and 2 clustering events were identified through genome sequencing.
• Participating schools detected SARS-CoV-2 RNA in wastewater samples.

Methods : Evaluation of a school-based weekly saliva PCR COVID-19 testing and environmental monitoring (wastewater, air, surface) pilot program in 3 Omaha, NE public schools (November 9–December 11, 2020); 773 in-person students and faculty were included. Genome sequencing conducted on positive saliva samples. Limitations : Findings may not be generalizable to other schools; incomplete testing among students may underestimate findings; conducted before vaccines were available.

Implications : Routine COVID-19 testing and environmental monitoring may be an effective school-based strategy to rapidly identify SARS-CoV-2 infections and enable implementation of risk-mitigation plans.

Note : Adapted from Crowe et al . Cumulative SARS-CoV-2 case rates detected by weekly saliva PCR testing. Comparing in-person school pilot program ( asymptomatic saliva PCR ) and conventional reporting for A) students and B) staff. Licensed under CC BY.

• Self-reported and physiological reactions to the third BNT162b2 mRNA COVID-19 (booster) vaccine dose external icon . Mofaz et al. medRxiv (Preprint; September 21, 2021). In a prospective observational study in Israel, self-reported reactions and biometrics were recorded for Israeli adults who received ≥1 of 3 doses of the BNT162b2 vaccine. Reactions were similar following the 2 nd and 3 rd doses, and were more frequent than after the 1 st dose. Reactions after the 3 rd dose were more common in participants who were aged <65 years, female, and had no underlying medical conditions.

Note: Adapted from Mofaz et al . Percentage of adults reporting symptoms following the first , second or third dose of Pfizer BNT162b2 vaccination. Used by permission of authors.

• Protection of BNT162b2 vaccine booster against COVID-19 in Israel external icon . Bar-On et al. NEJM (September 15, 2021). Among residents of Israel aged ≥60 years who had been vaccinated ≥5 months earlier (BNT162b2), a booster dose reduced the rate of SARS-CoV-2 infection by a factor of 11.3 (95% CI 10.4-12.3) and the rate of severe illness by a factor of 19.5 (95% CI 12.9-29.5), compared with persons who did not receive a booster dose. On each day between 12 and 25 days after receipt of the booster, the rate of confirmed infection was reduced by a factor of 7–20.

Note: Adapted from Bar-On et al. Factor reduction in the rate of confirmed infection among participants who received a 3 rd (booster) dose of the BNT162b2 vaccine as compared with those who did not receive a booster dose, by the number of days after the administration of the booster dose. The dashed horizontal line represents the level at which the booster dose provided no added protection. From the New England Journal of Medicine, Bar-On et al. , Protection of BNT162b2 vaccine booster against COVID-19 in Israel. September 15, 2021, online ahead of print. Copyright © 2021 Massachusetts Medical Society. Reprinted with permission from Massachusetts Medical Society.

• Prime boost vaccination with BNT162b2 induces high neutralizing activity against SARS-CoV-2 variants in naïve and COVID-19 convalescent individuals external icon . Luczkowiak et al. Open Forum Infectious Diseases (September 24, 2021). In an analysis of COVID-19 naïve and infected healthcare workers during convalescence and post-BNT162b2 vaccination, sera from convalescent people showed decreased neutralizing activity against variants at 1 month post-infection, compared with the reference strain. Those fully vaccinated with BNT162b2 showed high levels of neutralizing antibodies to all variants, with convalescent people showing the highest neutralizing response.

Note: Adapted from Luczkowiak et al. Plasma neutralizing levels (NT50) against SARS-CoV-2: Reference S D614G and variants Alpha , Beta , Gamma , and Delta during COVID-19 convalescence and after BNT161b2 vaccination. Convalescent individuals (n = 19) tested 1-month post-infection (mpi), 7 mpi, and after BNT162b2; naïve group (n = 17) after BNT162b2. NT50 dilution values are presented as reciprocals. Solid lines: geometric mean; error bars: geometric SD. Dashed lines: cut-off titer (NT50 = 1/66). Fold-decrease in NT50 above scatter plot; *** statistically significant changes. Licensed under CC-BY-NC-ND.

• Outcome comparison of high-risk Native American patients who did or did not receive monoclonal antibody treatment for COVID-19 external icon . Close et al . JAMA Network Open (September 21, 2021). Among Native American people eligible for monoclonal antibody (mAb) treatment (n = 481) at a rural acute care facility in Arizona, 201 COVID-19 patients received mAb and experienced lower odds of death (OR 0.44, 95% CI 0.29-0.66) than eligible patients who did not receive mAb.
• Understanding racial differences in attitudes about public health efforts during COVID-19 using an explanatory mixed methods design external icon . Nong et al. Social Science and Medicine (October 2021). In a study linking quantitative findings to explanatory qualitative interview questions (n = 1,000), Black or African American Michigan residents’ trust in public health agencies (adjusted beta coefficient [b] 0.07, p = 0.48) was not different from that of White residents (adjusted beta coefficient [b] 0.07, p = 0.48). An increased willingness to participate in public health interventions may be related to altruism and perceived risk of COVID-19 in the community.
• Identifying at-risk communities and key vulnerability indicators in the COVID-19 pandemic external icon . Thais et al . medRxiv (Preprint; September 22, 2021). In a validation study using open-source data to construct a model to describe communities at higher risk of COVID-19 and determine indicators for vulnerability during the COVID-19 pandemic, results suggest that prevalence of COVID-19 in a given area has more impact than prevalence of pre-existing co-morbidities. Childhood poverty, food insecurity, COVID-19 hospitalization rate, unemployment rate, and access to care were key indicators.
• The longitudinal kinetics of antibodies in COVID-19 recovered patients over 14 months external icon . Eyran et al. medRxiv (Preprint; September 21, 2021). Among 89 COVID-19 recovered patients and 17 infection-naïve BNT162b2 vaccinees followed over 14 months, antibody levels waned in 18% (IgG), 55% (IgM), and 62% (IgA) of persons to levels considered negative. Antibody decay rate in COVID-19-recovered patients was significantly slower compared with the decay in infection-naïve vaccinees.
• Impact of prior SARS-CoV-2 infection on post-vaccination SARS-CoV-2 spike IgG antibodies in a longitudinal cohort of healthcare workers external icon . Zhong et al . medRxiv (Preprint; September 22, 2021). Published in JAMA as Durability of antibody levels after vaccination with mRNA SARS-CoV-2 vaccine in individuals with or without prior infection external icon (November 1, 2021). From June–September 2021, healthcare workers (HCWs) who received 2 doses of an mRNA vaccine (n = 1,960) had higher serum spike IgG antibody levels than HCWs with natural infection (n = 98). Serum IgG antibody values were 14%, 19%, and 56% higher for those infected with SARS-CoV-2 prior to vaccination (n = 73) than naïve HCWs (n = 1,887) at 1, 3, and 6 months after vaccination, respectively. HCWs infected >90 days before vaccination (n = 32) had 10% higher IgG levels than those infected < 90 days before vaccination (n = 41).

Note: Adapted from Zhong et al . A) Serum spike S1 IgG antibody levels ≥14 days following 2 doses of SARS-CoV-2 mRNA vaccine in HCWs with prior SARS-CoV-2 infection , without prior SARS-CoV-2 infection , and in those following SARS-CoV-2 positive PCR test and before vaccination . B) Serum spike S1 IgG antibody mRNA vaccination among HCWs with SARS-CoV-2 infection ≤90 days before vaccination and >90 days before vaccination . The lines represent median IgG as a function of days following mRNA vaccination or natural infection, based on natural cubic splines (2 degrees of freedom) for each group. Shaded areas represent 95% confidence intervals. Licensed under CC-BY-NC-ND 4.0.

• Comparison of children and young people admitted with SARS-CoV-2 across the UK in the first and second pandemic waves: prospective multicentre observational cohort study external icon . Swann et al . medRxiv (Preprint; September 17, 2021). Published in Pediatric Research as Comparison of UK paediatric SARS-CoV-2 admissions across the first and second pandemic waves external icon (April 22, 2022). Compared with children and adolescents hospitalized with COVID-19 during Wave 1 (January–July 2020), children and adolescents hospitalized during Wave 2 (August 2020–January 2021) were more likely to be older (median age [years] 6.5 vs. 4.0), and less likely to be at risk for clinical deterioration at presentation (38% vs. 47%), be prescribed antibiotics (51% vs. 67%), and need respiratory/cardiovascular support. The percentage admitted to critical care did not differ between waves (12% vs. 13%).
• Childhood asthma and COVID-19: a nested case-control study external icon . Gaietto et al . medRiv (Preprint; September 22, 2021).  Published in Pediatric Allergy and Immunology as Asthma as a risk factor for hospitalization in children with COVID-19: A nested case-control study external icon (November 14, 2021). In a nested case-control study using clinical registry data, asthma severity in children was not associated with a higher risk of SARS-CoV-2 infection. Children with COVID-19 and asthma were more than 4 times as likely to be hospitalized compared with children with COVID-19 and without asthma; however, there was no difference in hospital stay length or need for respiratory support.

From the Morbidity and Mortality Weekly Report (Month, day, year) .

• Disparities in COVID-19 Vaccination Status, Intent, and Perceived Access for Noninstitutionalized Adults, by Disability Status — National Immunization Survey Adult COVID Module, United States, May 30–June 26, 2021
• Association Between K–12 School Mask Policies and School-Associated COVID-19 Outbreaks — Maricopa and Pima Counties, Arizona, July–August 2021
• COVID-19–Related School Closures and Learning Modality Changes — United States, August 1–September 17, 2021
• Pediatric COVID-19 Cases in Counties With and Without School Mask Requirements — United States, July 1–September 4, 2021
• Safety Monitoring of an Additional Dose of COVID-19 Vaccine — United States, August 12–September 19, 2021

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• Published: 07 December 2020

2021: research and medical trends in a post-pandemic world

• Mike May 1  

Nature Medicine volume  26 ,  pages 1808–1809 ( 2020 ) Cite this article

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Goodbye 2020, a year of arguably too many challenges for the world. As tempting as it is to leave this year behind, the biomedical community is forever changed by the pandemic, while business as usual needs to carry on. Looking forward to a new year, experts share six trends for the biomedical community in 2021.

Summing up 2020, Sharon Peacock, director of the COVID-19 Genomics UK Consortium, says “we’ve seen some excellent examples of people working together from academia, industry, and healthcare sectors...I’m hopeful that will stay with us going into 2021.” Nonetheless, we have lost ground and momentum in non-COVID research, she says. “This could have a profound effect on our ability to research other areas in the future.”

The coronavirus SARS-CoV-2 has already revealed weaknesses in medical research and clinical capabilities, as well as opportunities. Although it is too soon to know when countries around the world will control the COVID-19 pandemic, there is already much to be learned.

To explore trends for 2021, we talked to experts from around the world who specialize in medical research. Here is what we learned.

1. The new normal

Marion Koopman, head of the Erasmus MC Department of Viroscience, predicts that emerging-disease experts will overwhelmingly remain focused on SARS-CoV-2, at least for the coming year.

“I really hope we will not go back to life as we used to know it, because that would mean that the risk of emerging diseases and the need for an ambitious preparedness research agenda would go to the back burner,” Koopman says. “That cannot happen.”

Scientists must stay prepared, because the virus keeps changing. Already, Koopman says, “We have seen spillback [of SARS-CoV-2] into mink in our country, and ongoing circulation with accumulation of mutations in the spike and other parts of the genome.”

Juleen R. Zierath, an expert in the physiological mechanisms of metabolic diseases at the Karolinska Institute and the University of Copenhagen, points out that the pandemic “has raised attention to deleterious health consequences of metabolic diseases, including obesity and type 2 diabetes,” because people with these disorders have been “disproportionally affected by COVID-19.” She notes that the coupling of the immune system to metabolism at large probably deserves more attention.

2. Trial by fire for open repositories

The speed of SARS-CoV-2’s spread transformed how scientists disseminate information. “There is an increased use of open repositories such as bioRxiv and medRxiv, enabling faster dissemination of study and trial results,” says Alan Karthikesalingam, Research Lead at Google Health UK. “When paired with the complementary — though necessarily slower — approach of peer review that safeguards rigor and quality, this can result in faster innovation.”

“I suspect that the way in which we communicate ongoing scientific developments from our laboratories will change going forward,” Zierath says. That is already happening, with many meetings going to virtual formats.

Deborah Johnson, president and CEO of the Keystone Symposia on Molecular and Cellular Biology, notes that while virtual events cannot fully replace the networking opportunities that are created with in-person meetings, “virtual events have democratized access to biomedical research conferences, enabling greater participation from young investigators and those from low-and-middle-income countries.” Even when in-person conferences return, she says, “it will be important to continue to offer virtual components that engage these broader audiences.”

3. Leaps and bounds for immunology

Basic research on the immune system, catapulted to the frontlines of the COVID-19 response, has received a boost in attention this year, and more research in that field could pay off big going forward.

Immunobiologist Akiko Iwasaki at the Yale School of Medicine hopes that the pandemic will drive a transformation in immunology. “It has become quite clear over decades of research that mucosal immunity against respiratory, gastrointestinal, and sexually transmitted infections is much more effective in thwarting off invading pathogens than systemic immunity,” she says. “Yet, the vast majority of vaccine efforts are put into parenteral vaccines.”

“It is time for the immunology field to do a deep dive in understanding fundamental mechanisms of protection at the mucosal surfaces, as well as to developing strategies that allow the immune response to be targeted to the mucosal surfaces,” she explains.

“We are discovering that the roles of immune cells extend far beyond what was previously thought, to play underlying roles in health and disease across all human systems, from cancer to mental health,” says Johnson.

She sees this knowledge leading to more engineered immune cells to treat diseases. “Cancer immunotherapies will likely serve as the proving ground for immune-mediated therapies against many other diseases that we are only starting to see through the lens of the immune system.”

4. Rewind time for neurodegeneration

Oskar Hansson, research team manager of Lund University’s Clinical Memory Research, expects the trend of attempting to intervene against neurodegenerative disease before widespread neurodegeneration, and even before symptom onset, to continue next year.

This approach has already shown potential. “Several promising disease-modifying therapies against Alzheimer’s disease are now planned to be evaluated in this early pre-symptomatic disease phase,” he says, “and I think we will have similar developments in other areas like Parkinson’s disease and [amyotrophic lateral sclerosis].”

Delving deeper into such treatments depends on better understanding of how neurodegeneration develops. As Hansson notes, the continued development of cohort studies from around the world will help scientists “study how different factors — genetics, development, lifestyle, etcetera — affect the initiation and evolution of even the pre-symptomatic stages of the disease, which most probably will result in a much deeper understanding of the disease as well as discovery of new drug targets.”

5. Digital still front and center

“As [artificial intelligence] algorithms around the world begin to be released more commonly in regulated medical device software, I think there will be an increasing trend toward prospective research examining algorithmic robustness, safety, credibility and fairness in real-world medical settings,” says Karthikesalingam. “The opportunity for clinical and machine-learning research to improve patient outcomes in this setting is substantial.”

However, more trials are needed to prove which artificial intelligence works in medicine and which does not. Eric Topol, a cardiologist who combines genomic and digital medicine in his work at Scripps Research, says “there are not many big, annotated sets of data on, for example, scans, and you need big datasets to train new algorithms.” Otherwise, only unsupervised learning algorithms can be used, and “that’s trickier,” he says.

Despite today’s bottlenecks in advancing digital health, Topol remains very optimistic. “Over time, we’ll see tremendous progress across all modalities — imaging data, speech data, and text data — to gather important information through patient tests, research articles or reviewing patient chats,” he says.

He envisions that speech-recognition software could, for instance, capture physician–patient talks and turn them into notes. “Doctors will love this,” he says, “and patients will be able to look a doctor in the eye, which enhances the relationship.”

6. ‘Be better prepared’ — a new medical mantra

One trend that every expert interviewed has emphasized is the need for preparation. As Gabriel Leung, a specialist in public-health medicine at the University of Hong Kong, put it, “We need a readiness — not just in technology platforms but also business cases — to have a sustained pipeline of vaccines and therapies, so that we would not be scrambling for some of the solutions in the middle of a pandemic.”

Building social resilience ahead of a crisis is also important. “[SARS-CoV-2] and the resulting pandemic make up the single most important watershed in healthcare,” Leung explains. “The justice issue around infection risk, access to testing and treatment — thus outcomes — already make up the single gravest health inequity in the last century.”

One change that Peacock hopes for in the near future is the sequencing of pathogens on location, instead of more centrally. “For pathogen sequencing, you need to be able to apply it where the problem under investigation is happening,” she explains. “In the UK, COVID-19 has been the catalyst for us to develop a highly collaborative, distributed network of sequencing capabilities.”

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May, M. 2021: research and medical trends in a post-pandemic world. Nat Med 26 , 1808–1809 (2020). https://doi.org/10.1038/s41591-020-01146-z

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Flores R , Patel P , Alpert N , Pyenson B , Taioli E. Association of Stage Shift and Population Mortality Among Patients With Non–Small Cell Lung Cancer. JAMA Netw Open. 2021;4(12):e2137508. doi:10.1001/jamanetworkopen.2021.37508

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Association of Stage Shift and Population Mortality Among Patients With Non–Small Cell Lung Cancer

• 1 Department of Thoracic Surgery, Icahn School of Medicine at Mount Sinai, Mount Sinai Health System, New York, New York
• 2 Institute for Translational Epidemiology and Tisch Cancer Institute, Icahn School of Medicine at Mount Sinai, New York, New York
• 3 NYU School of Global Public Health, New York, New York
• 4 Milliman Inc, New York, New York

Question   To what extent does stage shift act as a confounding variable in the evaluation of population mortality of non–small cell lung cancer?

Findings   In this cohort study of 312 382 patients, stage shift from later to earlier stage disease over the last decade was associated with improved mortality among people with lung cancer.

Meaning   These findings suggest that studies investigating treatments for lung cancer must take into account stage shift and the confounding association with survival and mortality outcome.

Importance   Early detection by computed tomography and a more attention-oriented approach to incidentally identified pulmonary nodules in the last decade has led to population stage shift for non–small cell lung cancer (NSCLC). This stage shift could substantially confound the evaluation of newer therapeutics and mortality outcomes.

Objective   To investigate the association of stage shift with population mortality among patients with NSCLC.

Design, Setting, and Participants   This retrospective cohort study was performed from October 2020 to June 2021 and used data from the Surveillance, Epidemiology, and End Results (SEER) registries to assess all patients from 2006 to 2016 with NSCLC.

Main Outcomes and Measures   Incidence-based mortality was evaluated by year-of-death. To assess shifts in diagnostic characteristics, clinical stage and histology distributions were examined by year using χ 2 tests. Trends were assessed using the average annual percentage change (AAPC), calculated with JoinPoint software. Kaplan-Meier survival analysis assessed overall survival according to stage and compared those missing any stage with those with a reported stage.

Results   The final sample contained 312 382 patients; 166 657 (53.4%) were male, 38 201 (12.2%) were Black, and 249 062 (79.7%) were White; the median (IQR) age was 68 (60-76) years; 163 086 (52.2%) had adenocarcinoma histology. Incidence-based mortality within 5 years of diagnosis decreased from 2006 to 2016 (AAPC, −3.7; 95% CI, −4.1 to −3.4). When assessing stage shift, there was significant association between year-of-diagnosis and clinical stage, with stage I/II diagnosis increasing from 26.5% to 31.2% (AAPC, 1.5; 95% CI, 0.5 to 2.5); and stage III/IV diagnosis decreasing significantly from 70.8% to 66.1% (AAPC, −0.6; 95% CI, −1.0 to −0.2). Missing staging information was not associated with year-of-diagnosis (AAPC, −1.6; 95% CI, −7.4 to 4.5). Year-of-diagnosis was significantly associated with tumor histology (χ 2  = 8990.0; P  < .001). There was a significant increase in adenocarcinomas: 42.9% in 2006 to 59.0% in 2016 (AAPC, 3.4; 95% CI, 2.9 to 3.9). Median (IQR) survival for stage I/II was 57 months (18 months to not reached); stage III/IV was 7 (2-19) months; and missing stage was 10 (2-28) months. When compared with those with known stage, those without stage information had significantly worse survival than those with stage I/II, with survival between those with stage III and stage IV (log-rank χ 2  = 87 125.0; P  < .001).

Conclusions and Relevance   This cohort study found an association between decreased mortality and a corresponding diagnostic shift from later to earlier stage. These findings suggest that studies investigating the effect of treatment on lung cancer must take into account stage shift and the confounding association with survival and mortality outcome.

Lung cancer remains among the leading causes of cancer death in the United States. 1 , 2 Based on the Annual Report to the Nation, incidence rates for lung cancer have significantly declined from 2012 to 2016 (average annual percent change [AAPC] of −2.6% for male individuals and −1.1% for female individuals). 1 Moreover, mortality for lung cancer from 2013 to 2017 has decreased at a greater rate compared with the incidence and has experienced one of the largest declines in death rates compared with other common cancer deaths (AAPC of −4.8% among male individuals and −3.7% among female individuals). 1 The improved outcomes with lung cancer are quite multifactorial and can be attributed to advances in prevention, early detection, and treatment of lung cancer. 3 , 4

In recent years, the many advances in medical therapeutics, such as targeted therapy, immunotherapy, and chemotherapy, have garnered interest in the role they may play in affecting lung cancer population-level mortality. 5 , 6 In particular, Howlader et al, 5 using data from Surveillance, Epidemiology, and End Results (SEER) registries from 2001 to 2016 concluded that the observed lung cancer mortality during the study timeframe was likely to be explained by the approval and use of targeted therapies especially for non–small cell lung cancer (NSCLC). However, Howlader et al 5 do not provide direct evidence to support the direct effect of targeted therapies in affecting mortality but rather cite how the lack of other major advances in prevention or treatment explain the substantial decline in incidence-based mortality.

Many randomized clinical trials have demonstrated the significant survival benefit of targeted therapies among patients harboring driver variants among the druggable oncogenes, such as epidermal growth factor receptor (EGFR) and anaplastic lymphoma kinase (ALK). 7 - 9 Moreover, immune-based therapies, in particular programmed cell death protein 1–programmed death ligand 1 (PD-1–PD-L1) inhibitors have substantially improved survival among patients with NSCLC even if they do not carry EGFR and ALK variants. 10 - 13 Since 20% of patients with NSCLC have a substantial and sustained response to targeted and immunotherapies, these therapies certainly play a role in affecting population mortality. 14 Nevertheless, in associating the role of targeted and immunotherapies in decreasing mortality, Howlader et al 5 minimize the role of early detection and stage shift on mortality by suggesting that “patients moved from unknown stages to more specific stage categories (as a result of the availability of better imaging) rather than shifting from late to early stages.” 5 However, the role of stage shift due to early detection in affecting NSCLC population-level mortality may not be as minimal as suggested. As a matter of fact, computed tomography (CT) screening for lung cancer is the only modality demonstrating decreased disease-specific mortality. As per the National Lung Screening Trial (NLST), screening with low-dose CT resulted in a positive screening rate of 24.2% compared with 6.9% with chest radiography. 6 The increased rate of early detection has translated into decreased mortality among patients diagnosed with lung cancer. The NLST, Nederlands–Leuvens Longkanker Screenings Onderzoek (NELSON) trial, and International Early Lung Cancer Action Project (I-ELCAP) have demonstrated that CT screening can identify early stage disease in 4 of 5 patients unknowingly harboring lung cancer 6 , 15 , 16 . Given these survival benefits, the United States Preventive Services Task Force (USPSTF) has recommended since 2013 annual screening with low-dose CT as standard of care with further expansion of the screening criteria in 2021 to include younger adults with a smaller pack-year smoking history in order increase early detection and subsequently decrease mortality from lung cancer. 17

To better understand the association of early detection with lung cancer mortality, it is pertinent to evaluate the extent of stage shift in the last decade and its effect in contributing to NSCLC incidence-based mortality. We hypothesize that lung cancer early detection by CT, both intentional and nonintentional (back-alley screening), such as cardiac CT angiograms screening for coronary disease, and a more attention-oriented approach to incidentally identified pulmonary nodules, is associated with a stage shift and subsequent decreased mortality from earlier surgical intervention. We performed a more systematic exhaustive stage and histology evaluation over the same period (2006-2016) using the same SEER data set and methodology as Howlader et al. 5

The SEER Program compiles information on cancer incidence, including patient demographics, self-reported race and ethnicity, tumor characteristics, treatment, and vital status from population-based cancer-registries. 18 The registries included in SEER currently cover approximately 35% of the United States population. 18 This retrospective cohort study analysis was conducted from October 1, 2020, to June 30, 2021, using data extracted from SEER. The study followed the Strengthening the Reporting of Observational Studies in Epidemiology ( STROBE ) reporting guideline. 19 Since the SEER database is public and deidentified, the study was deemed as exempt research by the institutional review board at the Icahn School of Medicine at Mount Sinai and informed consent was waived.

Based on when the International Early Lung Cancer Action Program began recommending lung cancer screening, 16 SEER 18 registries were queried for patients from 2006 to 2016 with microscopically confirmed lung cancer (n = 502 583), where lung cancer was the first or only primary malignant neoplasm (n = 375 429) and was not reported on autopsy or death certificate (n = 374 855). Analysis was limited to those with non–small cell histology for a final sample of 312 382.

Clinical stage and histology distributions were examined by year to assess shifts in diagnostic characteristics over time using χ 2 tests. Additionally, the AAPC in tumor characteristics over time was calculated. Clinical stage was based on the American Joint Committee on Cancer sixth (2006-2015) edition and combined SEER stage group (2016). Because detailed stage information was missing for 6.3% of the sample, SEER historic staging was used to impute stage for these patients. Those with historic stage values of localized were coded as stage I/II, regional was coded as stage III, and distant was coded as stage IV. A sensitivity analysis was conducted through 2015, before the staging change in SEER and found similar results to what is presented. Histology was classified as squamous cell carcinoma, adenocarcinoma, or other NSCLC, using International Classification of Diseases for Oncology Third Edition (ICD-O-3) codes adopted from Egevad et al 20 and based on guidelines from the International Agency for Research on Cancer. In order to further characterize those patients missing any staging information, first course of treatment was examined, as surgical resection would reflect standard of care for early-stage tumors. Median survival was calculated according to stage, and Kaplan-Meier curves were used to compare those missing any stage with those with a reported stage. The AAPC was calculated using Joinpoint software version 4.9.0.0 (National Cancer Institute), other analyses were conducted using SAS software version 9.4 (SAS Institute). 21 Incidence-based mortality within 5 years of diagnosis, which was defined as the number of deaths among those with a NSCLC diagnosis in SEER, divided by the total population residing in the geographic areas of the SEER registries, was calculated in SEER*Stat for 2006 to 2016. 22 Figures were created in R version 3.4.0 (R Project for Statistical Computing). The significance threshold was P  < .05. Significance was based on χ 2 tests (for the association between characteristics and year), and t tests for the joinpoint trends. All testing was 2-sided. Statistical analysis was performed from October 2020 to June 2021.

There were 312 382 patients in SEER diagnosed with NSCLC during 2006 to 2016. Among these patients in the study, 166 657 (53.4%) were male, 38 201 (12.2%) were Black, and 249 062 (79.7%) were White; the median (IQR) age was 68 (60-76) years. Year of diagnosis was evenly distributed among the sample (approximately 9% diagnosed in each year of study). There were 88 179 patients (28.2%) diagnosed at stage I/II and 217 037 (69.5%) at stage III/IV; 7166 (2.3%) were missing any staging information. The majority of patients had adenocarcinoma histology (52.2% [n = 163 086]); 20.3% (n = 63 451) of patients were missing information about their tumor size; 13.3% (n = 41 610) had a tumor size less than 2 cm, whereas 26.9% (n = 84 150) had tumor size greater than or equal to 5 cm ( Table ).

Incidence and incidence-based mortality for NSCLC according to sex are presented in Figure 1 . The decline in the incidence for NSCLC was greater for male individuals (AAPC, −3.2; 95% CI, −3.6 to −2.9) compared with female individuals (AAPC, −1.8; 95% CI, −2.3 to −1.3) from 2006 to 2016. Incidence-based mortality for both male and female individuals declined at a greater rate compared with the incidence. For male individuals, incidence-based mortality AAPC from 2006 to 2016 was −4.2 (95% CI, −4.6 to −3.7), whereas for female individuals it was −3.4 (95% CI, −3.9 to −2.9).

There was a significant association between year of diagnosis and stage, with the percentage in each year diagnosed at stage I/II increasing from 26.5% to 31.2% from 2006 to 2016, corresponding to a statistically significant AAPC of 1.5 (95% CI, 0.5 to 2.5); the percentage of patients diagnosed at stage III/IV decreased significantly from 70.8% to 66.1% (AAPC, −0.6; 95% CI, −1.0 to −0.2). The percentage missing staging information did not significantly change from 2006 (2.8%) to 2015 (1.7%) (AAPC, 95% CI, −1.6; −7.4 to 4.5) ( Figure 2 ). A sensitivity analysis was conducted through 2015, before the staging change in SEER and found similar results.

Year of diagnosis was significantly associated with tumor histology (χ 2  = 8990.0; P  < .001). There was a large, statistically significant increase in those diagnosed with adenocarcinomas, from 42.9% in 2006 to 59.0% in 2016 (AAPC, 3.4; 95% CI, 2.9 to 3.9). There was also a significant increase in squamous cell carcinoma, from 23.7% in 2006 to 26.0% in 2016 (AAPC, 1.2; 95% CI, 1.1 to 1.4), and a significant decrease in those diagnosed with other NSCLC histologies from 33.4% in 2006 to 14.4% in 2016 (AAPC, −8.4; 95% CI, −10.5 to −6.4) ( Figure 3 ).

Those missing any staging information had a mean (SD) age of 71.5 (0.1) years at diagnosis. They were majority male (51.8%) and White (77.5%). Generally, those missing stage were more highly represented in earlier years. Fewer patients than in the overall group had adenocarcinoma (41.9%); 26.8% (n = 1921) had squamous cell histology and 31.3% (n = 2246) had other NSCLC histologies. The majority of patients (78.8%; n = 5718) were missing tumor size. Among patients without stage information, 86.7% (n = 6216) did not receive surgery to the primary site as part of their first course of treatment; 20.4% (n = 1463) were confirmed to have received chemotherapy; and 13.4% (n = 960) received external beam radiotherapy.

Among all patients, median (IQR) follow up was 61 (21-95) months. When compared with those with known stage, those without stage information had significantly worse survival than those with stage I/II, with survival between those with stage III and stage IV (log-rank χ 2  = 87 125.0; P  < .001) ( Figure 4 ). Median (IQR) survival for those with stage I/II was 57 months (18 months to not reached); for stage III it was 12 (4-34) months; for stage IV it was 5 (1-13) months; and for those missing stage it was 10 (2-28) months. Patients with stage I/II had significantly better survival compared with stage III/IV or missing stage (log-rank χ 2  = 65 866.9; P  < .001).

In this cohort study, we examined 312 382 patients in SEER diagnosed with NSCLC between 2006 and 2016 to describe trends in incidence, incidence-based mortality, stage, and histology at diagnosis. Over the last decade, lung cancer population mortality has decreased. This decline has been driven by many factors, including smoking cessation, medical therapies, CT screening, and earlier therapeutic interventions. While prior studies have explored the association of smoking cessation, earlier interventions, and targeted therapies to NSCLC mortality, the role of stage shift due to early detection has not been adequately studied. 3 , 4 , 23 With limited precedent, this study wished to evaluate the extent of stage shift on the population level in the last decade and its association with NSCLC incidence-based mortality through a more exhaustive evaluation of stage and histology.

Consistent with prior literature, we found that the incidence-based mortality for NSCLC from 2006 to 2016 has declined at a faster rate compared with the incidence. 1 , 2 To better elucidate the improvements in incidence-based mortality during the study period, we assessed the trends in stage at diagnosis. We detected a significant association between year of diagnosis and stage. Patients with stage I/II at diagnosis significantly increased (AAPC, 1.5; 95% CI, 0.5 to 2.5) from 2006 to 2016 while patients with stage III/IV at diagnosis correspondingly decreased (AAPC, −0.6; 95% CI, −1.0 to −0.2). The percentage of missing stage was relatively stable during this timeframe and did not significantly change. Moreover, we observed that of all NSCLC histologies, adenocarcinoma increased at the fastest rate from 2006 to 2016. Squamous cell carcinoma also increased during this timeframe but at a much smaller rate. Other NSCLC histologies significantly declined during this timeframe. Taken together, the increase in early stage NSCLC during the study timeframe with a corresponding increase in adenocarcinoma suggest a stage shift to earlier disease.

To corroborate these findings, we hoped to better classify patients with unknown stage to determine whether a stage shift occurred during the study timeframe or if patients with unknown stages were reclassified to more specific categories. Compared with the overall study population, those with missing stage were less likely to have adenocarcinoma and more likely to be squamous cell carcinoma and other NSCLC histologies. Furthermore, among patients without stage information, 86.7% did not undergo a surgical procedure for the primary site as part of their first course of treatment. As surgical resection is the standard of care of early stage NSCLC, the low proportion of patients with unknown stage receiving surgery seem to suggest that they might not be stage I or II at diagnosis but rather later stage.

We also examined survival rate from 2006 to 2016 to additionally define patients with unknown stage. Patients with missing stage had a median (IQR) survival of 10 (2-28) months, which was between those with stage III (12 [4-34 months]) and stage IV (5 [1-13] months). The survival rate for patients with missing stage was significantly lower compared with those with stage I/II who had a median survival of 57 months. Based on the trends in histology and survival, patients with missing stage seem to be more similar to those with stage III and IV rather than those with stage I/II. Since the proportion of patients with missing stage has remained stable over the course of 2006 to 2016, our findings support patients from later stages being shifted to earlier stages, rather than unknown stages being better classified to earlier stages.

The stage and histology shifts we describe in the SEER data are consistent on a population-level with prior studies assessing and corroborating the efficacy of low-dose CT screening for lung cancer. 24 - 28 In particular, in the NLST, of 649 positive screening tests with low-dose CT, 70.2% were stage I and II with III and IV accounting for only 29.8%. 6 Moreover, the majority of the early stage lung cancer tumors were indolent histologies, such as bronchioloalveolar carcinoma (BAC) and adenocarcinoma, which have an overall 5-year survival of approximately 89% and 70%, respectively, compared with 85% for stage I disease. 29 - 32 In particular, 84.6% of BAC and 66% of adenocarcinoma were classified as stage I or II at the time of diagnosis. 6 The NELSON trial further supported these results with 70.8% of participants diagnosed with stage I; 33 86% of adenocarcinoma and 100% of BAC were stage I or II at diagnosis with both accounting for 63.5% of early stage lung cancer with only 31.9% being late stage. 33 Other CT-based lung cancer screening trials, including the Danish Lung Cancer Screening Trial (DLST), Italian Lung Cancer Screening Trial (ITALUNG), DANTE, Multicentric Italian Lung Detection (MILD), and German Lung cancer Screening Intervention (LUSI) have described similar stage and histology results as presented by NLST and the NELSON trial. 24 - 28

Taken together, the increase in early-stage NSCLC with a corresponding increase in adenocarcinoma that we detected in the SEER data mirrors what prior clinical trials on CT- based lung cancer screening have described on a smaller scale. Our findings in context with these prior studies seem to suggest that awareness of CT lung cancer screening is associated with an earlier detection of NSCLC (back-alley CT screening). The greater decline in incidence-based mortality compared with the incidence of NSCLC over the past decade may be partially explained by stage and histology shifts. We realize that patient adherence to lung cancer screening with low-dose CT remains limited. 34 - 36 According to the National Cancer Institute (NCI), uptake of CT screening has been limited and stable since 2010, with 4.5% and 5.9% of adults aged 55 to 80 years in 2010 and 2015 respectively, who met the USPSTF criteria for lung cancer screening, received a CT scan within the prior year. 19 Thus, we cannot only attribute the trends in NSCLC incidence and incidence-based mortality over the past decade to purposeful lung cancer screening with CT.

The findings from this study should be interpreted within the context of its limitations. This was a retrospective study using a database that only contained preselected demographic and clinical variables. We did not have available data for smoking status, family history of lung and/or bronchial cancer, occupational exposure to carcinogens, and driver variations, such as EGFR , which would provide increased insight, especially when evaluating the trends in incidence-based mortality. Moreover, for the participants in the SEER database, we lack detailed information on the diagnostic method, thus limiting us from measuring the rate of CT scan uptake among the study population. Additionally, 2.3% of study population were either unstaged or their staging information was unknown. Although we performed an exhaustive analysis to better define these participants, we realize that the lack of staging for this portion of study population prevents us from recategorizing to a well-defined stage.

This cohort study found that population-level mortality for NSCLC has decreased from 2006 to 2016. Although advances in treatments, particularly targeted therapeutics, have played a role in affecting mortality, our analysis suggests that decreased mortality is also associated with a diagnostic shift from later to earlier stage lung cancer and a histology shift to adenocarcinoma. Studies investigating the population impact of treatment on lung cancer mortality must take into account the confounding association of stage shift with survival and mortality outcome.

Accepted for Publication: October 12, 2021.

Published: December 17, 2021. doi:10.1001/jamanetworkopen.2021.37508

Open Access: This is an open access article distributed under the terms of the CC-BY License . © 2021 Flores R et al. JAMA Network Open .

Corresponding Author: Raja Flores, MD, Department of Thoracic Surgery, Icahn School of Medicine at Mount Sinai, Mount Sinai Health System, One Gustave L. Levy Place, PO Box 1023, New York, NY 10029 ( [email protected] ).

Author Contributions : Drs Flores and Taioli had full access to all of the data in the study and take responsibility for the integrity of the data and the accuracy of the data analysis.

Concept and design: All authors.

Acquisition, analysis, or interpretation of data: Patel, Alpert, Pyenson, Taioli.

Drafting of the manuscript: Patel, Alpert, Pyenson, Taioli.

Critical revision of the manuscript for important intellectual content: All authors.

Statistical analysis: Flores, Patel, Alpert, Pyenson.

Administrative, technical, or material support: Flores, Patel, Pyenson.

Supervision: Pyenson, Taioli.

Conflict of Interest Disclosures: Mr Pyenson reported serving as a commissioner on the Medicare Payment Advisory Commission outside the submitted work. No other disclosures were reported.

Disclaimer: The views expressed in this study do not reflect those of Milliman Inc, which employs Mr Pyenson and provides actuarial consulting services to many organizations in health care.

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Our Favorite Healthy Habits of 2021

From labeling your feelings to exercise snacks, here’s a roundup of some of Well’s best advice for better living.

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By Tara Parker-Pope

What good things did you do for yourself in 2021?

This year on Well, we suggested a number of small habits that can make life just a little better. It’s not too late to try them, and pick a few you’d like to continue. Here are eight of our favorites.

Give the best hours of your day to yourself . What time of day do you feel your best? For some people, we may feel most energetic during the first few hours of the morning. For night owls, evening might be our best time of day. Now ask yourself, “Who gets those hours?” Do you spend your best hours checking emails, catching up on work or doing tasks for your family? Try giving that time to yourself instead. Use it to focus on your priorities, rather than someone else’s. You can use that hour or two for anything you want — it might be for a hobby, a project that you feel passionate about, time with your children or even to volunteer and help others. Setting aside your best hours to focus on personal goals and values is the ultimate form of self-care.

Enjoy exercise snacks . Too often we think of exercise as a formal activity we have to do for an hour at the gym each day. But a number of studies show that short bursts of exercise several times a day lead to meaningful gains in fitness and overall health. Just as you might grab a handful of chips or nuts to break the monotony of your day, an exercise “snack” is a quick movement break. Get up and pace when you’re on the phone. Do jumping jacks, lunges or a wall sit, or walk the stairs for 20 seconds. My go-to exercise snack is 10 wall push-ups.

Take a gratitude photo . If a gratitude journal isn’t your thing, make a plan to take one photo a day of something special in your life. It can be a cute picture of your dog, a sunset or a delicious meal. Take a moment to study the photo, sit with your feelings of gratitude, and then share it with a friend or post it on social media. When we make an effort to notice our surroundings or show appreciation for the people, places or things that make us happy, it’s called “savoring.” Scientists know that savoring exercises can lead to meaningful gains in overall happiness and well-being.

Print a “feelings” list . Every day when you brush your teeth or make your coffee, ask yourself: How are you, really? Think of a word that describes exactly what you’re feeling. Unsettled? Energetic? Delighted? Frazzled? (Avoid standard answers like “good,” “fine” or “OK.”) This simple labeling activity is surprisingly effective for calming stress and taking the sting out of negative thoughts. Studies show that when we label our feelings, it helps turn off the emotional alarm system in our brain and lowers our stress response. Click the link for a list of words, from the Hoffman Institute, to describe how you’re feeling and put it on your refrigerator or your bathroom. Ask your kids to pick a word from the list every day too. It can be a surprisingly fun family routine.

Do a five-finger meditation . This is an easy way to calm yourself, no matter where you are. Use the index finger of one hand to trace the outline of the opposite hand. As you trace up a finger, breathe in. As you trace down, breathe out. Continue finger by finger until you’ve traced your entire hand. Now reverse directions and do it again, making sure to inhale as you trace up, and exhale as you trace down. (Click on the link for a simple animation showing how it’s done.) I’ve used this method on airplanes, before getting my Covid vaccine shots and during stressful meetings, and it works every time.

Make it easy: In the scientific study of habit formation, the thing that makes it harder for you to achieve your goal is called friction, which typically comes in three forms — distance, time and effort. The friction-free habits you’ll keep are those that are convenient, happen close to home and don’t take much time or effort. For example, one of my goals this year was to cook more and stop ordering take out or buying expensive grocery-prepared foods. I hated going to the grocery store, and I found it difficult to cook for one person. Then I read a Wirecutter article on the best meal kit delivery services and realized I could make home cooking a lot easier on myself. I started using the Martha Stewart & Marley Spoon meal kits, and it was like having my own personal sous chef. By removing the friction, cooking is now fun, easy and delicious.

Watch the jellyfish. One of the best mindfulness tips I came across this year was from Cord Jefferson, the television writer who thanked his therapist on national television when he won an Emmy Award. Mr. Jefferson told me he struggled with traditional meditation, but he enjoys watching the feed from a web camera showing the jellyfish at the Monterey Bay Aquarium. Bookmark the jelly-cam on your phone or laptop browser and get lost in the gentle pulses of the jellyfish for a short mindfulness break during your workday.

Find a health buddy . Choose a friend who shares your health goals and make a plan. Meet each other once or twice a week for a walking date. Or it could be a daily text check-in to see how you’re doing on a diet, or a Zoom call to work together on a decluttering project. Studies show we’re more likely to reach our goals when we bring a friend along for the journey.

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When grief doesn’t go away

Prolonged grief disorder is a syndrome in which people feel stuck in an endless cycle of mourning that can last for years or even decades, severely impairing their daily life, relationships and job performance.

The disorder was recently added to the Diagnostic and Statistical Manual of Mental Disorders. Symptoms of P.G.D. can include emotional numbness; intense loneliness; avoidance of reminders the person is not there; feeling that life is meaningless; difficulty with reintegration into life; extreme emotional pain, sorrow or anger; a sense of disbelief about the death; and a feeling that a part of oneself has died.

In the immediate aftermath, or “acute” phase of a death, such feelings are considered normal. But when three or more of these symptoms persist nearly every day for a year after the loss in adults, or for six months in children and adolescents, grief counselors say it can be a worrisome sign of prolonged grief disorder.

The disorder, which was previously known as complicated grief and persistent complex bereavement disorder, isn’t new. But before it was listed in the D.S.M. as a condition for further study. Preliminary studies suggest that it affects around 7 percent of those in mourning, though estimates vary. With the coronavirus claiming nearly 800,000 lives so far in the United States alone, grief counselors are concerned about the ongoing fallout. Each Covid death is projected to leave a ring of nine bereaved: That’s roughly seven million grieving parents, children, siblings, grandparents and spouses. And the losses cast a shadow over many more.

Read more: As Covid Deaths Rise, Lingering Grief Gets a New Name

The Week in Well

Here are some stories you don’t want to miss:

Gretchen Reynolds explains why 9 cents can motivate you to exercise .

Roni Rabin tallies the pandemic effect on blood pressure .

Jane Brody explores the health toll of poor sleep .

And of course, we’ve got the Weekly Health Quiz.

Let’s keep the conversation going. Follow me on Facebook or Twitter for daily check-ins, or write to me at [email protected] .

Tara Parker-Pope is a columnist covering health, behavior and relationships. She is the founding editor of Well, The Times's award-winning consumer health site. More about Tara Parker-Pope

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• Published: 29 August 2022

Enhancing health and wellness by, for and with Indigenous youth in Canada: a scoping review

• Udoka Okpalauwaekwe 1 ,
• Clifford Ballantyne 2 ,
• Scott Tunison 3 &
• Vivian R. Ramsden 4  

BMC Public Health volume  22 , Article number:  1630 ( 2022 ) Cite this article

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Indigenous youth in Canada face profound health inequities which are shaped by the rippling effects of intergenerational trauma, caused by the historical and contemporary colonial policies that reinforce negative stereotypes regarding them. Moreover, wellness promotion strategies for these youth are replete with individualistic Western concepts that excludes avenues for them to access holistic practices grounded in their culture. Our scoping review explored strategies, approaches, and ways health and wellness can be enhanced by, for, and with Indigenous youth in Canada by identifying barriers/roadblocks and facilitators/strengths to enhancing wellness among Indigenous youth in Canada.

We applied a systematic approach to searching and critically reviewing peer-reviewed literature using the Preferred Reporting Items for Systematic Reviews and Meta-Analyses extension for Scoping Reviews [PRISMA-ScR] as a reporting guideline. Our search strategy focused on specific keywords and MeSH terms for three major areas: Indigenous youth, health, and Canada. We used these keywords, to systematically search the following electronic databases published in English between January 01, 2017, to May 22, 2021: Medline [Ovid], PubMed, ERIC, Web of Science, Scopus, and iportal. We also used hand-searching and snowballing methods to identify relevant articles. Data collected were analysed for contents and themes.

From an initial 1695 articles collated, 20 articles met inclusion criteria for this review. Key facilitators/strengths to enhancing health and wellness by, for, and with Indigenous youth that emerged from our review included: promoting culturally appropriate interventions to engage Indigenous youth; using strength-based approaches; reliance on the wisdom of community Elders; taking responsibility; and providing access to wellness supports. Key barriers/roadblocks included: lack of community support for wellness promotion activities among Indigenous youth; structural/organizational issues within Indigenous communities; discrimination and social exclusion; cultural illiteracy among youth; cultural discordance with mainstream health systems and services; and addictions and risky behaviours.

This scoping review extracted 20 relevant articles about ways to engage Indigenous youth in health and wellness enhancement. Our findings demonstrate the importance of promoting health by, and with Indigenous youth, by engaging them in activities reflexive of their cultural norms, rather than imposing control measures that are incompatible with their value systems.

Peer Review reports

Introduction

The term ‘Indigenous’ is internationally recognized to describe a distinct group of people that live within or are attached to geographically distinct ancestral territories [ 1 , 2 ]. In Canada, the term Indigenous is an inclusive term used to refer to the First Nations, Métis, and Inuit people, each of which has unique histories, cultural traditions, languages, and beliefs [ 3 , 4 , 5 ]. Indigenous peoples are the fastest-growing population in Canada, with a population estimated at 1.8 million, which is 5.1% of the Canadian population [ 6 , 7 ]. Within this population, 63% identify as First Nation, 33% as Métis, and 4% as Inuit [ 6 , 7 ]. Indigenous youth are the youngest population in Canada, with over 50% of Indigenous youth under 25 years [ 7 ]. Projections of Indigenous peoples in Canada have estimated a 33.3 to 78.7% increase in Indigenous populations, with the youth making up the largest proportion of the Indigenous population by 2041 [ 6 , 7 ].

Before European contact in North America, Indigenous peoples in Canada lived and thrived with their cultures, languages, and distinct ways of knowing [ 2 ]. However, Indigenous peoples in Canada rank lower in almost every health determinant when compared with non-Indigenous Canadians [ 8 , 9 , 10 ]. A report on health disparities in Saskatoon, Saskatchewan, described First Nations peoples to be “more likely to experience poor health outcomes in essentially every indicator possible” (page 27) [ 11 ]. This greater burden of ill health among Indigenous peoples in Canada has been attributed to systemic racism (associated with differences in power, resources, capacities, and opportunities) [ 9 , 10 , 12 , 13 ] and intergenerational trauma (stemming from the past and ongoing legacy of colonization such as experienced through the Indian residential and Day school systems, the Sixties Scoop, and the ongoing waves of Indigenous child and youth apprehensions seen in the foster and child care structures that remove Indigenous children from their family, community and traditional lands) [ 3 , 9 , 10 , 12 , 13 , 14 , 15 , 16 , 17 ]. These traumatic historical events, along with ongoing inequities, such as: socioeconomic and environmental dispossession; loss of language; disruption of ties to Indigenous families, community, land and cultural traditions; have been reported to exacerbate drastically and cumulatively the physical, mental, social and spiritual health of Indigenous peoples in Canada, creating “soul wounds” (3 p.208) that require interventions beyond the Westernized biomedical models of health and healing [ 3 , 9 , 10 , 12 , 13 , 14 , 15 , 16 , 17 , 18 , 19 , 20 , 21 ].

In the same way, Indigenous youth in Canada face some of the most profound health inequities when compared with non-Indigenous youth which can be further shaped by the rippling effects of intergenerational trauma caused by the historical and contemporary colonial policies that reinforce or legitimize negative stereotypes regarding Indigenous youth in Canada [ 2 , 10 , 14 , 20 , 22 , 23 , 24 , 25 , 26 , 27 ]. When compared with their non-Indigenous peers, Indigenous youth in Canada have been reported to be more likely to have higher rates of chronic conditions [e.g., diabetes, obesity, chronic respiratory diseases, heart diseases, etc.] [ 14 ], discrimination [ 28 , 29 ], youth incarceration and state care [ 12 , 20 , 30 ], poverty [ 31 ], homelessness [ 32 ], higher adverse mental health conditions [ 20 , 33 , 34 , 35 , 36 , 37 ], higher suicide rates [ 33 , 38 , 39 ], and lower overall life expectancies [ 24 , 40 , 41 , 42 ].

Indigenous peoples’ perception of health and wellness is shaped by their worldview and traditional knowledge [ 43 , 44 ]. While the Western concept of health broadly defines health as the state of complete physical, mental, social well-being, and not merely the absence of disease [ 45 ], Indigenous peoples understand health in a holistic way [ 26 ] that seeks balance between the physical, mental, emotional, and spiritual aspects of an Indigenous person in reciprocal relationships with their families, communities, the land, the environment, their ancestors, and future generations [ 46 , 47 , 48 ]. Unfortunately, this holistic concept of health and wellness opposes the individualistic and biomedically focused Western worldview of health, which is a dominant lens commonly used in health research, projects, and programs involving Indigenous communities [ 46 ]. This practice further perpetuates the legacy of colonization and excludes avenues for Indigenous communities to access holistic healing practices “grounded in their culture” [ 43 , 49 , 50 ]. For example, health research involving Indigenous peoples in Canada tends to focus on Indigenous health deficits and identified social determinants in the communities, more often and without proper representation [ 43 ]. Additionally, there is the imposition of research on rather than with youth [ 43 , 44 ]; and the failure to acknowledge Indigenous worldviews in research, to ensure in benefits them [ 43 ].

Authentically engaging with Indigenous youth has been cited by Indigenous scholars as one of the ways of achieving and enhancing wellness by, for, and with youth [ 51 , 52 ]. This is characterized by meaningful and sustained involvement of the youth in program planning, development, and decision-making to promote self-confidence and positive relationships [ 53 ]. Authentic engagement involves working with rather than on youth as research partners or program planning participants [ 54 ]. This shift to working with rather than on implies respect for the knowledge of the lived experiences of the youth involved [ 54 , 55 , 56 ] and is based on meaningful relationships built over time among all involved [ 53 , 57 , 58 ]. Research has shown that engaging youth (Indigenous or non-Indigenous) as partners in a project/program fosters a sense of belonging, self-determination, and self-actualization within their community; thus, enhancing community wellness [ 54 , 56 , 58 , 59 ].

This paper explores what is known in the peer-reviewed literature about strategies, approaches, and ways to engage Indigenous youth in health and wellness enhancement. Our main objective is to use information gathered from this review to inform youth engagement strategies, by considering the facilitators/strengths and barriers/roadblocks to enhancing wellness with Indigenous youth. We define facilitators in this context as factors that improve, enhance, strengthen, or motivate a journey to health, wellness, and self-determination. These are considered ‘strengths’ in the language of Indigenous peoples as they support equitable strength-based pathways towards reconciliation. Conversely, barriers are roadblocks, and demotivating factors or processes that limit and challenge Indigenous peoples’ access to achieving health and wellness. Our overarching research question was, in what ways can Indigenous youth enhance health and wellness for themselves, their family, and the Indigenous communities where they live?

Sub-questions included:

What factors do Indigenous youth in Canada identify as facilitators/strengths to enhancing health and wellness?

What factors do Indigenous youth in Canada identify as barriers/roadblocks to enhancing health and wellness?

Methodology and methods

Scoping reviews help provide an overview of the research available on a given area of interest where evidence is emerging [ 60 ]. While there are several accepted approaches to such reviews, this scoping review was undertaken using the Joanna Briggs Institute (JBI) Guideline for scoping reviews [ 61 ]. This approach was based on the Arksey and O’Malley methodological framework [ 62 ], which was further advanced by Levac et al. [ 60 ], and Peter et al. [ 61 ]. Our search strategy focused on primary sources that elucidated youth-driven, youth-led, or youth-engaged strategies carried out by, for, and with Indigenous youth to enhance health and wellness. We chose to explore all health programs and research inquiry that explore health challenges on the physical, mental, emotional, and spiritual aspects of an Indigenous person to encompass the definition of health and wellness as defined and understood from an Indigenous perspective. This scoping review is reported in accordance with the guidelines provided in the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) extension for Scoping Reviews (PRISMA-ScR) [ 63 ]. See Supplementary material file 1 for PRISMA-SCR checklist.

Protocol registration and reporting information

There was no pre-published or registered protocol before the commencement of this study.

Eligibility criteria

Types of studies.

A priori inclusion criteria for articles in this study included: 1] peer-reviewed journal articles reporting health and wellness programs, initiatives, and/or strategies among Indigenous youth in Canada, and 2] peer-reviewed journal articles published between January 01, 2017, to May 22, 2021. We chose a 5-year time frame to limit our findings to the most updated peer-reviewed literature which could provide implications for the growing body of work done in the field of Indigenous research among youth. Systematic reviews, meta-analyses, study protocols, opinion pieces, and narrative reviews were excluded.

Participants

Peer-reviewed studies involving Indigenous youth (First Nations, Métis, and Inuit) in Canada were eligible for inclusion. We considered the fluidity of definitions for youth by age range as literature sources generally defined youth in stages between adolescence to early adulthood [ 6 , 64 , 65 ]. In Canada, the Government of Canada uses several age brackets to identify youth depending on context, program, or policies in question. For example, Statistics Canada defines youth as between 15 to 29 years [ 6 ], Health Canada in the first State of Youth Report defined youth as between 12 to 30 years [ 65 ] when referring to statistical reports, and as between 13 to 36 years when referring to youth-led programs and policies [ 65 ]. However, for the purposes of this review we defined and referred to Indigenous youth or young people as between 10 to 24 years to be more representative of a broader definition of youth which is in keeping with Indigenous peoples’ worldviews, languages, and cultures and more representative of a broader definition of youth as offered by Sawyer et al. [ 64 ].

Information sources and search strategy

With the assistance of an Academic Reference Librarian, search terms were identified, which were categorized and combined into three conceptual MeSH terms that we adapted for the database-specific search strategy. These terms included: Indigenous youth (including synonyms and MeSH terms), health (including synonyms and MeSH terms) and Canada. Thus, studies were then identified for this scoping review by searching electronic databases and hand-searching reference lists of included articles.

Initially, the following databases (Medline (Ovid), PubMed, ERIC, Web of Science and Scopus) were used to identify relevant articles published between January 1, 2017, and April 30, 2021. This constituted our first search. We then carried out a second search (updated search) on May 22, 2021, using the same search queries on the same library databases; in addition, we included the University of Saskatchewan’s Indigenous Studies Portal (iPortal) [ 66 ] to ensure we had as many hits as possible for our search query on focused studies with Indigenous communities. To ensure exhaustiveness, we employed hand-searching techniques and snowballing methods to identify articles relevant to the research questions by reviewing reference lists of relevant articles that met the eligibility criteria. Following this, all the identified articles were collated in Endnote Reference Manager version X9.3 [ 67 ] and exported, after removing duplicates, into Distiller SR [ 68 ], a web-based systematic review and meta-analysis software. The syntax used on electronic databases and the University of Saskatchewan’s iPortal to identify potentially relevant articles for inclusion into this review study is outlined in Table  1 .

Selection of sources of evidence

Two iterative stages were employed to select sources of evidence for this review study. First, we created screening, coding, and data extraction forms using Distiller SR [ 68 ] for each stage. In the first stage, UO screened titles and abstracts of all articles using the following keywords: Indigenous youth; health; wellness; engagement and Canada. In the second stage, UO independently screened and reviewed the full-text articles (FTAs) of citations included from the first stage. The questions in Table  2 were used to screen the eligibility for inclusion of the article for data extraction. A second reviewer (ST) also independently reviewed and screened every 10th FTA citation from the first phase to check inter-rater reliability.

Data charting process and data items

Data were extracted using a pre-designed data extraction form on DistillerSR [ 68 ]. All extracted data were exported into Microsoft Excel [ 69 ] for data cleaning and analysis. The title fields used to extract data from included articles are shown in Table  3 .

Critical appraisal of individual sources of evidence

Conjointly, UO and CB appraised each article included considering characteristics and methodological quality using the JBI Critical Appraisal Tool for qualitative and quantitative studies [ 70 ]. The JBI Critical Appraisal Tool was designed to evaluate the rigour, trustworthiness, relevance, and potential for bias in study designs, conduct, and analysis [ 70 ]. Results on the critical appraisals are summarized in Supplementary material file  2 .

Synthesis of results

We categorized findings in this review as facilitators/strengths and barriers/roadblocks to enhancing wellness by, for, and with Indigenous youth, further describing how youth described wellness promotion. We met weekly via videoconference to discuss, review, and revisit our study evaluation protocol to ensure we adhered strictly to the scoping review guidelines.

As a result of our literature search, 1671 articles from five library databases and 24 articles through hand-search and snowball methods were identified. Of the 1695 articles, 253 were excluded as duplicates on EndNote vX9.3 using the ‘remove duplicates’ function on the software. Another 1227 articles were excluded following screening of title and abstracts on Distiller SR which we had fed with a series of screening questions (see Table 2 ) that were reviewed independently by two reviewers (UO and ST). Inter-rater reliability (Cohen’s kappa) calculated was 0.886, standard error = 0.147, p -value = 0.001. Where there were conflicts in article inclusion ratings, a third reviewer (CB), was brought in to discuss and provide a resolution. This left 215 articles for full-text article (FTA) screening. After reviewing 215 FTAs, a further 195 articles were excluded, leaving 20 articles for inclusion into the final review. Articles were excluded in the eligibility stage for the following reasons, 1) articles not focused on Indigenous youth or Indigenous communities, 2) articles not focused on Indigenous health and/or wellness, 3) articles not primarily focused in Canadian settings, 4) articles not written in English, 5) articles considered irrelevant or not applicable to addressing the research objectives or research questions of our study, 6) articles other than original research (i.e., we excluded review studies, opinion papers, and conference abstracts). A flowchart of article selection can be found in Fig.  1 .

PRISMA flowchart showing selection of articles for scoping review

Characteristics of sources of evidence

The general and methodological characteristics of all 20 included articles are summarized in Table  4 . Of these, one study was published in 2017, two in 2018, eleven in 2019, four in 2020 and two in 2021. Five (25%) studies that were included were set in the province of Ontario, four (20%) in the province of Saskatchewan, three (15%) in the Northwest Territories and two in the province of Alberta. Fifty percent (10/20) of the studies recruited or focused on Indigenous (First Nations, Métis, and Inuit) people as study participants, seven (35%) studies recruited or concentrated on First Nations peoples only, and three (15%), on Inuit peoples only. Sixteen (80%) articles were qualitative studies, three (15%) used mixed methods, and one (5%) was a quantitative study. Eleven (55%) studies used participatory research approaches (which included photovoice, community-based participatory research (CBPR) or participatory action research (PAR)) in their study designs, seven (35%) integrated Indigenous research methods (e.g., the two-eyed seeing approach) into their study design, and five (25%) studies used descriptive or inferential evaluation strategies in their study design. Interviews, focus-group discussions, and discussion circles were the most common data collection methodology used in 17 (85%) of the studies included. Youth were commonly engaged in non-cultural activities in twelve (60%) of the studies and employed a youth-adult co-led strategy in 16 (80%) of the included studies.

Results of individual sources of evidence

All included studies provided answers relevant to one or more of the research questions with the potential for changing practice and strategies for engagement. All the included studies explored, investigated, or evaluated issues addressing health and wellness among Indigenous youth in Canada. The age range of youth involved in included studies ranged between 11 to 24 years. All studies utilized fun and interactive strategies to engage youth in their respective studies with the outcomes aimed at promoting health, developing capacity in youth participants and engaging youth in collaborating on sustainable outcomes for and with their communities [ 5 , 8 , 40 , 44 , 57 , 71 , 72 , 73 , 74 , 75 , 76 , 77 , 78 , 79 , 80 , 81 , 82 , 83 , 84 ], save for one [ 16 ]. The summary of individual sources of evidence is described in Table  5 .

The key facilitators/strengths and barriers/roadblocks to enhancing health and wellness by, for, and with Indigenous youth that emerged from the included studies are described in Table  6 , in descending order of major themes for the frequency of citation by included articles per theme. The facilitators/strengths and barriers/roadblocks have also been categorized into sub-themes under five major themes for facilitators/strengths and six major themes for barriers/roadblocks. Health outcomes/programs examined by included studies included suicide prevention [ 40 ], mental health promotion [ 71 , 74 ], HIV prevention [ 75 ], wellness promotion through youth empowerment and cultural activism [5, 8, 16, 57, 72,,76, 77, 78,79, 80], social health [ 76 , 83 ], land-based healing and wellness [ 77 , 82 ], art-media based therapy and wellness [ 44 , 73 , 81 , 84 ]. An overview of the facilitators/strengths and barriers/roadblocks to enhancing health and wellness by, for, and with Indigenous youth is presented in Fig.  2 .

Summary of facilitators/strengths and barriers/roadblocks to enhancing wellness by, for and with Indigenous youth

Facilitators/strengths to enhancing health and wellness by, for, and with indigenous youth

Five major themes emerged and were identified as facilitators/strengths to enhancing health and wellness by, for, and with Indigenous youth in Canada. The most identified facilitator/strength of health and wellness among Indigenous youth in Canada, identified in 19 [95%] of the included studies, was the promotion of strength-based approaches to engaging with youth in the community [ 5 , 8 , 16 , 44 , 57 , 71 , 72 , 73 , 74 , 75 , 76 , 77 , 78 , 79 , 80 , 81 , 82 , 83 , 84 ]. A number of sub-themes also emerged from this major theme to include: peer-mentoring [ 5 , 8 , 44 , 57 , 71 , 73 , 74 , 75 , 76 , 79 , 80 , 81 , 82 , 83 , 84 ]; engaging youth in programs that developed and promoted self-determination, capacity building and empowerment [ 5 , 8 , 44 , 57 , 72 , 73 , 74 , 76 , 77 , 78 , 79 , 80 , 82 , 83 , 84 ]; building positive relationships and social connections with others, nature and the environment [ 5 , 8 , 44 , 57 , 72 , 73 , 76 , 77 , 79 , 80 , 81 , 82 , 83 , 84 ]; showing kindness to one another [ 5 , 16 , 44 , 57 , 77 , 79 , 80 , 81 , 83 ]; and engaging youth in cultural activities [ 57 , 76 , 82 , 83 ] that stimulate or encourage mutual learning, enhance critical consciousness and cause transformative change [ 5 , 8 , 75 , 76 , 79 , 81 ]. The next most common facilitator identified in 16 [80%] of included studies was enhancing cultural identity and connectedness through youth engagement in cultural activities [ 8 , 16 , 40 , 44 , 57 , 71 , 72 , 75 , 76 , 77 , 79 , 80 , 81 , 82 , 83 , 84 ]. Other facilitators included: reliance on the wisdom, skills, and teachings of community Elders, Traditional Knowledge Keepers and community leaders in the pursuit of health and wellness promotion with Indigenous youth [ 5 , 16 , 44 , 72 , 77 , 79 , 80 , 81 , 83 , 84 ]; taking responsibility for one’s journey to wellness [ 44 , 57 , 72 , 74 , 79 , 80 , 82 , 83 ]; and providing access to health services and other wellness supports (including traditional health services) for youth in Indigenous communities [ 76 , 78 ]. A summary of the facilitators/strengths is provided in Fig. 2 .

Barriers/roadblocks to enhancing health and wellness by, for, and with indigenous youth

Six major themes emerged and identified as barriers/roadblocks to enhancing health and wellness by, for and with Indigenous youth in Canada. The most identified barrier/roadblock to enhancing health and wellness identified in 55% (11/20) of the included articles was a lack of community support [including social, financial, and organizational support] for wellness promotion strategies among Indigenous youth [ 5 , 44 , 57 , 72 , 74 , 75 , 76 , 77 , 78 , 80 , 81 ]. Structural and organizational issues within Indigenous communities regarding wellness promotion strategies were identified as the second most common barrier/roadblock to enhancing wellness in 50% [10/20] of included studies [ 5 , 8 , 72 , 73 , 76 , 77 , 78 , 81 , 82 , 83 ]. These structural and organizational issues included: Indigenous community problems or concerns affecting the sustainability of instituted wellness programs/strategies [ 5 , 8 , 78 , 81 ]; dogmatism and debates about definitions regarding traditions of health among Indigenous communities [ 72 , 77 , 82 , 83 ]; social and structural instability within communities (e.g., leadership concerns) [ 8 , 76 , 83 ]; modest to low capacity of service providers (e.g. vendors, health service centers, social service centers, etc.) to meet the demands of communities [ 73 , 78 , 81 ]; and the misperception of a lack of control for self-governance in Indigenous communities [ 81 ]. Discrimination and social exclusion of Indigenous youth were also identified as a barrier/roadblock to enhancing wellness in eight (40%) studies included [ 5 , 8 , 44 , 57 , 74 , 76 , 80 , 83 ]. Forms of discrimination and social exclusion identified as subthemes included: Racism (e.g., personal, interpersonal, structural and systemic racism) [ 5 , 8 , 76 , 80 , 83 ]; low self-esteem and a low view of self-identity leading to self-deprecation and self-exclusion from engaging in youth activities [ 8 , 44 , 76 , 80 , 83 ]; mental health stigmatization [ 73 , 74 , 76 ]; lack of inclusivity of traditional Indigenous activities into Canadian teaching institutions [ 76 , 77 ]; and all forms of bullying, abuse and hunger [ 57 , 80 ]. Other barriers/roadblocks included: cultural illiteracy among Indigenous youth [ 44 , 57 , 73 , 74 , 75 , 83 , 84 ]; friction between Western and Traditional methods of promoting health and wellness [ 5 , 74 , 76 , 77 ]; and risky behaviours such as gang activity, substance use/abuse and addictions [ 44 , 57 , 75 , 76 , 80 ]. A summary of the barriers/roadblocks is provided in Fig. 2 .

Scoping reviews determine the extent, range, and quality of evidence on any chosen topic [ 60 , 61 , 62 , 63 ]. In addition, they can be used to map and describe what is known about an identified topic to identify existing gaps in the literature regarding the chosen topic [ 60 , 61 , 62 , 63 ]. In this scoping review, the peer-reviewed evidence regarding facilitators/strengths and barriers/roadblocks to enhancing health and wellness by, for and with Indigenous youth in Canada were mapped and synthesized. Key facilitators/strengths highlighted included: promoting culturally appropriate interventions [ 8 , 16 , 40 , 44 , 57 , 71 , 72 , 75 , 76 , 77 , 79 , 80 , 81 , 82 , 83 , 84 ] using strength-based approaches [ 5 , 8 , 16 , 44 , 57 , 71 , 72 , 73 , 74 , 75 , 76 , 77 , 78 , 79 , 80 , 81 , 82 , 83 , 84 ]. Key barriers to enhancing health and wellness by, for and with Indigenous youth identified in this review were the lack of community support for wellness promotion activities among Indigenous youth [ 5 , 44 , 57 , 72 , 74 , 75 , 76 , 77 , 78 , 80 , 81 ] and structural/organizational issues within Indigenous communities [ 5 , 8 , 72 , 73 , 76 , 77 , 78 , 81 , 82 , 83 ].

Strength-based approaches empower community members, academic researchers, and policymakers to effect community change while focusing on what has worked in the past and the community vision for success in the future [ 79 ]. This is contrasted with the common narrative in most studies exploring Indigenous health and wellness that focused on why and where the community has failed to thrive [ 79 ]. Promoting strength-based interventions by, for, and with Indigenous youth works in parallel with ensuring that health interventions are culturally appropriate [ 44 , 79 ] because Indigenous epistemologies or ways of knowing see reality as intricate processes of interdependent relationships between humans, nature, and the spirit world [ 44 , 77 ]. As such, wellness promotion in Indigenous communities should emphasize support for their traditional values such as respect, trust, non-judgement, and relationality, all of which support cultural revitalization [ 26 , 71 ].

Conversely, wellness promotion in Indigenous communities should disavow the use of Western-based epistemologies that embrace and emphasize control over risk factors and health [ 44 , 79 ]. The definition and perception of health and wellness by Indigenous peoples are starkly different from the Western perspective of health promotion [ 44 , 79 ] which was found in our study to be a barrier/roadblock to enhancing health and wellness by, for and with Indigenous youth [ 8 , 43 , 44 , 76 ]. Because of these contrasting and conflicting views on health and wellness, research carried out with Indigenous communities must be grounded in their culture. Elder Jim Dumont – a professor of Native Studies and a member of the Shawanaga First Nation on Eastern Georgian Bay, when describing the role of Indigenous culture in facilitating wellness among Indigenous peoples, defined Indigenous culture as a “ facilitator to spiritual expression” [ 85 p.11]. He described Indigenous culture as “an expression of the life-ways, the spiritual, psychological, social, and material practice of the Indigenous worldview, which attends to the whole person’s spiritual desire to live life to the fullest” [ 85 p.9]. This was the way of life for Indigenous peoples before colonization [ 2 ]. Back then, Indigenous peoples honoured and utilized traditional methods and practices connected to their respective unceded homelands to promote and sustain health and wellness by themselves within their respective communities [ 2 , 16 , 86 ]. These cultural practices provided and promoted health and wellness for the community, the peoples, the lands, and the environment [ 2 ].

Furthermore, Indigenous wellness promotion by, for and with Indigenous youth should go beyond making mainstream health promotion strategies more culturally appropriate. Indigenous wellness promotion should also invite youth as partners and co-researchers to authentically engage with the community, acknowledging their needs while working together with them to identify opportunities for change (which should include shared power and responsibilities in the relationship dynamic). This must be the fundamental principle for any work done by, for, or with Indigenous communities (i.e., authentic engagement) [ 54 , 55 , 59 ]. Authentic engagement is working and walking with rather than on communities [ 54 ] in a way that encourages respectful, compassionate, and genuine interest in the work undertaken by all partners involved [ 54 , 55 , 57 , 87 , 88 ]. In authentically engaging with Indigenous communities, emphasis should be placed on connecting with , rather than controlling, community members [ 44 , 89 ]. By doing so, enhances a community’s ability to answer their issues by identifying their community strengths and assets, considering opportunities for change, and co-creating meaningful solutions to mitigate them.

The Tri-Council Policy Statement (TCPS) on Ethical Conduct for Research involving Humans indicates in Chapter 9 that, where research involves First Nations, Métis, and Inuit peoples and their communities, they are to have a role in shaping and co-creating research that affects them; with respect being given to the autonomy of these communities and the individuals within them to decide to participate [ 90 ]. Our study showed that where youth were engaged as partners and co-researchers, promoted self-determination, capacity building and ultimately enhanced wellness [ 8 , 40 , 44 , 57 , 72 , 74 , 75 , 76 , 77 , 79 , 84 ].

From the outcomes of this review, youth were engaged as partners or co-researcher in 55% of the included articles using research approaches such as community-based participatory research [CBPR], photovoice, visual voice, participatory videography, performative arts, participatory narrative, and storytelling methods [ 8 , 40 , 44 , 57 , 72 , 74 , 75 , 76 , 77 , 79 , 84 ]. This review demonstrated that these methods helped foster an environment for transformative learning, reciprocal transfer of expertise, shared decision-making, and co-ownership of the research processes [ 8 , 40 , 44 , 57 , 72 , 74 , 75 , 76 , 77 , 79 , 84 ]. For example, Goodman et al. identified that through photovoice, youth identified how racism negatively influenced the types of social supports and relationships formed in their community, leading to improved access to mental health-promoting social programs [ 76 ]. Anang et al. reported that engaging Indigenous youth as co-researchers in exploring ways to promote suicide prevention revitalized awareness of their cultural identity, which was identified as a protective factor to youth suicide [ 40 ]. A group of First Nation girls involved in the Girl Power Program designed to build and foster empowerment using youth participatory action research approach indicated that working as co-researchers/co-creators in the program empowered them to find healing from wounded spirits, which helped enhance positive changes towards wellness through āhkamēyimowin (perseverance) [ 57 ]. Thus, we can conclude from our study that engaging youth as partners in research processes optimizes their personal experiences and gives them a voice which can stimulate action.

Engaging Indigenous youth in the co-creation of wellness strategies should also involve community Elders, Traditional Knowledge Keepers, and other Indigenous community leaders. This review demonstrated that reliance on the wisdom of Elders, Traditional Knowledge Keepers and Indigenous community leaders facilitated and enhanced wellness among Indigenous youth [ 5 , 16 , 44 , 72 , 77 , 79 , 80 , 81 , 83 , 84 , 91 ]. Elders, Traditional Knowledge Keepers, and Indigenous community leaders play a central role in increasing awareness related to the community’s histories, languages, knowledge, and ways of knowing [ 91 , 92 ]. For non-Indigenous researchers and allies, Elders and Traditional Knowledge Keepers can provide formal and informal teachings on: histories of the Indigenous community in question, their world views, languages in the community, arts, crafts and songs, value systems in the nation/community; knowledge of traditional plants and medicines; clan teachings in the nation/community; ceremonial knowledge or protocols; and understanding of wellness in the community that can increase cultural awareness and build Indigenous research competencies for non-Indigenous researchers and allies [ 91 , 92 , 93 ]. Hence, engaging Elders, Knowledge Keepers and Indigenous community leaders in youth wellness programs can provide an avenue for mutual learning, guiding non-Indigenous researchers/allies towards cultural appropriateness in co-developing youth-driven wellness strategies.

Practical implications

Overall, this review emphasized the importance of promoting wellness among Indigenous youth using ‘ culture as strength ’ rather than imposing control measures on Indigenous values. The historical experiences of Indigenous youth have revealed traumatic and distressful pasts propagated by the cumulative intergenerational impacts of colonization which evolved from Residential Schools, Day Schools, and the Sixties Scoop [ 15 , 16 , 33 , 94 , 95 ]. The 2015 Truth and Reconciliation Commission of Canada’s 96 Calls-to-Action stressed the need to decolonize mainstream health promotion strategies and embrace the promotion of self-determination in the use of and access to traditional knowledge, therapies, and healing practices Indigenous peoples [ 95 , 96 ]. This review provided a foundation for authentically engaging Indigenous youth in the co-creation of culturally appropriate wellness promotion strategies/programs driven and sustained by authentically engaged Indigenous youth in the community. Considering the number of qualitative studies we found in our review, a meta-synthesis of qualitative studies may guide future directions based on the findings in our study to further pursue to understand, appraise, summarize, and combine qualitative evidence to address the specific research questions particularly around the influences and experiences of cultural connectedness and wellness among Indigenous youth in Canada. Nonetheless, this review also contributes to the growing literature identifying strength-based approaches to enhancing health and wellness among Indigenous peoples in Canada.

Study limitations

This review aimed to provide an entire scope of all original studies published in peer-reviewed journals to allow for as broad a scope of literature synthesis as possible. However, this study is not without limitations. First, the search was limited to multiple library databases, including the University of Saskatchewan’s Indigenous Studies Portal (iPortal) [ 66 ]. Although this review produced many peer-reviewed and original studies, there is a potential that other relevant articles and reports were missed because we did not search the grey literature. Secondly, because this review was limited to peer-reviewed articles published in English, it is possible that potentially relevant studies in other languages were omitted. Moreover, the outcomes of this review are limited to the nature of the data reported in the articles included in the review. Additionally, we acknowledge the differences and nuances in Indigenous practices, values and culture which limits the generalizability of our review findings. Lastly, some of the studies in the scoping review utilized Indigenous study designs and methods that could not be appropriately evaluated using the JBI Critical Appraisal Tools [ 70 ].

This scoping review identified ways health and wellness can be enhanced by, for, and with Indigenous youth by identifying facilitators/strengths and barriers/roadblocks to enhancing health and wellness among Indigenous youth from identified studies published between January 1, 2017, and May 22, 2021. The outcomes of this review showed that promoting culturally based and appropriate interventions using strength-based approaches were key facilitators/strengths to enhancing health and wellness among Indigenous youth. Thus, the outcomes demonstrate the continued need to promote programs grounded in culture as a part of enhancing health and wellness while authentically engaging Indigenous youth in health and wellness strategies, interventions, and programs.

Availability of data and materials

Data sharing is not applicable to this article as no datasets were generated or analyzed during the current study.

Abbreviations

Community-based participatory research

First Nations

Full-Text Articles

University of Saskatchewan’s Indigenous Studies Portal

Joanna Briggs Institute

Medical Subject Headings

Participatory action research

Preferred Reporting Items for Systematic Reviews and Meta Analyses

Preferred Reporting Items for Systematic Reviews and Meta-Analyses extension for Scoping Reviews

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Funding provided by the Saskatchewan Health Research Foundation (SHRF) and the Canadian Institute of Health Research (CIHR)/Saskatchewan Center for Patient-Oriented Research (SCPOR) as part of the SHRF Leader Award held by Dr. Ramsden.

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UO contributed to the conceptualization, methodology, design, data analysis, original draft writing, review, editing and revision of this study. CB was involved in and contributed to the methodology, data analysis, original draft review and editing of this study. ST was involved in and contributed to the conceptualization, methodology, data analysis, review and editing of several versions of this study. VRR was involved in and contributed to the conceptualization, methodology, data analysis, review and editing of this study. All authors (UO, CB, ST, and VRR) read and approved the final the final manuscript.

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Okpalauwaekwe, U., Ballantyne, C., Tunison, S. et al. Enhancing health and wellness by, for and with Indigenous youth in Canada: a scoping review. BMC Public Health 22 , 1630 (2022). https://doi.org/10.1186/s12889-022-14047-2

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Judge finds last 4 of 11 anti-abortion activists guilty in a 2021 Tennessee clinic blockade

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NASHVILLE, Tenn. (AP) — The final four of 11 anti-abortion activists charged with blocking access to a Tennessee clinic in 2021 have been convicted of violating the federal Freedom of Access to Clinic Entrances Act.

Eva Edl, Eva Zastrow, James Zastrow, and Paul Place were found guilty Tuesday by a federal judge in Nashville. They face up to six months in prison, five years of supervised release, and fines of up to $10,000, according to the U.S. Attorney’s Office for the Middle District of Tennessee.

The four participated in a blockade of the carafem reproductive health clinic in Mount Juliet, Tennessee, a town 17 miles (27 kilometers) east of Nashville, nearly a year before the U.S. Supreme Court overturned Roe v. Wade . The event was organized by anti-abortion activists who used social media to promote and live-stream actions that they hoped would prevent the clinic from performing abortions, according to court documents.

At the time, abortion was still legal in Tennessee. It is now banned at all stages of pregnancy under a law with very narrow exemptions.

Prosecutors say the four people convicted on Tuesday positioned themselves directly in front of the main clinic door, physically blocking access to the clinic so that no patients were able to enter. Police asked them to leave or move multiple times, but they refused. After more than two hours, they were arrested.

Six other participants were convicted in January on more serious felony conspiracy charges for organizing and participating in the blockade. Chester Gallagher, Paul Vaughn, Heather Idoni, Calvin Zastrow, Coleman Boyd, and Dennis Green each face up 10 1/2 years in prison and fines of up to $260,000. Sentencing is scheduled for July 2.

One defendant, Caroline Davis, pleaded guilty in October to misdemeanor charges related to the blockade and cooperated with prosecutors. She is scheduled for sentencing later this month.

President Bill Clinton signed the clinic access law in 1994 following a string of high-profile attacks against abortion clinics, which included the fatal shooting of Dr. David Gunn outside an abortion clinic in Pensacola, Florida, in 1993 — the first abortion provider killed in the U.S.

This story has been corrected to show the defendants were convicted on Tuesday, not Wednesday.

The best health savings account (HSA) providers of 2024

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The tax advantages of a health savings account (HSA) are unbeatable — better than a 401(k), traditional IRA, Roth IRA or 529 savings plan. It can be used like a checking account to pay for medical bills as they arise, as an investment account to prepare for health care costs down the road or as a combination of the two.

An HSA is a savings account that lets you set aside pre-tax dollars to pay for health care expenses. Unlike flexible spending accounts (FSAs), money in an HSA carries over from year to year. To qualify for an HSA, you must have a high-deductible health plan (HDHP). Beginning January 1, 2024, the minimum deductible is $1,600 for individuals and $3,200 for families.

When shopping for an HSA, it’s important to consider account fees, investment options, minimum balance requirements, account accessibility, interest rates and customer service.  Depending on how you plan to use the HSA, certain account features will matter more to you than others.

To help you in your search, Bankrate has compiled a list of the best HSA accounts of 2023. To narrow our choices, we compared fees, balance requirements, investment choices, interest rates and account accessibility of more than a dozen top HSA providers.

Key takeaways

• HSAs offer significant tax advantages and can be used for both immediate medical expenses and long-term investments.
• When shopping for an HSA, it’s important to consider how you plan to use the account and to watch out for fees, minimum balances, interest rates and customer service.

The best HSA accounts in 2023

Best for accessibility: lively, best for investment options: fidelity investments, best for short-term spending: healthequity, best for mobile payments: hsa bank, best hsa offered by a traditional bank: bank of america.

Lively gets the nod for best HSA overall for individuals largely because there are no hidden fees to cut into your savings. Some HSA providers make it hard to find interest rates and other account details on their websites, forcing people to call or email for information. Lively’s website is simple, easy to follow and provides relevant details in plain view.

In addition, customers have access to lots of commission-free investments online through a self-directed brokerage account with Charles Schwab, which charges no fee for balances of $3,000 or more and $24 annually for balances below that. The other investment option is a guided portfolio by Devenir, which comes with an annual fee of 0.5 percent, but there is no cash minimum to invest in it.

Like many HSAs, a Lively HSA comes with a free debit card to pay health care expenses. It also offers online banking and a mobile app that lets you track and manage the account from anywhere. Cash balances in a Lively HSA are FDIC-insured and earn interest. The annual percentage yield (APY) starts at 0.01 percent and increases by balance tiers, with the highest tier of over $10,000 earning 0.1 percent. Lively also offers streamlined HSA administration to employers.

• No hidden fees
• No minimum opening deposit
• Website is clear and easy to navigate
• Interest rates are low
• The guided portfolio option comes with a high fee

Fidelity Investments offers a self-directed HSA (Fidelity HSA) and managed HSA (Fidelity Go HSA). The self-directed account has no maintenance fees, and neither account has minimum opening deposit requirements. The managed account has an annual fee of 0.35 percent if your account balance is $25,000 or more.

You can invest in stocks, bonds, ETFs, CDs, mutual funds and other options. Online U.S. stock and ETF trades are commission-free, but there may be underlying fees for certain investments. Fidelity also has fund options that are just for Fidelity HSA customers.

Cash balances in a Fidelity HSA are swept into an interest-bearing account that earns a much higher interest rate than other HSAs. It also earns a high interest rate on all balances.

• No maintenance fees for the self-directed account
• High interest rate earned on all balances
• There’s a 0.35 percent fee for balances of $25,000 or more in the Fidelity Go HSA

HealthEquity is a nonbank HSA custodian and one of the largest HSA providers. It’s a good choice for customers who need to use their HSA regularly for medical expenses because of the multiple ways available to spend and track the account. Account holders can access their funds with a debit card, by writing checks, through online banking or with the mobile app.

The HealthEquity mobile app lets you send payments and reimbursements, view the status of claims, take pictures with your device to initiate claims and payments and link debit card transactions to claims and documentation.

There is a required 0.36 percent annual investment fee, capped at $10 a month. For those who choose a guided HSA option (Advisor GPS), there’s an additional 0.05 percent monthly fee, capped at $15 a month.

Based in Draper, Utah, HealthEquity also offers 24/7 customer support by phone or live chat. HealthEquity savers do earn some interest, based on balance tiers, which starts at 0.01 percent APY for balances up to $2,000. Savers are FDIC-insured up to federal limits.

• Many ways to access funds
• All balances earn interest
• There’s a 0.36 percent annual administration fee
• Lower account balances earn minimal interest

HSA Bank is a division of Webster Bank , dedicated to health accounts. The HSA comes with minimal fees: There’s no monthly account fees unless you opt for printed account statements, in which case it’s $1.50 a month.

The bank allows you to seamlessly integrate health accounts into digital wallets . The HSA comes with a free debit card, which can be added to a digital wallet (Apple Pay, Samsung Pay or Google Pay) and used to pay for IRS-qualified medical expenses through a mobile device. In addition, HSA Bank offers a 24/7 customer support line as well as a mobile app.

There’s also no minimum balance requirement to open an HSA. However, balances of less than $5,000 earn meager interest. The highest APY of 0.5 percent is only offered on balances of $50,000 or more.

Customers have two self-directed investment options: a guided portfolio program offered through Devenir and a Schwab Health Savings Brokerage account. The Devenir program is ideal for new investors, since it comes with professional guidance and options to automatically adjust investments. The Schwab brokerage account comes with a wider variety of investment options, including stocks, bonds, mutual funds and ETFs. Devenir and Schwab may apply fees to investments.

• No monthly account fees when you opt for e-statements
• The debit card is equipped for digital wallet integration
• There’s a $1.50 monthly fee for paper statements
• To earn the highest APY, you need at least $50,000

Many people like the convenience of managing all their finances with one bank. Bank of America , the second-largest bank in the U.S., with around 3,900 branches and about 15,000 ATMs, combines broad physical access with a full suite of digital and online tools. It’s a good choice for people who prefer having a nearby bank branch as opposed to doing everything online.

You can submit claims and monitor the HSA through BofA’s member website or via the MyHealth BofA mobile app. The HSA comes with a Visa debit card with no transaction fees. It offers a savings calculator and customers have 24/7 support by phone or online chat. The bank also provides guidance and education in matching financial strategies with health and wellness goals.

Savers earn interest at tiered rates, with the highest rate, 0.7 percent APY, offered on balances of over $10,000. Investors have dozens of Merrill (a subsidiary of BofA) mutual funds to choose from. There’s no balance minimum to invest and a standard monthly account fee of $2.50 (which may be waived if the HSA is through your employer). BofA does not charge transaction fees to buy or sell investments, but there are internal expenses with mutual funds. BofA is also an HSA custodian for small and large businesses.

• Widespread branch access
• Broad selection of mutual funds to choose from
• There’s a $2.50 monthly account fee
• Other HSAs offer higher earning potential

How to choose the best HSA

There are advantages to opening an HSA through your employer, if it’s available. With an employer-provided HSA, you can reduce Social Security taxes, and your company might contribute to your account.

“In some cases, employer plans can get a better price point, but maybe you can’t get it for free on your own,” says Eric Remjeske, founder and president of Devenir, a Minneapolis-based HSA investment advisor and research firm. HSA shoppers might find Devenir’s HSASearch tool helpful.

If you decide to shop for an HSA, here’s what to consider.

• Decide how you will use the account. Knowing how you intend to use an HSA — whether for immediate and near-term medical expenses or as an investment account for future health care costs — will help you narrow your options.
• Watch out for fees. Always ask for a complete schedule of fees before you make a decision, as HSA fees vary greatly among providers. There may be maintenance fees, investment fees, paper statement fees and per-transaction charges. Some HSAs charge a fee to open the account, obtain, replace or renew a debit card or transfer money from a savings account to an investment account. HSAs may also have overdraft fees or nonsufficient funds fees.
• Inquire about minimum balances to open or invest in a HSA. Some HSA administrators waive fees if an account meets a balance threshold. Ask whether the fee waiver is based on a minimum savings balance or a combined savings and investment balance. Minimum balance requirements to invest usually range between $500 and $3,000.
• Compare interest rates. Much like a traditional savings account , HSAs offer an opportunity to earn interest. For savers who plan to maintain an HSA as a spending account, savings rates are something to look at.
• Make sure HSA funds are easily accessible. When health care bills arise, you need to be able to get to your HSA funds to pay them. Find out whether the HSA comes with a debit card, online bill pay or checks. Find out how easy or difficult it is to transfer funds out of the account to your personal checking, for example.
• Make sure investment options are diverse and strong. Some HSAs offer the chance to invest and grow the funds. HSA custodians offer a mix of mutual funds, stocks, bonds and other investment products. Look for investment options that charge low fees and don’t have balance thresholds to meet before you can invest. Look for varied investment options with a good performance. Keep in mind that stocks, bonds and other investments are not federally insured.
• Savers, choose a federally insured institution. If you plan to keep your HSA in a spending account, make sure the bank or credit union you select is insured by the Federal Deposit Insurance Corp. or the National Credit Union Share Insurance Fund . If your financial institution were to fail, you would be covered for up to $250,000.
• Evaluate the customer service. Make sure the bank, credit union or HSA custodian answers all your questions and tells you everything you need to know to make informed choices. Find out about customer service hours and tools that can help you track and manage your account, such as mobile apps. Some financial institutions are better at offering educational videos and articles online. If you prefer an in-person experience, inquire about branch locations and hours.

Methodology

— Bankrate’s René Bennett contributed to an update of this story.

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HSA vs. FSA: The difference and how to choose

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Oxide-Containing Mineral Fibers: Types, Manufacturing Methods, Applications, and Producers (Review)

• Published: 03 June 2022
• Volume 79 , pages 28–36, ( 2022 )

Cite this article

• B. L. Krasnyi 1 ,
• K. I. Ikonnikov 1 ,
• D. O. Lemeshev 2 &
• A. S. Sizova 1  

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Mineral oxide fibers of various chemical compositions are reviewed: aluminosilicate, alumina, silica, biosoluble, fibers made from zirconium oxide, and others. Methods for manufacturing discrete and continuous fibers are given, such as spinning fibers from melts, sol-gel technology, spinning from solutions of metal salts, and others. The physicochemical characteristics of mineral fibers are described and their applications are indicated, such as thermal insulation up to 1150 or 1000°C and high temperature filtration for aluminosilicate and biosoluble fibers; thermal insulation up to 1600 or 2000°C, and reinforcement of composites used in the aerospace and defense industries for alumina fibers and fibers based on zirconium dioxide, and so on. Manufacturers of mineral oxide-containing fibers and products based on them in and outside of Russia are indicated.

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A review on carbon fiber-reinforced hierarchical composites: mechanical performance, manufacturing process, structural applications and allied challenges

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Preparation, development, outcomes, and application versatility of carbon fiber-based polymer composites: a review

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Krasnyi, B.L., Ikonnikov, K.I., Lemeshev, D.O. et al. Oxide-Containing Mineral Fibers: Types, Manufacturing Methods, Applications, and Producers (Review). Glass Ceram 79 , 28–36 (2022). https://doi.org/10.1007/s10717-022-00448-7

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Architects, Architecture Firms, & Building Designers in Shcherbinka

Location (1).

• Use My Current Location

Popular Locations

• Albuquerque
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• Shcherbinka, Moscow Oblast, Russia

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Professional Category (1)

• Accessory Dwelling Units (ADU)

Project Type

• Floor Plans
• Structural Engineering
• Site Planning
• Custom Homes
• Building Design
• Contemporary
• Traditional
• Transitional

Credentials & Awards

• Best of Houzz winner

Featured Reviews for Architects, Architecture Firms, & Building Designers in Shcherbinka

• Reach out to the pro(s) you want, then share your vision to get the ball rolling.
• Request and compare quotes, then hire the Architect & Building Designer that perfectly fits your project and budget limits.
• Historic Building Conservation

The architect will help you throughout the entire process, from initial concept development to managing the construction phase and ensuring everything is built according to plan. They will also collaborate with other professionals, such as builders and contractors in Shcherbinka, to bring your dream home to life.

By working with a residential architect, you can benefit from their knowledge and experience in creating unique and personalized spaces that reflect your style and lifestyle. They will guide you through the design and construction process, making sure that your home is not only visually appealing but also practical and safe.

Consulting with an architect in Shcherbinka early on allows you to bring your residential vision to life in the most efficient and effective way possible.

• It’s best to involve an architect early in the planning stage of your project to benefit from their expertise and guidance.
• Hire an architect before selecting a builder or contractor to streamline the construction process.
• While there isn’t a specific time of year, consider engaging an architect during quieter periods like summer. It allows for more thoughtful discussions, better availability, and potentially shorter project queues.

How do I find the best Shcherbinka residential design architect for my project?

Questions to ask prospective shcherbinka interior architects:.

If you search for Architects near me you'll be sure to find a business that knows about the latest trends and styles in architecture, ensuring your bathroom, kitchen, or whole house remodel reflects contemporary design principles

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