This paper is related to the current stage of development in the Western Balkans. Despite becoming growing instruments to finance sustainable green development, debt swaps and social or sustainability bonds are relative novelties in this region. At the same time, the development needs are huge, especially in the light of the COVID-19 aftermath.The review of both historic financial instruments, such as the debt for nature swaps, and more recent ones, such as sustainability bonds in its variations, highlight the potential for use in developing countries. The relatively recent case from Montenegro and the recent issuance of the green bond in Serbia showcase the possibilities. The focus of this paper is an analysis of the public debt position of Western Balkan countries. The growing level of public debt over the past decade points to a lack of adequate interventions and a relatively imminent need for fiscal consolidation. The research suggests that environmental, social, governance/sustainability-linked bonds and debt-for-climate swap investments as innovative financial instruments that hold promise in leveraging additional finance to support the sustainability goals of the six countries of the Western Balkans. This influx of capital would be particularly advantageous, given their needs relative to EU accession and their economic and structural challenges. The recommendations for policymakers are derived based on the history and features of green bonds as well as debt-for-nature swaps and their diverse underlying mechanisms which are adaptable to the respective countries.The related countries would benefit from exploring more innovative approaches to finance sustainable societies. In close cooperation with the EU and taking the European Green Deal into consideration, it is recommended that the six countries of the Western Balkans design financing mechanisms that will bring increased transparency to the different policies and more accountability for their implementation. Applying the recommended modality may help keep the problem of the public debt at bay, while additional funds may support implementation of structural reforms. The adoption of the seventeen sustainable development goals (SDGs) in 2015 by the UN General Assembly marked the beginning of a new era for global policy coordination. Following the Millennium Development Goals (MDGs), adopted in 2000, the Sustainable Development Goals, or UN 2030 Agenda, became the anchor agenda for all stakeholders.As illustrated in a number of studies, the first global policy agenda was only partially met. For example, only 20% and 7% of low- and middle-income countries were on track to meet child and maternal mortality fast-track targets . DespiteAlthough academic literature on SDG financing and its challenges appears substantially limited , the impInnovative instruments are needed to scale up international finance for sustainability purposes, but only limited options are available for developing and transitional economies . For insHowever, expectations that blended finance can bridge the SDG financing gap and mobilize private investment in SDGs at scale are currently unrealistic. Each $1 of MDB and DFI invested mobilizes, on average, $0.75 of private finance for developing countries. Blended finance may tip the balance, but it will likely not be effective if the economic fundamentals are not in place. Therefore, the push for blended finance should not divert the attention from the need for grants to boost local investment environments. Donors, therefore, need to think carefully about the allocation of ODA and the risks and trade-offs of investing ODA in blended finance . There iIn the meantime, the countries of the Western Balkans Six  struggle to juggle all the policymaking tools to achieve sustainable economic development. In parallel, they are expected to meet benchmarks in a number of complex fields, while achieving good grades related mostly to the rule of law, quality public administration and economic governance to join the EU.One of the aspects that will be under particular scrutiny is the debt portfolio of the countries in question and the possibilities to improve the current situation, given the sustainable development requirements. This is of particular importance as it is important to address potential that lies ahead in using more innovative means of financing the development policy needs.Given the fact that early green bonds’ attempts are more than a decade old , this neDebt-for-nature swaps [and swaps for other sustainability purposes] offer another solution to avert both debt and sustainability challenges by providing debt relief alongside mobilizing new finance for achieving sustainability goals. While respective designs vary, all debt swaps share the same underlying mechanism: public debt of a developing country is cancelled in exchange for investments in projects linked to nature protection within the debtor country. There have only been a few debt-for-nature swaps in countries of other world regions so far, and the investigative team recorded one debt swap in Montenegro, but could not identify a recent surge in scholarly attention.The aim of this paper is to assess new sustainability-linked bonds and debt-for-climate swaps as innovative financial instruments, promising to leverage additional finance into sustainability goals in the Western Balkan Six. As a first step, an online search was conducted for published material on sustainability bonds and debt swaps by researchers, international institutions and think tanks. This also entailed the collection of reports, news articles, and web pages. All collected data was then reviewed and analysed from the perspective of drawing useful recommendations for the focus countries. Second, we analysed relevant data related to the debt situation in the countries and drew conclusions on the usability of instruments based on our experience in policymaking in the region. The subsequent section outlines recommendations for policymakers in designing future green bonds and debt-for-nature swaps and applies these to national circumstances in the Western Balkan Six. This study ends with conclusions highlighting key messages.All the new forms of the bonds are voluntary. However, the growing trend is obvious. Investors tend to identify the benefits of a particular intervention based on their interest to approach markets in different ways, the new instrument raises the country or corporation’s visibility or the innovation opens new financing channels as more and more investments funds are committed to keep share of their investments in the green, social or sustainability bonds —or as thOne of the consequences of COVID-19, related to this new bond market, was the slow-down of the green bonds against the growth of the social and sustainability bonds. The social bonds hit a record with an increase of 170% since the beginning of 2020. However, despite rising corporate interest, the rapid increase in social bond issuances as a response to the recent pandemic has been mainly led by IFIs and primarily multilateral development banks (MDBs) . In paraThe Green Bonds Principles just like the Social Bonds Principles or the Sustainability Bonds Principles are designed to promote the transparency and integrity needed to increase capital allocation to the projects that highlight either the green or social element [or the mix]. These investments are thus linked to the sustainability policy, as explained by the International Capital Markets Association’s briefs , 14. To Launched in 2007, with the European Investment Bank and the World Bank, issuance of the green market bond has grown significantly. The wider bond market started to react after the first USD 1 billion green bond sold within an hour of issuance by IFC in March 2013, while in November of the same year, corporate green bonds started to see the light.Normally, the projects funded are related to the climate change mitigation, climate change adaptation, natural resource conservation, biodiversity conservation, and pollution prevention and control, and are focused, for example, on energy or emissions reduction projects, sustainable agriculture, and green buildings.On the other hand, social bonds are intended to meet various social needs. Their role is to provide capital for projects that contribute to socioeconomic advancement and empowerment—such as affordable housing and infrastructure, access to essential services, employment generation, and food security .3 They aAll of these new instruments require vigilant reporting by external parties who monitor and certify accomplishments which adds to their credibility and makes them potentially preferred mechanisms in addressing the mid- to long-term needs to meet SDG benchmarks and help decarbonize the economy while making best use of private–public partnerships. However, the magnitude of the need is very large. Communicating the European Green Deal in December 2019, the Commission estimated the need for an additional EUR 260 billion per year or about 1.5% of 2018 GDP to reach energy and climate 2030 goals . It is oThe current total value of outstanding green, social and sustainability bonds is USD 1503 billion . HoweverThere is still much progress to be made when considering the regulatory framework, especially now that sustainable finance is becoming a part of mainstream discourse. The green transition in various sectors can be significantly supported by some of these sustainability or performance linked mechanisms. Therefore, it is expected that the EU will further work in this field by creating an EU Green Bond Standard , includiDemand for green bonds is continuously increasing. Until roughly 2012, the green bond market was dominated by multilateral development banks, which already had in place processes for assessing environmental, social and governance [ESG] risks for projects. This has, however, changed over time, with a growing number of green bond issuances by corporations, energy and utility companies and governments and their agencies from around the world. Notable examples include Chinese issuers, who in 2016 comprised about 40% of the overall green bond market, as well as Poland, which in the same year became the first sovereign state to issue a green bond, followed by France, which issued the largest ever and longest dated benchmark green bond, a Euro 7 billion, 22-year benchmark bond. In 2017, while holding the COP23 Presidency, Fiji became the first sovereign emerging market issuer of green bonds when it issued a green bond with a value of USD 50 million , remained the largest green bond issuer with 22.9bn USD issuance or 9% of the total. KfW, the German state-owned development bank, was the second largest issuer with a total of 9bn USD worth of green bonds in the market with proceeds used to provide financing or co-financing to renewable energy and green building projects. They were followed by the Dutch State Treasury Agency [DSTA] ranked as the third largest issuer with 6.7bn USD debut green sovereign bond.Another recent example of this phenomenon was the announcement of global biopharmaceutical company Pfizer about launching a $1 billion USD sustainability bond offering, with the use of proceeds funding R&D and capex for the company’s COVID-19 vaccine. The 10-year bond was priced at 1.75%. The issue marks the second for Pfizer under its Sustainability Bond Framework, following a $1.25 billion USD 2.625% 10-year offering in March of last year. According to the company, proceeds from the offering will be used to finance or refinance research and development expenses related to COVID-19 vaccine research and development, capital expenditures in connection with the manufacturing and distribution of COVID-19 vaccines, and other projects of Pfizer or any of its subsidiaries that have environmental and/or social benefits .Although to date, there has been very little academic work in the theory of the growth of the green bond market in the academic literature , some coBesides incentives related to the economic performance of the investor there are incentives that are not directly related to the financial performance of the green bond.  The fourCreating new markets could entail developing new investment products for customers interested in sustainable investing and/or attracting new classes of customers to existing and new product offerings . There aA variation to the above-mentioned bonds is the sustainability-linked bonds [SLBs] or ESG bonds. The proceeds of SLBs are intended for general purposes and due to the variability of the coupon, based on the accomplishment, may be further explored by the Western Balkan countries. During the preparation process objectives are measured through predefined key performance indicators [KPIs] and assessed against predefined sustainability performance targets [SPTs].The Sustainability-Linked Bond Principles [SLBP] , establiThe potential variation of the coupon is the most common example, but it is also possible to consider the variation of other SLB’s financial and/or structural characteristics.What adds to the transparency and the overall credibility of this mechanism is that issuers should seek independent and external verification [for example limited or reasonable assurance] of their performance level against each SPT for each KPI by a qualified external reviewer with relevant expertise, such as an auditor or an environmental consultant, at least once a year.Reference  provide The first debt-for-nature swaps appeared in the 1980s as a response to the worsening environmental conditions in developing countries. In the 1980s many countries particularly in Latin America increased their export volume in response to the debt and economic crisis that caused heightened rates of resource exploitation and deforestation.The volume of debt swaps grew in the 1980s to peak in 1990 and decline through the 1990s. Throughout the 1980s, the secondary market of debt titles grew rapidly and debt swaps were advertised as a standard instrument of debt relief by lending agencies seeking new ways to minimize their financial losses . Total sAlthough debt-for-nature swaps were performed at much smaller scales than debt-for-equity swaps, they raised hundreds of million of dollars for environmental projects in the 1990s. It is estimated that between 1987 and 1997 USD 134 million worth of debt allowed financing of USD 126 million in nature conservation . 38] es es38] esIn the months leading up to the climate summit in Copenhagen, Indonesia named debt swaps as a source of climate finance in informal UNFCCC consultations. Still, debt-for-climate swaps were never declared as an official climate finance instrument under the UNFCCC . NeverthDebt relief linked to environmental goals or debt-for-nature swaps is not a new story: after World War II the Paris Club comprised of major creditor countries initiated large-scale debt relief programs in the form of debt-for-equity swaps, and from 1991 onwards allowed debtors to convert their public debt into local payments for social or environmental projects. Since then, debt-for-nature swaps have raised hundreds of million of dollars for the environment.A good example of this approach is the 2015 debt swap scheme implemented by Seychelles and a club of public and private debtors which enabled the country to cancel EUR 21.6 million in exchange for domestic investments in protection of its unique marine ecosystem against a specific commitment of the Government of Seychelles to increase marine protected area from 1 to 30% of its territorial waters .Another good example was the swap between Italy and the Philippines in 2012 that entailed the cancellation of the Philippine’s public debt of EUR 2.9 million in exchange for investments in environmental protection and poverty reduction . The proAs  explain,After mutual agreement, expenditures of the debtor government are usually made gradually, often into a dedicated fund, and according to the original repayment schedule of the initial debt. They can either be channelled directly towards environmental projects or placed in a national trust fund, through which the interest earned on the deposited money can also be used to finance environmental projects, e.g., via grants to local NGOs. Such funds allow earmarking and increase accountability as they are governed by a committee composed of representatives from both governments and independent observers, such as national or international NGOs.If debt titles are bought on the secondary market, the price is determined by the credit rating, debt situation, and overall economic performance of the indebted state. If, alternatively, debt titles are bought back via bilateral agreements, no rules or restrictions on the discount rate by which the initial debt is reduced exist. Having mainly ranged between 0 and 50% in the past, discount rates are negotiated between the participating governments on a case-by-case basis.Overall, debt swaps are more feasible when creditor governments are willing to sell titles at a price lower than face value, because only then there is some fiscal space created for the debtor government. However, as bilateral debt is predominantly held in US dollars and investments in local environmental projects are generally made in local currency, preferable conditions could arise even at a discount rate of zero when scarce hard currency can be saved.Most debt swaps have involved bilateral public debt, but debt swaps can also be conducted in the case of multilateral public or commercial debt. Commercial debt, for example, can be bought on the secondary market by a donor country as a form of official development assistance [ODA] or climate finance. Multilateral creditors, such as the World Bank or the IMF, cannot provide debt relief per se because of their legal status, but donor countries could use their resources to pay off the debt held at such institutions.Debt-for-climate swaps are commonly referred to as ‘win–win’ agreements, as they benefit both debtor and creditor countries. Table The Montenegrin case Fig.  represenThe final consent of the Government of Federal Republic of Germany on the KfW report on completion of program activities was the last cancellation precondition. Debtor financial obligation was transferred to a special account of the Vodacom company, organized as the Joint Service and Coordination Company for Water and Wastewater Services for the Montenegrin Coast. It was established in 2005, after the Government of Montenegro recognized the need for active work on the improvement of water supply and sewerage infrastructure on the Montenegrin Coast. The last disbursement to the provider of construction works was completed in October 2013 by Vodacom which was considered as the closure of the swap. Figure References , 43 summSeek to achieve a positive difference between the original face value of the debt and the redemption price so that fiscal space is created. This can be done by either purchasing the debt title on the secondary market or by bilaterally agreeing on applying a discount rate greater than zero with the creditor.Negotiate the cancellation of the outstanding debt service payments before making counterpart payments to provide extra budgetary room.Convert the outstanding debt payments into local currency payments so that hard currency can be saved.Schedule payments according to the original repayment schedule so that a constant and predictable stream of finance is provided.Reinvest the interest rate earned by the funds to provide additional capitalization for the mechanism.Only conduct debt swaps if the debt volumes are large enough to justify the lengthy negotiation process and high transaction costs associated with deal structuring and implementation.The first recommendation to a debtor country when designing and negotiating the financial structure of a swap mechanism to maximize the financial values of such schemes:Furthermore, debt swaps and corresponding debt relief should be additional to the creditor’s ODA and not crowd out other ongoing investments in climate mitigation and adaptation. Second, climate-related projects, funded by debt swaps, should be additional to those already funded in debtor countries. While it is beneficial if concrete climate objectives and measures are envisioned and some infrastructure for delivering those is already established, payments originating from swap deals should not be used to legitimize cutting back governmental spending in other areas. And lastly, it is essential to ensure added finance for the debtor country through debt relief.The second recommendation is that the design of the climate swap mechanism should be aligned with national climate commitments. In particular, they should be fully anchored in and aligned with national climate change priorities and the objectives as communicated in the National Determined Contributions [NDCs].To ensure the achievement of climate and other environmental and social benefits of climate swap schemes, it is important to start with determining a baseline scenario against which progress and final outcomes are measured. This entails developing indicators and specific defining targets that should be set for various steps throughout the implementation phase. Monitoring plans and methodologies shall also be developed to enable regular progress tracking, reporting and communication to all involved stakeholders and the public-at-large to enhance transparency. Involvement of independent actors, such as NGOs, has proven to facilitate trust between debtor and creditor governments and has been crucial for encouraging civil society participation. While some international NGOs have gathered extensive experience in facilitating debt-for-nature swaps, the contribution of local or regional NGOs is similarly important to provide crucial insights about local conditions.The third recommendation is that effective implementation and governance structures are essential for the success of the swap mechanism. This, first of all, calls for an establishment of a scheme operator or a selection of one from existing organizations. This should be a financial institution with solid fund management expertise and technical capacities to implement climate projects. Such a combination of financial and climate expertise rarely exists in developing countries and often has to be built from scratch with additional technical assistance from international organizations. In addition, to ensure oversight and provide strategic guidance, a good practice is to establish a supervisory committee that is composed of representatives from both the debtor government and the creditor’s as well as international and national NGOs.The debtor government’s leading role and close involvement in designing and implementing a swap deal is crucial to ensure national ownership and longevity of the programme. At the negotiation stage, highest level political support of the climate swap proposal is particularly important for the deal to be secured. Climate-related projects should be anchored in national climate policies, and debt swaps should be embedded in a broader debt reduction strategy.For the purpose of reviewing the public debt conditions in the Western Balkans Six [WB6] countries, the trends of debt in the 10-year period 2010–2020 was assessed.What is noticeable in methodological terms is that there is no consistency in public debt reporting methodologies of the Western Balkan countries.Table Five countries, except North Macedonia, have fiscal rules in place. All of them have a rule limiting debt, but there are differences in the size and nature of the limit. Size of the limit differs from 40% in Kosovo to 45% in Albania and Serbia to 60% in Montenegro and Bosnia and Herzegovina . It is cAs for the public debt portfolio, each of the countries has certain specificities, depending on the economic and political heritage. Those who had liabilities based on old foreign currency savings, restitution and unpaid pensions have securitized them and they are present in the portfolio of their domestic debt. Each of the countries in its portfolio has loans from multilateral and bilateral creditors, government securities, euro-bonds and private sector creditors’ loans.At the beginning of the decade, multilateral and bilateral creditors’ loans were most dominant in the public debt portfolio; and, over time, their share decreased with the exception of Bosnia and Herzegovina, where these loans represented about 70% of the total portfolio. The decrease in share of these loans in most countries was in favor of the increase in share of government securities, this time with the exception of Montenegro, which has changed the structure of its portfolio in such a way that euro-bonds and private sector loans have become the most important means of financing public debt.Government securities involve the issuance of bonds and treasury bills. The fact that North Macedonia, Serbia, Kosovo and Albania have 30–60% of these securities in their portfolio speaks not only of domestic confidence, but also of the capacities of domestic banks and institutional investors.The fact that all countries except Kosovo and Bosnia and Herzegovina, and some even before 2010, had successful euro-bond issues, also indicates the presence of confidence of international investors.When it comes to the debt maturity, countries do not usually publish a single average maturity figure. Data which are mainly given refer to the maturity structure, which show that long-termAll of the above leads to the conclusion that the Western Balkan 6 will have a specific challenge to manage their public debt in this so-called traditional way. It will be particularly interesting to see how and to what extent the governments of these countries will know how to recognize and be able to introduce new borrowing instruments.One of the modalities recently proposed by an IMF researcher  is basedIn the context of the EU accession process and the recently revealed European Green Deal, newly shaped market mechanisms for the UN2030 Agenda financing in the form of the green, social or sustainability bonds are worth considering to ascertain if new approaches are possible. This innovation may arise from an already existing debt-for-nature swap, which can trace its way back to the post WWII debt restructuring and later debt-for-equity instruments as explained in the literature review. As already shown in the case study, one of the countries that has used this opportunity was Montenegro in 2009.On the other hand, it is evident that the EU is a willing partner and provides a different mechanism of support. The most important one, so-called Instrument of Pre-accession Assistance begins its third 2021–2027 iteration.The debt analysis of the WB6 countries, despite somewhat different situations, clearly points out that there are many macro-fiscal challenges ahead and an innovative approach is needed. At the same time, despite having relatively reduced fiscal space for additional borrowing, while many structural requirements lie ahead, it is obvious that individual countries’ GDP, in purchasing power, is still significantly lagging behind the EU average, as Table With an average score of 38However, prior to any concrete move, special attention is required to assess the legal aspects of the use of the above-described novel financial instruments—as some countries may be in differing positions. In addition, there is a need for more in-depth analysis of the particular public debt elements and their structures. This is of special relevance when it comes to the possibilities of the further use of the debt for nature swaps. It is, evidently, possible in its most intuitive form and only in case of bilateral or official development aid.Alternatively, bringing together IPA and private markets, while combining the swap model and new forms of bond issuance, a more transparent process that require vigilant reporting and verification, the EU may further support countries of the Western Balkans by repaying part of the principal debt upon the independent verification of how proceeds are used and whether targets have been met. This approach would not be entirely new as there are already examples of the so-called direct budgetary support mechanism, which is executed against a set of policy measures a candidate country is obligated to meet.Such an approach can be directly linked with the complementary Green Agenda for Western Balkans , establiIt is noticeable that there is no mention of the Human Development Index produced by the UNDP, which would also be of use when tracking progress in the social sphere, related to the education and health, in particular.16Going back to green, social and sustainability or ESG bonds in some form could prove beneficial as they have key performance indicators and sustainable targets. Given that the European Commission uses different key performance indicators to monitor the progress countries make, those indicators could play an important role. At the same time, the Green Agenda for the Western Balkans sets off a number of initiatives that could be transferred into the targets, both indicators and these targets can serve as an excellent basis for transparency and reporting required by the markets, as it is presented in Fig. The availability of IPA III funds completes the picture as those resources can be used for the adjusted swap mechanism and to pay for the fraction of issued green, social, sustainability bonds. Paying for that in the maturity year sets free additional resources in troubled state budgets. Another option could be to issue a higher amount of bonds, while the markets realize that providing the implementation of the policies and meeting targets means that the EU would use some of the funds to repay part of the bonds once they mature. Such mechanisms would bring further relief in the lower interest that would be paid each year, which provides additional financial means to implement the EU acquis. Altogether, countries could benefit from spurring economic growth based on sustainable and smart development while keeping public debt in check.What precise targets and what exact portion of the bonds would be repaid by the IPA III allocation would depend on the type of bond, given the varying levels of support the EU provides to different areas of investments.Some of the initiatives may easily be turned into clear targets, some would need further work to figure out the most proper indicators. As far as the initiative related to the Biodiversity Action plan is concerned, the first target might be the adoption of a proper action plan followed by some key action points to be carried out. In addition, there has already been some research produced that could serve as useful guidance in defining a conceptual framework, such as in the example of bioenergy . BesidesThe work on the SDG indicators as well as the efforts and the contribution of the UN Global Compact could be of tremendous help in this space.As illustrated throughout this paper, there are plenty of different tools to use in developing innovative investment models. The option summarized below, in Fig. All the WB6 countries strive to become member states of the EU. However, that road demands the introduction of the very specific legislation which normally brings about the need to accommodate and adjust institutions, requiring additional costs and more efficient and effective public administration in the end. In addition, infrastructure and overall development needs remain very high, and macro-fiscal room has shrunk—given the levels of the public debt, in particular.Therefore, the innovative approach presented below offers a new modality of ESG bonds which is based on the EU process combined with the Green Agenda initiatives for the Western Balkans. This new bond mechanism would use some of the lessons and practicalities learned from nature for debt swaps, where green investments could lead to some debt relief. Countries are still in the position to issue green bonds, such as the one Serbia recently released or pursue classic debt for nature swaps. The new mechanism may, in fact, serve as an extension. Countries should be encouraged to define clear targets based on the sustainable development policies and then go to the market with the transparent support of the EU through the IPA funds. The logic of the IPA funds is to prepare countries for the membership and is used to help meet various benchmarks. Even the modality by which countries benefit from the direct budget support is conditioned by some prior action.This new approach would bring about the synergy between private and public funds; introduce very transparent targets and indicators, verifiable by independent auditors; and use IPA funds as a powerful leverage to help save some interest or principal repayment costs and thus help a country lower public debt and reinforce international financial credibility or use the extra money for additional investments in the quality of public administration or social infrastructure. Instead of chopping IPA between different sectors it would be more transparent and effective to use the contribution as an additional verification that proper policies are in place [it may combine rule of law with public administration reforms or sustainable development]. Such an approach would increase the accountability of policymakers as well.It would be crucial to develop more measurable targets as far as the Green Agenda for the Western Balkans initiatives are concerned. Other indicators which are reported by international organizations . In some cases, it will require that new legislation be enacted to establish and implement these indicators. Any initiative which is measurable through additional regional mechanisms of cooperation is a value added as it contributes to the stability and prosperity of the whole region.The promise of the EU, made in 2003, that all Western Balkan countries are welcome to join the EU once established criteria are met, has set most of the policy goals for these countries. However, since then, only Croatia joined the EU on July 1, 2013. Whereas, Montenegro has advanced the most in the accession process [all the negotiating chapters are open] and Serbia following; the process overall seems to have slowed down. North Macedonia and Albania are still waiting for the real accession talks to begin, whereas Bosnia and Herzegovina and Kosovo seem to be nowhere near beginning.In the meantime, the UN 2030 Agenda, adopted in 2015 and establishing the SDGs, and the ongoing challenges related to COVID 19 have put additional ingredients on the table. The green transition has become an equally important policy for the respective countries discussed, and along with that emerges additional social and economic challenges. Economically speaking, the situation is complex and all the Western Balkan 6 countries are faced with significant development financing needs. Their average GDP in terms of the purchase power compared to the EU average is way below 50%. While the average public debt stands at around 50%, this figure, which may seem moderate, hides the growing trend over the past decade and major discrepancies amongst countries, such as Montenegro and Albania on one hand and Kosovo, for example, on the other.Therefore, the complex agenda involving EU accession, infrastructure and SDG needs requires innovation in the SDG financing.This paper analyses some of the new mechanisms, such as green, social and sustainability bonds and nature for debt swaps. It is obvious that some of the main benefits of the new form of ESG bonds is a higher level of transparency and, inevitably, a higher level of accountability that comes along with it. To achieve benefits such as lower interest rates of the longer maturity terms, it is important to incorporate independent verification metrics to determine whether the various KPIs and green/social/sustainability targets are met.On the other hand, nature for debt swaps is not entirely new and has been in place for some decades. Out of the six WB countries, it seems that only Montenegro has used it successfully and that happened once at the end of the first decade of the twenty-first century.Putting together ESG bonds along with nature for debt swaps in light of the EU accession plans of the Western Balkans countries can offer the basis for another layer of innovative financing, and this is the key recommendation of this paper. Countries should feel encouraged to enter the private markets—clearly stating their green and de-carbonization development plans and define policy goals that stem from the European green deal and the Green agenda for the Western Balkans which has to be combined with accountability mechanisms and methodologies such as those which govern European Union accession talks with candidate countries. This recommendation assumes that participating parties will develop policy targets and indicators that are independent and verifiable, as the whole agenda grows more and more complex at each stage.Such an innovative approach to the markets could also encourage the EU to adjust the ways pre-accession support is used [IPA III in particular] as those funds could be extremely useful leverage to access private markets and accelerate investment cycle by providing synergy between the huge opportunities private markets bring, with the crucial support of the public funds coming from the EU.The previously discussed Paris Club debt-for-nature examples can bring another element into the picture by providing the logic of a swap, which together with a new approach to the debt sustainability offered by IMF researchers, also discussed earlier; may result in a win–win situation for all the market agents, including governments. Hopefully, this approach may unlock missing fiscal space, which in the mid- to long-term could bring about many benefits in higher levels of GDP and human development indexes.


For this reason, they need to have at least a basic level of palliative care education since they are the professional cohort treating these patients in a very close way. This research aims to determine the level of knowledge in palliative care of Spanish nurses and establish any possible difference based on their experience and training in palliative care. (2) Methods: A cross-sectional design using survey methods (distributed an online questionnaire) aimed at Spanish registered nurses. A validated questionnaire (PCQN-SV) was used to determine the level of knowledge in palliative care; information on some variables to characterize the population was also collected . Uni and bivariate descriptive analyses were performed. A binary logistic regression model was also developed to identify those variables that influenced obtaining results higher than the population’s average. (3) Results: Spanish nurses have a medium–low level of knowledge in palliative care, higher in those who have previous experience or education in this area. Statistically significant differences were also found according to the area in which their caring activity was developed. (4) Conclusions: It is necessary to implement strategies for the basic training of nursing professionals in palliative care to offer quality care to people in advanced stages of illnesses or at the end of their lives. Palliative care means “improving the quality of life of patients and their families in the face of drawbacks associated with life-threatening diseases, through the prevention and relief of suffering, based on early identification and proper management and treatment of pain other physical, psychosocial, and spiritual problems” ,2,3.At first, palliative care emerges in the context of caring for people with oncological diseases, aiming to control their pain and other symptoms. However, nowadays, the inclusion of a palliative care approach is considered in the attention of any person with a chronic and degenerative disease. It is emphasized in early-onset diseases to help patients and families maintain a better quality of life ,4,5.The philosophy of palliative care is supported on the idea of maintaining the best quality of life for people affected by degenerative diseases and especially in the advanced stages of the disease , mainly The surge in life expectancy and the chronification of pathologies have increased interest in people’s care in the advanced and final stages of their pathological processes ,7,8,9,10Nurses are one of the bases in care for people with diseases in advanced and end-of-life stages, to whom it is necessary to show this consideration. However, to provide quality care, they need to have adequate training in these aspects, especially if professionals can find people who may require this kind of attention in any field of work and not only if working on a specific resource of palliative care ,17,18. NResearch conducted in recent years and several countries among nurses working in different assistance areas has shown that they present knowledge deficits when managing this sort of patient. This lack of skills has been established by results obtained in qualitative studies for their evaluation and qualitative studies that gathered the perceptions of such professionals on their need for more training in palliative care. It must be said that these studies have been carried out among nurses who developed their occupations in different workplaces. Some differences can be found among the diverse levels of care despite these deficits being identified globally ,21,22,23For this reason, it is essential for any nurse, as recommended by the various scientific associations and experts in this field, to be taught at least a basic level of palliative care. This knowledge would allow them to work with people susceptible to receiving this type of attention, whatever the area in which they develop their professional activity ,25,26,27In recent years, this training has been progressively included in the degree programs of different faculties in Spain, despite not being offered in all of them ,29. In aFew studies have been developed in our country to analyze Nurses’ education and knowledge in palliative care. Hence, this study was decided to be carried out nationwide to determine the level of knowledge in palliative care of Spanish nursing professionals and establish possible differences in this level of knowledge according to their experience and training in palliative care.A descriptive cross-sectional study was carried out.A sample of Spanish Registered Nurses was recruited using the Internet and the social networks Facebook and Twitter, as explained in previously published research . This meThe sample size was calculated considering that about 200,000 nurses are registered in the Spanish National Health System . The optimal sample size to get a proportion of 40% of nurses with a good level of knowledge in palliative care is 892. Therefore, the final number of participants in the study (1114 RNs) could be considered adequate to our interests.®, which included sociodemographic data of participants and their answers to the PCQN-SV.Data were collected between November 2018 and June 2019 using an online questionnaire developed with Google FormularThe first part of the questionnaire collected information about the descriptive population’s features that would later make it possible to explain the differences in obtained results. Among other data, it collected information on the age and gender of the participants, years of professional experience, level of training, the area where they developed their professional activity, and whether they had experience or training in palliative care.The instrument used to measure this level of knowledge is the Spanish version of the Palliative Care Quiz for Nurses (PCQN-SV). It is a tool with 20 questions of true/false with queries about philosophy and principles of palliative care (4 questions), psychosocial aspects (3 questions), and symptoms’ control (13 questions), developed at the University of Ottawa.The PCQN has been used in research developed in different countries, either the original in English or its versions in other different languages ,49,50,51The first page of the data collection form included an informative letter to explain the study objectives and to inform participants about data confidentiality and anonymity. The ethics committee of the University of Valencia indicates in its normative that, in those studies in which identification data of the participants is not required or in opinion surveys, it is enough to clarify their anonymity. Any personal data or contact information that could help identify the participant was included in the form, so data collection was completely anonymous. Although it could be understood that only those people who wanted to participate in the study would answer the questionnaire, their intention to participate was explicitly stated in a YES/NO question at the end of this informative letter. This question should be answered compulsorily before access to the data collection instrument itself.SPSS version 24 was used to analyze the data.Univariate and bivariate descriptive analyses of the data collected were performed. In the bivariate analysis, non-parametric tests  were used because of the violation of the normal distribution assumption.A binary logistic regression model was also developed to identify predictors of results (percentage of correct answers in PCQN). In this binary logistic regression model, the independent variable became dichotomous (1 = good knowledge/0 = poor knowledge), defining “poor knowledge” as obtaining a percentage of correct answers superior to 60% of correct answers obtained in the whole questionnaire. Categorical and numerical variables were used as explanatory ones.Finally, 1114 registered nurses from all over Spain participated, especially women, with an average age of almost 39 years and a professional experience of around 15.The participants’ features are shown in Many participants (43.4%) developed their care activity in acute care hospitals, and 22.5% currently work in primary care. On the other hand, only 52 of them (4.7%) worked in specific resources of palliative care or in-home hospitalization units. Besides this, 101 participants (9.1%) reported working in chronic diseases hospitals or long-term care centers, and only 40 professionals claimed they worked in centers for the attention of the elderly.Most professionals reported receiving it through ongoing education courses, and 51.5% reported receiving it in the last five years regarding specific palliative-care training.When analyzing the relationship between professional experience and the type of education in palliative care received, 37.1% of professionals with less than 10 years of professional experience reported having received such content during their university education. However, those with more than 25 years of professional experience received it mostly in postgraduate courses or ongoing education, reaching up to 51.5%.The results for each item composing the questionnaire are shown in Correlations between the years of professional experience , hours in palliative care training reported by participant nurses, and percentages of correct answers  were analyzed. The results are shown in When studying the percentage of right answers in the global questionnaire, it is observed that participants with experience in palliative care obtain higher percentages of correct answers and lower percentages of errors than those who report having no experience in this area. The same trend is also noted in the case of participants who report having training in palliative care. When analyzing the results obtained by the participants based on the health setting where they carry out their nursing activity, differences in percentages of right and wrong answers in the questionnaire were also found. These differences, shown in Thus, it is seen that nurses who have received training in palliative care are 58.1% more likely to be classified as “having good knowledge in palliative care” than those who have not received it. Nurses with experience in palliative care are 54.5% more likely to obtain a score higher than 60 than those without working experience in this field.Regarding the years of experience in palliative care, the model indicates that for each year of experience achieved in this area, the probability of being classified as “having good knowledge” increases by 3%.This research has pointed out that Spanish nurses have a medium–low level of knowledge in palliative care, higher in those who have previous education in this field, both practical and theoretical ones.These results about the influence of education in palliative care show the need to implement basic training programs in palliative care, including undergraduate training or ongoing education courses aimed at professionals. We should not forget that nursing professionals can find patients susceptible to needing palliative care in any field we develop our healthcare activity, so they need to have at least a basic level of knowledge.The professionals participating in this study and multiple studies developed in our country and other countries have identified this need for more and better training in palliative care. In various studies, the professionals themselves express their feelings of not being sufficiently trained in managing patients with the need to receive palliative care ,55,56,57The detailed analysis of the number of right and wrong answers to the items that compose PCQN-SV can serve as the basis for developing future palliative care education programs since it helps to identify misconceptions that could be solved through this training. Besides, the PCQN-SV allows, as other authors have done in their work, to evaluate the improvement of knowledge generated through a training program through intervention studies with a pretest–posttest design ,58,59,60Focusing on the precise results obtained by the participants, an average percentage of correct answers in PCQN of 61.4% was found. These results are better than those obtained when piloting the Spanish version of the PCQN , a studyOn the other hand, these results are similar or slightly lower than those obtained in other studies among nurses who developed their professional activity in various work environments or countries like Korea, Canada, Australia, Ireland, and the USA. In these studies, authors reported that participating nurses obtained results superior to 60% of correct answers ,47,67,68In addition to that, when evaluating these results separately for each questionnaire subscale, it is observable that Spanish nursing professionals obtain better results in the subscale of philosophy and principles of palliative care and the worst in psychosocial aspects subscale. Ronaldson  and RaudThese poor results in the subscale of psychosocial aspects of palliative care indicate the need to reinforce these contents in training programs, focusing on other aspects such as symptomatic management and basic palliative care concepts. This fact is also identified in studies exploring educational needs in palliative care for both students and professionals. Indeed, both groups refer to the need for training in these psychosocial aspects of palliative care ,73,74,75Regarding the influence of experience in the level of knowledge in palliative care of nursing professionals, it was demonstrated that those participants who reported having experience in this field obtained better results than those who did not. This leverage was also reflected in the relationship between years of experience in palliative care and results obtained in the PCQN-SV. This influence of experience shows the importance of the knowledge acquired in the work environment. Nevertheless, this knowledge needs a theoretical basis that underlies it, as the results suggest when revealing a more significant effect of education than practical experience.Hence, regarding having received training in palliative care and its influence on the level of knowledge, participants who reported having received training obtained higher percentages of correct answers, both in the global questionnaire and in each of the subscales that composed it. Regarding the number of training hours, it is also remarkable that there is also a relationship among the results obtained in the questionnaire.Many other studies about Nurses’ knowledge in palliative care have analyzed the percentage of subjects with experience or education in palliative care ,49,68,76Concerning the model developed to explain the achievement in the questionnaire of a percentage of correct answers of more than 60%, having both training and experience in palliative care could explain these results. These results highlight the importance of theoretical and practical training for nurses in this field to offer their patients the best quality care possible. They also highlight the need for ongoing training and updating in this ambit ,78,79,80Training is essential, but this training must be updated. Nurses participating in this study were asked if they had received such training in the last five years, with 67% answering affirmatively and obtaining better scores in PCQN-SV. Furthermore, when relating the years of professional experience and having received PC training, nurses with less professional experience reported receiving PC training during their undergraduate education. These results reflect the progressive implementation of palliative care contents in nursing university studies, as recommended by the different scientific societies regarding the need for any nursing professional to receive basic training in palliative care during their undergraduate training ,79,81,82One of the main limitations of this study is related to the methodology of the selection of the participants. Even though the final number of these can be considered high, it cannot be maintained that they are a representative sample of Spanish nursing professionals since no random sampling was done. The characteristics of the participants are indeed quite heterogeneous, and nurses from different areas of our country collaborated. However, at no time can it be said that it is a representative sample.The purpose of this research was to give an overview of the level of knowledge of nursing professionals in the field of palliative care. It is thought that in this study, the situation of Spain was accurately shown in this regard. In addition, this work is part of the adaptation and validation project of the PCQN-SV.Spanish nursing professionals have limited knowledge in palliative care, although this knowledge is higher in those who have experience or training in this field.The analysis of Nurses’ knowledge in palliative care permits identification aspects to be reinforced in a palliative care training program aimed at these professionals.


During the COVID-19 pandemic, increased stress factors affected people’s motivations to engage in potentially addictive behaviors. Sexuality, understood as one of the psychological aspects to be investigated to explore the level of psychological well-being of a person, has suffered considerable repercussions due to the pandemic. A growing body of evidence suggests an unprecedented increase in Internet use and online pornography consumption during the pandemic. Since March 2020, during the lockdown period, Pornhub has seen a worldwide increase in pornography use of 11.6% compared to the previous average days. This research was conducted with the aim of exploring the possible increasing use of pornographic material during the lockdown period, in order to assess whether dysfunctional behaviors, such as compulsive behaviors, and thoughts of sex-related obsessives can lead to hypersexual behavior or a more severe Sexual Addiction. The individuals who participated in our research were 18 years of age or older , and 48% male and 52% females and were recruited online to complete a self-report questionnaire in the period between April 2020 and April 2021. The questionnaires were delivered via main social networks. The tool used for our survey was the SAST , a questionnaire including socio-demographic data and data relating to sexual practices, such as sexual orientation and time spent on the Internet for sexual activities. The results revealed significant differences concerning the various factors investigated such as loss of control, addictive symptoms and hide score. During the COVID-19 pandemic, the increase in stressors  impacted people’s motivations to engage in addictive behaviors ,3. To beIn recent years we have been witnessing a growing number of people who manifest new forms of addiction no longer related to the intake of psychoactive substances but related to the recurrence of behaviors that cause mental discomfort and suffering. Behavioral addictions are defined as “new addictions” to distinguish them from those involving the use of drugs and psychoactive substances. Pathological gambling, compulsive shopping, Internet addiction, work alcoholism, study addictions, physical activity and Sexual Addiction are part of the new addictions . CurrentIn contemporary society, the problem of Sexual Addiction is potentially worsening. People are continually bombarded with sexual stimuli, so developing an addiction of this type could become extremely easy. Internet sites with hard photos and videos, escort sites, applications and chats represent only a small part of what the Internet world offers . As KrauAccording to Grubbs et al., the role of the media could be fundamental for the development and maintenance of problematic behaviors, including dysfunctional sexual behaviors . As showThe objective of this exploratory study was to offer a contribution to the scientific literature by providing additional information on the impact that COVID-19 has had on the psychological level of people, and in particular to examine whether and how sexual behaviors tending to hyper activation and dependence were also modified. In this context, we speculate that this period gives us the unique opportunity to explore how a pandemic may or may not change sexual behavior on a large scale. The primary objective of this study was to evaluate the possible alteration or not towards Sexual Addiction in Italians and its possible underlying reasons. This research also evaluated the tendency to engage in hypersexual behavior, or not, during the period of confinement due to the COVID-19 pandemic.The individuals who participated in our research were adults and were recruited online to complete a self-report questionnaire in the period between April 2020 and April 2021. The questionnaires have been delivered via the main social networks. Participants were recruited on a voluntary basis, informed consent was received online before respondents answered the questionnaire, and data confidentiality was ensured according to the principles of the General data protection regulation (GDPR). For this reason, it was developed in Google Docs format and sent to participants electronically along with the researchers’ instructions and contact information. Participants were required to fill it in, completely and truthfully. The importance  of the questionnaire was also explained at the beginning of the questionnaire. In addition, participants were informed of the type and duration of the procedures used.The tool used for this study is the SAST  . This tet-test for paired measures, which was employed to verify if there were significant differences in the four sub-scales measured by the SAST tool before and after the pandemic. Descriptive statistics have also been calculated.ANOVA one-way was used in order to assess statistical differences in sexual behavior as assessed by SAST between participants with different sentimental situations (married or not). This research examined differences regarding the time spent using pornography, online and offline, before and after the pandemic period by using the Information on gender, age, and level of education have been collected. The total daily time (in minutes) participants spent on the Internet at pornographic sites before and after the COVID-19 outbreak was examined. This allowed having both current and pre-pandemic data available in order to assess and define whether the time for pornographic material, both online and not, has increased or not during the pandemic period. Additionally, the risk factors for increased time spent on the Internet, as well as the severity of Internet addiction before and after the COVID-19 outbreak were also investigated.A total of 1706 survey participants have been recruited and 305 questionnaires with incomplete answers have been excluded, leaving 1401 participants for final analysisThe reference sample is made up of 671 males (47.8%) and 730 females (52.0%), for a total of 1401 people (100%), 582 (41.5%) were unmarried boys or men, 581 (41.4%) were unmarried girls or women and 50 married (3.6%) subjects for a total of 1213 (86.4 %) subjects who answered the question relating to their marital status . ParticiTo check if there were any differences relating to the sentimental situation—single or married—(independent variables) and the factor addiction symptom and hide scores (dependent variables) we proceeded with the ANOVA one way.t-test for paired measures.t is similar to, 949 (d: 0.4) and the significance is equal to, 343; therefore, there are no significant differences in the use of porn material.The t-test.To conclude, we wanted to verify if there were significant differences in the four sub-scales measured by the SAST tool concerning the use of pornographic material before and after the pandemic. To do this, we proceeded with a Paired The pandemic caused by COVID-19 has been the most striking social phenomenon in recent years and has led to the emergence of clinically significant distress from a psychological point of view , includiThe results obtained from our study can be compared with a cross-sectional survey conducted on 6003 Italian adults aged between 18- and 74-years, representative of the general Italian population . The stuDespite the relatively large sample of 1401 participants, the present study focused on limited geographical areas, leaving out the non-urban population entirely. This represents a limit of the present study, which will be addressed in a subsequent investigation. A second limit could be related to the method of administration of the questionnaire, because the online administration could have compromised the response due to disturbing factors or elements related to the processes of social desirability, which could not be controlled. A third limit is that possible alterations towards Sexual Addiction and/or the tendency to engage in hypersexual behavior during the lock-down period was assessed once but no one could predict what would happen with COVID-19.The present study shows that overall, there was no increase in Sexual Addiction and hypersexual behavior during the lockdown period caused by the COVID-19 pandemic. However, we found that single men display more symptoms of Sexual Addiction than the other categories. The correlation between single men and the compulsive use of online pornography is widely discussed in the literature ,33. HoweFurther research is needed that will allow us to better understand this phenomenon in women, in disadvantaged groups, in people of different sexual orientations and in people with physical and intellectual disabilities. Furthermore, it is necessary to build an ad hoc instrument similar to the one we used, but which also contains sub-scales of the “lie” type able to bring out the incongruent answers and complete the assessment at different time points.


Massive Open Online Courses (MOOCs) is the product of “internet + education,” which offer the open educational resources to global students. This study analyzed the factors influencing the continued intention to use the MOOCs by students. To achieve research objectives, this study integrated the unified theory of acceptance and use of technology (UTAUT) and connected classroom climate (CCC). In this study, 312 valid samples were used to verify the hypothesis proposed with the help of structural equation modeling and PROCESS. The results showed that the factors of UTAUT model  had significant positive effects on continued intention to use MOOCs. More importantly, there was a significant moderating effect of CCC between UTAUT and the continued intention to use MOOCs. Based on this research the findings, implications and limitations are discussed. A Massive Open Online Course (MOOC) is usually a free online course offered to anyone who wants to sign up to study. The registered students may download the video and content of courses, fulfill the assignments, and conduct quizzes with the help of MOOCs platform , effort expectancy , social influence , facilitating conditions  and continued intention .The CCC was measured by the scale of Dwyer et al. , which iAll measurement scales reliability analysis show that the Cronbach's α coefficient exceeds the 0.70 threshold  to test the relationship between independent variables and the dependent variable. The moderating effect of CCC was tested by the bootstrapping procedures and used the plug-in of PROCESS , AVE exceeds 0.50 (p < 0.001), CR exceeds 0.70 (p < 0.001), and SMC exceeds 0.50, indicating that the measure has adequate reliability and convergent validity.First, item reliability examines is estimated by evaluating the loadings of all the items on their latent variable. And the standardized loadings of the items should be 0.50 or higher, and ideally 0.70 or higher and all factor loadings should be statistically significant  may be found in the studies. Thus Harman's single factor test was conducted to assess whether the CMB existed  were computed  of the model. The proposed hypotheses (H1–H4) have been tested using SEM. The results of the SEM analysis of the structural model indicated .The structural model is mainly analyzed in two aspects: testing the significance levels of the path coefficients and the explanatory power (R2) for the endogenous variable is regarded as the essential criterion for the structural model test  proposed in this study.The explanatory power  by the bootstrapping procedures and used Hayes  statistip < 0.001, p < 0.001, p = 0.003, and p < 0.001, respectively), which means that the regression coefficient of independent variables  to the dependent variable (CI) will increase by 0.195, 0.121, 0.113, and 0.266 units with the moderation variable of CCC increasing one unit. The moderation role of CCC exists. In addition we used the information in the results to calculate simple effects at low and high levels of CCC (see The results of PROCESS are shown in  CCC see . The resThis study attempted to explore the following two questions: the key factors affecting students continued intention to use MOOCs and the moderating effect of the CCC. With the help of UTAUT theory and CCC theory, this research investigates the effects of performance expectancy, effort expectancy, social influence, facilitating conditions on continued intention to use MOOCs and the moderation effect of CCC. The results show that our model has a good explanatory power in predicting the continued intention to use MOOCs. Data were collected using a survey instrument and 312 valid samples were recruited from a public University in China. The data were analyzed by SEM and Process 3.0. Moreover, this research shows that factors such as performance expectancy, effort expectancy, social influence, and facilitating conditions have a significant impact on continued intention to use MOOCs and the CCC has a significant moderating effect between UTAUT and students continued intention to use MOOCs.The MOOCs provide a lot of meaningful opportunities for educational stakeholders, especially students in higher education (Sabi et al., This research showed that performance expectancy, effort expectancy, social influence, and facilitating conditions have a significant impact on the continued intention to use MOOCs. Moreover, our findings also have confirmed the moderation role of CCC in the effect of UTAUT on the continued intention to use MOOCs. Previous studies have shown that performance expectancy, effort expectancy, and social influence had an influence on behavioral intention (Venkatesh et al., The previous research had confirmed that the CCC is beneficial for students to learn, integrate, and retain in face-to-face environments (MacLeod et al., This research integrated UTAUT and CCC to explain the continued intention to use MOOCs, which provided a new model to interpret online course learning. The results from the analysis of the structural equation model indicated that continued intention to use MOOCs by students could be influenced by learning environmental expectancy, such as performance expectancy, effort expectancy, social influence, and facilitating conditions. That is to say when considering the intention of continued participation in MOOCs by students, we should consider the acceptance of information technology according to the learning environments.In addition, the research verified the role of CCC in computer-mediated environments and combined with the UTAUT model, the study analyzed the relationships between performance expectancy, effort expectancy, social influence, facilitating conditions with continued intention to use MOOCs and CCC. Because a person's learning should not be separated from the social environment, but depends on the interaction with others Schunk, . The finOur research found that performance expectancy, effort expectancy, social influence, and facilitating conditions in the UTAUT model had direct positive effects on the continued intention to use MOOCs, which provided the theoretical basis for how to improve the continued intention to use MOOCs. Specifically, for the technology attributes of performance expectancy and effort expectancy, which mean that students attach great importance to the practicability and ease of use of the technology in question. Therefore, the teachers should focus on improving the ease of use and practicability of MOOCs, such as selecting technology that is more suitable for students.In addition, social factors had a positive impact on the continued intention to use MOOCs. The teachers may proactively manage social influence by organizing forums for sharing best practices. Strengthening interaction between student–student interaction or instructor–student interaction is helpful to improve continued intention to use MOOCs. For example, providing a platform that offers personalized feedback, creates real-life context, and encourages social interaction and more student reflection (Johnson and Aragon, This study and previous literatures showed that he CCC was considered to be very important in both traditional face-to-face classroom teaching (Johnson and LaBelle, Although the current research is of great implications, it is not without limitations. First, for the convenience of sample collection the participants of this study were obtained from only one University, whether the conclusion of this study can be extended to a wider range is questionable. In future, more diversified samples and larger samples size can be investigated to enrich the research conclusions. Second, for the convenience of data collection, this study collected data through questionnaires conducted by self-reported. Although this study tried to standardize the data collection process, as self-reported survey relies heavily on human memory, errors could occur (Sudman and Bradburn, The raw data supporting the conclusions of this article will be made available by the authors, without undue reservation, to any qualified researcher.Ethical review and approval was not required for the study on human participants in accordance with the local legislation and institutional requirements. Written informed consent for participation was not required for this study in accordance with the national legislation and the institutional requirements.YL design, data collection, and write the manuscript. MZ analyzed data. All authors contributed to the article and approved the submitted version.The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.All claims expressed in this article are solely those of the authors and do not necessarily represent those of their affiliated organizations, or those of the publisher, the editors and the reviewers. Any product that may be evaluated in this article, or claim that may be made by its manufacturer, is not guaranteed or endorsed by the publisher.


In recent years, pyrethroids have emerged as a less toxic alternative to eliminate insect pests. However, some animal studies and studies with children show that these pesticides are toxic and lead to neurobehavioral effects similar to other pesticides, such as organophosphates. The purpose of this review was to systematize the epidemiological scientific evidence about the neurobehavioral, neuromotor, and neurocognitive effects in agricultural workers and their children exposed to pyrethroid pesticides. We conducted two searches (with different terms) in PubMed and Scopus databases, including articles in Spanish and English language on the effects of occupational exposure to pyrethroid pesticides associated with neurobehavioral, neuromotor, and neurocognitive functioning of agricultural workers and their children. There were no filters by year, and the search included studies till march 2021. To develop the search, we followed the recommendations contained in the PRISMA guidelines and the PICO strategy. The results show that in 66.6% of the studies reviewed (8 of 12 studies), agricultural workers or their children occupationally exposed to pyrethroid pesticides have a higher risk of presenting difficulties in their neurocognitive, neuromotor, or neurobehavioral performance, mainly associated with attention, processing speed (linked to hand-eye coordination), and motor coordination. There are still few studies that address this issue. However, the quality of most of the research conducted  confirms the risk for neurobehavioral health in agricultural workers due to occupational exposure to pyrethroids. More research is required evaluating the exposure to pyrethroids, including biomarkers and validated neurobehavioral and neuromotor tests, in addition to evaluating the effect of simultaneous exposure to other hazardous pesticides. Assuming that the use of pyrethroids is increasing considerably and faster than the scientific evidence, it is suggested as a precautionary principle to regulate, more strictly, the sale of pyrethroids and other pesticides. Neurotoxins are chemical substances external to the body, synthetic in general, that cause structural, biochemical, and functional damage to the central nervous system, peripheral nervous system, and sensory organs  AND  AND (workers). In the second search, also including the three databases, the terms entered were as follows: (pyrethroid) AND . In the Scielo database, no studies related to pyrethroid exposure and health effects were found. Original publications in English, Spanish, or Portuguese were considered. Inclusion criteria were as follows: (a) assessment of chronic exposure to pyrethroids pesticides; (b) assessment of neurobehavioral, neuromotor, and neuropsychological functioning; and (c) adolescent or adult farmers and children of agricultural workers. There were no search filters by year, and the revision included articles published until March 2021.n = 12). The studies were organized according to the evidence of neurobehavioral, neuromotor, and neuropsychological effects associated with pyrethroid pesticide exposure , so three studies were considered for review. After excluding the articles that did not include pyrethroids exposure measures, 10 studies in PubMed and 2 from Scopus were selected for synthesis , four studies reported that exposure to pyrethroids impacts neurological or neurobehavioral functioning in pesticide applicators  and anxiety (p < 0.05) were observed mainly in those workers who store pesticides (pyrethroids and others) at home. Among these workers, pyrethroids were the most widely used pesticide, with 7% of farmers using a very dangerous pyrethroid and 34% a moderately dangerous one. The adverse health effects were greater in agricultural workers with high chronic exposure than those with medium exposure to pesticides . It is noteworthy that only bivariate chi-square analyses were applied to establish associations between exposure and symptoms in this study.In agricultural workers in India with high and medium chronic exposure to pesticides, Kori et al.  found thAnother research conducted with part-time or full-time male and female agricultural workers in the Philippines Lu,  found thOn the other hand, only one investigation with South African women . For more than 20 years, different studies have shown how chronic exposure to low doses of organophosphates over time causes neurobehavioral and neurodevelopmental health issues. Also, there is evidence that they are carcinogenic, genotoxic, and are related to immunological and reproductive alterations, among others, affecting the quality of life of children and adults and polluting the environment  and the evidence collected provide information that confirms the risk for neurobehavioral health in agricultural workers due to occupational exposure to pyrethroids. More research is required addressing this subject that evaluates pyrethroids exposure over time through biomarkers and the neuro outcomes with validated neurobehavioral and neuromotor tests, besides evaluating the effect of simultaneous exposure to other hazardous pesticides, such as organophosphates. The relationship with other neurotoxins could be addressed through the real-life risk simulation (RLRS) approach as a complementary instrument aiming to reduce clinical studies with animals and the high cost of longitudinal studies with human populations to accelerate evidence delivery that allows for prompt actions and policies from the authorities to regulate the use of pesticides  or the possible effects that the risk behaviors of applicator can cause during the application and mixing of pesticides. It should be encouraged that the participation of communities to collaborate with the interventions designing and planning, so they fit well with their own needs and culture. Furthermore, it should be promoted to involve them actively in the discussion of regulatory measures for better agricultural practices that allow for clean production in the agri-food industry.Regarding the assessment of neuro outcomes, it is advisable to incorporate, in future epidemiological investigations brain functioning measures as EEG recordings or functional magnetic resonance imaging (fMRI). These measures have the advantage of allowing for studying the brain activity to determine with greater precision, together with the classic neurobehavioral and neurocognitive tests, the impact of chronic exposure to pyrethroids in humans. Some of these neuroimaging measures have already been used in recent studies that evaluated the effects of organophosphates exposure on brain structure (Rauh and Margolis, The original contributions presented in the study are included in the article/supplementary material, further inquiries can be directed to the corresponding authors.BL prepared and carried out the bibliographic searches. MM-Q and BL screened articles for inclusion and extracted data. MM-Q and BL critically reviewed the important intellectual content and approved the manuscript. All authors contributed to the article and approved the submitted version and developed the idea for the review and wrote the manuscript.The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.


Bond strength of orthodontic composite is strongly influenced by molecular and structural mechanisms. Aim of this in vitro study was to compare bond strength of light-cure orthodontic composites by measuring debonding forces and evaluating locations of bond failure. Investigations on chemical compositions clarified adhesive behaviors and abilities, exploring effects of ageing processes in this junction materials.Twelve enamel discs, from human premolars, were randomly coupled to one orthodontic adhesive system  and underwent to Shear Bond Strength test. Metallic brackets were bonded to twenty-seven human premolar, with one of the adhesive systems, to quantify, at FE-SEM magnifications, after debonding, the residual material on enamel and bracket base surfaces. Raman Spectroscopy analysis was performed on eight discs of each composites to investigate on chemical compositions, before and after accelerated aging procedures in human saliva and sugary drink.Orthodontic adhesive systems showed similar strength of adhesion to enamel. The breakage of adhesive-adherent bond occurs in TXT at enamel-adhesive interface while in Bisco and Leone at adhesive-bracket interface. Accelerated in vitro aging demonstrated good physical–chemical stability for all composites, Bisco only, was weakly contaminated with respect to the other materials.A similar, clinically adequate and acceptable bond strength to enamel for debonding maneuvers was recorded in all orthodontic adhesive systems under examination. No significant chemical alterations are recorded, even in highly critical situations, not altering the initial mechanical properties of materials. Adhesion can be defined as the sum of the chemical and physical forces that represent the molecular attraction between materials in close contact. It expresses the resistance to separation forces. Adhesion phenomena are critical in many clinical applications of dental materials, including orthodontic bonding. The success of the adhesion is strictly linked to the characteristics of the interfacing surfaces and to the properties of the material used as bonding. In orthodontics, polymeric adhesive resins are widely used as a dental bonding system to ensure an intimate and strong joint between the base of the bracket and the enamel surface .An ideal adhesive system should have an optimal bond strength, i.e. able to withstand both chewing and orthodontic forces. At the same time, it should also allow an extremely easy and safe manual detachment of the bracket. This avoids the onset of permanent damage to the dental enamel and/or the persistence of residual material in situ, which is commonly removed mechanically with some manoeuvres, as drilling or air abrasion, able to produce alterations in the roughness of the tooth surface .2 and then, by measuring the force necessary to obtain the bracket debonding, which turned out to be on average 120 N, they were able to calculate the minimum value of the adhesion strength, i.e. equal to 7.5 MPa  ranging from 20 to 30%. Typically, tensile force tests produce a lower coefficient of variation than the more common shear strength analysis .By comparing the data obtained in our study, it is possible to highlight how all the adhesive systems under examination provide average SBS values in the range of 3—4.5 MPa. As shown in Table However, it is important to underline that all the data collected by us are far from the parameters suggested by I.R. Reynolds as clinically acceptable levels of adhesion strength, i.e. 6–8 MPa . VariousThe objective of many studies in the literature is to demonstrate, following the detachment of the bracket, at what level the breaking of the bond of the bracket to the tooth surface occurs. When testing for adhesive bond failure, three situations may arise: bond failure at the base bracket/adhesive interface, at the adhesive/enamel interface, or cohesive failure . The litThe orthodontic adhesive resin however remaining on the enamel surface, after the bracket debonding, is necessarily mechanically removed from the tooth surface by milling and this entails the risk of accidentally removing even the most superficial layer of the dental tissue .According to S. Elekdag-Turk, the prevalence of adhesive bond failure at the bracket/resin interface becomes a protective phenomenon for the enamel, precisely because, at the moment of detachment, this structure remains intact, preventing damage such as the loss of superficial tissue fragments therefore, cleaning the dental surface from the residual adhesive resin is perhaps less risky than the damage induced by bracket debonding . RegardiIt is also true that the removal of a bracket attached to the tooth through a high SBS adhesive system can increase the incidence of fractures or micro-cracks affecting the enamel, because of the increased effort have to be spend to remove the retained adhesive resin from the enamel surface . ActuallThe greater SBS to dental enamel demonstrated by TXT, could increase the probability of iatrogenic lesions of the hard tissues of the tooth occurring during the manoeuvre of bracket debonding. On the other hand, the greater affinity for chemical bonding, or cohesion, of TXT for the metal surface of the base of the bracket, would guarantee the orthodontist better holding performance of the bracket, during the active phases of the treatment.The FE-SEM analysis Fig.  of the bIt has been reported that, enhancement of bond strength may compromise safe bonding, in fact, the detachment of a large part of TXT from the dental surface could expose, even if in a minimal percentage (1–30%), the enamel to damages such as micro-fractures or loss of superficial hard tissue. Bisco and Leone, which have instead shown a greater tendency to remain adherent to the enamel surface, have to be mechanically removed from the tooth by mechanical milling, taking care not to damage the dental enamel. It has been observed that, the resin tags that remain on the enamel surface, for a long time after the bracket debonding, can change colour as well as constitute sites for bacterial adherence . Finally−4 g, which is however considered not significant in terms of the chemical stability of the examined materials. These minimal modifications in weight values can be expected and caused by the surface adsorption phenomenon of organic saliva residues, proteins and mucus, as the result of reversible interactions, as it does not imply any type of irreversible chemical reaction as can be seen also by the unchanged colour of the sample surface. Overall, this enhancement in weighting resulted not uniform in the trends belonged to each orthodontic adhesive resins, although it showed a tendency to stabilize over time. The investigation of ageing in saliva, it has been followed that the minimal dimensional variation recorded in the tested orthodontic resins does not able to alter physical–chemical properties in the surface.The investigation of aging in saliva and in sugary drink has been performed with the intent of establishing whether the recorded dimensional variations, even if minimal, were still capable of altering the physical–chemical properties of the surface of the three orthodontic composite resins under examination. Data on weight changes in saliva, Fig. As showed in Fig. Overall, the weight changes of the three materials are again considered almost negligible and no materials losses can be evaluated in all the tests; therefore, all the orthodontic resins have shown to be resistant to the acidic and corrosive components of the sugary drink used in the experiment.−1 associated to the higher percentage of quartz in its chemical composition (Fig. −1 ascribed to a possible fluorescence signal coming from the adsorption of organic residues [Raman Spectroscopy was a powerful tool, it has been used to investigate on the chemical composition of the three orthodontic adhesive resins, especially on the nature of their dispersed phase and, to establish the effects that occur following phenomena of aging in saliva and sugary drink, precisely at the level of the surface. Therefore, the purpose of this analysis has been twofold: a simple compositional comparison of the three adhesive resins Fig. b and an ion Fig. , as alsoion Fig. a with thion Fig. b, c. It residues . Here, aIn all the orthodontic adhesive systems under examination, a rather similar bond strength to the dental enamel is recorded, clinically adequate and acceptable for debonding manoeuvres. Breakage of the adhesive-adherent bond occurs for TXT at the enamel-adhesive interface and conversely, for Bisco and Leone, it occurs mainly at the adhesive-bracket interface. All the resins are stable in human saliva, which is not able to alter the physicochemical properties of surface and they are also resistant to the acid and corrosive components of the sweetened drink used in the experiment. This testifies to the good biocompatibility of these resinous polymers, given their chemical stability even in highly critical situations. Raman analysis shows that no significant chemical alterations are observed on the resins, thus not altering the initial mechanical properties of these materials of and therefore also the expected clinical performances.