Green entrepreneurial orientation (GEO) and sustainability have been the hot topics in green entrepreneurship research. The GEO integrates market orientation (MO) and environmental orientation (EO), and enterprises need to increase resource investment. However, it is not clear whether this strategic orientation can help new ventures achieve sustainable competitive advantages (SCA). In addition, the integrated role of opportunities and resources in the process of green entrepreneurship cannot be ignored. To fill the gap, we analyzed survey data from 274 emerging green enterprises in China, and we examined the effect of GEO on SCA. Additionally, we proposed the concept of integration of opportunity and resources capabilities (IORC) by integrating the core factors of green entrepreneurship. It can be divided into internal integration (ITI) and external integration (ETI), and the moderating effect of IORC on this relationship was also inspected. The results indicated that GEO significantly affects SCA, and IORC positively moderates the relationships between GEO and SCA. Indeed, compared with the enterprises that adopt a single strategic orientation, enterprises that adopt GEO can obtain greater SCA. In addition, focusing on the internal and external integration of IORC can further enhance the acquisition of SCA. This study not only integrates the theories of entrepreneurship and sustainable development but also compensates for the lack of green entrepreneurship theory while providing practical guidance for new enterprises seeking to engage in green entrepreneurship. The global economy develops rapidly, but the environment has become increasingly degraded. The contradiction between environment and economy development has become a difficult problem in theory and practice. Green entrepreneurship has gradually attracted the attention of scholars concerned about increasingly degraded natural environment . More anGreen entrepreneurship not only integrates two important theories of business entrepreneurship and sustainable development but also plays a vital role in environmental, economic, and social sustainability . HoweverThe nature of green start-ups remains entrepreneurship. The essence of entrepreneurship is to realize the maximum value of opportunity under resource constraints . TherefoThis study is guided by the following research question: whether the new enterprises with GEO as a strategic orientation can gain SCA and whether the relationship between the two is associated with IORC. In answering this question, we explored the relationship between GEO and SCA using survey data from 274 emerging green enterprises in China. Then, we innovatively proposed the concept of integration of opportunity and resources capabilities (IORC), which not only systematically integrates the two core elements of entrepreneurship but also reveals the essence of entrepreneurship. Finally, we examined the role of IORC in GEO and SCA.This paper contributes to the theory and practice. First, we integrate the theory of entrepreneurship and the sustainable development theory and reveal the significance and essence of GEO and its relationship with SCA. In this, we compensate for the inadequacy of entrepreneurship theory, which is prone to focus on economic benefit, while promoting the development of GEO theory. Second, the new concept of IORC proposed in this study is of substantial value in revealing the essence of entrepreneurship and improving its success rate. This contribution should be of interest to prospective entrepreneurs. Finally, the paper establishes a complete theoretical model for use in a comprehensive empirical test and systematically investigates issues that green start-ups must pay attention to in the process of pursuing SCA, including adhering to GEO and cultivating IORC.Traditionally, in developing countries, when enterprises transform products and services into profits, managers rarely care about the negative impact of their decisions and behaviors on the environment . With thIn the research on green entrepreneurship, scholars have reached consensus on the following three points. First, defined according to its purpose, green entrepreneurship should seek to actively achieve ecological environmental goals by means of entrepreneurship, whereby a green participation tendency is emphasized. Secondly, from the perspective of the development opportunities, green entrepreneurship emphasizes the use of green market opportunities gradually popularized and expanded by green values to open up new markets and create new profit growth points. Finally, from the perspective of the main business of green entrepreneurship, green entrepreneurs primarily open the market and improve the competitiveness of their enterprises by a forward-looking understanding of the future market and developing green products and services that will meet future demand. It can be noted that green entrepreneurship is an entrepreneurial behavior that involves the dual roles of ecological environment orientation and market orientation. From the perspective of society, green entrepreneurship, as a new way of entrepreneurship, can also be understood as a green ecological revolution carried out by an entire society to reform the original business model and improve the economic structure.“Orientation” refers to an enterprise’s strategic attitude. Regarding orientation, entrepreneurship scholars have proposed the mature concept of entrepreneurship orientation . EntreprPublic awareness of environmental protection, government policies, global standards, and other factors urge enterprises to pay attention to the green strategy . Where GBased on the competitive advantage theory, SCA refers to the enterprise can always have an advantage over its competitors. SCA enables enterprises to obtain long-term benefits, which implies creating products or services that cannot be duplicated or imitated by competitors. Some scholars find that resources and capabilities are the keys for enterprises to obtain SCA from the perspective of strategic management . In partEO emphasizes that the enterprise should consider the influence of environment in the process of strategy formulation. It is a strategic attitude at the corporate level. This strategic orientation promotes the sustainable development of the ecological environment by means of, e.g., green product development and technological ecological process reengineering . EO can Based on this reasoning, this paper proposes that GEO is a composite orientation of market-oriented and environment-oriented interaction and helps enterprises obtain higher SCA. We propose the following three hypotheses.H1: Enterprises with higher levels of MO has a positive effect on SCA.H2: Enterprises with higher levels of EO has a positive effect on SCA.H3: Enterprises with higher levels of GEO has a positive effect on SCA.The relationship between opportunities and resources is complex, but the research on them is fragmented. The introduction of the IORC helps to clarify the connection between opportunities and resources, and makes them form an “integration effect” in the process of entrepreneurship . ReviewiYin-Yang balance theory as the classification principle of ITI and ETI. This theory comes from the dialectical materialism in traditional Chinese culture. It argues that the existence and development of things include two sides: “Yin” and “Yang.” The relationship between the two is opposite and mutual. The opposite relationship is not static, but relative and dynamic. The balance between the two needs to be maintained  are selected as potential samples through the two platforms of the “Statistical Yearbook of Chinese Small and Medium-sized Enterprises” and “Big Data Platform of National Small and Medium-sized Enterprises.” Through a site visit and the original questionnaire, we explored the green entrepreneurial orientation and sustainable competitive advantage of the enterprises. Then, before the formal investigation, the questionnaire design was improved and the content validity and face validity were verified by experts. Since this study revolves around the green entrepreneurship orientation and practices, we surveyed middle or senior managers of new green enterprises, they have a more comprehensive understanding in terms of their operations. And these respondents were from cities with different levels of development, including Beijing, Shanghai, Changchun, Shenyang, Hangzhou, and Shenzhen. And they were from different industries, including software and communications, manufacturing, real estate, etc. This avoids the impact of regional economic development and industry heterogeneity on the research. During the survey, we promised them the confidentiality of the information and completed the questionnaire through a face-to-face interview. The survey started from July 2017 to June 2018, and a total of 274 valid questionnaires were collected. We revised the questionnaire regarding the suggestions of three experts  to ensure that the measurement dimension of each item in the questionnaire was scientific and clear to the respondents. The questionnaire uses a five-point scale, with “1–5” indicating “respondents strongly disapprove” to “strongly approve” respectively.GEO is an interactional composite orientation of MO and EO. MO is defined as the process by which an enterprise realizes its competitive advantage through competition and other means in the target market, reflecting information acquisition and information dissemination. According to The IORC is reflected by the synergies between ITI and ETI. ITI can be divided into the integration of opportunity creation and resource patchwork (IOCRP) and the integration of opportunity utilization and resource-matching (IOURM). According to The SCA means that the enterprise can always have an advantage over its competitors. Referring to Because the questions about independent and dependent variables were asked in the same questionnaire, there is a risk of common method bias (CMB) in the responses . To exclThe descriptive statistical results of each variable and the correlation coefficient are shown in First, in the study of the relationship between strategic orientation and competitive advantage, scholars have primarily focused on a single strategic orientation and its relationship with competitive advantage. However, few researchers have investigated the relationship between composite orientation and competitive advantage . Particu“Yin-Yang Balance” and “cultivation between internal and external” elements, systematically combining these ideas in the theory of entrepreneurship. Based on this approach, we constructed a model of IORC, which proposes that the two core elements of opportunity and resources are integrated and connected. IORC, which represents the essence of entrepreneurship, is a core competence that entrepreneurial enterprises must possess and that has innovation and research value in the field of entrepreneurship.Second, we propose and construct a core measurement system for IORC in the field of entrepreneurship, which is an absolutely novel research contribution. In the study of entrepreneurship, numerous scholars base their research on the duality theory, focusing on opportunity orientation or resource orientation . HoweverThird, the paper examines the role of IORC in the adjustment between GEO and SCA, which is not only systematic but also innovative research. In the literature, the core theory of entrepreneurship remains to be applied in green entrepreneurship. Green entrepreneurship possesses the essential characteristics of entrepreneurship, while continuing to belong to the category of entrepreneurship. In any case, a green enterprise must break through the constraints of limited resources to implement green entrepreneurship activities and obtain SCA. Relevant to our results, First, the paper proposes that GEO helps enterprises obtain SCA. Since GEO is a composite orientation, it represents the interaction between MO and EO. Therefore, the two orientations are mutually reinforcing but not exclusive, which should be noted by start-ups seeking to engage in green entrepreneurship. In the past, many enterprises have rejected green entrepreneurship in their entrepreneurial activities. Entrepreneurs have worried that activities such as green technology cultivation or the introduction and transformation of green production systems will generate more costs for their enterprises. Research has shown this concern to be unwarranted. Conversely, enterprises that have the confidence to expand their markets based on an orientation toward the natural environment and the market are more likely to gain SCA rather than enterprises with short-term strategies. Particularly, with the improvement of the market structure, the diversification of customer needs and corporate information has been continuous, and past advantages of relying on information asymmetry have proven transient. Compared with competitors who adopt composite strategies, entrepreneurship with a single orientation will still gain a competitive advantage but will inevitably fall behind or be surpassed. In addition, today, EO will increase the credibility and ethical level of the enterprise. In addition, the brand value of the enterprise will eventually increase SCA. In short, new enterprises must pay attention to the entrepreneurial process of the combination of MO and EO, which can enable startups to obtain greater SCA.Second, we propose and construct an IORC measurement system and investigate its role in green entrepreneurship and SCA. The research results have important practical value for entrepreneurial enterprises. Since such enterprises are inherently constrained by limited resources, how to break through this constraint and maximize the value of opportunities represents the core of entrepreneurship. The opportunity and resource orientations cannot be separated or opposed in this process. The two must be matched and integrated into one. The integration of the opportunity orientation and the resource orientation makes the core of entrepreneurship clear to startup ventures, that is, they must first ensure the integration of opportunities and resources. In addition, it offers enterprises a way to effectively cultivate this key capability. Moreover, empirical research shows that in the process of cultivating IORC two important dimensions of competence, ITI, and ETI, help GEO enterprises obtain SCA.Third, it necessary for the government to encourage new ventures to undertake green entrepreneurial activities. The government must support and supervise firms that engage in green entrepreneurial behavior in two ways. It should create preferential policies to favor enterprises with environmentally friendly new products, new technologies or green management models. In addition, government supervision should be implemented. Emphasis should be placed on enterprises that steal, exceed greenhouse gas emissions and produce substandard products. Particularly the governments of developing countries must improve green system standards, accelerate the speed with which green standards are adopted by society through extensive publicity efforts, or establish social norms in an informal system to promote green enterprise management. Finally, the government and relevant institutions should improve training and education for new ventures and establish training institutions to help enterprises cultivate effective IORC so that new ventures can effectively obtain SCA.Since green entrepreneurship must take both economic interest and the ecological environment into account, it is undoubtedly valuable for researchers to investigate the relationship between GEO and SCA under the dual aspects of MO and EO. Since GEO is a composite orientation and the literature does not pay much attention to it, revealing its essence and measuring it represents the most important research contribution of this paper. In addition, green entrepreneurial activities must follow the core of entrepreneurship since their essence is entrepreneurship. That is, attention must be paid to the matching and integration of opportunities and resources. Therefore, the concept of IORC proposed by this paper not only integrates the two core elements of opportunity and resource from a systemic perspective but also constructs a measurement system that includes ITI and EIT. This effort also represents a valuable contribution to the literature. Based on this approach, the project further investigates the regulatory effect of IORC on GEO and SCA. Based on our research results, we offer the following conclusions.Yin-Yang balance” and the “consideration of both internal and external” elements. This approach is used to establish a systemic perspective from which to propose the concept of IORC, which includes two sub-dimensions: ITI and EIT. This study not only compensates for a deficiency in general entrepreneurial theory but also provides a new research perspective for future research. Finally, we examine the effect of IORC on green entrepreneurship and SCA and find that both ITI and EIT increase the role of green entrepreneurship in promoting SCA. That is, enterprise IORC is of substantial significance, particularly for green startups, for which it is advisable to focus on the patching together and integration of limited resources in ITI while seeking to identify and develop green opportunities in ETI.First, both MO and EO positively promote SCA, which suggests that even a firm’s single-orientation entrepreneurial activity contributes to achieving SCA. Additionally, GEO has a positive effect on SCA, which indicates that taking both orientations into account can further increase SCA. Therefore, enterprises must pay attention to capitalizing on opportunities and market trends to continuously innovate green products, green technology, and green management mode. This composite strategy is a more valuable approach in the new economic circumstances. Next, based on entrepreneurial theory, the study breaks through the limitations of the entrepreneurial duality theory by creatively drawing on the ideas of “Although our study integrates the theories of sustainable development and entrepreneurship and reveals the importance of green entrepreneurship in today’s economy, several limitations remain. First, the sample studied in the paper consists of Chinese green start-ups. Using data from a single country makes it difficult to generalize our conclusions. Future research should expand the scope of the sample. Secondly, the IORC measurement system represents promising but immature research in the field of entrepreneurship. It is necessary to revise and perfect this theory in the future. Finally, to measure the non-financial performance indicators of SCA, we focus on the evaluation and response of customers to enterprise products. Actually, the evaluation of enterprise’s products and strategies by the other stakeholders is also very influential. In follow-up research, the validity of the theoretical model proposed in this paper must be tested for other SCA indicators.The raw data supporting the conclusions of this article will be made available by the authors, without undue reservation.Ethical review and approval was not required for the study on human participants in accordance with the local legislation and institutional requirements. The patients/participants provided their written informed consent to participate in this study. Written informed consent was obtained from the individual(s) for the publication of any potentially identifiable images or data included in this article.WL: designing. YS: writing. YG: method and revising. All authors contributed to the article and approved the submitted version.This work was supported by “The 13th Five-Year” Science and Technology Project of Jilin Provincial Department of Education (Grant No. JJKH20200136KJ).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.


Advances in systems science creates an opportunity to bring a complexity perspective to health care practices and research. While medical knowledge has greatly progressed using a reductionist and mechanistic philosophy, this approach may be limited in its capacity to manage chronic and complex illness. With its holistic foundation, naturopathy is a primary health profession with a purported alignment with a complexity perspective. As such this pilot study aimed to investigate the application of complexity science principles, strategies, and tools to primary health care using naturopathy as a case study.Gephi, a network mapping, exploration, and analysis software. Various layouts of the data were produced, and these were analysed using exploratory data analysis and computational network analysis.A network mapping and analysis of the naturopathic case management process was conducted. Mind maps were created by naturopathic practitioners to reflect their clinical conceptualisation of a common paper clinical case. These mind maps were inputed into Seven naturopathic practitioners participated in the study. In the combined network mapping, 133 unique elements and 399 links were identified. Obesity, the presenting issue in the case, was centrally located. Along with obesity, other keystone elements included: systemic inflammation, dysbiosis, diet, the liver, and mood. Each element was connected on average to 3.05 other elements, with a degree variation between one and 36. Six communities within the dataset were identified, comprising: the nervous system and mood, gastroinstetinal and dietary factors, systemic inflammation and obesity, the endocrine system and metabolism.This pilot study demonstrates that it is feasible to apply a complexity science perspective to investigating primary health care case management. This supports a shift to viewing the human organism as a complex adaptive system within primary health care settings, with implications for health care practices that are more cognisant with the treatment of chronic and complex conditions and research opportunities to capture the complex clinical reasoning processes of practitioners.The online version contains supplementary material available at 10.1186/s12906-022-03585-2. In recent decades the scientific advances of systems science , 2 has oThe study of complex systems generally arises from a desire to explore and understand real systems , and is All systems of medicine are based on a philosophical paradigm. While biomedicine is founded on reductionism and mechanism , traditithe whole is greater than the sum of its parts [The essence of complexity can be summed up by the statement: ts parts , 23. Comts parts ; systemsts parts  and theits parts  allow fots parts , 13 and,CAS, a common form of complex system, have the capacity to learn and adapt in the face of changing environments . While lwhole medicine system; a complete medical system of theory and practice that has evolved alongside or independently from biomedicine [holism and vitalism) and principles  form the basis of how naturopathy is currently taught and practiced [Naturopathy is a traditional system of medicine practiced in over 40 countries  with itsmedicine . Naturopracticed , 32.Naturopathy is philosophically consistent with complex, dynamic and extended network models , 24 baseGephi, an open source network mapping, exploration and analysis software [Gephi was used in this study to manage, visualise and analyse the data contained in the mind maps. Various layouts were implemented in order to graphically alter the presentation of the data. The network mappings created in Gephi underwent an exploratory data analysis (EDA) process, before being analysed using the mathematical and computational analysis tools of Gephi.This study was conducted as a network mapping and analysis of the naturopathic clinical case mangagement process, following the method published in Graham et al. , and an software . Gephi wEthics approval was obtained from the University of Technology, Sydney Human Research Ethics Review Committee .Gephi and various layouts were created from this dataset.Participants responded to a social media recruitment campaign conducted via professional naturopathic Facebook groups. All participants were required to hold Bachelor-level naturopathic qualifications, currently be in naturopathic clinical practice, and be a member of a professional association that accredits naturopaths in Australia. All participants were required to routinely make use of mind maps to conceptualise their patient cases as part of the health management process. Interested participants were provided with an information sheet and required to sign an informed consent form. Each participant was emailed the same paper case study, and were requested to independently create a mind map, based solely on the information contained in the case study and using their preferred process and style, and software generated or drawn by hand, depending on their preference. While the case study was fictional, it contained information which was consistent with the type of information gathered during a standard naturopathic consultation . Once crGephi: a force based attribute layout, a modularity layout, and a condensed modularity layout. These are outlined in greater detail below. Within the Gephi-generated network mappings there were two aspects depicted: edges (links) and nodes (elements). The elements were represented by circles, and the links by lines. Each element included in the network mappings was an aspect of the case study identified by one or more of the participants as being relevant to their case conceptualisation process. The links signified connection between the elements, and were representative of any form of influence or relationship between the elements as identified by the participants. In the network mappings, the links were directional; the curve of each link travelling clockwise denoting the direction of influence. The size of each element indicated the number of connections it had: the larger the element, the more connections incoming or outgoing.Three types of network mappings were created using The first layout algorithm was force based in that linked nodes attracted each other, and non-linked nodes repelled, resulting in the most connected elements clustering in the centre and those least connected being pushed to the extremities. In the force based layout, the elements identified by the participants were coloured according to five different attribute types. The attribute types were assigned by the research team and were: presenting issue, environmental influence, sign / symptom, hypothetical risk, and organ or functional sub-system Table .Table 1AGephi algorithm was implemented which decomposed the network mapping into cluster based communities. Community clustering was based on the linkage patterns within the network – densely linked elements formed cliques, while less densely elements were separated. Elements were no longer coloured according to attribute, but instead by the colour of the community of which they were a member of. The third layout created was a condensed version of the modularity mapping and was comprised only of the elements with seven or more connections, in order to generate a simpler image on which to conduct exploratory data analysis.The second layout created was based on modularity. In this graphical representation, a force based, modularity and condensed modularity) in order to generate novel information based on the relationships amongst the data and the structure of the network mapping. EDA is a method of looking at visual representations of a dataset in order to gain insights [An exploratory data analysis (EDA) approach was taken with the three different network mappings of the dataset , the shortest path between the furthest two elements in the network (diameter), the frequency an element appears on the shortest path between two elements , the level of interconnectedness within a network (average clustering co-efficient), and the capacity of the network to decompose into communities or subgroups (modularity). Table The network mappings were then analysed using various algorithms available within Seven Australian based naturopathic practitioners participated in the study. Years of experience ranged from two to 11 years, with an average of 5.43 years.The merged network mapping of the seven individual mind maps, coloured according to attribute and using a force-based layout, contained a total of 133 unique elements and 399 links , orange , pink (predominantly relating to systemic inflammation and obesity), and blue (predominantly endocrine and metabolic aspects), revealing underlying layers of structure within the network.An alternative layout based on modularity represented the community structure within the network as identified by a ted Fig. . ModularA condensed modularity mapping where all elements with six links or less were removed provided information on the most highly connected elements identified by the participants, and ‘cleaned’ the image Fig. . Thus, tEach element was connected to an average of 3.05 other elements, with variation in degree between one and 36, and a degree distribution pattern that was skewed to the left (supplementary file 2). Betweenness centrality, the frequency an element appears on the shortest path between any other pair of elements is shown on a distribution plot with a table of the elements with the highest values (supplementary file 3), and indicates the extent that an element might act as a bridge or intermediary between elements. The majority of elements appeared up to 500 times on the shortest pathway between any other pair of elements. The liver and systemic inflammation appeared between 1,000 and 2,000 times and obesity (the presenting issue), flat mood / depression and dysbiosis appeared more than 2,000 times each.Eigenvector centrality is a measure of the importance of each element, based on the number of links the element has and the number of links their connections have, measured across the network. It is a measure of ‘popularity’ indicating importance based on who their connections are linked to, and not just the immediate elements that an element is linked to. A distribution of eigenvector centrality appears in supplementary file 4. The highest eigenvector value elements in the mapping included the liver (0.39), hypertension (0.41), systemic inflammation (0.48), dysbiosis (0.60), obesity (0.68), and flat mood / depression (1).The diameter of the network was nine, indicating the parameters of the network. The average path length (the average minimum distance between any two elements) was 3.71; phrased differently there are on average 3.71 degrees of separation between the elements. The average clustering co-efficient with a possible range of zero to one is a measure of the density of the network, and in this network meausured 0.114. Therefore, in this network each element was linked on average to 11.4% of other elements in the network.Gephi modularity algorithm, six communities in total were detected in the network. These can also be seen visually in the modularity mapping. Within a community, there is increased interactional potential with possible structural aspects of the network revealed. The size distribution of the communities ranged from 12 to 33 elements. The modularity score of this network was high at 0.40, indicating a decidedly connected internal structure with a high density of internal connections inside communities, measured against the links between communities, as compared with a low modularity score which would indicate clusters that were more disparate.Using the Gephi allows this process to be scaled up so that in addition to exploring a single case presentation as demonstrated here, multiple cases could be simultaneously explored to more thoroughly investigate a condition or pattern of symptoms, or even to create a more comprehensive mapping of the human organism. According to Newman [This study demonstrates that it is viable to graph clinicians’ reasoning of a primary healthcare case in the form of a network mapping, and to identify and examine its structural characteristics using exploratory data analysis and network analysis tools. In doing so, clinical reasoning is made overt enabling it to be examined by both researchers and clinicians; this novel depiction potentially enables new knowledge and insights. The application of a complexity science perspective to clinical management also supports paradigmatic integration, facilitating the assimilation of reductionist and holistic philosophies. This may expediate a shift in clinician thinking from linear, mechanistic and reductionist to one cognisant of the human organism as a complex adaptive system (CAS) while retaining the knowledge gains afforded by a reductionist and mechanistic approach. Software such as o Newman , the firA complexity science perspective potentially enables innovative insights to emerge regarding the primary causality of the condition, perpetuating factors, potential future risks, and prospective individualised treatment targets. In this study, particular elements were identified as being keystones due to the centrality of their position in the force based mapping, the importance of their connections, the value of their mediary positions, and their size relative to other elements. These keystone elements are not just integral to the case presentation, they are potential leverage points within the CAS on which to focus treatment efforts in order to initiate the most positive outcomes. Additionally, the directional connections existing between elements may be traced back, resulting in insights regarding causative and perpetuating factors of a presentation. Depending on individual factors, these may constitute health disturbing triggers best removed or the existence of modifiable treatment targets that when altered will potentially more profoundly resolve the presenting condition as compared with that afforded by specific linear treatment targeting an overt population generalisable symptomotology. Additionally, the presence of multiple linked elements may alert the clinician to the existence of potentially problematic sub-clinical disease processes in action. A systems approach creates the possibility for treatment to be tailored to the individual, causative rather than reactive, and more profound by encompassing the entire human organism in its scope. While this study has focused on incorporating a systems science perspective within primary health care, it may be applicable to any setting that is engaged with managing and supporting human health.While linear systems in nature are rare , the redHealth management is a sophisticated and multifaceted task given the complexity of the human organism, the influence of environmental factors on health, and the prevalence of chronic illness, comorbidities, and polypharmacy. Clinicians are sifting and evaluating vast amounts of intricate information, and the efficacy and safety of healthcare is largely dependent upon this process. Evidence based practice (EBP) is founded on patient values, best available evidence, and clinician expertise , 46. OoiIn addition to supporting clinical processes, a network mapping and analysis approach may enable clinical reasoning and practices to be made more explicit for the benefit of the research community. Links made by practitioners between different elements of a patient presentation may be made overt and therefore more amenable to analysis and investigation, increasing scientific research opportunities within the field. Additionally, this facilitates an exploration of the alignment between clinical reasoning and current research, with gaps identified and investigated, and potentially exposes clinician blindspots and biases. Further research based on clinical network mappings may also supplement knowledge of individual conditions, enable exploration of the systematic patterns of chronic conditions, and increase understanding of the symptoms and causative factors common across conditions. Causative chains may also be defined, leading to knowledge advancements in disease prevention and health promotion. While contemporary biomedical research is founded on the concept of identifying a specific treatment for a specific symptom of disease  and randThis paper is limited in that the mind maps created by the participants were constrained by the information contained within the paper case study. While the case study was detailed, it did not replicate the extent of information that typically would be gathered within an initial naturopathic consultation. Also, the combined mapping was generated using mind maps provided by seven naturopaths. While this provides preliminary insight into how complexity tools and strategies might be utilised within the clinical setting, it does not provide a definitive understanding of this process. At best this data could be considered indicative rather than representative, although it was deemed sufficient for the purpose of an introductory exploration of the alignment between clinical health management and complexity science. While naturopathy was chosen for this initial exploratory study due to its stated philosophical and practice framework aligning with complexity science, it is unknown how useful this methodology may be for other health professions without first testing it within these populations, suggesting a possible future avenue for research of this nature.While this is an preliminary demonstration of the use complexity tools to investigate the clinical management of a patient case, it is possible that with further use and development new insights will emerge that will improve healthcare practices and treatment outcomes. Medicine has gained considerable ground in viewing the human organism as being composed of discrete components, distinct functional systems, and organised in linear causal chains. The next stage of development may be to explore, understand and relate to the human organism as a complex system, embedded within larger complex systems, and with multiple smaller systems nested within. This complexity perspective does not need to occur at the expense of reductionist knowledge and understanding, but rather allows the potential for the integration of both. The value of network mapping and analysis is to deepen the understanding of the network being explored; a complexity perspective of health and the human organism offers potential benefits for both clinical practitioners and researchers. The findings of this study highlight the clinical reasoning underpinning the management of a case, and potentially offers insights into clinician knowledge and expertise that could tested against current research as well as used to inform future research.Additional file 1.Additional file 2.Additional file 3.Additional file 4.


Background: Internet use, which provides the opportunity to access information from anywhere, and anytime, is increasing among adolescents and young adults. In studies examining the effect of technology use in adults, it has been observed that there is a relationship between cyberchondria and vaccine hesitancy. This study aimed to uncover the potential relationship between cyberchondria and vaccine hesitancy in adolescents and to obtain data for combating anti-vaccination in this age group.Materials and methods: A total of 2.353 high school students were enrolled within the scope of this research. The forms were delivered to the students online and 531 volunteers participated in the survey. The Cyberchondria Severity Scale and Vaccine Hesitancy Scale were used to evaluate the details of the relationship between cyberchondria and vaccine hesitancy levels in adolescents.Results: The compulsion subscales of the Cyberchondria Severity Scale in males and vaccine repugnance subscales of the Vaccine Hesitancy Scale in females were statistically significantly higher. Cyberchondria and vaccine hesitancy have a strong relationship with each other except benefits and protective value of vaccines subscale of vaccine hesitancy.Conclusion: Health policymakers should be aware of this relationship and there is a need to develop novel online intervention programs for combating anti-vaccination, particularly among cyberchondriac adolescents who have relatively high vaccination hesitancy, particularly during the pandemic. The 21st century can be summarized as a time period where dramatic progress has been achieved in curing diseases and developing innovative treatment methods, as well as enhancing preventive healthcare all over the globe [The change in the lifestyle of individuals along with digitalization also changed individuals' behavioral attributes to search for any kind of knowledge. Although technology serves as a useful tool to access data, some people generate excessive distress and anxiety about their health through it . AnxietyPeople and groups who claim that vaccines are unnecessary and even harmful cause confusion in society about the efficacy and side effects of vaccines by citing different reasons. These individuals are said to have 'vaccine hesitancy' . While hThe administration of COVID-19 vaccines to adolescents requires obtaining their consent and this became a major issue during the pandemic period. As these individuals will be caregivers and decide on the vaccinations of their children in the future, it is important to impose scientific insight and evaluate their ideas. Additionally, they should have an understanding of the importance of protecting public health. To our knowledge, there is no study in the literature about the possible relationship between cyberchondria and vaccine hesitancy in adolescents. Within the scope of this research, we aimed to elucidate the link between cyberchondria and vaccine hesitancy in adolescents to obtain data for combating anti-vaccination in this age group.Adolescents in selected schools in İzmir, Turkey, between April and May 2022 were included in this study. Cyberchondria Severity Scale (CSS) and Vaccine Hesitancy Scale (VHS) were used to evaluate the relationship between cyberchondria and vaccination hesitancy in adolescents. In addition to the scales, the grade and gender of the adolescents were recorded. Approval for this study was granted by the University of Health Sciences, Tepecik Training and Research Hospital Non-Interventional Research Ethics Committee  and the Directorate of National Education  in high school students.The stratified cluster method was utilized in the selection of the sample population, and the 'school' was used as the sample unit. The power analysis was calculated with a 95% confidence interval (CI), 80% power, and 2% error acceptance, and the overall study population was determined as 2353 students. The questionnaire was applied via draw methodology. Care was taken to have at least one general high school and one vocational high school from each district. A questionnaire was applied to all students who were present on the day of the application and participated in the research voluntarily. Students were informed in advance about the scales and confidentiality. A total of 2.588 high school students in İzmir were invited to participate within the scope of this research. The forms were delivered to the students via the internet and 586 volunteer adolescents accepted to participate in the study and incomplete responders were excluded from the study. Finally, of 586 respondents, 531 were valid (20.5% response rate).The CSS was defined as a form of anxiety characterized by excessive health research on the Internet by McElroy and Shevlin in 2014, and its Turkish validity and reliability were provided by Uzun and Zencir in 2016. There are 33 questions consisting of a five-point Likert scale . The scale consists of five subscales: (i) compulsion, (ii) distress, (iii) excessiveness, (iv) reassurance, and (v) mistrust of medical professionals. The distrust of doctor subscale is scored inversely. The CSS is not a categorical but a continuous scale and has no cut-off point. The CSS items can be summed to form a total score. The higher scores indicate higher levels of cyberchondria  ,12.The VHS was developed by Kılınçarslan et al. in 2020. There are 12 questions consisting of a five-point Likert scale. It has three subscales: (i) benefits and protective value of vaccines, (ii) vaccine repugnance, and (iii) solutions for non-vaccination. The benefits and protective value of vaccine factor items are reverse scored because they consist of statements in favor of the vaccine. Thus, this subscale has also a meaning that higher scores indicate greater vaccine hesitancy. There is no calculated cut-off value. The VHS items can be summed to form a total score. The higher scores indicate higher levels of vaccine hesitancy  .The CSS and VHS scores were examined regarding the grade and gender of the students.Statistical analysisData were evaluated in the IBM SPSS Statistics for Windows, Version 25.0  statistical package program. Gender distribution and class distribution were given as values and percentages. CSS and VHS scale scores were evaluated with median and standard deviation. Cases were grouped according to these factors and categorical data were compared with Student’s t-test and Chi-square. The relationship between CSS and VHS scores controlling for grade and gender was evaluated by partial correlation coefficient. Pearson correlation was used for the relationship between the scale scores. A p-value <0.05 was considered statistically significant.The sample consisted of 216 (40.7%) male and 315 (59.3%) female students. The gender and class distribution are shown in Table Regarding gender, the compulsion subscale of CSS in males and the vaccine repugnance subscale of VHS in females were statistically significantly higher. The comparison of VHS and CSS scores according to gender is shown in Table When the bivariate correlations between CSS and VHS were evaluated, it was observed that total and subscale scores of cyberchondria and vaccination hesitancy generally have a strong relationship with each other. The only exception was between the benefits and protective value of the vaccines subscale of VHS and cyberchondria. The details of the correlation analysis are presented in Table The mass misinformation through online platforms about health issues is one of the most crucial public health problems of the present century and there is limited data about this subject in the literature ,15. ThisThe gender distribution among the volunteer students was similar; however, the class was not homogenous. In our country, the education period is between September and June, and the fourth graders of high school should study more in the last days for the university entrance exam. Due to this, they were not inclined enough to volunteer for this study.The general vaccine hesitancy, the benefits and protective value of vaccines, and solutions for non-vaccination were not significantly different in terms of gender. However, vaccine repugnance was higher among female students than males. With the pandemic, the anti-vaccination attitude was expected to decrease; on the contrary, vaccine hesitation has been re-discussed ,17. UnfoIn terms of gender, the general cyberchondria score and the subscales of distress, excessiveness, reassurance, and mistrust of medical professionals did not show any significant difference. It has been reported that females with higher cyberchondria scores searched for health information more on the internet and felt more anxious than males as females not only feared for themselves but also for their families and friends ,20. In aWe observed a strong relationship between cyberchondria and the total score of vaccine hesitancy, subscales, vaccine repugnance, and solutions for non-vaccination. In many studies, it has been shown that the internet was among the determining factors in the decisions of vaccination ,21. We aWhile there was a strong correlation between cyberchondria and anti-vaccine total and subscale scores, there were findings that need to be discussed in detail. Although a strong relationship was observed between the reassurance subscale and all subscales of vaccine hesitancy, there was no positive relationship between reassurance and the total score of vaccine hesitancy. The reassurance subscale dimension means a request to consult health professionals after desktop research on the internet in patients with cyberchondria. In addition, it was observed that individuals who were hesitant about vaccination admitted that they could not get sufficient information either from the health professions or that the ministry of health did not provide sufficient information ,27. TherLimitations and strengthsThe results of this study should be interpreted with some limitations. First, the cross-sectional design of this study may have damaged the ability to detect direct causal relationships between the scales. Second, the data was obtained on self-reporting instruments, which may be subject to bias. Third, the contents of the websites that the students checked were not questioned. For this reason, the relation of the contents on the high vaccine repugnance in girls could not be evaluated. Despite these limitations, this is one of few studies to evaluate vaccine hesitancy and cyberchondria in adolescents with highly validated instruments.Our findings elucidated an association between vaccine hesitancy and cyberchondria in adolescents. Considering the potential danger of cyberchondria spreading through nonevidence-based rumors, especially during the pandemic, health literacy should be improved and vaccine hesitancy precautions should be taken. By drawing on the findings of the current study and leveraging the power of online media, health policymakers should focus not only on the topic but also on paying more attention to the content to reduce antivaccine misinformation. Future studies should focus on the content of websites that cyberchondriac adolescents frequent or indulge in. Health professionals also have an important role in this regard and they should take responsibility for the success of the mass vaccination program.


The elderly population in China is expected to exceed 300 million and enter the stage of moderate aging during the 14th Five-Year plan period from 2021 to 2025. From the sustainable development perspective of elderly care enterprises, the supply of elderly care services would be unsustainable if enterprises suffer long-term losses. In the latter pursuit of high profits, the burden on consumers will increase. Equity financing of these enterprises is the key to achieving high-quality transformation and development by considering economic and social benefits. This study considers 20 well-known China-based elderly care enterprises as the research object. It uses a fuzzy set to explore system logic, operation mode, management performance, and attitude of elderly care enterprises toward investment through the qualitative comparative analysis method. The causal relationship between them is clarified—because, before the endowment enterprise equity financing intention of China, it is important to explore the effective path of equity financing of endowment enterprises. In the past, this helped Chinese elderly care enterprises actively cope with the trend of population aging, meet the needs of diversified and multi-level elderly care services, establish a sustainable development mode, and achieve high-quality transformation and development. The results show that ( China had 267.36 million people aged 60 years and older in 2021, accounting for 18.9% of the population of the country. The Ministry of Human Resources and Social Security has predicted that during the 14th five-year plan period, the elderly population of China will exceed 300 million and enter the stage of moderate aging. Currently, the social scale of the aging population of China is large, the speed of aging is fast, and the endowment of urban and rural development is unbalanced. State Assets Report found that development of the elderly care industry in China lags behind the aging trend and the aging population market demand. Therefore, the elderly care industry must take the development path of scale, chain, and informatization.From the sustainable development perspective of elderly care enterprises, the supply of elderly care services will be unsustainable if enterprises suffer long-term losses. The burden on consumers will increase if these enterprises continue pursuing high profits. The equity financing intention of enterprises is the key to achieving high-quality transformation and development by considering economic and social benefits. The system logic of elderly care enterprise development includes business and social welfare logic, that is, its pursuit of economic and social benefits.In particular, Pache and Santos  pointed Driven by different sets of institutional logic, elderly care enterprises choose different operation modes, such as wholly owned self-funding, cooperative investment, and crowdfunding modes. The system logic and business model will affect elderly care enterprise business performance and determine their equity financing intention.The problem of the aging population is becoming increasingly severe. The standardization, scale, and expanding chain of elderly care enterprises need a large amount of capital support to improve the elderly care service supply system , 6. ExisIt would be helpful for Chinese elderly care enterprises to respond actively to this aging trend. It would enable them to meet the diversified and multi-level demand for elderly care services, establish a sustainable development mode, and realize high-quality transformation and development by clarifying the esthetics of equity financing intention and exploring an effective path of equity financing.Therefore, this study considers 20 well-known endowment enterprises as the research object and uses a fuzzy qualitative comparative analysis method to explore the causal relationship among system logic, operation mode, management performance, and elderly care business attitude to investment. It is expected to introduce suitable investors for pension enterprises in Hebei Province, steadily expand the enterprise scale, and improve the supply system and their quality of service. This can effectively meet the diversified and multi-level needs of elderly care services and provide them with a theoretical basis and decision-making reference.The service mode of elderly care enterprises includes institutional, community, and home elderly care services. The operation mode of elderly care enterprises can be divided into wholly-owned self-financing, cooperative investment, real estate investment trust (REIT), trust investment, and build–operate–transfer (BOT) modes. The wholly owned self-financing mode mainly refers to the operation of elderly care enterprises that expands their funds through existing funds or other financing channels . The pubThere are three sets of system logic for social enterprises in China: business, social welfare, and government logic . Social Capital is profit-driven. The appeal of self-interest may also push the focus of external investment too much on its short-term benefits. External investment can provide external resources for elderly care enterprises. From the concrete influence mechanism, external investment can provide enterprises with direct capital flow, indirect information flow, and technology flow. First, capital flow provision is a direct mechanism for venture capital to help elderly care enterprises. Start-up elderly care enterprises have uncertain profit prospects, insufficient collateral, and an unstable profit flow, which make it difficult to obtain indirect financing from banks, thereby causing difficulties in carrying out elderly care services. Investment institutions have professional experience in project management and market demand. They can provide enterprises with technical resources oriented to project operation, management, and development. This can reduce the management cost of enterprises to a certain extent . The behCorporate earnings may also influence the attitude of an endowment enterprise toward investment. The investor is bound to the enterprise management concept and management pattern question if a loss-making state investment introduces the endowment enterprise. Under the trend of short-term profit goals, investors are likely to reduce reversed transmission endowment enterprise long-term strategic investment to give up for service to mid-level income of the elderly. However, the low-margin business is at odds with the social consciousness of elderly care companies , 14. BasThe study selected 20 elderly care enterprises involved in the interview program of the founder of a well-known elderly care enterprise. Respect the elderly in your family as well as the elderly of other families. As the aging trend is increasingly obvious, the demand for elderly care is gradually increasing, and a well-known old-age care dialogue program came into being. We-Media elderly care dialogue program, jointly created by a well-known health newspaper and senior scholars in health and elderly care, is the first large-scale program in China. From 2017 to 2020, the program was conducted to interview 30 elderly care enterprises. The study dealt with the equity financing intention of the founders of elderly care enterprises. After evaluating the interview data of all 30 programs, the researcher selected 20 elderly care companies whose interview content involved the founder's intention of equity financing as the research object. The 10 elderly care companies whose other interview content did not involve relevant topics were not selected. The program interview video, the official website of related elderly care companies, and the news were the sources of information. The research framework is shown in The method of data coding and qualitative comparative analysis of fuzzy sets was used to study the causal relationship between variables. This study follows the data analysis procedures recommended by Strauss and Corbin  to carryFirst, a coding team was set up. To avoid the influence of researchers' subjective bias on coding and to reduce error in research results, one author from the financial management department was selected as the group leader; two authors from the technical economy and management and strategic management departments formed the coding team. The group leader provided theoretical and technical training for the other two group members. Subsequently, each was responsible for the trial coding of a case object. They discussed results to find problems in the coding process and recommended solutions. Consequently, the team members did the coding work on the case objects. They discussed their contrary opinions until the coding results were consistent.Second, a coding database was built. Excel was used to create a form for each case object to record the detailed coding process. The modification steps in the process were recorded.Finally, the qualitative comparative analysis of fuzzy sets was divided into three steps. The first found the correspondence between the vector space angle defined by the fuzzy set and rows in the truth table. The second was to evaluate the distribution of cases in various combinations of conditions. The third was to evaluate the consistency of the result's fuzzy subset.This study followed the research of Rihoux and Ragin  to conduFrom their operating mode, there are two ways to realize profits for elderly care enterprises. The first path shows that the operating mode is only for private enterprises, which is the path for these enterprises to achieve profitability. This path is relatively consistent and explains most cases . The second path shows that the operating mode is only a crowdfunding model, which is another path for these enterprises to achieve profitability. The consistency of this path is higher than that of the previous path (consistency = 0.86), but the number of cases explained was smaller (coverage ratio = 0.11). The consistency of the entire solution is 0.76, and the coverage rate is 0.81, which is satisfactory.From the institutional logic perspective of elderly care enterprises, there is only one way to realize profits for elderly care enterprises. This path shows that social welfare logic is the path for elderly care enterprises to achieve profitability. The consistency of the entire solution is 1, and the coverage rate is 0.85, which explains several cases where elderly care enterprises are profitable, which is satisfactory.When the elderly care enterprises' operating mode was a private enterprise and/or public construction and private operation, the effects of institutional logic, operating mode, and performance of the elderly care enterprises on their equity financing intention were investigated. It was found that there were three implementation paths of the elderly care enterprises' active equity financing intention. The first path showed that the elderly care enterprises were driven by commercial logic and that they were in a profitable state. At the same time, their operating mode was not public construction and private operation. These three conditions were the path for elderly care enterprises to actively seek equity financing intention. This path was relatively consistent and explained most cases of active equity financing intention of elderly care enterprises . The second path showed that these enterprises were driven by high commercial and low social welfare logic and that they were in a profitable state. At the same time, the operating mode of the elderly care enterprises was a private enterprise. These four conditions existed at the same time because the elderly care enterprises actively had equity financing intention. The consistency of this path was higher than that of the previous path (consistency = 0.83), but the number of cases explained was relatively small (coverage ratio = 0.33). The third path showed that the elderly care enterprises were driven by low commercial and high social welfare logic. The operating mode was public construction and private operation, rather than private enterprise, and their performance was poor. This was the path for such enterprises for active equity financing intention. The agreement was high (consistency = 0.77), but only a few cases were explained (coverage = 0.07). The consistency of the whole solution was 0.87 and the coverage was 0.81, which was satisfactory.When the operating mode of elderly care enterprises was crowdfunding, the influence of their institutional logic, operating mode, and performance on the equity financing intention was investigated. It was found that there were two ways to realize the active equity financing intention of the elderly care enterprises. The first path showed that such enterprises were driven by high commercial and low social welfare logic and that they were profitable. These three conditions were the path for elderly care enterprises for active equity financing intention. This path was relatively consistent and explained some cases of active equity financing intentions of elderly care enterprises . The second path showed that such enterprises were driven by commercial logic and that they were in a profitable state. At the same time, their operating mode was crowdfunding. These three conditions were the path for the elderly care enterprises to have active equity financing intention. The consistency of this path was higher than that of the previous path (consistency = 0.1), but the number of cases explained was smaller (coverage ratio = 0.13). The consistency of the whole solution was 0.46 and the coverage 0.875, which was quite satisfactory.The schemes and paths for equity financing intention of elderly care enterprises are shown in When the operating mode of elderly care enterprises was private enterprise and/or public construction and private operation, it was found that there were three implementation paths of active equity financing intention of elderly care enterprises. When the operating mode of elderly care enterprises was crowdfunding, it was found that there were two ways to realize the active equity financing intention of the elderly care enterprises.This study explored the public construction and private operation of elderly care enterprises. Previous studies have mostly discussed for-profit and non-profit nursing homes .Regarding the impact of the operating mode on the performance of elderly care enterprises, the solution showed that non-public construction and private operation were necessary conditions for the profitability of elderly care enterprises.Regarding the impact of institutional logic on the performance of elderly care enterprises, social welfare logic was necessary for the profitability of elderly care enterprises.When the operating mode of elderly care enterprises was private enterprise and/or public construction and private operation, under the combined effect of institutional logic, operating mode, and performance of the elderly care enterprises on its equity financing intention, and if the influence of individual cases in path 3 was excluded, the effect was large. In most cases, commercial logic was a necessary condition for such enterprises to have active equity financing intention. In addition, high performance was also a necessary condition for elderly care enterprises to have active equity financing intention. Low social welfare logic was a sufficient condition  for elderly care enterprises to have active equity financing intention. The operating mode as a private enterprise was a sufficient condition  for elderly care enterprises to have active equity financing intention. At the same time, the operating mode as non-public construction and private operation was a sufficient condition  for elderly care enterprises to have active equity financing intention.Based on the relationship between business performance and equity financing intention, for-profit organizations can attract private investors, such as private equity firms, because they can pay dividends. By contrast, non-profit organizations rely on financial means such as loans, donations, or grants .As per Bos et al. , most foLike the Netherlands, Sweden, Norway, Canada, the United Kingdom, the United States, and other European and American countries, in China, the for-profit nursing home industry has witnessed significant growth in recent years . It is eBos et al.  found thWhen the operating mode of the elderly care enterprises was crowdfunding, institutional logic, operating mode, and the performance of these enterprises had a combined effect on their equity financing intention. Commercial logic was necessary for the elderly care enterprises' active equity financing intention. In addition, high performance was a necessary condition. Low social welfare logic was a necessary condition for equity financing intention, a sufficient condition  for elderly care enterprises to have equity financing intention. Crowdfunding for operating mode was a sufficient condition  for elderly care enterprises to have an active equity financing intention.According to the discussion, the following conclusions can be drawn:(1) Elderly care enterprises under the public construction and private operation mode perform poorly.The elderly care model of “public construction and private operation” refers to the government-funded infrastructure for elderly care institutions, where bidding is used to allow social organizations or service groups to perform specific management operations. It is important to note that even if non-governmental organizations or enterprises are introduced for management and operation, “public construction and private operation” elderly care institutions still cannot be profit-making. They must reflect welfare and social welfare in the price and eligibility of accommodation and housing. The subjects are mainly elderly people with difficulties in life. At the same time, the ownership of “public construction and private operation” elderly care institutions still belongs to the government. Consequently, they must accept the supervision and management of the government civil affairs department.“Public construction and private operation” elderly care institutions must be social welfare and commercial to ensure their long-term sustainable development. It is appropriate to allow “public construction and private operation” elderly care institutions to maintain meager profits and, at the same time, strengthen policy incentives to enhance the institutions' economic strength and service capabilities. This is conducive to promoting the healthy and rapid development of “public construction and private operation“ elderly care institutions to meet more disadvantaged needs of elderly care services.(2) Elderly care enterprises driven by social welfare logic are more likely to obtain higher performance.In this case, most profitable elderly care enterprises focused on serving the disabled and elderly people and on the mid-end elderly care market, operating at a meager profit of 10–15%. Their feelings, that is, the social welfare logic of operating elderly care enterprises were mostly prompted by their past or current life events. Driven by social welfare logic, elderly care enterprises establish a good reputation. With word of mouth from the elderly and their families, the occupancy rate of senior care companies is relatively high, and the occupancy rate is an important guarantee for their profitability with meager profits.(3) Elderly care enterprises driven by commercial logic are more willing to equity financing intention when they have already achieved profits.In this case, the elderly care enterprises driven only by social welfare logic had very low-profit margins, and some were even in a state of loss. Under the guidance of the profit-seeking nature of capital, external investors have good business acumen and know ways to achieve profitability if external investment is introduced. It is likely to conflict with the founders of elderly care enterprises. This may be the reason why elderly care enterprises driven only by social welfare logic are unwilling to have the equity financing intention. Elderly care enterprises driven only by commercial logic, that is, driven by seeking profits, are more willing to introduce external investment and earn more profits with the help from investors. These enterprises are driven by commercial and social welfare logic. They may refuse external investment to realize their social welfare value if they are in a state of loss. At the same time, elderly care enterprises that have achieved profits are more willing to introduce capital, to be driven by capital and large-scale operations to provide high-quality services for the elderly.First, the study used secondary data. Second, the study sample size was small. Future studies can increase the case enterprise, and they can bring endowment enterprise by looking into for-profit and non-profit enterprises and comparing the quality of care of the two. Finally, future research can add the endowment enterprise service model and investors' decision-making variables, such as vision, and explore its influence on the investment attitude of elderly care enterprises.The original contributions presented in the study are included in the article/supplementary materials, further inquiries can be directed to the corresponding author/s.YZ was responsible for manuscript writing. XZ was responsible for conceptualization. DW was responsible for formal analysis, and all of us were jointly responsible for the data coding. All authors contributed to the article and approved the submitted version.The study supported by Hebei Natural Science Foundation (G2022210003) and Humanities, Social Science Research Projects of Colleges and Universities in Hebei Province (SQ2021162), and Humanities and Social Science Research Project of Colleges and Universities in Hebei Province (SQ201025).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 Japan, medical education and training are the combined responsibility of two ministries namely Ministry of Education, Culture, Sports, Science and Technology, and the Ministry of Health, Labor and Welfare. The medical education system underwent a major transformation in August 2021 making it a seamless clinical education blending pre-graduation and post-graduation training. Not all universities offer rehabilitation medicine curriculum. Furthermore, where rehabilitation medicine is taught, the curriculum content is not standardized. All medical students sit for a common national medical practitioner qualifying examination. However, only a few questions on Rehabilitation Medicine are included. The personal experience of the author's teachings in rehabilitation medicine at Saga University medical school is described. Emphasis is placed on experiential learning on subjects that are current and state-of-the-art in Japan including robotics. It is aimed at promoting inspired motivation for the students to pursue specialized training in rehabilitation medicine. Japan can take lessons from the European Union's white book on Physical Medicine and Rehabilitation as well as the International Society of Physical and Rehabilitation Medicine core curriculum. In addition, the Rehabilitation Medicine education system can be further improved through a well-coordinated preclinical and clinical medical education. There is also a need to expand the rehabilitation medicine field and address the gaps with other specialties. The objective of this paper is to describe the Japanese medical school education system highlighting the rehabilitation medicine component at undergraduate and postgraduate levels.Since its early beginnings in 2021, medical education has undergone transformation toward meeting the needs of the Japanese population. It has been common practice that high school graduates can pursue medical studies which conventionally consists of 6 years of medical education governed by the Ministry of Education, Culture, Sports, Science and Technology (MEXT). An internship of 2 years follows, and this is under the governance of Ministry of Health, Labor, and Welfare. Specialty education (residency) is then continued under the latter ministry and lasts for 3–5 years depending on the specialty. For Rehabilitation Medicine, the residency training is 3 years. All doctors are then expected to continue with lifelong education.The August 2021 revised Up till now, many medical schools throughout Japan have offer rehabilitation medicine courses, but the curriculum content is not standardized. Some offer up to 20 h, while others just offer a few hours of rehabilitation medicine teaching.Numerous universities offer only a few days of rehabilitation clinical training in clinical clerkship. Furthermore, the National Medical Practitioners Qualifying Examination has included only a few questions related to rehabilitation medicine.Only 2 to 3% of interns learn about rehabilitation medicine through their respective postings. This indicates that most of them are not exposed to rehabilitation medicine, hence very few interns venture into that field. Those who intend to make rehabilitation medicine their specialty have to learn the majority of their practice during the 3 years of residency. But there are far too few instructors in that sector of medical education.Rehabilitation medicine is a unique field that focuses on activities. It needs to meet the major demands placed upon it in recent years by Japan's aging society. The average lifespan in 2020 was 81.64 years for males and 87.74 years for femalesWhen one examines trends in occupations in rehabilitation in Japan, one notes that physical therapy and occupational therapy came under national licensing status in 1965. Speech-language-hearing therapists came under national licensing status in 1997. These professionals took responsibility for highly specialized forms of rehabilitative medical care for children and disaster victims with disabilities. The acceleration in the number of older persons in the 2000s resulted in the increase of the total number of therapists by 8.7 times, from 32,400 in 1998 to 282,400 in 2018.The specialization system for physiatrists (rehabilitation physicians) started in 1980 as one of 18 clinical specialties. Although the number of physiatrists showed an upward trend, in 2019 there were just 2,531, i.e., only 1.3% of specialists in all fields With regards to healthcare services covered by the medical insurance system, rehabilitation fees account for only 5% of all medical costs , 4. In tThe author has been passionate about and has dedicated herself to medical education, clinical practice, and research at both universities and university hospitals since her graduation in 1984. Education is the cornerstone of the sustainable development of rehabilitation medicine and standards . For theJapanese rehabilitation medicine education demands that students learn a great deal, and exemplary services and research have emerged amongst the crème de la crème of the specialty. At Saga University there are only two rehabilitation medicine instructors for both the pre- and post-graduate levels. Medical School classes are small. The two are also responsible for engaging approximately 3,000 patients per year. In addition, they are responsible for handling approximately 28,000 physical therapy, 10,000 occupational therapy and 7,000 speech-language-hearing therapy cases per year.In spite of lack of academic resources and overwhelming workload in clinical practice, research, and education, the author has attempted to provide “handmade” medical education. One is through clinical education with the use of rehabilitation robotics, including virtual reality (VR) and myoelectric prosthetic hands. These are among the most advanced medical devices that can stimulate the curiosity of young people  6). At . At 6). The August 2021 landmark initiative taken by two distinct Ministries responsible for churning out medical specialists is promising. It brings Japan closer to the current practice in Europe that evolved out of the sheer need for standardization for the European Union where medical positions among countries is seamless. Japan's Ministry of Education, Culture, Sports, Science and Technology (MEXT) along with its partner Ministry of Health, Labor, and Welfare can take lessons from this (?) years of collaborative work amongst member countries The European Union's white book on Physical Medicine and Rehabilitation and the International Society of Physical and Rehabilitation Medicine (ISPRM) core curriculum can provide an excellent insight to an educational and clinical framework (refs?). However, it is necessary to keep in mind that clinical practice is not a pure science and that it is a system that comprises many kinds of wisdom, including skills that have been developed over a long history of tinkering. Thus, clinical education should not be just school education or just apprenticeship, but rather it needs to be both.Motivation is an important element in educational success . CuriosiHighlighting the rehabilitation medicine component at undergraduate and postgraduate levels of the Japanese medical school education system has revealed the shortcomings of clinical education in Japanese medical education. In order to solve this problem advances must be made in coordinating pre-clinical medical education and clinical clerkship. In the field of rehabilitation medicine education, there is a need to solve specific problems related to coordination with pre-clinical medical education while keeping in mind effective clinical clerkship education. In the meantime, there is a need to expand the field and address the gap compared to other specialties. What is necessary when doing this is not to disregard the inspired motivation of apprenticeship that promotes sufficient motivation and curiosity.The raw data supporting the conclusions of this article will be made available by the authors, without undue reservation.The author confirms being the sole contributor of this work and has approved it for publication.The author declares 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.


Two and a half years later, SARS-CoV-2 continues to infect millions of people and has taken the lives of at least 6 million people worldwide.3 The COVID-19 outbreak brought along social isolation and feelings of uncertainty to everyone around the world, including doctorate students.5 Ironically, our projects have been more relevant than ever, as the pandemic has highlighted the important relationship between age-related changes in hematopoiesis and disease severity. Below, we aim to discuss the timeline of the ARCH project throughout the pandemic and how we managed to courageously pull through the hardships of doing research during a global pandemic within different settings (academia/institutes and industry). We provide recommendations to future PhD students on how to manage their PhD projects during global emergencies.We are 15 PhD students funded by this network, based around Europe, and our common aim is to understand functional changes in the hematopoietic system with age, how these changes link to the development of age-associated diseases and in parallel work towards the development of new treatments.9 or planning experiments for when we would eventually return to work. By summer 2020, many of us began to slowly get back to the laboratory in shifts or for a limited time to avoid overcrowding of spaces. Times were still uncertain and the pandemic was of great concern to the global scientific community. With the whole world waiting for vaccine developments to stop the pandemic, our slow training process commenced. However, by fall, new lockdown measures were set against a new surge of infections and deaths .