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Research Methods in Early Childhood: An Introductory Guide

Student resources, multiple choice quiz.

Test your understanding of each chapter by taking the quiz below. Click anywhere on the question to reveal the answer. Good luck!

1. What is a ‘case study’?

• An in depth investigation of an individual or group or situation or event
• A study aiming at improving practice over time
• An experimental design in laboratory conditions
• An in-depth analysis of data

2. When might it be appropriate to carry out a case study as a researcher?

• When you don’t want a lot of depth/detail
• When you want to make generalisations to the wider population
• When you want to study a child, group or situation in a lot of detail
• When you want to continue the research for your MA

3. What methods might be employed in a case study?

• Narrative observations
• Questionnaires
• Any of these and potentially others

4. Who from the following list famously carried out case study research on his own child?

• Sigmund Freud
• Charles Darwin
• Claude Levi Strauss
• Harry Harlow

5. Look at the following potential studies and consider which indicates that a case study might be appropriate

• When you want to find out the effect of maternal alcohol use on infants
• When you want to find out the effect of parental education on children’s achievement
• When you want to find out how a nursery organises its outdoor provision
• When you want to find out whether there is a correlation between summer-born children and later achievement

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Next Generation NCLEX Case Study Sample Questions

One of the big changes on the Next Generation NCLEX exam is a shift toward case studies. Case studies often require a deeper level of critical thinking, and understanding diseases on a more in-depth level (especially the pathophysiology) will make these types of questions easier to answer.

In this article, you’ll be able to watch a free video to help you prepare for the new Next Generation NCLEX case study format. Nurse Sarah will walk you step-by-step through each scenario and help you understand how to use critical thinking and nursing knowledge to answer these types of questions.

Next Generation NCLEX Case Study Review Questions Video

NGN Case Study Sample Questions and Answers

First, let’s take a look at our case study summary below:

Case Study Summary:

A 68-year-old male is admitted with shortness of breath. He reports difficulty breathing with activity, lying down, or while sleeping. He states that in order to “breathe easier,” he has had to sleep in a recliner for the past week. The patient has a history of hypertension, myocardial infarction (2 years ago), and cholecystectomy (10 years ago). The patient is being transferred to a cardiac progressive care unit for further evaluation and treatment.

Question 1 of 6: The nurse receives the patient admitted with shortness of breath. What findings are significant and require follow-up? The options are listed below. Select all that apply.

To answer this first question in the NGN case study, let’s look at the information provided in the nursing notes and vital signs tabs provided:

This question is asking us to identify findings that are significant and require the nurse to follow-up. In other words, what is presenting that we can’t ignore but need to investigate further.

Therefore, let’s comb through the nursing notes and vital signs to see what is abnormal and requires follow-up.

First, the patient arrived to the room via stretcher. That’s fine and doesn’t necessarily require follow-up.

Next, the patient is alert and oriented x 4 (person, place, time, event). This tells us that the patient’s neuro status is intact so far. Therefore, the shortness of breath isn’t affecting the patient’s mental function yet (we have enough oxygen on board right now for brain activity).

However, the nurse has noticed the shortness of breath with activity and talking, which should not normally happen. This tells us something is wrong and is significant enough to require follow-up. We want to know why is this happening, is it going to get worse, etc.

The patient’s weight and vital signs were collected (this is good). Weight is 155 lbs. and BMI is within a healthy range (doesn’t tell us too much but may be useful later). The patient is also connected to a bedside monitor, so they need to be monitored constantly like on a progressive care unit.

The monitor shows sinus tachycardia . This is significant because it seems the patient’s shortness of breath is causing the heart to compensate by increasing the heart rate to provide more oxygen (hence the lungs may be compromised).

Then we find out that the lungs are indeed compromised because crackles are heard in both lungs , and this may be why our patient is short of breath. This is significant (could the patient have pulmonary edema?)

Then we find out the nurse has noted an S3. This is an extra heart sound noted after S2. And what jumps out to me about this is that it is usually associated with volume overload in the heart like in cases of heart failure . However, S3 may be normal in some people under 40 or during pregnancy, but that’s not the case with our patient based on what we read in the case summary.

Therefore, based on everything I’m reading in this case study, I’m thinking this patient may have heart failure, but we need those test results back (especially the echo and chest x-ray, and hopefully a BNP will be in there too).

We are also told that the patient has an 18 gauge IV inserted (which is good thing to have so we can give medications if required), orders have been received, labs drawn, and testing results are pending.

Now let’s look at the “Vital Signs” tab above, and ask yourself what is normal vs. abnormal for this patient (adult male).

• The heart rate is high at 112 (tachycardia), and should normally be 60-100 bpm (see heart rhythms ).
• Blood pressure is higher than normal (normal is 120/80), which indicates hypertension.
• Oxygen saturation is 94% (this is on the low side as we’d normally want around 95% or higher, and the patient is on 4 L nasal cannula, which tells us the lungs are not okay).
• Respiratory rate is increased (26 breaths per minute)…normal is 12-20 breaths per minute.

Based on the information we were provided, I’ve selected the answers below. These findings are significant and definitely require follow-up by the nurse.

When answering these NGN case study questions, it’s helpful to think of the ABCDE (airway, breathing, circulation, etc.) as all of these fall into that category. If we don’t follow-up on the shortness of breath, crackles, respiratory rate, o2 saturation (94% on 4 L nasal cannula), the respiratory system can further decline.

In addition, the sinus tachycardia, S3 gallop, and hypertension could indicate fluid overload in the heart. This may cause the heart to tire out and lead the lethal rhythm. On the other hand, temperature, pain, weight, and BMI are not abnormal and do not require follow-up.

See the Complete Next Generation NCLEX Case Study Review

Each question in the case study builds on the previous question. To see how these questions evolve based on the patient’s condition and labs, watch the entire Next Generation NCLEX Case Study Review video on our YouTube Channel (RegisteredNurseRN).

NCLEX Practice Quizzes

We’ve developed many free NCLEX review quizzes to test your knowledge on nursing topics and to help you prepare for the Next Generation NCLEX exam.

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ECG Case 001

• Ed Burns and Robert Buttner
• Dec 21, 2021

Middle-aged patient presenting with chest pain and diaphoresis. BP dropped to 80/50 following sublingual nitrates.

Describe and interpret this ECG

• Sinus rhythm, rate 84bpm
• Normal axis
• 1st degree AV block  (PR 220ms)

Signs of  inferior STEMI :

• STE in inferior leads II, III, aVF
• Reciprocal STD in lateral leads I, aVL, V6

Signs of associated  right ventricular infarction :

• STE in III > II
• STE in V1-2

This patient also had STE in V4R, confirming the diagnosis of RV infarction:

• RV infarction complicates 40% of inferior STEMIs
• ST elevation in V1, the only lead that looks directly at the RV
• ST elevation in III > II, as lead III is more rightward facing
• Diagnosis can be confirmed with right-sided leads
• These patients are preload sensitive and may have an exaggerated hypotensive response to nitrates

Read more about diagnosing RV infarction and how to record the V4R lead

TOP 100 ECG Series

Emergency Physician in Prehospital and Retrieval Medicine in Sydney, Australia. He has a passion for ECG interpretation and medical education | ECG Library |

Robert Buttner

MBBS (UWA) CCPU (RCE, Biliary, DVT, E-FAST, AAA) Adult/Paediatric Emergency Medicine Advanced Trainee in Melbourne, Australia. Special interests in diagnostic and procedural ultrasound, medical education, and ECG interpretation. Editor-in-chief of the LITFL ECG Library . Twitter: @rob_buttner

Dr. Burns I find a interesting aspect in the ecg: ST ELEVATION V2>V3>V4 It’s important to know the result of coronariogram. Please give us this date. Thanks

It seems to be an occlusion of a big dominant RCA with PDA rapping around the apex causing antero-inferior MI

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Experts say a twice-yearly injection that offers 100% protection against HIV is ‘stunning’

A study has shown that twice-yearly injections of a drug used to treat AIDS have been 100% effective in preventing new HIV infections in young women. The new injections could be especially important for the fight against HIV in parts of the developing world, like in Cape Town, South Africa, one of the locations for the trial. South Africa has the highest number of people living with HIV in the world. (AP video: Wesley Fester; Production: Sebabatso Mosamo)

A pharmacist holds a vial of lenacapavir, the new HIV prevention injectable drug, at the Desmond Tutu Health Foundation’s Masiphumelele Research Site, in Cape Town, South Africa, Tuesday, July 23, 2024, which was one of the sites for Gilead’s lenacapavir drug trial. (AP Photo/Nardus Engelbrecht)

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A pharmacist holds a vial of lenacapavir, the new HIV prevention injectable drug, at the Desmond Tutu Health Foundation’s Masiphumelele Research Site, in Cape Town, South Africa, Tuesday, July 23, 2024. (AP Photo/Nardus Engelbrecht)

Clinical trials co-ordinator Thandeka Nkosi, poses for a photo as lab technician Xolile Mhlanga, who works with vials of the anti-HIV drug lenacapavir, works in the background at the Desmond Tutu Health Foundation’s Masiphumelele Research Site, in Cape Town, South Africa, Tuesday, July 23, 2024. (AP Photo/Nardus Engelbrecht)

A pharmacist holds vials of lenacapavir, the new HIV prevention injectable drug, at the Desmond Tutu Health Foundation’s Masiphumelele Research Site, in Cape Town, South Africa, Tuesday, July 23, 2024, which was one of the sites for Gilead’s lenacapavir drug trial. (AP Photo/Nardus Engelbrecht)

Lab technician, Xolile Mhlanga, works with vials of lenacapavir, the new HIV prevention injectable drug, at the Desmond Tutu Health Foundation’s Masiphumelele Research Site, in Cape Town, South Africa, Tuesday, July 23, 2024. (AP Photo/Nardus Engelbrecht)

Lab technician Xolile Mhlanga works with vials of lenacapavir at the Desmond Tutu Health Foundation’s Masiphumelele Research Site, in Cape Town, South Africa, Tuesday, July 23, 2024. Twice-yearly shots of the drug used to treat AIDS were 100% effective in preventing new infections in women, according to study results published Wednesday. (AP Photo/Nardus Engelbrecht)

A pharmacist holds a vial of lenacapavir, at the Desmond Tutu Health Foundation’s Masiphumelele Research Site, in Cape Town, South Africa, Tuesday, July 23, 2024. (AP Photo/Nardus Engelbrecht)

CAPE TOWN, South Africa (AP) — Twice-yearly shots used to treat AIDS were 100% effective in preventing new infections in women, according to study results published Wednesday.

There were no infections in the young women and girls that got the shots in a study of about 5,000 in South Africa and Uganda, researchers reported. In a group given daily prevention pills, roughly 2% ended up catching HIV from infected sex partners.

“To see this level of protection is stunning,” said Salim Abdool Karim of the injections. He is director of an AIDS research center in Durban, South Africa, who was not part of the research.

The shots made by U.S. drugmaker Gilead and sold as Sunlenca are approved in the U.S., Canada, Europe and elsewhere, but only as a treatment for HIV. The company said it is waiting for results of testing in men before seeking permission to use it to protect against infection.

The results in women were published Wednesday in the New England Journal of Medicine and discussed at an AIDS conference in Munich. Gilead paid for the study and some of the researchers are company employees. Because of the surprisingly encouraging results, the study was stopped early and all participants were offered the shots, also known as lenacapavir.

While there are other ways to prevent HIV infection , like condoms or daily pills, consistent use has been a problem in Africa. In the new study, only about 30% of participants given Gilead’s Truvada or Descovy prevention pills actually took them — and that figure dropped over time.

The prospect of a twice-a-year shot is “quite revolutionary news” for our patients, said Thandeka Nkosi, who helped run the Gilead research at the Desmond Tutu Health Foundation in Masiphumelele, South Africa. “It gives participants a choice and it just eliminates the whole stigma around taking pills” to prevent HIV.

Experts working to stop the spread of AIDS are excited about the Sunlenca shots but are concerned Gilead hasn’t yet agreed on an affordable price for those who need them the most. The company said it would pursue a “voluntary licensing program,” suggesting that only a select number of generic producers would be allowed to make them.

“Gilead has a tool that could change the trajectory of the HIV epidemic,” said Winnie Byanyima , executive director of the Geneva-based U.N. AIDS agency.

She said her organization urged Gilead to share Sunlenca’s patent with a U.N.-backed program that negotiates broad contracts allowing generic drugmakers to make cheap versions of drugs for poorer countries worldwide. As an HIV treatment, the drug costs more than $40,000 a year in the U.S., although what individuals pay varies.

Dr. Helen Bygrave of Doctors Without Borders said in a statement that the injections could “reverse the epidemic if it is made available in the countries with the highest rate of new infections.” She urged Gilead to publish a price for Sunlenca that would be affordable for all countries.

In a statement last month, Gilead said it was too early to say how much Sunlenca would cost for prevention in poorer countries. Dr. Jared Baeten, Gilead’s senior vice president of clinical development, said the company was already talking to generics manufacturers and understood how “deeply important it is that we move at speed.”

Another HIV prevention shot, Apretude, which is given every two months, is approved in some countries, including in Africa. It sells for about $180 per patient per year, which is still too pricey for most developing countries.

Byanyima said the people who need long-lasting protection the most include women and girls who are victims of domestic violence and gay men in countries where same-sex relationships are criminalized. According to UNAIDS, 46% of new HIV infections globally in 2022 were in women and girls, who were three times more likely to get HIV than males in Africa.

Byanyima compared the news about Sunlenca to the discovery decades ago of AIDS drugs that could turn HIV infection from a death sentence into a chronic illness. Back then, South African President Nelson Mandela suspended patents to allow wider access to the drugs; the price later dropped from about $10,000 per patient per year to about $50.

Olwethu Kemele, a health worker at the Desmond Tutu Health Foundation, predicted the shots could boost the number of people coming in for HIV prevention and slow the virus’ spread. She said young women often hide the pills to avoid questions from boyfriends and family members. “It makes it hard for the girls to continue,” she said.

In a report on the state of the global epidemic released this week, UNAIDS said that fewer people were infected with HIV in 2023 than at any point since the late 1980s. Globally, HIV infects about 1.3 million people every year and kills more than 600,000, mainly in Africa. While significant progress has been made in Africa, HIV infections are rising in Eastern Europe, Latin America and the Middle East.

In other research presented at the AIDS conference, Andrew Hill of the University of Liverpool and colleagues estimated that once production of Sunlenca is expanded to treat 10 million people, the price should fall to about $40 per treatment. He said it was critical that health authorities get access to Sunlenca as soon as possible.

“This is about as close as you can get to an HIV vaccine,” he said.

Cheng reported from London.

The Associated Press Health and Science Department receives support from the Howard Hughes Medical Institute’s Science and Educational Media Group. The AP is solely responsible for all content.

Quiz 14: Case Study Research

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( Multiple Choice )

Nate conducted a study with the purpose of describing the role of teachers' collective efficacy in work climate. He examined four schools in the Philadelphia City School District. Nate's case study can best be described as which of the following?

Which of the following is the most common form of sampling in case study research?

Which of the following represents the most appropriate topic of a case study?

The tool used in cross-site analysis designed to assist the researcher in seeing differences across cases is best described as a

James is interested in describing some plausible cause and effect relations within his case study data. Which of the following will James find most useful in his analysis?

Which of the following represents a topic most suitable for study using case study methodologies?

Which of the following is a strategy for cross-site analysis?

Of the following, which is the best example of a multiple case study?

Which of the following is the statement most consistent with your textbook's perspective of case study research?

Which of the following represents an appropriate application of a case study?

Which of the following represents the most appropriate application of case study research?

Val decides to study one district as a case in her study of teacher professional development opportunities and outcomes. Of the following, which is a primary data source for her study?

Case study research is most appropriate under which of the following conditions?

Which of the following describes the end result of a case study?

Which type of cross-site analysis tool would be the best way to examine the history of events that led to the decision of principals to implement an educational change

Which of the following is a typical characteristic of case study research?

Case studies are referred to as particularistic. This definition assumes which of the following characteristics?

Which of the following illustrates the most viable case study research problem?

Jamal needs a cross-site analysis tool to assist him in creating master charts. Which of the following would best serve his purpose?

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New Evidence Supports Autoimmunity as One of Long COVID’s Underlying Drivers

New research offers evidence that autoimmunity—in which the body’s immune system targets its own tissues—is a driver in some cases of Long COVID.

Why COVID-19 sometimes leads to Long COVID still confounds doctors, but researchers have several hypotheses to explain its often-debilitating symptoms. These include lingering SARS-CoV-2 remnants, the reactivation of such latent viruses as Epstein-Barr, infection-induced tissue damage, and autoimmunity.

Now, in this new study, when researchers transferred antibodies from patients with Long COVID into healthy mice, the animals began exhibiting symptoms including heightened pain sensation and dizziness. The study is among the first to show a causal link between antibodies and Long COVID symptoms. It was posted as a preprint on medRxiv on June 19.

“We’re very excited to have a mechanism to study and learn more about so we can help people with specific reported symptoms,” says Akiko Iwasaki, PhD , Sterling Professor of Immunobiology and the study’s principal investigator at Yale School of Medicine.

We believe this is a big step forward in trying to understand and provide treatment to patients with this subset of Long COVID. Akiko Iwasaki, PhD

Several factors prompted Iwasaki’s team to zero in on autoimmunity as one of Long COVID’s drivers. First, there was the persistent nature of the condition. “This suggested to us that there is some chronic triggering of an immune response that is pathogenic,” she says.

Second, women between the ages of 30 and 50 are among the most susceptible to Long COVID. Women in this age group also face a greater risk of autoimmune diseases in general. Finally, in earlier research, Iwasaki’s team detected significant levels of autoantibodies in individuals who were infected with SARS-CoV-2. “All of these things were pointing to the possibility of autoimmune responses being one of the triggers of Long COVID,” Iwasaki says.

Human antibodies induced Long COVID symptoms in mice

In their latest study, Iwasaki’s team analyzed blood samples from patients in the Mount Sinai-Yale Long COVID study . This cohort of over 215 Long COVID patients is part of a collaboration between Iwasaki and David Putrino, PhD , professor in the Department of Rehabilitation and Human Performance at Icahn School of Medicine at Mount Sinai in New York City. As part of this joint effort, Putrino’s clinic obtained blood samples from patients enrolled in the study. Iwasaki’s laboratory then purified antibodies from the blood and transferred them into healthy mice.

Next, the researchers led by Keyla Sá, a postdoctoral fellow in Iwasaki’s lab, conducted multiple behavioral experiments to look for Long COVID symptoms. While many of these experiments found no significant difference between the experimental and control mice, a few revealed striking changes in those that received antibodies.

In one such experiment, researchers placed the mice on a heated plate and measured how long it took for them to react. Some mice that received antibodies reacted significantly more quickly to the heat, indicating a heightened sensitivity to pain. The researchers went back and identified the patients whose antibodies had been injected into the mice. Interestingly, these patients reported pain as one of their Long COVID symptoms.

Another experiment was the rotarod test, in which researchers placed mice on a rotating cylinder to measure coordination and balance. Mice that received antibodies were more likely to struggle to stay on the apparatus. Once again, when the researchers looked at the source of these antibodies, they learned that they were mostly from patients who reported suffering from dizziness.

The mice also underwent a grip strength test, in which researchers measured the force applied by the animals to a grid apparatus. A group of mice were found to have reduced muscle strength if they received antibodies from patients reporting tinnitus and headache. Thus, antibodies capable of impairing muscle function are found in patients with these symptoms. How exactly these antibodies cause pathology needs more study.

Treatments targeting autoimmunity may help some Long COVID patients

Developing diagnostic tools and therapies for Long COVID will require knowledge of its underlying disease mechanisms. The new study offers important evidence that autoimmunity is one of these contributors. Recently, the autoimmunity hypothesis has been further supported by a research group in the Netherlands led by Jeroen den Dunnen, DRS , associate professor at Amsterdam University Medical Center, which posted a preprint a couple of weeks earlier also showing a link between patients’ Long COVID antibodies and corresponding symptoms in mice. “We believe this is a big step forward in trying to understand and provide treatment to patients with this subset of Long COVID,” says Iwasaki.

Intravenous immunoglobulin (IVIg) is commonly used as treatment for various autoimmune disorders such as lupus, for example—antibodies from healthy human donors are given to patients in the hope that they will alleviate or reduce symptoms. This therapy may also have promise in treating cases of Long COVID caused by autoimmunity. A 2024 study led by Lindsey McAlpine, MD , instructor at YSM and first author, and Serena Spudich, MD , Gilbert H. Glaser Professor of Neurology and principal investigator, suggests that this type of treatment may be beneficial in treating small fiber neuropathy associated with Long COVID. (Small fiber neuropathy, a condition in which patients suffer numbness or pain in their hands or feet, occurs in some cases of Long COVID.) Iwasaki hopes that future clinical trials may show potential in treating some of the other painful symptoms of the disease.

Furthermore, researchers are developing other biologics, or drugs produced from living organisms, that may also help Long COVID patients, including FcRn inhibitors. FcRn is a receptor that binds to antibodies and recycles them. Through blocking this receptor, these drugs can reduce levels of circulating antibodies. This type of drug was recently approved by the Food and Drug Administration (FDA) for the treatment of myasthenia gravis, another kind of autoimmune disease.

The study also offers insights for developing diagnostic tools to identify which patients will benefit from these kinds of treatments. “Targeted therapy is going to be key for each of these subsets of Long COVID,” says Iwasaki. “This study demonstrates that we can identify people with pathological antibodies.”

Future studies to focus on autoimmunity pathogenesis in Long COVID and new therapeutics

In future studies, Iwasaki hopes to explore further why and how autoantibodies cause disease in Long COVID. She also hopes to conduct randomized clinical trials for testing therapeutics targeting autoimmunity. In addition to IVIg and FcRn inhibitors, she believes there are a range of promising treatments for reducing antibodies, including B cell depletion therapy and plasmapheresis.

Unfortunately, it’s highly unlikely that a single drug could cure everyone with Long COVID, she says. While this study focuses on autoantibodies, the disease likely has multiple underlying causes, and different subtypes will require different treatments. Iwasaki is also working closely with Harlan Krumholz, MD , Harold H. Hines, Jr. Professor of Medicine (Cardiology), on the Yale Paxlovid for Long COVID (PAX LC) Trial . This trial is testing the lingering virus hypothesis by investigating the efficacy of a 15-day course of the antiviral Paxlovid in treating Long COVID.

There are many avenues for future studies, but in the meantime, Iwasaki is excited about her team’s promising results. “Seeing this one-to-one correlation of antibodies that cause pain from patients who reported pain is really gratifying to me as it suggests a causal link,” she says. “It’s a first step, but I think it’s a big one.” Iwasaki’s team is currently expanding these antibody transfer studies to other post-acute infection syndromes including myalgic encephalomyelitis/chronic fatigue syndrome.

Featured in this article

• Akiko Iwasaki, PhD Sterling Professor of Immunobiology and Professor of Dermatology and of Molecular, Cellular, and Developmental Biology and of Epidemiology (Microbial Diseases); Investigator, Howard Hughes Medical Institute
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• Serena Spudich, MD, MA Gilbert H. Glaser Professor of Neurology; Division Chief, Neurological Infections & Global Neurology; Co-Director, Yale Center for Brain & Mind Health; Affiliated Faculty, Yale Institute for Global Health
• Lindsay McAlpine, MD, BSc Assistant Professor

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Why Is It So Hard for Olympic Host Cities to Control Costs?

An Oxford study estimates that despite cost-cutting efforts, Paris is spending more than $1 billion above the Games’ historical median cost.

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By Vivienne Walt and Sarah Kessler

Follow live updates of the women’s gymnastics qualifying at the 2024 Paris Olympics.

Like every city that hosts the Olympics, Paris designed its opening ceremony to make a splash, with ethereal dance performances, athletes floating down the Seine and a blowout performance by Celine Dion. A big display is table stakes, and hundreds of thousands of people jammed the city’s bridges and riverbanks for hours to cheer the flotilla.

But to make these Olympics truly unique, Paris also had something quieter in mind: It vowed to buck the decades-long trend of spending a dizzying fortune on hosting them.

That vision for a budget-conscious Olympics does not seem to have panned out. The tab for the Games in Paris, the first city to fully test cost-cutting reforms that the International Olympic Committee introduced in 2019, is at least $8.87 billion. That isn’t an eye-popping bill compared with the $17 billion that London spent in 2012, the estimated $28 billion that Tokyo spent in 2021 or the $24 billion that Rio de Janeiro spent in 2016 — the three most expensive Summer Games to date. But the figure is more than $1 billion above the historical median cost of hosting the Games, according to a study by researchers at Oxford’s Said Business School published in May. And it is about 115 percent above Paris’s initial estimate.

“This is not the cheap Games that were promised,” the study concluded.

Figuring out how to keep host city expenses on budget is vital for the Olympics, which have struggled to find host cities in places where citizens have a say in the decision. When the I.O.C. voted on Wednesday to give the 2030 Winter Games to the French Alps and the 2034 Winter Games to Salt Lake City, both cities were the only candidates.

Repurposing buildings hasn’t necessarily solved the Games’ budgeting problem. Paris’s central argument in its bid for hosting rights was that reusing existing sporting facilities would help it avoid the steep capital investment that inflicted lasting economic pain on Olympic cities like Athens and Rio de Janeiro, as well as stave off anti-Olympic sentiment in the city. Los Angeles, host of the 2028 Summer Games, has promised no new Olympic buildings.

But while refurbishing buildings may be more sustainable , adapting old monuments for the Olympics has taken years — at a cost that has not been revealed. Take the 125-year-old Grand Palais, a soaring iron, glass-roofed exhibition hall in central Paris, where fencing and taekwondo competitions will take place. It shut down for renovations in March 2021 and was scheduled to be closed for so long that the city constructed a new Grand Palais near the Eiffel Tower.

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Not a B movie: Sharks are ingesting cocaine in the ocean, scientists find

It’s not a b movie: scientists say sharks are ingesting cocaine in drug-tainted water.

Sharks off the coast of Hawaii. Hugh Gentry/AP hide caption

Scientists in Brazil have come up with the first evidence that sharks are being exposed to cocaine.

Rachel Ann Hauser Davis, a biologist who worked on the study at Brazil’s Oswaldo Cruz Foundation, told NPR that they dissected 13 wild sharpnose sharks caught near Rio de Janeiro. All tested positive for cocaine in their muscles and livers.   “The key findings of the study are the presence of cocaine in sharks," Hauser Davis says. "The actual high levels of cocaine detected in muscle is indicative of chronic exposure.”   Narcotraffickers being chased in the high seas often toss bales of cocaine overboard. But Hauser Davis says it’s more likely the sharks in the study were exposed to Rio de Janeiro wastewater contaminated with the drug.

“Probably the main source would be human use of cocaine and metabolization and urine and feces discharge, and the second source would be from illegal refining labs,” she says.

Hauser Davis points out that cocaine affects the brain and could lead to hyperactive behavior among sharks — though she says the issue needs more research.

The findings in Brazil add to a growing body of research on marine wildlife and cocaine. For example, a 2018 study in the United Kingdom found that eels exposed to cocaine were having trouble mating.

Tracy Fanara, an environmental engineer at the University of Florida, told NPR the findings aren't surprising.

“Exposure to recreational drugs can slow down their processes to the point where they miss migration periods that are essential for the survival of their species," Fanara says.

She took part in a documentary last year called Cocaine Sharks in which scuba divers tried to determine whether sharks were being exposed to the drug.

Cocaine isn’t the biggest problem sharks face. But Fanara says, the documentary was an excuse to remind people that all kinds of human pollution are wreaking havoc on ocean life.

“You know this could be really catastrophic, but cocaine does a good job of getting people’s attention.”

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Latest HIV Cure Case Comes With a Twist

Richard Mark Kirkner

July 29, 2024

The first HIV cure case in which the stem cell donor had a single — rather than double — gene mutation is opening the donor pool in renewed cure efforts to make stem cell transplants more widely available.

The anonymous patient is the first to achieve long-term HIV remission — in this case approaching 6 years — after receiving a single CCR5 delta 32 mutation. Specifically, the patient received a CCR5 wild-type, delta 32 transplant, known as a heterozygous transplant, for acute myeloid leukemia , investigators reported at the International AIDS Conference 2024 in Munich, Germany.

Other cures have involved donors with two copies of the CCR5 delta 32 mutation, known as homozygous.

Researchers are calling the anonymous patient "the next Berlin patient," an homage to Timothy Ray Brown, the first, now renowned, American patient living at the time in Germany who was cured of HIV.

Brown — dubbed an ambassador of hope — would never test positive for HIV again, but at age 54, it would be the leukemia that led to his HIV cure that would take Brown's life after spreading to his brain and spinal cord.

Expanding the Donor Pool

Since then, four others who received the dual-copy mutation in a homozygous stem cell transplant have experienced long-term HIV remission.

Another case, known as the "Geneva patient," received a stem cell transplant from a wild-type CCR5 donor. Researchers from Geneva, Switzerland, reported that case last year at the conference.

Using donors with single mutations in addition to those with double mutations could meaningfully expand the pool of donors and the availability of allogeneic stem cell transplantation, said Christian Gaebler, MD, coleader of the personalized infectious medicine program at the Berlin Institute of Health and associate professor at Charité – Universitätsmedizin Berlin, who presented the case at the conference.

"When we don't find a donor with these delta 32 mutations — and it's hard to find them, especially in geographical regions outside western or northern countries where it's almost impossible to find a homozygous delta 32 donor — it may be beneficial to take a heterozygous donor," Gaebler said during an interview. "They're easier to find."

"This case is giving us hope that there is still a cure and underlying mechanisms that we're currently not understanding," said Christoph Spinner, MD, MBA, an infectious disease specialist at the University Hospital of the Technical University of Munich, and AIDS 2024 conference co-chair.

"Research is needed to understand and translate the findings of this case for the cure research around the globe," he said.

Reducing the HIV Reservoir

The key mechanism in a cure is depletion of the HIV reservoir, Gaebler said, but more work is needed to better understand its role.

The most recent cured patient had the stem cell transplant to treat acute myeloid leukemia initially, Gaebler explained, and more than 5 years after the stem cell transplant and after discontinuing antiretroviral therapy, the patient has undetectable levels of HIV DNA and HIV RNA as well as higher levels of CD4+ and CD8+ T cells, he said.

"When we see this next Berlin patient and that we're coming close to 6 years of HIV remission, I think we can quite confidently say we can have HIV reservoir reduction, HIV remission, and potentially HIV cure independent of the CCR5 status," Gaebler said.

"These initial cases of HIV cure have triggered a lot of studies looking at CCR5 and basically modulating CCR5 expression, gene-edited cells, [and] CCR5 blockage," he pointed out after his presentation. "This is all very valid and it will likely play a role, but it probably comes down to a combination of these things," he said.

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Deadline set for DNA testing of duct tape in convicted murderer Scott Peterson's case

In as little as 45 days, Scott Peterson could find out if a piece of duct tape will give him a shot at a new trial.

In an order filed July 24, a judge outlined how DNA testing on a piece of duct tape recovered from Laci Peterson's pants at the time of her autopsy on April 13, 2003, will proceed.

Scott is serving a life sentence for the 2002 murders of his pregnant wife, Laci Peterson, and their unborn son. The Los Angeles Innocence Project took over Scott's case in January.

RELATED STORY | Scott Peterson claims new evidence exonerates him in 2002 murder

Previously, San Mateo County Superior Court Judge Elizabeth Hill denied the defense's motion to have DNA testing done on multiple pieces of evidence, delivering a huge blow to Scott's quest for a new trial. The 15.5-inch length of duct tape, however, is the one item out of more than a dozen physical pieces of evidence for which the judge granted testing.

The latest order states that Pure Gold Forensics, Inc. will conduct the DNA testing, and lists the mandatory chain of command and testing methods. It also states that "the DNA testing shall be conducted within 45 days of this order or as soon as practical."

The final results are also to be submitted "under seal."

This story was originally published by Ivy Brown and Katie McLaughlin at Court TV .

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Where Harris stands on Israel, abortion, climate change, education and the economy

[Editor's note: An earlier version of this story misstated Harris' proposed 2019 climate plan investment levels. The correct estimate is nearly seven times more than Biden's current proposal.]

Vice President Kamala Harris has emerged as the Democratic party’s presidential frontrunner after Joe Biden dropped his reelection bid Sunday.

Most Democrats have backed Harris, who announced her 2024 campaign for president shortly after Biden penned a letter explaining his decision to exit the 2024 race. Depending on who you ask, Harris is viewed as a moderate or a progressive reformer.

A former prosecutor, Harris was elected San Francisco’s district attorney with a “tough on crime” message in 2003 and worked in that role for seven years. She became the state’s attorney general in 2011 and served until 2017, when she was elected to represent California in the U.S. Senate.

Text with USA TODAY: Sign-up now and get answers to all your election questions.

More: Election 2024 live updates: Endorsements rush in for Harris; Trump attacks begin

Harris launched her own unsuccessful presidential campaign at a rally in her hometown of Oakland, California in 2019. She dropped her bid for the White House and joined President Joe Biden’s ticket in August the following year. In 2021, she was sworn in as vice president.

Decades in the public spotlight and on the public record, here is what we know about where Harris stands on key issues:

Foreign Policy

As Biden’s second-in-command, Harris has largely stood behind his foreign policy positions, but there are signs she could be tougher on Israel over the war in Gaza than the president.

Harris has not given reason to believe she will deviate much from Biden on issues relating to China , for example. She is also unlikely to sway from supporting Ukraine. Harris said earlier this year that Russia has committed “crimes against humanity” in Ukraine over the last two years.

Harris has not directly opposed Biden’s staunch support for Israel, but has expressed sympathy for the more than 38,000 Palestinian lives lost during the conflict. She was one of the first high-profile members of his administration to call for an immediate temporary cease-fire in March. She acknowledged the “immense scale of suffering” in Gaza and said the Israel-Hamas war is a “humanitarian catastrophe” for innocent civilians.

Harris’ support for women’s access to abortions has been a focal point of her tenure as the country’s first female vice president. She embarked on a nationwide Reproductive Freedoms Tour earlier this year to draw attention to attacks on abortion access following the Dobbs decision . She attended her first stop in Wisconsin on Jan. 22, the 51st anniversary of Roe v. Wade .

Harris proposed federal protections that would limit state abortion restrictions during her first presidential campaign. Under her proposal, states would need to clear laws regulating abortion with the Department of Justice, which would need to confirm they are constitutional before taking effect, she explained in 2019 .

“How dare these elected leaders believe they are in a better position to tell women what they need, to tell women what is in their best interest?” Harris asked during a visit to a Minnesota Planned Parenthood clinic in March. “We have to be a nation that trusts women.”

Harris has traveled on an Economic Opportunity Tour this summer to defend the Biden administration’s economic policy and attack former President Donald Trump’s economic agenda.

While on tour, she touted legislation passed during Biden’s time in office, including the American Rescue Plan and Inflation Reduction Act . Harris has tried to emphasize that wage increases have outpaced inflation since the pandemic and made the case that Trump has plans to give more tax cuts to the rich.

“Donald Trump gave tax cuts to billionaires,” she said in a June social media post . “President Joe Biden and I are investing in the middle class and making sure billionaires and big corporations pay their fair share.”

The vice president has made clear that climate change is a key issue a Harris administration would seek to address.

While running for president in 2019, she proposed a climate plan with a $10 trillion price tag — nearly seven times more than the $1.6 trillion Biden has invested in addressing the issue. She also called for a ban on fracking.

As a senator, she co-sponsored the Green New Deal , which called for a dramatic increase in the production of renewable fuels, including wind, solar, and hydropower sources. The 10-year mobilization plan pushed for a transition to energy systems less reliant on generating greenhouse gases, which are the primary contributors to climate change.

Harris has been an advocate inside the Biden administration pushing for the president to forgive student loan debt , which became a staple of his domestic policy agenda.

As a senator, she co-sponsored Vermont Sen. Bernie Sanders’ legislation to make two-year college free for all students and waive tuition for middle-class students attending four-year public universities.

At a Pride Month event last year, she criticized Florida’s 2022 “Don’t Say Gay” law banning educators from discussing sexual orientation and gender identity in elementary and middle school classrooms. Shortly after she announced her presidential campaign Sunday, the American Federation of Teachers endorsed Harris.

Rachel Barber is a 2024 election fellow at USA TODAY, focusing on politics and education. Follow her on X, formerly Twitter, at @rachelbarber_

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CDC reveals new data on bird flu in Michigan farmworkers as US case count ticks up

Whether it spread from sick cows or sick poultry to people, the type of H5N1 avian flu virus that infected a commercial poultry worker in Colorado earlier this month is very similar to the virus that sickened a Michigan dairy farmworker in May, according to new genetic sequencing test results released by the U.S. Centers for Disease Control and Prevention.

And that's good news, said CDC Director Dr. Mandy Cohen, who visited Michigan this week to talk with local and state health leaders about efforts to better understand how the virus is spreading to humans, whether it is mutating to become more dangerous or causing asymptomatic infections.

"We are taking the cases of avian flu that we are seeing very seriously, but I want folks to know the overall risk right now to the population is low," Cohen told the Free Press during a Tuesday morning visit to an immunization clinic at the DMC Children's Hospital of Michigan Specialty Center in Detroit. "That's because we've never seen a human-to-human transmission of that virus. But we also learned very much through COVID that these viruses like to change. So our work is now to make sure we're giving that virus less opportunity to change and potentially then become something that can transmit humans to human."

"We are doing two things: One, we want less virus to be circulating so that it has less chance to change. The other is get ready, be prepared. We want to make sure we have tests that are available, treatments that are available and vaccines that are available."

Since April, 11 poultry and dairy cattle workers in Texas, Michigan and Colorado have been sickened following exposure to infected animals.

Genetic sequencing tests suggest the subtype of the virus in a Colorado poultry worker is B3.13 clade 2.3.4.4b and hasn't mutated enough to easily spread from person to person, evade antiviral treatments, or cause more severe disease.

"The findings are reassuring, showing it is closely related to the first human case discovered in Michigan and that it does not have changes associated with antiviral resistance," the CDC wrote in an online update . "The full sequence was uploaded to a public database so that researchers in the U.S. and around the world can analyze it."

Has the risk to people from H5N1 bird flu risen?

"There are no changes to the virus that would suggest the risk to human health has increased," the CDC reported. "Overall, the genetic analysis of the HPAI A(H5N1) virus in Colorado supports CDC's conclusion that the human health risk currently remains low."

So far, all 11 people with known cases of H5N1 influenza A in the U.S. this year have had mild symptoms such as conjunctivitis, also known as pink eye, and/or upper respiratory symptoms.

But that hasn't always been the case with this elusive virus; other H5N1 subtypes that have spread globally since the late 1990s have had mortality rates that topped 50% , the CDC reported.

More: How Michigan became ground zero for H5 avian influenza in the US

More: Michigan’s top agricultural leader cautiously optimistic about bird flu in state

What else is known about the virus in Michigan?

To get a better idea of whether there is asymptomatic spread of the bird flu virus among Michigan dairy farmworkers, the state Department of Health and Human Services led a seroprevalence study in June that tested blood samples of 35 people who worked directly with cows sickened by H5N1 infections.

Many of the workers did not wear the recommended personal protective equipment such as N95 respirator masks or goggles around the animals, and had different jobs on farms across multiple Michigan counties. Most worked directly with the sick cows, the health department said.

The Michigan Department of Health and Human Services analyzed the blood samples, looking for antibodies, which are produced when people develop an immune response to a virus, suggesting they have been infected even if they didn't feel sick or had had only mild symptoms.

The CDC published preliminary results of that study July 19, finding:

• None of the 35 workers whose blood samples were analyzed developed neutralizing antibodies to the H5N1 avian influenza A virus, which suggests none of them had previous infections with the virus currently circulating in the U.S.
• Many of the farmworkers' blood samples showed neutralizing antibodies to seasonal flu viruses, which suggests they previously were vaccinated or infected with seasonal flu. It also means their bodies most likely could muster an immune response to seasonal flu viruses.

The seroprevalence tests are important, the CDC said, "because it suggests that asymptomatic infections in people are not occurring and provides support to the current testing approach — i.e., collecting samples from symptomatic people who have been exposed to sick animals."

What is the CDC doing to make sure it's ready if the H5N1 virus changes?

Cohen said the nation is in "a very different place" than it was at the start of the coronavirus pandemic, when scientists had to scramble to develop tests, vaccines and treatments.

"We have tests for avian flu that are specific," Cohen said. "We have them in all of our public health labs, and by the end of the year, we're working to have them in our commercial labs as well. We already have a treatment that is available — Tamiflu or oseltamivir. We have it not only in our pharmacies, but in our stockpiles as well.

"And then on vaccines, we have vaccine candidates. We learned from COVID that you want to match that vaccine with the exact ... type of virus that we see circulating. So we have candidates and we have the ability to scale up rapidly. So that's what we're focused on.

"We do have vaccine that is matched to the current strain, but we're seeing mild disease right now. ... What we are thinking about is if the virus were to change and get the ability to spread human to human, that would be when we'd scale up production. That is waiting in the wings."

What is the scope of the H5N1 virus spread in Michigan and the U.S.?

The H5N1 bird flu virus has been spreading for two years among wild birds and domestic poultry — forcing poultry farmers and egg producers in Michigan and across the country to cull millions of birds.

The virus adapted to infect mammals and leapt to cows in late 2023, with high levels of viral particles identified in the milk and udders of sick livestock. Since then, the virus has been identified in cattle on 26 dairy farms in 10 Michigan counties : Allegan, Barry, Calhoun, Clinton, Gratiot, Ingham, Ionia, Isabella, Montcalm and Ottawa counties, according to the state Department of Agriculture and Rural Development. The disease also has been detected in dairy herds in 12 other states, according to the U.S. Department of Agriculture.

Four U.S. dairy farmworkers  have contracted bird flu after working closely with infected cows; two worked on Michigan farms, the CDC reported. The other confirmed U.S. human cases of bird flu this year have occurred among workers at two separate commercial egg-laying operations in Colorado, where the employees were culling infected chickens.

Who is at highest risk for bird flu infection?

Workers on dairy cattle and poultry farms, at commercial egg-laying operations, slaughterhouses and meat-processing plants, as well as people who have close or prolonged, unprotected exposures to infected animals or their environments are at greater risk of H5N1 infection.

The CDC recommends:

• Avoiding unprotected exposure to sick or dead animals, including wild birds, poultry, dairy cattle and other animals, as well as with their feces or other materials that could be infected with H5N1 viral particles.
• Wearing personal protective equipment (PPE) if direct or close contact with sick or dead animals, feces, or other materials potentially contaminated with H5N1 viral particles can't be avoided. That PPE should include safety goggles, disposable gloves, boots or boot covers, a particulate respirator such as an N95 filtering facepiece respirator that has been fit-tested, disposable fluid-resistant coveralls, and disposable head cover or hair cover.
• Anyone exposed to H5N1-infected birds or other animals should monitor themselves for new respiratory illness symptoms, including pink eye, beginning after their first exposure and for 10 days after their last exposure.
• If anyone who had close contact with infected animals develops symptoms, state and federal health leaders recommend seeking medical care for evaluation, testing and treatment. If you are symptomatic, you should isolate from others until infection is ruled out (except to seek medical care).

Are eggs, beef, dairy products and chicken safe to eat?

Yes, so long as you fully cook your eggs, chicken and beef and consume only pasteurized dairy products, the U.S. Food and Drug Administration says.

Although the FDA  detected fragments of the H5N1 virus in the commercial pasteurized milk supply, the particles are not capable of replicating or causing disease.

Contact Kristen Shamus: [email protected]. Subscribe to the Free Press.

ORIGINAL RESEARCH article

Evaluation and influencing factors of ecological resilience in tourism villages from farmers’ perspectives: a case study of chinese minority settlement areas.

• 1 School of Civil Engineering and Architecture, Jishou University, Zhangjiajie, China
• 2 Rural Planning and Development Research Center of Wuling Mountain Area, Zhangjiajie, China
• 3 College of Tourism, Jishou University, Zhangjiajie, China

Rural social-ecological systems have been significantly impacted by the development of rural tourism, creating substantial challenges for the synergistic development of rural ecological restoration and agricultural workers’ household livelihoods. In alignment with the United Nations Decade on Ecosystem Restoration action plan, it is crucial to understand the ecological resilience of tourism villages from the perspective of farmers to achieve sustainable development. Questionnaires and semi-structured interviews were conducted in this study to gather livelihood data from farmers in tourism villages in Xiangxi, China, a region primarily inhabited by ethnic minorities. A measurement index system for the ecological resilience of rural tourism was constructed based on the three dimensions: pressure, state, and response. A comprehensive index method was employed for quantitative evaluation, and influencing factors were analyzed using an obstacle model. The results show that farmers’ livelihoods can be divided into four types: tourism-led, labor-led, agriculture-led, and part-time tourism-based. Their ecological resilience indices are 0.4516, 0.4177, 0.4001, and 0.4590, respectively, representing an overall intermediate level. There are differences in various indices for different livelihood types, with the highest stress index observed in labor-led farmers (0.1655), the highest state index in agriculture-led farming households (0.1585), and the highest response index in tourism-led farming households (0.1766). Common obstacles to the ecological resilience of farmers and their villages include the number of family members engaged in tourism work, the area of forest land, and the farmers’ understanding of ecological policies affecting them. Additionally, core family members’ education levels and the area of homesteads emerged as important obstacle factors. Based on these research findings, recommendations are proposed to enhance the ecological resilience of rural farmer households in the tourism villages of ethnic minority areas. The aim is to provide valuable case studies for promoting the sustainable development of rural tourism in underdeveloped regions worldwide.

1 Introduction

Human activities have inflicted damage on the natural ecological environment, prompting global attention towards ecological protection and restoration. The United Nations Environment Programmer (UNEP) and the Food and Agriculture Organization of the United Nations (FAO) co-lead the United Nations Decade on Ecosystem Restoration Programmer, which aligns with the Sustainable Development Goals (SDGs) in the objective of restoring ecosystems to promote social transformation ( Linster, 2003 ).

Rural areas, as the fundamental form of human settlement and the world’s basic societal unit, constitute a vital component of the global ecological environment. Safe-guarding rural ecologies and advancing rural ecological governance are essential pre-requisites for achieving sustainable development. The world’s accelerating urbanization and globalization processes have propelled rural tourism as a means of enhancing agricultural workers’ livelihoods and providing impetus for rural economic development. In ethnic areas, rural tourism is an economic form based on natural landscape and historical and cultural resources, which is an important and effective way to inherit ethnic culture and realize rural revitalization ( Rosalina et al., 2021 ). However, the unchecked destruction of rural social-ecological systems during tourism development cannot be overlooked. This phenomenon significantly hampers the economic progress of tourism villages and the improvement of farmers’ household livelihoods ( Diaz-Sarachaga, 2020 ).

Rural tourism yields both positive and negative feedback effects on rural social-ecological systems, which has garnered increasing scholarly attention from researchers examining the impact of tourism. On the positive side, rural tourism can enhance the rural ecological environment through improvements in the production environment, living environment, and environmental governance ( Ingrassia et al., 2023 ). Factors such as population, capital, land, and policy play pivotal roles in transforming and developing the rural tourism ecological environment ( Cheng et al., 2022 ). However, negative tourism-related effects such as resource wastage ( Rodriguez-Perez et al., 2022 ), soil and water pollution ( Mihai et al., 2022 ), and the destruction of ecosystem services ( Assiouras et al., 2022 ) adversely affect rural ecosystems.

Rural tourism is also associated with the development of rural industries ( Andersson, 2021 ), up-grades to infrastructure ( Zhu et al., 2022 ), and the creation of diverse employment opportunities, thereby enhancing the livelihoods of agricultural workers and their households ( Hussain et al., 2019 ; Lin, 2020 ). Nevertheless, uncertain risks, homogenized competition, and predicaments related to low participation in the tourism sector ( Kwaramba et al., 2012 ; Randelli et al., 2014 ) can be problematic. Considering these complex risks and disturbances, many scholars have argued that resilience is a crucial means of improving the environment and fostering the sustainable development of human societies ( Ferguson and Wollersheim, 2023 ). Consequently, research on the ecological resilience of tourism villages (or simply, “tourism villages”) from the farmer’s perspective holds significant practical importance. This approach aims to identify ways to cultivate villages’ adaptability to disturbances and, in turn, enhance farmers’ household livelihoods.

In 1973, ecologist Holling (1973) introduced the concept of resilience to the field of ecology, defining it as the ability of an ecosystem to maintain its structure and functions in the presence of external disturbances. As the contradiction between human society and the natural environment becomes increasingly prominent, resilience has evolved into an important criterion for measuring the sustainability of social-ecological systems has expanded into the realm of sociology ( Gunderson and Holling, 2004 ). According to Walker et al. (2004) , resilience denotes the capacity of social-ecological systems to revert to their initial state while continually adapting in response to external disturbances.

Research on ecological resilience at the micro-rural is gradually being prioritized. Current research on rural resilience mainly centers on frameworks for resilience analysis, resilience-level assessments, and investigations of the factors influencing resilience ( Calgaro et al., 2014 ; Li et al., 2022 ; Huang et al., 2017 ). Scholars commonly collect data through questionnaire surveys or in-depth interviews ( Li et al., 2022 ; Zhong et al., 2022 ), constructing multidimensional indicator systems based on their specific subject areas or research perspectives. For example, some scholars have assessed comprehensive rural resilience based on production, ecology, society, system, and economy as the core ( Wang et al., 2021 ), while others have constructed frameworks for assessing rural system resilience with resources, form, and function as the core based on the rural system resilience (RRS) mechanism ( Li et al., 2022 ). Some scholars have established indicator systems for rural resilience based on ecological sub-systems, economic sub-systems, social sub-systems, cultural sub-systems, and governmental sub-systems ( Wang et al., 2023 ). However, there is a lack of consensus regarding the most effective assessment framework for rural resilience.

Various quantitative measurement methods, such as the entropy weight method ( Wang et al., 2021 ), Topsis method ( Qin et al., 2023 ), and comprehensive index method ( Wang et al., 2023 ) have been employed for assessing rural resilience. Analytical tools like the obstacle model ( Qin et al., 2023 ), the structural equation model ( Zhao et al., 2023 ), regression analysis ( Tomás et al., 2020 ), and the geographic detector ( Wang et al., 2023 ) have also been widely used in exploring the factors that influence rural resilience ( Ingrassia et al., 2023 ; Berkes and Ross, 2013 ; Espiner et al., 2017 ). Among them, the entropy weight method can reduce the influence of subjective factors, so the calculation results are more reliable. Composite index method can reflect the overall direction and degree of change of complex phenomena, and can quantitatively illustrate the actual effect of phenomenon change. Obstacle degree model can find out the key factors limiting things, and clarify the degree of influence of key constraints. Existing research indicates that issues like land degradation can adversely impact rural societies, economies, and natural environments, leading to a reduction in rural resilience ( Baird, 2018 ). Safeguarding the ecosystem has been identified as the key to improving the resilience of farmers to external disturbances and achieving high-quality rural development (He et al., 2017). Socio-economic diversity is further recognized as a promoter of high-quality rural development ( Chen et al., 2017 ), while local culture ( Chiang et al., 2014 ), carbon emissions ( Sena et al., 2022 ), and government management ( Henderson et al., 2020 ) also significantly impact on rural resilience. Despite extensive studies on influencing factors and cultivation paths for rural resilience, there is a notable gap in targeted studies on rural tourism, which is a significant contemporary disturbance factor. Few studies have vividly or subtly characterized the current level of ecological resilience in tourism villages.

Rural tourism has a dual impact on local rural ecosystems and on the livelihoods of rural households ( Cheng et al., 2022 ; Ingrassia et al., 2023 ). While the influence of rural tourism on rural social eco-logical systems is widely recognized, there has been little research attention given to the manner in which famers respond to rural tourism and the consequential effects of farmers’ behavior on the rural social-ecological system. Consequently, exploring the ecological resilience of tourism rural areas from the perspective of farmers holds significant theoretical and practical importance. In this study, we adopted micro-farming households as a research unit, incorporating the resilience theory, sustainable livelihoods theory, and farmers’ behavior theory into our analysis ( Wu et al., 2023 ). Utilizing the pressure-state-response (PSR) analysis framework, we comprehensively structured an analytical basis for evaluating the ecological resilience of tourism villages ( Zhang et al., 2023 ). This evaluation spanned three dimensions: pressure, state, and response. By categorizing farmers’ households based on their livelihood types and employing the comprehensive index method, along with the obstacle degree model, we explored the differentiation characteristics and obstacle factors of farmers’ ecological resilience amidst the impacts of tourism-related disturbances to their environment. Emphasizing the role of farmers’ subjective initiative in rural ecology, we conducted targeted research delving into the nuanced aspects of ecological resilience in the countryside. This work not only broadens the theoretical understanding of rural resilience, but also enriches the perspectives within rural resilience research. We also offer case studies that may serve as a valuable reference in the sustainable development of tourism villages in other underdeveloped ethnic regions of the world.

2 Theoretical framework and Index system

2.1 theoretical framework.

The tourism village’s social-ecological system is a complex entity formed by interconnections among people, industry, and land. The system is diverse, dynamic, and unstable, among other notable characteristics ( Becken, 2013 ). As pivotal actors in rural social-ecological systems, farmers play a crucial role in the sustainable development of tourism villages. Tourism villages are affected by tourism development as well as the activities of agricultural workers in sustaining their livelihoods, which together continuously restructure resources, environments, and production relations within these villages ( Wang et al., 2021 ). Ecological resilience, as an intrinsic property of the social-ecological system in tourism villages, enables adaptation of functional structures, leading villages to return to a new state of stability after external disturbances.

The PSR framework is widely utilized in social-ecological research. It is a practical approach to elucidating interactions among human behaviors, the environment, and resources ( Chen et al., 2022 ). This framework may also be utilized to gain systematic insights for ecological resilience research. In this study, pressure (P) characterizes the disturbance of rural ecosystems by the livelihood-related activities of farmers’ households, which specifically manifests in disturbances on villages caused by population pressure, environ-mental pressure, and land pressure. State (S) signifies the horizontal state of farmers’ household livelihood systems after the villages have endured disturbances, encompassing social resources, production land, and living standards. Response (R) refers to the ability of farmers to respond and adapt to external disturbances, ultimately improving the rural social-ecological system. The ecological resilience of tourism villages from the perspective of farmers is the result of combined internal and external disturbances at work in the system. The development of these villages is a dynamic evolutionary process.

Firstly, through various livelihood-related activities, farmers’ households obtain the resources required for survival and development from the rural social-ecological system ( Wu et al., 2022 ). While at the same time exerting pressure on the rural population, environment, and land. Secondly, tourism-related disturbances induce changes in the organization and function of the rural social-ecological system, impacting the livelihoods of farmers and their households through positive and negative feedback. This alters their social resources, production land, and living standards. Finally, farmers’ households enhance their risk resilience and information acquisition capacity through livelihood-related responses, transforming their livelihoods in alignment with the tourism sector, gaining ecological awareness, and managing livelihood-related behaviors in other adaptive ways.

These insights can be applied to the practical management of rural social-ecological systems. The above analysis was utilized to construct a framework for evaluating the ecological resilience of tourism villages from the perspective of farmers ( Figure 1 ).

Figure 1 . PSR relationship of tourism-village ecological resilience from farmers’ perspective (Modified from Linster’s PSR analysis framework).

2.2 Index system

Based on the above analytical framework ( Figure 1 ), referring to the existing research results of other scholars, and combining the farmers livelihood theory ( Wu et al., 2021 ), resilience theory ( Dong et al., 2022 ), farmers behavior theory ( Sok et al., 2021 ), and the nuances of the case-study villages, the ecological resilience evaluation index system of the tourist villages from the farmers’ perspective was constructed. This comprehensive system includes 18 indexes and three dimensional layers: a pressure layer, state layer, and response layer ( Table 1 ). In this study, rural ecological resilience is understood as a composite of three dimensions: stress index, state index and response index. And the pressure index, state index and response index can be characterized by six indicators. The entropy method was applied to calculate the weights of each index ( Qin et al., 2023 ), facilitating the interpretation of each factor and index layer. The composite index method was used to calculate the level of ecological resilience.

Table 1 . Indicator system for measuring ecological resilience in tourism villages from farmers’ perspectives.

The pressure index layer is a subjective manifestation of farmers’ disturbances within rural ecosystems, reflecting the extent of disruption to the social-ecological system of tourism villages caused by farmers’ livelihood-related activities ( Becken, 2013 ). A higher pressure index indicates more pronounced disturbance to the rural ecology. There is a total of six indices in this layer. Among them, number of family surplus laborers C 1 is an important indicator of population pressure; greater household surplus labor indicates increased resource consumption. Monthly energy costs C 2 , transportation mode C 5 , and homestead area C 6 reflect the demand for rural resources and the degree of utilization of rural households. Land pesticide costs C 3 and fertilizer costs C 4 specifically express the pressure on the rural environment exerted by farmers’ livelihood-related activities. Higher pesticide and fertilizer costs correlate with stronger disturbance to the rural ecological environmental.

The state index layer represents the objective state level of the rural social-ecological system after disturbances. A higher state index indicates a higher livelihood level for farmers. This layer encompasses six indices. Among them, the type of access to subsidies C 7 directly reflects the social resources available to farm households. Agricultural acreage C 8 and family forest land area C 9 are direct indicators of the land used for production; annual per capita income C 10 , education level of core family members C 11 , and total household fixed assets C 12 are indicators of the household’s standard of living.

The response index layer gauges farmers’ abilities to respond to tourism-related disturbances, enabling behavioral adjustments to improve the rural social-ecological system ( Xiao et al., 2023 ). A higher response index reflects a stronger ability of farmers to adapt. Once more, there are six indices in this layer. Increasing annual family education expense C 13 is a particularly effective measure of farmers’ abilities to withstand risks when faced with external disturbances. Monthly mobile phone communication costs C 15 and the type of eco-policy understanding C 16 form the basis for strengthening the farmers’ abilities to obtain information, helping them to improve ecological awareness and adapt their livelihood-related behaviors. The number of migrant workers C 14 , the number of family members engaged in tourism work C 17 , and the support for rural tourism development C 18 can promote the ecological resilience of the farming house-holds. Resilience enhancement serves as a crucial pathway toward sustainable development in this regard.

3 Methodology

3.1 study area.

The Xiangxi region is located in the western part of Hunan Province, China, encompassing the Xiangxi Autonomous Prefecture, Huaihua City, and Zhangjiajie City within its administrative areas. Spanning 78,700 km 2 , the region has a minority population accounting for 80.5% of its inhabitants. Renowned as one of China’s most culturally rich ethnic regions, Xiangxi is home to 395 national level traditional villages showcasing a profound ethnic cultural heritage. The region also hosts seven nation-al-level nature reserves and 28 national AAAA grade or above scenic spots, making it abundant in natural ecological resources.

The Xiangxi region is one of the most famous tourist destinations in China, with the tourism industry accounting for more than 50 percent of regional GDP and contributing more than 70 percent to economic growth, and tourism has become a pillar industry in the Xiangxi region. Currently, hundreds of villages in Xiangxi region have been developed for tourism, and a large number of farmers family have been affected by rural tourism, which plays an important role in promoting regional development and enhancing the livelihoods of farming families. However, while rural tourism has had a profound impact on the livelihoods of local farmers, it has also significantly damaged the rural ecological environment. Particularly in ethnic minority areas, rural tourism has led to the destruction of many traditional buildings, as well as significant changes in the livelihoods of farmers and the gradual extinction of ethnic cultures, with indelible effects on ecological resilience. Following preliminary research and a comprehensive evaluation of factors such as the scale of rural tourism operations, social benefits, and tourism development intensity, eight tourism villages were selected as research subjects: Disun Village and Huangdu Village in Jingzhou County, Huaihua City and Zhushan Village in Fenghuang County, Dehang Village in Jishou City, Shibadong Village in Huayuan County, Laochehe Village in Longshan County, and Luotan Village and Maershan Village in Zhangjiajie City ( Figure 2 ).

Figure 2 . Location of study area: Xiangxi Region, China.

These villages were selected not only for their abundant natural resources, significant popularity with tourists, and the notable environmental impact of tourism development they evidence - the livelihoods of farmers in these villages are diverse in type and rich in information, providing a comprehensive reflection of the differentiation in farmers’ household livelihoods and their ecological resilience under the influence of tourism development. Therefore, these eight tourism villages hold strong typicality and representativeness.

3.2 Data collection

To enhance the scientific rigor of this study, a diverse array of data collection methods was employed. Initially, basic information about the case-study villages was gathered from the official websites of each city (state) in Xiangxi Region. Subsequently, we conducted on-site investigations in December 2021, January 2022, and August-September 2022 to obtain detailed data on the livelihoods of farmers’ households in the tourism villages through questionnaires and semi-structured interviews. The questionnaire content mainly includes the human capital, social capital, natural capital, physical capital and financial capital of farmers, changes in farmers’ livelihood and farmers’ behavior. Semi-structured interviews were used to investigate farmers’ attitudes toward rural tourism, the process of rural tourism development and rural socio-economic conditions, and to support the questionnaire content. Ultimately, more than 100,000 words of text data and hundreds of hours of voice data were obtained, mainly including farmers’ household livelihood capital, rural socio-economic conditions and farmers’ behavioral activities ( Zhao et al., 2023 ).

We employed a random sampling survey method to conduct a comprehensive survey of the farmers, dedicating 40–50 min per household. The respondents primarily consisted of the core family labor force ( Yang et al., 2021 ), so as to be able to get a true and objective picture of the situation of farming families and rural tourism. The research team also immersed themselves in the daily activities of farmers in each case-study village, living alongside them and participating in farming, other work, and tourism management. This hands-on approach allowed us to experience the impacts of tourism-related disturbances on the rural social-ecological system from the farmers’ perspectives (He et al., 2017). A total of 388 respondents were interviewed, and questionnaires and semi-structured interviews were conducted with all 388 farmers, obtaining 388 questionnaires and interview materials. After excluding abnormal questionnaires and questionnaires with missing information, 373 questionnaires were considered valid, accounting for 96.1% of the sample. The number of questionnaires collected in each case-study village exceeded 40, which satisfies requirements for the validity and representativeness of the research data ( Xiao et al., 2023 ).

To systematically examine the disparities in ecological resilience among farmers, we referred to the classification of livelihood types utilized in a previous study ( Wu et al., 2021 ). We integrated this framework with the specific conditions of our study area with household income as the basis for categorization. The interviewed farmers were classified accordingly into four distinct livelihood types: tourism-led, labor-led, agriculture-led, and part-time-led ( Table 2 ).

Table 2 . Classification of farmer types.

In labor-led households, the primary income source is derived from work with a minimal supplement from agriculture. Tourism-led households, on the other hand, garner the majority of their income through engagement in tourism-related work—in these households, income from tourism constitutes more than 60% of the total. Part-time tourism-led households adopt a more diversified approach to livelihood, participating not only in tourism-related work but also in external labor or agricultural activities within the village. In contrast, agriculture-led types are limited to simple agricultural activities, resulting in lower household incomes than other types. These tend to be middle-aged and elderly individuals who have lost their abilities to engage in labor due to physiological reasons (e.g., illness).

3.3 Data analysis

3.3.1 comprehensive index method.

Ecological resilience is referred to in this paper as a composite of three dimensions: pressure, state, and response. Each of these dimensions is constituted of several indices. The composite index method was used to calculate the ecological resilience of farmers ( Xie et al., 2023 ) with the following formula:

where E I is the ecological resilience index; P I , S I , and R I denote the pressure index, state index, and response index, respectively. W P , W S , and W R denote the weights of the pressure index, state index, and response index, respectively; ω j represents the jth index layer weight and X ij represents the standardized value of the ith index of the jth research unit.

3.3.2 Obstacle degree model

The obstacle degree model was used to analyze the obstacles hindering ecological resilience in tourism villages from the farmers’ perspectives ( Zhao et al., 2021 ). It was operated using the following formula:

where P ij denotes index deviation, which indicates the gap between a single index and the optimal target value; I j is the obstacle degree, which indicates the degree to which the jth index impedes ecological resilience; ω j denotes the weight of a single factor on the total target, or the weight of the jth index with respect to ecological resilience.

3.3.3 SPSS 24.0 statistical analysis software

SPSS 24.0 statistical analysis software was used for factor analysis. Cronbach’s alpha coefficient was used to test the reliability of the original data obtained from the questionnaire research. KMO test coefficient and Bartlett’s test coefficient were used to test the validity of the original data. The results show that the Cronbach’s α coefficient is 0.755. It is generally believed that when the Cronbach’s α coefficient reaches 0.7–0.8, the scale has considerable reliability. The KMO test coefficient (0.776) is greater than 0.5, and the Bartlett test coefficient (Sig.) is 0.000, which indicates that the validity of the measurement index is well tested.

The interviewee demographics exhibited minimal gender disparity, primarily comprising middle-aged and elderly (40 years of age and over) individuals (88%). The population was predominantly Miao (50%), with a majority holding an elementary school education or below (54%). Per capita annual income for farmers’ households mainly fell within the range of 10,000–20,000 RMB (53%). The vast majority of these households gained their income by working outside the home (90%), indicating that the predominant type of farmer in the region is labor-led ( Table 3 ).

Table 3 . Basic data for farmers in research sample.

4.1 Characteristics of ecological resilience of farmers in tourist villages

Equations 1 – 4 were applied to compute the farmers’ ecological resilience index and the indices for each dimension of the PSR model. The pressure index, state index, response index, and ecological resilience index were 0.1631, 0.1263, 0.1337, and 0.4231, respectively ( Figure 3 ). The natural breakpoint method was utilized to classify the in-dices of these dimensions into three levels: low, medium, and high. Among them, we observed low (0.0103–0.1186), intermediate (0.1187–0.1821), and high (0.1822–0.2786) levels of the stress index; low (0.0054–0.01040), intermediate (0.1041–0.1721), and high (0.1722–0.2641) levels of the state index; and low (0.0169–0.1110), intermediate (0.1111–0.1845), and advanced (0.1846–0.3068) levels of the resilience index. The ecological resilience low level (0.2087–0.3725), intermediate level (0.3726–0.4704), and advanced level (0.4705–0.7320) were also determined. Statistical analysis indicated that the index of ecological resilience for farmers in tourism villages in Xiangxi Region accounted for 31%, 39%, and 30% of low, medium, and high levels, respectively, with the mean value falling into the medium-level range.

Figure 3 . Dimensional indices and ecological resilience of farmers in Xiangxi Region.

4.2 Ecological resilience in farmers’ households with different livelihood types

To further explore the nuances of livelihood differentiation and the divergence in ecological resilience among farmers’ households after tourism-related disturbances, we conducted a statistical analysis of the ecological resilience indices of households with varying livelihood types ( Figure 4 ; Table 4 ). The ecological resilience indices of different livelihood types of farmer households were, in descending order: part-time-led (0.4590), tourism-led (0.4516), labor-led (0.4177), and agriculture-led (0.4001). Specifically, tourism-led farmers showed the highest response index (0.1766) but the lowest stress index (0.1499); part-time-led farmers exhibited a high status index (0.1376) and response index (0.1647), but a low stress index (0.1567). Labor-led farmers showed the highest stress index (0.1636), a relatively low response index (0.1306), and an extremely low status index (0.1216). Agriculture-led farmers exhibited the highest status index (0.1585), a relatively high stress index (0.1636), and the lowest response index (0.078). Overall, the majority of farmers in Xiangxi Region demonstrated medium-level ecological resilience and dimensional indices. Only the response index of agriculture-led farmers was relatively low, and there was substantial convergence of the dimensional indices among farmers of different livelihood types.

Figure 4 . Dimensional and ecological resilience indices for farmers of different livelihood types.

Table 4 . Ecological resilience indicators for households of different livelihood types.

The stress indices for various livelihood types were, in descending order: labor-led (0.1655), agriculture-led (0.1636), part-time-led (0.1567), and tourism-led (0.1499). The mean value of the overall stress index fell within the medium range ( Figure 5 ). The lowest stress index observed for tourism-led farmers implies that this type exerts the most significant disturbance on the rural social-ecological system. This phenomenon can be primarily attributed to the variability in livelihood-related behaviors among tourism-led farmers.

Figure 5 . Correspondence of stress indices for households with different livelihood types.

Tourism-led farmers’ households exhibited the lowest indices for monthly energy costs C 2 , transportation mode C 5 , and homestead area C 6 , while showing the highest indices for pesticide costs C 3 and fertilizer costs C 4 . These results indicate that farmers change their livelihoods through participation in tourism, thereby reducing the environmental impact of agricultural cultivation. However, as their income increases and their quality of life improves, the acquisition of cars, expansion of homes, and more widespread energy consumption exacerbate the disturbance to the rural social-ecological system. Despite these nuances, tourism-led farmers still maintain the lowest overall stress index. Conversely, labor-led farmers do not strictly rely on traditional agriculture and have a lower demand for rural resources, so their overall level of disturbance to the rural social-ecological system is relatively low; therefore, their stress index is the highest.

The state indices for different livelihood types, in descending order, are: agriculture-led (0.1585), part-time-led (0.1376), tourism-led (0.1251), and labor-led (0.1216). The mean value of the overall state index falls into the intermediate range ( Figure 6 ). Agriculture-led households exhibited the highest values for agricultural acreage C 8 and family forest land area C 9 , indicating that agricultural livelihoods contribute to maintaining productive land in rural areas and safeguarding the ecological functions of the countryside. In contrast, labor- and tourism-led livelihoods, while enhancing house-hold income, cause damage to the environment through practices such as land abandonment and transfers. The development of tourism has not only contributed to the diversification of farmers’ household livelihoods but has also intensified their exploitation of rural resources and the environment.

Figure 6 . Correspondence of state indices for households with different livelihood types.

The response indices for different livelihood types were, in descending order: tourism-led (0.1766), part-time-led (0.1647), labor-led (0.1306), and agriculture-led (0.0780). The former three types had medium-level response indices while the latter had a low response index ( Figure 7 ). This ranking primarily reflects the farmers’ capacities to access information and adapt their livelihoods to the development of tourism. Tourism-led farmers demonstrated the highest indices for annual family education expenses C 13 , type of eco-policy understanding C 16 , and the number of family members engaged in tourism work C 17 , among other indicators. The substantial impact of tour-ism development on the livelihoods of farmers’ households, resulting in higher in-comes and enhanced awareness, effectively improved the decision-making abilities of these households and influenced their choices of livelihood. Additionally, an influx of tourism capital led to the restructuring of rural social networks, motivating farmers to actively engage in tourism-related work and adjust their livelihood-related behaviors to the benefit of the rural social-ecological system. Agriculture-led households, despite possessing relatively abundant productive land, exhibited a weaker ability to access information and transform their livelihoods. Consequently, they showed the lowest levels of each indicator and the lowest response indices among the farmer types.

Figure 7 . Correspondence of response indices of house-holds with different livelihood types.

The ecological resilience indices of farmers’ households of different livelihood types are, in descending order: part-time-led (0.4590), tourism-led (0.4516), labor-led (0.4177), and agriculture-led (0.4001) ( Figure 8 ). The mean value of the overall ecological resilience index falls into the intermediate range, which aligns with the field research findings. This outcome was primarily shaped by the specificities of the house-holds’ livelihood types. Diversified livelihoods are conducive to securing farmers’ living standards, providing more access to social resources and information ( Becken, 2013 ). Farmers, as the mainstay of rural communities, can enhance their social cognition and behavior through participation in the tourism sector ( Wu et al., 2023 ), contributing to improved state and response indices. Despite fostering diversified livelihoods, tourism development also intensifies the demand for rural resources, alters resource utilization practices, initiates land transfers, and introduces the construction of tourism-related projects, resulting in significant disturbances to the rural ecological environment. Overall, diversified livelihoods contribute more effectively to the sustainability of rural social-ecological systems ( Chen et al., 2017 ). Rural tourism should be planned and developed under the premise of protecting the ecological environment.

Figure 8 . Correspondence of ecological resilience indices of households with different livelihood types.

4.3 Obstacles to ecological resilience

The obstacle degree model serves to elucidate the relationships between system factors and reveal the impact of each indicator on the system based on the magnitude of the obstacle degree. In the context of farmers’ ecological resilience, a higher obstacle degree for a given indicator implies a more adverse effect on ecological resilience improvement, and vice versa . Eqs 5 , 6 were used to calculate the obstacle degree of each index. A cumulative obstacle degree exceeding 50% can be regarded as indicating a primary obstacle factor ( Zhao et al., 2021 ). In this study, the obstacle factors of ecological resilience were ranked for different livelihood types. We screened the common obstacle factors for different livelihood types accordingly ( Table 5 ).

Table 5 . Ecological resilience obstacles for farmers of different livelihood types.

The number of family members engaged in tourism work, family forest land area, and the awareness of ecological policies emerged as common obstacle factors for different livelihood types. Among them, the number of family members engaged in tour-ism work C 17 was the primary obstacle factor for all four types, with obstacle degrees of 18.90%, 26.91%, 28.86%, and 21.76%, respectively. The problem of low participation among households is prevalent in rural tourism development processes. Though farmers’ households can transform their livelihoods and enhance the stability of their livelihood system through participation in tourism-related work, they are often excluded from municipal or regional decision-making due to the weak foundation of their livelihoods ( Chen et al., 2022 ).

Furthermore, as a key element of the rural social-ecological system in terms of maintaining ecological functions, forest land is a critical indicator of ecological resilience. Tourism development often results in significant transfers of rural forest land to construction areas, which adversely affects ecosystem services and directly diminishes ecological resilience. The proactive role of farmers is decisive in rural ecological governance; farmers’ ecological awareness influences their daily activities and livelihood-related behaviors, directly impacting the ecological environment.

In addition to the three common obstacle factors, the education levels of core family members C 11 and homestead area C 6 also emerged as significant impediments to the ecological resilience of farm households. The field research data revealed that 54% of the farmers’ households had received only elementary school educations, only 34.4% had received junior high school educations, and only 11.6% had received senior high school educations or above. The inefficiency of rural education resources has led to a relatively overall education quality for farmers’ households, hindering behavior that would be advantageous to the rural social ecosystem. These relatively low levels of education can lead farmers to interfere with or even directly damage the ecological environment in their daily lives—a phenomenon that is commonly observed in under-developed regions ( Raleigh, 2011 ). Simultaneously, rural areas experience significant land resource waste while unregulated construction practices severely damage the natural environment. Therefore, rational planning and development to encourage the effective usage of rural resources are necessary measures to promote enhanced ecological resilience. Obstacle factors impeding ecological resilience across different types of rural households, such as low enthusiasm for participation in tourism development, restricted access to information, and minimal investment in education, were found to be prevalent in the case-study region. These factors significantly impede the improvement of rural areas’ ecological resilience.

5 Discussion and conclusion

5.1 discussion.

Rural tourism has evolved into a pillar industry for the economic development of ethnic areas, creating a significant challenge in terms of achieving synergistic development between the ecological protection of tourism villages and the livelihoods of rural residents ( Pjerotic et al., 2017 ). Within rural social-ecological systems, ecological resilience is not only affected by external social-economic factors but also by the pressure on the environment stemming from farmers’ behavior, the altered state of households’ livelihood systems following tourism-related disruptions, and the responsiveness of farmers in adjusting their behaviors to improve their local areas ( Latkova and Vogt, 2012 ). Integrating farmers’ house-hold livelihoods and behaviors into an analysis framework of rural social-ecological systems can expand the scope of ecological resilience research. Targeted findings from farmers’ perspectives may also deepen ecological resilience research at a conceptual level.

The results of this study revealed an overall low level of ecological resilience among rural residents in tourism villages of Xiangxi Region, primarily attributable to the nascent stage and uneven progress of rural tourism development ( Latkova and Vogt, 2012 ). Infrastructure construction and tourism project implementation, marked by large-scale land acquisition and transfer, have significantly disrupted the ecological environment ( Assiouras et al., 2022 ). However, positive effects on ecological resilience were observed in cases where local governments and community management organizations actively protected rural resources ( Lin, 2020 ). Conversely, farmers’ livelihood-related behaviors may have caused two-way interventions in rural ecosystems, highlighting the dual impact of tourism development on rural ecological resilience and necessitating positive, nuanced policy constraints ( Li et al., 2022 ).

The specificity of certain livelihoods contributes to variability in ecological resilience among different types of farmers ( Lin, 2020 ). Farmers’ participation in tourism development plays a crucial role in enhancing their families’ stability and adapting to tour-ism-related changes in their environment. However, the weak foundation of their livelihoods and unequal positions in local decision-making processes make many tourism villages a “the game of the few” ( Xiao et al., 2023 ). Enhancing rural households’ participation in tourism development and increasing the incomes of agricultural workers are pivotal factors for promoting the ecological resilience of the countryside. Additionally, there is a notable convergence of ecological resilience obstacles across various livelihood types, primarily stemming from the limited options for earning one’s livelihood in an under-developed region ( Zhang et al., 2022 ). Resource constraints hinder regional economic development and rural households’ livelihoods, leading to rural tourism featuring state leadership, tourism-company interventions, and, ideally, the participation of rural residents. However, cases that genuinely benefit farmers are scarce. To achieve sustainable development, rural tourism development must not only provide financial income but also create opportunities for rural households to gain stable livelihoods.

There are various research methods and indicators on rural ecological resilience, however, few scholars have explored rural ecological resilience from the perspective of farmers, and the role of farmers’ livelihoods and behavioral interventions in rural socio-ecological systems has often been overlooked. The main contribution of this study is to introduce the PSR framework into the rural socio-ecological system, emphasizing the important role of farmers’ subjective initiative on rural ecosystems. This study contributes to a more comprehensive assessment of rural ecological resilience, and can provide a new perspective for a deeper understanding and cognizance of the interrelationships between farm households and rural social-ecological systems.

5.2 Conclusion and recommendations

This study constructed a framework for analyzing the ecological resilience of tourism villages from the perspective of farmers, and explored the differentiated characteristics and obstacles of ecological resilience of different types of farmers in a Chinese ethnic minority area. The main conclusions are as follows. First, there are differences in the ecological resilience of different types of farmers. The primary factors contributing to these differences were the immaturity of the rural tourism sector and the un-even level of tourism development across the region. Second, the overall level of ecological resilience in Xiangxi region is sub-par, reflecting the weak foundation for farmers’ livelihoods in ethnic areas. Last, There is a convergence of barriers to ecological resilience among different types of farmers, which is mainly determined by the specificity of the economic backwardness of the Xiangxi region. Therefore, more support needs to be given to ethnic minority villages and farmers in order to realize the sustainable development of tourist villages.

Based on the results of the study, we offer several recommendations for improving the ecological resilience of tourism villages in underdeveloped regions and ethnic areas globally. Firstly, the government should adopt a macro-control role, guided by scientific planning, to ensure tourism development aligns with ecological protection. Adequate policy support and financial support should be provided to create conducive investment and employment conditions for rural tourism. Secondly, community management organizations should leverage regional characteristics and cultural resources to establish a diversified tourism industry chain, enhancing competitiveness and creating more local job opportunities. This would also encourage farmers to remain in (or return to) their hometowns to start their own businesses and bolster the local economy. Finally, farmers should actively engage in rural tourism work, continuously improving their skills and transforming their livelihoods in accordance with the influx of tourism. They should enhance their ecological and environmental awareness, applying this knowledge to rural production and daily living practices to prevent resource wastage and achieve harmonious coexistence with nature.

There are some limitations to this study, such as the small sample size of the study and the lack of research on the dynamics of ecological resilience in tourist villages. We assessed the ecological resilience of tourism villages from farmers’ perspectives using cross-sectional data. However, this approach fell short of fully elucidating the evolutionary characteristics and influencing mechanisms of farmers’ ecological resilience in tourism villages in ethnic areas. Subsequent research efforts should expand the scope of the survey, increase the sample size of the study, as well as follow up on farm household livelihood data over time to enhance the robustness and comprehensiveness of the findings.

Data availability statement

The raw data supporting the conclusion of this article will be made available by the authors, without undue reservation.

Ethics statement

The studies involving humans were approved by the Jishou University Biomedical Ethics Committee. The studies were conducted in accordance with the local legislation and institutional requirements. Written informed consent for participation in this study was provided by the participants’ legal guardians/next of kin.

Author contributions

JW: Conceptualization, Funding acquisition, Supervision, Writing–original draft, Writing–review and editing. YY: Formal Analysis, Investigation, Supervision, Writing–review and editing. JZ: Investigation, Writing–review and editing. QC: Investigation, Writing–review and editing. DG: Investigation, Writing–review and editing. SL: Methodology, Writing–review and editing.

The authors declare that financial support was received for the research, authorship, and/or publication of this article. This research was funded by the National Natural Science Foundation (Grant Numbers: 42061036, 42361032) and Research Foundation of Hunan Provincial Education Department (Grant Number: 18A283).

Acknowledgments

The authors appreciate the insightful and constructive comments and suggestions of the editor and two reviewers. We would also like express gratitude for the technical and financial support of Jishou University and the support of our colleagues.

Conflict of interest

The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.

Publisher’s note

All claims expressed in this article are solely those of the authors and do not necessarily represent those of their affiliated organizations, or those of the publisher, the editors and the reviewers. Any product that may be evaluated in this article, or claim that may be made by its manufacturer, is not guaranteed or endorsed by the publisher.

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Keywords: tourism villages, farmers’ household livelihoods, ecological resilience, obstacle factors, Xiangxi region, China

Citation: Wu J, Yang Y, Zuo J, Cao Q, Guo D and Liu S (2024) Evaluation and influencing factors of ecological resilience in tourism villages from farmers’ perspectives: a case study of Chinese minority settlement areas. Front. Environ. Sci. 12:1400546. doi: 10.3389/fenvs.2024.1400546

Received: 14 March 2024; Accepted: 28 May 2024; Published: 23 July 2024.

Reviewed by:

Copyright © 2024 Wu, Yang, Zuo, Cao, Guo and Liu. This is an open-access article distributed under the terms of the Creative Commons Attribution License (CC BY). The use, distribution or reproduction in other forums is permitted, provided the original author(s) and the copyright owner(s) are credited and that the original publication in this journal is cited, in accordance with accepted academic practice. No use, distribution or reproduction is permitted which does not comply with these terms.

*Correspondence: Shuiliang Liu, [email protected]

Disclaimer: All claims expressed in this article are solely those of the authors and do not necessarily represent those of their affiliated organizations, or those of the publisher, the editors and the reviewers. Any product that may be evaluated in this article or claim that may be made by its manufacturer is not guaranteed or endorsed by the publisher.

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Research on the impact of landscape planning on visual and spatial perception in historical district tourism: a case study of laomendong.

1. Introduction

2. literature review, 2.1. importance of historical landscapes to visual perception, 2.2. the crucial role of visual perception in shaping spatial perception, 2.3. the interdisciplinary study of spatial perception and its impact on urban design, 2.4. the impact of historical landscapes on visual and spatial perception in historic districts, 3. the research framework, 4. methodology, 4.1. model theory, 4.2. the study site, 4.3. measurement, 4.4. data collection, 4.5. data analysis, 5.1. multiple-variable normality, 5.2. measurement for historical landscapes, 5.3. measurement for spatial perception, 5.4. measurement for the overall model, 5.5. measurement for the structural model, 6. conclusions and discussions, 6.1. summary of the research findings, 6.2. practical implications for the sustainable development of historical district tourism, 6.3. contributions, 6.4. limitations, author contributions, data availability statement, acknowledgments, conflicts of interest.

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Shao, L.; Ma, P.; Zhou, Z. Research on the Impact of Landscape Planning on Visual and Spatial Perception in Historical District Tourism: A Case Study of Laomendong. Land 2024 , 13 , 1134. https://doi.org/10.3390/land13081134

Shao L, Ma P, Zhou Z. Research on the Impact of Landscape Planning on Visual and Spatial Perception in Historical District Tourism: A Case Study of Laomendong. Land . 2024; 13(8):1134. https://doi.org/10.3390/land13081134

Shao, Lingfang, Pengfei Ma, and Zijin Zhou. 2024. "Research on the Impact of Landscape Planning on Visual and Spatial Perception in Historical District Tourism: A Case Study of Laomendong" Land 13, no. 8: 1134. https://doi.org/10.3390/land13081134

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• Published: 26 July 2024

Online digital health and informatics education for undergraduate nursing students in China: impacts and recommendations

• Hongxia Shen 1 , 2 , 3   na1 ,
• Chong Chen 1   na1 ,
• Sijing Yan 1 ,
• Cynthia Hallensleben 2 , 3 ,
• Rianne van der Kleij 2 , 3 ,
• Minyi Li 1 ,
• Huohuo Dai 2 , 3 ,
• Niels Chavannes 2 , 3 &
• Ying Zhou 1  

BMC Medical Education volume  24 , Article number:  803 ( 2024 ) Cite this article

65 Accesses

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Digital health plays a vital role in healthcare services. Governments in many countries, including China, are increasingly advocating for the appropriate use of digital technologies to address significant health system challenges. It is crucial to incorporate digital health education into the curriculum for future nurses to adapt to the changes in the digital medical system. This study aimed to evaluate the impact of an online Digital Health and Informatics Course in China on the knowledge and comprehension of key digital health and informatics topics, self-assessment of nursing informatics competencies, and satisfaction among undergraduate nursing students. The findings of this study provide recommendations for the design and implementation of future digital health education.

This study employed a one-group, quasi-experimental mixed-methods design with pre- and post-assessments. The participants received digital health and informatics education through six three-hour online sessions in six interactive days, with online self-learning materials in between. An online quiz and focus group discussions pre- and post the course were designed to evaluate the knowledge and comprehension of key digital health and informatics topics. Also, a validated Chinese version of the Self-assessment of Nursing Informatics Competencies Scale was conducted pre- and post-course to assess self-assessment of nursing informatics competencies. Additionally, all students were invited to participate in an online survey with a performance-focused course evaluation form as well as focus group discussions to gather their feedback on the learning experience and their evaluations of the course.

A total of 24 undergraduate nursing students were enrolled in the course. All students completed all sessions of this course, resulting in an attendance rate of 100%. Additionally, all students completed both pre- and post-assessments. In terms of the knowledge and comprehension of key digital health and informatics topics, scores of the quiz on knowledge assessment improved from the pre-test [mean pretest score: 78.33 (SD 6.005)] to the post-test [mean post-test score: 83.17 (SD 4.86)] upon completion of the course ( P  < 0.001). Also, students acknowledged that the course enhanced their knowledge and comprehension of informatics and digital health, the benefits of (nursing) informatics in clinical practice, and the role of health care professionals in informatics and digital health. In terms of self-assessment of nursing informatics competencies, scores on nursing informatics attitudes demonstrated significant improvement (P  < 0.001). Furthermore, students reported high satisfaction with various aspects of this course, including the opportunity to explore broad horizons in informatics for future careers, engaging in group discussions, and analyzing case studies on the use of informatics and digital health in clinical practice.

Conclusions

This Online Digital Health and Informatics education effectively improved undergraduate nursing students’ knowledge and comprehension of the key digital health and informatics topics, nursing informatics attitudes in the self-assessment of nursing informatics competency with high levels of satisfaction. In order to ensure that future education in digital health and informatics for nursing students is in line with the technological advancements in clinical settings, it is necessary to foster collaboration between medical school training and clinical practice. This collaboration should involve the use of clinical examples to illustrate advanced digital health applications and the inclusion of practical exercises on the use of digital health technology in clinical settings.

Peer Review reports

Digital health is defined by the World Health Organization (WHO) as the field of knowledge and practice associated with the development and use of digital technologies to improve health. Developments such as digitally mediated diagnosis and treatment, cloud computing, machine learning, artificial intelligence, block-chain, telehealth, and consumer-facing mobile health applications have enhanced the delivery of care for individuals across the spectrum of health promotion and disease prevention, diagnosis, treatment, and rehabilitation [ 1 , 2 ]. Digital health solutions are also recognized for their benefits in nursing practice, including integrating data records across various databases, providing electronic decision support and resources, and developing digital devices that facilitate remote monitoring and individuals’ positive behavior change [ 3 , 4 , 5 ]. Especially during the coronavirus disease (COVID-19) pandemic, digital health applications have been noted as an innovative health solution that improves continued healthcare accessibility and streamlines public health action to stop the rapid spread of the crisis [ 6 , 7 ].

Governments in the United States, India, Tanzania, Ethiopia, and other countries have developed national digital health strategies, which outline a shared vision for addressing health priorities through the coordinated and strategic use of interoperable digital technologies [ 8 , 9 , 10 ]. As the largest developing country, policymakers and healthcare experts in China have launched the national health strategy ‘Healthy China 2030’ [ 11 ]. This strategy recognizes digital health technology as an essential pillar to enhance disease self-management, as well as improving the accessibility and cost-effectiveness of care in (rural) China- where over 558 million people have access to mobile phones. According to the correspondence from the National Health Commission of China, as of August 2022, more than 1700 internet hospitals have been established nationwide [ 12 ]. In order to promote the appropriate use of digital technologies and therefore help address key health system challenges in general and in China in specific, it is important to enhance individuals’ understanding and use of digitally enabled approaches to care. This will ultimately lead to improved quality of care, better health outcomes and reduced medical costs.

Currently, numerous digital health technologies remain in the pilot stage and have not yet demonstrated their effectiveness or been successfully implemented on a larger scale in a real-world setting. The limited knowledge and skills of healthcare professionals (HCPs) in utilizing new technologies and concerns regarding privacy, and security quality are significant obstacles to the adoption of digital health in clinical practice [ 13 ]. The Global Digital Health Strategy 2020–2025 of WHO emphasizes the importance of incorporating specific actions to ensure that all health professionals and allied workers, at all levels of formal education and informal training, receive education and training on digital health [ 14 ]. Developing high levels of digital health informatics competencies among health professional students will facilitate their understanding of the essential requirements for successful implementation of digital health [ 15 ]. Therefore, there is an urgent need to develop courses on digital health in medical schools to educate future HCPs on integrating digital health technological innovations and preparing them to adapt to future changes in the digital medical system within their workforce.

At present, many medical schools and research institutions worldwide have incorporated the digital health education into their curricula for the next generation of HCPs. For instance, digital health education programs were designed and implemented as mandatory or elective courses for bachelor or master health professional students at the University of Maryland-Baltimore, Vanderbilt University, Duke University, New York University, the University of Pittsburgh [ 16 , 17 ]. These programs cover a range of topics, including an introduction to health informatics, system design, implementation, evaluation, and policy and ethics in digital health.

While there has been an increasing amount of research on digital health education within the medical school curriculum in Western countries, a systematic review has shown that the literature on digital health courses often lacks comprehensive evaluation, and more evaluation and implementation research is recommended in low and middle-income countries [ 17 ]. Also, there is a lack of literature on this topic in the Chinese context. Health professional students in China have expressed a need for digital health knowledge and skills in their medical curriculum [ 18 ].

Nurses, as the largest group of HCPs, play a crucial role in the digital health transformation. It is important to enhance the readiness and education of the nursing workforce in digital health to provide effective, safe, and efficient patient care with the support of existing and emerging digital health technologies. Therefore, to prepare future nurses to meaningfully contribute to the design, development, implementation, and evaluation of digital health technologies in China, the present study aimed to evaluate the impact of an online Digital Health and Informatics Course in China on undergraduate nursing students’ knowledge and comprehension of key digital health and informatics topics, self-assessment of nursing informatics competencies, and satisfaction. Based on the actual experiences of nursing students, our study will also provide recommendations for medical educators, medical universities, and health institutions to improve the design and implementation of digital health education in China and beyond.

Study design and participant

This study employed a one-group, quasi-experimental mixed-methods design with pre- and post-assessments. The study focused on an online Digital Health and Informatics Course for undergraduate nursing students in China. All students who enrolled in the course at our university, a medical university located in Guangzhou, southern China, were invited to participate in the study. To be eligible, students had to agree to participate and successfully complete the six-week course. Students who expressed disinterest or were already engaged in other digital health learning or programs were excluded from the study.

Course details

Development of course.

A multidisciplinary team of experts in digital health, informatics, and the medical field was established at a medical university in Guangzhou, southern China. The team consisted of three nurses, two doctors, two health informatics specialists, and a teacher with extensive experience in designing and conducting medical courses for nursing students. The team held monthly meetings to discuss the development, implementation, and evaluation planning of the course.

The course was developed in three stages. Firstly, a comprehensive list of digital health and informatics areas was generated based on previous education in this field [ 16 , 17 ]. This list was used to define the most relevant topics for nursing students. Secondly, the team of eight experts reviewed the objectives, learning activities, and assessment tools for the course. Based on this review, a proposed course with five core topics was devised, which all eight experts agreed upon. Thirdly, the course procedure was enhanced by incorporating multimedia learning materials such as illustrations, photos, animations, and videos. This was in accordance with the Multimedia Learning Theory [ 19 ]. Through group meetings and discussions, the multidisciplinary team reached a consensus on the final course module and procedure.

Digital health and nursing innovation topics

The course was named as the Digital Health and Informatics course and was held at a medical university in Guangzhou, China, for eleven days in six weeks. Details of the overview and content of the course are shown in additional file 1 . The content of this course focused on five key topics: digital health informatics, nursing informatics, emerging technologies for eHealth solutions, patient data security and privacy, and eHealth. The timetable and focus of each topic are shown in Table  1 .

In the final week of the course, students were assigned group work-based learning activities to present a critical reflection on the following three questions:

Given the recent emergence and certification of health informatics professionals, will there continue to be a role for nurses in informatics within the next decade?

Should there be a specific professional designation for nurses with informatics expertise? What will the role of the Informatics Nurse look like in the future?

In the face of the evolving sophistication of technology, will there still be a need for nurses with informatics expertise?

During the group work, students were encouraged to read materials such as scientific papers and textbooks related to digital health and nursing informatics. Following each group’s presentation, the teachers provided feedback on students’ performance and on the material they were presenting, thus enabling them to review their strengths, areas that needed improvement, their development and learning, and to reconsider their learning processes.

Teaching members

For the Digital Health and Informatics course, teachers were eligible if they had extensive experience in digital health and informatics, software engineering, information management, and knowledge management. They were also eligible if they had previous teaching experience in software engineering and enterprise systems development, or if they had conducted wide-ranging research in the areas of information sharing, healthcare informatics, artificial intelligence, machine learning, and digital health.

In this course, all lectures were delivered by two teachers, all of whom hold a Doctoral degree and have a proven academic or professional background in the fields of software engineering, artificial intelligence, and information systems, or digital health research, nursing, public health, and implementation science. Additionally, both teachers have obtained Teacher Qualification Certificates, which demonstrate that they possess the basic teaching skills necessary to perform educational and teaching activities in higher education. Furthermore, both teachers have in-depth knowledge of the course content, aligning with the course’s subject expertise. Moreover, they have more than three years of teaching experience and were extensively involved in digital health course planning and education administration. As a result, they are capable of delivering engaging online lessons, promoting interactive student online participation, and maintaining open discussions between students and teachers.

Course procedure

The course commenced on July 23, 2022. The students who enrolled in the course were sent a link via email. In order to take part in the study, they were required to provide informed consent and complete the electronic baseline questionnaires. Following each lesson, students were granted access to the course through various modalities, including offline and online access to downloadable lesson videos for offline viewing on their electronic devices. Participants had the flexibility to watch the modules in their preferred order. The course structure for each topic is outlined in Table  1 .

The assessment of the impacts of the course was conducted using a mixed methods approach to evaluate (1) knowledge and comprehension of the key digital health and informatics topics, (2) the self-assessment of nursing informatics competencies, and (3) the students’ satisfaction with the Digital Health and Informatics course. Table  2 summarizes the below-described outcome and outcome measurements.

Research materials

The demographic questionnaire.

The questionnaire was used to collect students’ demographic data, including age, gender, year of bachelor study, and experience with nursing informatics use.

Knowledge and comprehension of key digital health and informatics topics

To evaluate the knowledge and comprehension of key digital health and informatics topics, an online quiz with a total score of 100 points and focus group discussions pre-and post the course were designed.

The quiz consisted of a total of 25 choice questions that were developed by the multidisciplinary team of experts. These questions were considered important learning topics and were based on relevant lecture materials. Before finalizing the quiz, a pilot version was tested by ten nurses who had graduated from the same medical university within one year and had experience with digital health learning. The pilot test aimed to improve the content, length, and understandability of the quiz. The final version of the quiz focused on eliciting students’ knowledge and comprehension of digital health, health informatics, and nursing informatics including definitions, nursing’s early role, and nursing informatics competencies (see additional file 2 ).

In addition to the quiz, all students were invited to participate in focus group discussions pre- and post-course. The focus group topic lists were developed based on examples from similar studies and research team discussions. The focus group discussion questions aimed to assess participants’ knowledge and comprehension on informatics and digital health such as definitions and emerging technologies. The discussion also explored the importance of informatics and digital health as well as the role of nurses in nursing informatics and digital health implementation (See additional file 3 ).

Self-assessment of nursing informatics competencies

All students were invited to participate in an online nursing informatics competency survey pre- and post-course. According to previous literature [ 20 ], nursing informatics competencies include not only computer-related skills, but also the knowledge and attitudes needed by nurses to complete specific informatics tasks. The online survey consisted of two parts (See additional file 4 ).

• Part one provided instructions for completing the survey.

• Part two included a validated Chinese version of the Self-assessment of Nursing Informatics Competencies Scale (SANICS) [ 21 ] developed by Yoon [ 22 ]. The scale consisted of a total of 28 items, covering three domains: computer technology, information technology, and information knowledge. The Cronbach’s alpha of the Chinese version of SANICS was 0.931 [ 21 ]. Five-point Likert-type criteria was applied (1 = not competent; 2 = somewhat competent; 3 = competent; 4 = proficient; 5 = expert), with a higher total score indicating a higher level of nursing informatics competency. The Chinese version of SANICS items were categorized into 5 sub-scales: role of clinical informatics (Factor 1; items 1–5), basic computer knowledge and skills (Factor 2; 6–16), applied computer skills (Factor 3; 17–20), wireless device skills (Factor 4; 21–24), and nursing informatics attitudes (Factor 5; 25–28). The five domains and examples of items are presented in Table  3 .

Satisfaction with the Digital Health and Informatics course

Following the implementation of the course, all students were invited to join an online survey using a performance-focused course evaluation form (See additional file 5 ). The survey aimed to gather feedback on students’ learning experience and obtain specific comments regarding the course. Also, students were invited to take part in focus group discussions on the course evaluation. The focus group discussion questions were as follows:

“What do you like about the course?”

“What do you dislike about the course?”

“Do you have any suggestions on the future improvement of the course?”

Data collection

Quiz and survey.

Prior to the study, participants were provided with information regarding the purpose of the study. They were asked to complete web-based questionnaires in the form of an online quiz, SANICS surveys, and course evaluation forms. The surveys were conducted between June and July 2022. A link containing a password to access the private survey questionnaires was sent to each student’s individual email inbox. Participants were informed that their participation in the study was voluntary and that choosing not to participate would not affect their learning or assessments. They were assured that they could withdraw from the study at any time without any negative consequences or impact on their academic grades. Furthermore, their privacy and confidentiality would be protected, and all participants provided written consent to participate. Participation in the online poll was also voluntary and anonymous.

Focus group discussions

A total of five pre- and post-course focus group discussions were conducted with all students to explore their knowledge and comprehension of key topics in digital health and informatics, as well as their satisfaction with the course. The face-to-face focus group discussions were conducted by one researcher (HS, PhD, female). The interviewer had received training and possessed extensive experience in qualitative research. Each focus group discussion lasted approximately 50–60 min and was recorded with the participants’ consent. The recordings were later transcribed and used as textual data.

Data analysis

For the quantitative data, survey data were exported from SPSS version 23 (IBM, Armonk, NY, USA) for analysis. After data cleaning, frequency descriptive statistics were utilized for categorical variables. Descriptive statistics such as the mean, standard deviation, median, and range of linear variables were calculated, along with frequencies and percentages of categorical variables. We compared the difference of the SANICS scores pre- and post-course using paired t-test analysis. P -values < 0.05 was considered statistically significant.

For the focus group discussion data, transcripts were imported into Atlas.ti for Windows version 7.5.18 (Scientific Software development, Berlin). Qualitative content analysis was performed inductively using the following steps: (1) open coding, (2) categorization, and (3) theming. Rigor was enhanced by repeatedly reading the transcripts, keeping a record of the analytic decision trail, and through crystallization with multiple researchers engaging in discussions of evolving categories and emergent themes. In terms of students’ knowledge and comprehension of key digital health and informatics topics, related quotations were compared to identify the changes in the same themes extracted pre- and post-course. For instance, the theme of emerging digital health technologies was extracted from pre- and post-course focus group discussions. We will compare the differences in relevant quotations, such as whether students mentioned more types of technology after the course.

Additionally, based on the focus group discussion data and responses to two open-ended questions in the course evaluation form provided by students, we analyzed their evaluations and suggestions regarding the course. Data saturation was achieved as being the point at which no new or relevant information could be identified through the iterative, preliminary analysis of the data [ 23 ]. After the first two focus group discussions, a preliminary analysis using the proposed codes was performed, and a data saturation grid [ 23 ] was developed to determine if saturation was reached. The data saturation grid consists of a report of the occurrence of themes and codes (displayed in rows) during each focus group (displayed in columns) in a tabular format. In the grid, saturation is considered reached when the grid column for the current focus group indicates no new information emerged for that particular theme or code. We found that in the fifth focus group discussion, data saturation on all themes and codes was achieved (data saturation table included as additional file 6 ).

Ethics and consent

This study was assessed and approved by The University Ethics Committee of Guangzhou Medical University (Reference Code: L202303012). All methods were carried out per relevant guidelines and regulations. Informed consent was obtained from all participants.

Demographic characteristics of students

A total of 24 undergraduate nursing students were enrolled in the course. All students completed all sessions of this course (attendance rate 100%) and pre- and post-assessments. Most participants (83.33%; n  = 20) were in the 19 to 20-year age category. Also, 22 students (91.7%) were in the first or second year of their bachelor study. Additionally, students’ experience with nursing informatics was limited before launching the digital health and nursing informatics course, with only 41.7% of students having prior experience with nursing informatics system use.

Impact of the Digital Health and Informatics course

Scores of the quiz on knowledge assessment improved from the pre-test [mean pretest score: 78.33 (SD 6.005) to the post-test [mean post-test score: 83.17 (SD 4.86)] upon completion of the course ( P  < 0.001).

Furthermore, when analyzing the data from focus group discussions, three key themes emerged regarding nursing students’ knowledge and comprehension of key digital health and informatics topics before and after the course. Overall, the students acknowledged that the course improved their understanding of informatics and digital health, the benefits of (nursing) informatics in clinical practice, and the role of HCPs in informatics and digital health. For instance, after the course, the theme of ‘Understanding of informatics and digital health’ was formulated based on constructs that emphasized the application of information management and analytical abilities, more guiding principles of nursing informatics and digital health use, and more emerging technologies of digital health compared with pre-course. Also, after the course, students highlighted detailed technologies for improving clinical practice. In addition, students noted the different types of informatics roles held by HCPs working in the field of informatics and the critical roles they play after the course. The main constructs frequently mentioned by students were summarized from the interview transcripts before and after the course, which were translated into English from colloquial Chinese, supporting these findings (Table  4 ).

Scores of students’ nursing informatics attitudes improved significantly after the course. There were no statistically significant changes observed in the scores of students’ competency including the role of clinical informatics, basic computer knowledge and skills, applied computer skills, and wireless device skills (Table  5 ).

Students’ satisfaction with Digital Health and Informatics course

All 24 Students responded to six questions regarding the effects of the digital health and informatics course (Table  6 ). A total of 50% of the students indicated that “I am now somewhat familiar with the concept of (nursing) informatics.” and 41.7% of the students indicated that“I am now really familiar with the concept of (nursing) informatics.” Also, a total of 83.3% of the students indicated that,“The learning made me more sensitive to issues related to (nursing) informatics”.

Furthermore, based on the focus group discussions and responses to two open-ended questions in the course evaluation form, three themes were generated including the pros and cons of the course, and suggestions for the course. Details are presented in Table  7 .

Digital health and informatics education is an unmet need to address the global shortage of health workers by promoting the adoption of digital health technologies among future HCPs. This study analyzed the impacts of an online digital health and informatics course for nursing students in China. Students reported improved knowledge and comprehension of key digital health and informatics topics, nursing informatics attitudes in the measure of self-assessment of nursing informatics competencies, and high satisfaction with the course. Also, qualitative results showed notable advantages of the course, including the provision of a broader understanding of informatics for future careers, opportunities for engaging in group discussion, and case analysis on the use of informatics and digital health in clinical practice. The findings of this study provide recommendations for the design and implementation of incorporating digital health and informatics education into the course for health professional students.

What content of digital health and informatics education should be provided?

Previous research has shown that an individual’s performance expectancy has an impact on their acceptance and use of information technologies in the workplace [ 24 ]. Our study highlights that improving education on the role of HCPs in health information systems, raising awareness of the impact of informatics, and introducing emerging digital health technologies in clinical care can potentially enhance the adoption of digital health technologies. This finding is consistent with previous research [ 25 ].

To ensure that students develop a comprehensive understanding of digital-enabled healthcare, we have designed this course to provide a broad and foundational education in digital health and informatics for undergraduate students. However, we did not observe significant improvements in students’ self-assessment of nursing informatics competencies in the areas of basic computer knowledge and skills, applied computer skills, and wireless device skills. This may be explained by that these domains are more practical aspects of competence in digital health and informatics. Online lectures may not be the most effective approach for developing practical competency, and real-life practice with digital innovation is necessary. Also, nursing students in our study expressed a need for more practice lessons on digital health use. Therefore, we suggest that nursing students should be exposed to specialized digital health innovation use to enhance their digital literacy in clinical decision support and quality improvement in future course development. This could include trainings on handling medical data and applying data in patient care. Also, case analysis should be incorporated to help students understand how technology and data are used in modern health and social care services, such as electronic medical records, telehealth, and mHealth.

What teaching methods and components should be provided in digital health and informatics education?

Through a review and reflection of this online education, we have identified useful components of the course that can be applied to other educational programs. Firstly, our course utilized information communication technologies to enhance the quality, accessibility, and sustainability of education. Consistent with previous research [ 26 , 27 ], the online course offers significant benefits in terms of self-paced, self-directed, and personalized learning. Also, due to the adaptability of an online platform, this course can be easily and flexibly implemented in various settings within medical schools with minimal adjustments. Secondly, students reported that a valuable feature of the course is the group work. In our program, students with different levels of ability and readiness in groups worked together in groups to critically reflect on the role of HCPs in informatics and digital health, promoting interactive group work. Students may lack confidence initially. However, through continuous group cooperation, they were able to develop skills and make progress in the learning and building process. Third, given the distance-learning nature of our course, emphasis is placed on online collaboration tools; both formal and informal synchronous and asynchronous communication tools were used to facilitate communications between instructors, students, and members of student groups (e.g., chat rooms, video-conferencing software). Since each course was conducted online, an interactive class management system can provide students with access to course information, reading assignments, and electronic resources for their final presentation.

How to improve the quality the digital health and informatics education?

Most students are in the first or second year of their bachelor’s studies and have limited experience in the use of computers and wireless devices in clinical practice. Therefore, we recommend that digital health and informatics should be longitudinally integrated into a compulsory course throughout nursing education, with specific learning objectives and content for each year of nursing student education. Previous studies have shown that at the undergraduate level, students should be equipped with the necessary digital skills to practice medicine in a digital-enabled healthcare environment while also assuring the mastery of compassionate care and improving outcomes for patients [ 28 , 29 ]. Some studies have reported that digital health education should be provided earlier in the medical university curriculum such as in the first year, and that digital health-specific practice or clinical innovation use should be trained in the final year of health professional education [ 30 , 31 ]. Additionally, prior studies show that specialized digital skills, such as using digital health for specific clinical tasks in an interdisciplinary environment, should be taught in the advanced years of medical training when HCPs enter residency and train to become specialists [ 32 ]. Therefore, we suggest that future research should use the digital health competency framework, such as the International Medical Informatics Association Recommendations on Medical Informatics Education, to design and tailor education for the undergraduate health professional students.

Furthermore, we highlighted the value and significance of collaboration efforts between medical school training and clinical practice [ 33 ]; using clinical examples to explain more novel digital health applications, such as the application of artificial intelligence or big data in patient-centered care. To ensure that this course is aligned with the technological advances in clinical settings, training to improve digital competencies in students’ clinical practice is necessary. One way to achieve this is by incorporating a practical exercise on the use of digital health technology in the clinical setting, while also considering the need for patient privacy and liability concerns [ 34 ].

Limitations

Nevertheless, several limitations need to be considered. Firstly, the main limitation of the study was that it was a single-arm study. This raises questions about whether the observed improvements in outcomes, such as knowledge, were solely due to the course or if other factors may have influenced the results. For example, students’ previous use of digital health and eHealth literacy levels could have potentially influenced their experience and evaluation of the course. This could have resulted in a bias in their responses towards course evaluation. Additionally, improvements in students’ learning outcomes could be attributed to the test itself, as factors such as participants remembering questions or the questions raising awareness and triggering learning after the pre-test may have influenced the results, independent of our course implementation. Therefore, future course evaluations should consider using a two-arm or Solomon four-group design. Secondly, this was a small study with a sample size of 24 students and may not be generalizable to all health professional students in China or a larger population. Also, study results report the nursing students’ subjectively experienced changes in nursing informatics competence, and no objective measures in this area were conducted. Therefore, self-reported data may be subject to bias, and may not accurately reflect the actual improved competency of the students. Additionally, the measurement of knowledge and comprehension of key digital health and informatics topics must be interpreted with caution since the quiz has not been validated. Furthermore, the duration of the course was only six weeks. The relatively short duration of the course may limit the depth of knowledge and competencies that students can acquire. A longer course with follow-up assessments could provide a more comprehensive understanding of the long-term impacts.

Digital health and informatics education for future healthcare professionals is an urgent need to equip them to adapt to future digital medical system changes in their workforce. This Online Digital Health and Informatics education showed promising results for undergraduate nursing students in their knowledge and comprehension of the key digital health and informatics topics, nursing informatics attitudes in the self-assessment of nursing informatics competency, and satisfaction. To optimize the digital health course effect, future course developers should improve students’ basic knowledge and comprehension of digital health and informatics. Also, to enable the standard design and scale-up of effective digital health and informatics education for nursing students, collaboration between medical school training and clinical practice is needed to enhance students’ practical exercise on the application of digital health technologies in the clinical setting. We suggest that the content and teaching methods of this course may form a mandatory part of digital health education for health professional students and could be expanded to students in other contexts and countries.

Data availability

The datasets used and/or analysed during the current study are available from the corresponding author upon reasonable request.

Abbreviations

World Health Organization

Coronavirus disease

healthcare professionals

Self-assessment of Nursing Informatics Competencies Scale

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Acknowledgements

We would like to express our appreciation to the students for participating in our study and for their valuable responses.

This study is supported by the Guangdong Higher Education Teaching Research and Reform Program of the Department of Education of Guangdong Province (grant numbers: 01-408-2301062XM, 2023) and The Key Discipline Project (Nursing) of Guangzhou Education Bureau (grant numbers: 06-410-2001016, 2022).

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Hongxia Shen and Chong Chen contributed equally to this work.

Authors and Affiliations

School of Nursing, Guangzhou Medical University, 195# Dongfeng West Road, Guangzhou, Guangdong, 510182, China

Hongxia Shen, Chong Chen, Sijing Yan, Minyi Li & Ying Zhou

Department of Public Health and Primary Care, Leiden University Medical Centre, Leiden, Netherlands

Hongxia Shen, Cynthia Hallensleben, Rianne van der Kleij, Huohuo Dai & Niels Chavannes

National eHealth Living Lab, Leiden University Medical Centre, Leiden, Netherlands

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HS, CC, SY, and ZY contributed to the conceptualization, methodology, validation, formal analysis, investigation, resources, writing original draft, reviewing, and editing. CH contributed to methodology, validation, reviewing, and editing. RK, ML HD and NC contributed to conceptualization, methodology, validation, reviewing, and editing.

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Correspondence to Hongxia Shen or Ying Zhou .

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Informed consent was obtained from all participants (all participants are older than 16), which was in the form of online questionnaires. The informed consent form described the purpose and method of data collection and ensured that the data would be kept confidential. The University Ethics Committee of Guangzhou Medical University approved the study (Reference Code: L202303012). All methods were carried out per relevant guidelines and regulations.

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Shen, H., Chen, C., Yan, S. et al. Online digital health and informatics education for undergraduate nursing students in China: impacts and recommendations. BMC Med Educ 24 , 803 (2024). https://doi.org/10.1186/s12909-024-05785-5

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• Volume 14, Issue 7
• Childhood neurodivergent traits, inflammation and chronic disabling fatigue in adolescence: a longitudinal case–control study
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• http://orcid.org/0000-0002-5896-916X Lisa Quadt 1 ,
• Jenny Csecs 2 ,
• Rod Bond 3 ,
• Neil A Harrison 4 ,
• Hugo D Critchley 1 ,
• Kevin A Davies 5 ,
• http://orcid.org/0000-0002-0062-1216 Jessica Eccles 1 , 6
• 1 Department of Clinical Neuroscience , Brighton and Sussex Medical School , Brighton , UK
• 2 Berkshire Healthcare NHS Foundation Trust , Bracknell , Bracknell Forest , UK
• 3 School of Psychology , University of Sussex , Brighton , UK
• 4 Cardiff University Brain Research Imaging Centre , Cardiff University , Cardiff , UK
• 5 Department of Clinical and Experimental Medicine , Brighton and Sussex Medical School , Brighton , UK
• 6 Sussex Partnership NHS Foundation Trust , Worthing , UK
• Correspondence to Dr Lisa Quadt; l.quadt{at}bsms.ac.uk

Objectives To test whether inflammatory processes link the expression of childhood neurodivergent traits to chronic disabling fatigue in adolescence.

Design Longitudinal case–control study.

Setting We analysed data from The Avon Longitudinal Study of Parents and Children (ALSPAC).

Participants 8115 and 8036 children of the ALSPAC cohort at ages 7 and 9 years, respectively, 4563 of whom also completed self-report measures at age 18 years.

Primary and secondary outcome measures We assessed if children scoring above screening threshold for autism/attention deficit hyperactivity disorder (ADHD) at ages 7 and 9 years had increased risk of chronic disabling fatigue at age 18 years, computing ORs and CIs for effects using binary logistic regression. Mediation analyses were conducted to test if an inflammatory marker (interleukin 6 (IL-6)) at age 9 years linked neurodivergent traits to chronic disabling fatigue at age 18 years.

Results Children with neurodivergent traits at ages 7 and 9 years were two times as likely to experience chronic disabling fatigue at age 18 years (likely ADHD OR=2.18 (95% CI=1.33 to 3.56); p=0.002; likely autism OR=1.78 (95% CI=1.17 to 2.72); p=0.004). Levels of IL-6 at age 9 were associated with chronic disabling fatigue at age 18 (OR=1.54 (95% CI=1.13 to 2.11); p=0.006). Inflammation at age 9 years mediated effects of neurodivergent traits on chronic disabling fatigue (indirect effect via IL-6: ADHD b=1.08 (95% CI=1.01 to 1.15); autism b=1.06; (95% CI=1.03 to 1.10)). All effects remained significant when controlling for the presence of depressive symptoms.

Conclusions Our results indicate higher risk of chronic disabling fatigue for children with neurodivergent traits, likely linked to higher levels of inflammation. The implementation of transdiagnostic screening criteria to inform support strategies to counteract risk early in life is recommended.

• adolescents
• developmental neurology & neurodisability

Data availability statement

All data are available on the ALSPAC data dictionary and variable search tool ( http://www.bristol.ac.uk/alspac/researchers/our-data/ ).

This is an open access article distributed in accordance with the Creative Commons Attribution 4.0 Unported (CC BY 4.0) license, which permits others to copy, redistribute, remix, transform and build upon this work for any purpose, provided the original work is properly cited, a link to the licence is given, and indication of whether changes were made. See:  https://creativecommons.org/licenses/by/4.0/ .

https://doi.org/10.1136/bmjopen-2024-084203

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STRENGTHS AND LIMITATIONS OF THIS STUDY

A large, longitudinal data set was used to assess potential mechanisms underlying the association between childhood neurodivergent traits and chronic disabling fatigue.

Sample size was too small for subgroup analysis to detect risk according to sex.

Neither neurodivergent traits nor chronic disabling fatigue was clinically assessed, but based on self-report and parent report.

Introduction

There is an increasing interest in the aetiology and maintenance of chronic fatigue, including experiences of fatigue symptoms associated with medical conditions, and chronic fatigue syndromes such as myalgic encephalomyelitis (ME/CFS). 1 Fatigue has particularly come into focus in the wake of the COVID-19 pandemic and the emergence of Long COVID, where prolonged fatigue is a major symptom in both children 2 and adults. 3 4 However, there is still substantial debate about which risk factors may make certain groups more susceptible to developing chronic fatigue throughout the lifespan.

‘Neurodivergence’ describes neurodevelopmental conditions such as autism and attention deficit hyperactivity disorder (ADHD) and supersedes the traditional, deficit-based view of these conditions. 5 In this article, we align our language with the preferences of the neurodivergent community, including using identity-first language where appropriate and avoiding ableist and pathologising terms. 6–8 The prevalence for autism is estimated at 1% 9 and between 2.7% and 5.4% for ADHD. 10 However, recent reports estimate that at least 10%–15% of the population is neurodivergent. 11 12 Conservative diagnostic criteria perhaps contribute to underdiagnosis of individuals assigned female at birth 13 and ethnic minorities, 14 making accurate prevalence estimates difficult.

Neurodivergent individuals are likely at higher risk of experiencing chronic fatigue. A substantial evidence base indicates that neurodivergence frequently co-occurs with mental and physical health conditions. These include chronic pain (eg, fibromyalgia), 15 conditions related to hereditary connective tissue disorders (eg, Ehlers-Danlos syndrome/hypermobility spectrum disorder), 16 digestive and gut issues, 17 18 frequent dental complaints, 19 and common psychiatric conditions, such as anxiety and depression. 20 21 Increasingly, it is suggested that ADHD and chronic fatigue share transdiagnostic clinical features, such as executive dysfunction in personal, occupational and social domains, 22–24 atypical attention and sleep patterns 25 26 and increased risks for co-occurring health conditions. 27 28 Previous studies have investigated the overlap between ADHD and (chronic) fatigue, with a focus on symptomatic overlap, 29–32 and neurochemical mechanisms. 33 A study comparing patients with ME/CFS, autistic participants, and a comparison group without diagnoses of these conditions, found that ME/CFS patients did not score higher on an autism screening tool than the comparison group. 34 Recent qualitative research may suggest symptomatic overlap between (chronic) fatigue and ‘autistic burnout’, 35 36 and one empirical study found increased rates of ‘central sensitivity syndromes’, including ME/CFS, in autistic adults. 37

Research into the potential co-occurrence of neurodivergence and chronic fatigue has focused hitherto on adult populations, although neurodivergent children are likely also at higher risk. Crucially, there is evidence that children with chronic fatigue present differently to adults, 38 and it is important to differentiate the experience of (chronic) fatigue from fatigue syndromes, such as ME/CFS. One classification criterion for fatigue conditions is the duration of fatigue, ranging from acute fatigue (<1 month), prolonged (>1 month, <6 months) to chronic fatigue (>6 months). 39 ME/CFS, in contrast to acute and prolonged fatigue, has very specific diagnostic criteria, and is characterised by unrefreshing sleep and rest, chronic widespread pain, memory, attentional and cognitive dysfunction. 40 In many countries, a medical diagnosis of ME/CFS requires the presence of postexertional malaise (PEM) as a cardinal feature. 41

Despite its evident detrimental impact on quality of life, prolonged or chronic fatigue as a medical symptom is frequently described as an ‘unexplained’ symptom, 42 and patients regularly report being dismissed about their experience. However, there is robust evidence 43 for a variety of biological mechanisms, including inflammation in the pathobiology of fatigue. 44 Dysregulated immunological and inflammatory processes are likely implicated in the development of fatigue symptomatology, including persisting production of proinflammatory cytokines after viral or bacterial infections, or other stressors. 40 44 In chronic fatigue syndrome, mitochondrial, T cells, B cells and natural killer cells dysfunction and dysregulated circulating cytokines in combination with dysfunctional activation of the hypothalamic–pituitary–adrenal axis may be involved in the onset of chronic fatigue. 45 A recent case–control study with Long COVID patients shows that exercise resulted in attenuated mitochondrial enzyme activity, reduced T-cell response and tissue infiltration in skeletal muscle, strongly indicating that local and systemic metabolic disturbances underlie PEM. 46 Aberrant immune responses and increased inflammation may underlie fatigue in the general population, where increased interleukin 6 (IL-6) is associated with so-called ‘sickness behaviours’. 47 Sickness behaviours are a normal reaction to signals from peripheral inflammatory cytokines, and include fatigue, anhedonia and social withdrawal. 48 The production of the proinflammatory cytokine IL-6 is part of an immediate immune response to homeostatic threats, and its synthesis usually ceases when homeostasis is restored. When IL-6 synthesis is dysregulated and persists, however, fatigue may persist, making IL-6 a target for clinical and interventional research. 49

Both neuroinflammatory and peripheral inflammatory dysfunction may further provide a mechanistic link between neurodivergence and chronic fatigue. Dysregulation of peripheral inflammatory cytokines is documented for autism 50 and ADHD, 51 where higher levels of IL-6 are found in both populations. It is also suggested that neuroinflammation links ADHD with pain disorders. 52 Additionally, increased inflammation mediated by mast cell activation is proposed to play a mechanistic role in the neurodevelopment of autism 53 54 and ADHD. 55 Mast cells are blood cells reacting to immune stressors, often described as the ‘immune gate to the brain’. 56 Mast cell activation syndrome (MCAS) describes a range of mast cell disorders, typically characterised by overactivation of mast cell mediators in response to internal or external triggers. Symptoms range widely from mild allergic reactions to life-threatening anaphylaxis. 57 There is furthermore increasing evidence to suggest a mechanistic and symptomatic overlap between variant connective tissue, MCAS and chronic fatigue. 58 These conditions are over-represented in neurodivergent populations, 16 strengthening a potential role of aberrant inflammatory processes involved in chronic fatigue experienced by neurodivergent individuals.

We aimed to investigate the relationship between increased experiences of chronic fatigue and neurodivergent traits in a longitudinal birth cohort. We hypothesised a neurodevelopmental pathway from childhood neurodivergent (autism, ADHD) traits to experiencing chronic disabling fatigue in adolescence and tested whether increased peripherally circulating inflammatory markers (IL-6) impacted on this relationship. We chose IL-6 as previous studies showed increased levels in both autistic 50 and ADHD populations. 51

Study design and participants

We used data from The Avon Longitudinal Study of Parents and Children (ALSPAC), a birth cohort that records data of 14 541 live births from women in Avon County in southwest England between April 1991 and December 1992. 59 Parents and children regularly completed postal questionnaires about a comprehensive number of aspects of their child’s and their own health and development from birth. Children attended annual assessment clinics from the age of 7 years, during which a series of physiological tests and face-to-face interviews was conducted.

Data from assessments at ages 7, 9 and 18 years were used for this study, as variables of interest were tested at these timepoints ( figure 1 ). At age 7 years, parents and carers of 8115 children filled out the Social and Communication Disorders Checklist (SCDC), 60 of which the Social Cognition Score was used as an indication of autistic traits. At age 9 years, parents or carers of 8063 children completed the Strengths and Difficulties Questionnaire (SDQ), 61 of which we used the Hyperactivity Score to get an estimate of ADHD traits. 5072 of these children also attended a clinic where IL-6 was assessed. At age 18 years, the same participants were asked to complete the Clinical Interview Schedule Revised (CIS-R), 62 4563 respondents provided data.

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Participant Flow and available data at each timepoint. ADHD, attention deficit hyperactivity disorder; ALSPAC, Avon Longitudinal Study of Parents and Children; CIS-R, Clinician Interview Schedule Revised; SCDC, Social and Communication Disorders Checklist; SDQ, Strengths and Difficulties Questionnaire.

Childhood neurodivergent traits at ages 7 and 9 years

Neurodivergent traits were measured at ages 7 and 9 through parent report using the SCDC 60 for autistic traits and the SDQ 61 Hyperactivity subsection for ADHD traits. The SDQ entails five subscales (hyperactivity, conduct problems, emotional symptoms, peer problems and prosocial behaviour), of which we used the hyperactivity subscale as an index of ADHD traits. Scores range between 0 and 40, with higher scores indicating greater difficulties. In the case of missing data at the item level, scores were prorated. The SCDC is a brief, 12-item questionnaire assessing autistic traits. Scores range between 0 and 24, with higher scores indicating higher likelihood of meeting diagnostic criteria for autism. The SCDC and SDQ were completed by parents when children were 7 years and 7 months, and 9 years and 7 months old, respectively.

We calculated binary variables for presence/absence of likely autism and ADHD using the recommended cut-off scores of ≥8 for likely presence of ADHD 63 and ≥9 for likely presence of autism. 64

IL-6 at age 9 years

Blood draws for serum IL-6 concentrations were taken during assessment clinic visits from non-fasting participants. Blood draws were taken either in the morning or early afternoon, depending on whether the child attended a morning or afternoon clinic. We excluded cases that had reported very recent or current infections at the time of the blood draw to avoid confounding by higher inflammation markers.

Chronic disabling fatigue and depression at age 18 years

Chronic disabling fatigue and depression were assessed at age 18 years using the self-administered computerised version of the CIS-R. 62 We included a measure of depression to test for potential confounding effects of depressed mood. Participants were classified as experiencing ‘chronic disabling fatigue’ as defined by Collin et al 65 if they met the following criteria: (1) they had been lacking energy and getting tired during the last month, (2) they responded ‘yes’ to more than two of the following four items: (a) feeling tired or lacking energy for 4 days within the past 7 days; (b) feeling tired of lacking energy for more than 3 hours in total on any day in the past 7 days; (c) feeling so tired or lacking in energy that they had to push themselves to get things done on one or more occasions in the past 7 days; (d) feeling tired or lacking energy when doing things they enjoy in the past 7 days, (3) their fatigue lasted longer than 6 months, (4) their fatigue was not explained by exercise or medication, (5) their fatigue was not alleviated by rest and (6) their fatigue was worse after exercise. 65 We use the term ‘chronic disabling fatigue’ instead of ME/CFS to indicate that this was based on self-report instead of a clinical assessment by a physician following a diagnosis of ME/CFS. 66

Statistical analyses

Statistical analyses were conducted using IBM SPSS Statistics V.26 and MPlus V.8. 67 We tested whether scoring above cut-off for autism and ADHD traits at ages 7 and 9 years predicted subsequent chronic disabling fatigue at age 18 years by using logistic regression to calculate ORs and 95% CIs for chronic disabling fatigue separately for ADHD and autistic traits. We used logistic regression to explore the association between IL-6 at age 9 years and subsequent chronic disabling fatigue at age 18. We repeated these analyses controlling for depression.

As a sensitivity analysis, we repeated these analyses again using continuous SDQ and SCDC scores to test whether we would get similar results.

We also performed two separate mediation analyses 68 with chronic disabling fatigue at 18 years as binary outcome (present/absent), or SCDC or SDQ scores (continuous) at 7 and 9 years as predictors, and levels of IL-6 at 9 years as the potential mediating variable. We repeated mediation analyses to control for CIS-R Depression Score. For the mediation analysis, we used probit regression with full information maximum likelihood (MPlus estimator command ML with Monte Carlo integration), applying bootstrapping (n=2000) with the generation of 95% bias-corrected bootstrap CIs to test inferentially for direct and indirect mediation effects.

We applied full information maximum likelihood estimation, 69 where a likelihood function calculates the relationship between a probability estimate based on observed data from variables in the respective analytical model and different estimate values. Full information maximum likelihood estimation chooses parameter estimates that maximise this likelihood function based on complete cases, thereby providing robust parameter estimates, despite missing data. 70

Patient and public involvement

This research was motivated by ongoing patient and public involvement work, where neurodivergent young people, and parents and caregivers of neurodivergent children and young people often express their concerns about physical and mental health conditions. Chronic fatigue and fatiguing conditions in adolescence are specific concerns that are exacerbated by the COVID-19 pandemic and the emergence of Long COVID. In conversation with patients, parents and caregivers, it was often expressed that postviral or postinflammatory fatigue was experienced but dismissed and underappreciated by healthcare professionals. Two patient representatives commented on this manuscript. Our patient and public involvement members will support the dissemination of our findings among public stakeholders in an accessible manner, and the author team includes neurodivergent individuals.

Frequency of chronic disabling fatigue and neurodivergent traits

Table 1 shows frequency of scoring above threshold for autism and ADHD traits at ages 7 and 9 years, and for chronic disabling fatigue at age 18 years.

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Frequency of neurodivergent traits and chronic disabling fatigue

Risk of chronic disabling fatigue at age 18 years according to neurodivergent traits at ages 7 and 9 years

Children who met criteria for likely autism or ADHD showed higher frequency of chronic disabling fatigue at age 18 years in comparison to children who did not meet criteria ( figure 2 ).

Frequency of chronic disabling fatigue in percent at age 18 years for children with likely neurodivergence (likely autism (A); likely ADHD (B); red bars) and without likely neurodivergence (blue bars). Error bars are 95% CIs.

Children who showed an indication of autism at age 7 years were almost two times as likely (OR=1.78 (95% CI=1.17 to 2.72; p=0.008)) to experience chronic disabling fatigue at age 18 years. Children who scored above threshold for ADHD at age 9 years were two times as likely (OR=2.18 (95% CI=1.33 to 3.56; p=0.002)) to experience chronic disabling fatigue at age 18 years. These effects remained significant when controlling for depression (autism: OR=1.65 (95% CI=1.04 to 2.61; p=0.34); ADHD: OR=1.88 (95% CI=1.09 to 3.22; p=0.022)).

Sensitivity analyses showed that when using continuous SCDC and SDQ scores, differential relationships remained and likelihood of experiencing chronic disabling fatigue at age 18 years increased with higher SCDC (OR=1.06 (95% CI=1.03 to 1.09; p<0.001)) and SDQ (OR=1.08 (95% CI=1.03 to 1.14; p=0.003)). These effects remained significant when controlling for depression (SDQ: OR=1.07 (95% CI=1.02 to 1.14; p=0.013); SCDC: OR=1.05 (95% CI=1.02 to 1.09; p=0.003)).

Association between inflammation at age 9 years and subsequent presence of chronic disabling fatigue at age 18 years

IL-6 levels at age 9 years were significantly associated with a higher likelihood of chronic disabling fatigue at age 18 years (OR=1.54 (95% CI=1.13 to 2.11); p=0.006; figure 3 ). This indicates a 1.5 times higher likelihood of experiencing chronic disabling fatigue at age 18 years per unit increase of IL-6 levels at age 9 years. This remained significant when controlling for depression (OR=1.59 (95% CI=1.34 to 2.22); p=0.006).

Group comparison of participants at age 18 years old who scored above threshold for chronic disabling fatigue (CDF) (CDF; red) and who did not (no CDF; blue). (A) A violin plot displaying the distribution of IL-6 levels at age 9 years old. (B) The mean IL-6 values and SEM in each group at age 9 years old. CDF, chronic disabling fatigue; IL-6, interleukin 6.

Mediation analysis

Both mediation models showed that continuous scores of neurodivergent traits (SCDC at age 7 years/SDQ at age 9 years) and IL-6 at age 9 years were significantly associated with presence of chronic disabling fatigue at age 18 years. This was demonstrated by significant indirect effects of IL-6 on the relationship between autistic traits and chronic disabling fatigue (b=1.06 (95% CI=1.03 to 1.10); figure 4A ), and on the relationship between ADHD traits and chronic disabling fatigue (b=1.08 (95% CI=1.02 to 1.15); figure 4B ). This indicates that per unit increase in IL-6, the odds that children with higher neurodivergent traits at ages seven and 9 years would experience chronic disabling fatigue at age 18 years increased by 1.06 and 1.08.

Two separate mediation analyses showing significant indirect effects of autistic traits at age 7 years (Social and Communication Disorders Checklist scores (A)) and attention deficit hyperactivity disorder traits (Strengths and Difficulties Questionnaire Hyperactivity subscale scores (B)) at age 9 years on chronic disabling fatigue at age 18 through IL-6. ADHD, attention deficit hyperactivity disorder; CDF, chronic disabling fatigue; IL-6, interleukin 6.

Both effects remained significant after controlling for levels of depression at age 18 years (autistic traits: b=1.06 (95% CI=1.02 to 1.10); ADHD traits: b=1.08 (95% CI=1.01 to 1.16)).

Using a large birth cohort, we found a link between neurodivergent traits in childhood and increased frequency of experiencing chronic disabling fatigue in adolescence, mediated by levels of childhood inflammation. We found that children who scored above cut-off on parent-reported autism and ADHD measures at ages 7 and 9 years were approximately two times as likely to meet self-reported criteria for chronic disabling fatigue at age 18 years. Increased inflammation, as indicated by IL-6 levels at age 9 years, provides a potential mechanistic explanation for this link, even when controlling for depression.

Adding to previous research indicating that there is a transdiagnostic overlap between (chronic) fatigue and ADHD, we provide evidence that also extends to autism, where little research has hitherto shown such a relationship. In line with findings that fatigue conditions may be inflammation-related, 47 heightened IL-6 in childhood was found to be a potential explanatory link between childhood neurodivergent traits and chronic disabling fatigue.

There is ample evidence of increased inflammation in neurodivergent children and young people. Most prominently, digestive and gut issues have been associated with increased local and systemic inflammation, 71 but frequent dental issues may also be connected with inflammatory conditions. 72 Additionally, higher biopsychosocial stress in neurodivergent children perhaps accounts for increased levels of inflammation and subsequent experience of chronic disabling fatigue. In the ALSPAC cohort, blood samples from which IL-6 levels were detected were drawn at a clinical appointment. It is possible that this session and the blood draw itself introduced stress to young participants, especially those with higher neurodivergent traits, which may have impacted on IL-6 levels.

Research shows that neurodivergent children experience higher levels of loneliness, 73 74 and are more likely to experience bullying. 75 Neurodivergent children are also more vulnerable to experience pain. 76–78 Different reasons are suggested in the literature, including differences in pain perception, 79 dopaminergic dysregulation, 52 and increased prevalence of hereditary connective tissue disorders, such as (hypermobile) Ehlers-Danlos syndrome. 80 Variant connective tissue is linked to increased pain 16 and a higher risk for psychiatric disorders in adolescents. 81 Neurodivergence and chronic fatigue are conditions with complex individual neurodevelopmental pathways. It is therefore likely that inflammation is not the only mediating or moderating factor that plays into the over-representation of (chronic) fatigue in neurodivergent individuals. Additional mechanistic insights are needed to disentangle the intricacies of this relationship. It is likely that a convergence of exogenous factors in a vulnerable body increases the risk of experiencing chronic fatigue in neurodivergent young people, as evidence from our results suggests.

Strengths and limitations

Although both SDQ and SCDC have good psychometric properties in identifying indications of ADHD and autism, 64 82 it is important to note that they cannot replace clinical evaluations for neurodivergent conditions. Additionally, these were not child-completed questionnaires. Parents’ report on neurodivergence in their children has been shown to be biased depending on race 83 and sex 84 of the child and may thus be a biased resource. Autistic advocates and researchers call for using measurement tools that meaningfully reflect the autistic experience, which may not always align with their psychometric properties. 85 Furthermore, the concept of chronic disabling fatigue was carefully conceptualised in this study, but again cannot replace clinical assessment. Future research can improve robustness by testing associations between clinically evaluated diagnoses.

Although we used a large birth cohort, we did not perform a subgroup analysis to detect risk according to sex, as sample size was too small.

ALSPAC blood sample collection clinics ran both morning and afternoon sessions. As IL-6 exhibits diurnal variation with decreasing levels throughout the day, the collection time may have impacted on IL-6 levels in participant blood samples depending on time of attendance and blood draw.

We found a rather large incidence of chronic disabling fatigue in cohort participants at age 18 years (8%). In contrast, a systematic review and meta-analysis found for ME/CFS ‘an average prevalence of 1.40%±1,57%, with a pooled prevalence of 0.39% and a meta-analysis prevalence of 0.68%’. 86 However, chronic fatigue conditions, including ME/CFS, are likely largely underdiagnosed or misdiagnosed, 87 with one study citing up to 91% of patients being undiagnosed or misdiagnosed. 88 Additionally, our sample was not clinician tested for ME/CFS, perhaps also accounting for a higher number of chronic disabling fatigue.

Our findings call for transdiagnostic screening practices to support health and well-being during development and adolescence. Critically, children who are suspected to be or diagnosed as neurodivergent should routinely be screened for physical and mental health concerns. Earlier integration of brain-body concerns in a holistic framework can facilitate tailored support and improve quality of life of neurodivergent individuals of all ages. We therefore call for timely access to healthcare, extra attention, and early intervention targeting health concerns at critical timepoints for neurodivergent children.

Ethics statements

Patient consent for publication.

Consent obtained from parent(s)/guardian(s).

Ethics approval

Ethical approval for the study was obtained from the ALSPAC ethics and law committee and the local research ethics committees. Informed consent for the use of data collected via questionnaires and clinics was obtained from participants following the recommendations of the ALSPAC ethics and law committee at the time. Children were invited to give assent where appropriate. Study participants have the right to withdraw their consent for elements of the study or from the study entirely at any time. Full details of the ALSPAC consent procedures are available on the study website ( http://www.bristol.ac.uk/alspac/researchers/research-ethics/ ). Initial Approval Reference numbers: Bristol and Weston Health Authority: E1808, Southmead Health Authority: 49/89 and Frenchay Health Authority: 90/8. 7 Year Clinic Approval Reference numbers: United Bristol Healthcare Trust: E4168 ALSPAC Hands on Assessments at Age Seven (30 September 1998), Southmead Health Services: 67/98 Avon Longitudinal Study of Pregnancy and Childhood (ALSPAC)—Hands on Assessments at Age Seven (14 September 1998) and Frenchay Healthcare Trust: 98/52 Avon Longitudinal Study of Pregnancy and Childhood (ALSPAC). Hands on Assessments at Age Seven (8 December 1998). 9 Year Clinic Approval Reference numbers: United Bristol Healthcare Trust: E5018, Southmead (North Bristol Trust): 008/01 and Frenchay (North Bristol Trust): 2001/35 Avon Longitudinal Study of Parents and Children (ALSPAC) Assessments at Age Nine (9 May 2001). 17 Year Clinic Approval Reference numbers: North Somerset & South Bristol Research Ethics Committee: 08/H0106/9.

Acknowledgments

The authors are extremely grateful to all the families who took part in the ALSPAC study, the midwives for their help in recruiting them and the whole ALSPAC team, which includes interviewers, computer and laboratory technicians, clerical workers, research scientists, volunteers, managers, receptionists and nurses. Special thanks go to Dr Monica Bolton and Dr Emma Reinhold, for sharing their expertise and insight with helpful comments on earlier drafts of this manuscript.

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X @BendyBrain

Deceased RB deceased.

Contributors RB advised on data analysis, conducted initial mediation analyses and data interpretation. He approved the initial draft of this manuscript but did not approve the full and final versions of this manuscript. JE conceived, planned and designed this study and obtained data from ALSPAC. LQ conducted all final data analyses. RB, LQ and JE interpreted data. JC drafted an initial version of the manuscript. LQ drafted the final full manuscript. KAD advised on introduction and discussion, and overall reporting. JE, HDC and NAH revised the manuscript. LQ, JC, NAH, KAD, HDC and JE approved the final version. JE acts as guarantor and accepts full responsibility for the work and conduct of the study, had access to the data, and controlled the decision to publish.

Funding The UK Medical Research Council and Wellcome (Grant ref: 217065/Z/19/Z) and the University of Bristol provide core support for ALSPAC. A comprehensive list of grants funding is available on the ALSPAC website ( http://bristol.ac.uk/alspac/external/documents/grant-acknowledgements.pdf ). This research was specifically funded via a fellowship to JE (MRC MR/K002643/1).

Competing interests None declared.

Patient and public involvement Patients and/or the public were involved in the design, or conduct, or reporting, or dissemination plans of this research. Refer to the Methods section for further details.

Provenance and peer review Not commissioned; externally peer reviewed.

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Do you know enough about the case study to pass this true-false-based quiz on the case study? What do you know about the case study? A case study can be understood as an intensive and detailed study about a person, a group of people or a unit focused on generalizing over several units. Here are some questions we have brought to test whether you know about the case study. You will learn more as you attempt each question.

A case study is a research method that examines all of the variables of a situation in great detail.

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Thick description means describing in depth every aspect of a subject.

The data collected in case studies are typically quantitative., the critical instance is a type of case study., using adjectives, adverbs, bold print, and underlining in the description is the most important part of the case study., examining one aspect of a situation in great detail is also a case study., case study research often requires a holistic interpretation., case study research questions generally begin with how or why., case studies are a good choice for the beginning researcher because they are one of the easier types of research., case study reports should be written in an engaging style which takes considerable skill and talent..

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