ARTICLE | doi:10.20944/preprints202009.0645.v2
Online: 18 November 2020 (12:18:02 CET)
In 2015, the World Health Organization substantially revised its guidance for vaccination coverage cluster surveys (revisions were finalized in 2018) and has since developed a set of accompanying resources, including definitions for standardized coverage indicators and software (named the Vaccination Coverage Quality Indicators - VCQI) to calculate them. The current WHO vaccination coverage survey manual was used to design and conduct two nationally representative vaccination coverage surveys in Nigeria – one to assess routine immunization and one to measure post-measles campaign coverage. The primary analysis for both surveys was conducted using VCQI. In this paper, we describe those surveys and highlight some of the analyses that are facilitated by the new resources. In addition to calculating coverage of each vaccine-dose by age group, VCQI analyses provide insight into several indicators of program quality such as crude coverage versus valid doses, vaccination timeliness, missed opportunities for simultaneous vaccination, and, where relevant, vaccination campaign coverage stratified by several parameters, including the number of previous doses received. The VCQI software furnishes several helpful ways to visualize survey results. We show that routine coverage of all vaccines is far below targets in Nigeria and especially low in northeast and northwest zones, which also have highest rates of dropout and missed opportunities for vaccination. Coverage in the 2017 measles campaign was higher and showed less geospatial variation than routine coverage. Nonetheless, substantial improvement in both routine program performance and campaign implementation will be needed to achieve disease control goals.
ARTICLE | doi:10.20944/preprints202007.0702.v1
Online: 29 July 2020 (17:35:57 CEST)
The world is suffering from the Coronavirus pandemic and is undergoing some drastic changes in day to day lives. The survey was conducted to analyze the situation of Pharmacy students in India. What are the types of challenges being faced by them during this lockdown due to the Pandemic COVID-19 and how are they getting adapted to the situations? A cross sectional survey was conducted via snowball sampling technique in which 226 participants submitted their response. The chief issue of concern to students was the change in the study pattern which has made the process much difficult for both the faculties and students. Online examination was also be reported as a point of concern. The normal life that we used to have is not acceptable in today’s scenario, hence, the institutions have to make the students more comfortable and adaptable towards the online studies and make the most out of it.
ARTICLE | doi:10.20944/preprints201908.0170.v1
Online: 15 August 2019 (16:17:46 CEST)
As mental health problems tend to increase during adolescence and is a serious public health issue in the Republic of Kazakhstan. Early detection is necessary and monitoring at the population level can be used to evaluate the progress of national programmes promoting positive well-being. Physical activity (PA) can be protective whereas increased screen time behaviours (STB) can be a risk for low levels of well-being. A national representative sample (n=4,731) of young adolescents aged 11y, 13y, and 15y from the Republic of Kazakhstan took part in the WHO collaborative Health Behaviour in School-aged Children (HBSC) study. Respondents completed the WHO-5 Well-being scale, and items in on PA and STB. Internationally recognised, recommended cut-offs were used for analyses. Two models of binary logistic regressions were performed to examine the associations with PA (Model 1) and PA with STB (Model 2) after stratification by gender and controlling for age, locality and family affluence. Three quarters of young adolescents in the Republic of Kazakhstan have good overall well-being, despite the proportion reduces as adolescents age from 11y to 15y (boys, OR=0.66 CI=0.49-0.80; girls, OR=0.55, CI=0.43-0.71). The odds ratio for positive well-being were more than twice for boys and more than 3.5 for girls who reported daily PA than not being active daily. Spending less time on STB for girls was associated with positive well-being than spending more STB time (OR=1.28, CI=1.04-1.59). Well-being among young adolescents drops dramatically between the ages of 11y and 15y and is higher among rural schools attendees than in urban schools. The recommended amounts of PA can be protective of low well-being for both boys and girls. However, meeting reporting STB recommendations was only protective for girls and not boys. Designing and implementing positive well-being programmes require consideration of locality and amounts of PA and STB
ARTICLE | doi:10.20944/preprints202112.0089.v1
Subject: Biology, Plant Sciences Keywords: Antimicrobial activities; Medicinal plants; Herbal medicines; WHO
Online: 6 December 2021 (15:40:36 CET)
Medicinal plants have antibacterial, antifungal and antiviral activities. More or less all plants have medicinal properties. In this research article, we have selected four economically important plants (three fruit plants and an economically important plant), Malus domestica Borkh., Prunus persica L., Ricinus communis L., and Carica papaya L. found in several areas of Indian state Uttarakhand. Using the methanolic extract of leaves, we have screened those four plants against four human pathogenic bacteria, Escherichia coli, Streptococcus pneumoniae, Staphylococcus aureus and Micrococcus luteus. For our experiment we have screened the methanolic leaf extracts of four plants against the above-mentioned bacteria. Statistical analysis was also performed for validation. Result revealed the said bacteria have potential antibacterial activities. So, these leaves can be used for clinical trial. These plants can also be used for making herbal medicines.
ARTICLE | doi:10.20944/preprints202203.0350.v1
Subject: Biology, Entomology Keywords: insecticide resistance; resistance monitoring; method validation; WHO tube
Online: 25 March 2022 (15:40:56 CET)
Accurately monitoring insecticide resistance in target mosquito populations is important to combating malaria and other vector-borne diseases, and robust methods are key. The “WHO susceptibility bioassay” has been used for +60 years: mosquitoes of known physiological status are exposed to a discriminating concentration of insecticide. Several changes to the test procedures have been made historically which may seem minor but could impact bioassay results. The published test procedures and literature for this method were reviewed for methodological details. Areas where there was room for interpretation in the test procedures or where the test procedures were not being followed were assessed experimentally for impact on bioassay results: covering or uncovering of the tube end during exposure, number of mosquitoes per test unit, and mosquito age. Many publications do not cite the most recent test procedures, methodological details are reported which contradict the test procedures referenced or methodological details are not fully reported. As a result, the precise methodology is unclear. Experimental testing showed that using fewer than the recommended 15-30 mosquitoes per test unit significantly reduced mortality, covering the exposure tube had no effect, and using mosquitoes older than 2-5 days old increased mortality, particularly in the resistant strain. Recommendations are made for better reporting of experimental parameters.
ARTICLE | doi:10.20944/preprints202007.0051.v2
Subject: Social Sciences, Library & Information Science Keywords: COVID-19; WHO; database; systematic review; data quality
Online: 2 August 2020 (17:43:38 CEST)
Introduction: A large number of COVID-19 publications has created a need to collect all research-related material in practical and reliable centralized databases. The aim of this study was to evaluate the functionality and quality of the compiled World Health Organisation COVID-19 database and compare it to Pubmed and Scopus. Methods: Article metadata for COVID-19 articles and articles on 8 specific topics related to COVID-19 was exported from the WHO global research database, Scopus and Pubmed. The analysis was conducted in R to investigate the number and overlapping of the articles between the databases and the missingness of values in the metadata. Results: The WHO database contains the largest number of COVID-19 related articles overall but retrieved the same number of articles on 8 specific topics as Scopus and Pubmed. Despite having the smallest number of exclusive articles overall, the highest number of exclusive articles on specific COVID-19 related topics was retrieved from the Scopus database. Further investigation revealed that PubMed and Scopus have more comprehensive structure than the WHO database, and less missing values in the categories searched by the information retrieval systems. Discussion: This study suggests that the WHO COVID-19 database, even though it is compiled from multiple databases, has a very simple and limited structure, and significant problems with data quality. As a consequence, relying on this database as a source of articles for systematic reviews or bibliometric analyses is undesirable.
REVIEW | doi:10.20944/preprints201811.0178.v1
Subject: Social Sciences, Other Keywords: aircraft noise; annoyance; dose-response; environment; WHO Guidelines
Online: 7 November 2018 (15:21:07 CET)
The new WHO Environmental Noise Guidelines for the European Region have recommendations for limiting noise exposure associated with adverse health effects. The limits are said to be based on a systematic review of existing evidence. This paper gives a systematic assessment of the presented evidence with respect to aircraft noise annoyance and demonstrates that the new guidelines are based on an arbitrary selection of existing studies comprising an imperfect and faulty set of data not representative for the general airport population.
REVIEW | doi:10.20944/preprints202005.0060.v3
Online: 6 July 2021 (11:30:53 CEST)
The greatest pandemic of the century, COVID-19, is an ongoing global public health problem. With a clinically approved treatment available only for those who are acutely ill and are hospitalized, the control of this disease in the general population is still largely dependent on the preventive measures issued by the World Health Organization. Among the general control measures other than immunization with the COVID-19 vaccines, handwashing with soap and water has been emphasized the most because it is cost-effective and easily accessible to the general public. Studies have reported that soaps offer unique chemical properties that can completely destroy enveloped viruses. However, the general public seems to be still uncertain about whether soaps can shield us from a highly contagious disease such as COVID-19. In an attempt to help eliminate the uncertainty, we analyzed the mechanisms underlying the efficacy of soap and its prospect for preventing the spread of COVID-19. In this paper, we provide an overview of the history and characteristics of the SARS-CoV-2 virus, the current global COVID-19 situation, the possible mechanisms of the deactivation of viruses by soaps, and the potential effectiveness of soap in eliminating coronaviruses including SARS-CoV-2.
ARTICLE | doi:10.20944/preprints202004.0078.v1
Subject: Behavioral Sciences, Social Psychology Keywords: COVID-19; R0; WHO; social distancing; H1N1; H2N2; influenza
Online: 7 April 2020 (02:48:13 CEST)
The current outbreak of the novel coronavirus also known as COVID-19 was declared as a public health emergency by the WHO where over a million people have been affected by the disease with over 50000 deaths till date. Social distancing is a method to minimize crowd interactions and prevent the spread of disease within groups of people. This is a common practice which has been carried out over generations to minimize the spread of virus by limiting its reproduction rate (R0) among communities. The article focuses on how social distancing has been used to deal previous pandemics globally and the issues that needs to be addressed to tackle the COVID-19 threat.
COMMUNICATION | doi:10.20944/preprints202007.0159.v1
Subject: Life Sciences, Virology Keywords: COVID-19; herd immunity; pandemic; pathogenesis; SARS-CoV-2; WHO
Online: 8 July 2020 (18:33:41 CEST)
Herd immunity happens when a relatively large proportion of a population becomes infected by an agent, subsequently recovers, and attains immunity against the same agent. That proportion thus indirectly protects the naïve population by preventing the spread of the infection. Herd immunity has been suggested to interrupt and control the COVID-19 pandemic. However, relying on establishing herd immunity can be catastrophic considering the virulence and lethality of SARS-CoV-2. Meanwhile our understanding of the pathogenesis, case-fatality rate, transmission routes, and antiviral therapy for COVID-19 remains limited now. Interrupting or slowing the COVID-19 transmission seems more opportune than vaccination, antiviral therapy, or herd immunity, all of which will take some time to yield. Thus, social distancing, face-masking, and hygiene are the most appropriate immediate countermeasures. Because the social fabrics, economic implications, and local demands of various nations are unique, early relaxation of restrictions may seem hasty particularly when fatality rates are high, or when the healthcare systems could be inadequate or become inundated. Conclusively, avoiding any overwhelmingly risky approach in fighting the pandemic is prudent.
REVIEW | doi:10.20944/preprints202006.0290.v1
Subject: Medicine & Pharmacology, Nursing & Health Studies Keywords: PPE; personal protective equipment; WHO; CDC; healthcare workers; COVID-19
Online: 24 June 2020 (09:13:08 CEST)
Background: The healthcare workers are exposed to dangerous pathogen agents during the outbreak of the new coronavirus COVID-19. To minimize the risk of becoming infected by this virus, healthcare workers need to wear the most appropriate personal protective equipment (PPE). Objective: The objective of this study was to analyze the guidelines that the World Health Organization (WHO) and the Centers for the Disease Control and Prevention (CDC) recommend for the rational use of EPP to protect healthcare workers against the novel coronavirus COVID-19.Methodology: To learn how to effectively protect healthcare workers against the COVID-19, a detailed analysis and comparison of the WHO and CDC guidelines related to the proper use of personal protection equipment (PPE) in different healthcare settings was carried out. Results: The results of this study based on an analysis of PPE recommended by the World Health Organization (WHO) and the Centers for the Disease Control and Prevention (CDC) indicated that the safety and protection of healthcare workers can be maximized if the guidelines suggested by these institutions are followed. In general, the WHO and CDC recommendations based on medical practices are similar, and depending on the healthcare activities and settings where the healthcare workers perform their work, suggest wearing medical/surgical facemasks, respirators, googles and face shields (eye protection), gloves, gowns and aprons. Conclusions: The protection and safety of the healthcare workers can be maximized during the outbreak of COVID-19 by following the WHO and CDC recommendations described in this study. The general guidelines offered by these institutions are similar and based on medical practices.
ARTICLE | doi:10.20944/preprints202103.0646.v1
Subject: Medicine & Pharmacology, Allergology Keywords: WHO-5 Well-being; COVID-19; social distancing; preventive measures; Vietnam
Online: 25 March 2021 (16:35:46 CET)
The COVID-19 pandemic and associated restrictive measures implemented may considerably affect people’s lives. This study aimed to assess the well-being of Vietnamese people after COVID-19 lockdown measures were lifted and life gradually returned to normal. An online survey was organized from 21st to 25th April 2020 among Vietnamese residents aged 18 and over. Besides collecting socio-demographic and COVID-19-related data, the WHO-5 Well-Being Index (scored 0–25) was used to score participants’ well-being. A multivariate logistic regression model was used to determine the predictors of well-being. A total of 1922 responses were analyzed (mean age: 31 years; 30.5% male). Mean well-being score was 17.35±4.97. Determinants of high well-being score (≥13) included older age, eating healthy food, practising physical exercise, working from home, and adhering to the COVID-19 preventive measures. Female participants, persons worried about their relatives’ health, and smokers were more likely to have a low well-being score. In conclusion, after the lockdown measures were lifted, the Vietnamese people continued to follow COVID-19 preventive measures and most of them scored high on the well-being scale. Waiting to achieve large scale COVID-19 vaccine coverage, promoting preventive COVID-19 measures remains important, together with strategies to guarantee the well-being of the Vietnamese people.
REVIEW | doi:10.20944/preprints202208.0194.v1
Subject: Medicine & Pharmacology, Pharmacology & Toxicology Keywords: biosimilar; analytical assessment; animal testing; clinical pharmacology; clinical efficacy; FDA; EMA; MHRA; WHO
Online: 10 August 2022 (05:19:49 CEST)
Scientific, technical and bioinformatics advances have made it possible to establish analytics-based molecular biosimilarity for the approval of biosimilars. If the molecular structure and other product- and process-related attributes are comparable within the limits of testing then a biosimilar candidate would have safe safety and efficacy as its reference products. The current model of animal and human testing becomes redundant since all of these studies have much lower sensitivity and reproducibility in confirming biosimilarity. The recent AI-based protein structure prediction model has confirmed that the 3D structure can be predicted from the amino acid sequence, reducing the need for structural analysis; however, the new test methods based on MS are millions of times more sensitive and accurate. While the regulatory agencies have begun waiving animal testing and, in some cases, clinical efficacy testing, removing clinical pharmacology profiling brings a dramatic paradigm shift, reducing development costs without compromising safety and efficacy. Also shared is a list of 160+ products ready to enter as biosimilars. Major actions from regulatory agencies and developers are required to make this paradigm shift.
REVIEW | doi:10.20944/preprints202107.0367.v1
Subject: Biology, Anatomy & Morphology Keywords: Fever; Beneficial fever; Infections; WHO; Fever Management; Guidelines; Antipyretic; Mortality; Heat Shock; Inflammation; COVID-19; Respiratory diseases; Paracetamol
Online: 16 July 2021 (09:40:35 CEST)
Fever remains an integral part of the acute clinical diseases management, esp. viral, for which effective therapeutics remain desired. However, the presence of often confusing fever reduction recommendations for COVID-19 in the public domain during the pandemic, as late as 28 April 2021, seems to suggest the reduction of any ‘uncomfortable’ fever ranging from 37.8 - 39oC, as opposed to WHO fever reduction guidelines (≥39oC), urgently need attention. The confusion could percolate down into different agencies who look up to these agencies for guidance in framing their own, denying the benefits of fever to populations, and effectively undo whatever successive WHO’s guidelines have achieved in the last two decades. The existence of conflicting guidelines in public domains which are open to interpretations has consequences to public health and the healthcare infrastructure, on implementation. For controlling acute infectious diseases, esp. viral, the fever remains the most important enabler. Historically, our chief obstacles to harnessing the benefits of fever in acute clinical diseases with limited therapeutics had been: a) widespread myths about ‘fevers’ arising from a general misunderstanding of basic facts; b) presence of confusing guidelines by different agencies which are open to alternate interpretation. The article attempts to briefly indicate the benefits of fever in disease resolution, dispel myths, underline vagueness in illustrative national guidelines and the need to align them with evidence-based WHO guidelines, as it has the potential to perpetuate myths/confusion in masses leading to adverse impact on disease management – more morbidity and mortality from diseases including COVID-19.
ARTICLE | doi:10.20944/preprints202206.0192.v1
Subject: Medicine & Pharmacology, General Medical Research Keywords: eCDC; WHO; Sanger sequencing; Omicron variant; minor subvariants; BA.4/BA.5; BA.2; mul-ti-allelic; SNPs; recombinant
Online: 14 June 2022 (04:30:41 CEST)
Large population passages of the SARS-CoV-2 in the past two and a half years have allowed the circulating virus to accumulate an increasing number of mutations in its genome. The most recently emerging Omicron subvariants have the highest number of mutations in the Spike (S) protein gene and these mutations mainly occur in the receptor-binding domain (RBD) and the N-terminal domain (NTD) of the S gene. The eCDC and the WHO recommend partial Sanger sequencing of the SARS-CoV-2 S gene RBD and NTD on the PCR-positive samples in diagnostic laboratories as a practical means of determining the variants of concern to monitor a possible increased transmissibility, increased virulence, or reduced effectiveness of vaccines against them. The author’s diagnostic laboratory has implemented the eCDC/WHO recommendation by sequencing a 398-base segment of the N gene for the definitive detection of SARS-CoV-2 in clinical samples, and sequencing a 445-base segment of the RBD and a 490-509-base segment of the NTD for variant determination. This paper presents 5 selective cases to illustrate the challenges of using Sanger sequencing to diagnose Omicron subvariant when the samples harbor a high level of co-existing minor subvariant sequences with multi-allelic single nucleotide polymorphisms (SNPs) or possible recombinant Omicron subvariants containing a BA.1 NTD and a BA.2 RBD, which can only be detected by using specially designed PCR primers. The current large-scale surveillance programs using next-generation sequencing (NGS) do not face similar problems because NGS focuses on deriving consensus sequence.
REVIEW | doi:10.20944/preprints202011.0445.v1
Subject: Medicine & Pharmacology, Allergology Keywords: Peptide Receptor Radionuclide Therapy; PRRT; 68Ga-labeled somatostatin analogue; 18F-FDG; response assessment; RECIST; SWOG; WHO; neuroendocrine tumors; NET
Online: 17 November 2020 (10:35:21 CET)
The NETTER-1 study has proven peptide receptor radionuclide therapy (PRRT) to be one of the most effective therapeutic options for metastatic neuroendocrine tumors (NETs), improving progression-free survival and overall survival. However, PRRT response assessment is challenging and no consensus on methods and timing has yet been reached among experts in the field. This issue is owing to the suboptimal sensitivity and specificity of clinical biomarkers, limitations of morphological response criteria in slowly growing tumors and necrotic changes after therapy, a lack of standardized parameters and timing of functional imaging, and the heterogeneity of PRRT protocols in the literature. The aim of this article is to review the most relevant current approaches for PRRT efficacy prediction and response assessment criteria in order to provide an overview of suitable tools for safe and efficacious PRRT.
REVIEW | doi:10.20944/preprints201611.0120.v1
Subject: Medicine & Pharmacology, Oncology & Oncogenics Keywords: pNENs; 2010 WHO classification; Ki-67 index; mitotic count; pNEC; tumor differentiation; whole-exome sequence data; everolimus; sunitinib; platinum regimen
Online: 24 November 2016 (10:59:33 CET)
Pancreatic neuroendocrine neoplasms (pNENs) are rare tumors accounting for only 1-2% of all pancreatic tumors. pNENs are pathologically heterogeneous and are categorized into three groups (neuroendocrine tumor: NET G1, NET G2 and neuroendocrine carcinoma: NEC) on the basis of Ki-67 proliferation index and mitotic count according to the 2010 WHO classification of gastroenteropancreatic NENs. NEC in this classification includes both histologically well-differentiated and poorly differentiated subtypes, and modification of the WHO 2010 classification is under discussion based on genetic and clinical data. Genomic analysis has revealed NETs G1/G2 have genetic alterations in chromatin remodeling genes such as MEN1, DAXX and ATRX, whereas NECs have an inactivation of TP53 and RB1, and these data suggest that different treatment approaches would be required for NET G1/G2 and NEC. While there are promising molecular targeted drugs, such as everolimus or sunitinib, for advanced NET G1/G2, treatment stratification based on appropriate predictive and prognostic biomarkers is becoming an important issue. The clinical outcome of NEC is still dismal, and a more detailed understanding of the genetic backround together with preclinical studies to develop new agents, including those already under investigation for SCLC, will be needed to improve the prognosis.
REVIEW | doi:10.20944/preprints201910.0362.v1
Subject: Mathematics & Computer Science, Probability And Statistics Keywords: tuberculosis (TB); human immunodeficiency virus (HIV); Acquired Immune Deficiency Syndrome (AIDS); World Health Organization (WHO); panel data; poisson; negative binomial; regression
Online: 31 October 2019 (04:33:45 CET)
Tuberculosis cause of death worldwide and the leading cause from a single infectious agent, ranking above Human immunodeficiency virus (HIV) and Acquired Immune Deficiency Syndrome (AIDS). The aim of this study is to ascertain the trend of tuberculosis prevalence and the effect of HIV prevalence onl Tuberculosis case in some West African countries from 2000 to 2016 using count panel data regression models. The data used annual HIV and Tuberculosis cases spanning from 2000 to 2016 extracted from online publication of World health Organization (WHO). Panel Poisson regression model and Negative binomial regression model for fixed and random effects were used to analyzed the count data, the result revealed a positive trend in TB cases while increased in HIV cases leads to increase in TB cases in West African countries. Among the competing models used in this study, Panel Negative Binomial Regression Model with fixed effect emerged the best model with log likelihood value of -1336.554. This study recommended that Government and NGOs need more strategies to fight against HIV menace in West Africa as this will in turn reduced TB cases in West Africa.
ARTICLE | doi:10.20944/preprints202207.0397.v1
Subject: Behavioral Sciences, Other Keywords: Familial hypercholesterolemia; Neuropsychological outcomes; Cognition; Health literacy; Quality of Life; Affective ranges; HADS; WHO-QOL BREF; Oman; Famiilial hypercholesterolemia; Neuropsychological outcomes; Cognition; Health Literacy; Affective ranges; HADS; Oman
Online: 26 July 2022 (08:16:04 CEST)
BACKGROUND: Over the past few years, there has been an increasing interest to view the diagnosis of Familial hypercholesterolemia (FH) through the lens of the biopsychosocial model. However, other than a few epidemiological surveys, there is a dearth of studies from emerging economies that have examined FH using the biological, psychological and socio-environmental facets of the aforementioned model. AIM. The three aims of the current study were as follows: (i) to examine the psychosocial status among patients with genetically confirmed FH, (ii) to compare the intellectual capacity and cognitive outcomes with a reference group, and (iii) to examine the relationship between health literacy and cognitive functioning. METHOD: Consecutive FH patients referred to the lipid clinic at a tertiary care center for an expert opinion were recruited into this study, conducted from September 2019 to March 2020. Information regarding psychosocial functioning, health literacy, quality of life, and affective ranges were surveyed. Indices of current reasoning ability (attention and concentration, memory, and executive functioning) were compared with an age-matched reference group. The current hypothesis also explored the impact of FH on health literacy and cognition. RESULT: A total of 70 participants out of 106 (response rate: 66.0%) initially agreed to participate. However, 18 out of 70 dropped out of the study, yielding a final total of 52 FH patients. With 27 (51.9%) males and 25 (48.1%) females, the mean participant age stood at 37.2 years (SD=9.2), ranging from 21 to 52 years of age. In the psychosocial data, thirty-two percent (n=17) of them had anxiety (HADS≥ 8), and twenty-five percent (n=13) had depressive symptoms (HADS≥ 8). The performance of the FH patients was significantly impaired compared to the control group on the indices of current reasoning ability and all domains of cognitive functioning. In univariate analysis conducted to compare cognitive functioning with health literacy status, only indices of attention and concentration emerged as being significant. CONCLUSION: To date, there are only a few studies employing the biopsychosocial paradigm to investigate the FH population. The current study indicates that the FH population is marked by an impediment in almost all of the core features that are characteristically assessed by the biopsychosocial approach.