Most countries record maternal death only up to 42 days postpartum because of the assumption that avoidable death in pregnant women occurs during pregnancy or shortly thereafter. Although limited, the available data suggest otherwise.Avoidable deaths from pregnancy complications occur on a global scale, with the greatest burden of mortality among women in low-to-middle income countries has suggested International Classification of Diseases (ICD) coding principles that define maternal death up to a year after delivery from causes directly related to pregnancy or indirectly precipitated by the effects of pregnancy on underlying diseases. The ICD Code (ICD10) makes it obligatory to document the occurrence of pregnancy within a year of the death of any woman. What is known as late maternal death falls into the main following categories: cardiovascular cause, thromboembolism, cancer, and suicide (often related to postpartum depression).The WHO Working Group on Maternal Mortality . Maternal mortality, no matter when and where it occurs, results in sequelae that extend beyond the loss of the life of a single woman. The death of a mother adversely affects the ability of her family to survive and thrive, especially under conditions of socioeconomic deprivation. The overall poor documentation of late maternal death is a neglected global responsibility.Globally, there are more postpartum and late maternal deaths from direct and indirect obstetric causes than maternal deaths during pregnancyCardiovascular adverse events in pregnancy: A global perspective (https//doi.org/10.21542/gcsp.2021.5) a global perspective of cardiovascular maternal mortality, focusing on events during and after pregnancy, their predictors and risk stratification.The article by Suzy Kotit and Magdi Yacoub on First, the authors address the disparity in maternal mortality rates in the different regions of the world, and discuss the tools available to estimate morbidity and mortality risk in pregnant women with cardiac disease. Additionally, they discuss the continuum of maternal risk from pregnancy to late after childbirth, and highlight the mounting evidence pointing to a significant link between several events and the risk of cardiovascular disease later in life. Finally, they suggest the ways forward towards reduction of preventable maternal deaths due to cardiovascular disease.Pregnancy can trigger cardiovascular disease , aggravate underlying disease , or cause specific diseases, such as peripartum cardiomyopathy (PPCM).,5.PPCM is a global disease that is often not diagnosed timely, leading to significant morbidity and mortality. It is an important contributor to early (<42 days) and late (up to 1 year) postpartum maternal death. The reported 1-year mortality ranges from 5–25% . The fact that many of the women with cardiac disease in the peripartum period are diagnosed beyond the standard date of reporting (<42 days) is of concern because no matter how late these deaths occur, they are related to pregnancy. Additionally, counselling about the risks of future pregnancy, access to adequate contraceptive services, and adequate therapeutic management is not always providedIn the last two decades, remarkable advances in the comprehension of the pathogenesis and the improvement in peripartum patient management and therapy have been achieved, largely due to team-efforts and close collaboration between basic scientists, cardiologists, intensive care specialists and obstetricians.There is substantial progress in the options of cardiovascular imaging modalities available for pregnant women to confirm the diagnosis, to assess disease severity and stratify risk, to prognosticate, to plan for appropriate management and to assess response to therapy.. Under the umbrella of the Heart Failure Association of the European Society of Cardiology (ESC), a PPCM Study Group was established in 2009, which led to several research projects advancing the knowledge about this condition.There are many examples of recent studies on cardiac condition in the peripartum periodEuroObservational research program, which recruited >700 patients from more than 40 countries. Follow-up will be concluded in 2021. Many lessons will be learned from this program but also from the multi-centre Nigerian PEACE PPCM registry and the large clinical service dedicated to women with PPCM in Iraq .The need to create more awareness about this condition globally, as well as to understand differences in mode and presentation, led to the establishment of the international registry on PPCM, funded by the ESC under the umbrella of the We hope that over the next decade many more studies on peripartum women with cardiac conditions will be conducted in low-to-middle income countries to not only create better awareness but to improve patient care.Nothing to declare related to the content of this editorial.


The threat from antimicrobial resistance (AMR) continues to grow. Japan’s National Action Plan on Antimicrobial Resistance, which was formulated in 2016 and targets six areas, has already had a major impact on the countermeasures implemented against AMR. Particular advances have been made in AMR-related surveillance, and we now know the situation regarding antimicrobial use and antimicrobial-resistant bacteria in the country. Educational and awareness-raising activities for medical professionals and the general public have been actively implemented and seem to have contributed to a gradual move toward an appropriate use of antimicrobials. However, there is still insufficient understanding of the issue among the general public. Determining how to use surveillance results and implementing further awareness-raising activities are crucial to address this. Tasks for the future include both raising awareness and the promotion of AMR research and development and international cooperation. The government’s next Action Plan, which will detail future countermeasures against AMR based on the outcomes of and tasks identified in the current Action Plan, has been delayed due to the COVID-19 pandemic and is urgently awaited. Antimicrobial agents have made it possible to treat and prevent bacterial infections, thereby saving countless lives. However, the effectiveness of these agents is declining due to increase in antimicrobial resistance (AMR). It is estimated that AMR is responsible for at least 700,000 deaths a year worldwide . AMR is The World Health Organization (WHO) published the Global Action Plan on Antimicrobial Resistance  in 2015,Japan’s Action Plan consists of six areas, each with goals and detailed measures for achieving them . The strThe second major characteristic is that the Action Plan sets target figures (outcome indices) . For exaA new Action Plan was expected to start from 2021, continuing on from the first 5-year Action Plan (2016–2020), in order to continuously implement measures against AMR. However, the formulation of the next Action Plan was delayed due to the impact of the 2019 novel coronavirus (COVID-19) pandemic, and its contents have not yet been released as of this writing (October 2021). Against this backdrop, this article reviews the outcomes of the current Action Plan narratively and discusses potential future countermeasures against AMR in Japan. To our knowledge, this is the first article that summarizes the AMR-related activities and results under the National Action Plan in Japan.To effectively implement measures against AMR, it is essential to increase awareness of AMR and provide educational opportunities to both medical professionals  and the general public. In Japan, the Cabinet Secretariat has been holding the National Awareness Conference on Measures Against Antimicrobial Resistance every November since 2016 and presents awards for significant public awareness and educational activities on measures against AMR . The conThe AMR Clinical Reference Center at the NCGM is responsible for education and awareness-raising activities for medical professionals . It orgaA questionnaire survey on antimicrobial management for doctors working at clinics across Japan revealed that they have high levels of awareness  and suggHealth literacy is also lower in Japan than in Europe , which mExposure to information on antibiotics and AMR from reliable sources such as specialists or public organization websites has been shown to lead to good awareness and motivation for behavioral changes , indicatPharmaceutical companies have conducted campaigns to promote the proper use of antimicrobial agents among the general public, but they are relatively limited in scale and may not be very effective. The involvement of pharmaceutical companies is expected to have a great effect on physicians and other healthcare professionals.Surveillance of both antimicrobial-resistant organisms and the use of antimicrobials is essential to implement measures against AMR. In Europe, both types of surveillance have been conducted and are used as indicators for AMR control. In Japan, drug-resistant bacteria surveillance has been conducted since before the implementation of the Action Plan, when it was already known that the proportion of drug-resistant bacteria varied according to the type of bacteria compared with other countries . HoweverThe Clinical Laboratory Division of the Japan Nosocomial Infections Surveillance (JANIS) run by the Ministry of Health, Labor, and Welfare is responsible for surveillance of antimicrobial-resistant bacteria, and the results of surveillance were used when setting the outcome indices for the Action Plan. According to the 2019 annual report, the number of participating medical institutions was 2075, which was 24.8% of the total number of hospitals (8372) in Japan , su, su26], The Action Plan includes the promotion of basic and clinical research related to AMR control as well as research to clarify the socioeconomic impact of the AMR-related diseases. The Japanese government has allocated more funds to projects and research related to AMR. In the medical field, the Ministry of Health, Labor, and Welfare has established the Antimicrobial Resistance Research Center and the AMR Clinical Reference Center as well as a surveillance system to provide a platform for promoting research. The impact of AMR in Japan has become clear as a result of these efforts ,4. The MNew antimicrobials and therapeutic agents with novel concepts need to be developed to tackle AMR. Although the governments of various countries and a number of international organizations have funded such research and development, the profits achieved to date do not yet cover the development costs. As a result, development remains inadequate to control the spread of AMR. A system that ensures a sufficient return on investment in drug development is needed . The devAnother important issue is the stable supply of the antimicrobials currently used in clinical settings. A shortage of cefazolin  in 2019 caused increased demand for other antimicrobials and consequent instability in antimicrobial supply ,42. ManyNeedless to say, action on AMR is an important international issue. Cross-border movement of individuals is currently limited due to the COVID-19 pandemic, but the spread of AMR across borders will attract attention again after the pandemic. Sharing information with international organizations and other developed countries and promoting measures against AMR in developing countries will help with the implementation of measures against AMR within Japan.The Ministry of Health, Labor, and Welfare has organized the Tokyo AMR Health Conference four times since 2016. The number of participating countries was 12 in 2016, 10 in 2017, 17 in 2018, and 20 in 2021 (online). Each conference reaffirms the policy that Japan, in conjunction with the WHO Western Pacific Office, will promote measures against AMR in the Asia-Pacific region and proactively support each country’s actions ,46,47. AThese efforts are expected to lead a range of actions in future, although the outcomes might not be seen for a while.Streptococcus pneumoniae isolates and in the resistance rates to methicillin in Staphylococcus aureus isolates and carbapenems in Pseudomonas aeruginosa isolates. However, these are all still much higher than the corresponding outcome indices. The resistance rates to carbapenems in Escherichia coli and Klebsiella pneumoniae isolates were unchanged or slightly decreased, whereas the resistance rate to fluoroquinolones in E. coli isolates clearly increased. The development of antimicrobial resistance in Enterobacterales is of concern worldwide, and Japan is no exception. Even after the first 5-year Action Plan ended, the development of AMR had not abated. Thus, a sense of crisis may be needed in order to tackle this problem.The achievement in terms of the outcome indices is summarized in Antimicrobial use has decreased gradually since the Action Plan was published, with a marked drop in 2020 . BecauseAs described above, at present, most of the outcome indices have not yet been met. However, the gaps are closing for many of the indices, indicating that the implementation of the Action Plan is producing some results, albeit not fully satisfactory.Measures against AMR, especially the surveillance system that provides the basis of actions, have shown considerable advancements since the implementation of the Action Plan started. Although this article focuses on the human medical sector, various measures have also been taken in the veterinary and environmental sectors. Activities implemented in accordance with the Action Plan and achievements relative to the outcome indices need to be reviewed when considering future activities.The Japanese government plans to implement further measures against AMR in the next Action Plan after 2021. However, because of the COVID-19 pandemic, formulation of the next Action Plan has not yet been completed as of this writing (October 2021). Early formulation of the next Action Plan would help with the continuous implementation of measures against AMR.Staphylococcus aureus (MRSA) and fluoroquinolone-resistant E. coli [E. coli, is high [E. coli resistant to third-generation cephalosporins, which was added as the global indicator 3.d.2 of the Sustainable Development Goals (SDGs) [For the next Action Plan, outcome indices must be decided carefully. For example, simply reducing the total use of antimicrobials should not be the target. Any reduction would be pointless if the necessary use of antimicrobials was decreased as well. Thus, specific indices for the inappropriate use of antimicrobials need to be set based on reports from Japanese institutions. Moreover, while the decreases seen in the resistance rates to antimicrobials in bacterial isolates are favorable, the impact of these decreases will be lost if the number of cases of infectious diseases caused by these bacteria increases. Thus, more specific indices, such as the number of cases of bloodstream infections caused by antimicrobial resistance bacteria, will be more significant for clinical practice and public health. More than 8000 individuals die every year due to bloodstream infections by methicillin-resistant  E. coli . The bur is high . The pers (SDGs) , could bAwareness of the appropriate use of antimicrobials has risen in recent years. The importance of measures for preventing infections in the clinical settings as well as collaboration between governments and medical institutions has been recognized anew during the COVID-19 pandemic. The existing directions will be maintained by introducing actions based on new outcome indices in the new Action Plan. Furthermore, the One Health approach will continue to be followed to further promote action in the veterinary and environmental sectors, and new issues, such as a stable antimicrobial supply, will be taken into account.Measures against AMR are an important theme requiring constant, long-term efforts. It is worth emphasizing that, globally, implementation needs to be done within the context of the SDGs . This isThis study has several limitations. First, the Action Plan is extensive, and this study did not cover every aspect of it. For example, this study did not evaluate the AMR-related efforts being made by the agricultural and environmental sectors. In addition, this study is a narrative review and may not fully reflect all of the achievements of the Action Plan to date. Finally, the movement within the government toward the next Action Plan may not have been fully taken into account.A variety of measures have been implemented under the Action Plan for AMR Measures published by the Government of Japan in 2016. Novel approaches have been taken in various fields, including the promotion of the One-Health approach. In the field of surveillance in particular, significant progress has been made compared with the pre-Action Plan period, including the establishment of novel surveillance systems and the launch of a website summarizing AMR-surveillance results. Antimicrobial use has decreased and is approaching target levels, but there is a need for careful monitoring due to the impact of the COVID-19 pandemic. In addition, the target percentage of drug-resistant bacteria has not yet been reached. The next Action Plan should set targets and decide what measures to take in the future based on a careful consideration of the efforts made so far.


We propose and test a model of food policy acceptability. The model is structured in four levels: government, topic, policy, and individual. In this study, we focus on two levels that are actionable for policy-makers: the topic and policy levels. We assess nine factors using a first online survey with 600 UK nationals and replicate our results in a second survey with 588 participants. Our results suggest that three factors have a positive effect on acceptability at the topic level: awareness of the issue, the legitimacy of state intervention, and social norms. At the policy level, we report a positive effect of the policy’s expected effectiveness, its appropriate targeting of consumers, and the perceived support of the majority. On the other hand, more coercive interventions and those generating inequalities are judged to be less acceptable. Additionally, we report an interaction between awareness and coerciveness on acceptability. Participants who are aware of the issue were more likely to support coercive policies. We also find evidence for a trade-off between coerciveness, effectiveness, and acceptability, as more coercive measures are considered more effective, but less acceptable by participants. Our findings offer policy-makers, nutrition experts, and advocates for healthier and more sustainable diets a new and integrated understanding of the underlying factors that determine food policy acceptability. Population growth, combined with global changes in diets that are increasingly rich in sugars, refined fats, and animal-based products, is putting both our environment and public health under great stress. Food production is responsible for more than 25% of our greenhouse gas emissions , occupieRecent works have shown that healthier and more sustainable diets can efficiently mitigate these issues, namely by reducing sugar consumption and shifting to plant-based proteins and unsaturated oils ,7,8,9. HAppeals for public interventions supporting food transitions are therefore accumulating . Authoriany governmental intervention. The topic level adds factors that relate to the acceptability of public interventions for a specific topic. Citizens might have preferences for interventions depending on what the policy concerns . The policy level corresponds to factors that influence the acceptability of a specific policy for a given topic . Finally, the individual level includes demographics and personal characteristics that may influence acceptability perceptions. In this study, we focus on the topic and policy levels. We restrict our attention to these two levels as we seek to understand what drives the variation of acceptability for different interventions across topics and policies for a given government and population.The objective of this paper is to offer a better understanding of the different factors that are actionable for policy-makers to increase the acceptability of policies regulating food. To that aim, we propose and test a level-based model of food policy acceptability. The governmental level includes macroscopic factors that influence the acceptability of In this work, we asked about 1200 UK nationals about their perceptions of different policies regulating a given food item . The policies are composed of two education interventions  and four increasingly coercive market interventions . Regarding the topic-level factors, we found that participants were more likely to support a food policy when they were more aware of the issue at stake, when they believed that it was legitimate to have collective rules regulating the product under scrutiny, and when there were strong social norms regarding the necessity to reduce the consumption of said product. As far as policy-level factors are concerned, we observed that policies were more popular when they were seen as more effective and when they targeted the appropriate group of consumers. On the contrary, consumers found coercive interventions and policies that generated inequalities less acceptable. Our results show the existence of a trade-off between coerciveness, effectiveness, and acceptability, as participants judged more coercive policies to be more effective, but also less acceptable. These conclusions can help guide policy-makers in the design of policies supporting a dietary transition.The interest in food policy acceptability has grown in the past decades, mainly following the increasing prevalence of obesity in developed countries . The resWe propose a structuring of these factors in a multilevel model of food policy acceptability, which we relate to the existing literature, which often considers them in isolation ,25,26. IIn our model, the governmental level includes factors that relate to perceptions about the government itself, such as the level of (mis-)trust in the government or the level of corruption, which can influence the acceptability of any policy proposed. At the topic level are factors that affect acceptability of an intervention due to a certain reason, such has limiting deforestation or preventing obesity. At the policy level are factors that determine acceptability of a specific type of policy. Finally, the individual level includes demographics, political leaning, and other personal characteristics. Although previous works showed that individual-level factors may influence acceptability, such as women finding interventions generally more acceptable ,35, someIn this paper, we focus on the roles of the topic and policy levels in the acceptability of public interventions and how they vary across topics and types of policies for a given government and population. Our ultimate objective is to identify factors that are actionable by policy-makers to maximize the chances of a successful dietary transition. The model and the factors that were tested in the online survey are summarized in The acceptability of a specific policy might depend on the underlying issue calling for governmental intervention, i.e., the topic of the policy. Previous research found that the level of awareness of the issue at stake is a key determinant of policy acceptability. Bos et al.  showed, Scientific research is regularly used as a basis for the implementation of new policies, but does it affect public acceptability? Policy-makers in the USA and New Zealand have suggested that more scientific evidence and/or a larger spread of scientific results could increase the public support for taxes on sugar-sweetened beverages ,39, as tSocial norms have also been established as a determining factor of the acceptability of public policies. Stok et al.  reportedLast, views about the boundary between decisions that should remain inherently private and those that should be regulated by the state may influence the acceptability of public policies. As the body of evidence emphasizing the link between diets and chronic diseases has grown, governments have started taking action to influence diets . In 2014Despite being favorable to public intervention on a particular topic, citizens might consider a specific policy choice unacceptable. The perceived fairness of a policy has been consistently reported to increase its acceptability for both health interventions and environmental ones ,45. HoweMoreover, citizens are also more prone to accepting interventions that are perceived as effective ,36. In aRestricting freedom of choice, i.e., the coerciveness of the policy, is, on the other hand, expected to negatively impact acceptability judgements. This effect has been documented for dietary interventions and for different health-related behaviors ,34.We investigated the role of the nine aforementioned factors in the determination of the acceptability of public interventions using an online survey.We explored the determinants of policy acceptability for dietary interventions on three products that address the main challenges that food systems currently face: sugar , palm oil (environment), and cage eggs .Sugar consumption has been shown to be a major driver of obesity and is associated with greater health risks ,50. ThisWe designed an online survey to elicit the factors that determine the acceptability of food policies. We adapted the survey to each of the three topics (between-subject design). The three questionnaires are displayed in the Sugar treatment, the public intervention focuses on snacks that have a high sugar content (more than 33 g of sugar per 100 g). In the Palm and Eggs treatments, the policies target snacks that contain palm oil or cage eggs, respectively. The six interventions are similar across topics: introducing a label to identify the targeted products, setting up an information campaign to educate consumers about the social impact of the products, introducing taxes of GBP 0.10, 0.30, or 0.50 for the targeted 30 g individual snacks, and removing the targeted snacks from the market , the perception of the problems generated by the consumption of the targeted product (awareness), the social norms about whether the consumption of the targeted product should be reduced , and whether the product was over-consumed compared to the latest scientific recommendations (scientific norm).Second, on a seven-point Likert scale, participants were required to indicate the extent to which they agreed with a list of statements regarding topic-level factors. The statements concerned the legitimacy of having collective rules on the consumption of the targeted product (effectiveness), targeted the appropriate group of consumers (targeting), was coercive (coerciveness), was acceptable for the participant (acceptability), if majority of citizens would agree with its implementation (majority), and if it would increase inequalities in society . As an attention check, the questionnaire displayed the effectiveness question twice (once in the first position and once in the second-lowest position).Third, we asked participants about the degree to which they agreed with a second list of statements regarding policy-level factors for each of the six public interventions listed at the beginning of the survey . Using a seven-point Likert scale, participants were required to report whether they agreed that the intervention was effective in reducing the consumption of the targeted product (vote) of each of the proposed interventions individually .Last, we asked participants whether they would vote “In favor” or “Against” the implementation  .effectiveness question twice and removing participants who gave significantly different answers to the same series of questions. We computed the average absolute deviation in answers given to the effectiveness questions for the six policies under consideration: Sugar, 32 in Palm Oil, and 24 in Eggs). We retained the answers to the first effectiveness question in the analysis.To be eligible for the study, participants had to be born in the UK, to be UK nationals, and to have English as their native language. About 36,000 participants on the platform fulfilled our selection criteria (checked in early 2021) and were considered as active . All Prolific participants who fulfilled the above selection criteria could take part in our study until it reached the maximum number of participants. We defined an exclusion rule prior to the survey with Prolific by asking the Sugar, 191 participants in Palm, and 193 participants in Eggs (some participants revoked their consent to transmit the data to the researchers). We further asked Prolific for data on the BMI scores.In total, 600 participants completed the study and passed the attention check (200 respondents per topic). As it was not the focus of this study, we did not ask for demographics during the survey to avoid cross-contamination, but still exported the data previously gathered by Prolific. We were able to retrieve the demographics for 198 participants in Descriptive statistics of the three samples are displayed in acceptability scores . Third, interventions regulating palm oil and cage eggs displayed similar acceptability levels, but were more accepted than those related to sugar consumption We begin by discussing the policy y scores . First, acceptability, and vote was strongly correlated . The multivariate analysis below clusters the observations at the individual level to take into account the repeated observations in the data). We observed similar patterns, and some of the above figures are even more salient. The highest shares of votes were found in label and information campaign, followed by tax10. Here, the lowest share of votes was also for withdrawal for Sugar and for tax50 for Palm and Eggs. Moreover, only 20% of the participants supported the withdrawal of the products with high sugar content compared to 60% for palm oil and cage eggs. Last, a majority of respondents rejected the highest level of taxation for palm oil and cage eggs, but they were more than 60% likely to accept the withdrawal from the market.The findings for the hypothetical votes  were verlegitimacy), (ii) there are negative effects associated with the targeted product (awareness), (iii) the product is over-consumed compared to scientific recommendations (scientific norm), and (iv) it is commonly accepted that consumption should be reduced . Indeed, all averages were greater than four points . Second, we can see that the intervention of the state was as legitimate for Palm as for Eggs , followed by palm oil  and cage eggs . Similarly, people were more likely to consider that the product was over-consumed for sugar  than for palm oil  and cage eggs .We now consider the topic-level factors, whose descriptive statistics are displayed in acceptability scores given to each of the six policies. We then correlated it with the topic-level factors  and demographics , and effectiveness, targeting, coerciveness, majority, inequality). The terms To identify the determinants of the acceptability of food policies, we estimated the following mixed linear model on acceptability and vote are displayed in acceptability and vote correlated with similar factors. The more one believes that it is legitimate to have collective rules for the topic under scrutiny (legitimacy), the more acceptable public interventions are. Policies that are expected to be more effective (effectiveness), to target the appropriate group of consumers (targeting), and to be accepted by the a majority of fellow citizens (majority) are also more likely to be accepted. On the contrary, coercive policies and those that are perceived as a source of inequalities in the society are less likely to be supported . On the other hand, the scientific norm did not significantly correlate with the level of acceptability in the multivariate analysis. Two variables showed weaker evidence. Social norm positively and significantly correlated with acceptability, but only partially with vote . The second variable that showed weaker associations was awareness. It positively and significantly correlated with vote in all specifications, but not for acceptability (the association was significant only in Sugar), which we discuss in the next section.Estimates of the majority is associated with an increase of 0.5 points in acceptability and an increase of eight percentage points in vote. Legitimacy is the second-largest contributor to acceptability (+0.26) and vote (+4 pp). The policy’s effectiveness is estimated to be the third-largest contributor . Perceived increases in inequalities and coercion have overall similar negative impacts on individual acceptability (−0.07) and vote (−1.5 and −1.3 pp respectively). The appropriate targeting of the policy has a similar but positive impact on acceptability (+0.12) and vote (+1.3 pp). Last, we ran a backward model selection analysis to understand which set of variables best explained acceptability and vote. To do so, we started with the full models . To do scientific norm were significantly associated with the acceptability of food policies. The results are displayed in acceptability score, all variables but scientific norm were significant in the pooled analysis. Regarding vote, we obtained a similar pattern, except for the social norm, which was not significant. Finally, we can note that the average levels of acceptability showed similar patterns to those obtained previously. We reproduced We pre-registered that all variables but All but one (scientific norm) of the nine factors tested correlate with acceptability judgments or hypothetical voting behavior. At the topic level, the perceived legitimacy of having collective rules to regulate the product at stake and favorable social norms are associated with stronger support for public intervention. At the narrower policy level, policies that are expected to have majority support, that target the appropriate group of consumers, that do not generate inequalities, and that are less coercive benefit from a larger acceptability. Our results concur with previous conclusions on food and health policy acceptability ,23,34, aawareness did not significantly correlate with acceptability in the multivariate analysis. We explored the possibility that the effect of awareness on policy acceptability depends on the type of policy. To do so, we regressed the acceptability scores and hypothetical votes for each type of policy separately . Policy-makers must therefore choose the appropriate level of coercion that maximizes the change in behaviors while maintaining a sufficiently high level of acceptability for the population. In this paper, we did not investigate the actual capacity of a policy to change behaviors. However, it is worth noting that recent evidence indicates that certain information interventions, which are considered widely acceptable, can affect food consumption behaviors in the short and mid term [This trend corroborates the established trade-off that public authorities face between coerciveness and popular support. Coercive measures are appealing to policy-makers, as they are more likely to be effective, which participants also acknowledge. mid term . When pomid term ,60.acceptability and vote scores across topics. A notable exception was the change in acceptability between tax50 and withdrawal. A priori, one could reasonably expect a lower acceptability for withdrawal than for tax50, as removing the possibility to buy the product should be judged as more coercive than taxing it. However, this decrease in acceptability was observed for the Sugar survey only, and people were more likely to accept the withdrawal than the highest level of taxation for Palm and Eggs. While participants indeed perceived the withdrawal as more coercive than taxation for all topics, we observed that their views diverged regarding its effectiveness: The effectiveness gain of shifting from high taxation to withdrawal was smaller for Sugar than for Palm and Eggs , while they are mainly borne by others in the cases of palm oil (deforestation) and cage eggs . Consuming sugar is thus more likely to be perceived as a personal choice, unlike palm oil and cage egg consumption, which can be seen as mainly a social issue. This idea is supported by the data, as we observed a lower legitimacy for interventions regarding sugar. In this case, coercive measures for sugar could be considered as a way to protect consumers from themselves, which can be perceived as paternalistic, while they would be considered as a way to protect others in the cases of cage eggs and palm oil.Future research can build on this work in three main ways. First, our study focused on two levels of a four-level food policy acceptability model, as we excluded perceptions of the central government, judging them to be hardly actionable for policy-makers, and did not seek more individual information from our participants than what was already available. Future researchers would still benefit from incorporating these macro- and microscopic factors into their analyses. Cross-country comparisons could, for example, provide interesting insights on the variation of the effect of such factors in countries with different institutions and social capital.Second, our research did not specifically measure the behavioral costs of policies. Policies with similar designs and pursuing the same objectives might still have very different behavioral implications. For example, citizens might have different acceptability judgements regarding the banning of meat compared to the banning of palm oil, even though both policies would help prevent deforestation. Other factors than those that we identified here might come into play. These could include citizens’ personal preferences, such as attachment to a certain part of their diet , or the Third, our work reports correlations between factors and acceptability judgments, which does not allow us to rule out reverse causality. Motivated beliefs (see ) can, foFuture works could investigate the robustness of our results in terms of two dimensions. First, the participants in our study were not representative of the UK population. As discussed in


Day and night dominate our life and profoundly influence society. We feel the importance of the differences between day and night if we need sleep or if we have a jetlag. Both phenomena are triggered by our circadian clock, which can be influenced by light. Deprivation of light as well as perturbation of the circadian clock leads to severe health problems (Lee et al., For many people, including researchers, it comes as a surprise that microbes also react strongly to light and that they have sophisticated circadian clocks as well (Hurley et al., Trichoderma reesei (Stappler et al., However, despite the wealth of data already available, the question remains why growth in light on the same medium and under equal conditions alters the metabolism and physiology of fungi so drastically, as seen in the case of the fungus The articles of this Research Topic highlight effects of light on fungi as well as non-phototropic bacteria, reflecting the breadth of studies on light response in microbes. Their findings bring us one step closer to understanding the biological relevance behind the complex regulation of light dependent processes in microbes.For bacteria, the studies in this Research Topic tackle the issue of light response from two different angles: substrate utilization and growth as well as genome wide transcriptome alterations. Moreover, both studies showed that in the microbes responding to light putative photoreceptor proteins were also detected.Alsanius et al. investigated the influence of white, blue, and red light on non-phototrophic bacteria inhabiting the phyllosphere. They found altered substrate utilization patterns for carbon, nitrogen, and phosphorous sources in dependence of light. These alterations varied for different bacteria and the extent of the responses was strain specific. Interestingly, biofilm formation and biosurfactant production also correlate with responses to light, although in this case it remains to be shown whether light directly influences these phenomena or if the effects are indirect via an alteration of growth rates due to illumination. Overall, this study nicely shows that light responses in bacteria are species specific and it indicates that the microbiome of the phyllosphere likely changes in different light regimes.Hempel et al. investigated transcriptomes of two species of actinobacteria over a time course of several hours. They especially looked at genes involved in carbon metabolism. This study shows interesting differences in the regulation of genes associated with the TCA cycle between species. Interestingly, the genes responding to light in these two species are largely dissimilar, even though many light-dependent effects are comparable. The authors conclude that the reaction to light is widespread, but direction and specificities are different, suggesting that different species deal with light in unique ways.Fusarium fujikuroi and Trichoderma atroviride. Pardo-Medina et al. focused on the white collar-1 homolog WcoA of F. fujikuroi and could show that most of the fast, intermediate, and slow responses to light in terms of gene regulation are dependent on WcoA. The impact of light was especially significant for the regulation of secondary metabolite gene clusters. Moreover, reminiscent of earlier studies in T. reesei (Tisch and Schmoll, F. fujikuroi WcoA has broad functions in darkness—to an even larger extent than T. reesei. Consequently, the previously revealed flat hierarchy of the transcription factor function in Neurospora crassa (Smith et al., The two studies on fungal light responses tackle the question of how the light response machinery works, with intriguing investigations of fungal photoreceptors in Pola-Sánchez et al. added a new and important chapter to the function of the photoreceptor ENV1: the Trichoderma homolog of N. crassa VVD. This PAS-domain protein already showed diverse functions in T. reesei (Schmoll, Pola-Sánchez et al. now connect the photoreceptor function of ENV1 to DNA repair and central metabolism in T. atroviride and postulate that ENV1 prevents exacerbated light responses. In N. crassa a comparable function was shown in that VVD blocked excitability of the light response machinery after a first light pulse (Schwerdtfeger and Linden, Pola-Sánchez et al., further show that the cryptochrome/photolyase family proteins CRY1 and CRY-DASH contribute to regulation of conidiation, and that ENV1 as well as CRY1 impact light dependent carbon and nitrogen metabolism.Schmoll,  and addsIn conclusion, both fungi and bacteria show distinct responses to light. As could be concluded from previous work on microbial light response, the studies here also reflect that the aim of metabolic responses for an optimal coping with light is similar for different species. However, the mechanisms for achieving this aim in terms of gene expression, regulation, and substrate utilization are divergent. Consequently, for a given species, prediction of how it might react to light physiologically is difficult. While the studies presented in this Research Topic provide intriguing new insights into microbial light response, still more investigations are needed to understand the complexity of light response in microbes. Moreover, together with previous work, these studies highlight the importance of using controlled light conditions when working with microbes, as there is hardly any regulatory aspect of microbial physiology that is known to not be subject to alteration by light conditions.MS drafted the manuscript and wrote the final version of the manuscript. CS and WZ edited the draft. All authors read and agreed to submission of the article. All authors contributed to the article and approved the submitted version.Author MS was employed by the company AIT Austrian Institute of Technology GmbH. The remaining 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.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.


This study focused on medical care in a single country (China) and in regions with different economic backgrounds and different economic development levels to determine the effect of healthcare expenditure on short- and long-term economic growth. The study supported some interesting conclusions: (1) For most areas of China, increasing healthcare expenditure has a negative impact on economic growth in the short term but promotes growth in the long run; (2) Under different levels of economic development within China, there is significant heterogeneity in the interaction between healthcare expenditure and economic growth; (3) The negative effects of healthcare expenditure on short-term economic growth are greater during periods of economic turbulence than during times of stability; and (4) Healthcare expenditure has a negative effect on underdeveloped areas through the accumulation of material capital, while in economically developed areas, this channel has the opposite effect. To improve the quality of medical and health protection and the quality of life and welfare, China needs to consider the development characteristics of different economic zones and establish a multilevel, systematic and diversified medical and health protection system. White Paper on China's Action against the Epidemic of Coronavirus Pneumonia published by the Press Office of the State Council of China showed that the average medical cost for confirmed patients nationally was ~23,000 yuan, and the treatment cost of individual critically ill patients reached up to millions of yuan. All of these costs were borne by the state, and the total expenditure was well-beyond 1 billion yuan. The interaction between healthcare expenditure and economic growth is one of the key areas of public health research in China. The sudden outbreak of COVID-19 and the resulting trade-off between “protecting people's livelihood” and “promoting the economy” increase the value of discussing the impact of healthcare expenditure on the market economy. Not only China, but the whole world is facing such a test, especially at the time when the COVID-19 epidemic is raging. Is it possible to balance “protecting people's livelihood” and “promoting growth” as much as possible, directly affecting the development of a country or region's medical and health security system, people's livelihood and welfare, and long-term economic development. For the whole world, the establishment of a multi-dimensional, three-dimensional, and targeted medical and health security system is of great practical significance.In early 2020, COVID-19 unexpectedly swept the world, with more than 80 million people diagnosed and nearly two million dead in less than a year. Governments worldwide launched a series of targeted measures to protect people's health and save their economies. However, it is not possible to both “protect people's livelihood” and “promote the economy.” If strict isolation is implemented to prevent the further spread of the virus, it will result in a costly sharp drop in income, a soaring unemployment rate and an economic downturn. Even countries that try to maintain economic activities with the expectation that mass immunization will take effect may find that this strategy does little to maintain the normal operation of the economy. From a global perspective, with the advent of autumn and winter, the number of infected people has not decreased. Instead, the new coronavirus has mutated. The pain brought by COVID-19 may continue to affect human society well into the future. China was the first country to confront this new epidemic, but it also took the lead in restoring economic order under the epidemic, which was closely related to the anti-epidemic disaster relief provided by the government for the Chinese people regardless of the cost. China has made great efforts in the fight against COVID-19. On June 7, 2020, the A medical and health security system can provide people with better medical care, effectively improve the health status of residents, improve life expectancy, and increase social welfare and overall safety , 2. HoweFrom the above analysis, it can be seen that previous studies have discussed the effect of health expenditure on economic growth from various perspectives and reached many meaningful conclusions. However, there are still several research gaps to be filled. The previous literature generally studied the economic growth effect of healthcare expenditure based on the constant parameter method, but, in fact, there should be differences in the impact of healthcare expenditure on economic growth against different economic contexts, and the constant parameter model cannot describe this subtle variety. Previous research that adopted an econometric model to identify the economic growth effect of healthcare has been able to partially identify the different impacts of health expenditure on economic growth among countries with diverse economic systems but has not paid sufficient attention to the same differences in impacts across different development regions within a country. Most of these studies treat the impact of domestic healthcare expenditure on regional economic growth as homogeneous, and they do not explore the dynamic trajectory of the impact of healthcare expenditure on economic growth in different economic zones. In addition, there is no research that incorporates the numerous economic variables involved in the process through which healthcare expenditure acts on economic growth into the systematic analysis framework. The lack of important influencing variables may lead to a large deviation between the analysis results and the real economy, which is another reason why many studies fail to reach a unified conclusion on whether healthcare expenditure drives or inhibits economic growth.In view of this gap, this paper attempts to construct a non-linear model of the dynamic time-varying relationship between healthcare expenditure and economic growth in China under a systematic analysis framework with a large number of possible economic variables and then empirically identifies the impact of medical and health spending on economic growth in China and in its distinct domestic economic regions, analyzing the possible transmission path for the impact of healthcare expenditure on economic growth. Compared with the existing literature, the marginal contribution of this paper is as follows. First, an econometric model with time-varying parameters is constructed to identify the effect of healthcare expenditure on economic growth to effectively capture whether healthcare expenditure stimulates or inhibits economic growth given different economic contexts in different periods. We also identified and distinguished the economic growth effect of healthcare expenditure in China nationally and regionally, which provides empirical evidence for the differential and comprehensive improvement in China's medical security system. Second, this paper provides not only an effectively analysis of the dynamic adjustment mechanism behind healthcare expenditures' impact on economic growth but also discusses the path through which healthcare expenditure impacts economic growth under a systematic analysis framework including a broad set of possible economic variables. This work offers a new understanding of the transmission characteristics for the effect of medical care and health on economic growth and can be regarded as a critical supplement to current research on the improvement in the medical security system.The rest of this document is arranged as follows: the second section offers a literature review and develops the hypotheses. The third section constructs the time-varying parameter measurement model and introduces the selection of variables and data description. The fourth section analyzes the economic growth effect of healthcare expenditure, discusses the influence and transmission path between China's health expenditure and economic growth in different economic areas, and conducts a robustness test. The last section summarizes the full work and provides policy recommendations.As a vital guarantee of national livelihood security, the medical security system plays a stabilizing role in economic development. During rapid economic development, the government can increase medical security expenditure on a large scale and improve medical security treatment to buffer the speed of economic development; when the economy is at a low, medical security expenditure can replace residents' preventive savings and stimulate domestic demand to encourage residents' consumption. In the past, most studies on the relationship between expenditure and economic growth have focused on the macro perspective –16. SomeHypothesis 1a. China's healthcare expenditure has a positive effect on economic growth.Hypothesis 1b. China's healthcare expenditure has an inhibitory effect on economic growth.Although the direction of medical and health spending on economic growth is indeterminate, a considerable number of studies have discussed this issue. In contrast, the specific mechanism through which healthcare expenditure effects economic growth has been ignored. Representative research results show that the economic growth effect from healthcare expenditure is mainly realized through the accumulation of material and human capital. Specifically, healthcare expenditure will occupy household consumption expenditures and directly affect the consumption allocation of residents. Based on precautionary savings theory, this behavior will raise household consumption and reduce savings as well as the speed of material capital accumulation . As a reChina is a developing economy: the medical security system is not perfect, the population is large, and a considerable part of the population has little disposable income. Therefore, in the short term, healthcare expenditure creates real pressure on middle- and lower-level families, further reducing their disposable income and thereby affecting economic growth. A long-term medical insurance system can effectively alleviate the family poverty caused by illness, providing a significant umbrella for ordinary families in the face of natural and man-made disasters and preserving the time and energy of residents for investment in human capital reserves, so it may have a positive impact on economic growth. Based on this reasoning, the second assumption of this paper is proposed:Hypothesis 2. China's healthcare expenditure plays a role in economic growth through the accumulation of material and human capital. The material accumulation channel has a negative impact on the economic growth effect of healthcare expenditure in the short term and a positive effect in the long term. The human capital accumulation channel has a positive impact on the economic growth effect of healthcare expenditure in both the short and long term.Few researchers have also attempted to seek the mechanism through which medical security expenditure affects economic growth considering aspects such as residents' consumption, aging, degree of economic openness, employment rate, economic development level, etc. –32. TakiHypothesis 3. The economic growth effect of China's healthcare expenditure is significantly different in different regions.To test hypotheses 1, 2, and 3, this paper designs the following research process.This paper focuses on the effect of China's healthcare expenditure on economic growth and holds that healthcare expenditure will have different effects on long- and short-term economic growth. The impact of healthcare expenditure on economic growth is regulated by the medical security system and is mainly realized through the accumulation of material and human capital. In this study, China's healthcare expenditure is represented by the proportion of healthcare expenditure in GDP (%), short-term economic growth is represented by the quarterly per capita GDP growth rate (%), and long-term economic growth is represented by the 5-year per capita GDP growth rate (%). When discussing the transmission path for the effect of medical expenditure on economic growth, the accumulation of physical capital and human capital are, respectively represented by the total amount of fixed assets investment and the percentage of education expenditure in GDP (%). The specific data are described in In addition, considering that the effect of healthcare expenditure on economic growth will be influenced by many other economic factors, if the many economic variables potentially involved are not included in the systematic analysis framework, the empirical research results may deviate from the actual economic situation. Considering the latent factors that may affect the relationship between health expenditure and economic growth and the availability of data, this paper identifies and classifies 78 influencing factors, mainly related to the level of economic development, macroeconomic status, economic openness degree, population aging and so on. All data are quarterly data from the Wind database. The obvious seasonal factors are processed by X-12, the non-stationary data are processed by the ADF test, and some missing data need to be supplemented by interpolation.Databaset. Concurrently, to eliminate the curse of dimensionality caused by including too many variables in the traditional model, we use the method of Bernanke and Boivin lt, wt] is composed of long- and short-term economic growth rate and health expenditure as observation variables and proxy variables, respectively.t = 1, …, T,i=1,…,p, Equation (2) be random walks; then, by solving the equation, we can obtain:Furthermore, let the residuals in L) = diag(ρ1(L), …, ρn(L)), j = f, l, w;H = diag(exp(ht1), …, exp(hnt)). The form of residuals with the random walk is Γ, let the model have the form of random fluctuation, and all the residuals conform to the innovative random walk. Then, this model can verify how the leading factors in the effect of health expenditure on economic growth change under diverse economic contexts. If hypothesis 2 is true, Following In reality, China possesses a vast territory, and its economic development gap between different regions is large. To comprehensively test hypothesis 3, considering China's economic areas and data availability, we select Beijing, the capital of China; Tianjin, a municipality directly under the central government in northern China; Jilin, a representative in the northeastern part of the old industrial base; Sichuan, a representative area in southwestern China; and Inner Mongolia, a representative in the Yellow River basin, to fit the impact of health expenditure in each region on the short- and long-term growth of China's economy and transmission channels. For a description of the economic data selected in this paper, please refer to Before conducting empirical research, it should be noted that all economic variables included in the systematic analysis framework should be handled as stable to avoid the problem of spurious regression. This section is based on the model in the previous section. First, the historical characteristics of the evolving effect of China's healthcare expenditure on economic growth are analyzed by the time-varying parameter method, and then the possible transmission path for the healthcare expenditure effect on short-term and long-term economic growth is discussed based on the pulse response method. Overall, the comprehensive combination of the dynamic change in the effect of China's healthcare expenditure on economic growth and its mechanism in recent years allows us to obtain some revealing findings as follows:In conclusion, the results of the three-dimensional impulse response function illustrate the impact of health expenditure on short- and long-term economic growth and offer an initial exploration of the possible causes of heterogeneity in the effects of medical and health expenditures on economic growth in different economic contexts and different economic regions. The empirical results show that hypothesis 1 is incomplete. In the short run, increasing health expenditures will have a negative impact on economic growth, while in the long run, the benefits of increasing health expenditure gradually emerge, as reflected in the acceleration of long-term economic growth. Specifically, for distinct economic regions in China, the growth of short-term healthcare expenditures will lead to a decline in economic growth, but the corresponding results for the long-term impact of healthcare expenditure on economic growth are significantly different, so hypothesis 3 is tenable. To further test hypothesis 2 and to further explore the impact of health expenditure on economic growth, we simulated the role of the physical and human capital accumulation channels in the transmission process.There are significant differences between physical capital accumulation and human capital accumulation. Physical capital investment has a faster effect, including it among short-term capital returns. However, human capital investment often has an exceedingly long lag before returns are realized. Whether the returns come through improving national health and then improving effective labor time or through accumulating investment in education for the next generation, they cannot be obtained in a short time. This paper investigates the role of physical and human capital accumulation channels in the economic growth effect of healthcare expenditure in China, Inner Mongolia, Jilin, Beijing, and Tianjin; the results are summarized in As shown in In this section, we utilize two common robustness test methods to verify the above empirical results. First, the sampling interval is replaced by other subintervals to verify whether the main conclusions we obtained are still valid in other time periods and to try to avoid the influence of the sampling interval on the main research conclusions. Second, by changing the lag order in the SV-TVP-FAVAR model, we can measure the reliability of the above empirical research conclusions from the perspective of the model.In the baseline analyses, to explore the economic growth effect of national medical and health expenditure, we selected a sampling interval from the first quarter of 2006 to the fourth quarter of 2019; however, the sampling range for analyzing the economic growth effect of medical and health spending in other economic regions of China is limited by the availability of data in each economic region. The effect of health expenditure on economic growth mainly occurs through the accumulation of physical and human capital, but the effect of health expenditure on economic growth is inevitably also affected by other economic variables. To address this issue, this paper introduces the idea of factor enhancement, which abstracts major possible economic variables into three unobservable common factors to include as many factors as possible in the systematic analysis framework. However, the problem is that a longer sampling interval implies that more factors that may ultimately affect the effect of health expenditures on economic growth are included, and the sampling intervals selected in different areas are also diverse. Apart from the sampling interval selected in this paper, does the effect of medical and health expenditure on economic growth still support our main conclusions? To verify the robustness of the empirical research conclusions for other sampling intervals, we choose the first quarter of 2017 to the fourth quarter of 2019 as a new adoption interval that is unified in each region. The verification results are shown in In the baseline model, the first-order lag is adopted according to the AIC; thus, in this section, we change the lag order in the model. With the other conditions remaining unaltered, we change the lag order of the model and then use the second-order lag model and the third-order lag model to analyze the effect of medical and health expenditure on economic growth. The results are shown in This paper conducts an empirical analysis under a framework that contains many variables related to the effect of China's healthcare expenditure on economic growth. In the factor extraction section, we extracted three common factors. To further verify the robustness of the model test results, we attempt to conduct four and five common factor extractions, and the results show that changing the number of common factor extractions does not change the core conclusion of this article. Due to space limitations, the specific empirical results are not listed but have been maintained for reference.The coverage of the medical security system has a vital impact on people's economic ability to support their lifestyle, and medical and health expenditures also significantly affect the speed of economic growth. However, few scholars have deeply investigated the impact of medical and health expenditures on economic growth in distinct regions of the same country or explored the mechanism behind these effects. By constructing a systematic research framework, this paper analyzes the mechanism through which medical and health expenditures influence economic growth. It offers a comprehensive consideration of potential influencing factors and selects time series data of China and its different economic regions  from the first quarter of 2006 to the fourth quarter of 2019 to empirically test the effect of medical and health expenditure on economic growth and its internal mechanism by using a time-varying parameter model, which can capture slight dynamic changes in the economic system.The results of the empirical research presented in this paper demonstrate that in China as a whole, increasing medical and health expenditure will produce a negative impact on economic growth in the short term, but in the long term, it will stimulate economic growth. Due to China's vast territory, the level of healthcare and economic development vary greatly for different regions, which will undoubtedly affect how medical and health expenditures influence growth in diverse economic regions within China. When our research focuses on China, we find that there are obvious differences in the effects of medical and health spending on economic growth in different regions. The increase in medical and health expenditures suppresses economic growth in Inner Mongolia and Jilin over the sampling range. It also played a negative role in the economic growth of Sichuan most of the time, though its role has become positive in recent years. Medical and health expenditures play a driving role in the economic growth of Beijing, Tianjin, and other regions, which illustrates that these are a relatively heavy burden on the local finances of subdeveloped areas in China. Due to the fragile economic environment, inadequate infrastructure and other reasons, the benefits brought by the improved medical security system are insufficient to alleviate the pressure on residents and local governments caused by increased expenditures, thereby causing the regional economic growth rate to slow down in the short and long term. For the developed areas in China, due to the high level of infrastructure construction and the high disposable income of residents, medical and health expenditures can provide more convenient health protection for residents. Through the substitution effect, residents can enhance their leisure time for health management and engage in education expenditures to promote investment and consumption, which in turn will benefit the local economy in the long run.The empirical analysis of the effect of medical and health economic growth also reveals that the long- and short-term effects of medical and health expenditures on economic growth are achieved through the accumulation of physical and human capital. The direction of the effect of the accumulation of physical capital on the growth of medical and health economies is uncertain, but the accumulation of human capital tends to play a positive role in the short and long term. Through the in-depth analysis, it can be seen that an increase in medical and health expenditure in underdeveloped areas  in China plays a negative role in short-term economic growth through the channel of material accumulation, while in developed regions , that same channel plays the opposite role. The effect of the transmission channel is consistent with the above empirical results in that the economic growth of underdeveloped areas is restrained by an increase in medical expenditure, and the economic growth of developed areas is restrained in the short term but significantly increased in the long term.Not only China but the whole world is facing the need to balance between “protecting people's livelihood” and “promoting growth,” especially when COVID-19 is spreading globally. Finding a balance between the two with limited resources is a momentous task. The research conclusion of this paper further verifies that the medical security system is a necessity, and its construction as well as its coverage is an important path to ensure people's livelihood and while simultaneously promoting growth. The research illustrates that a sound medical and health security system must be established, producing a positive impact on economic growth in the long run and effectively promoting economic growth through long-term material capital accumulation and human capital accumulation. Substantial economic growth can increase government revenue and provide strong support for the enrichment of livelihood projects. However, there is a major imbalance in China's internal regional development. Therefore, the construction of China's multilevel medical security system cannot be deferred, and certain policy preferences and supporting expenditures are needed for economically underdeveloped areas. The research conclusion of this paper is that a medical security system is irreplaceable for people's livelihood in China, as “ensuring the people's livelihood” is a vital way to promote long-term economic growth; the results affirm the need for the government to spare no effort to treat COVID-19 during the epidemic, motivated by the desire to restore order to the economy as soon as possible, and this need is of great significance to the establishment of a long-term sustainable medical security system in China.Publicly available datasets were analyzed in this study. This data can be found at: raw data were generated by the Wind Database. Derived data supporting this study's findings are available from the corresponding author (SW) upon request, without undue reservation.SW: conceptualization, methodology, software, formal analysis, data curation, writing—original draft preparation, writing—review, and editing. BZ, SW, and ZQ: validation. BZ: investigation, resources, supervision, project administration, and funding acquisition. ZQ: visualization. All authors contributed to the article and approved the submitted version.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.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.


Adverse drug reactions (ADRs) may be a serious public health problem and have received widespread attention in recent years. This study has analyzed the factors leading to the occurrence of serious ADRs (SADRs), determined the factors affecting the prognosis of patients with severe adverse reactions at different levels of medical institutions, and finally made corresponding recommendations for the monitoring, prevention, and treatment of SADRs. We used descriptive analysis and chi-square test to analyze the year, age, gender, proportion of SADRs, and the results of the ADRs in the report. Use the logistic regression to analyze the factors affecting the prognosis of SADRs in different levels of medical institutions. A total of 387 642 people’s 394 037 ADRs were collected from the Henan Provincial Adverse Drug Reaction Monitoring Center from 2016 to 2020. Among them 35 742 cases of serious ADRs (9.1%), 96.1% were eventually relieved or cured, but 39 cases of SADRs caused death. The main causes of death included hemorrhages, organ failure, and allergies. Age, number of medication and illnesses, level of medical institution, history of adverse reactions, and type and method of medication were all factors that affected the severity of ADR. The prognosis of SADRs is worse than normal ADRs. The ADRs in autumn and winter and new adverse reactions are unique risk factors found in this study. The elderly and patients with multiple diseases or taking multiple drugs should pay attention to their adverse reactions. They should be closely observed within a week after taking the medicine. The supervision of patients with a history of allergies and new adverse reactions should be strengthened by primary medical institutions, and in nonprimary medical institutions should paid attention with past medical histories, and use imported drugs and biological agents with caution to ensure the safety and health of patients. ADRs refer to unrelated or unexpected adverse reactions of qualified drugs under normal usage and dosage3. Serious ADR (SADR), a heterogeneous reaction completely unrelated to normal pharmacological effects, cannot be detected by conventional toxicological screening, has a low incidence, and is delayed, not dependent on dose, and unpredictable4. Once SADRs occur, multiple organs throughout the body are involved, seriously threatening the life and safety of patients.Given the increased development and utilization of drugs, adverse drug reactions (ADRs) have gradually become a public concern6. The average length of stay of each hospitalized patient due to ADRs is extended by two days, and the average cost increases by $25008. In recent years, the number of ADR reports in China has increased rapidly. The China Adverse Drug Reaction Monitoring System has received 1.676 million ADR reports in 2020 (1251 cases per million population), and SADRs account for 10% of these reports9. SADRs increase the cost of medical treatment for patients, may delay the treatment time of patients, and seriously affect the quality of life of patients. SADRs also cause patients to lose trust in doctors, causing both parties to fall into medical disputes and aggravating the tense doctor–patient relationship. SADR has become one of the main factors that increase the uncertainty of clinical drug research and development and may terminate research and development due to damage to the health of patients10. Thus, SADRs affect the health of patients and adversely affect the operation of medical institutions.SADRs seriously threaten the lives and health of patients and cause a lot of waste of medical resources. From 1966 to 1996, in the United States, an average of 6.7 in every 100 hospitalized patients have SADRs, and the mortality rate reaches 0.32%Adverse Drug Reaction Reporting and Monitoring Provision in 201011. By 2015, more than 280 000 are registered users of the China Adverse Drug Reaction Monitoring System (an online spontaneous reporting system). Users include pharmaceutical manufacturers, drugstores, and medical institutions, and nearly 16.87 million ADR/event reports are collected from 1999 to 20209. The ADR reporting and monitoring have developed rapidly, and report numbers and reporting rates are increasing12, providing data support for this research.China has introduced the Therefore, this study has analyzed the factors leading to the occurrence of SADRs, determined the factors affecting the prognosis of patients with severe adverse reactions at different levels of medical institutions, and finally made corresponding recommendations for the monitoring, prevention, and treatment of SADRs.The data of the adverse drug reaction reports collected by Adverse Drug Reaction Monitoring Center of Henan Province from January 2016 to December 2020 were classified and analysed, and spontaneously reported by medical institutions, enterprises, and the public in Henan.Data were cleaned and preprocessed to ensure that they were clean and complete. A total of 571 326 initial data were obtained. Everyone will record a code once an ADR occurs, but there are cases where the same code includes multiple entries of different drugs. We use excel to ensure that each code retains one to eliminate duplicate data, and 394 037 records of ADRs were retained.The year, age, gender, proportion of serious adverse reactions, and the results of the adverse reactions in the report were subjected to descriptive analysis and chi-square test. The logistic regression was used to analyze the factors affecting the prognosis of SADRs in different levels of medical institutions. All data analyses were performed using the SPSS 24.0 software . A p-value less than 0.05 was considered statistically significant.Adverse Drug Reaction Event Report Form. This research encoded and assigned variables in accordance with the Adverse Drug Reaction Reporting and Monitoring Management Measures13.The variables analyzed all came from the This study based on the regulations of the National Adverse Drug Reaction Monitoring Center, Among the reported ADRs, Death; teratogenic, carcinogenic, or birth defect; permanent sequelae; permanent damage to organ function; leading to hospitalization or prolonged hospital stay were regarded as “Serious ADRs” (Abbreviated as SADR), other cases were regarded as “Normal ADRs”.The measures for the administration of the hospital grade issued by the Ministry of Health institutions that mainly provide basic public health services and basic medical services as primary hospitals, and other comprehensive medical institutions as non-primary hospitals in accordance with relevant national policies. All primary institutions are first-level hospitals, secondary hospital is a regional hospital that provides comprehensive medical and health services to multiple communities and undertakes certain teaching and scientific research tasks, tertiary hospitals are usually provincial and municipal hospitals.About the distinction of medical institutions, This study refers to The study outcomes were ADR results and the impact on the original disease. In the binary logistic regression, we defined patients who had recovered from ADRs and had no significant impact on the pre-existing disease as a good prognosis, and defined patients who did not improve or had a worsening of the original disease as a poor prognosis.The study protocol was reviewed. Ethical approval was obtained from the Ethics Committee of Tongji Medical College, Huazhong University of Science and Technology (2020S204).This study obtained written informed consent statements from all human participants, and obtained the written informed consent statements of Ganyi Wang, the legally authorized representative of the minor participants.The study protocol is performed in accordance with the relevant guidelines.Among the 394 037 reports of ADRs, Figs. According to the occurrence of ADRs in the medication process, 60.5% (238 545) of ADRs occur on the day of medication. About 94.7% of ADRs occur within one week of medication, and only 0.9% of adverse reactions occur after one month.Figure Figure Table Table Table Table 15.This study is a retrospective analysis of a regional section within the database of the spontaneous reporting system of Henan Province. The number of ADRs reported in Henan Province has nearly doubled from 2016 to 2020, and the proportion of SADRs has gradually increased, reaching about 10%. In the future, increased adverse events may occur, and drug safety is facing remarkable challenges19. All 39 deaths are caused by SADRs. The causes of death are hemorrhages and organ failure20. The present study has also found that high-level medical institutions have a high proportion of SADRs although people generally think that these institutions are standardized and safe21, and this may be due to the fact that high-level medical institutions use multiple drugs and newly developed drugs more commonly. Season is also a factor that should be paid attention. The proportion of SADRs increased significantly in autumn and winter. It may be that the autumn and winter seasons are more susceptible to influenza, and the patient's physique is weaker than other seasons during this period23.The results of the present research suggest that general factors, such as age, disease, type of drug, medication way, new and recurring ADRs and multiple medications, increase the probability of SADRs. Once SADR occurs, it is likely to lead to aggravation of the patient’s original illness and sequelae, which can lead to death in severe cases24. However, different factors cause different results in different levels of medical institutions. For example, patients who use proprietary Chinese medicines in primary medical institutions have a higher risk of SADRs than those who use compound drugs, but the opposite is true in nonprimary medical institutions. This finding may be because the indications of traditional Chinese medicine preparations are wide, and the ADRs of some raw materials are not yet clear. The primary medical institutions cannot fully grasp this information25. Injection, as one of the risk factors for SADRs, is evident at the primary level27. This finding reminds primary medical institutions of the need to strengthen the management of proprietary Chinese medicines and injections28. Primary medical institutions pay more attention to patients who are not sure whether they have SADRs and history of drug allergies than other hospitals. Their risk of SADRs is lower than that in normal people, which may be the result of the combination of drug use methods in primary medical institutions and attention to special populations29.Overall, this research on primary and nonprimary medical institutions in Table 31. This report also found the probability of poor prognosis in nonprimary medical institutions increases in winter. This phenomenon may be due to the shortage of medical beds and insurance funds at the end of the year21. In addition, this study has found that although the risk of SADRs caused by minor is high, the prognosis of ADRs in minors is better than adults. This finding shows that medical institutions should pay attention to the risks of the elderly patient. In particular, non-primary medical institutions need to pay more attention to the elderly (> 80 years old) patients because these institutions undertaked more tasks32.The report on the prognosis of ADRs is similar to those of previous studies. All medical institutions’ patients with multiple medications, history of ADRs, injection, smoking and drinking and patients with a time interval more than three days have worse prognosis33. This finding may be the lack of the corresponding training in primary medical institutions. Compared with non-primary institutions, the prognosis of patients with recurrent ADRs is better, indicating that the primary medical institutions are more cautious towards patients with a history of ADRs, however, the prognosis of patients with new ADRs is worse in primary medical institutions and better in non-primary institutions, and it may be due to the fact that primary medical institutions lack effective response measures to new ADRs.The prognosis of patients in primary medical institutions who use other methods of drug delivery is worse because of the lack of professionals or equipment. Patients with drug allergies have worse prognosis34.This study has several limitations. First, due to the limitation of data source, the study uses the database of Henan Province, which does not necessarily represent the true situation of the whole country. Second, the database is large and difficult to clean. This study has not analyzed the specific drugs and symptoms that cause ADRs. Third, some recorded ADRs information is not complete, and there are a few missing values in some indicators, which may cause a certain degree of bias. Fourth, due to the insufficient content of the original database, this study has not specifically analyzed the relationship between ADRs and drugs used. Finally, And media attention and recent publication of an ADR in the literature might affect the reporting behaviorsThis study analyzes the influencing factors and countermeasures of ADRs. The absolute number of SADRs is increasing, and a high proportion occurs in nonprimary medical institutions. Patients with multiple medications, history of ADRs, and the interval between medication and ADRs exceeding three days have high risk of SADRs and poor prognosis. Other factors lead to different results in different levels of medical institutions. We suggest strengthening the supervision of proprietary Chinese medicines and injections; Introduce a plan to deal with new ADRs in primary medical institutions and paying attention to the safety and health status of patients with history and used imported drugs and biologic with caution in nonprimary medical institutions.


Commonly classified as individual, task or environmental, constraints are boundaries which shape the emergence of functional movement solutions. In applied sport, an ongoing challenge is to improve the measurement, analysis and understanding of constraints to key stakeholders. Methodological considerations for furthering these pursuits should be centred around an interdisciplinary approach. This integration of methodology and knowledge from different disciplines also encourages the sharing of encompassing principles, concepts, methods and data to generate new solutions to existing problems. This narrative review discusses how a number of rapidly developing fields are positioned to help guide, support and progress an understanding of sport through constraints. It specifically focuses on examples from the fields of technology, analytics and perceptual science. It discusses how technology is generating large quantities of data which can improve our understanding of how constraints shape the movement solutions of performers in training and competition environments. Analytics can facilitate new insights from numerous and complex data through enhanced non-linear and multivariate analysis techniques. The role of the perceptual sciences is discussed with respect to generating outputs from analytics that are more interpretable for the end-user. Together, these three fields of technology, analytics and perceptual science may enable a more comprehensive understanding of constraints in sports performance. The fields of technology, analytics and the perceptual sciences offer opportunities to further the understanding of constraints in applied sport.Developments in the fields of technology, analytics and the perceptual sciences can accelerate the benefits of an interdisciplinary approach to some of sport’s most pervasive performance questions and challenges.Sport science, in general, has long been criticised for its insular nature, with various sub-disciplines typically looking to solve existing problems internally –5. In reAccordingly, there have been numerous calls for sport science to progress beyond this insularity and embrace an inter- and even transdisciplinary approach , 12–15. A true interdisciplinary approach would see sports performance disciplines working collaboratively to fully encompass principles, concepts, data and methods to solve problems and support practice . This coFrameworks such as ecological dynamics or Newell’s constraint model offer a basis upon which sports performance can be measured , 17. EitConstraints are understood as the boundaries which shape the emergence of functional movement solutions  and are An understanding of the manipulation of constraints and their impact on skilled performance is, therefore, central to the design of activities intended to promote performance and learning in sport. This can be achieved through the manipulation of constraints to design representative practice tasks which preserve key information-movement couplings experienced during competition. However, a central feature of constraints and their impact on emergent movement solutions relates to their interaction , 24. TheFortunately, for multiple reasons, an interdisciplinary approach to measuring constraints in applied sport is arguably more feasible now than ever before. Recent improvements in a number of seemingly disparate fields and disciplines have the potential to progress this opportunity. Using examples from technology, analytics and the perceptual sciences, this review details how advancements in a range of fields can be leveraged to achieve interdisciplinarity and disciplinary integration in high-performance sport.Ongoing, and recently accelerated, improvements in the field of technology have enhanced the measurement of almost all aspects of sport . Sport sIn addition to incremental improvements, some technological developments have facilitated the identification and measurement of variables and metrics which were previously unrecognised in research and practice. For example, eye-tracking, the detection of emotion in competition , 40 and To represent the influence of technology on the measurement of constraints, the concept of pressure in a team sport context presents a useful example. As a scientific construct, pressure has been measured in multiple ways; through the proximity of opponents on the field as measured by player tracking systems , 108, anExtending these ideas, technology can enable greater clarity with regards to the measurement of constraints players experience during competition. Beyond helping practitioners contextualise actions observed during competition, it can assist with the design of practice tasks that are more representative of the requirements of competition to support athlete development and learning . For exaOf course, both researchers and practitioners will always experience some limitations with respect to the volume of data they collect. Furthermore, the continual addition of new types of data has the potential to overcomplicate modelling and limit user interpretability . From a One criticism leveraged at ecological dynamics points towards its complexity, with research to date being largely conceptual or performed in a laboratory . The meaAnalytics refers to the methods based on the computation of statistics and data  and, theA key benefit of analytics when applied to sports performance relates to its flexibility. Specifically, in regard to how different machine learning algorithms can often be used interchangeably on the same dataset –129. ThiThe collection of more data related to different interacting constraints can ultimately make the analysis of variables more difficult. The principle of parsimony is critical within analytics to strike a balance between feasibility and obtaining a high-level understanding of phenomena of interest. Without enhanced analytical tools, the translation of model outputs which contain a large number of variables into meaningful information remains a challenge , 132. PaParsimony also helps to avoid problems with overfitting. Overfitting describes a model, which is generated specifically to a training dataset, but where the results are not generalisable or validated on a new or unseen test dataset , 135. InThe growth in data along with the enhanced analysis of these data have been emphasised to this point of the review. However, without the output from such analyses being appropriately communicated to and interpreted by key stakeholders, the gains achieved by sport science will go unrealised. Learnings from the perceptual sciences could hold the key to assist in this area. Perceptual sciences refers broadly to the integration of neuroscience, computer science and psychology with the aim to understand the link between external properties and cognition , 137. SpVisualisations have been proposed as a method to leverage data communication to highlight findings clearly with precision and efficiency. This is required as despite the improvements in technology and analytics, a linear improvement in performance has not occurred . This maGiven the inherent complexity of ecological dynamics, visualisations are critical in their ability to indirectly convey key information. Visualisations are an essential tool to enable the appreciation of complex and multidimensional constraints in a system. The ability to visualise multiple variables may further enhance the communication of complex information. For instance, five dimensions can be displayed and manipulated through the two regular axes as well as hue, shape and size of data points. The impact of visualisations on stakeholder decision-making has been examined in forecasting, communication and planning –143. FurReturning to the pressure example discussed in earlier sections, it is apparent that despite their visual potential, pressure or defensive actions are often reported as aggregate data, for example as a frequency count in a table , 150. HoThis narrative review has provided some methodological considerations for the measurement of constraints though an interdisciplinary approach. The benefits of an interdisciplinary approach could arise from greater consistency between disciplines, more efficient workflows and optimised communication procedures . These i