The China–Pakistan Economic Corridor (CPEC) has been an economic game changer for both China and Pakistan. We investigate stakeholder satisfaction with CPEC projects in Pakistan, particularly with respect to the affected local communities. Given the project application and adaptability, two provinces—Khyber Pakhtunkhwa and Punjab—and eight districts were selected randomly. Primary data from approximately 250 respondents as well as secondary data were collected. Among other models, a logit model was adopted to determine the role of certain factors in the perceived level of satisfaction. Results reveal that with respect to the relationship between land acquisition and dissatisfaction with a CPEC project, the level of dissatisfaction is 2.45 times higher when land is acquired by force or when compensation for the land is perceived to be inadequate by the local people. Individuals favor economic zones and development projects over road projects; the likelihood of being dissatisfied is approximately nine times greater in regions without economic zones than that in regions with such zones. Similarly, when no development project is allocated to a community, the probability of dissatisfaction of the local people is about 7.6 times greater. In addition, expectations of poor financial outcomes for CPEC projects cause significant dissatisfaction and are a source of tension among the local people. To reduce dissatisfaction, organizations and business communities must actively support the success of CPEC projects. A more equitable allocation of economic zones and development projects may help ease tensions and increase satisfaction among the local people. The Belt and Road Initiative (BRI), formerly known as One Belt One Road, is a global development strategy initiated in 2013 by the Chinese government to restore the paradigms of economic development along the historic Silk Road. The goal of restoring the Silk Road trade routes by connecting Asia, the Middle East, Africa, and Europe through the development of fiber optic systems, infrastructure, airports, seaports, roads, and railway networks is to provide economic benefits through trade and to empower countries that participate in this initiative with respect to their industrial, energy, and agricultural efforts [An economic corridor (EC) is a network of connections between two geographic territories. The China–Pakistan Economic Corridor (CPEC) is one example of the ECs within the Silk Road Economic Belt , 5. CPECThe development of transportation and road infrastructures can impact upon a local community either positively or negatively. However, local business activities are also expected to benefit. CPEC development will impact upon local residents by increasing opportunities in areas such as tourism, transportation, and new businesses and will provide other economic benefits in the region –10. CPECThe balance between the burdens and benefits of CPEC is highly questionable. Signs of imminent conflict are already emerging between Punjab and the less-developed provinces in Pakistan because of tensions as well as the lack of satisfaction among the local people in terms of the project activities. Local communities, primarily from Khyber Pukhtunkhwa (KPK) and Balochistan, claim a change in the CPEC route made by the government favors the Punjab and Sindh provinces with more economic zones and energy projects. Leaders of affected communities from less-developed provinces claim that they were kept out of the decision-making process, which created severe tensions among stakeholders with respect to the distribution of benefits. A significant number of people whose land has been acquired for various projects are extremely dissatisfied with CPEC because of what is seen as inadequate compensation for their land and a decline in their financial situations because of the development projects. The well-being of these people depends upon not only employment opportunities arising from road improvements but also other CPEC developments, including economic zones and projects, especially energy-related projects. Depriving the local people of what is seen as their rightful economic benefits may lead to worsened financial conditions and could be a large hurdle in the way of achieving sustainable development.Most of the studies in this area have emphasized the importance of CPEC in various ways. Those studies also focused on pre-implementation plans, general perceptions held by the people involved, and challenges anticipated subsequent to implementing the CPEC projects. Most of the studies published have been qualitative; however, public opinion remains quantitatively low and therefore usually not sufficiently valid for measuring the impact of significant decisions. Hence, it is important to understand the level of satisfaction/dissatisfaction among local stakeholders that arises from different CPEC activities and the level of trust between local residents and CPEC administrators. This study is the first of its kind to use survey data and real-time information to investigate the level of satisfaction/dissatisfaction with respect to CPEC projects among the local communities in Pakistan. The primary focus of this study is to analyze different CPEC activities and their role in creating satisfaction or dissatisfaction among local stakeholders. These activities mainly include land acquisition and the manner in which it affects the local people’s ability to purchase alternative parcels of land of the same quality, as well as their perception about their financial situation. We also consider the impact of providing economic zones, road linkages, and other developmental projects, principally related to energy, in specific areas. The study presents policy measures and recommendations in order for the reduction of conflicts, increase in satisfaction among all stakeholders, and promotion of good governance and sustainable development. The remainder of this paper is organized as follows. The literature review is presented in Section 2. Section 3 covers the methodology used in the study. The results and discussion are presented in Section 4. Last, Section 5 offers our conclusions.Large-scale infrastructure projects are important to a country’s economic progress; however, such projects impose a non-trivial cost on a specific portion of the population and have major socioeconomic impacts upon the local people. Land acquisition is required for almost all large infrastructure projects, and most of the time, it is done involuntarily , with loThe CPEC project is intended to enhance economic stability and provide other benefits to both Pakistan and China. However, building a road from the Gwadar port to Khunjerab is more beneficial for China because it is safe and is the cheapest and fastest route. It allows China to save on cost, time, and distance . In addition, developing the new CPEC route provides China with an alternative to the Malacca seaport that poses a threat to Chinese businesses because of frequent incidents of piracy and armed robbery in the Strait of Malacca , 27. A mIt is important that policymakers, government officials, and business leaders recognize the perceptions of local residents regarding CPEC development projects and the changes that need to be adopted to improve the locals’ attitudes toward CPEC.The goal of CPEC from Pakistan’s perspective is to promote education, improve health and employment for its people, and help address energy issues. The investment opportunities provided through the CPEC would bring new business to local communities . This woCPEC development projects have the potential to create entrepreneurial ventures and investment opportunities for local residents, such as kiosks, workshops, real estate, and SMEs that can start with a low level of investment. New trade links, gas pipelines, and oil and cable projects would benefit local communities through economic and technical cooperation and the construction of industrial zones, roads, and railway networks . ChineseAttitudes, perceptions, and the level of satisfaction among local residents have been found to support CPEC development projects. Building roads, undertaking other infrastructure improvements, and developing tourism have the most significant socioeconomic impact upon local residents , 42. ResOn the basis of the above literature review and discussion, we develop the following hypotheses:H1: There is a relationship among categorical variables.Ho: There is no relationship among categorical variables.To fulfill the objectives of this study, we use primary data obtained at the household level via a multistage sampling technique. We collect these data from two provinces in Pakistan, Khyber Pakhtunkhwa and Punjab. These two provinces were divided into clusters according to the districts linked to CPEC. Eight districts were randomly selected from the two provinces, namely, Faisalabad, Toba Tek Singh, Jhang, Bahawalpur, Abbottabad, Haripur, Mansehra, and Nowshera. About 266 households whose land had been occupied for any of the CPEC activities were randomly selected after several visits at the local tehsil  and village levels. The sample of 266 is a significant portion of the total population of approximately 1500 households that were affected across the eight districts, based on a 95% confidence interval (CI), a 5% margin of error, and a 30% response distribution as suggested by Hamburg (1935) . Of the Secondary sources of information were also used to supplement the results qualitatively and to help us interpret the results more effectively. This information included the literature published by government organizations about CPEC and information obtained through national and regional daily newspapers. Although these sources of information may not be typical in this type of research, they have been used in a number of previous studies –52. BecaInformation gathered from the 213 valid questionnaires was used both qualitatively and quantitatively. Variables related to infrastructure development, land acquisition, and households’ land use changes were considered for quantitative analysis. Further description of the variables is presented in We performed a Chi-square test to describe the satisfaction/dissatisfaction of respondents regarding factors related to land use changes, infrastructure development, and the financial condition of the local people. This is a common test of the relationship between categorical variables. The null hypothesis of this test states that there is no relationship between categorical variables.O = observed value,E = expected value.A logit regression model was also used to investigate the respondents’ level of satisfaction and to further analyze the data. By using this model, we can predict the likelihood of the occurrence of an event on the basis of independent variables. It estimates the relationship between one or more explanatory variables and an output binary variable:Y = satisfied/dissatisfied (P(Y))/(1 − P(Y)) = probability of the occurrence of the dependent (response) variable1 = land acquisition willingness. A binary variable indicating satisfaction or dissatisfaction with compensation for land X2 = respondent was able to buy the same quality of land after their land was acquired for the CPEC project X3 = a CPEC road linkage to the region/area X4 = a special economic zone in the region/area X5 = a development project (other than road and economic zone) in the specific region/area X6 = household perception of a change in financial situation due to the CPEC XThis section presents the results obtained through analysis and discusses the findings. The results are divided into a descriptive section and other sections that address the logit model.1) and the ability of respondents to purchase the same quality of land with the amount of compensation received (X2). They are statistically significant at the 5% level, which allows us to reject the null hypothesis that these results occurred by chance. Between the dependent variable and X1, 2 show that 141 respondents were dissatisfied with the public authorities overall and had not been able to buy land of quality equivalent to that of the land they were required to sell to the CPEC. Thirty-three respondents were satisfied overall but could not purchase land of the same quality. Eighteen respondents were satisfied overall even though they had been unable to buy land of the same quality. Finally, 21 respondents were generally satisfied with the authorities regarding the CPEC and had been able to buy land of the same quality. Overall, the results are mixed, as some level of satisfaction existed, while at the same time, many were dissatisfied. The results also reflect the fact that the quality of land differs in those provinces and districts and that this is a concern for old tenants of the land when they need to buy a new piece of property. Land compensation is a major issue in these types of projects, and inadequate or delayed compensation leads to dissatisfaction among stakeholders, creating tension and conflicts [The results for the dependent variable Xonflicts . These ponflicts . In mostonflicts . Buying onflicts .3 and X4. The variable X4 is statistically significant at the 5% level, allowing us to reject the null hypothesis that the results occurred by chance. However, X3 lacks significance and 4 show that 103 respondents who had no special economic zone in their area were dissatisfied with the CPEC project. Thirty-five respondents were satisfied even without having a special economic zone in their area. Forty-nine respondents were dissatisfied with CPEC overall but had an economic zone in their area. Finally, 26 respondents were both satisfied with the CPEC project and had an economic zone in their area. Although several people suffered a loss of employment due to the large infrastructure and development projects, these projects bring many employment opportunities to an area. Still, jobs associated with infrastructure construction are temporary and insecure by nature. Local people affected by these projects prefer secure and permanent jobs [The results of the analysis for the dependent variable and Xent jobs . The con5 and X6, which represent the existence of development projects in the area and respondents’ satisfaction with changes in their financial situation, respectively. Both are statistically significant at the 5% level, thus rejecting the null hypothesis that the results occurred by chance. In considering the relationship between the dependent variable and X5, the results show general dissatisfaction with the CPEC administration on the part of 116 respondents who had no development projects other than the CPEC in their area. In contrast, 27 respondents were generally satisfied even though they had no other development project in their area. Forty-three respondents were dissatisfied overall even though they did have a development project in their area. Finally, 27 respondents were satisfied overall with the CPEC project and also had a development project in their area.6 show that 81 respondents were dissatisfied with changes in their financial situation because of the CPEC and were dissatisfied overall with the public authorities. Twenty-two respondents were satisfied overall but were dissatisfied with the degree of improvement (or lack thereof) with respect to their personal financial situation. Seventy-one respondents were dissatisfied with the CPEC project overall but were satisfied with their financial situation. Finally, 39 respondents were satisfied overall and were also satisfied with their financial situation. The governance and management of large-scale projects should be done such that they improve the living standard of the local people [The results for the dependent variable and Xl people ; howeverl people . People l people , and thel people  and inadl people . Becausel people .1) and the dependent variable shows that the probability of being dissatisfied was 2.45 times higher when land was appropriated for the project or when the local people were not satisfied with the amount of compensation offered to them for their land. Similarly, the probability of being dissatisfied was about seven times higher when the affected local respondent was not able to buy land of the same quality as the one that was taken by the government for the CPEC project. Regarding the link to the CPEC road, the odds of being dissatisfied were about 0.3 times lower when there was no road link to their area but their land was taken for some other CPEC-related projects or economic zones. That there was no road link meant that the area had an economic zone or some other development project providing local people with better economic opportunities, which reduced the likelihood of conflict caused by the dearth of a road link. These findings support the view that people in these regions are less interested in road projects and are more interested in economic zones and other projects. The regions with no economic zones were about nine times more likely to be dissatisfied with CPEC overall than regions that had an economic zone. Similarly, the odds of being dissatisfied were about 7.6 times higher when there was no development project allocated to the area. Furthermore, people’s expectations of a poor financial outcome due to CPEC cause them to be dissatisfied and could create conflicts. Odds ratios are plotted in This study focused on whether people in selected regions of Pakistan were generally satisfied or dissatisfied with CPEC. We explained as to whether dissatisfaction existed with respect to different CPEC project activities and the manner in which the local people perceived them. We also tested our two hypotheses, and the null hypothesis that there is no relationship between our categorical variables was rejected in each case. It was interesting to see that some of the people who were directly or indirectly involved in the CPEC project were satisfied and some were dissatisfied. A minority of locals surveyed sold their lands to the CPEC project willingly, and land acquisition occurred smoothly regardless of whether or not they were able to acquire land of equivalent quality. There were also people who sold their land unwillingly but were still satisfied with the project. This satisfaction was highly dependent upon the availability of job opportunities through economic zones and/or energy projects, as their areas had been allocated special economic zones and energy projects that provided them with good job opportunities. However, a number of them sold their land unwillingly, were generally dissatisfied with the public authorities, and had concerns regarding the distribution of economic zones within their regions. Moreover, some of the respondents were concerned regarding the allocation of development projects and roads in their areas as they expected economic opportunities to arise with the arrival of CPEC. A majority of the people were dissatisfied with respect to improvements in their financial situation because of the opening of CPEC in Pakistan although some were still satisfied with the CPEC overall. Therefore, the situation could be said to be quite mixed throughout the areas studied. More clarity, based on and backed by further analysis, may arise after complete implementation of the CPEC project.Nonetheless, on the basis of our results, we believe that the distribution of economic zones and energy projects, particularly their equal distribution, and the participation of all stakeholders in decision-making could play a significant role in conflict mitigation and satisfaction for all stakeholders. Our results have a number of policy recommendations, which are as follows: governments, private organizations, and business communities have a significant role in making the CPEC projects successful. Public officials should try to resolve situations that give rise to conflicts as early as possible. Distribution and allocation of economic zones should be fair and equitable. This study has certain limitations. While multiple variables and factors were considered in this study, other factors related to infrastructure, environment, energy, and the local and agricultural sectors could be considered in future studies. The results of the study and the method of analysis could be applied to many other BRI countries for, and in anticipation of, post-implementation work related to various projects. In addition, from the Chinese perspective, this type of study should be conducted to analyze their ability to improve outcomes for the BRI.S1 Appendix(DOCX)Click here for additional data file.S1 Data(XLSX)Click here for additional data file.S1 File(PDF)Click here for additional data file.


When the treatment process of cancer patients changes to outpatient treatment, the burden on family members increases and they often experience burnout. Burnout not only effects the family members themselves but may also have a negative effect on the health of the cancer patient. Therefore, healthcare providers should evaluate burnout in the family members of cancer patients and actively make efforts towards their burnout management. This study investigated the mediating effect of depression on the relationship between social support, spirituality, and burnout in family members of patients with cancer. Participants were 151 family members of patients with cancer who were receiving chemotherapy as outpatients at a single university hospital in Korea. Data was collected from 2 March to 31 May 2016, using self-reported questionnaires. Collected data was analyzed with t-tests, analysis of variance (ANOVA), Pearson’s correlations, Baron and Kenny’s three-step regression method, and the Sobel test. The participants’ mean burnout was below the median. The participants’ depression partially mediated the relationship of both social support and spirituality on burnout. Strategies to assess depression and strengthen social support and spirituality should be developed to manage burnout in family members’. Regardless of the country, cancer directly and indirectly changes the lives of not only patients but also families ,2. When Korea is experiencing an increase in the average life expectancy due to economic development and improved healthcare, while the incidence of patients with cancer is also increasing due to changes in lifestyle and the environment . HoweverFrom the moment a patient is diagnosed with cancer, their family members perform various roles including physical nursing, psychological nursing, financial support, and housework . ConfuciBurnout can be affected by internal and environmental factors . SeveralSocial support has been reported to play a key role in alleviating physical and psychological health problems due to the stress of daily life and in promoting psychological wellbeing ,23. SociSpirituality is an internal resource that allows humans to cope with stress and re-establish positive values even in negative circumstances , and it Furthermore, the most common emotional problem experienced by family members of patients with cancer is depression . DepressAlthough there have been studies investigating the direct effects of depression on burnout, no studies have examined the relationships between the variables, including social support and spirituality, which may be protective factors for depression and burnout. Given the recent tendency to focus on strengthening protective factors when intervening in health problems such as burnout ,28,35, iThe aims of this study were as follows. First, we determined the how the prevalence of burnout correlates with the general characteristics of family members of patients with cancer. Second, we identified the mediating effect of depression on the relationship between social support and burnout in family members of patients with cancer. Third, we identified the mediating effect of depression on the relationship between spirituality and burnout in family members of patients with cancer.This research employed a cross-sectional, descriptive design.The participants were the family members of patients with cancer undergoing outpatient chemotherapy at one university hospital in Sejong city, Korea. They were conveniently sampled. The inclusion criteria were adults aged 20–79 years without a history of a cognitive or mental illness diagnosis/treatment, who understood the content and purpose of the study, as well as provided written consent to participate.The number of participants was estimated using G-power 3.1.5. With the significance level set at 0.05, a medium effect size of 0.15, a statistical power of 80%, and 13 predictive factors . The number of participants needed for a multiple regression analysis was 131. Allowing for a dropout rate of 20%, we surveyed 160 people.The participants’ general characteristics that we measured were age, sex, education, religion, occupation, financial burden, relationship to patient, number of family caregivers, recurrence, and patients’ activities of daily living.The burnout measurement tool we used was developed by Pines et al.  and tranThe social support measurement tool we used was developed by Park . It consThe spirituality measurement tool we used was developed by Lee et al.  for the The depression measurement tool we used was the Center for Epidemiologic Studies Depression Scale, which was developed by Radloff  and tranData was collected from 2 March 2016 to 31 May 2016 using self-reported questionnaires. A study investigator and research assistants who were trained in data collection visited the outpatient departments of internal medicine and surgery, as well as outpatient injection rooms of the university hospital that allowed data collection. Participants were informed of the study purpose and content directly. Questionnaires were completed independently and collected immediately. All 160 questionnaires were collected with 151 questionnaires included in data analyses. Nine questionnaires were missing data and excluded .This study was conducted after obtaining approval from the institutional review board and the department head of the involved institution. The investigator explained the study purpose, protection of personal information, anonymity, and statistical analysis techniques. Participants were also informed that the data would only be used for this study and that they could withdraw their participation at any time without consequence. All participants provided written consent. The survey took about 30 min to complete, and completed questionnaires were collected immediately.Collected data were analyzed using SPSS 25.0 . The means and standard deviations of the degree of social support, spirituality, depression, and burnout were identified. The difference in burnout according to the general characteristics of the participants was analyzed with t-tests and an analysis of variance. Scheffé’s test was used for post-hoc analysis. For the correlations between variables, Pearson’s correlations were used. To test the mediating effect of depression on the relationships among social support, spirituality, and burnout, we used a three-step simple and multiple regression analysis and the Sobel test, as suggested by Baron and Kenny .The three conditions for establishing the mediating effect were as follows: in the first step of the regression analysis, the independent variable must have a significant influence on the mediator; in the second step of the regression analysis, the independent variable must have a significant influence on the dependent variable; in the third step of the regression analysis, the mediator must have a significant influence on the dependent variable, and the influence of the independent variable on the dependent variable must be reduced in the third step compared to the second step. If the relationship between the independent variable and the dependent variable is not significant in the third step then it is interpreted as full mediation, whereas it is interpreted as partial mediation if the relationship is significant.For all scales, Cronbach’s α values ranged from 0.83 to 0.97, indicating acceptable to excellent reliability. All measures used in this study had been previously validated with family members of patients with cancer or adult populations in Korea.Participants’ demographic characteristics are shown in The mean scores and correlations among study variables are shown in There was a difference in burnout in participants based on their education, financial burden, number of family caregivers, recurrence, and patients’ ADL . The posConcerning social support, the first step of the regression analysis, which addressed the effect of social support (an independent variable) on depression (a mediator) was significant. The second step, which addressed the effect of social support (an independent variable) on burnout (a dependent variable) was significant. Lastly, the effect of depression (a mediator) on burnout was significant after controlling for social support (an independent variable). Here, the effect of social support (a dependent variable) on burnout was significant, and it showed a partial mediation of depression. Further, depression significantly mediated the relationship between social support and burnout .Concerning spirituality, the first step of the regression analysis, which addressed the effect of spirituality (an independent variable) on depression (a mediator) was significant. The second step, which addressed the effect of spirituality (an independent variable) on burnout (a dependent variable) was significant. Lastly, the effect of depression (a mediator) on burnout was significant after controlling for spirituality (an independent variable). Here, the effect of spirituality (a dependent variable) on burnout was significant, and it showed a partial mediation of depression. Further, depression significantly mediated the relationship between spirituality and burnout .The purpose of this study was to identify the mediating effect of depression on the relationship of both social support and spirituality on burnout in family members of patients with cancer. Interventions to reduce burnout in family members of patients with cancer can be developed and introduced based on the results of this study.In this study, the mean burnout in participants was below the median. Considering that recurrence of cancer increases caregivers’ burnout , our resParticipants’ burnout significantly differed with respect to education, number of family caregivers, financial burden, recurrence, and ADL. The degree of burnout was higher in the elementary graduate group than in the college or higher graduate group, which aligned with prior results ,21. LessThe burnout in participants was lower when the number of family caregivers was high and when the patient was independent. Considering the reality in Korea, where families are primarily responsible for caring for cancer patients , if therMoreover, the degree of burnout was higher with high financial burden and with cancer recurrence, which also aligned with prior results . In KoreDepression may partially mediate the relationship between social support and burnout in family members; in other words, having a higher level of perceived social support may reduce burnout by decreasing depression. This aligned with the results of Karadavut and Uneri , who repPerceived social support fosters positive psychological characteristics—such as hope—to help individuals effectively cope with stress ,48. ThisDepression partially mediated the relationship between spirituality and burnout. This aligned with the results of Ho et al. , who repIndividuals with spiritual wellbeing tend to display less emotional coping in stressful situations ,50. ThisThe findings of this study may contribute to broadening the understanding of burnout in family members of patients with cancer. Our study has important implications for healthcare providers in clinical nursing and community settings, providing a useful guideline for healthcare providers when establishing practical and specific intervention strategies for managing burnout in family members of patients with cancer. We only collected data from one university hospital; therefore, there are limits to the generalizability of the current results. Further, because self-reporting questionnaires were used, the possibility of participants responding defensively or responding according to socially desired characteristics cannot be excluded.Burnout in family members of patients with cancer not only has negative effects for their own health but it also compromises the health of the patients. It is necessary for healthcare providers to assess burnout in family members of patients with cancer and identify related factors to actively intervene in burnout management. We found that family members’ depression partially mediated the effects of both social support and spirituality on burnout. Therefore, to manage family members’ burnout, it may be effective to strengthen social support and spirituality, as well as assess for depression and intervene when necessary.Based on our results, we have the following suggestions. First, it is necessary to validate our results through repeated research that extends the number of participants and regions. Second, a study should examine how to strengthen the spirituality and social support of family members of patients with cancer. Third, a program should be developed to that evaluate depression and the effects of burnout. Lastly, there should be a study about the potential behavioral mediators that impact burnout in family members of patients with cancer.


Measuring quality of care in low-income and middle-income countries is complicated by the lack of a standard, universally accepted definition for ‘quality’ for any particular service, as well as limited guidance on which indicators to include in measures of quality of care, and how to incorporate those indicators into summary indices. The aim of this paper is to develop, characterise and compare a set of antenatal care (ANC) indices for facility readiness and provision of care.We created nine indices for facility readiness using three methods for selecting items and three methods for combining items. In addition, we created three indices for provision of care using one method for selecting items and three methods for combining items. For each index, we calculated descriptive statistics, categorised the continuous index scores using tercile cut points to assess comparability of facility classification, and examined the variability and distribution of scores.Our results showed that, within a country, the indices were quite similar in terms of mean index score, facility classification, coefficient of variation, floor and ceiling effects, and the inclusion of items in an index with a range of variability. Notably, the indices created using principal components analysis to combine the items were the most different from the other indices. In addition, the index created by taking a weighted average of a core set of items had lower agreement with the other indices when looking at facility classification.As improving quality of care becomes integral to global efforts to produce better health outcomes, demand for guidance on creating standardised measures of service quality will grow. This study provides health systems researchers with a comparison of methodologies commonly used to create summary indices of ANC service quality and it highlights the similarities and differences between methods. To our knowledge, this is the first study that uses multiple methodologies to develop and compare indices for antenatal care (ANC) facility readiness and provision of care.Our approaches to item selection and combination were based on the most commonly used approaches in the literature and we included those most likely to be useful to low-income and middle-income countries.The analysis was conducted using data from multiple countries, which strengthens our ability to generalise the findings to other similar contexts.The Service Provision Assessment survey, while quite comprehensive, does not capture every aspect of quality of care that may be important to include in quality of care metrics.This analysis does not provide a formal validation of any one ANC quality of care index.Reducing maternal morbidity and mortality has been a global priority over the last several decades. While progress has been made in both improving coverage and reducing mortality, there remains an unacceptably high number of deaths of women globally.Low-income and middle-income countries (LMICs) are increasingly shifting focus towards making improvements in the quality of health services delivered, which requires measuring quality of care and monitoring progress. However, for LMICs to systematically and comprehensively measure quality of care, they require a definition of quality of care and clear, specific indicators to operationalise the definition. Many quality of care frameworks exist, most of which build from Donabedian's 1988 framework characterising quality at three levels: structure, commonly called facility readiness , process , and outcome .Studies on quality of care in LMICs largely rely on data from health facility surveys that collect data on facility readiness and provision of care. These studies often use summary indices or composite scores to provide an overall description of service quality.10.1136/bmjopen-2019-032558.supp1Supplementary dataAs quality of care indices are increasingly used by countries, global agencies and researchers to quantify the quality of health services and estimate effective coverage, there is a need to standardise the methodology for creating these measures. To our knowledge, no studies have compared the methodologies used to create indices of ANC service quality. The objective of this paper is to develop, characterise and compare a set of facility readiness and provision of care indices for ANC.Using data from an expert survey, we created nine facility readiness indices using three methods for selecting items  and three methods for combining items  . We creaThe SPA is a health facility assessment used in LMICs to generate nationally representative data on health service delivery.We examined all SPA surveys for inclusion in the analysis . We included all SPA surveys which used the DHS-VI or DHS-VII questionnaire (four surveys excluded), that included observations of ANC consultations (three surveys excluded), were conducted in the last 5 years (between 2013 and 2018) (two surveys excluded), and for which recode data files were available (four surveys excluded). The included surveys are from Haiti (2013), Malawi (2013/2014) and Tanzania (2014/2015). The SPA final country reports contain comprehensive information on the survey methodology and questionnaires.To identify elements of facility readiness and the provision of ANC considered by experts to be the most important to ANC service quality, we reviewed the Service Availability and Readiness Assessment (SARA) indicators, World Health Organization (WHO) Focused Antenatal Care (FANC) guidelines and WHO recommendations on ANC for a positive pregnancy experience, as well as the SPA questionnaire. This process identified a total of 121 items organised according to the dimensions of quality of care proposed by the WHO Quality of Care Framework for maternal and newborn health: essential physical resources (41 items), competent and motivated human resources (four items), provision of care (65 items) and experience of care (11 items).We then conducted a survey of 50 maternal health experts who had experience working in LMICs . For human resources items, each item is a proportion ranging from 0 to 1. For provision of care items, a binary score was created based on whether or not the activity was conducted during the ANC visit  or whether or not the client had a problem with the item during the ANC visit . The list of items included in each readiness and provision of care index can be found in core set of readiness items required to deliver ANC services. This set of items was identified by reviewing the provision of care items required for an ANC visit based on WHO FANC guidelines and WHO recommendations on ANC for a positive pregnancy experience, and by determining the human resources, equipment and supplies, medicines, and diagnostics required to deliver each specific item. In creating the core set of items for facility readiness, we mapped each provision of care item to the facility readiness items required to deliver the specific service component. We found that of the 49 provision of care items, 36 items required only human resources and 13 items required human resources plus equipment, diagnostics, medicines or basic amenities. The core index did not include standard precautions for infection prevention items because these are not explicitly required for any one provision of care item. A total of 21 items were selected for the core set readiness index.Three methods were used to select items to include in the facility readiness indices. The first method identified the expert survey to identify the set of readiness items maternal health experts identified as essential to deliver ANC services. Mean ratings were calculated for each readiness item  were not incorporated into the analysis as the goal of this analysis was not to make inferences about the entire population from which the sample of health facilities was drawn. In addition, for the indices created using PCA to combine items, we calculated factor loadings, the eigenvalue and the per cent of total variance explained by the first component. Since the PCA method was used to create weights for a composite variable rather than estimating a latent variable we did not report out the number of components with an eigenvalue greater than one. Next, to compare scores from the nine facility readiness indices, we categorised the continuous index scores into low, medium and high readiness categories using tercile cut points. We then assessed the comparability of the facility classification across the indices by calculating the per cent agreement and Cohen’s kappa, which accounts for the possibility of the agreement occurring by chance, between each combination of indices. Cohen’s kappa ranges from −1 to 1 and can be interpreted as follows: <0 as no agreement, 0–0.20 as slight, 0.21–0.40 as fair, 0.41–0.60 as moderate, 0.61–0.80 as good and 0.81–1 as almost perfect agreement.Next, we examined the variability and distribution of the index scores. As countries are interested in being able to compare facilities with each other to understand better and worse performers , we are interested in being able to capture that variation in an index score. The examination of variability and distribution of the index scores aims to understand the level of variability being captured but does not indicate that an index is necessarily ‘better’ because it captures more variability. The coefficient of variation (CoV) was used to measure the variation captured by each index, with a higher CoV indicative of more variation captured in the index. Distribution of the scores was examined by assessment of floor and ceiling effects. Floor and ceiling effects were considered to be present if more than 15% of facilities achieved the lowest or highest possible index score (0% or 100%), respectively.All statistical analyses were carried out using R V.3.5.1.It was not appropriate or possible to involve patients or the public in this work.The final analytical sample consisted of 358 health facilities and 779 ANC clients in Haiti, 253 health facilities and 815 ANC clients in Malawi, and 632 health facilities and 1681 ANC clients in Tanzania. A total of 6 ANC clients in Haiti, 44 ANC clients in Malawi and 73 ANC clients in Tanzania were excluded from the analysis due to missing data.The results of the expert survey are available in The mean readiness score varied by index from 56.6 to 64.1 in Haiti, 52.3 to 69.6 in Malawi and 61.2 to 75.9 in Tanzania . Across The mean provision of care score varied by index from 38.9 to 85.9 in Haiti, 35.8 to 53.1 in Malawi and 40.4 to 58.0 in Tanzania . The expThe results from the PCA analysis are presented in Across all countries for provision of care, the items with the highest loadings  differed by country. For Haiti, the items that loaded the highest were related to client experience. For Malawi and Tanzania, the items that loaded the highest were related to history taking and counselling; although for each country, the highest loadings were largely on different items. For provision of care indices in all countries, the per cent of variance explained by the first principal component was low, ranging from 9.89% in Malawi to 10.49% in Haiti. In addition, we found that items such as history taking, client education and counselling on danger signs in pregnancy, and haemoglobin testing had negative loadings.The variability and distribution of the nine facility readiness indices are presented in To our knowledge, this is the first study that uses multiple methodologies to develop and compare indices for ANC facility readiness and provision of care. Our results showed that, within a country, indices containing different items combined using different approaches were quite similar in terms of median index score, facility classification, CoV, floor and ceiling effects and inclusion of items with a range of variability. Although similar overall, we found that the indices created using PCA were the most different from the other indices. In addition, the core weighted index had lower agreement with the other indices when looking at facility classification. This may be the result of some domains in the core weighted index having few items, making each of those items more influential in the overall index score.Our analysis highlighted the importance of competent, motivated human resources to all aspects of delivering high-quality ANC services. Our approach to defining the core set of items highlighted the lack of metrics for human resources captured by facility surveys, as well as the inconsistency between what inputs are required for provision of care and how facility readiness is often defined. This is especially important considering there is a health workforce crisis globally, which is particularly pronounced in LMICs.This study’s findings also suggest that to provide more comprehensive measures of ANC quality some items could be added to SPAs and other facility surveys, particularly items related to the experience of care. While the global community is moving towards more person-centred care, data collected through health facility assessments is generally deficient in experience of care measures.We also found that the indices differed in terms of their ease of construction and interpretation. The simple additive and weighted additive approaches were straightforward to construct because they required taking averages of items, while the PCA necessitated more complex analysis. In addition, the simple additive approach was the easiest to interpret since facilities with more items available had a higher quality score. The weighted additive approach was also relatively easy to interpret. However, item weighting whereby each domain receives an equal weight was based on an implicit conceptual framework for quality which has not been formally validated. The PCA approach was perhaps the most difficult to interpret as the PCA score represents the linear combination of variables that explained the most variance in the data. As the loadings of each variable on the first component were used as the weights, and some items were negatively correlated and consequently had negative loadings; having all items present in a facility did not always result in the highest PCA score. In addition, the weights assigned by PCA reflected the variation in the data that was different across countries. As a result, PCA did not produce the same weights across different contexts. As we were working with a common definition for what an ANC visit should include across country contexts, this variability in loadings resulted in concerns regarding the face validity and construct validity of the PCA indices. Overall, the low per cent of total variance explained by the first principal component, diverging items with high loadings between countries, negatively correlated items, and the complexity in creating and interpreting the measure highlights concerns for the use of PCA for creating quality of care indices.Due the variation in ease of construction and interpretation, different methodologies may be better suited for different purposes. For example, the simple additive approach using the maximum number of items may be easiest for Ministries of Health in LMICs to understand and implement. However, if there is particular interest in using facility readiness as a proxy for provision of care, it might be conceptually important to ensure that items align well between facility readiness and provision of care, thus making the core set of items a good choice. In addition, while the weighted additive method aims to give equal weights to domains of facility readiness and provision of care, as the contents of each domain are determined by what data are available as opposed to an ideal set of items, this approach implicitly weights certain items more heavily because of the unavailability of data on other items and therefore may not be well-suited depending on the purpose of the index. While different methodologies may be better suited for different purposes, there remains a need for standardised, meaningful, valid measures of quality of care that take into account the variation in ease of construction and interpretation and can be used both by countries and at global level.We note several limitations of the analysis. First, this analysis was conducted using data from three countries, two in Africa and one in Latin America and the Caribbean, which may limit generalisability of findings to low-income countries globally. However, the findings were relatively consistent across the three countries. The two African countries are in the Southern and Eastern Africa region and represent two different types and sizes of health systems within that region. Second, the SPA survey, while quite comprehensive, does not capture every aspect of quality of care that may be important to include in quality of care metrics. However, the SPA represents the most comprehensive information on quality of care in LMICs that is currently available.While the goal of this study was not to identify the best index for measuring quality of care, we did endeavour to characterise the various indices to make more information available in order to assist health systems researchers in choosing a methodology for creating quality of care indices. Overall, we found the indices to be quite similar within a country. In addition, we found that different methodologies may be better suited for different purposes. Future research on the association between facility readiness and provision of care would be helpful to further characterise the quality of care indices and inform selection of an index. As quality of care becomes integral to global efforts to improve health outcomes, demand for guidance on creating standardised measures of service quality will grow. This study provides health systems researchers with a comparison of methodologies commonly used to create summary indices of ANC service quality and highlights the similarities and differences between methods. Further research will be required at global and country level to develop standardised, meaningful, valid measures of quality of care that take into account multiple services and various country contexts.10.1136/bmjopen-2019-032558.supp2Supplementary data


During the first phase of the Movement Control Order, many medical lecturers had difficulty adapting to the online teaching and learning methods that were made compulsory by the institutional directives. Some of these lecturers are clinicians who need to juggle between clinical work and teaching, and consider a two-week adaptation during this period to be not enough. Furthermore, converting traditional face-to-face learning to online formats for undergraduate and postgraduate clinical programmes would reduce the learning outcomes, especially those related to clinical applications and the acquisition of new skills. This editorial discusses the impact that movement restrictions have had on medical teaching and learning, the alternatives and challenges and the way forward. The coronavirus disease 2019 (COVID-19) outbreak was designated as a public health emergency on 30 January 2020  . In spitNevertheless, the adoption of online learning is not without obstacles. Studies have shown that the attitudes of teachers and learners are strong determinants of the successful implementation of online learning and of its effectiveness –17. The A number of lecturers have echoed their concerns about converting face-to-face learning to online formats for undergraduate and postgraduate clinical programmes, which they believe might limit their chances of achieving their learning outcomes, especially those related to clinical application and the acquisition of skills. A number of suggestions have been made to overcome the teacher’s resistance and misconceptions regarding online teaching and learning , 21. SucClearly, the unprecedented outbreak of the COVID-19 pandemic has led to changes in the way online teaching and learning are perceived. With the complete lockdowns, called the MCO in Malaysia, that were enforced in many countries, educators worldwide have been left with no options except to conduct online teaching and learning to ensure continuous provision of education to students. This has also been the unique real-time experience of many medical lecturers in Malaysian medical schools, as they must conduct online teaching and learning within their own capabilities and in spite of their limitations. At the time of writing this, Universiti Sains Malaysia has just released an appreciation note on the amazing number of 1,421 online teaching and learning sessions conducted in the second week (12 April–17 April 2020) of its implementation directive  22). A . A 22).


In the EU, clinical assessors, rapporteurs and the Committee for Medicinal Products for Human Use are obliged to assess the ethical aspects of a clinical development program and include major ethical flaws in the marketing authorization deliberation processes. To this date, we know very little about the manner that these regulators put this obligation into action. In this paper, we intend to look into the manner and the extent that ethical issues discovered during inspection have reached the deliberation processes.To gather data, we used the Dutch Medicines Evaluation Board database and first searched for the inspections, and their accompanying site inspection reports and integrated inspection reports, related to central marketing authorization applications  of drugs submitted to the European Medicines Agency (EMA) from 2011 to 2015. We then extracted inspection findings that were purely of ethical nature, i.e., those that did not affect the benefit/risk balance of the study . Only findings graded at least major by the inspectorate were included. Lastly, to identify how many of the ethically relevant findings (ERFs) reach the application deliberation processes, we extracted the relevant joint response assessment reports and reviewed the sections that discussed inspection findings.From 2011 to 2015, there were 390 processed applications, of which 65 had inspection reports and integrated inspection reports accessible via the database of the Dutch Medicines Evaluation Board. Of the 65, we found ERFs in 37 (56.9%). The majority of the ERFs were graded as major and half of the time it was informed-consent related. A third of these findings were related to research ethics committee processes and requirements. Of the 37 inspections with ERFs, 30 were endorsed in the integrated inspection reports as generally GCP compliant. Day 150 joint response assessment reports and Day 180 list of outstanding issues were reviewed for all 37 inspections, and none of the ERFs were carried over in any of the assessment reports or list of outstanding issues.None of the ethically relevant findings, all of which were graded as major or critical in integrated inspection reports, were explicitly carried over to the joint assessment reports. This calls for more transparency in EMA application deliberations on how ERFs are considered, if at all, in the decision-making processes. Points to consider on Good Clinical Practice (GCP) inspection findings and the benefit-risk balance where the mandate of regulators in terms of the place of these ethical issues in the evaluation process is explained as follows:even if not directly influencing the benefit-risk balance—will still be important if they raise serious questions about the rights, safety and well-being of trial subjects and hence the overall ethical conduct of the study. It is an obligation of clinical assessors, rapporteurs and the CHMP also to assess the ethics of a clinical development programme, and major ethical flaws should have an impact on the final conclusions about approvability of an application. Consequently, ethical misconduct could result in rejection of the application [italics mine).GCP inspection findings – lication .  speak of the place of ethics in the regulatory processes involved in a marketing authorization application  –4. One oIn a previous publication, we identified the types of ethical issues that pharmaceutical regulators encounter post-marketing through inspection reports . In thisBefore we elaborate on our methodology, it is imperative that we quickly go through the European centralized procedure for authorizing medicinal products, which we have outlined in Fig. As can be seen from Fig. inspection reports, integrated inspection reports, Day 150 joint assessment reports, and Day 180 List of Outstanding Issues.Given the centralized procedure outlined above, to understand the extent to which ethical issues have reached the application deliberation processes, we searched for To gather data, we used the Dutch Medicines Evaluation Board database and first searched for inspections, and their accompanying site inspection reports and integrated inspection reports, related to central application of drugs submitted to the EMA from 2011 to 2015. For the list of drugs processed for central marketing authorization, we used the European public assessments report database .Points to consider for assessors, inspectors and EMA inspection coordinators [IC), research ethics committees (REC), and respect for persons.Inspection findings include both scientific and ethical issues. To determine which issues to extract, we used the following system. In another publication, we extracted the ethical issues from GCP inspection reports and came up with the following classifications of ethical issues: informed consent, monitoring and oversight, patient safety, professionalism and or qualification issues, protocol compliance or protocol issues, research ethics committees, and respect for persons . It can dinators . We useddinators  to definEven within the latter three categories, since we are testing how far purely ethical issues identified in inspections reach the evaluation processes, we excluded inspection findings that may influence the benefit-risk balance evaluation. For example, one of the issues identified as likely to influence benefit-risk evaluation is “inadequate reporting of adverse events and other safety endpoints.” If we look at the definition of respect for persons, patient safety is an aspect of its definition and inadequate reporting of (severe) adverse events a concrete example. Because this finding is likely to affect benefit-risk evaluation, i.e., it is clearly both a scientific and an ethical issue, it was excluded from our analysis.ERFs). We used the integrated inspection reports to validate if the inspection findings still hold after the evaluation of the responses of the responsible parties on the initial inspection reports  and the list of outstanding issues see Fig.  were extTo avoid privacy and confidentiality issues, the results are on an aggregated format.From 2011 to 2015, 390 applications were processed, of which 65 had inspection reports and integrated inspection reports accessible via the database of the Dutch Medicines Evaluation Board. Of the 65, we found ERFs in 37 (56.9%). These findings are summarized in Table As can be seen from Table Of the 37 inspections with ERFs, 30 were endorsed in the integrated inspection reports as generally GCP compliant. Table From Table In all the 30 endorsed inspections, the gravity ratings were retained and the corrective and preventive action (CAPA) proposals of the sponsors and investigators to address the ERFs were accepted by the inspectors. Note that CAPAs would in most instances be preventive, i.e., changes can be made only for future trials. Seven of the inspections were not fully endorsed as GCP compliant, partly due to ERFs.Of the seven not-fully-endorsed inspection cases, three were declared non-GCP compliant with the consequence that (part of) the data were not endorsed for use for the assessment of an application. One was declared non-GCP compliant but data were still endorsed for use during assessment. In three cases, data were endorsed for use for assessment, but the inspectors expressed lingering concerns about ERFs and required a better approach from the sponsor in the future.Day 150 joint response assessment reports and Day 180 list of outstanding issues were reviewed for all 37 inspections, and none of the ERFs were carried over in any of the assessment reports or list of outstanding issues. Table In our study, we wanted to see how many of the ethical issues that were not likely to affect the scientific validity of the study and that were discovered during inspection have reached the evaluation processes for centralized applications of drugs. We did this by investigating how many of the ERFs from integrated inspection reports were reflected in Day 150 and Day 180 joint assessment reports. Our results are straightforward: of the 77 ERFs found in 56.9% of all inspections from 2011–2015, none of the ERFs were factored in, i.e., none of them were mentioned at all as factors to consider in either Day 150 joint response assessment reports or Day 180 list of outstanding issues. This means that though these ERFs may have been discussed internally, none of these were explicitly carried over to the joint assessment reports. Whether or not the inspections were endorsed was not a factor in the uptake of ERFs in Day 150 and Day 180 assessments. This is disturbing especially for the seven inspections where the inspectors did not guarantee general GCP compliance of the trial sites, three of which lingering concerns about ERFs were expressed by the inspectors. Overall, and based on inspection and assessment reports, this means that the mandate obliging clinical assessors, rapporteurs and the CHMP to also “assess the ethics of a clinical development programme, and major ethical flaws should have an impact on the final conclusions about approvability of an application” [Major/critical issues are defined as “conditions, practices or processes that might adversely/adversely affect the rights, safety or well-being of the subjects and/or the quality and integrity of data” [First, it is unclear what standards inspectors use to declare that the inspected sites were generally GCP compliant in spite of major/critical ERFs. of data” . If majoSecond, though the grading of critical/major/minor is used by the inspectors, it is not clear in EMA documents if the assessors should use the same grading system. Whether inspectors and assessors should and in fact use the same grading system is an area for future research.Third, ERFs are best addressed early, and not during application deliberations when “damage” has already been done. This may mean encouraging preventive measures at the design stage of clinical trials, widening the capacity of research ethics committees to monitor approved clinical trials, reviewing sponsor responsibility in actively pursuing ethically compliant trials, and/or more active collaboration between RECs and drug regulators in terms of approving and monitoring clinical trials, among others.Fourth, inspection reports provide a lot of insight on ethical and scientific matters such as the ethical acceptability of the elements of a pharmaceutical clinical trial which eventually becomes a basis for an application, integrity of the clinical trial data based on which pharmaceutical products are provided marketing authorization, among others. This should be sufficient reason for drug regulatory agencies to make them more accessible, if not public. This is a concern that was earlier made by Dal-Re, Kesselheim, and Bourgeois  in an opFifth, we saw above the EMA position that GCP issues, even those that do not affect the benefit-risk balance so long as these issues raise “serious questions about the rights, safety, and well-being of trial subjects” should have an “impact on the final conclusions about approvability of an application” . In our from the vantage of these joint assessment reports, none of the ethically relevant findings seemed to have reached or impacted the application deliberation processes. This calls for more transparency in EMA application deliberations, specifically on how ERFs are considered in the decision-making processes.None of the ethically relevant findings, all of which were graded as major or critical in integrated inspection reports, were explicitly carried over to the joint assessment reports. This means that


Internet search data on health-related terms can reflect people’s concerns about their health status in near real time, and hence serve as a supplementary metric of disease characteristics. However, studies using internet search data to monitor and predict chronic diseases at a geographically finer state-level scale are sparse.The aim of this study was to explore the associations of internet search volumes for lung cancer with published cancer incidence and mortality data in the United States.We used Google relative search volumes, which represent the search frequency of specific search terms in Google. We performed cross-sectional analyses of the original and disease metrics at both national and state levels. A smoothed time series of relative search volumes was created to eliminate the effects of irregular changes on the search frequencies and obtain the long-term trends of search volumes for lung cancer at both the national and state levels. We also performed analyses of decomposed Google relative search volume data and disease metrics at the national and state levels.The monthly trends of lung cancer-related internet hits were consistent with the trends of reported lung cancer rates at the national level. Ohio had the highest frequency for lung cancer-related search terms. At the state level, the relative search volume was significantly correlated with lung cancer incidence rates in 42 states, with correlation coefficients ranging from 0.58 in Virginia to 0.94 in Oregon. Relative search volume was also significantly correlated with mortality in 47 states, with correlation coefficients ranging from 0.58 in Oklahoma to 0.94 in North Carolina. Both the incidence and mortality rates of lung cancer were correlated with decomposed relative search volumes in all states excluding Vermont.Internet search behaviors could reflect public awareness of lung cancer. Research on internet search behaviors could be a novel and timely approach to monitor and estimate the prevalence, incidence, and mortality rates of a broader range of cancers and even more health issues. Cancer affects people at all socioeconomic levels and has become a worldwide public health problem. In 2018, the International Agency for Research on Cancer reported the substantial global burden of cancer . MoreoveAlong with the rapid spread of social media and medical forums, people frequently search internet resources for symptom-related information, basic medical advice, and to exchange information -10. As mThe past decade has witnessed an exponential increase in internet penetration. As of April 2019, 56% of the world’s population was reported to have internet access, with rates in the developed world now exceeding 80% ,15. AccoPrevious studies have attempted to utilize search engines  to improve the surveillance of some epidemics. Some scholars have made use of online social networks  to mine public interest in medical-related issues such as diagnosis and treatment knowledge, patient experience sentiments, and quality of medical services. Meanwhile, more and more studies have elucidated trends in disease communications through internet communities  -22. SincIn the present study, we tested the hypothesis that the volumes of internet search queries related to lung cancer reflect real-world spatiotemporal variation in the incidence and mortality rates of lung cancer in the United States. Our findings suggest that internet search volumes may reflect disease characteristics of lung cancer  and provide an additional means of national- and state-level cancer surveillance in the United States.We collected monthly search data for lung cancer through Google Trends  from 200When downloading search data, we could freely choose our own time range. The earliest search data available for Google Trends are from 2004. Therefore, to illustrate and analyze more complete changes in search trends, we first chose to download data from 2004. Although the search data are updated in real time, as mentioned above, the publication of cancer registration data usually lag behind data collection for several years; thus, the latest incidence and mortality rates of lung cancer available for the present analysis were those published in 2015 by the CDC. To explore the association of internet search volumes for lung cancer with published cancer incidence and mortality rates in the United States, we downloaded the relevant data for the same period of time and set the year 2015 as our first deadline. We downloaded data in January 2019 so that we could obtain complete search data from 2004 to 2018 before conducting the subsequent analysis.Lung cancer awareness was examined on the basis of the general population’s ability to seek such information or pay attention to it . We seleThe age-adjusted incidence and mortality rates per 100,000 individuals with lung cancer in both sexes were obtained at the state and national levels from the CDC for the period of 2004-2015 [RSVs at national and state levels are represented as time-series data. Each time series was divided into four parts: long-term trend, seasonal change, cycling, and random fluctuation. We used a time-series decomposition method to eliminate the effects of irregular changes and obtained the long-term trends of the internet search data from January 2004 to December 2018. Each long-term trend is a continuously increasing or decreasing trend that an objective phenomenon exhibits over a long period of time, which may be due to a fundamental cause. The purposes of studying long-term trends are to understand the regularity of the development of internet search data, provide the necessary conditions for statistical prediction, and remove them from the time series to ultimately analyze the influence of other factors on the time series. The steps of this procedure were as follows. First, we chose a multiplication model based on the time-series graph of the RSV of each state. Second, we used a moving-average method to smooth the time series, and used a monthly average method to calculate the seasonal index. Third, we drew a scatter plot and selected the long-term trend of the appropriate curve model to fit the sequence and obtain the long-term trend. Finally, after decomposing the seasonal index and the periodic variation factors, the remaining factors represented the long-term trend.We performed Spearman correlation analysis to evaluate the relationship between the known lung cancer incidence and mortality rates and Google RSVs over the period of 2004-2015. As Spearman correlation analysis is a nonparametric method, no assumptions of distributions were required on the original variables. We also performed Spearman correlation analysis to evaluate the relationship among the incidence and mortality rates and search data after time-series decomposition.We assumed that trends in lung cancer-related internet hits would be consistent with those reported for national lung cancer incidence. As the search data could be downloaded in real time, we downloaded complete search data from 2004 to 2018. However, publication of incidence and mortality rates usually lags 3 years behind the actual data. Hence, after the correlation analysis, we conducted a simple linear prediction of the incidence and mortality rates of lung cancer from 2016 to 2018 based on previous epidemiological data, and explored whether trends in lung cancer internet hits would be consistent with the future incidence and mortality rates of lung cancer in the same manner as described above. Therefore, we set the year 2018 as our second deadline for the present analysis.t test. The significance level was set at alpha=.05 for all tests.Statistical analysis was conducted using IBM SPSS , EViews , and R project . The statistical significance of the correlation for each dataset was computed using a two-tailed Student We separately extracted the Google RSVs for each of the 12 keywords selected in the above method. However, except for “lung cancer,” the other query terms lacked Google RSVs for all states. Thus, we only selected the common lay term “lung cancer” in this study in consideration of the integrity of the data see .Previous studies have mainly focused on the epidemiology of infectious diseases by analyzing internet searches or using social media data sources  to conduct health research. The present study examined the association between internet searches and the incidence and mortality rates of lung cancer at national and state levels in the United States over a 12-year period, and predicted the incidence and mortality rates of lung cancer based on their correlations with internet searches. We found an association between RSVs and actual incidence rates of lung cancer for 42 states. Upon examining lung cancer mortality rates, we found statistically significant correlations between mortality rates and RSVs for all but four states.Our results support the concept of using internet search data and broader public access in health topics for estimating disease characteristics such as incidence and mortality rates. For Kentucky, which had the highest lung cancer incidence and mortality rates in the United States, both incidence and mortality rates were strongly correlated with Google RSVs. In Utah, which had the lowest incidence and mortality rates of lung cancer, RSVs were not correlated with either of these two rates. One possible explanation for this pattern could be that prior online search activities are amplified by individuals at risk for lung cancer, their caregivers, or those who want to acquire knowledge on lung cancer -37. Our Many other factors may contribute to this association. Although most of the states surveyed in the present study showed statistically significant correlations of RSVs with incidence and mortality rates, some states did not show such correlations . However, our study contained only one query term, which was not able to reflect people’s search needs and changes in search patterns. Additionally, data downloaded from Google Trends are not raw and unprocessed data, and Google’s search algorithm is not static. The algorithm itself is constantly being tested and improved. The instability of Google searching caused by algorithmic dynamics may induce Google Trends to also offer an unstable depiction of the occurrence of lung cancer. Algorithmic dynamics represent changes made by engineers to improve business services and consumer use of their search services. Google’s search algorithms and user behavior changes can affect the tracking of Google Trends. The multitude of algorithmic changes is the result of Google’s numerous programmers working on small units combined with the use of search engines by millions of consumers around the world. Hence, it is difficult to reproduce the original algorithm of Google Trends. When users search for disease information, Google may automatically provide more entries that are helpful for diagnosis, such that changes in each user’s search result in changes in the Google Trends due to the recommendation of the search bar. Google does offer a function called “related queries,” which allows users to identify the retrieved data after a given time series, but this only applies to data at the national level. The key concepts are the lack of transparency regarding absolute search volumes, the exact query text and search Boolean logic used to calculate search volumes, and preprocessing in the temporal domain. After processing by Google, the filtered data may have lost much of the information contained in the original raw data . SeveralTwitter, Facebook, Google, and the entire internet are changing day by day. Studying these changes, trends, and algorithms may help us to develop more efficient data analysis models. This situation may also be influenced by various public health activities related to lung cancer. The launch of these activities may increase the public’s online searches for lung cancer, regardless of disease indicators. One study found that RSVs increased in lung cancer screening after trials reported their potential to reduce the risk of death in heavy smokers . PreviouThere are also regional differences in search volumes. In recent years, the emergence of corresponding therapy and new early screening methods for lung cancer have helped to prevent and treat lung cancer, but the level of development of lung cancer prevention and treatment, along with the diagnostic rate and survival time of lung cancer, vary from state to state. It is well known that indoor and outdoor air pollution increases the incidence of lung cancer, including smoking, air pollution, secondhand smoke, and radon ,46. For We also forecasted the incidence and mortality rates of lung cancer in all states from 2016 to 2018 based on correlations between these rates and Google RSVs. Our direction for future work may focus on predicting the incidence of lung cancer by combining RSV data and real-world medical data. This approach may not only benefit the development of early warning, intervention, prevention, and control measures for lung cancer but may also extend the research findings of lung cancer to other chronic diseases.Studying search engine data is inevitably restricted by some random factors. As such, the present study had some limitations. First, since the internet search data of other query terms in some states were not included in Google Trends, the present study only contained one search term. Second, Google Trends is not a real epidemiological instrument. The use of Google Trends to estimate lung cancer is not fully representative of the general population, since only individuals with access to the internet can be accounted for via this approach. Third, we were unable to determine which types of internet users conducted search activities. Fourth, we only utilized search data from one search engine, which may not represent search preferences of the whole population, although Google leads the explicit core search market in the United States ,50. We hThe widespread proliferation and increasing utility of the internet have fundamental impacts on the ways in which people seek and acquire medical information. Studying internet search data can augment traditional methods for cancer surveillance when registry data are lagging, and help to achieve improved prevention and control of diseases. In addition, underscoring the potential utility of internet searches may be beneficial to identify people or regions at risk for cancers or other chronic noncommunicable diseases.