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Work health, and well-being, related articles, how covid-19 has changed the standards of worker safety and health — and how organizations can adapt, it’s not just personal: the economic value of preventing bullying in the workplace, a healthy workplace starts in bed, the changing face of worker safety, health, and well-being in a post-pandemic future.

by Katherine J. Igoe

It’s not a surprise: the COVID-19 pandemic has changed worker health and safety in permanent ways. From the rise of remote work and manufacturing automation to the effects of burnout and unsafe working environments, we experience work differently. For workers who can do their jobs remotely, they’ve still been able to maintain a modicum of security during the pandemic. For others—those who have to work in person, those undertaking arduous physical labor, those who don’t have a safe workplace—it has increased the precarity of their work life. 

If there’s one positive, though, the pandemic has “brought well-being to the forefront of the conversation,” says Jack Dennerlein , PhD, adjunct professor of ergonomics and safety in the Department of Environmental Health and co-director of Work Health and Well-being: Achieving Worker Health at the Harvard T.H. Chan School of Public Health. “Now all of a sudden people realize the impact work has on mental health and other aspects of well-being, through impacts like reliance on childcare and disparities in work. The conversation has changed.” 

Thinking ahead to the future of work, both now with the threat of potential new variants and in the future post-COVID, the response in both the public and private sectors will need to be more robust, according to a recent The Lancet article titled “ Work and Worker Health in the Post-Pandemic World: A Public Health Perspective ,” authored by Dennerlein and other experts in the field. 

“Some of the support systems that we had were blown up during the pandemic,” explains Dennerlein. “When you think about 40 percent of the workforce working remotely in the future, it’s going to have deep impacts on communities, cities, real estate prices, urban planning, and transportation.” Like it or not, the future of worker health and safety will mean a broader, more strategic approach. 

Understanding Worker Health and Safety in 2022

Rapidly changing working conditions, accelerated by the pandemic, will have significant—and not yet fully known—impacts on workers. The first, and most obvious, is worker stress and burnout. The millions of workers who have left their jobs (a.k.a. The Great Resignation or The Great Reshuffle) speak to the long-term exhaustion workers face, particularly in health care but extending to the vast majority of industries.

Technology is another aspect, with AI, machine learning, holographic imaging, and the Internet of Things bringing the potential for rapid workplace innovation—but also job obsolescence and the need for new skill sets. “It’s already impacting people,” says Nicolaas Pronk , adjunct professor of social and behavioral sciences, president of the HealthPartners Institute, chief science officer at HealthPartners, Inc., and co-director of Work Health and Well-being: Achieving Worker Health . “If you look at Uber, for example, these platforms use AI to decide which driver gets what ride, deciphering workloads and things like that. We have no clue how that impacts worker well-being.” 

Another important aspect is the prevalence of working from home, which some organizations have embraced—or at least accepted a hybrid work model. However, this can also lead to worker isolation and sedentariness. “Based on our experience with COVID-19, we know that physical inactivity is a huge factor in severe outcomes, hospitalizations, and death,” says Pronk. “So is obesity. These challenges, which were tough enough before, still need to be addressed. We can start talking about work arrangements, the redesign of work, the workplace, and the workforce. But let’s not forget the foundational stuff, too.” 

Taking a Holistic View of Work and Worker Health

During the pandemic, the overall response has been patchwork, with some local governments, businesses, educational programs, public health experts, and health care systems responding faster and more effectively than others. Now, in a time of uncertainty, that response has been even more varied—with debate over vaccine mandates, organizations differing over whether and how in-person interaction should take place, and rapidly changing regulations. This has often increased workers’ stress levels.   

Referencing the Biden presidential administration’s Build Back Better initiative, Dennerlein notes that there’s now a stronger understanding of the interconnectedness between systems, particularly how they should work together to provide more effective support. In essence, he says, “what are all the support systems that we’ve built into our economy, communities, and governments that help a single business have a healthy workforce and a healthy business in and of itself? And how can we do that more at a systems level? How do we make sure that vital conditions for thriving communities are addressed?” 

Partnering across sectors is essential for post-pandemic worker health and safety, explains Pronk. And he’s not simply referring to the immediate needs brought on by the pandemic, but other changes necessitating fast and decisive action.

“We need to start thinking about the future to address disruptions—they can’t be fixed by one sector itself. It’s a collective, and we’re going to need to work as a collective. This includes non-pandemic issues like climate change: respecting biodiversity, preventing habitat destruction. It literally has an impact on our workforce. We need to think about infrastructure, capacity, and structural changes.”

“What are all the support systems that we’ve built into our economy, communities, and governments that help a single business have a healthy workforce and a healthy business in and of itself?”

How to Begin Improving Worker Health and Safety Within an Organization

For those with leadership positions, in health care or otherwise, this cross-sector collaboration is an important aspect of worker health and safety—and something that is covered in Work Health and Well-being: Achieving Worker Health . But even before that, it means looking at the workplace from within one’s own organization. Critically, this is not the same thing as telling workers to do better or otherwise putting the onus on them to improve. 

“You need to start addressing the conditions of work, the environment in which people work,” says Dennerlein. “And, in doing that, the business itself will actually create resiliency.” The course, he says, addresses this notion of organizational resiliency—how that system responds to rapid changes and passes that capacity to adapt, grow, and evolve onto its workers. Focusing on initiatives that create societal benefit while working to generate economic value is challenging but critical.

“In terms of the Total Worker Health ® approach within a company, this could mean: what happens when a new technology comes along? How do you integrate it with your workers? You’ve got a new pandemic and new regulations: how do you make sure that you’re engaging the workers and workforce to positively impact them? How do you need to adapt and be resilient so that you can stay productive and continue working?” adds Dennerlein.

“We want people to thrive in work.”

Harvard T.H. Chan School of Public Health offers Work Health and Well-being: Achieving Worker Health , an online program teaching integrated employee health strategies.

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• Review Article
• Published: 18 November 2019

A review and critique of academic lab safety research

• A. Dana Ménard   ORCID: orcid.org/0000-0002-3503-5559 1 &
• John F. Trant   ORCID: orcid.org/0000-0002-4780-4968 2  

Nature Chemistry volume  12 ,  pages 17–25 ( 2020 ) Cite this article

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Over the past ten years, there have been several high-profile accidents in academic laboratories around the world, resulting in significant injuries and fatalities. The aftermath of these incidents is often characterized by calls for reflection and re-examination of the academic discipline’s approach to safety research and policy. However, the study of academic lab safety is still underdeveloped and necessary data about changes in safety attitudes and behaviours has not been gathered. This Review article critically examines the state of academic chemical safety research from a multifactorial stance, including research on the occurrence of lab accidents, contributors to lab accidents, the state of safety training research and the cultural barriers to conducting safety research and implementing safer lab practices. The Review concludes by delineating research questions that must be addressed to minimize future serious academic laboratory incidents as well as stressing the need for committed leadership from our research institutions.

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Acknowledgements

ADM and JFT would like to thank the University of Windsor for salary support for the preparation of this work. We would also like to thank C. Houser, K. Soucie, M. Bondy, J. Hayward and D. Cavallo-Medved for their comments on earlier drafts of this paper.

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The investigation report prepared by California’s Division of Occupational Safety & Health relating to the laboratory accident at UCLA in 2008 that led to the death of Sheharbano Sangji.

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Ménard, A.D., Trant, J.F. A review and critique of academic lab safety research. Nat. Chem. 12 , 17–25 (2020). https://doi.org/10.1038/s41557-019-0375-x

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• Systematic Review
• Open access
• Published: 06 May 2024

Efficacy, immunogenicity and safety of respiratory syncytial virus prefusion F vaccine: systematic review and meta-analysis

• Yi Pang 1   na1 ,
• Haishan Lu 2 , 3   na1 ,
• Demin Cao 2 , 3 ,
• Xiaoying Zhu 2 , 3 ,
• Qinqin Long 2 , 3 ,
• Fengqin Tian 2 , 3 ,
• Xidai Long 2 , 3 &
• Yulei Li 2 , 3  

BMC Public Health volume  24 , Article number:  1244 ( 2024 ) Cite this article

265 Accesses

Metrics details

A notable research gap exists in the systematic review and meta-analysis concerning the efficacy, immunogenicity, and safety of the respiratory syncytial virus (RSV) prefusion F vaccine.

We conducted a comprehensive search across PubMed, Embase, the Cochrane Central Register of Controlled Trials, and ClinicalTrials.gov to retrieve articles related to the efficacy, immunogenicity, and safety of RSV prefusion F vaccines, published through September 8, 2023. We adhered to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines.

A total of 22 randomized controlled trials involving 78,990 participants were included in this systematic review and meta-analysis. The RSV prefusion F vaccine exhibited a vaccine effectiveness of 68% (95% CI: 59–75%) against RSV-associated acute respiratory illness, 70% (95% CI: 60–77%) against medically attended RSV-associated lower respiratory tract illness, and 87% (95% CI: 71–94%) against medically attended severe RSV-associated lower respiratory tract illness. Common reported local adverse reactions following RSV prefusion F vaccination include pain, redness, and swelling at the injection site, and systemic reactions such as fatigue, headache, myalgia, arthralgia, nausea, and chills.

Conclusions

Our meta-analysis suggests that vaccines using the RSV prefusion F protein as antigen exhibit appears broadly acceptable efficacy, immunogenicity, and safety in the population. In particular, it provides high protective efficiency against severe RSV-associated lower respiratory tract disease.

Peer Review reports

Introduction

Respiratory syncytial virus (RSV), discovered in 1956, is a negative-sense single-stranded RNA virus belonging to the Pneumonaviridae family. RSV is highly contagious and represents a major burden of respiratory disease worldwide, causing severe and even fatal respiratory infections and bronchiolitis, especially in the elderly (≥ 65 years), young children (< 5 years), and those with underlying chronic diseases (e.g., pulmonary and circulatory diseases) [ 1 ]. In 2019, globally, there were 33 million events of RSV-associated acute lower respiratory tract infection (uncertainty range, 2.54 to 446 million) and 1.01 million total RSV-attributable deaths (84 500 to 125 200) in young children [ 2 ].

There has been a long road with multiple obstacles to developing a safe and effective RSV vaccine. Earlier vaccines provided insufficient protection as they used the post-F conformation as the vaccine antigen. This is because multiple unique antigenic sites are exposed on the surface of the F protein before RSV fuses with the host cell membrane. Following fusion, the F protein adopts a very different confirmation in which several antigenic sites are no longer exposed [ 3 ]. Thus, the stabilization of the pre-F conformation has made it possible to develop effective subunit vaccines [ 4 ]. On May 3, 2023, the U.S. Food and Drug Administration (FDA) approved the world’s first RSV vaccine (developed by GSK) and on May 31, 2023, the Pfizer vaccine, both for adults older than 60 years of age. Both vaccines use a prefusion stable variant of the F protein. RSV prefusion F vaccine has become a hot spot in the research of vaccines against RSV. A large number of clinical studies have investigated its protective efficacy. However, to date, no systematic reviews have been performed on the efficacy, immunogenicity and safety of RSV prefusion F vaccine. In this review, we compared the protective efficacy, antibody titer levels, and adverse reaction profiles of different RSV prefusion F vaccines between immunized individuals and controls.

This systematic review adheres to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines [ 5 ].

Search strategy

In September 2023, in accordance with the study protocol, we conducted searches across several databases, including Medline via PubMed, Embase, Cochrane Central Register of Controlled Trials (CENTRAL), and ClinicalTrials.gov, to identify articles published up to September 8, 2023. The following MeSH (Medical Subject Heading) terms and search terms were used: (“Respiratory Syncytial Viruses or RSV”) AND (“vaccine or vaccination or efficacy or adverse event”).

Eligibility criteria

The inclusion criteria included: (1) individual study populations being at least twenty cases; (2) the use of prefusion F protein as an immunogen is explicitly stated; (3) clinical trials in human subjects have been published. No language restrictions were imposed on the publications. To enhance the validity of the data, we excluded non-peer-reviewed articles from preprint databases.

Study selection

In this review, we employed a two-stage approach for screening, initially assessing titles and abstracts followed by full-text articles. Two researchers independently reviewed each title, abstract, and full text, with any discrepancies resolved through consensus with a third researcher. The efficacy of the vaccines were assessed on three endpoints. First, the efficacy of the vaccine in preventing RSV-associated acute respiratory illness which was defined as the ability of the vaccine to prevent RT-PCR-confirmed RSV infection within seven days of acute respiratory illness symptom onset. Second, the efficacy of the vaccine in preventing medically attended RSV-associated lower respiratory tract illness which was defined as at least two symptoms or signs of acute respiratory infection lasting at least 24 h (cough, abnormal breathing, fever, lethargy, or any other respiratory symptom of concern). Third, the efficacy of the vaccine in preventing medically attended severe RSV-associated lower respiratory tract illness which was defined as tachypnea (respiratory rate ≥ 70 breaths per minute in infants younger than two months [60 days] of age or ≥ 60 breaths per minute in those between two months and 12 months of age); SpO2 < 93% while the infant was breathing ambient air; use of oxygen delivered through a high-flow nasal cannula or mechanical ventilation; admission to an intensive care unit for more than 4 h; and unresponsiveness or unconsciousness. The efficacy of the RSV vaccine was based on assessing its efficacy during the first RSV season (about 6 months) after vaccination. All the efficacy endpoints were considered if they occurred at least seven days after the full regimen of the vaccine.

Data extraction

Two researchers extracted data using a predefined extraction form. Subsequently, all key extracted data underwent review and quality checking by the same two researchers at the conclusion of the data extraction phase. Data on study characteristics encompassed information regarding the setting, primary and secondary outcomes, study design, sample size, and exclusion and inclusion criteria. Participant data included details such as sex, age, and relevant medical history, including disease and treatment history. Intervention-related data consisted of the vaccine type and brand, dosing schedule, the number of participants receiving each type and brand of vaccine, and the median or mean interval between doses. Data pertaining to immunogenicity results included details such as the assay type, the specific antibody measured, T cell response, the method of measurement, intervals of sample collection, and the number of measurements conducted.

Risk of bias assessment

Two investigators independently evaluated the risk of bias in the included studies based on critical criteria, including random sequence generation, allocation concealment, blinding of participants, personnel, and outcomes, incomplete outcome data, selective outcome reporting, and other potential sources of bias, following the methods recommended by The Cochrane Collaboration. The risk of bias graph was generated using Revman 5.4 software. The following judgments were used: low risk, high risk, or unclear. Authors resolved disagreements by consensus and further article review if necessary.

Data analysis

We used RevMan 5.4 statistical software to pool dichotomous outcomes, with the risk ratio (RR) and its 95% confidence interval (CI) as the effect measures. RR < 1 implies a lower risk in the vaccinated group compared to the control group, and P  < 0.05 indicates that this difference is statistically significant. The I 2 statistic was used to estimate the level of heterogeneity, and significant heterogeneity was considered when the I 2 value was > 50%. Vaccine efficacy was calculated using the fixed effects RR. This study applied the accepted statistical vaccine efficacy formula, (1 − RR) ×100, for calculating the pooled vaccine efficacy from the pooled RR. We conducted visual examinations of funnel plots and utilized Egger’s test to assess potential publication bias. Additionally, we employed the trim-and-fill analysis to evaluate the effect of publication bias on the pooled effect size estimates. Influence analysis, which constitutes a form of sensitivity analysis, was performed to identify the impact of individual studies on the combined estimates.

Study selection and study characteristics

A total of 10,554 records were initially retrieved from the database. After screening titles and abstracts, we evaluated 298 full texts of potentially eligible reports; a total of 22 articles were included, involving 78,990 participants (Fig.  1 ) [ 6 , 7 , 8 , 9 , 10 , 11 , 12 , 13 , 14 , 15 , 16 , 17 , 18 , 19 , 20 , 21 , 22 , 23 , 24 , 25 , 26 , 27 ]. Of the 22 eligible studies, eight (36%) studies were analyzed to evaluate the efficacy of RSV prefusion F vaccines, 20 (91%) studies were analyzed to evaluate immunogenicity, and 22 (100%) studies were analyzed to evaluate safety (Table  1 ). The included studies reported data for four vaccine types: 15 (68%) for subunit vaccines, five (23%) for adenovirus vaccines, one (4%) for mixed adenovirus and subunit vaccines, and one (4%) for mRNA vaccines. The 22 included studies involved diverse populations, with 10 involving older adults over 60 years of age, 4 involving pregnant women, 3 involving non-pregnant women, and 7 involving healthy adults. The included studies involved more than 20 countries or regions, with 11 (50%) studies being multinational, six (27%) studies from Spain, followed by two (9%) studies from Australia, and one each from Japan, Canada, and the United Kingdom. 12 (55%) of the eligible studies were observer-blinded and 10 (45%) were double-blinded.

Flowchart of study selection

Risk of bias assessment of included studies

Twenty-two studies used Cochrane collaboration tools for independent risk of bias assessment, only two studies had high risk in blinding of outcome assessment, and most studies were low risk in all evaluated domains (Fig.  2 ). Overall, all of these included studies had a low risk of bias, with blinding and other biases in outcome assessment being the main risk factors.

Risk of bias graph: review authors’ judgements about each risk of bias item presented as percentages across all included studies

Efficacy of RSV prefusion vaccine

Six (27%) studies were included to evaluate the efficacy of RSV prefusion vaccine in the prevention of RSV-associated acute respiratory illness. Data from 31,645 vaccinated patients compared with 31,672 controls showed a significant pooled risk reduction in the vaccinated group, with a RR of 0.32 (95% CI: 0.25 to 0.41, I 2  = 1%) and an overall vaccine efficacy of 68% (95% CI: 59–75%) (Fig.  3 ). A total of seven (32%) studies assessing the efficacy of vaccination against medically attended RSV-associated lower respiratory tract illness with data from 35,521 vaccinated versus 35,243 controls showed similarly significant pooled risk reductions in vaccinated groups, with a RR of 0.30 (RR 0.30, 95% CI: 0.23 to 0.40, I 2  = 22%). Three (14%) studies reported the lowest RR (RR 0.13, 95% CI: 0.06 to 0.29, I 2  = 0%) and minimal heterogeneity in severe RSV-associated lower respiratory tract illness requiring medical attention in the group that received the RSV prefusion F vaccines, with an overall vaccine efficacy of 87% (95% CI: 71–94%). When sensitivity analyses were performed, the heterogeneity of the pooled effects of the results did not change substantially after retaining only subunit vaccines, indicating that our results are robust and reliable.

Vaccine efficacy compared with placebo calculated using the Mantel–Haenszel fixed effects model

Immunogenicity of RSV prefusion vaccine

Following the inclusion criteria, 20 studies (91%) on the immunogenicity of RSV prefusion F vaccines were included in this systematic review article (Table  2 ). There was a significant increase in neutralizing antibody titers against RSV-A in all studies, with a maximum increase of more than 20-fold from baseline. The neutralizing antibody titer against RSV-B was also significantly increased at about one month after immunization, with an increase of more than 1.4-fold compared with baseline. Seven studies examined T cell responses after vaccine immunization simultaneously, and the results showed that mixed adenovirus and subunit vaccine produced the strongest cellular immune responses, with up to 13-fold increase in interferon-γ secretion compared with baseline.

Safety of RSV prefusion vaccine

The safety profiles of 22 studies were reviewed, and adverse effects of RSV prefusion F vaccination included local reactions such as pain, redness, and swelling at the vaccination site and systemic reactions such as fatigue, headache, Myalgia, joint pain, nausea, and chills (Table  3 ). The subunit vaccine had the lowest risk of local and systemic adverse reactions, with RR of 2.79 (95% CI: 1.47 to 6.00, I 2  = 77%) and 1.24 (95% CI: 0.95 to 1.63, I 2  = 74%), respectively, and the risk of serious adverse events (grade ≥ 3) was also the lowest (RR 2.11, 95% CI: 1.41 to 3.15, I 2  = 25%) (Fig.  4 ; Table  3 ). Redness was the predominant local reaction observed among recipients of the subunit vaccine (RR 4.77, 95% CI: 3.08 to 7.38, I 2  = 41%). Conversely, pain at the injection site was the most common local symptom in the mRNA vaccine (RR 40.63, 95% CI: 5.85 to 282.44). Myalgia (RR 3.96, 95% CI: 2.35 to 6.66, I 2  = 29%), nausea (RR 3.74, 95% CI: 0.83 to 16.9, I 2  = 75%) and chill (RR 7.37, 95% CI: 4.20 to 12.94, I 2  = 0%) were the most common symptoms reported in recipients of adenovirus vaccine. Of note, the mRNA vaccine exhibited the highest risk of adverse effects graded as 3 or higher (RR 20.79, 95% CI: 1.30 to 333.14). No RSV prefusion F vaccine-related deaths were recorded in these studies.

Incidence of grade ≥ 3 adverse events among the vaccination versus the control group

In this systematic review and meta-analysis of 22 studies, we explore for the first time the efficacy, immunogenicity, and safety of RSV prefusion F vaccine. We found that administration of the RSV prefusion F vaccine significantly reduced the risk of RSV-associated acute respiratory illness, particularly the risk of severe cases of RSV-associated lower respiratory tract illness requiring medical attention. Previous studies have found that vaccines using the fused RSV F protein as antigen, although immunogenic, do not prevent RSV-associated acute respiratory illness in the elderly, and there is no clinically identifiable patient population that may benefit from this vaccine [ 28 ]. The failure of these clinical studies has led to intensive investigation of the immune mechanism of RSV. Valuable experience has been accumulated for the development of safe and effective vaccines targeting the F prefusion protein of RSV. In eight studies involving the evaluation of vaccine efficacy, subunit vaccines appeared to provide better protection than adenovirus vaccines, but due to the limited number of studies of the two vaccines included in this study, further research remains imperative.

This study provides a comprehensive assessment of the available literature on RSV prefusion F vaccines. We found that existing subunit vaccines, adenovirus vaccines, mixed subunit and adenovirus vaccines, and mRNA vaccines were able to generate significant immune responses against RSV in vaccine recipients. The titers of neutralizing antibodies against RSV-A and RSV-B and RSV-specific ligation antibodies were significantly different among different vaccine types due to the differences in immunogenicity composition, whether they contained adjuvants or not, immunization dose, immunization times, and detection time. In our study, five studies used the ELISPOT assay to measure T-cell immune responses and showed that subunit vaccines elicited weaker T-cell responses than adenovirus vaccines, mixed subunit and adenovirus vaccines, and mRNA vaccines, which is consistent with the results of a large number of studies of COVID-19 vaccines [ 29 , 30 ].

Local adverse reactions after vaccination are more common than systemic adverse reactions. For different vaccine types, subunit vaccines are significantly safer and have lower incidence of local and systemic adverse reactions. Consistent with our results, the mRNA vaccine was associated with the highest incidence of adverse reactions except for a few [ 31 ]. In addition, mRNA vaccines have a higher association with serious adverse effects than other vaccine types [ 32 ]. Myalgia, nausea, and chills were the most common symptoms reported by adenovirus vaccine recipients, findings that were also similar to those previously reported for influenza and COVID-19 vaccines [ 30 ]. In theory, these differences could be attributed to differences in the strength of the immune response to the different vaccines [ 33 , 34 ], as confirmed by the efficacy and immunization results of this review.

In addition, there is concern about whether RSV vaccination can cause a potentially risky rare neurologic disorder (Guillain-Barre syndrome). While GBS is considered uncommon, it remains a significant subject of discussion in the context of vaccination. Previous research on influenza vaccination has reported an eightfold rise in the risk of GBS [ 35 ]. Similarly, investigations into COVID-19 vaccines have indicated diverse clinical associations between COVID-19 vaccination and GBS [ 36 , 37 ]. It is noteworthy that, reassuringly, there is currently no observed elevated risk of GBS associated with RSV vaccination.

This study has several limitations. First, current studies of RSV vaccine protection have been based on assessments of effectiveness during the first RSV season after vaccination (approximately 6 months). There were insufficient data to evaluate the duration of efficacy and immune effects after vaccination, and whether the vaccines result in long-term adverse events, thus necessitating long-term surveillance and study for the population. Second, the study included four vaccine types, but there was considerable variation in the number of studies across vaccine types. To eliminate this effect, we performed a subgroup analysis.

In conclusion, our meta-analysis suggests that vaccines using the RSV prefusion F protein as antigen exhibit favorable efficacy, immunogenicity, and safety in the population. In particular, it provides high protective efficiency against severe RSV-associated lower respiratory tract disease.

Data availability

The original contributions presented in the study are included in the article/supplementary material. Further inquiries can be directed to the corresponding author.

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Acknowledgements

We also thanks for the support of Construction of Key Clinical Specialties in Guangxi (Guiweiyifa [2022]-NO.21) and the Key Laboratory of Molecular Pathology of Guangxi.

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Yi Pang and Haishan Lu contributed equally to this work.

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Youjiang Medical University for Nationalities, Baise, China

Clinicopathological Diagnosis & Research Center, The Affiliated Hospital of Youjiang Medical University for Nationalities, Baise, China

Haishan Lu, Demin Cao, Xiaoying Zhu, Qinqin Long, Fengqin Tian, Xidai Long & Yulei Li

Key Laboratory of Tumor Molecular Pathology of Guangxi Higher Education Institutes, Baise, China

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Y.P. and H.L. analyzed the data, and drafted and revised the manuscript. X.Z., D.C., Q.L. and F.T. retrieved and collected the data. X.L. and Y.L. supervised the study and approved the final manuscript. All authors have agreed to the published version of the manuscript. All authors read and approved the final manuscript.

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Pang, Y., Lu, H., Cao, D. et al. Efficacy, immunogenicity and safety of respiratory syncytial virus prefusion F vaccine: systematic review and meta-analysis. BMC Public Health 24 , 1244 (2024). https://doi.org/10.1186/s12889-024-18748-8

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ORIGINAL RESEARCH article

The influence of water safety knowledge on adolescents’ drowning risk behaviors: a framework of risk-protect integrated and kap theory.

• 1 School of Physical Education, Southwest University, Chongqing, China
• 2 School of Physical Education, Hubei Minzu University, Enshi, Hubei, China
• 3 School of Physical Education, Huzhou University, Huzhou, China

Introduction: Although previous research has examined the risk factors for drowning behavior among adolescents, it is unclear whether this association is influenced by water safety knowledge. This study aimed to examine whether water safety knowledge is associated with adolescents’ drowning risk behaviors and whether drowning risk perceptions and attitudes could have a chain mediating role in the association between water safety knowledge and adolescents’ drowning risk behaviors.

Methods: This study included 7,485 adolescents from five Chinese provinces and cities. We used the Drowning Risk Behaviors Scales (DRBS) to evaluate the risk of drowning behaviors. The Water Safety Knowledge Scale (WSKS) was used to evaluate the competence level of water safety knowledge. The Drowning Risk Perceptions Scale (DRPS) was used to evaluate the risk level of perceptions, and the Drowning Risk Attitudes Scale (DRAS) was used to evaluate the risk level of attitudes.

Results: The results of the mediating effect test showed that water safety knowledge (WSK) affected drowning risk behaviors (DRB) through three indirect paths. Drowning risk perceptions (DRP) and attitudes (DRA) have significantly mediated the association between WSK and DRB. In conclusion, DRP and DRA can act as mediators between WSK and DRB, not only individually, but also as chain mediators, where the direct effect is-0.301, the total indirect effect is-0.214, and the total mediated indirect effect is 41.5%.

Discussion: Water safety knowledge negatively predicts adolescents’ drowning risk behaviors; water safety knowledge has an inhibitory effect on drowning risk perceptions. Water safety knowledge can directly influence adolescents’ drowning risk perceptions and indirectly affect drowning risk behaviors through the mediation of drowning risk perceptions and attitudes comprising three paths: (1) the drowning risk perceptions mediation path, (2) the drowning risk attitudes mediation path, and (3) the drowning risk perceptions and attitudes mediation paths.

1 Introduction

Drowning claimed more than 2.5 million lives worldwide from 2010 to 2019. According to the WHO’s most recent global health estimates, 236,000 people drowned in 2019, demonstrating that drowning deaths exceeded deaths from either protein-energy malnutrition or maternal conditions ( 1 ). Approximately 57, 000 people die from drowning annually in China, accounting for 20% of all drowning deaths worldwide. 56% of these deaths occur in children aged 5–14, in other words, 88 children die from drowning each day ( 2 , 3 ). Therefore, it is crucial to understand how we can effectively prevent drowning among adolescents.

Drowning accidents of children and adolescents aged 5–14 are more likely to occur in open waters, such as rivers, lakes, ponds, reservoirs, and seas, owing to the hot summers resulting from global warming. Previous studies have found that the main causes of drowning accidents are drowning risk behaviors (DRB) and unintentional falls into water. Drowning risk behaviors refer to individuals putting themselves in risky circumstances on their own initiative, and unintentionally falling into open water refers to individuals’ risk ignorance ( 4 ). However, swimming skills and water safety knowledge (WSK) are key factors in these two causes. Mastering swimming skills and water safety knowledge is greatly significant to water safety education. Adolescents who acquire swimming skills may be able to overcome drowning, but without water safety knowledge, they still face the threat of drowning ( 3 ). Mastery of water safety knowledge not only changes adolescents’ drowning risk attitudes (DRA) and behaviors, but also strengthens their drowning risk perceptions (DRP). However, few studies have examined the mechanisms underlying water safety knowledge, drowning risk perceptions, drowning risk attitudes, and drowning risk behaviors.

Adolescents’ drowning risks are directly related to their drowning risk behaviors ( 5 ). A previous study found that individuals with a higher drowning risk tended to drown more than those with a low risk of drowning ( 6 ). Various types of water activities exist in China, including diving, snorkeling, water skiing, surfboard skiing, planking, catching fish, splashing, and swimming. Drowning accidents during these activities among adolescents are increasingly common because of the lack of guardian supervision and the induction of deviant behaviors from partners.

Mastering water safety knowledge helps adolescents reduce their drowning risk behaviors. Water safety knowledge consists of declarative knowledge about swimming safety and procedural knowledge about swimming rescue, including common sense of water safety, water safety legislative knowledge, and water safety judgments ( 5 ). (1) Common sense of water safety refers to a fundamental understanding of water activities, rescues, equipment, and the production of simple floating devices. (2) Water safety legislative knowledge refers to awareness of the laws and regulations of the water activity area, warning signs, beach flags, etc. (3) Water safety judgments refer to the ability to assess one’s own physical condition, weather, and water environment ( 4 ). In 2007, The International Lifesaving Federation stated that most drowning episodes can be prevented by understanding water safety and swimming skills ( 5 ). In general, a high level of water safety knowledge helps adolescents efficiently identify potential drowning risks. For example, adolescents would have better knowledge of various warning signs, could assess their own health, weather, and water conditions more effectively, and would use life-saving knowledge and skills to approach drowning events more reasonably. Moreover, water safety awareness and behaviors underpinned by water safety knowledge help avoid adolescents’ unintentional falls into open water, unintentional submersions, and drowning ( 4 ). Additionally, empirical studies have demonstrated that water safety knowledge strongly promotes pandemic prevention behaviors and health-related adaptive behaviors ( 7 , 8 ), and prevents risky diving behaviors and unintentional injuries ( 9 , 10 ). Based on this previous literature, we hypothesized that water safety knowledge may reduce the occurrence of drowning risk behaviors in adolescents.

Hypothesis 1 : Water safety knowledge has an inhibition effect on drowning risk behavior.

In addition to directly influencing adolescents’ drowning risk behaviors, water safety knowledge can also indirectly prevent drownings by enhancing risk perceptions. Empirical research has demonstrated that the combination of water safety knowledge and risk perceptions has a substantial impact on drowning risk behaviors ( 8 ). Risk perceptions are used to describe people’s attitudes and intuitive judgments towards risk and play a crucial role in human safety behaviors ( 11 ). Altarawneha et al. ( 12 ) first applied a dual-process approach to the study of risk perception, arguing that public risk perception studies should combine cognitive and affective appraisals to form a dynamic “dual-process” ( Figure 1 ). Risk perceptions are significantly related to the level of subjective knowledge (risk awareness) and the degree of personal familiarity with water environments; thus, they can drive individuals’ behavioral decisions ( 12 ). Furthermore, the dual-process approach model also supports Finucane’s point that “understanding how affect and cognition interact and collaborate in human judgment and decision-making is crucial for understanding risk perceptions” ( 13 ). Adolescents’ understanding of water environments’ risks originate from their water safety knowledge. For example, recognizing water safety signs and beach safety flags may warn adolescents to inhibit some drowning risk behaviors ( 4 ). Moreover, water safety knowledge enhances adolescents’ drowning risk perceptions, alerts them to drowning risks, and encourages persuasion and precautions against drowning risk behaviors. However, it is unclear whether water safety knowledge inhibits drowning risk behaviors through drowning risk perceptions. Accordingly, we predicted that drowning risk perceptions would have an inhibition role in the relationship between water safety knowledge and drowning risk behaviors ( 14 , 15 ).

Figure 1 . Conceptual illustration of the cognition-affect-intention (CAI) model.

Hypothesis 2 : Drowning risk perceptions have an inhibition role in the relationship between water safety knowledge and drowning risk behaviors.

The Knowledge, Attitude, and Practice (KAP) theory commonly utilized to study people’s health behavior divides human behavior change into three sequential processes: (1) acquiring knowledge, (2) forming beliefs and positive attitudes, and (3) eventually changing behaviors. In this process, knowledge is the basis for behavioral change, while beliefs and attitudes are the forces behind behavior change ( 16 ). Moreover, the KAP model is one of the most effective methods for drowning prevention because it considers people’s existing knowledge, beliefs, local environments, and social norms to understand why they engage in risky drowning behaviors ( 4 ). However, a study of young surfers in New Zealand found that surfing safety knowledge and attitudes had a significant impact on their high-risk surfing behaviors, which contributed to their high drowning probability ( 17 ). Many studies have demonstrated that the application of KAP theory to mediation models is a reliable predictor of drowning risk for all types of water activities, and that attitudes are important as a mediating variable between knowledge and behavior ( 15 , 18 , 19 ). Therefore, we posit that drowning risk attitudes can work as a mediator in the relationship between water safety knowledge and drowning risk behaviors.

Hypothesis 3 : Drowning risk attitudes will mediate the relationship between water safety knowledge and drowning risk behaviors.

The Knowledge, Risk perception, Attitude, and Practice (KRPAP) theoretical model was created by adding risk perception factors based on the KAP theory. It is conceivable to investigate the potential chain mediation of risk perceptions and attitudes on drowning risk behavior using the KRPAP theory, which holds that people’s behavior undergoes a knowledge-risk perceptions-attitudes-behavior change process. Taking the COVID-19 pandemic as an example, factors such as the administration’s inability to release pertinent information adequately and in a timely manner, the public not being well informed about COVID-19, and information asymmetry all might result in erroneous risk perceptions. This impact has the potential to transform people’s attitudes and behaviors over time, leading to verbal and behavioral radicalization among the public and contributing to societal instability ( 20 ). Compared with the KAP model, the KRPAP model has been used less frequently in previous drowning prevention research. Based on the above analysis, we hypothesized that drowning risk perceptions and attitudes would have a chain mediating effect between water safety knowledge and drowning risk behaviors ( Figure 2 ).

Figure 2 . Theoretical model.

Hypothesis 4 : Drowning risk perceptions and attitudes have a chain-mediating effect on water safety knowledge and drowning risk behaviors.

2 Materials and methods

2.1 participants and procedure.

We used cross-sectional data from primary and secondary school students in China, and conducted pre-test training for local teachers and students to normalize the investigation process. Before completing the formal questionnaire, all primary and secondary school students agreed to participate, and written informed consent forms were obtained from their primary guardians. We distributed and obtained 8,000 questionnaires, of which 7,485 (93.6%) were valid. Finally, this study included 3,663 males (48.9%) and 3,822 females (51.1%). Ethical approval was obtained from the Institutional Review Board of the College of Physical Education at Southwest University (ethical approval number: SWU20180601).

2.2 Measures

2.2.1 drowning risk behaviors scale.

The Drowning Risk Behaviors Scale (DRBS) was used to evaluate an individual’s risk level for drowning behavior ( 15 ). The Chinese version of the DRBS is considered to have good reproducibility and validity ( 21 ). The drowning risk behaviors scale consisted of 10 items (e.g., “Swimming with no adults”; “Swimming in the wild waters without safety protection”; “Diving in the unknown depth of water”; “Playing roughshod with your mates while swimming”; “Swimming when you are sick”) rated on a five-point Likert scale ranging from 1 (Never) to 5 (Always). All items were added to produce a total score, with higher scores indicating a more severe drowning risk. The internal consistency coefficient (Cronbach’s alpha) was 0.934.

2.2.2 Drowning risk perceptions scale

The Drowning Risk Perceptions Scale (DRPS) was used to evaluate an individual’s level of drowning risk perceptions ( 22 ). The reliability and validity of the Chinese version of the DRPS have been previously described ( 6 ). DRPS consists of 13 items and four subscales, including F1 = Susceptibility to drowning (e.g., “Drowning is a leading cause of death among children”; “Every student is at the risk of drowning”; “You and your partners are at the risk of drowning”), F2 = Seriousness of drowning (e.g., “Drowning is a serious problem”; “Drowning students must be taken to hospital”; “Most drowning victims would die”). F3 = Benefits of swimming skills (e.g., “Swimming is a life skill”; “Swimming skills will decrease drowning risk”; “Swimming skills are necessary for a particular professional career”), and F4 = Barriers perceived (e.g., “Lack of swimming instructors”; “Lack of swimming lessons in school”; “Unaffordable swimming lessons”; “Swimming pool is too far”). Each item was rated on a five-point Likert scale ranging from 1 (strongly disagree) to 5 (strongly agree). All items were summed to produce a total score, with higher scores indicating a higher drowning risk perception. In this study, the internal consistency reliability (Cronbach’s alpha) of the overall scale was 0.839, and the internal consistency coefficients (Cronbach’s alpha) of the four-dimensional scales were 0.703, 0.788, 0.746, and 0.720. From the degree of fit of the four-factor model, CFI, IFI, NNFI, and GFI >0.90, and RMSEA <0.08, indicating that the four-factor structural model fits well.

2.2.3 Water safety knowledge scale

We used the Water Safety Knowledge Scale (WSKS) to evaluate an individual’s level of water safety knowledge ( 23 ). The Chinese version of the WSKS has good reproducibility and validity ( 6 ). The water safety knowledge scale consisted of 10 items: (1) “Do you know about water safety?”; (2) “Do you know the common methods for rescuing those who fall into water?”; (3) “Do you know how to perform self-rescue in water?”; (4) “Do you know how to perform CPR?”; (5) “Can you recognize common water safety signs?”; (6) “Do you know how to react when someone else falls into the water?”; (7) “Do you know the correct use of life jackets and life preservers?”; (8) “Do you know the most effective ways to call for help while drowning?”; (9) “Do you know how to rest when fatigued by swimming?”; and (10) “Do you know how to swim safely?.” These were rated on a five-point Likert-type scale ranging from 1 (very unfamiliar) to 5 (very familiar). All items were summed to produce a total score, with higher scores indicating a higher level of education. The internal consistency coefficient (Cronbach’s alpha) was 0.943.

2.2.4 Drowning risk attitudes scale

The Drowning Risk Attitudes Scale (DRAS) was used to evaluate an individual’s drowning risk attitudes. The Chinese version of the DRA has good reproducibility and validity ( 23 ). The DRAS consists of 10 items: (1) “Before swimming, is there no need to consider whether the waters are safe?”; (2) “Are good swimmers always safe from drowning?”; (3) “Is swimming in rivers safe?”; (4) “Is it best to enter water immediately to help your partner draw?”; (5) “Does swimming in shallow water guarantee that you will not drown?”; (6) “Is it safe to swim with a partner who can swim, instead of an adult?”; (7) “Is it always safe to go swimming with a lifejacket?”; (8) “Is it safe to play near the edge of water without entering it?”; (9) “Is walking on ice safe?”; and (10) “Is it safe to swim while wearing clothing?”. These were rated on a five-point Likert-type scale ranging from 1 (strongly disagree) to 5 (strongly agree). All items were summed to produce a total score, with higher scores indicating higher levels of risk intention. The internal consistency coefficient (Cronbach’s alpha) was 0.964.

2.3 Data analysis

SPSS version 26.0 was used to explore the correlations among water safety knowledge, drowning risk perceptions, drowning risk attitudes, and drowning risk behaviors. Harman’s single-factor test was utilized to examine 42 items for the common method bias test ( 24 ). The results revealed 11 factors with eigenvalues greater than one, and the variance explained by the first factor was less than 40% (19.246%), indicating that there was no common method bias in this study.

Mediating hypotheses were examined based on the mediating effects analysis process ( 25 ). All data were analyzed using Hayes’ SPSS macro program PROCESS ( 26 ). Water safety knowledge was used as an independent variable, drowning risk perceptions and attitudes as mediating variables, and drowning risk behaviors as dependent variables. The mediating effect was tested using bootstrapping (repeated sampling of 5,000 times). If the 95% confidence interval did not include zero, the mediating effect was considered significant.

3.1 Descriptive and Pearson correlation analysis

The results of the correlation analyses for all variables are shown in Table 1 . Drowning risk perceptions are positively correlated with water safety knowledge; drowning risk attitudes and behaviors are negatively correlated with water safety knowledge; drowning risk attitudes and behaviors are negatively correlated with drowning risk perceptions; and drowning risk behaviors are positively correlated with drowning risk attitudes.

Table 1 . Descriptive statistics and correlations of key variables ( n  = 7,485).

3.2 Testing for chain mediating effect

The results of the regression analysis are presented in Table 2 . Water safety knowledge positively predicted drowning risk perceptions (β =0.371, p < 0.001). Water safety knowledge and drowning risk perceptions negatively predicted drowning risk attitudes (β = −0.194, p < 0.001; β = −0.305, p < 0. 001). When incorporating water safety knowledge, drowning risk perceptions and drowning risk attitudes into the equation, their predictive effects were significant. Namely, water safety knowledge and drowning risk perceptions negatively predicted drowning risk behaviors (β = −0.260, p < 0. 001; β = −0.213, p < 0. 001), and drowning risk attitudes positively predicted drowning risk behaviors (β =0.345, p < 0.001).

Table 2 . Regression analysis of the mediation model between drowning risk perceptions and drowning risk attitude.

The results of the mediating effects tests are presented in Table 3 and Figure 3 . WSK affected DRB through three indirect paths. The 95% confidence interval (CI) of the indirect effect paths did not include zero, revealing that DRP and DRA had significant mediating effects on the association between WSK and DRB. The first path, WSK → DRP → DRB, accounts for 17.7% of total effect. The second path, WSK → DRA → DRB, accounted for 15.1% of the total effect. The third path, WSK → DRP → DRA → DRB, accounted for 8.7% of the total effect. In conclusion, DRP and DRA can act as mediators between WSK and DRB, not only individually, but also as chain mediators, where the direct effect is-0.301, the total indirect effect is-0.214 (a1b1 + a2b2 + a1a3b2), and the total mediated indirect effect is 41.5%.

Table 3 . Mediation effect volume analysis.

Figure 3 . The chain mediating model. Path coefficients are standardized coefficients. *** p  < 0.001.

4 Discussion

The resolution adopted by the General Assembly on April 28, 2021 stresses the need to raise awareness of the importance of drowning prevention and the need for urgent coordinated multisectoral action to improve water safety through education, knowledge sharing, and other activities, with the aim of reducing preventable deaths ( 27 ). Our results support the role of water safety knowledge as a significant negative predictor of drowning risk behaviors and are consistent with previous findings ( 28 , 29 ). Adolescents who have a high level of water safety knowledge can be sensitive to physical conditions, weather, and potential risks of aquatic environments, and can combine the skills they have learned to save themselves and others. For instance, adolescents’ familiarity with water warning signs will enable them to reduce their drowning risk.

China currently ranks first in the world in terms of drowning fatalities, and water safety education lags severely. We found that few primary and secondary schools had teaching materials related to the recognition of water warning signs. It is noteworthy that the proportion of schools and universities with swimming pools was relatively low. Taking the nine top economic districts in Chongqing as an example, only 8 of the 446 (1.79%) primary schools, 18 of the 249 (7.23%) middle schools, and 12 of the 71 (16.9%) universities were equipped with swimming pools. In this context, two factors are extremely important for promoting the rapid development of water safety education in China. The first factor is parental involvement. Morrongiello et al. ( 30 ) found that, in addition to schools, parents were an especially critical element in the development of adolescents’ drowning prevention skills, which was even more apparent in China. Some parental approaches, such as enrolling children in aquatics training, are the most beneficial in helping children develop the water safety knowledge and swimming skills ( 31 ). The second most important factor is the financial support. The WHO ( 3 ) has noted that more than 90% of drowning fatalities occur in low-and middle-income countries (LMIC). However, certain urban and rural parts of China can be compared with both developed countries and LMICs. There are families in China’s rural areas whose parents earn little income and cannot cover the costs for their children to receive water safety education. Therefore, financial support can help reduce the incidence of drowning accidents by providing more adolescents with opportunities to receive water safety education.

Our results support the inhibitory effect of water safety knowledge on drowning risk behaviors through drowning risk perceptions. Meanwhile, regarding Hypothesis 2 of this study, the second path (WSK → DRA → DRB) is consistent with previous research findings ( 32 ) while the first path (WSK → DRP → DRB) is our new finding. However, water safety knowledge strengthens adolescents’ drowning risk perceptions and can thus decrease the probability of adolescents intentionally exposing themselves to risk. Moreover, the dual-process approach model indicated that risk perceptions were significantly related to subjective knowledge and personal familiarity with the water environment, which in turn, helped adolescents avoid drowning risk behaviors. More specifically, individuals develop the ability to identify risk through the collection, comprehension, and application of knowledge, and build up their “antibodies” to self-protect against drowning. These “antibodies” are a stress response to water environments and enable one to remain alert to threats in the aquatic environment.

However, sensitivity to the aquatic environment and the ability to be aware of potential drowning risks in advance also rely on mastering water safety knowledge. Furthermore, a combination of knowledge and risk perception is also essential, especially when drowning prevention and rescue of oneself or others requires the most appropriate judgement and decision-making. However, unintentionally falling into the water and drowning requires extra attention ( 33 ). In China, most children and adolescents do not know how to swim or are not good swimmers. According to a vast number of drowning accidents reported, diving, swimming in deep water, and physical exhaustion are the leading causes of drowning in adults, whereas unintentional falls into water are more common among children and adolescents ( 2 ). In the case of unintentional drowning, it is difficult for a drowning adolescent or adult to survive because of heavy and wet clothing reducing the speed of swimming, countercurrents, and other factors ( 34 ). The strengthening of drowning precautions and the improvement of risk perception and risk identification stem from the continuous learning of water safety knowledge, so that the drowning risk can be reduced.

In this study, we found that drowning risk attitudes partially mediated the relationship between water safety knowledge and drowning risk behaviors, which is consistent with previous studies ( 15 , 17 ). The use of KAP theory in drowning prevention research has been well established, and the WHO ( 4 ) has also specifically highlighted its use of KAP theory ( 4 ). In China, the Ministry of Education, schools, and students are the three key participants in the implementation of water safety education. First, the Ministry of Education plays a general directive role in drowning prevention education in schools by establishing a dedicated educational website and propagating drowning prevention on its official website. Schools are more direct implementers of water safety education, primarily through awareness campaigns and lectures just before summer holidays, as well as through public education on WeChat. However, owing to academic pressure and the paucity of teachers and teaching equipment, water safety courses have limited class time and are not as popular as they should be. Finally, students, who are the target audience for water safety education, participate in courses and lectures to gain water safety knowledge. Nevertheless, many students lack motivation to attend water safety education courses and learn very little about water safety knowledge simply because these courses are not part of the main academic assessment system for students.

In summary, the water safety education program in Chinese schools lacks organization, resulting in a low level of adolescent water safety knowledge and passive drowning risk attitudes. Negative attitudes invariably lead to negative behaviors, which can exacerbate issues such as drowning accidents, shortsightedness, and deteriorating health. Negative attitudes towards health-harming behaviors generated by exam-oriented education tend to result in negative behaviors and exacerbate drowning accidents, shortsightedness, deteriorating physical fitness, and other issues that the Chinese society must address.

Our study also demonstrated that drowning risk perceptions and attitudes act as chain mediators between water safety knowledge and drowning risk behaviors. An increase in water safety knowledge promotes drowning risk perceptions, which in turn can improve drowning risk attitudes and prevent risky behaviors. This pathway, which has not been extensively explored in previous drowning prevention studies, is consistent with findings on the prevention of heat-related illnesses ( 35 ). Negative information refers to information that threatens individuals’ safety and sensitizes them to environmental dangers. However, owing to the limited knowledge volume, water safety knowledge does not contain much negative information. This may easily lead adolescents to lose awareness of water environment dangers, resulting in negative attitudes and riskier behaviors. Chinese transportation authorities have attempted to include negative information in dangerous driving education, such as the use of vehicle accident videos, to make drivers more alert of risky behaviors including drink driving, speeding, and running red lights.

In drowning prevention studies, a similar strategy can be employed to raise awareness of the serious consequences of drowning accidents to prevent high-risk rescue behaviors, such as direct diving, hand-holding, and direct hand rescuing by adolescents. Summarizing and learning from other people’s drowning experiences can help individuals avoid mistakes. Moreover, according to psychological education, we should ensure that the warning bells are always ringing, because risk perceptions, like knowledge and memory, will diminish with time and the influence of other people and events. Currently, China’s birth population is decreasing each year, and the deaths of adolescents due to drowning accidents pose a threat to the young population. Therefore, more emphasis should be placed on water safety education to protect young people as well as the future of families and the country at large.

5 Limitations and future research

This study has several limitations. First, this study followed a cross-sectional design; therefore, we could not establish the causal association between water safety knowledge and drowning risk behaviors. Cross-lagged designs and experimental interventions are needed in future studies. Second, this study was limited to exploring the mediating effect of drowning risk perceptions and attitudes on adolescents’ water safety knowledge and drowning risk behaviors; whether other factors, such as sensation seeking, emotion, swimming overconfidence, verbal persuasion, and behavioral imitation, also play a moderating role needs further examination. Third, future studies may need to apply water competency models and Behavioral Event Interviews (BEI) to identify the characteristics of various water competencies and behaviors to better prevent adolescent drowning accidents.

6 Conclusion

Water safety knowledge negatively predicts adolescent drowning risk behaviors, and has an inhibitory effect on drowning risk perceptions. Water safety knowledge can directly influence adolescents’ drowning risk perceptions and indirectly affect drowning risk behaviors through the mediation of drowning risk perceptions and attitudes comprising three paths. The first was the drowning risk perceptions mediation path. Second was a drowning risk attitudes mediating path. The third chain mediation path involved drowning risk perceptions and attitudes. In conclusion, the establishment of the mediation model reveals the mechanism by which water safety knowledge influences adolescents’ drowning risk behaviors, serving as a reference for the prevention of adolescent drowning risk behaviors. In the future, the level of water safety knowledge can be improved to help adolescents enhance their drowning risk perceptions, avoid negative risk attitudes, and reduce drowning risk behaviors.

Data availability statement

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

Ethics statement

The studies involving humans were approved by the Institutional Review Board of the College of Physical Education at Southwest University (ethical approval number: SWU20180601). 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. Written informed consent was obtained from the minor(s)' legal guardian/next of kin for the publication of any potentially identifiable images or data included in this article.

Author contributions

ShiL: Writing – review & editing, Writing – original draft, Visualization, Validation, Supervision, Software, Resources, Project administration, Methodology, Investigation, Funding acquisition, Formal analysis, Data curation, Conceptualization. ShuL: Writing – review & editing. ZR: Writing – review & editing, Writing – original draft, Visualization, Validation, Supervision, Software, Resources, Project administration, Methodology, Investigation, Formal analysis, Data curation, Conceptualization. HZ: Funding acquisition, Writing – review & editing, Validation, Supervision. XL: Writing – review & editing. LL: Writing – review & editing.

The author(s) declare that financial support was received for the research, authorship, and/or publication of this article. This research was supported by the Education of Humanities and Social Science Research on Youth Fund (project 20YJC890016), Fundamental Research Funds for the Central Universities (project SWU2109329), and Higher Education Teaching Reform Project of Hubei Province under Grant Number (project 2021378).

Acknowledgments

We thank all primary and secondary school students who agreed to participate in this study and provided informed consent for data analysis. We also thank the local staff at primary and secondary schools for their dedicated work.

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: adolescents, water safety knowledge, drowning risk perceptions, drowning risk attitudes, drowning risk behaviors

Citation: Luo S, Luo S, Ren Z, Zhang H, Li X and Liu L (2024) The influence of water safety knowledge on adolescents’ drowning risk behaviors: a framework of risk-protect integrated and KAP theory. Front. Public Health . 12:1354231. doi: 10.3389/fpubh.2024.1354231

Received: 13 December 2023; Accepted: 29 April 2024; Published: 10 May 2024.

Reviewed by:

Copyright © 2024 Luo, Luo, Ren, Zhang, Li 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: Lian 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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Thousands Believe Covid Vaccines Harmed Them. Is Anyone Listening?

All vaccines have at least occasional side effects. But people who say they were injured by Covid vaccines believe their cases have been ignored.

Shaun Barcavage, 54, a nurse practitioner in New York City, said that ever since his first Covid shot, standing up has sent his heart racing. Credit... Hannah Yoon for The New York Times

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By Apoorva Mandavilli

Apoorva Mandavilli spent more than a year talking to dozens of experts in vaccine science, policymakers and people who said they had experienced serious side effects after receiving a Covid-19 vaccine.

• Published May 3, 2024 Updated May 4, 2024

Within minutes of getting the Johnson & Johnson Covid-19 vaccine, Michelle Zimmerman felt pain racing from her left arm up to her ear and down to her fingertips. Within days, she was unbearably sensitive to light and struggled to remember simple facts.

She was 37, with a Ph.D. in neuroscience, and until then could ride her bicycle 20 miles, teach a dance class and give a lecture on artificial intelligence, all in the same day. Now, more than three years later, she lives with her parents. Eventually diagnosed with brain damage, she cannot work, drive or even stand for long periods of time.

“When I let myself think about the devastation of what this has done to my life, and how much I’ve lost, sometimes it feels even too hard to comprehend,” said Dr. Zimmerman, who believes her injury is due to a contaminated vaccine batch .

The Covid vaccines, a triumph of science and public health, are estimated to have prevented millions of hospitalizations and deaths . Yet even the best vaccines produce rare but serious side effects . And the Covid vaccines have been given to more than 270 million people in the United States, in nearly 677 million doses .

Dr. Zimmerman’s account is among the more harrowing, but thousands of Americans believe they suffered serious side effects following Covid vaccination. As of April, just over 13,000 vaccine-injury compensation claims have been filed with the federal government — but to little avail. Only 19 percent have been reviewed. Only 47 of those were deemed eligible for compensation, and only 12 have been paid out, at an average of about $3,600 .

Some scientists fear that patients with real injuries are being denied help and believe that more needs to be done to clarify the possible risks.

“At least long Covid has been somewhat recognized,” said Akiko Iwasaki, an immunologist and vaccine expert at Yale University. But people who say they have post-vaccination injuries are “just completely ignored and dismissed and gaslighted,” she added.

In interviews and email exchanges conducted over several months, federal health officials insisted that serious side effects were extremely rare and that their surveillance efforts were more than sufficient to detect patterns of adverse events.

“Hundreds of millions of people in the United States have safely received Covid vaccines under the most intense safety monitoring in U.S. history,” Jeff Nesbit, a spokesman for the Department of Health and Human Services, said in an emailed statement.

But in a recent interview, Dr. Janet Woodcock, a longtime leader of the Food and Drug Administration, who retired in February, said she believed that some recipients had experienced uncommon but “serious” and “life-changing” reactions beyond those described by federal agencies.

“I feel bad for those people,” said Dr. Woodcock, who became the F.D.A.’s acting commissioner in January 2021 as the vaccines were rolling out. “I believe their suffering should be acknowledged, that they have real problems, and they should be taken seriously.”

“I’m disappointed in myself,” she added. “I did a lot of things I feel very good about, but this is one of the few things I feel I just didn’t bring it home.”

Federal officials and independent scientists face a number of challenges in identifying potential vaccine side effects.

The nation’s fragmented health care system complicates detection of very rare side effects, a process that depends on an analysis of huge amounts of data. That’s a difficult task when a patient may be tested for Covid at Walgreens, get vaccinated at CVS, go to a local clinic for minor ailments and seek care at a hospital for serious conditions. Each place may rely on different health record systems.

There is no central repository of vaccine recipients, nor of medical records, and no easy to way to pool these data. Reports to the largest federal database of so-called adverse events can be made by anyone, about anything. It’s not even clear what officials should be looking for.

“I mean, you’re not going to find ‘brain fog’ in the medical record or claims data, and so then you’re not going to find” a signal that it may be linked to vaccination, Dr. Woodcock said. If such a side effect is not acknowledged by federal officials, “it’s because it doesn’t have a good research definition,” she added. “It isn’t, like, malevolence on their part.”

The government’s understaffed compensation fund has paid so little because it officially recognizes few side effects for Covid vaccines. And vaccine supporters, including federal officials, worry that even a whisper of possible side effects feeds into misinformation spread by a vitriolic anti-vaccine movement.

‘I’m Not Real’

Patients who believe they experienced serious side effects say they have received little support or acknowledgment.

Shaun Barcavage, 54, a nurse practitioner in New York City who has worked on clinical trials for H.I.V. and Covid, said that ever since his first Covid shot, merely standing up sent his heart racing — a symptom suggestive of postural orthostatic tachycardia syndrome , a neurological disorder that some studies have linked to both Covid and, much less often, vaccination .

He also experienced stinging pain in his eyes, mouth and genitals, which has abated, and tinnitus, which has not.

“I can’t get the government to help me,” Mr. Barcavage said of his fruitless pleas to federal agencies and elected representatives. “I am told I’m not real. I’m told I’m rare. I’m told I’m coincidence.”

Renee France, 49, a physical therapist in Seattle, developed Bell’s palsy — a form of facial paralysis, usually temporary — and a dramatic rash that neatly bisected her face. Bell’s palsy is a known side effect of other vaccines, and it has been linked to Covid vaccination in some studies.

But Dr. France said doctors were dismissive of any connection to the Covid vaccines. The rash, a bout of shingles, debilitated her for three weeks, so Dr. France reported it to federal databases twice.

“I thought for sure someone would reach out, but no one ever did,” she said.

Similar sentiments were echoed in interviews, conducted over more than a year, with 30 people who said they had been harmed by Covid shots. They described a variety of symptoms following vaccination, some neurological, some autoimmune, some cardiovascular.

All said they had been turned away by physicians, told their symptoms were psychosomatic, or labeled anti-vaccine by family and friends — despite the fact that they supported vaccines.

Even leading experts in vaccine science have run up against disbelief and ambivalence.

Dr. Gregory Poland, 68, editor in chief of the journal Vaccine, said that a loud whooshing sound in his ears had accompanied every moment since his first shot, but that his entreaties to colleagues at the Centers for Disease Control and Prevention to explore the phenomenon, tinnitus, had led nowhere.

He received polite responses to his many emails, but “I just don’t get any sense of movement,” he said.

“If they have done studies, those studies should be published,” Dr. Poland added. In despair that he might “never hear silence again,” he has sought solace in meditation and his religious faith.

Dr. Buddy Creech, 50, who led several Covid vaccine trials at Vanderbilt University, said his tinnitus and racing heart lasted about a week after each shot. “It’s very similar to what I experienced during acute Covid, back in March of 2020,” Dr. Creech said.

Research may ultimately find that most reported side effects are unrelated to the vaccine, he acknowledged. Many can be caused by Covid itself.

“Regardless, when our patients experience a side effect that may or may not be related to the vaccine, we owe it to them to investigate that as completely as we can,” Dr. Creech said.

Federal health officials say they do not believe that the Covid vaccines caused the illnesses described by patients like Mr. Barcavage, Dr. Zimmerman and Dr. France. The vaccines may cause transient reactions, such as swelling, fatigue and fever, according to the C.D.C., but the agency has documented only four serious but rare side effects .

Two are associated with the Johnson & Johnson vaccine, which is no longer available in the United States: Guillain-Barré syndrome , a known side effect of other vaccines , including the flu shot; and a blood-clotting disorder.

The C.D.C. also links mRNA vaccines made by Pfizer-BioNTech and Moderna to heart inflammation, or myocarditis, especially in boys and young men. And the agency warns of anaphylaxis, or severe allergic reaction, which can occur after any vaccination.

Listening for Signals

Agency scientists are monitoring large databases containing medical information on millions of Americans for patterns that might suggest a hitherto unknown side effect of vaccination, said Dr. Demetre Daskalakis, director of the C.D.C.’s National Center for Immunization and Respiratory Diseases.

“We toe the line by reporting the signals that we think are real signals and reporting them as soon as we identify them as signals,” he said. The agency’s systems for monitoring vaccine safety are “pretty close” to ideal, he said.

Those national surveillance efforts include the Vaccine Adverse Event Reporting System (VAERS). It is the largest database, but also the least reliable: Reports of side effects can be submitted by anyone and are not vetted, so they may be subject to bias or manipulation.

The system contains roughly one million reports regarding Covid vaccination, the vast majority for mild events, according to the C.D.C.

Federal researchers also comb through databases that combine electronic health records and insurance claims on tens of millions of Americans. The scientists monitor the data for 23 conditions that may occur following Covid vaccination. Officials remain alert to others that may pop up, Dr. Daskalakis said.

But there are gaps, some experts noted. The Covid shots administered at mass vaccination sites were not recorded in insurance claims databases, for example, and medical records in the United States are not centralized.

“It’s harder to see signals when you have so many people, and things are happening in different parts of the country, and they’re not all collected in the same system,” said Rebecca Chandler, a vaccine safety expert at the Coalition for Epidemic Preparedness Innovations.

An expert panel convened by the National Academies concluded in April that for the vast majority of side effects, there was not enough data to accept or reject a link.

Asked at a recent congressional hearing whether the nation’s vaccine-safety surveillance was sufficient, Dr. Peter Marks, director of the F.D.A.’s Center for Biologics Evaluation and Research, said, “I do believe we could do better.”

In some countries with centralized health care systems, officials have actively sought out reports of serious side effects of Covid vaccines and reached conclusions that U.S. health authorities have not.

In Hong Kong, the government analyzed centralized medical records of patients after vaccination and paid people to come forward with problems. The strategy identified “a lot of mild cases that other countries would not otherwise pick up,” said Ian Wong, a researcher at the University of Hong Kong who led the nation’s vaccine safety efforts.

That included the finding that in rare instances — about seven per million doses — the Pfizer-BioNTech vaccine triggered a bout of shingles serious enough to require hospitalization.

The European Medicines Agency has linked the Pfizer and Moderna vaccines to facial paralysis, tingling sensations and numbness. The E.M.A. also counts tinnitus as a side effect of the Johnson & Johnson vaccine, although the American health agencies do not. There are more than 17,000 reports of tinnitus following Covid vaccination in VAERS.

Are the two linked? It’s not clear. As many as one in four adults has some form of tinnitus. Stress, anxiety, grief and aging can lead to the condition, as can infections like Covid itself and the flu.

There is no test or scan for tinnitus, and scientists cannot easily study it because the inner ear is tiny, delicate and encased in bone, said Dr. Konstantina Stankovic, an otolaryngologist at Stanford University.

Still, an analysis of health records from nearly 2.6 million people in the United States found that about 0.04 percent , or about 1,000, were diagnosed with tinnitus within three weeks of their first mRNA shot. In March, researchers in Australia published a study linking tinnitus and vertigo to the vaccines .

The F.D.A. is monitoring reports of tinnitus, but “at this time, the available evidence does not suggest a causal association with the Covid-19 vaccines,” the agency said in a statement.

Despite surveillance efforts, U.S. officials were not the first to identify a significant Covid vaccine side effect: myocarditis in young people receiving mRNA vaccines. It was Israeli authorities who first raised the alarm in April 2021. Officials in the United States said at the time that they had not seen a link.

On May 22, 2021, news broke that the C.D.C. was investigating a “relatively few” cases of myocarditis. By June 23, the number of myocarditis reports in VAERS had risen to more than 1,200 — a hint that it is important to tell doctors and patients what to look for.

Later analyses showed that the risk for myocarditis and pericarditis, a related condition, is highest after a second dose of an mRNA Covid vaccine in adolescent males aged 12 to 17 years.

In many people, vaccine-related myocarditis is transient. But some patients continue to experience pain, breathlessness and depression, and some show persistent changes on heart scans . The C.D.C. has said there were no confirmed deaths related to myocarditis, but in fact there have been several accounts of deaths reported post-vaccination .

Pervasive Misinformation

The rise of the anti-vaccine movement has made it difficult for scientists, in and out of government, to candidly address potential side effects, some experts said. Much of the narrative on the purported dangers of Covid vaccines is patently false, or at least exaggerated, cooked up by savvy anti-vaccine campaigns.

Questions about Covid vaccine safety are core to Robert F. Kennedy Jr.’s presidential campaign. Citing debunked theories about altered DNA, Florida’s surgeon general has called for a halt to Covid vaccination in the state.

“The sheer nature of misinformation, the scale of misinformation, is staggering, and anything will be twisted to make it seem like it’s not just a devastating side effect but proof of a massive cover-up,” said Dr. Joshua Sharfstein, a vice dean at Johns Hopkins University.

Among the hundreds of millions of Americans who were immunized for Covid, some number would have had heart attacks or strokes anyway. Some women would have miscarried. How to distinguish those caused by the vaccine from those that are coincidences? The only way to resolve the question is intense research .

But the National Institutes of Health is conducting virtually no studies on Covid vaccine safety, several experts noted. William Murphy, a cancer researcher who worked at the N.I.H. for 12 years, has been prodding federal health officials to initiate these studies since 2021.

The officials each responded with “that very tired mantra: ‘But the virus is worse,’” Dr. Murphy recalled. “Yes, the virus is worse, but that doesn’t obviate doing research to make sure that there may be other options.”

A deeper understanding of possible side effects, and who is at risk for them, could have implications for the design of future vaccines, or may indicate that for some young and healthy people, the benefit of Covid shots may no longer outweigh the risks — as some European countries have determined.

Thorough research might also speed assistance to thousands of Americans who say they were injured.

The federal government has long run the National Vaccine Injury Compensation Program , designed to compensate people who suffer injuries after vaccination. Established more than three decades ago, the program sets no limit on the amounts awarded to people found to have been harmed.

But Covid vaccines are not covered by that fund because Congress has not made them subject to the excise tax that pays for it. Some lawmakers have introduced bills to make the change.

Instead, claims regarding Covid vaccines go to the Countermeasures Injury Compensation Program . Intended for public health emergencies, this program has narrow criteria to pay out and sets a limit of $50,000, with stringent standards of proof.

It requires applicants to prove within a year of the injury that it was “the direct result” of getting the Covid vaccine, based on “compelling, reliable, valid, medical, and scientific evidence.”

The program had only four staff members at the beginning of the pandemic, and now has 35 people evaluating claims. Still, it has reviewed only a fraction of the 13,000 claims filed, and has paid out only a dozen.

Dr. Ilka Warshawsky, a 58-year-old pathologist, said she lost all hearing in her right ear after a Covid booster shot. But hearing loss is not a recognized side effect of Covid vaccination.

The compensation program for Covid vaccines sets a high bar for proof, she said, yet offers little information on how to meet it: “These adverse events can be debilitating and life-altering, and so it’s very upsetting that they’re not acknowledged or addressed.”

Dr. Zimmerman, the neuroscientist, submitted her application in October 2021 and provided dozens of supporting medical documents. She received a claim number only in January 2023.

In adjudicating her claim for workers’ compensation, Washington State officials accepted that Covid vaccination caused her injury, but she has yet to get a decision from the federal program.

One of her therapists recently told her she might never be able to live independently again.

“That felt like a devastating blow,” Dr. Zimmerman said. “But I’m trying not to lose hope there will someday be a treatment and a way to cover it.”

Apoorva Mandavilli is a reporter focused on science and global health. She was a part of the team that won the 2021 Pulitzer Prize for Public Service for coverage of the pandemic. More about Apoorva Mandavilli

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Children and adults are gobbling supplements. Do you know the risks?

Among some population groups, it’s not unusual to down four or more vitamins or supplements every day, new research shows

Americans spend billions of dollars every year on dietary supplements that claim to promote almost every aspect of our health. But how much do you know about the supplements you’re taking?

A recent government study found that nearly 60 percent of adults take vitamins, minerals, fish oil, herbal capsules, melatonin, probiotics and other types of dietary supplements. While most people used just one or two supplements — multivitamins and vitamin D were the two most popular products — it was not uncommon for people to report using three, four or more supplements at a time.

Among some parts of the population, it’s not unusual to down a handful of vitamins or supplements every day. About 15 percent of adults said they used four or more dietary supplements. Among older adults, the number reporting multi-supplement use is even higher — about 25 percent of adults 60 or older use four or more. About 35 percent of children and adolescents used dietary supplements, and nearly 10 percent of children between 2 and 5 years old were given two or more dietary supplements.

Experts say that vitamin and mineral supplements are generally safe when taken in small to moderate doses, like the amounts found in a basic multivitamin. Dietary supplements can be beneficial for pregnant women and for people with nutrient deficiencies and other health conditions. A clinical trial earlier this year found that for people who are 60 and older, taking a daily multivitamin helped to slow memory loss. Other studies have found that probiotic supplements can help with gastrointestinal disorders such as irritable bowel syndrome.

But taking supplements comes with risks, and for many healthy adults, it’s not always clear from research that the benefits outweigh the risks.

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In fact, some randomized trials have found that assigning people to take supplements with large doses of beta-carotene, selenium, and vitamins A, C, and E actually increased mortality rates. Rigorous clinical trials have also failed to support the hype around vitamin D, finding that people who were assigned to take the popular supplement did not develop lower rates of cardiovascular disease, cancer or bone fractures despite widespread marketing claims to the contrary.

Supplements don’t follow the same rules as drugs

Many people assume that the Food and Drug Administration tests supplements for safety. But that’s not how it works .

“Dietary supplements enter the market before there’s any real review of them by the FDA,” said Amy B. Cadwallader, the director of regulatory and public policy development at the United States Pharmacopeia, a nonprofit organization that examines the quality of drugs, food and dietary supplements.

Under federal law, companies are allowed to operate on the honor system. The FDA’s role in regulating supplements mostly involves trying to make sure products are safe and accurately labeled after they have already entered the marketplace.

Are you getting what you paid for?

In the United States, companies sell an estimated 90,000 dietary supplements, representing a roughly $50 billion industry . As a result, some experts say, consumers who buy supplements can’t always be sure that they are getting what they paid for. Studies of melatonin , fish oil , probiotics , ginkgo biloba , and other supplements have found that the doses and compounds listed on their labels are often not what are found in their bottles.

• In one study in the journal Pediatric Research , researchers tested 16 probiotic supplements and found that only one of them contained the specific bacterial strains listed on its label.
• In another study , researchers tested 30 dietary supplements that claimed to strengthen immune health and found that 17 of the products were “misbranded.” These supplements either lacked key ingredients listed on their labels — such as vitamin B12, garlic extract, ginger root and folate — or they contained a variety of unlisted ingredients.
• One study by the FDA estimated that the agency is notified of less than 1 percent of all adverse events linked to supplement use. Another study by the federal government estimated that injuries caused by supplements are responsible for about 23,000 emergency room visits each year.

Howard Luks, an orthopedic surgeon and sports medicine specialist in New York, said he routinely encounters patients who worry about potential side effects from medications but have no problem taking 10 or 20 supplements that they heard about from health influencers on social media. He said that many people who lost trust in public health authorities during the pandemic have turned to social media influencers for health advice.

“They view supplements as being holistic, natural, and therefore not potentially harmful for them,” he said.

In one case study published in March, doctors in New Jersey described a 76-year-old woman who went to an emergency room after experiencing heart palpitations, dizziness and fainting episodes. It turned out she had been taking black cohosh, an herbal supplement often used to treat hot flashes. A few days after stopping the supplement, her heartbeat returned to normal, and her other symptoms disappeared.

In another recent case , a 47-year-old woman in Houston suffered jaundice and liver damage after taking a supplement containing a blend of probiotics and herbal extracts. The case report noted that dietary supplements account for about 20 percent of drug-induced liver injuries nationwide.

How to shop smarter for supplements

Here are some tips when buying supplements.

Look for third-party certifications: The United States Pharmacopeia, or USP, vets dietary supplements to ensure they are meeting high standards for factors such as purity and potency. USP has a voluntary program through which companies can have their supplements and facilities routinely tested and examined. Companies that meet the organizations high standards are allowed to use a black and yellow “USP Verified” logo on their products. You can find them using the product-finder search tool on USP’s website. NSF is another independent group that tests and reviews dietary supplements. You can look for the blue and white “NSF” logo on your supplements or go to the group’s website to look up products.

Do your homework. Consumerlab.com is an independent laboratory that tests dietary supplements to see if they contain the ingredients and doses listed on their labels. The company publishes reports with their findings on a wide variety of supplements, which you can access on their website for a fee.

Talk to your doctor or pharmacist . Many people don’t realize that a lot of supplements and medications use the same metabolic pathways and that they can cause dangerous side effects when you combine them, said Michael Schuh, an assistant professor of pharmacy, family medicine and palliative medicine at the Mayo Clinic in Florida.

Vitamins E and K, ginseng, ginkgo biloba, resveratrol, turmeric and CoQ10 for example can interact with blood thinning medications. Vitamin C can interact with statins, niacin, estrogen, warfarin and chemotherapy drugs. St. John’s wort can make antidepressants and birth control pills less effective.

“We see it with a lot of supplements,” Schuh said. “Even something like resveratrol from grape skins: When you take it in concentrated form, it can interact with a lot of medications.”

Do you have a question about healthy eating? Email [email protected] and we may answer your question in a future column.

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