An attitude-behavioral model to understand people's behavior towards tourism during COVID-19 pandemic.

The impact of pandemics on the tourism industry should be explored from the perspective of those who will travel, go to the tourist places on vacation, and avail services from tourism and hospitality-related organizations. This study has aimed to identify the reasons for the changed human psychology towards tourism during the COVID-19 Pandemic to develop an attitude-behavioral model. This investigation thus conducted an extensive empirical study among tourists to capture their social, emotional, and financial beliefs. The research then examined the measurement model through confirmatory factor analysis (CFA) before investigating the cause-effect relationship through the structural model. Analysis revealed that the negative effect of attitude on behavioral intention toward this new equilibrium is controlled by the emotional aspect of attitude. Furthermore this paper made several contributions to the literature on human psychology, crisis management, human behavior, marketing, and tourism.

Physicians' Perspective on Percutaneous Left Atrial Appendage Closure in Patients with Atrial Fibrillation and Chronic Kidney Disease in Pakistan.

This study, conducted in Pakistan, examines the perspectives of 1200 physicians across diverse specialties regarding Left Atrial Appendage Occlusion (LAAO) procedures for atrial fibrillation (AF) patients with chronic kidney disease (CKD). Using a random sampling approach, physicians participated in a survey that assessed their familiarity with LAAO, views on its effectiveness and safety, experience levels, and encountered challenges. The results unveil a spectrum of knowledge levels among physicians, reinforcing the need for tailored medical education and training programs. The majority of respondents were between 30 and 49 years old (59.8 %). A notable proportion, 33.3 %, had limited or no knowledge of LAAO, with 16.7 % having never heard of the procedure, and 16.7 % having limited knowledge but no experience. About 36.2 % of physicians believed LAAO was moderately to extremely effective in reducing stroke risk, with 23.3 % considering it very effective and 25.4 % believing it to be extremely effective. The most commonly cited clinical indications were a history of recurrent strokes despite anticoagulation (34.6 %) and a high CHA2DS2-VASc score (27.3 %). Renal considerations played a significant role, with 33.1 % considering LAAO for CKD stage 4 or 5 patients with elevated stroke risk. Patient preferences, such as a desire to avoid long-term anticoagulant use, were important for 28.7 % of physicians. Identified challenges encompass limited equipment access, training gaps, patient reluctance, and administrative complexities. Furthermore, the study underscores the pivotal role of shared decision-making in healthcare delivery. These findings lay essential groundwork for improving LAAO utilization and patient-centered care in Pakistan's healthcare system.

Hyperemesis gravidarum and fetal gender: a retrospective study.

This retrospective study of 9,980 women who delivered at the James Paget Hospital, Norfolk, UK, over 5 years, aimed to primarily determine whether the incidence of hyperemesis gravidarum (HG) is higher in the presence of a female fetus. The results showed that more women with HG had a female fetus compared with women without HG. Also found was that heavy ketonuria was more prevalent in women with a female fetus compared with women with a male fetus, and the mean number of admissions per woman was also higher in women with a female fetus compared with women with a male fetus. It can be concluded that women presenting with HG are more likely to have a female fetus and that women with HG and a female fetus tend to a higher level of ketonuria and an increased number of hospital admissions.

Fluoroquinolone and macrolide co-resistance in clinical isolates of Campylobacter species: a 15-year study in Karachi, Pakistan.

Fluoroquinolone and macrolide antibiotics are generally considered as first-line drugs for the treatment of severe campylobacteriosis. This study was conducted to analyse the trend of erythromycin and ofloxacin resistance among Campylobacter spp. isolated from stool specimens over a period of 15 years (1992-2007) at The Aga Khan University clinical laboratory in Karachi, Pakistan. A total of 83 396 stool specimens were processed, with a 14% isolation rate for enteric pathogens. The isolation rate of Campylobacter spp. was low during 1992-93 (6%-13%), peaked in 1996 (46%), then ranged from 20% to 40%. We report a rising trend in ofloxacin resistance, re-emergence of erythromycin resistance and indications of co-resistance to both drugs in clinical isolates of Campylobacter spp.

Cultivating Innovative Work Behavior of Nurses Through Diversity Climate: The Mediating Role of Job Crafting.

Introduction: Innovative work behavior of nurses is essential to deliver affordable quality healthcare services. Diversity climate and job crafting are a few of the supportive managerial strategies that can be applied to cultivate the innovative capacity of nurses. Objective: Aim for the current study is to: (a) examine the role of diversity climate in cultivating innovative work behavior of nurses directly; and (b) indirectly through job crafting. Methods: For this study data was collected through cross-sectional design employing simple random sampling using structured questionnaires from 283 nurses. Data was analyzed using SPSS.Amos.21. Results: Results revealed the positive influence of diversity climate on innovative work behavior directly (γ = 0.51, p < .001) and indirectly through job crafting (ρ = 0.235, p < .001). Conclusion: The current study revealed that diversity climate significantly influences the innovative work behavior of employees directly and indirectly through Job crafting. Healthcare management can integrate diversity management policies and job crafting techniques in their strategies to foster innovative work behavior of nurses.

The ultrastructural development and 3D reconstruction of the transparent carapace of the ostracod Skogsbergia lerneri.

The Skogsbergia lerneri is a marine ostracod which possesses a carapace that is both protective and transparent. Since development of this carapace and how it is maintained in the adult is not known, the aim of this investigation was to carry out an in-depth ultrastructural study of the ostracod carapace at different developmental stages. Standard transmission electron microscopy and novel serial block face scanning electron microscopy (SBF-SEM) were undertaken to discern carapace ultrastructure in both two and three dimensions. Analysis revealed a carapace consisting of the same basic layer structure as other myodocopid ostracods, namely an epicuticle, exocuticle, endocuticle and membranous layer, but with a thinner adult carapace of mean thickness of 19.2 ± 1.78 µm, n = 5. The carapace layers, except for instar 1 ostracods, had similar relative proportions throughout development. The endocuticle and membranous layer thickened through advancing developmental stages due to an increase in calcified crystalline polyhedrons and a greater number of chitinous lamellae in the membranous layer. Crystalline polyhedron dimensions were significantly smaller near the boundary with the membranous layer. The borders between the carapace layers were indistinct; SBF-SEM revealed an abundance of epicuticle projections into the exocuticle and apparent gradual merging at the boundary of the exocuticle and the endocuticle. Here, we discuss how the S. lerneri carapace layer structure has evolved to serve a specific mechanical function, allowing surface protection and rigidity. In addition, we suggest that the lack of pigment and graduated layer boundaries contribute to the transparency of the carapace. SUPPLEMENTARY INFORMATION: The online version contains supplementary material available at 10.1007/s00227-021-04006-7.

Characterisation of carapace composition in developing and adult ostracods (Skogsbergia lerneri) and its potential for biomaterials.

The protective carapace of Skogsbergia lerneri, a marine ostracod, is scratch-resistant and transparent. The compositional and structural organisation of the carapace that underlies these properties is unknown. In this study, we aimed to quantify and determine the distribution of chemical elements and chitin within the carapace of adult ostracods, as well as at different stages of ostracod development, to gain insight into its composition. Elemental analyses included X-ray absorption near-edge structure, X-ray fluorescence and X-ray diffraction. Nonlinear microscopy and spectral imaging were performed to determine chitin distribution within the carapace. High levels of calcium (20.3%) and substantial levels of magnesium (1.89%) were identified throughout development. Amorphous calcium carbonate (ACC) was detected in carapaces of all developmental stages, with the polymorph, aragonite, identified in A-1 and adult carapaces. Novel chitin-derived second harmonic generation signals (430/5 nm) were detected. Quantification of relative chitin content within the developing and adult carapaces identified negligible differences in chitin content between developmental stages and adult carapaces, except for the lower chitin contribution in A-2 (66.8 ± 7.6%) compared to A-5 (85.5 ± 10%) (p = 0.03). Skogsbergia lerneri carapace calcium carbonate composition was distinct to other myodocopid ostracods. These calcium polymorphs and ACC are described in other biological transparent materials, and with the consistent chitin distribution throughout S. lerneri development, may imply a biological adaptation to preserve carapace physical properties. Realisation of S. lerneri carapace synthesis and structural organisation will enable exploitation to manufacture biomaterials and biomimetics with huge potential in industrial and military applications.

Memory instructions, vocalization, mock crimes, and concealed information tests with a polygraph.

Accuracy rates with polygraphs using concealed information tests (CITs) depend on memory for crime details. Some participants read instructions on murdering a dummy victim that specified exact crime details asked on the subsequent CIT. Others read instructions not stating details, but still requiring interaction with the exact same details for the crime. For example, the murder weapon was under four heavy boxes. Instructions stated either "... remove the 4 boxes ..." or "... remove the boxes ..." Thus, each group removed four boxes, but only one group was primed with the number "4" beforehand. In addition, the victim unexpectedly shouted at some participants during the crime. An innocent group was not exposed to either manipulation. Memory, detection scores, and detection rates were lower for guilty participants not primed with details. Sound affected detection scores but not memory, and there was no interaction between the two factors. Information tests are limited by how crime information is received.

Biomimetic Transparent Eye Protection Inspired by the Carapace of an Ostracod (Crustacea).

In this study we mimic the unique, transparent protective carapace (shell) of myodocopid ostracods, through which their compound eyes see, to demonstrate that the carapace ultrastructure also provides functions of strength and protection for a relatively thin structure. The bulk ultrastructure of the transparent window in the carapace of the relatively large, pelagic cypridinid (Myodocopida) Macrocypridina castanea was mimicked using the thin film deposition of dielectric materials to create a transparent, 15 bi-layer material. This biomimetic material was subjected to the natural forces withstood by the ostracod carapace in situ, including scratching by captured prey and strikes by water-borne particles. The biomimetic material was then tested in terms of its extrinsic (hardness value) and intrinsic (elastic modulus) response to indentation along with its scratch resistance. The performance of the biomimetic material was compared with that of a commonly used, anti-scratch resistant lens and polycarbonate that is typically used in the field of transparent armoury. The biomimetic material showed the best scratch resistant performance, and significantly greater hardness and elastic modulus values. The ability of biomimetic material to revert back to its original form (post loading), along with its scratch resistant qualities, offers potential for biomimetic eye protection coating that could enhance material currently in use.

Clinical Presentation, Management and In-Hospital Outcome of COVID-19 among Non-Healthcare Personnel and Healthcare Personnel in a Tertiary Cardiac Care Hospital.

The huge numbers of non-healthcare personnel (non-HCP) who get infected by corona virus disease 2019 (COVID-19) not only paralyze health care systems but also put health care personnel (HCP) at potential risk globally. Objective of the study was to compare the Healthcare personnel (HCP) and non-HCP COVID-19 cases. This prospective observational study was carried out in National Heart Foundation Hospital and Research Institute of Bangladesh from March 08, 2020 to July 20, 2020. During this study period all admitted non-HCP who subsequently was diagnosed as COVID-19 positive by rRT-PCR and HCP of this hospital, who experienced fever or respiratory symptoms or came in close contact with COVID-19 patients at home or their workplace and become COVID-19 positive, were included. Out of 320 infected patients, 181(56.6%) patients were non-HCP and 139(43.4%) were HCP. Non-HCP were older than HCP (Mean age: 52.95±13.82 years vs. 34.08±11.11 years; p=0.001). Non-HCP were predominantly male and HCP were predominantly female (73.5% vs. 41% & 26.5% vs. 59%; p=0.001). Non-HCP had more risk factors and co-morbidities than HCP (p=0.001). Typical symptoms of COVID-19 such as fever and cough were prevalent in HCP. More aggressive treatment was required for non-HCP. Non-HCP had more severe disease and higher case fatality rate (9.4% vs. 0.7%; p=0.001) than HCP. Disease severity (OR 0.03, 95% CI 0.01-0.15) and DM (OR 0.09, 95% CI 0.01-0.94) were the independent predictor of mortality. Non-HCP was older in age, predominantly male and had more co-morbidities than HCP. Typical symptoms of COVID-19 were prevalent in HCP. Non-HCP had more severe disease and higher case fatality rate than HCP.

Human papillomavirus infection in women with and without cervical cancer in Karachi, Pakistan.

BACKGROUND: No data exist on the population prevalence of, or risk factors for, human papillomavirus (HPV) infection in predominantly Muslim countries in Asia. METHODS: Cervical specimens were obtained from 899 married women aged 15-59 years from the general population of Karachi, Pakistan and from 91 locally diagnosed invasive cervical cancers (ICCs). HPV was detected using a GP5+/6+ PCR-based assay. RESULTS: The prevalence of HPV in the general population was 2.8%, with no evidence of higher HPV prevalence in young women. The positivity of HPV was associated with women's lifetime number of sexual partners, but particularly with the age difference between spouses and other husbands' characteristics, such as extramarital sexual relationships and regular absence from home. The HPV16/18 accounted for 24 and 88% of HPV-positive women in the general population and ICC, respectively. CONCLUSION: Cervical cancer prevention policies should take into account the low HPV prevalence and low acceptability of gynaecological examination in this population.

National Clinical Guidance for the Management of Cardiovascular Intervention in the COVID-19 Pandemic: From Bangladesh Society of Cardiovascular Interventions (BSCI).

Since the first recorded case of SARS-CoV-2 in Bangladesh on 8th March 2020, COVID-19 has spread widely through different regions of the country, resulting in a necessity to re-evaluate the delivery of cardiovascular services, particularly procedures pertaining to interventional cardiology in resource-limited settings. Given its robust capacity for human-to-human transmission and potential of being a nosocomial source of infection, the disease has specific implications on healthcare systems and health care professionals faced with performing essential cardiac procedures in patients with a suspected or confirmed diagnosis of COVID-19. The limited resources in terms of cardiac catheterization laboratories that can be designated to treat only COVID positive patients are further compounded by the additional challenges of unavailability of widespread rapid testing on-site at tertiary cardiac hospitals in Bangladesh. This document prepared for our nation by the Bangladesh Society of Cardiovascular Interventions (BSCI) is intended to serve as a clinical practice guideline for cardiovascular health care professionals, with a focus on modifying standard practice of care during the COVID-19 pandemic, in order to ensure continuation of adequate and timely treatment of cardiovascular emergencies avoiding hospital-based transmission of SARS-COV-2 among healthcare professionals and the patients. This is an evolving document based on currently available global data and is tailored to healthcare systems in Bangladesh with particular focus on, but not limited to, invasive cardiology facilities (cardiac catheterization, electrophysiology & pacing labs). This guideline is limited to the provision of cardiovascular care, and it is expected that specific targeted pharmaco-therapeutics against SARS-CoV-2 be prescribed as stipulated by the National Guidelines on Clinical Management of Corona virus Disease 2019 (COVID-19) published by the Director General of Health Services, Ministry of Health and Family Welfare of Bangladesh.

Directional instability of microtubule transport in the presence of kinesin and dynein, two opposite polarity motor proteins.

Kinesin and dynein are motor proteins that move in opposite directions along microtubules. In this study, we examine the consequences of having kinesin and dynein (ciliary outer arm or cytoplasmic) bound to glass surfaces interacting with the same microtubule in vitro. Although one might expect a balance of opposing forces to produce little or no net movement, we find instead that microtubules move unidirectionally for several microns (corresponding to hundreds of ATPase cycles by a motor) but continually switch between kinesin-directed and dynein-directed transport. The velocities in the plus-end (0.2-0.3 microns/s) and minus-end (3.5-4 microns/s) directions were approximately half those produced by kinesin (0.5 microns/s) and ciliary dynein (6.7 microns/s) alone, indicating that the motors not contributing to movement can interact with and impose a drag upon the microtubule. By comparing two dyneins with different duty ratios (percentage of time spent in a strongly bound state during the ATPase cycle) and varying the nucleotide conditions, we show that the microtubule attachment times of the two opposing motors as well as their relative numbers determine which motor predominates in this assay. Together, these findings are consistent with a model in which kinesin-induced movement of a microtubule induces a negative strain in attached dyneins which causes them to dissociate before entering a force-generating state (and vice versa); reversals in the direction of transport may require the temporary dissociation of the transporting motor from the microtubule. The bidirectional movements described here are also remarkably similar to the back-and-forth movements of chromosomes during mitosis and membrane vesicles in fibroblasts. These results suggest that the underlying mechanical properties of motor proteins, at least in part, may be responsible for reversals in microtubule-based transport observed in cells.

Nucleotide specificity of the enzymatic and motile activities of dynein, kinesin, and heavy meromyosin.

The substrate specificities of dynein, kinesin, and myosin substrate turnover activity and cytoskeletal filament-driven translocation were examined using 15 ATP analogues. The dyneins were more selective in their substrate utilization than bovine brain kinesin or muscle heavy meromyosin, and even different types of dyneins, such as 14S and 22S dynein from Tetrahymena cilia and the beta-heavy chain-containing particle from the outer-arm dynein of sea urchin flagella, could be distinguished by their substrate specificities. Although bovine brain kinesin and muscle heavy meromyosin both exhibited broad substrate specificities, kinesin-induced microtubule translocation varied over a 50-fold range in speed among the various substrates, whereas heavy meromyosin-induced actin translocation varied only by fourfold. With both kinesin and heavy meromyosin, the relative velocities of filament translocation did not correlate well with the relative filament-activated substrate turnover rates. Furthermore, some ATP analogues that did not support the filament translocation exhibited filament-activated substrate turnover rates. Filament-activated substrate turnover and power production, therefore, appear to become uncoupled with certain substrates. In conclusion, the substrate specificities and coupling to motility are distinct for different types of molecular motor proteins. Such nucleotide "fingerprints" of enzymatic activities of motor proteins may prove useful as a tool for identifying what type of motor is involved in powering a motility-related event that can be reconstituted in vitro.

Review of drug treatment for female sexual dysfunction.

Female sexual dysfunction (FSD) incorporates various sexual disorders including hypoactive sexual desire disorder, sexual arousal disorder, orgasmic and sexual pain disorders. Although many strategies have been formulated for the treatment of male sexual problems, FSD remains an area that warrants further research and trial studies to identify the most efficacious treatment options. Research has highlighted numerous pharmacological interventions that have been trialled and found to exhibit positive effects. These include hormonal therapies, prostaglandins, dopaminergic agonists, phosphodiesterase type-5 (PDE-5) inhibitors and melanocortin agonists.

Molecular detection of Ehrlichia canis in dogs from three districts in Punjab (Pakistan).

Canine monocytic ehrlichiosis is a tick-borne disease caused by an intracellular alpha-proteobacterium, Ehrlichia canis, which replicates within mononuclear cells in the host. This study was designed to use a polymerase chain reaction (PCR) protocol for the molecular detection of E. canis by the amplification of a portion of its 16S rRNA gene, as well as the effects of this alpha-proteobacterium on the haematological parameters of the sampled dogs and the risk factors associated with E. canis infection. A total of 151 blood samples were collected from dogs of various breeds at three sampling sites (Lahore, Rawalpindi/Islamabad and Multan) in Punjab, Pakistan. Data regarding the epidemiological factors (including age, gender, breed, body temperature, deworming, vaccination, mucous membrane status, hydration status, the presence of haematuria and tick infestation) were collected through a questionnaire at the time of sample collection. A 400 bp DNA fragment of the 16S rRNA gene of E. canis was amplified from 42 dog blood samples (28% of the total), [Lahore (N = 24), Rawalpindi/Islamabad (N = 13) and Multan (N = 05)] through PCR. Data analysis revealed that the character of the animals (age, sex and breed) had no significant association (P > 0.05) with the presence of E. canis. Various haematological parameters were also compared, and the results revealed that all of the parameters remained unaffected, except significantly lower white blood cell counts (P = 0.004) in E. canis-positive blood samples, as compared with the control group. We concluded that this is the first molecular confirmation of canine infection by E. canis using PCR. Moreover, no specific epidemiological parameter was found associated with the prevalence of E. canis in dogs.

Secular trends of Streptococcus pyogenes sepsis in Pakistan and analysis of clinical features in a hospitalized cohort.

Streptococcus pyogenes or Group A Streptococcus (GAS) is a re-emerging pathogen of significant public health importance. We present trends in GAS blood cultures over a 10 year period in Pakistan and characteristics of hospitalized patients with GAS sepsis over three years at a tertiary care hospital in Karachi, Pakistan. Blood cultures positive for GAS from 2004 -2014 were recorded at the clinical microbiology laboratory of the Aga Khan University and studied for trends in positivity rates. Medical records of patients hospitalized at the Aga Khan University hospital from 2012-2014 were also examined for clinical features and outcomes. GAS trends show a steady rate of blood culture positivity over 11 years, with higher rates in those >50 years, and seasonality favouring winter months. Case fatality rate in the hospitalized cohort was 34.1% (n= 14; of 41 patients). Malignancy predominated as the underlying predisposing factor among the 15-49 age group. Presence of sepsis was an independent predictor of mortality in GAS bacteremia. Studies of GAS trends in developing regions are important to inform changing epidemiology. GAS septic shock continues to have high case fatality despite antibiotic treatment. Early recognition, aggressive, goal-directed therapy for sepsis and prevention are possible control measures to prevent high mortality.

Under-utilization of pacemaker therapy for sinus node dysfunction - Real world data from South Asia.

OBJECTIVE: Chronic symptomatic sinus node dysfunction (SND), the most common bradyarrhythmia, can be effectively managed by permanent cardiac pacing. Yet the care pathway and barriers to adoption of pacing therapy are not well understood - particularly in low volume implanting countries. The IMPROVE Brady study is a quality improvement initiative being conducted at centers in South Asia, Latin America, and Russia. We assessed the rates of SND diagnosis and pacemaker treatment for SND in the South Asia cohort. METHODS: The prospective study enrolled patients with heart rate of ≤50 beats per minute presenting with symptoms including syncope, dizziness, and/or dyspnea from ten centers in India and Bangladesh. Patients were followed to identify the proportion diagnosed with SND and subsequently treated with pacemaker therapy. RESULTS: A total of 508 patients meeting criteria were enrolled and followed on average for 8.3±8.0months. Patients were on average 58 years of age, 77% were male, and 91% had completed at least primary education. An SND diagnosis was made in 368 (72%) of patients, with the majority (80%) of diagnoses occurring within 1 month of enrollment. Of the patients with an SND diagnosis, 63 (17%) were treated with a pacemaker. Reasons for not receiving treatment were: subject refusal or deferred decision (45%), unaffordability (34%), physician determined - not-indicated (20%), and other (1%). Older age, female gender, history of hypertension, lower resting heart rate, and syncopal or pre-syncopal symptoms were associated with a higher probability of implant. CONCLUSIONS: In a care pathway assessment for the diagnosis and treatment of symptomatic SND in South Asia only 1 in 6 patients received pacemaker indicated therapy, largely due to patient refusal and physician decision. Phase II of the study will be aimed to improve this treatment rate.

Fluoroquinolone consumption and -resistance trends in Mycobacterium tuberculosis and other respiratory pathogens: Ecological antibiotic pressure and consequences in Pakistan, 2009-2015.

OBJECTIVE/BACKGROUND: Fluoroquinolones (FQs) are important anti-tuberculous drugs for the treatment of multidrug-resistant (MDR) tuberculosis. Resistance to FQs leads to fewer options for treatment of tuberculosis (TB), and infection with such strains may also require longer treatment duration. Trends of resistance in Mycobacterium tuberculosis (MTB) are indicators of MTB-resistance evolution. Drivers of such resistance need to be understood and studied to inform preventive strategies. METHODS: Here, we present FQ-resistance rates and trends in Pakistan from 2010 to 2015 and compare rates with FQ-consumption data and rates in other community pathogens. RESULTS: Our results reveal a recent decrease in FQ-resistance rates in MTB, but an increase in resistance for Haemophilus influenzae and Shigella spp. Correlation of FQ resistance with FQ consumption at the population level was weak for MTB, although strong associations were noted for H. influenzae and Shigella spp. CONCLUSION: We discuss the possible reasons for the decrease in resistance rates in TB, putative drivers of resistance other than volume of FQ consumption, and the possible impact of the National Tuberculosis Programme and drug regulatory activities.

Prevalence of Vitamin D deficiency in Pakistan and implications for the future.

BACKGROUND AND AIMS: vitamin D deficiency (25-hydroxyvitamin D) affects over one billion people worldwide. Vitamin D deficiency results in progression of osteoporosis as well as other conditions. Previous studies have shown high rates of vitamin D deficiency in Pakistan despite appreciable levels of sunshine. However, none have assessed vitamin D deficiency across all age groups, genders, incomes, and locations to guide future strategies. METHODS: Questionnaire and blood sampling among 4830 randomly selected citizens. RESULTS: High levels of deficiency among all age groups, genders, income levels, and locations. Amongst the selected citizens, 53.5% had vitamin D deficiency, 31.2% had insufficient vitamin D, and only 15.3% normal vitamin D. CONCLUSION: High rates of vitamin D deficiency in Pakistan despite high levels of sunshine and previous Food Acts asking for food fortification with vitamin D. Public health strategies are needed to address high deficiency rates, including food fortification, i.e. nurture, alongside increasing exposure to sunlight, i.e. nature. This will involve all key stakeholder groups.