Since February 14, 2022, Ukraine has once again been under attack by the Russian forces, putting the nation in one of the biggest emergencies in Europe since World War II. This puts Ukrainians at high risk of psychiatric disorders, amidst unseen attacks on infrastructure that have put massive strain on Ukraine’s mental health services. Despite this, the prevalence of psychiatric disorders among adolescents and their changes over time have not yet been documented in Ukraine during the invasion. More generally, there is a need to more comprehensively uncover the long-term consequences of war on youth, especially their risks and protective factors.The Adolescents of Ukraine During the Russian Invasion (AUDRI) Cohort is the largest cohort of war-affected Ukrainian adolescents. We will recruit adolescents aged 15 to 18 years attending any school in Ukraine. Data collection will start early 2023, and will be held via online questionnaires every six months during the war as well as after the war has terminated. We will use several well-validated tools to screen for PTSD, depression, anxiety, substance use disorder, and eating disorders. In addition, we will ask participants about possible risks and protective factors of their mental health including resilience and social capital. Using the cohort, we will evaluate the trends in psychiatric disorder prevalence among adolescents in Ukraine over time and evaluate risks and protective factors of adolescents’ mental health.The AUDRI Cohort will provide a unique opportunity to learn more about trauma and resilience among youth in conflict settings, in addition to aiding international efforts to save the mental health of youth in Ukraine. At-risk adolescents identified from our study can directly become beneficiaries of targeted intervention themselves. Building evidence on the mental health of adolescents is especially valuable, as protecting the mental health of war-affected adolescents could help rebuild society and have positive consequences for generations to come. Starting in 24 February 2022, Ukraine, one the largest countries in Europe, has been facing one of the biggest emergencies in Europe since World War II . Of UkraAccording to the United Nations International Children’s Emergency Fund (UNICEF), as of June 1, 2022, three million children inside Ukraine and over 2.2 million children in refugee-hosting countries were in need of humanitarian assistance,  and almoThe consequences of war have been previously studied, especially among veterans, with former child soldiers and veterans experiencing large burdens of mental disorders such as post-traumatic stress disorder (PTSD) and depression –15. HoweThe AUDRI Cohort will give us a unique opportunity to learn more about trauma and resilience among youth in conflict settings. Collecting data on adolescents is especially valuable, as protecting the mental health of war-affected adolescents could have positive consequences for generations to come and help rebuild society . Our cohThe Adolescents of Ukraine During the Russian Invasion (AUDRI) Cohort is a large cohort of war-affected Ukrainian adolescents.Participant recruitment will take place in all regions of Ukraine, where youth aged 15 to 18 years attending any school in Ukraine will be recruited. The maximum expected number of participants is about 400,000 youth, with the aim of obtaining a representative sample of all adolescents attending school in Ukraine. Data collection will start in early 2023, and will be held every six months during the war as well as after the war has terminated.We will contact schools in all regions of Ukraine, who will distribute the links and/or QR codes of the questionnaire to eligible students through their electronic mailing systems. In the follow-up phases, participants will be sent links to access the questionnaire at appropriate timings. In each phase, both participants and their legal parent/guardian will be asked to read a description of the study and ethical considerations and complete an informed consent form. All questionnaires will be self-administered, conducted in Ukrainian, and answered online.We will use Qualtrics to build and distribute the questionnaire, store the data, link individuals’ data across waves, and extract the de-identified data for analyses. Qualtrics ensures that the privacy of participants is protected, complying with the General Data Protection Regulation and the California Consumer Privacy Act . Using QA full list of the measures used in the AUDRI cohort and the waves that they will be administered is shown in the Table In each wave, we will use several well-validated tools to screen for PTSD, depression, anxiety, substance use disorder, and eating disorders. The Child and Adolescent Trauma Screen (CATS), a well-validated tool for evaluating post-traumatic stress symptoms among youth, will be used to screen for PTSD, using recommended cutoff scores , 24. TheWe will use several methods to examine the prevalence of psychiatric disorders over time and their relationship with exposure to war, as well as their risk and protective factors. First, we will plot the changes in the prevalence of psychiatric disorders over time. Next, we will use causal inference methods   to examiThe study will be conducted in accordance with the principles of the Declaration of Helsinki. The Ethics Committees of the Institute of Psychiatry at the Taras Shevchenko National University of Kyiv (No. 7/23/11/2022) and the University of Tokyo (No. 2023022NI) approved this study. The study staff will ensure the participants’ anonymity is protected, and the email addresses used to merge data across time points will be deleted immediately after linkage has been completed. All documents will be stored online securely and will only be accessible by authorized staff.The results of this study will be published in academic journals and conferences. A policy paper will be prepared for the Office of the President of Ukraine for further dissemination to domestic and international stakeholders  as well as the public. The study will also be widely disseminated in social media platforms  so that the study participants, their family, and domestic and international stakeholders could easily access the findings of this study.The AUDRI cohort will evaluate the mental health of adolescents using a longitudinal design. A major strength of this study is that it not only provides information on the prevalence of major psychiatric disorders in war-affected Ukraine, but also identify important risks and protective factors during a humanitarian crisis. Such data are extremely difficult to accumulate in a humanitarian setting, given the difficulty in accessing affected sites. Our surveys will be solely internet-based, and adolescents will be able to participate wherever they are. We believe this is essential, as war-affected populations are often displaced multiple times during war, making physical access to the same individuals  quite challenging. Ultimately, using technology to our advantage, we plan to build a large, sustainable cohort to help protect the future of Ukraine and its people.


Osteoporosis is a disease of global concern, with significant implications for mortality, morbidity, strain on national health resources, and the negative impact on the quality of life associated with the condition. As we witness a primarily aging population, future predictions indicate that risk factors for osteoporosis will be more prevalent, leading to an increase in the number of individuals suffering from the condition and associated fractures. However, the future of osteoporosis in terms of diagnosis and treatment is optimistic. Understanding of bone quality and examination of it has improved with the onset of magnetic resonance imaging (MRI) and other imaging techniques such as micro-computer tomography. Innovative therapies specifically targeting osteoporotic bone metabolism on a microscopic level hold promise. This narrative review provides details on the background, prognosis, and future treatment strategies of osteoporosis. Osteoporosis is widely considered to be a silent condition. It is defined as having a bone mineral density (BMD) with a standard deviation difference equal to or less than 2.5 from ordinary high levels for fit young adults ,2. Its cNot only does the condition result in hundreds of thousands of fractures every year, but it also imposes a significant cost to the NHS, amounting to over £940 million. This leads to a 20% requirement of orthopaedic bed occupancy and brings about obvious disability and distress to osteoporotic patients [Fractures following the onset of osteoporosis are increasing on an international level in terms of both number and proportion. This change is attributed mainly to the associated decline in physical activity (resulting in increased frailty) and an ageing population . The futIncidenceOsteoporosis is a key public health threat, affecting approximately 40% of women over 70 years in the United Kingdom .Proximal femur (hip) fractures are regarded as the most critical of all osteoporotic fractures since they are coupled with significant morbidity, mortality, and strain on national healthcare . Global Currently, over 50% of all hip fractures occur in North America and Europe, but as the elderly populations of particularly Latin America and Asia increase quite drastically, by 2050, it is predicted that this proportion will fall to 25% in North America and Europe .PrognosisIt has been suggested that 95% of all osteoporotic patients who have suffered hip fractures will require surgery . Worse sThe health-related quality of life of patients following osteoporotic fractures is often poor, leading to disability and a lack of self-supporting living. Indeed, only half of the patients will return to complete independence following a fracture, and there is an increase of roughly nine consultations with their GP the year after. It has been estimated that 20-50% of patients following a hip fracture will require long-term nursing home care, which is associated with a decreased quality of life . MoreoveUS studies have pointed out that this impact on the quality of life is the case regardless of age group after menopause for women. They have called for primary and secondary preventive methods to reduce such high levels of mortality and morbidity and to improve the quality of life for osteoporotic patients before and after fracture .Primary preventive methods mainly tackle the morbidity of osteoporosis by diminishing the number of falls, particularly in post-menopausal women. These methods include introducing weight-bearing exercises in the community and enhancing the diet with supplements to optimize BMD. Patients are encouraged to lead a bone-healthy lifestyle by quitting smoking, reducing alcohol intake, and increasing their level of activity to reduce the risk of fragility fractures and promote bone health . As a laThe FRAX algorithm (Fracture Risk Assessment Tool) has been developed by the World Health Organization to aid clinicians in examining the comparative risk of fracture. Since osteoporosis is an asymptomatic condition that often only presents post-fracture, it is essential to be able to assess the risk before such a fracture occurs. The FRAX tool helps clinicians determine whether a DXA  scan is required to measure BMD and further assess the risk of fracture.Following NICE  guidelines , after pLow Risk of Fragility FractureThose below the 10% recommended threshold are not offered drug treatment but rather lifestyle advice such as reducing alcohol intake and smoking.Intermediate Risk of Fragility FractureThose that fall close to but are below the 10% threshold and have risk factors that are underestimated by the FRAX assessment, that is, heavy alcohol intake, are advised to arrange a DXA scan to measure BMD. Drug treatment is offered if the T-score is negative 2.5 or below.High Risk of Fragility FractureThose that are 10% or above the recommended threshold are offered a DXA scan, followed by a BMD measurement, and subsequently a bone-sparing drug treatment if the T-score is negative 2.5 or below. Risk factors are modified where possible, and DXA scans are repeated at an interval that usually falls within two years.The main pharmacological options for osteoporosis are categorized into antiresorptive and anabolic agents, with the most mainstreamed being the antiresorptive agent bisphosphonate (BP). The fundamental goal of the therapeutic approach is to reduce the risk of osteoporotic fractures.BP has been used in the management of osteoporosis for decades, primarily because it is relatively cheap and can be administered in different forms: orally  and intravenously  . The mecFutureMuch improvement has been seen in this century in terms of both the diagnosis and treatment of osteoporosis, and this is set to continue as our understanding of the condition improves . The preFracture liaison services (FLS) have been effective within the UK in identifying, investigating, and treating patients with fragility fractures. Patients who have experienced a fragility fracture can receive support in onward management to prevent further fractures. However, currently, only 60% of the UK population has access to this service, and half of the service operations were ceased following COVID. The Royal Osteoporosis Society has suggested that opportunities to expand this service, such as nationalization, may bring about a positive change in the well-being of many people .The International Osteoporosis Foundation (IOF) and International Federation of Clinical Chemistry and Laboratory Medicine (IFCC) Working Group suggest that bone turnover markers, such as S-P1NP  (bone formation) and s-CTX  (bone resorption), may independently predict future fracture risk from BMD. This discovery is promising as their inclusion in assessment algorithms, along with further research, may provide us with a greater ability to diagnose and treat the condition .The significance of osteoporosis in terms of the great mortality and morbidity following fractures and the high risk of re-fracture has received increased international focus .Therapeutic options for osteoporosis have also advanced and are set to progress further in the coming years. Emerging medications include inhibitors of Cathepsin K, a prevalent protein protease in osteoclasts involved in bone degradation , and romIt is clear that osteoporosis is a major public health threat with significant morbidity and mortality associated with the condition. It is also highly debilitating too: only half of all patients following hip fractures will be able to resume completely independent lives, requiring much more assistance from clinicians and other healthcare professionals. This puts significant stress on national health services in terms of bed occupancy and healthcare economics. One crucial factor to note here is that osteoporosis is principally an asymptomatic disease, usually diagnosed and treated only after the onset of fragility fractures. Therefore, prevention, as opposed to therapeutic options, is crucial. Dietary supplements and weight-bearing exercises, particularly for postmenopausal women, need to become more widespread to prevent the recent surge in osteoporotic fractures on a global level and the predicted increases yet to be witnessed over the years.The future of osteoporosis is predicted to be bleak, particularly in terms of morbidity. As the proportion of people in the elderly population bracket increases, and physical activity among many decreases on an international level, the frequency of osteoporotic fractures is set to increase dramatically too. However, recent advancements in the early diagnosis and understanding of bone tissue, coupled with innovative therapeutic options, shed light on improvements in the diagnosis and treatment of the disease.


Background: Enterprise resource planning (ERP) is critical to enhancing the ability to control commercial activities and results in a competitive advantage when combined with an organisation's existing competitive advantages. However, our practise review reveals that end users resist ERP implementation because the resulting changes will alter the current status quo. The implementation of an ERP system in an organisation is complex as it affects multiple areas of the business. Resistance to change is cited as a factor of ERP failure.Methods: In this study, we conducted a systematic literature review using Transfield’s five stages and established a conceptual framework for ERP system implementation in science and technology parks (STPs). Articles collected from Emerald, Science Direct, ProQuest and Scopus databases between 1st June 2021 and 15th June 2021. Two authors were assigned to check the suitability of the articles in order to avoid risk of bias. Articles were analysed based on components of a research paper and the data was tabulated using MS Excel.Results: Only eight papers  appeared when we searched for papers related to ERP with a focus on post ERP Implementation, end-user behaviours, organisational performance, and the accelerated SAP (system application and product) methodology. We found that there are hardly any articles on ERP post implementations in STP context particularly based on the evaluation part of accelerated SAP.  Conclusions: Results indicate the lack of studies in this field, particularly those addressing issues related to STP. This study attempted to broaden the understanding of the ERP's effectiveness, particularly in terms of an organisation's operational performance. In terms of ERP implementation, one of Malaysia's selected science and technology parks (STPs) is in a similar situation. End-users frequently object to ERP implementations due to the inevitable changes in their current work environment. According to a study, ERP implementations fail because employees cannot articulate and meet their changing expectations. The acceptance or rejection of technological change has long been recognised as a factor in a person's ability to enhance performance and productivity, while low productivity and dissatisfied customers may result from the unfavourable attitude of employees towards ERP implementation. In addition, excessive organisational spending can lead to a negative view of the ERP system among stakeholders. The selected STP organisation for this study decided to continue implementing ERP based on an assessment of the benefits and challenges of the implementation because it is an important component of their digital transformation initiative. The non-financial and financial benefits were used to justify the organisation's decision to implement ERP. After years of implementing the ERP system in the selected STP in Malaysia, it is still unsure whether the anticipated benefits, such as improved operational performance and the value-added through the integration of business processes with best practices, have been realised as no evaluation of the ERP system's post-implementation benefits has been conducted. From the preliminary interviews with end-users in the STP organisation, mixed reactions to the use of ERP, both positive and negative, can be reasonably assumed.Organisations must improve their own business practices and procedures to survive in a rapidly changing business environment. Enterprise resource planning (ERP) systems are the most significant development incorporating information technology use and are quickly becoming the backbone of organisations. The challenges and high failure rates associated with ERP implementation have been extensively discussed in the literature. Companies typically experience business problems after investing a significant amount of money in an ERP system but are inevitably left with an ERP investment for which they received nothing in return. Most leading ERP providers, such as SAP (system application and product), have their own implementation methodologies. The accelerated SAP (ASAP) methodology was created by SAP. ASAP is a methodology for planning, managing, and delivering SAP efficiently and cost-effectively. However, as the ERP lifecycle has no evaluation component, the benefits of implementing and using ERP for the selected STP could not be evaluated. Thus, after completing the ERP implementation project, these evaluation elements may be incorporated into ASAP, demonstrating the benefits of ERP. This study will eventually lead to the development of a framework that incorporates evaluation elements into the post ERP implementation phases of the ASAP methodology. Therefore, this study aims to analyse the factors that contribute to user resistance and provide necessary information for decision-makers to complete the actions required to achieve success in the case of STP.The most difficult phase of an ERP project is the implementation. A study recommended several strategies for maximising the ERP system’s benefits and thus improving the overall organisational performance. Businesses primarily implement ERP to streamline operations, improve performance and create value by integrating business processes with best practices, management functions, real-time reporting, and the ability to study data. An ERP system enables a business to holistically manage all aspects of its operations to remain competitive in the current business environment.ERPs are critical tools for acquiring the capability to control commercial activities and result in a competitive advantage when combined with a firm’s existing competitive advantages. Furthermore, ERP has resulted in substantial cost savings, increased return on investment, and improved access to information, ultimately improving consumer decision-making. In addition, ERP increases productivity, decreases downtime, reduces lead times, decreases the order cycle time, minimises inventory, reduces the system installation time, reduces quality issues, decreases the scrap rate, decreases the rework rate, and increases the overall company productivity and pay. According to studies, ERP systems can also help an organisation increase its capacity and flexibility in response to changing client needs.ERP systems enable companies to handle their operations effectively with possible benefits, including increased process efficiency, improved data analysis, increased consistency in decision-making, lean inventory, improved communication across the supply chain, and strong customer experience. In terms of ERP implementation, the STP in Malaysia selected for this study is in a similar situation. Following the implementation of ERP in the selected STP, the lack of end-user support in the system’s use and the absence of organisation performance evaluation were observed. Understanding critical issues will aid organisations in the successful carrying out of ERP systems in the future. Managers and those responsible for information must also understand and quantify the benefits of the ERP system to justify ongoing costs and the impacts to the organisation. Generally, the impacts and benefits of implementing an ERP system are not realised until the system has been completed and is fully operational.Companies usually have business problems after investing a significant amount of money in an ERP system but end up with an ERP investment for which they have not received anything in return.According to the literature, several theories can shed light on the challenges mentioned above for STP context in theWhile there are other theories such as TAM, DOI, and RBV that could potentially be relevant to ERP implementation study, our initial reading led us to focus on Sociotechnical system theory, UTAUT, and BSC due to their strong alignment with the specific context of Science and Technology Parks (STPs) and ERP implementation. The novelty of this research lies in the context of this study which is STP. These theories are aligned to lead to most pertinent insights and direction for the research objectives of an empirical study following this SLR paper.a)To analyse the research gaps on the implementation of ERP in the STP organisation in Malaysiab)To propose a conceptual framework for the STP based on the literature reviewThe objectives of this proposal are as follows:This study was approved by the Research Ethical Committee (REC) of Multimedia University (EA2722021). This article is reported in line with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. Tranfield's method is a well-known and highly cited method for carrying out systematic reviews of the literature. Our literature review was based on the following five stages:a)Planning the reviewb)Identifying and evaluating studiesc)Extracting and synthesising datad)Reporting descriptive findingse)Utilising the findings to inform research and practiceThis is a systematic literature review paper that highlights the challenges faced by STPs regarding ERP. Thus, we aim to present a preliminary conceptual framework that the body of knowledge in the field of ERP can adopt in STPs. To bridge the research gap in this field, we searched the current research landscape using Tranfield’s five stages.The primary objective of this review is to ascertain the nature and scope of the research conducted on the selected STP’s ERP implementation and subsequent organisational performance. We intend to provide researchers with a comprehensive review of post ERP implementation in STP, with particular emphasis on end-users who oppose ERP implementation due to the disruption of the current status quo. The objective is to provide information on the hidden causes of such behavioural change and inform the knowledge community about potential research directions for the field. The knowledge gained from this research might have broad implications for raising managers’ and employees’ awareness of the critical nature of preparation before implementing ERP systems and technical change.This study aims to identify solutions that will enable managers to make more informed decisions, mitigate the impact of technological change on the organisation’s social system, significantly reduce the implementation time, increase manager training and balance the effectiveness of ERP in manufacturing firms.This study aims to examine the organisational benefits of ERP after implementation and their impact on the organisational efficiency and operational performance of a Malaysian STP. This study's objectives include determining the ERP system's post-implementation benefits and its effective use in Malaysia’s STP. The researchers believe that understanding all the shortfalls is critical to the full comprehension of the consequences of ERP implementation in the Malaysian STP. Additionally, this research aims to develop an ERP framework for future use in Malaysian STP organisations to maximise the benefits of post-ERP implementation.Inclusion and exclusion criteriaArticles were collected from database inception to 15 June 2021.Search strategyEmerald,Scopus,Pro Quest,Science Direct) as they are largest databases for social science journal articles. The following keywords were used: (1) enterprise resource planning (ERP), (2) ERP AND post-implementation, (3) ERP AND post-implementation AND end-user behaviours, and (4) ERP AND post-implementation AND end-user behaviours AND organisational performance AND Accelerated SAP (ASAP) methodology. The keywords set used in this study is provided inWe searched four major online databases  approachWe propose a conceptual framework in•Theme 1: Post ERP implementation evaluation using BSC to evaluate organisation performance•Theme 2: ERP end-user behaviour towards resistance to changesResearchers involved in examining the relationship between post ERP implementation success and STP could consider the main findings of the current study to explore options for future work. The two major themes for future research consideration include the following:This study aims to inform the ERP for STP knowledge community about the research gaps in the application of theories in post ERP implementation success and organisation performance based on the published literature. In this study, we applied the five-stage methodology of Tranfield et al. (2003) in writing papers based on the comprehensive review of the literature in a given area. This methodology was used to understand the extent and nature of post ERP implementation in STP research in organisational performance. From the extensive search of 72,635 papers in the ERP domain, our search list was narrowed to eight papers (0.011%) that examined the post ERP implementation involving STPs, end-user behaviour, organisational performance, and the ASAP methodology. Our review of the eight papers suggests that the scope for more significant research on the two major areas is present. More empirical work is required to improve the understanding of the determinants of post ERP implementation success factors in the context of STPs. The implication for organisations is that they will have an improved plan in place to harvest their ERP investment in the future.All data underlying the results are available as part of the article and no additional source data are required.https://doi.org/10.6084/m9.figshare.16821982.Figshare: PRISMA checklist for ‘Enterprise resource planning implementation within science and technology park (STP) organisations: an avenue for future research. A systematic review’.Creative Commons Attribution 4.0 International license (CC-BY 4.0).Data are available under the terms of the The authors gave a good and valid response to my suggestions. Courteous and highly professional in their responses. I agree with them and approve the publication of the article.Are the rationale for, and objectives of, the Systematic Review clearly stated?YesIs the statistical analysis and its interpretation appropriate?YesAre sufficient details of the methods and analysis provided to allow replication by others?YesAre the conclusions drawn adequately supported by the results presented in the review?YesReviewer Expertise:Technology management, ERP,  Cloud computing, Entrepreneurship, and general managementI confirm that I have read this submission and believe that I have an appropriate level of expertise to confirm that it is of an acceptable scientific standard. Enterprise resource planning (ERP) is a well-rounded technology that streamlines the activities of a firm for seamless operations and a competitive advantage. Hence, this article addresses gaps/issues concerning ERP and provides a framework for successful implementation in a less-researched context (Science and technology park), contributing significantly to the literature. More importantly, the issue of realising value from ERP implementation which has been a major discourse in the literature is addressed, giving the article its relevance.The paper is well-written. The objectives and rationale for the systematic review were spelled out and achieved. The methodology is clear and replicable, especially using PRIMA. The conceptual framework developed for studies to improve post-implementation success by focusing on the ASAP methodology is of great value, especially in the STP context. The conclusion is good. MajorHowever, the authors had a narrow view of the applicable theories. I expected them to review some theories such as TAM, DOI, RBV, etc., and justify why Sociotechnical system theory, UTAUT, and BSC were better. It will be of immense value if authors could incorporate this suggestion. Nevertheless, the paper is well-structured and delivered.MinorAre the rationale for, and objectives of, the Systematic Review clearly stated?YesIs the statistical analysis and its interpretation appropriate?YesAre sufficient details of the methods and analysis provided to allow replication by others?YesAre the conclusions drawn adequately supported by the results presented in the review?YesReviewer Expertise:Technology management, ERP,  Cloud computing, Entrepreneurship, and general managementI confirm that I have read this submission and believe that I have an appropriate level of expertise to confirm that it is of an acceptable scientific standard, however I have significant reservations, as outlined above. Thank you for your feedback and acknowledgment of the importance of our article. We appreciate the acknowledgment of how the article addresses ERP gaps in the Science and Technology Park context, significantly contributing to the literature. We agree that focusing on value realization from ERP implementation and developing a clear and replicable methodology using PRIMA are critical aspects of our research. We are pleased that you find the conceptual framework useful for improving post-implementation success, particularly in the STP context. Your comments are encouraging and motivate us to continue researching in this area. Thank you for your feedback and acknowledgment of the importance of our article. We appreciate the acknowledgment of how the article addresses ERP gaps in the Science and Technology Park context, significantly contributing to the literature. We all agree that focusing on value realization from ERP implementation and developing a clear and replicable methodology using PRIMA are critical aspects of our research. We are pleased that you find the conceptual framework useful for improving post-implementation success, particularly in the STP context. Your comments are encouraging and motivate us to continue researching in this area. While we appreciate your recommendation to investigate additional theories such as TAM, DOI, and RBV, our reading led us to focus on Sociotechnical system theory, UTAUT, and BSC due to their strong alignment with the specific context of Science and Technology Parks (STPs) and ERP implementation. However, we have included a paragraph to acknowledge these theories in the article. We will consider incorporating a brief justification for our theory choice in future revisions. We are pleased that you found the paper to be well-organized and presented. Your feedback assists us in enhancing the caliber of our work. The authors have revised and responded to the earlier comments. A systematic review of prior work clarifies the gap in the existing knowledge that the study proposes to investigate further. The method to pursue the research process is also being revised.Are the rationale for, and objectives of, the Systematic Review clearly stated?PartlyIs the statistical analysis and its interpretation appropriate?Not applicableAre sufficient details of the methods and analysis provided to allow replication by others?PartlyAre the conclusions drawn adequately supported by the results presented in the review?PartlyReviewer Expertise:Management Accounting and Control SystemI confirm that I have read this submission and believe that I have an appropriate level of expertise to confirm that it is of an acceptable scientific standard. The aim of the study is to understand that ERP adoption in STP organisations is a current research topic. However, the justification for the motivation of the study is unclear. Given that the ERP has a long development history starting back in the 1990s, what aspect of ERP is the study focusing on? The ERP concept itself has a very broad term and definition, coming from various perspectives and fields of knowledge, hence the focus of ERP itself needs to be clarified. There are various success factors related to ERP adoption, such as technology challenges, human factors, and financial constraints. Thus, a systematic review of prior research is pertinent to highlight the significance of the proposed study. The paper states high failure reported on ERP implementation, critical discussion on past evidence contributing to the failure may highlight the challenges which could be investigated further. Despite the very limited study done in STP organisations, substantial work published related to ERP adoption need to be reviewed to strengthen and clarify the research focus. Additionally, the study foresees the ERP as a tool for enhancing business competitive advantage. Yet, technology cannot stand alone to promise success. It facilitates organisations to create capability and ability to succeed. Hence, it is suggested that the conceptual framework be revised. A revisit on the proposed theories is also recommended as the Balanced Scorecard is not a theory.Are the rationale for, and objectives of, the Systematic Review clearly stated?PartlyIs the statistical analysis and its interpretation appropriate?Not applicableAre sufficient details of the methods and analysis provided to allow replication by others?PartlyAre the conclusions drawn adequately supported by the results presented in the review?PartlyReviewer Expertise:Management Accounting and Control SystemI confirm that I have read this submission and believe that I have an appropriate level of expertise to confirm that it is of an acceptable scientific standard, however I have significant reservations, as outlined above.


Previous research has not fully explored socioeconomic factors that influence the Black–White food insecurity disparities at the state and county levels in the United States. The goal of this study was to identify socioeconomic determinants associated with the Black–White food insecurity gap in the US at the state and county levels with rigorous quantitative investigation. The 2019 Map the Meal Gap dataset and multivariate regression analyses were used to identify factors associated with the prevalence of the Black–White disparity in food insecurity rates. Unemployment rate and median income gaps were found to be the strongest predictors of the Black–White disparity in food insecurity and the Black food insecurity rates in both state- and county-level models. Specifically, a 1% increase in Black unemployment rate compared with White unemployment rate was associated with a 0.918% and 0.232% increase in the Black–White disparity in food insecurity on average at the state and county levels, respectively. This study highlights the potential root causes of food insecurity and significant socioeconomic determinants associated with the Black–White food insecurity gap at the state and county levels in the US. Policymakers and program creators should implement action plans to address the income disparities and reduce unemployment rates among Blacks to eradicate this gap and ensure equity in food access between Blacks and Whites. Food insecurity, known as the limited ability to acquire adequate food, remains an issue of great concern in the US. The estimated healthcare costs of hunger and food insecurity were around USD 160 billion . The burIn the literature, food insecurity has been described as economic and social problems of food shortages due to various socioeconomic constraints. Food insecurity is related to unemployment, inflation , lack ofLimited access to food among Blacks and increasingly severe Black–White disparities in food insecurity in the US may intertwine with risk factors, such as unemployment, poverty, and low incomes. Previous research suggests that the concentration of social and economic disadvantage among African Americans is a significant predictor of their higher rates of food insecurity, and the vulnerability is highest among those characterized by low incomes, renting rather than having house ownership, reliance on employment insurance, unemployment benefits, and social assistance ,13,20,21Nevertheless, socioeconomic risk factors associated with Black–White inequities in food insecurity at the state and county levels have not been fully explored. Prior studies illustrated that states with a high proportion of Blacks tend to have lower wages, higher housing costs and food prices, higher unemployment rates, and regressive tax policies, having a higher burden of food insecurity . AccordiWe used cross-sectional data from the Map the Meal Gap (MMG) in 2019. MMG data were developed and sourced from the American Community Survey (ACS), Current Population Survey (CPS), and Bureau of Labor Statistics data . The ACSThe MMG data at the state level were derived from the Core Food Security Model (CFSM) within the CPS. Using the household information in the CPS on food insecurity status and socioeconomic factors, including unemployment, poverty, homeownership, and median income, MMG aggregated the data to the state level and race. CPS survey data were mainly used to assess the relationship between food insecurity and its determinants at the state level. County and district level data on the above variables were drawn from the ACS, except for unemployment data, which were drawn from the BLS. The data from MMG, originally sourced from CFSM and the CPS, contained food insecurity rates by race and an established rich set of socioeconomic characteristics, including unemployment, poverty, homeownership, and median income. To assess the prevalence of food insecurity, respondents were asked about situations potentially conducive to food scarcities. The data were based on 15 food insecurity questions of the USDA concerning food shortages in the household, including: (1) “We worried whether our food would run out before we got money to buy more. Was that often, sometimes, or never true for you in the last 12 months?” (2) “We couldn’t afford to eat balanced meals. Was that often, sometimes, or never true for you in the last 12 months?” and (3) “In the last 12 months did you or other adults in your household ever not eat for a whole day because there wasn’t enough money for food? If yes, how often did this happen—almost every month, some months but not every month, or in only 1 or 2 months?”The food insecurity rates at the county level were estimated using a two-step approach. In the first stage, a multivariate regression was used to estimate state-year-level food insecurity rates using state-level data from 2009 to 2018. Variables in the model included unemployment, non-undergraduate student poverty rate, median income, disability rate, percent of homeowners, percent of Blacks, percent of Hispanics, state, and year fixed effects. These variables were selected based on the literature guidance [We used univariate analyses to determine the descriptive statistics for food insecurity rates and socioeconomic determinants among Blacks and Whites at the state and county levels. Furthermore, multivariate linear models were performed to examine socioeconomic factors that are significantly associated with the Black–White gap in food insecurity rates in the US in general and food insecurity rates for African Americans in the US.t-test to examine whether the means of two populations, Blacks and Whites, were different. The two-independent-samples t-test was employed when the Black and White populations were compared on one common variable. In this case, the t-tests were performed to analyze whether the differences in average food insecurity rates, average poverty rates, average unemployment rates, average homeownership rates, and average median incomes between Blacks and Whites were statistically significant at the state level and county level, respectively. We used the student To determine the factors that are significantly related to the relationship between food insecurity and Black–White race, we used multivariate regression models at the state level and county level, respectively. The dependent variable was the Black–White food insecurity gap, which was measured as the difference in food insecurity rates between Blacks and Whites. Socioeconomic predictors of the outcome were differences in unemployment rates, differences in poverty rates, differences in homeownership rates, and differences in median incomes between Blacks and Whites.To identify socioeconomic factors that are significantly associated with the food insecurity rate among Blacks at the state and county levels, given their social and economic disadvantages and the need for policies to help address the severity of the Black food insecurity rate, multivariate regression models were also conducted at the state level and county level, respectively, with the dependent variable of Black food insecurity rates and the independent variables of Black unemployment rates, Black poverty rates, Black homeownership rates, and Black median incomes.The regression analyses were performed using Feeding America’s Map the Meal Gap (MMG) 2019 data with 50 states and the District of Columbia and 1675 counties. Model AModel BStatistical analyses were performed using STATA statistical software . Based on a nationally representative study sample of 51 states/District of Columbia and 1675 counties as the sampling units from MMG 2019, we found that the overall prevalence of food insecurity was significantly higher for Blacks than Whites at both the state and county levels. The detailed characteristics of the sample are displayed in p < 0.01) from the t-test results demonstrated in p < 0.01). We found that Blacks experienced significantly higher levels of food insecurity than Whites at both the state and county levels (As shown in p < 0.05) at the county level. Specifically, Model A’s prediction presents that a 1% increase in the Black unemployment rate compared with the White unemployment rate was associated with a 0.918% increase in the Black food insecurity rate compared with the White food insecurity rate on average at the county level, after controlling for other variables in the model . p < 0.001). The prediction suggests that a 1% increase in the Black unemployment rate compared with the White unemployment rate was associated with a 0.232% increase in the Black food insecurity rate compared with the White food insecurity rate on average at the county level, after controlling for other variables in the model at the county level. Results from Model A presented in p < 0.001). These findings indicate that to reduce the food insecurity rate among Blacks, it is necessary to increase Black median income and homeownership, together with diminishing unemployment rate and poverty rate for Blacks. In addition, we examined socioeconomic factors that influence Black food insecurity rates in 2019. To reduce the gap in food insecurity between Blacks and Whites, we will need to identify Black socioeconomic factors that can reduce this gap. Four multivariate regression models are presented in Multicollinearity and heteroscedasticity were diagnosed for these models as well. In this study, multicollinearity was not an issue since no significant correlation among independent variables in the regressions at both the state and county levels was found from the correlation matrix, as shown in Our results suggest that difference in unemployment rates between Blacks and Whites is the strongest predictor of the Black–White disparity in food insecurity rates, as it was statistically significant in both state- and county-level models. The average Black food insecurity rate was approximately double the average White food insecurity rate at both the state and county levels. In addition, the average Black unemployment rate was more than double the average White unemployment rate at both the state and county levels. This finding is in light of previous research at the household level that the individuals and families from Black communities are often at risk of suffering from food insecurity ,4 due toFurthermore, we found that the Black–White difference in unemployment rates, median income, and poverty rate were statistically significant predictors that can be attributed to the Black–White gap in food insecurity rates at the county level. Based on the model of predicting Black food insecurity rates, and consistent with prior research at the household level, the significant predictors of high levels of food insecurity among African Americans are low median incomes ,12,13,21Contrary to Black food insecure adults, White food insecure adults were more likely to report that stores did not have the food they wanted, or the main food access barrier was more likely to be temporary due to supply issues, market shifts, labor shortages, or the COVID-19 pandemic period, where stores experienced certain food shortages ,19. HoweSince the data were derived from an observational study rather than a natural experiment, these findings illustrate the association or correlation between the Black food insecurity rate and other characteristics as well as the gap in food insecurity rates between Blacks and Whites and its determinants rather than suggesting causality. Another potential limitation of this research could be the omitted variables and endogeneity. If unobservable or unmeasurable factors that affect the food insecurity rate among Blacks or Black-and-White gaps in food insecurity rates exist, such as Black ability, Black-and-White gap in ability or education, and omitted state or county unobserved heterogeneity, we might have some biased estimates. Our analysis of panel data on US food insecurity rates at the state and county levels is not available at this stage. Future studies should expand on data collection to gather panel data of US food insecurity rates across time to control for state fixed effects or county fixed effects. Future research with panel data will address the issue of unobserved heterogeneity at the state or county levels, especially rural vs. urban communities and regional variations of the Mid-Atlantic, Pacific, Midwestern, and Southern areas of the US.Moreover, it is crucial that future research consider risk factors that are eligible for extensive systematic reviews . For example, behavioral risk factors and risk factors mapped to the food availability dimension of food security require further investigation to better assess human behavior and environmental factors linked to food availability and barriers that impact Black communities in the United States.Based on the findings of this paper, further research around the socioeconomic determinants of food insecurity, especially low-income households and systemic racism, should consider distinguishing further by race to determine other socio-characteristics tied to the barriers to food security.The aim of this study was to fill in the gap in the literature by examining the relationship between county-and-state-level socioeconomic determinants and the Black–White gap in food insecurity in the United States. This study examined the difference in food insecurity rates between Blacks and Whites in the US using 2019 data at the state and county levels with 50 states and the District of Columbia, as well as nearly 1700 counties from the Map the Meal Gap (MMG) dataset. Multivariate regression analysis was conducted to estimate the relationship of the difference in projected food insecurity rates between Blacks and Whites based on actual 2009 to 2018 data reported by the sample, including socioeconomic factors, such as differences in unemployment rates, median income, poverty rates, and homeownership rates. In summary, these results suggest that the difference in unemployment rates between Blacks and Whites is the strongest predictor of the Black–White disparity in food insecurity rates since the relationships were statistically significant in both state- and county-level models. In addition, differences in poverty rates and median income between Blacks and Whites can also explain the difference in food insecurity rates between Blacks and Whites at the county level, which is consistent with the previous studies ,13. We fAn understanding of the nature and determinants of food insecurity is imperative for improving policies that seek to reduce domestic hunger. To achieve food security, effective interventions are needed, along with adequate funding for, and increased utilization of, food and nutrition assistance programs; inclusion of nutrition education in such programs; strategies to support individual and household economic stability; and research to measure the impact on food insecurity- and health-related outcomes ,11. To eFurthermore, in determining the levels of food insecurity and social determinants at the state and county levels between Black and White individuals, previous research highlights how policies can negatively impact access to resources across populations. For instance, when there are economic resources available across communities, previous research notes more favorable economic conditions and job availability across communities and states. This access helps reduce economic uncertainty and increase the overall economic strength of a community . FederalMost importantly, to achieve food security, besides food and nutrition assistance programs or nutrition education programs, it is necessary to focus on the root causes of the Black–White gap in food insecurity rates. Strategies to support individual and household economic stability need to be enhanced. Creation of new jobs and creating more training programs for Blacks should be encouraged to reduce unemployment, increase income, and improve financial resources for Black individuals.


This paper examines the factors that led to the collapse of hemp grown for cannabidiol (CBD) in Arizona, the United States of America (USA), and particularly in Yuma County, which is a well-established agricultural area in the state.This research uses a combination of mapping analysis along with a survey of hemp farmers to assess the reasons why the hemp industry collapsed as well as to foster solutions to these problems.In 2019, 5430 acres were sown with hemp seed in Arizona with 3890 acres inspected by the state to determine if they could be harvested. By 2021, there were only 156 acres planted, and only 128 of those acres were inspected by the state for compliance. Pythium crown and root rot and beet curly top virus. Addressing these factors will go far in making hemp a profitable and widespread crop in Arizona. Additionally, hemp grown for other traditional uses  as well as new applications  offers other pathways for successful hemp agriculture in this state.A lack of knowledge about the hemp life cycle greatly contributed to the failure of high CBD hemp crops in Arizona. Other problems included noncompliance with tetrahydrocannabinol limits, poor sources for seeds and inconsistent genetics of the hemp varieties sold to farmers, and diseases that hemp plants were susceptible to such as  Cannabis sativa L. is a plant grown by farmers for a multitude of reasons. For medical and recreational uses, the plant is desired for the psychologically active secondary metabolites found mostly in trichomes on and around the female flowers. For industrial and commercial uses, the plant is valued for its fibers that are used in ropes, clothing, and sails, flowers for oil, and seeds for oil or food. Hemp cultivation in the USA was not legal at the federal level until the passage of the 2018 Farm Bill (U.S. Government The Arizona Department of Agriculture (AZDA) started an industrial hemp program in 2019 (Arizona Department of Agriculture (AZDA) Δ9-THC over the legal 0.3% limit by dry weight). All data were tallied by AZDA in April 2022. This study relied mainly on the field inspection data, as it contained more precise information about what was actually growing in agricultural fields in Arizona. The locations of farms were geocoded using the coordinate information contained in the public records. The data were then separated by year, and a time series of maps was assembled using ArcGIS Pro  to visualize the boom and bust of hemp for of the entire state of Arizona, USA, with an emphasis on Yuma County.The Arizona Department of Agriculture issues licenses for growing and producing hemp, maintaining records every year since 2019 (Arizona Department of Agriculture (AZDA) Where are you from?What is your role in agriculture?What media sources do you like to receive educational information from?What agricultural topics would you like more educational resources provided to you from the Yuma County Cooperative Extension Department?Which topics of hemp production would you like to know more about?During the 2019, 2020, and 2021 hemp growth seasons, one of the authors (Masson) met with about 75 hemp farmers in Yuma County as a part of the University of Arizona (U of A) extension’s outreach program. Extension activities during these growing seasons included numerous talks and presentations about growing industrial hemp that produced large quantities of CBD. The talks focused on agricultural techniques and unique issues involved in growing hemp in the farms of Yuma County. We met with farmers in the 2019 and 2020 hemp grow season meetings and collected farmers’ opinions about seed sources and marketing issues. We also distributed a five-question survey to the farmers to identify their agricultural interest and educational needs. This survey was detailed and reported in another publication Masson , and theΔ9-THC , which if not remediated would render the crop illegal and necessitate its destruction. Due to the initial boom overwhelming the ability of AZDA to perform field inspections, many fields exceeded the legal limit before they could be assessed for compliance  Figure First and foremost, the failure of high CBD hemp in Arizona, USA, is a market consequence. Because of the low prices for CBD Jibilian  and limiSome of the problems that this variation can present to outdoor farming operations often involve the photoperiod of the cannabis plant. Cannabis is a short-day plant, meaning it will start to flower when the length of daylight falls below a certain amount . Selecting strains that would be successful in the climate of Yuma County should start with varieties bred for similar climates in other regions of the world. Leafy greens, or microgreens, are leaves harvested from young plants and are currently prized by consumers for their nutritional qualities and flavor (Martínez-Sánchez et al. Any discussion of sustainable agriculture in Arizona, USA, must also consider the current state of water resources. Arizona is an arid state, and water for agriculture is provided from surface waters such as the Colorado River in the case of Yuma County. Colorado River water is a disappearing resource, and recently, the federal government has asked the states of the Colorado basin to revise their allotted amounts of river water based on the decline of reservoirs in the system due to climate change (Vasilogambros Hemp agriculture in Arizona, USA, in terms of a crop that produces significant amounts of CBD, would seem to have failed based on the boom and bust cycle of the 2019, 2020, and 2021 grow seasons. This trend mirrors those seen across the USA (Alpert Other approaches to making hemp successful in Arizona, USA, could be developed, including novel applications such as microgreens for human consumption or for other products such as hempcrete. Traditional hemp-based crops could also be considered, such as seed oil or fiber. Any of these approaches will have to take into consideration the limits unique to Arizona agriculture, especially the climate and availability of water. With climate change making water scarcer, and the human population increasing, it would be prudent to assess alternative crops, including the many uses of hemp, in creating sustainable agriculture in Arizona for the twenty-first century and beyond.


Background: The Zika virus outbreak has affected pregnant women and their infants. Affected infants develop microcephaly and other congenital malformations referred to as congenital Zika syndrome. The neurological manifestations of congenital Zika syndrome may result in some feeding disorders, including dysphagia, swallowing dysfunction and choking while feeding. The aim of this study was to assess the prevalence of feeding and breastfeeding difficulties in children with congenital Zika syndrome and to estimate the risk of developing feeding disabilities. Methods: We searched PubMed, Google Scholar and Scopus for studies published from 2017 to 2021. From the total of 360 papers, reviews, systematic reviews, meta-analyses and publications in languages other than English were excluded. Therefore, the final sample of our study consisted of 11 articles about the feeding/breastfeeding difficulties of infants and children with congenital Zika syndrome. Results: Infants and children with congenital Zika syndrome were likely to suffer from feeding difficulties at various levels, including breastfeeding. Dysphagia problems ranged from 17.9% to 70%, and nutritional and non-nutritive suckling of infants was also affected. Conclusions: In addition to continuing to investigate the neurodevelopment of affected children, future research should also focus on the severity of factors influencing the degree of dysphagia, as well as the impact of breastfeeding on the child’s overall development. In early 2015, some incidents of patients with symptoms of rash, mild fever, arthralgia and conjunctivitis were reported in northeastern Brazil. After the Chikungunya and dengue infections were ruled out, Zika virus (ZIKV) was detected by reverse transcription-polymerase chain reaction from the sera of eight patients . By the Swallowing is a complex behavior, involving both reflex and volitional activities implicating more than 30 nerves and muscles . There aAccording to the above, the neurological manifestations of CZS in infants may result in some feeding disorders , which complicate the already existing situation by increasing the risk of morbidity and mortality through malnutrition ,26. For Breastfeeding has many short-term and long-term benefits for both mother and infant. Exclusive breastfeeding for the first 6 months is associated with a significant reduction in infection and diseases , as wellThus, the need for a systematic review of the literature was noted in order to find relevant articles concerning the feeding (including breastfeeding) of children with the special needs of CZS. The aim of this study was to assess the prevalence of feeding and breastfeeding in children with CZS and to estimate the risk of developing feeding disabilities.Nevertheless, feeding abilities differ between neonates, infants and children. For example, suckling and swallowing are already observed from the fetal life stage (14–15th week). Coordination of suckling, breathing and swallowing is developed in neonates from birth. In addition, they adjust suckling according to the different types of milk flow (breast or bottle milk). At the age of 2 months, the infants can move the food from the spoon to the back of the mouth, and between 4 and 6 months, when the infant learns to control the tongue, purees or smooth foods are introduced into the infant’s diet. At the period of 6–12 months the front teeth emerge, so they can chew soft pieces, while between 12 and 24 months, they can cope with most food textures and most foods in the family meal .We included prospective studies as well as cohort and cross-sectional studies from 2017 onwards that evaluated the association between CZS and feeding/breastfeeding disabilities. This review followed the guidance of the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) . We exclWe defined exposure as all infants diagnosed with CZS. Furthermore, all infants had some degree of neurological impairment, with developmental delays at all levels, hypertonia and pyramidal and extrapyramidal signs.To investigate our outcome, we included all studies that provided information on feeding and breastfeeding in infants and children with CZS.We searched all published English articles on the following databases: Scopus, PubMed/Medline and Google Scholar, and conducted a literature review from 3 August to 26 October 2022. The terms we used were: infants with CZS OR ZIKV infected infants OR ZIKV and congenital malformations AND breastfeeding outcomes OR breastfeeding problems; infants with CZS OR ZIKV infected infants OR ZIKV and congenital malformations AND feeding problems OR feeding disabilities; and infants with CZS OR ZIKV infected infants OR ZIKV and congenital malformations AND nutritional status OR nutritional deficiency.Two authors (E.A. and E.O.) evaluated the titles and abstracts independently. Then, the full texts of all shortlisted articles were retrieved and evaluated for eligibility using the predefined inclusion and exclusion criteria. There were no disagreements; therefore, they were not reviewed by another author.No significant difference appeared in the methodological quality and risk of bias of the articles. The main problems in all studies were that exposure was not assessed more than once over time, and the outcome assessors were not blinded to the exposure status of the participants because the types of studies did not support this design . The quaFurthermore, selection bias in all articles was low because participants did not differ in their basic characteristics. Performance bias did not exist because no group of children was exposed to factors that affected the results. The way results were collected was reliable across all articles so detection bias was not present. Finally, no data were hidden from any article so the results were not distorted (reposting bias).The initial search of the databases found 360 papers. After removing all duplicate and “other title subject” papers, 117 remained to be evaluated. Subsequently, 106 papers were removed as they were reviews, systematic reviews, meta-analyses, letters to the editor or published in another language than English. Finally, 11 articles were included in the systematic review .Four studies had a cohort design ,29,37,43We identified feeding disabilities in all articles. One of them  associatAmong the remaining articles, the results of the first one  showed tThe infant’s ability to suckle is a necessary condition for the initiation of feeding through breastfeeding. However, nutritional and non-nutritive suckling problems in children with CZS result in breastfeeding difficulties. Abnormal swallowing was confirmed in some studies ,41,43, wHowever, a worse nutritional status can be counteracted by the beneficial properties of breastfeeding. The weight of infants who were fed with their mother’s milk, either through breastfeeding, expressing breast milk or using donor milk, was much better than the infants who drank formula milk ,40.The results of this study showed that children with CZS were likely to suffer from feeding difficulties at various levels, including breastfeeding. Several studies have shown that children with CZS have feeding difficulties, which are related to the insufficient suckling ability and dysfunction in the orofacial muscles ,46. FeedSwallowing that follows the breastfeeding reflex is a voluntary process of the infant that requires optimal functioning of the cerebral cortex, which is not fulfilled in children with CZS . For thiAccording to our results, the majority of infants who breastfed did not continue to do so past 6 months, and few breastfed for the whole first year of their life. However, we could not determine whether the infants with CZS had dysphagia problems or whether the early introduction of formula feeding was a cause of breastfeeding cessation. Additional explanations could be the mother’s lack of cooperation, her mental distress and the lack of breastfeeding promotion programs for mothers of children with CZS ,51. In aThere is no recommendation to stop breastfeeding in mothers exposed to ZIKV or in infants exposed intrauterine to ZIKV ,55, but A key limitation of the study was that it was conducted only in Brazil; in the future, more cohort studies on the effects of CZS on children’s nutrition from all affected countries are needed. In addition, the registration protocol was not peer reviewed in PROSPERO.For the majority of children with CZS, feeding is a difficult process. In addition to continuing to investigate the neurodevelopment of affected children, future research should also focus on the severity of factors influencing the degree of dysphagia, as well as the impact of breastfeeding on the child’s overall development. It is considered imperative to develop education and psychological support programs for families who have children with CZS. In addition, breastfeeding should be supported by any method possible .


In China, public medical insurance has expanded rapidly in the past 20 years. Many studies have discussed the benefits of medical insurance in improving residents’ health and financial stability, and increasing the utilization of medical services. Less attention is paid to the effect of medical insurance on family support between parents and children. This study focuses on the effect of medical insurance on promoting family financial support in China.Fifty-five thousand sixty-two individual samples were obtained from four waves of the China Health and Retirement Longitudinal Study (CHARLS): 2011, 2013, 2015 and 2018. Linear-regression model and propensity score matching are used to determine the relationship between medical insurance and family financial support. Then, mediation model is introduced to identify the mediation mechanisms. Also, moderation model is used to estimate the moderation effect of parental education and health.Medical insurance has significantly increased family financial support between the insured parents and their children. Moreover, this positive effect is heterogeneous since only families living in rural areas were affected, and the direction of family financial support changed with the aging of the parents. The welfare of medical insurance on financial status have also been proven in this paper. The results indicate that medical insurance reduces the out-of-pocket ratio of medical expenses and increases health investment, which can perform as as two mediation mechanisms to affect family financial support. Besides, the education and health status of the insured parents play a role in moderating the effect of medical insurance. The public medical insurance system for urban workers was established in 1998, and since then, China’s medical insurance coverage has been expanded to include both urban and rural residents. By the end of 2022, the number of residents enrolled in Urban and Rural Resident Basic Medical Insurance (URRBMI) had reached 983 million, and the national coverage rate had increased rapidly from 64.6% in 2009 to more than 95%.While most of the existing research on medical insurance has focused on its direct effect on health outcomes, medical utilization, and financial protection, the essential benefit of medical insurance to regulate family support and intergenerational relations has received little attention. Admittedly, the effect of medical insurance on private financial decision, such as family financial support within a family, is not as noticeable as its direct effect on improving health status and reducing medical expenses. However, it still deserves closer attention, considering that Chinese attach great importance to mutual support and material exchanges between their families. It is highly possible that the expansion of medical insurance in China can work as a public channel, which firstly influence the financial status of the insured and then influence their financial support between the children. As a result, the medical insurance can affect the net welfare of the family members.Based on the preliminary assumption that the benefits from the public channel will affect the financial support from the private channel, this study empirically examines the impact of medical insurance on family financial support, based on panel data from the China Health and Retirement Longitudinal Study (CHARLS). China is a good case for this study because it has experienced rapid expansion in its medical insurance for urban and rural residents. What’s more, the Chinese attach great importance to family support between parents and children. Frequent and intensive family financial support between parents and children is considered an essential symbol of family harmony and family happiness.This study contributes to the literature on medical insurance and family welfare in three ways. First, most previous studies on the effects of insurance programs on family support have focused on public pension programs, while the effects of medical insurance are less discussed. As a part of social security systems, URRBMI may also crowd out or crowd in family support, resulting in a change in the welfare of the families. Therefore, exploring the effect of medical insurance on family support is essential for evaluating the net welfare of medical insurance. Second, we consider the heterogeneous effects of medical insurance, which has received scant attention in previous studies about public support and private support. Third, we introduce two mechanisms by which medical insurance affects family financial support. Thus, we are able to provide more comprehensive explanations for the inconclusive answers regarding whether and how medical insurance affects family financial support.The remainder of this study is organized as follows. We first introduce the background of the basic medical insurance of China. In the following two sections, we review the relevant literature and provide a theoretical analysis. Data, descriptive statistics, and empirical framework are subsequently presented. Then, we present the empirical results and provide a discussion on the results. In the last section, we give a conclusion of this paper.In 1998, China established the UEMI as a supporting program for the reform of state-owned enterprises. The UEMI was the first formal medical insurance program in the country. Since then, a series of programs have been launched to provide medical services to both rural and urban residents. In 2003 and 2007, China established the NCMS and the URMI, respectively. The former aims to cover the vast majority of rural residents and the latter is designed to cover unemployed urban residents. Thus far, China has essentially achieved the goal of providing universal coverage of basic medical insurance for its citizens.Since 2016, many regions have merged NCMS with URMI and implemented a unified URRBMI. Therefore, the coverage, financing mechanism, treatment, catalog, and management of NCMS and URMI have achieved equality between urban and rural residents. URRBMI employs a combination of individual contributions and financial subsidies financing mechanisms, residents can enjoy the benefits from URRBMI after paying the premiums for that year. What’s more, the financing standard and government subsidies of URRBMI have been continuously improved since its establishment. According to the requirement of the National Medical Security Bureau, the individual payment standard of URRBMI in 2022 is 350 yuan per capita, and the financial subsidy standard is no less than 610 yuan per capita. After enrollment, residents can enjoy the benefits from URRBMI for inpatient and outpatient medical expenses. For the inpatient medical expenses incurred in the first, second and third level hospitals, the payment line, i.e., the deductible of URRBMI is 200 yuan, 400 yuan, and 600 yuan respectively. The payment proportions for the expenses between the payment line and maximum payment line are 65%, 60%, and 50% respectively. As for the outpatient expenses, the payment line is 600 yuan. The payment proportion for the expenses between the payment line and the maximum payment line is 50%. The maximum annual payment is 3000 yuan per capita.So far, a large number of literatures have studied the remarkable policy effects of URRBMI, including reducing medical burden  and the Many scholars have studied the impact of public policies on family financial support from both theoretical and empirical views, but most of them focused on public pension programs and ignored the potential effect of medical insurance. In the theoretical field, scholars generally believe that if a public program achieves its expected effect and improves the economic and health status of the insured, then both the insured parents and their children will change their financial support to each other. Whether a public program will crowd out or crowd in family financial support depends on the people’s motivation. For example, Becker and Barro point out that under altruistic motivation, the improvement of parents’ economic or health status will crowd out family financial support from their children , 13. HowIn the empirical studies, Deindl and Brandt study the social insurance systems of 14 European countries and find that social insurance will crowd out family support received by parents and the intensity of the crowd-out effect increases with the amount of social insurance benefits . Lin et Although medical insurance is less discussed as a public channel which may affect the private channel within the family, many studies have sufficiently confirmed its effect on reducing the medical expense, improving the health status and financial expectations, and stimulating the consumption demand of the insured , 23, 24.Based on the above literature, we can conclude that the existing studies have conducted in-depth research on the effect of benefits from public channel on private support. However, these studies mainly focus on public pension programs and have yielded inconclusive results. Moreover, existing studies generally use cross-sectional data, and thus it is difficult to provide a convincing examination of the causal relationship between insurance and family support. In addition, the heterogeneous effect and mediation mechanism are seldomly addressed in the existing literature. To address the aforementioned problems, this study uses the CHARLS panel database to analyze the impact of URRBMI on family financial support and investigate the heterogeneity and mediation mechanism of its effect comprehensively.When analyzing the effect of medical insurance on residents’ decision-making, existing literature often starts from two theoretical perspectives: Health performance and economic performance of medical insurance. Health performance refers to that medical insurance is expected to improve the health level of insured individuals. Economic performance refers to that medical insurance is expected to reduce medical expenses and improve the financial status of insured individuals. As an important component of the social security system, the health and economic performance of medical insurance have been well-discussed and demonstrated in previous studies. In terms of health performance, studies have indicated that basic medical insurance in China could boost preventive care utilization and increase citizens’ self-rated health –31. In tAs for the effect of medical insurance on financial support from insured parents to children, scholars generally believe that with the improvement of economic and health conditions, the dependence of elderly people on their children can be weakened, and they tend to have more ability to provide financial assistance to their children, i.e., increase their financial support to children. This effect can be more significant in China because Chinese parents attach higher importance to family support and have stronger behavioral inertia in supporting children . MoreoveAs for the effect of medical insurance on financial support from children to insured parents, studies consider that it depends on what kind of motivation the children hold. Generally, there are two kinds of motivation that can produce opposite results: Altruistic Motivation and Exchange motivation. Under “Altruistic Motivation”, children tend to reduce financial support for elderly parents if the health and economic conditions of their parents can be improved by medical insurance, which means that medical insurance crowd out financial support from children to parents. The portion of the financial support that was originally transferred to parents will be returned to children, thereby maximizing the utility of the offspring generation , 13. WhiOur data comes from the CHARLS database in 2011, 2013, 2015, and 2018. CHARLS uses multistage stratified probability proportional to size sampling to conduct a nationwide survey of respondents aged 45 years or older. The survey follows detailed protocols for sampling, field surveying, and data quality verification. The baseline CHARLS was conducted in 2011. The second-, third-, and fourth-wave national surveys conducted in 2013, 2015, and 2018 aimed to revisit the same respondents sampled in the first wave. The information in CHARLS includes individual demographic backgrounds, family contacts and transfers, health care, and insurance. Thus, this dataset has been widely used in international health economics research, aging research, and family welfare analysis –35.By the time the national follow-up was completed in 2018, the survey had covered 150 county-level units and 450 village-level units in 28 provinces, with 19,000 yearly respondents in approximately 12,400 families. We generate a series of variables required in our study based on the original database and questionnaires, such as URRBMI, family financial support from parents to children, and family financial support from children to parents. To identify the impact of URRBMI on family financial support, we exclude respondents who were enrolled in other social medical insurance, such as UEMI and Supplementary medical insurance. The participants from commercial medical insurance are also excluded from the full sample. Since NCMS and URMI in some areas were merged into URRBMI after 2016, both those enrolled in NCMS and URMI are regarded as being enrolled in URRBMI in this study. Specifically, those enrolled in NCMS, URMI, and URRBMI constitute the treatment group. After excluding respondents with missing information, we finally obtain unbalanced cross-sectional data on 55,062 observations. We define the treatment group as “the parents enrolled in URRBMI” and the control group as “the parents without any medical insurance.” There are 52,734 samples in the treatment group and 2,328 samples in the control group.The independent variable in our study is URRBMI, the value of insured is 1, and the value of non-insured is 0. The dependent variables are We are also interested in two factors that may mediate the effect of URRBMI on family financial support: the out-of-pocket ratio of medical expenses and health expense. The out-of-pocket ratio of medical expenses is equal to out-of-pocket inpatient medical expenses in the past year divided by the total inpatient medical expenses in the last year. Health expense is equal to the expense of health investment and health care in the last year. The control variables in our analysis include both individual-level and household-level characteristics. The individual-level variables include age, gender, urban residence, marriage status, education, self-rated health status, and public pensions. The household-level variables include the number of children, living arrangements, and family financial assets.Table In empirical analysis, the dependent variables The linear regression model in Eq.  examinesSince enrollment in URRBMI is not randomly assigned, the decision to enroll in URRBMI is likely to be affected by individuals’ personal characteristics. For example, people with higher education and stronger risk awareness are more inclined to enroll in medical insurance. Therefore, the observed differences in family financial support between the treatment group and the control group may be caused by two things: one is the effect of enrollment in URRBMI, and the other is the natural differences of the two groups. To eliminate the endogeneity problem caused by sample selection bias, we use the PSM method to check the robustness of the main results presented in the previous section. For individual entclass1pt{minimaFor individual We use the “propensity score” proposed by Rosenbaum and Rubin to measure the distance between ument}Xj . The proSupport by affecting some mediator variables, then we can use the following regression equation to describe the causal relationship between the variables. This framework for mediation analysis was first proposed by Baron and Kenny, based on the linear structural equation model [If the independent variable on model . It was on model . The sigSpecifically, the mediator variables in this study are b in Eq.  represenc in Eq.  represenBaron and Kenny suggest that mediation effects can be tested under the following conditions : First, t in Eq. ; and thit in Eq. . The tesr in Eq.  than in r in Eq. .a and coefficient b in Eqs. , , a and cThe causal effect of URRBMI on family financial support might be affected by personal backgrounds, such as education level and health status. With higher education and better health status, parents may engage in more activities and generate more entertainment expenses, which may have a moderate effect on the financial support between themselves and their children. In addition, healthier parents may also have less medical and health care consumption, thus moderating the support between themselves and their children. Therefore, we use hierarchical regression to perform moderation analysis in this section. First, we repeat the regression between URRBMI and family financial support in Eq. . Other cFirstly, we use ordinary least squares (OLS) regression to analyze the effect of URRBMI on family financial support. Table Additionally, the coefficient of respondents’ age on family financial support from their children to themselves is significantly positive, while the coefficient of respondents’ age on family financial support from themselves to their children is significantly negative. This indicates that the older an individual is, the more financial support he/she receives from his/her children, and the less financial support he/she gives to his/her children. The coefficient of urban residence indicates that rural residents tend to receive more financial support from their children, while urban residents tend to provide more financial support to their children. The above results preliminarily show that the elderly and rural parents are more dependent on family financial support, which may lead to the heterogeneity of the effect of URRBMI.The results of heterogeneity analysis are shown in Table The results in Columns 3) and (4) of Table  and (4) In the first robustness test, we use three matching methods: nearest neighbor matching k = 4), radius matching, and kernel matching. The balance check of the distribution of the covariates between the treatment group and control group is shown in Table , radius In the second robustness test, we use entclass1pt{minimaIn the previous section, we find that enrollment in URRBMI has a significant effect on family financial support between the insured parents and their children. We examine the indirect effects of URRBMI through the out-of-pocket ratio of medical expenses and health expense in this section. First, enrollment in URRBMI could reduce the out-of-pocket ratio of medical expenses and alleviate the burden of medical expenses. As a result, parents who are enrolled in URRBMI can provide more financial support to their children. Second, URRBMI may raise individuals’ health awareness and stimulate health consumption, thus crowding in children’s financial support to parents.The results in Columns (1) to (3) of Table Next, we examine whether URRBMI has a crowd-in effect on family financial support from children to parents by stimulating health consumption. The results presented in Columns (4) to (6) of Table a indicates that enrollment in URRBMI significantly reduces the out-of-pocket ratio of inpatient medical expenses by 3.0%, which is consistent with the results in Table b indicates that a 10% decrease in the out-of-pocket ratio significantly increases family financial support from parents to children by 3.35%. Therefore, URRBMI promotes family financial support from parents to children by reducing the out-of-pocket ratio of inpatient medical expenses. This positive mediating role accounts for 5.4% of the total effect. The results of health consumption shown in the second part of Table The results of the Sobel-Goodman mediation tests are given in Table The results in Table The empirical findings in this paper make several contributions to the understanding of public program, family decisions, and family welfare. Before this study, empirical evidence on the positive effect of medical insurance on intergenerational support within Chinese family was limited. Our study is one of the first attempts to thoroughly examine the impact of medical insurance on family financial support. Through our evidence, we confirm the positive effect of URRBMI on personal financial status and family welfare. Our results indicate that URRBMI could significantly reduce the out-of-pocket ratio of inpatient medical expenses, thus reducing the burden of medical expenses. We also demonstrate that URRBMI has a positive effect on increasing the health investment and health consumption, which may further improve people’s health. Different from the previous literature, which mainly focuses on the preliminary effect of URRBMI on health and personal finance , 9, 23, In addition, the results from the heterogeneity effect are also striking. The positive effect of URRBMI on family financial support is more significant among rural residents. This may be related to the fact that rural residents in China place more importance on family solidarity and support. The previous study has indicates that the core functions of the family as the major welfare provider in rural China have remained . TherefoIt is important to note some limitations in our study. First, although one of the strengths of our data is that CHARLS data are nationally representative, this data may not objectively reflect some characteristics of respondents. Slight errors may have occurred when a respondent was asked to recall the money and in-kind support between his/her children. In addition, the use of self-rated health status as a representation of physical health status may bring some deviation. Second, we consider that medical insurance has a positive effect on family harmony since it can increase financial support between family members. However, we did not measure this welfare improvement effect by an individual or family utility function. Thus, there are some difficulties in comparing the effects of different medical insurance policies. Future studies might introduce an expected utility model and measure the utility improvement of this effect.This article uses data from CHARLS for the years 2011–2018 to estimate the effect of URRBMI on family financial support. The results show that URRBMI significantly improves financial support between insured parents and their children. The out-of-pocket ratio of inpatient medical expenses and the health expense of insured parents are important mechanisms that mediate the effect of URRBMI on family financial support. In addition, both the heterogeneity effect and moderation effect are discussed in our study, providing a comprehensive understanding of the effect of URRBMI on different family backgrounds. Overall, URRBMI could significantly promote financial support between family members, which we believe is conducive to family harmony and intergenerational mutual assistance.The results from our study have several implications for the literature on medical insurance and other social welfare programs, and for literature focused on family economics and labor economics. Our results suggest that it is important to recognize the roles of both preliminary and spillover results in the evaluation of public policy. The medical program may not only influence the benefits of beneficiaries, but also affect their cognition and decision-making through a direct or mediation mechanism. In addition, the government and policymakers should pay attention to the fact that the benefits of a public program can be moderated by other factors. Therefore, it is important to consider the needs of different groups when developing and evaluating public policies.