This article investigates the practice of female genital mutilation (FGM) as a long-held custom in Qeshm Island, which makes many African-descended women face different physical and psychological health problems.To investigate the prevalence of female genital mutilation in Qeshm Island and the traditional mode of thinking of Afro-Iranian people of the Island about this practice.This study is based on the descriptive analysis method. The questions of the study are (a) Why female genital mutilation is still practiced in Qeshm Island; (b) What are the mental and physical effects of female genital mutilation on women; and (c) How government or NGOs are fighting against this tradition.This article has found out that female genital mutilation resulted in many lifelong diseases and sexual degradation in African-descended women of Qeshm Island. This article also illustrates that the best way to combat this wrong tradition is to inform people by gradual training without any insult to their beliefs.This study reveals the prevalence of a false tradition and the necessity of behavioral change. In doing so, the government and NGOs' strong actions and attracting the support of the community elders are also needed. Female genital mutilation, sometimes called “Female Cutting” or “Female Genital Cutting” Generally speaking, FGM is cutting part of the female genital, usually without any sanity FGM carry out on young girls between ages 1 to 9 in countries where it is practiced Iran is one of the Asian countries where FGM is practiced. 20This Island has significant ethnic diversity, and in addition to indigenous Iranians, some of the African descent people live there. The arrival of Africans from East and Southeast Africa to Iran dates back to three centuries ago, mainly during the eighteenth and nineteenth centuries. Africans were brought as slaves. 23Since FGM is an integral part of the African descent community's traditions in Qeshm Island - who have preserved the tradition- this small community is chosen as the case study for this research. This paper takes to investigate this tradition among the African-descent community in Qeshm and its current practice implications. The main hypothesis says that persistence on implementation of old traditions among Afro-Iranians in Qeshm Island is the main reason for the continuation of FGM in the Island. The main research questions addressed here are (a) Why Female Genital Mutilation is still practiced among the African-descent community in Qeshm Island? (b) What are the mental and physical consequences of female genital mutilation for Afro-Iranian women? And (c) How Government and non-government entities, are combating this tradition?Most of the data is based on the analysis of the responses to the questionnaires. The sample was chosen from Afro-Iranian women in three selected villages of Qeshm IslandSome of the information was gathered through interviewing several medical female doctors and midwives in three rural medical centers about the effects of Female Genital Mutilation on Afro-Iranian women of the IslandThe researcher also used some books, scholarly papers, and credible databases.Data: The data presented in this article was extracted from the content analysis of available documents as well as investigation, validation, and codification of questionnaires.The data are divided into three parts:There was a total of 80 participants in this study including seventy African-descents and ten medical staff. Afro-descents women were from the villages of “Suza,” “Table,” and “Dargahan” With very little education. 30 of them were completely illiterate whilst 20 had passed 3 elementary years only. The rest of 20 had passed elementary level. Participants' ages varied between 35 and 60 years old. 10 of them were between 35 to 42 ages, 25 of them were from 45 to 52 years old and the rest of 35 were from 55 to 60 years old and due to this age differences, had different views on FGM and its complications on those who have undergone the Sunnah. All of them were married, had children and had experienced FGM. Participants were assured that we would endeavor to keep their identities hidden and were requested to give accurate information to the best of their knowledge. Collected information indicates that there are misconceptions about the “clitoris” among the Afrian-descent women as a male organ, and negative responces of respondents, show their utterly hidden beliefs against uncut women as not appropriate mothers and wives. Most of these negative opinions are based on narratives of elders that are not necessarily experiential. Additionally, most African-descent people of Qeshm Island believe that circumcision starts girls' puberty process, and it makes them ready for marriage, and having a family. Furthermore, African-descent elders in Qeshm believe that most Afro-Iranian young men, based on their traditional principles, are unwilling to marry uncircumcised girls and consider them impure. 25Another part of the information was obtained from interviews with 10 women staff of medical clinics located in the villages of “Suza,” “Tabl,” and “Dargahan.”These people's education levels ranged from bachelor to doctorate degrees, and their ages varied between 35 and 45 years. Six of them were married, and four were single. All of them gained experiences because of the continuous interactions with African women, and had a good knowledge of FGM, and provided significant information about the physical and mental effects of circumcision. The information they offered of psychological effects was precious.th, 2020 on 70 local Afro-Iranian females as well as 10 originally-Iranian female nurses or doctors, in some villages in the Qeshm Island. Medical centers were selected as the sampling frame of the study. Multistage sampling was used, and three medical centers in Qeshm Island were randomly selected. Then, convenience sampling was used to select the required number of participants from each stratum. The paper used the method of descriptive content analysis. The descriptive content analysis identifies and designates the main content of the data, chronologically, thematically, or otherwise, either subject-focused or researcher-focused, and encompasses counting, listing, practicalizing, classifying assessment, and clarification. This study is a cross-sectional descriptive content analysis study carried out November 12th to December 14There is no doubt that FGM accompanies by an extensive variety of temporary and long-held physical, psychological, sexual, and obstetric health risks Types of Female Genital Mutilation in Qeshm Island: Although based on the World Health organization, generally, there are four types of Female Genital Mutilation in the world 1 including: I Clitoridectomy, II excision, III infibulation and IV – all other harmful procedures32Based on Unicef 2021 report, child marriage specially those who have already been circumcised threaten the well-being of millions of girls around the world Circumcised Afro-Iranian women in Qeshm Island experience physical problems and face mental health problems. Some of the health providers in Qeshm Island's clinics mentioned that anxiety, permanent phobia, low self-confidence, and low self-esteem are some of the mental health problems of circumcised African-descended women on Qeshm Island. Furthermore, some Afro-Iranian families in Qeshm Island – who are suffering from poverty and lack of proper education - believe that their girls must get married immediately after puberty to avoid any sexual perversion. Among these families, many girls are married between the ages of 12 and 14 while they are not physically or psychologically ready, which usually causes some mental disorders for them in the long run.Mostly based on extracted information as well as available sources; African ancestral cultures, family associations, social circumstances, and lack of education are some provided justifications for circumcision among Afro-Iranian families in Qeshm Island. 37Most Afro-Iranian girls are raised to believe that mutilation is not harmful but is in their favor and for having a better future. 38Most of the data is based on the analysis of the responses to the questionnaires. The sample was chosen from Afro-Iranian women in three selected villages of Qeshm IslandSome of the information was gathered through interviewing several medical female doctors and midwives in three rural medical centers about the effects of Female Genital Mutilation on Afro-Iranian women of the IslandThe researcher also used some books, scholarly papers, and credible databases.The data presented in this article was extracted from the content analysis of available documents as well as investigation, validation, and codification of questionnaires. The data are divided into three parts:As mentioned, some of the data were collected by using a five-part researcher-made questionnaire. The first table includes questions about demographic information, including age and educations.The second part of the questionnaire asks about their knowledge of FGM's benefits, and the third part evaluates Afro-Iranian women's general opinion about the continuation of FGM. Responses to these questions were combined and presented in The fifth part of the data extracted from interviews with a number of educated women in Qeshm Island who work as doctors and nurses in Qeshm's medical centers. The questions and answers were mainly related to the mental health of circumcised women. Based on the mentioned interviews, lower self-esteem and lower self-confidence than the uncircumcised girls, feeling nervous, constant phobia, and anxiety disorder are permanent mental complications that circumcised Afro-Iranian girls experienced throughout all their lives. Article 386 criminalizes the mutilation of the body. If the crime were intentional, it would be punished according to the retaliation (Qisas) law – the perpetrator shall be given a sentence that is equal to the crime committed. If the crime was unintentional, the penalty might be either Diya (monetary compensation or blood money) as prescribed by Islamic law for that particular crime, or “Ta'zir” . 41Article 479: If a woman's genital is totally severed, she shall be entitled to her full blood money, and if only half of her genital is severed, half of her blood money is due her. 42Article 664: Cutting or removing each of the two sides of the female genitalia leads to “Diya” (compensation) equal to half of the full amount of “Diya” for a woman's life.Article 706: Elimination of the power of ejaculation or male reproduction or female pregnancy or eliminate the pleasure of the sexual ability of a man or woman causes compensation (Diya or blood money)Article 707: Complete elimination of the power of intercourse leads to complete blood money. 41Female Genital Mutilation has not yet been outlawed in the Islamic Republic of Iran, and talking about it in public is considered taboo.As already mentioned, there is no direct law against FGM in Iran. On the other hand, Iran has accepted the convention on the rights of persons with disabilities, and FGM has been considered a disability, and its practice should be stopped. 43Since Female Genital Mutilation is still taboo in Iran -including in Qeshm Island- and the public doesn't have enough information about it, the NGOs' activities in this area are slow, gradual, and limited. One of the important non-governmental organizations that has been active in this issue during the last decade is the “Step by Step to Stop Female Genital Mutilation Campaign,” and Qeshm Island has been one of the focus areas of the campaign. Activities of this campaign include talking to heads of local communities (Sheikhs) in Qeshm, meeting elderly women who have become so-called Sunnah (been circumcised), meeting traditional female circumcisers known as “Khatan,” the publication of several books and articles, and set up some educational workshops. As a result of this campaign's activities, the percentage of Female Genital Mutilations on the Island has decreased compared to the past ten years, especially since the campaign leaders gained the trust of indigenous people, including Afro-Iranian women.One of the problems in combating Female Genital Mutilation in Qeshm Island is the secrecy of the FGM procedure, which is usually performed at home and secretly by local midwives. In addition, the tradition of female genital mutilation is still known as taboo among Qeshm' African-descent and is less discussed in societies. The concealment of this FGM procedure also means that there are no reliable statistics about it. On the other hand, there are no reliable resources for comprehensive pathological research for responsible institutions, especially for the Ministry of Health and Medical Education and the Welfare Organization on Qeshm Island. Local officials usually avoid addressing this issue and even avoid using the word Female Genital Mutilation, which they consider a red line.Since there is no prohibition or restriction on Female Genital Mutilation in Iran, there are no specific penalties for those who circumcise their wives and daughters. Medical staff in Qeshm Island have not yet been specifically trained in the dangers of FGM. Despite some measures by NGOs, government officials have not yet acted to raise public awareness about Female Genital Mutilation. Also, many African-descent families in Qeshm Island still consider uncircumcised girls unclean. They believe that only if they circumcise them they will be clean and they will have a promising future and good marriage.Other obstacles and challenges include – but are not limited to - illiteracy and lack of education among traditional families, social prejudices, and commitment to customs and traditions among African-descent people of Qeshm Island.Fortunately, during the last decade, significant actions in controlling and reducing female genital circumcision have been taken in different parts of Iran -in particular Qeshm Island- which hold promise for a better future on stopping this sociocultural custom. Field studies, as well as available information and published data by some NGOs, indicate that due to the efforts of NGOs and the support of some religious authorities, the number of FGM operations in Iran is continuing to decrease. 29As a result, it is possible that in the next years, Female Genital Mutilation will be announced outlaw by the Iranian parliament. Yet, to eliminate this social contract from Iran – in provinces of Kurdistan, Kermanshah, West Azerbaijan, and Hormozgan, and among the African-descent community in Qeshm Island, which is the case study of this paper- a strong platform is needed for change in the behaviors, viewpoints, and values of ethnic groups. Some researches carried out about FGM in Iran suggest that the best remedy for the abolishment of Female Genital Mutilation is to convince the central government to declare it an illegal act as well as the establishment of close cooperation with the traditional communities, elders, and local leaders where FGM is still prevalent.While concentrating on the African-descent community in Qeshm Island, social activists and NGOs who are campaigning against Female Genital Mutilation in the Island should first take time to know this ethnic group and should avoid policies that may be perceived by the people in that region as aggressive toward their traditions and cultural protocols. Due to African-descent tradition, they need a longer time to accept the realities of this harmful tradition.An important consideration of FGM practice in Qeshm Island is the parent's persistence to mutilate their daughters; they believe it will protect and provide a promising future for their girls. In fact, family dignity and social situation play an influential role in preserving FGM among African-descent families, which makes it difficult for them to end the practice. Even after parents realize that FGM can cause severe damage, they will keep it up because they are afraid of their daughters' future, repercussions, and ethical judgments of society's expectations.For the African-descent community of Qeshm, failure to imitate FGM leads to social segregation, exclusion, displeasure, reproach, or even ferocity – as well as having an outcome on a girl's marriageability. Therefore FGM is still considered a social norm that members have to follow it. Although Afro-Iranians of Qeshm are somehow aware of FGM's dangerous effects, Female Genital Mutilation is a part of their ancestral culture. Any strategy to combat it should be done gradually and with caution.Indeed, the most important task to fight against FGM among Afro-Iranians of the Qeshm Island is understanding the traditions of these people, at the same time broadcasting the detrimental consequences of some customs that have to be either updated or set aside, while FGM is on the top of them. Therefore, any action against FGM as entering a sensitive and private arena must be taken cautiously based on a thorough knowledge of African-descent customs and knowing their women's pre-existing assumptions. Also, their gradual enlightenment should be done via the existing framework of tribal chiefs. Fighting FGM needs patience, wisdom, and an understanding of Afro-Iranian traditions directly connected to female destiny. Interestingly, apart from African-descent fathers who insist on circumcision of their girls, mothers who have already experienced this awful operation will follow their husbands and do expressed that they intend to subject their daughters to FGM to guarantee their futures and avoid the likely dishonor and disgrace that would encompass them if it doesn't happen.Therefore, the author suggests that the fight against Female Genital Mutilation -at least among the Afro-Iranians community of Qeshm Island -requires enduring, long-term planning, and local administrators' mobilization NGOs, health centers, religious leaders, freelance volunteers, social activists, and women's associations. It is also important to emphasize that any strategy toward combatting FGM regarding African-descent people should not be perceived by people as aggressive toward their traditional and cultural protocols, while it has to be done through gradual culture building and understanding.In addition, nurses working in urban and rural hospitals and clinics must be trained to inform African-descent families in Qeshm. They have to try to play an incisive role to reduce the percentage of circumcisions in this traditional society.Fortunately, over the past decade, in addition to some grand Iranian Shiite Ulama who have stated their opposition to Female Genital Mutilation, Iranian Sunni scholars have also opposed Female Genital Mutilation by issuing statements that have had a positive effect on the changing views of local communities whose still insist on continuing the tradition.Of course, over the past decade, with the increase in the number of the educated female of African-descent in Qeshm Island, an increase in the use of social networks such as “Instagram” and “WhatsApp,” and an increase in reading articles about the consequences of female genital mutilation, a gap has emerged among women across the generations. The older un-educated generation continues to emphasize the preservation of circumcision as an old tradition and believes it would guarantee the families' survival; while young educated women consider circumcision a violation of women's rights. They consider FGM a tradition, harmful to the physical and mental health of girls, and they believe that this tradition should be abolished. This duality indicates that not in a distant future, with the death of the elders of this society, FGM will gradually be abandoned in this community. So, through enlightening and increasing the number of educated women in the community, definitely in the future, there would be a fundamental behavioral change among the next generation of Afro-Iranians of Qeshm to either reduce or abandon it.Enforcement of national laws prohibiting FGM in the Islamic Consultative Assembly of Iran;Implementation of Islamic penal code for female mutilation;Add contents about FGM in medical and paramedical courses to let graduates learn more about this tradition;Culture building by raising awareness of traditional communities' leaders to abandon some of the harmful old traditions, including FGM;Teaching and warning midwives about the dangers of circumcising for girls with the help of local health officials;Production of educational programs to broadcast on radio and television for explaining the long-term physical and mental dangers of FGM on women;Collaboration of central government with UNESCO and UNICEF, to use their experience in combating FGM;Engagement of NGOs against FGM through organizing educational seminars, workshops, and publishing books and pamphlets, in order to inform traditional communities about the urgent necessity of stopping FGM;Improving the public knowledge about FGM and its health consequences.Encouragement of the girls and women subjected to FGM, to seek healthcare;Provision of healthcare, in the form of surgery or psychosexual consulting to the victims;To establish specialist medical centers with HCPs who have experience of FGM, in the regions with high prevalence rate;Remarkable information of the current study are extracted from questionnaires answered by several African-descent women of Qeshm Island who live in towns and villages. Therefore, outcomes neither present all Afro-Iranian families in Qeshm Island nor the experience of all African-descent circumcised women living on the Island. Female Genital Mutilation is still considered a cultural and social taboo among African-descent women of Qeshm especially when they want to express their feelings. They even consider FGM as an essential part of their ancestral culture that has to be preserved. Many of them were reluctant to answer the questionnaires provided to them by female nurses in several medical centers in Qeshm and the surrounding villages; they believed that we are violating their privacy by asking such questions. So, convincing them to participate was a big task and, to some extent, time-consuming. Clarifying the extracted results during the data analysis to have accurate results was another difficult task. Assuring them that their identity will be completely hidden was very problematic. Some of them afraid that if their identity reveals, they might face complications in their private lives. The scarcity of reliable sources and documents was another serious problem.


The accessibility of medical service facilities is a vital influence on elderly people choosing medical treatment. Encouraging residents to seek nearby medical treatment can facilitate the rational layout and diversion of urban medical facilities and reduce health resource waste. However, due to accessibility factors, elderly people may not choose the nearest hospital. In order to investigate such factors, we conducted a questionnaire survey among the elderly from 10 tertiary general hospitals in Hefei, China. On the basis of the origin-destination (OD) cost matrix analysis and statistical analysis of 830 valid questionnaires, this paper analyzed the elders’ selection rules when choosing medical facilities and the factors considered when making a choice. The study found that although 85% of elderly participants valued a short distance to tertiary hospitals, only 31% of them attended the closest hospitals in reality, which correlated with regularity according to their education level, travel activity status, and place of residence. The elderly highlighted road congestion, convenience of public transport stations, and number of transfers as critical in determining whether they sought nearby medical treatment. According to the results, effective ways to encourage the elderly to attend their nearest hospital, from the perspective of accessibility, include easing road congestion, improving the layout of public transport stations, and optimizing urban public transport routes. In particular, when planning future medical facilities, attention should be paid to the elderly with primary school education or below, who cannot travel independently, and those who live far from the city center. Opinions on Formulating and Implementing Elderly Care Service Projects report issued by the General Office of the State Council of the Chinese Government in 2017 indicates that it is necessary to support the elderly by developing elderly-friendly cities and improving elderly-oriented systems in the provision of urban public service facilities [Medical service facilities have become an important part of China’s urban public health service over the last decade. The With the improvement of the Chinese medical insurance system, the overall medical service level, and the number of elderly medical service facilities, there are now more options for elderly people seeking medical care ,3,4,5. NIt should be noted that the facility where the elderly seek medical advice and treatment is restricted by their spatial mobility due to physical conditions ,12,13,14In the academic literature, distance is an important indicator of accessibility. Some scholars define accessibility as a spatial barrier and operationalize it in terms of spatial distance and time cost ,18,19,20Apart from the accessibility factor of distance, other factors are related to elderly patients’ decisions in choosing a medical institution: other accessibility issues , the quality of available medical and nursing staff, and the level of the medical institution itself. This study investigates tertiary general hospitals, which are the highest level of medical facilities in China. They are medical institutions that provide medical and health services across counties (districts), cities, and provinces, including comprehensive medical care, teaching, scientific research, and public health services. The bed number, diagnosis and treatment subjects, medical equipment, and health technicians must correspond to the hospital’s service functions, technical level, and management requirements. China has a unified evaluation standard for such hospitals . HoweverImplementation Plan for the Constructing Efficient and High-Quality Medical and Health Service System during the 14th Five-Year Plan, it is mentioned that the elderly should be guaranteed high-level medical services within the proximity [At present, most of the Chinese literature provides discussions on proximity of primary medical facilities ,27. In troximity . TherefoThe addition of the accessibility variable complicates the medical facility selection of the elderly, who may be torn between attending the closest facility or the one that can provide the best treatment. Personal circumstances may also be considered, leading them to decide to attend a more distant facility rather than the nearest. Thus, it may not be possible to choose the nearest hospital. This leads to the present research hypothesis that most older people in China do not consider the nearest hospital when seeking medical care because proximity is less important than other accessibility factors. Our research aims to understand older adults’ considerations and strategies when making this trade-off, such as what factors are related to their behavior in choosing the closer tertiary general hospital. On this basis, we make practical suggestions for urban planning that promote choosing nearby medical treatment. The outcomes of this research provide a rational basis for locating urban medical service facilities and resources, particularly to meet the needs of the elderly, while also saving energy.This paper addressed the following research questions: (1) How highly do the elderly evaluate the distance to tertiary general hospitals in relation to other considerations? (2) What type of elderly patients prefer the nearest facility for medical treatment? and (3) What factors do they take into account in reaching this decision? A questionnaire survey of elderly patients at Hefei tertiary general hospital was conducted. The data were analyzed by OD cost matrix model calculation, correspondence analysis, and regression analysis to answer the research questions.The case study is in Hefei, the capital city of Anhui Province, China. Hefei urban city is formed by four administrative districts, including districts of Luyang, Shushan, Baohe District, and Yaohai  Figure . AccordiAt the end of 2017, there were 1198 medical facilities in Hefei . According to the evaluation standard of tertiary hospitals in Anhui Province  and an OD cost matrix model in Geographic Information Systems (GIS) to investigate whether the elderly seek medical treatment at the nearest hospital and the rules they follow when making such decisions. This helps to explore the behavior regularity of choosing nearby medical treatment in relation to elderly people’s attributes. For scientific purposes, the subjects had been followed since 2018. In addition, as the second stage of the survey, on the premise of knowing whether or not they went to the nearest hospital, we conducted follow-up telephone interviews to them during January–June 2021 to learn which accessibility factors were considered.The sample size for the one-to-one interviews conducted in 2018 was determined by referring to the number of visits by the elderly to tertiary general hospitals in Hefei urban city in the previous year. According to 2017 statistics from the Hefei Municipal Statistics Bureau and Hefei Municipal Health Commission, there were 2.75 million annual visits by the elderly to these hospitals . The forN is the total visit number of the elderly (2.75 million), e refers to the margin of error (5%), p is the response distribution (50%), confidence level is 95%, and z-score is 1.96 [In the formula,  is 1.96 ,34. A mi is 1.96 ,36. SincM × N (M refers to the set of origins and N refers to the set of destinations) problem and record the minimum distance between each source point and each end point. There are two advantages of this model. One is that it allows each of the elderly to freely specify the number of destinations that they had considered in making their hospital decision. The other one is to consider the road network in reality. In ArcGIS, the OD cost matrix solver can only output straight lines but cannot display the actual shape of the path. However, this does not affect the analysis result because the distance cost stored in the “line” attribute table reflects the distance of the road network rather than the straight-line distance [i is the elderly, j is the hospital, M refers to the set of origins , and N refers to the set of the destinations . The distance from where each elderly i is to the nearest hospital isThe distance from each participants’ residence to the selected hospital and the nearest hospital can be obtained using the OD cost matrix model analyzed by the GIS network. As a component of GIS network analysis, the OD cost matrix model is often used to find and measure the lowest cost path from multiple source points to multiple destinations in the network. In this research, the OD cost matrix model was able to quickly solve the large matrix distance ,39,40,41m is the total number of residences and n is the total number of hospitals. Finally, the program calculated which hospital was the nearest for each elderly person, as well as the distance between the residence of each elderly and the nearest hospital. By comparing the actual medical distance of the elderly with the closest medical distance, we can determine whether they obtained medical treatment nearby.In this formula, The purpose of the telephone follow-up interview was to find out what factors were related to the elderly’s behavior of seeking medical treatment nearby. During the survey, both elderly participants who did and did not go to their nearest hospitals were included. Before the telephone follow-ups, the nearest hospitals to the participants were determined through the GIS model and Matlab. The participants were asked to evaluate the accessibility of the nearest hospitals they went to or would go to, including the mode of transportation needed or usually used, as well as details such as travel time, cost, and the number of transfers required for each mode of transportation. In this way, the accessibility factors of the nearest hospitals that encourage or hinder their access would be explored.Each evaluation index contained specific evaluation criteria. For example, for elderly patients who needed to take public transport to their nearest hospital, further evaluation items under the time category included the time spent from home to the public transportation station, waiting time, riding time, transfer time, time spent from the station to the hospital, and other required timings. Other evaluation indicators and evaluation methods are shown in IBM SPSS Statistics 25 was used for input and analysis of the result at the two survey stages (one-to-one interview and telephone interview). The data were entered by two people and cross-checked.(1)p < 0.05) were screened out. Then, multiple correspondence analysis was performed again on these significant attributes and the preference for distance.In order to analyze the preference for hospital distance among the elderly with different attributes, the chi-squared test was performed on their basic attributes of the elderly and perceived importance of distance. The elderly’s preference for distance, or, namely, the importance of distance, was used as the dependent variable. The elderly’s attributes of gender, age, household registration type, number of people at home, number of generations at home, education background, original occupation, number of children, household per capita annual income, medical insurance type, travel activity status, residence place, and number of private cars owned were used as independent variables In order to analyze the regularity of the elderly’s behaviors in seeking medical treatment nearby, the chi-squared test was also firstly performed on the data. The elderly’s actual behaviors, or, namely, whether or not they chose the nearest hospital, was used as the dependent variable, and the attributes of the elderly were used as independent variables (see (3)In order to find out the factors associated with the elderly’s behaviors in seeking medical treatment nearby, statistical analysis was conducted for the elderly’s evaluation on accessibility under different means of transportation and their actual behaviors  on the basis of the data obtained from telephone interviews. The assignment of variables are referred to in To further analyze the distance preferences of the various elderly patient sub-groups, their attributes and the results shown in The attributes of the elderly and their preference for distance were subjected to a chi-squared test, and the results are shown in The relationships between a distance preference and the attributes of elderly participants were analyzed using chi-squared tests . Accordip = 0.000). The regression coefficient is positive, meaning that when a greater number of transfers is required to reach the nearest hospital, that hospital will be less likely to be chosen. In addition, the convenience of public transport stations was also correlated with their behavior (p = 0.016). The results show that the less convenient the station is, the more likely the nearest hospital is to be bypassed. Road congestion was also an associated factor (p = 0.034). The more congested the road to the nearest hospital is, the more likely it will be bypassed. Similarly, for elderly people using private vehicles, non-motor vehicles, mixed vehicles, or walking, traffic congestion was also associated with their behavior. The less congested the roads are, the more likely the nearest hospital will be chosen. The number of transfers and the convenience of the station were also correlated with whether elderly users of mixed-mode transportation would choose their nearest hospital. It was easier for them to bypass the nearest hospital if there were more frequent transfers and fewer convenient stations.As previously discussed, distance had little to do with the choice of hospital for the elderly. In addition, more than two-thirds of the elderly bypassed the nearest hospital and chose a more distant one. Through the telephone follow-up survey data, we obtained a multifaceted evaluation of the accessibility factors of the nearest hospital. Then, the promotion and inhibition factors of choosing the nearest hospital were able to be summarized. Chi-squared analysis was conducted on the accessibility evaluations of elderly patients and whether they chose the nearest hospital or not. The results in The farther away the elderly lived from the city center, the higher the proportion that sought treatment at their closest medical facilities. This phenomenon can be explained from the perspective of road congestion. As mentioned above, more straightforward navigation to the closest hospital promoted the seeking of medical treatment nearby. This is because urban road congestion becomes gradually alleviated further away from the city center. Additionally, in the investigation and interview processes, it was reported that most elderly participants with higher education levels either worked in public institutions before retirement or had professional employment. Many were still residing in unit housing in the old city or nearby, experiencing a congested road environment. In contrast, the majority of respondents with a low level of education were farmers. The majority of them lived in the city’s fringe areas outside the Second Ring Road with good road accessibility and, consequentially, they were more likely to seek nearby medical treatment.By considering and contrasting the spatial distribution of Hefei tertiary general hospitals and the residential locations of the respondents, together with the questionnaire survey data, this research found that although the majority of elderly patient regarded the distance to tertiary hospitals as important, only about one-third of them sought medical treatment nearby. Hence, there was no correlation between the elderly’s subjective concern on the distance and their actual behavior. However, further exploration indicates that the accessibility of the nearest hospitals, according to traffic congestion, location of public transportation station, and number of transfers, is closely related to the decision of whether or not to seek medical treatment nearby, rather than distance. From an urban planning perspective, we argue that the most effective way to encourage nearby medical treatment is to alleviate road congestion, adjust the location of public transportation stations to increase convenience, and optimize public transportation lines to reduce the number of transfers required, rather than simply shortening the distances between hospitals and residential areas.Urban traffic is a critical component in the development of a city’s functional layout. Traffic congestion has become an essential restrictor of urban development. It directly affects the quality of residents’ lives and travel and generates many social problems. This research confirms that severe road congestion in the urban center, such as within the First Ring Road, seriously impacts the daily lives of vulnerable groups, including the elderly who have difficulty traveling, and discourages them from visiting the nearest hospital, even if they can walk there. Improving the urban medical treatment environment and medical services should be considered from many aspects, including alleviating traffic congestion. Field investigations revealed that some of the causes of road congestion in downtown Hefei include disorderly parking and inadequate traffic organization. Initiation of a traffic improvement project in the Hefei city center would be an effective and immediate strategy for helping the elderly utilize the closest medical treatment facilities.Public transport is an important part of the overall urban transportation system. Its development is an important symbol of a city’s degree of modernization and is the best way to solve urban traffic congestion. During the interviews, many participants mentioned that the public transportation lines in Hefei were insufficient, requiring them to transfer several times to reach a hospital, even close ones. The results of the study show that the Hefei public transport network does not adequately meet the needs of its residents. A well-functioning urban public transport system requires theoretical and technical support. Establishing an applicable urban public transportation network model and then determining the optimal travel paths will have a positive impact on improving the overall efficiency of the public transportation system and the convenience of daily travel, such as for medical treatment.In line with the outcomes of this research, we suggest that it is critical to optimize the locations of public transport stations, although this is a multi-perspective problem. We argue that a reasonable station layout can reduce the investment cost of road construction and increase passenger convenience, especially for vulnerable groups such as the elderly. Most existing stations in China, including in Hefei, are planned by the urban road planning department according to station setting norms. However, this research suggests that station locations and passengers’ choice behavior should be interactive. The planning of stations needs to consider the relationship between public transport lines and the surrounding residents.The outcome of this research raises a concern about social equality and providing public services for all. In line with the survey outcomes, elderly people with greater education or living closer to the city center were more likely to bypass the nearest hospital. This is because that these categories of the ageing population may be of governmental official, high-skilled laborers or those who used to work for state own enterprises and/or research institutions. They have more options in selecting hospitals. However, the elderly with a lower education level, e.g., elementary school or below, those living far from the city center due to the cost of housing, or those with low mobility that restricts independent travel, have to select the nearest hospitals. As vulnerable groups, they may not have more options. On the basis of the outcomes of this research, we would suggest that in the planning stage for the provision of medical facilities, the distributions of these groups should be considered. The distance between them and any newly built medical facility should be lessened to meet their high demand for seeking nearby medical treatment.Overall, the findings of this study have clarified the rules of the elderly’s medical behavior and the factors considered when choosing a hospital. Moreover, instead of shortening the distance between hospitals and residential areas to encourage the elderly to seek medical treatment nearby, it would be more effective to address issues such as traffic congestion, inconvenient platform settings, and the high number of transfers required for public transportation. This observation has important implications for urban planning and medical care for the elderly in China. Although this study took place in Hefei City, the findings have reference significance for other similarly sized cities in China. Specifically, the description of elderly people with high demand for proximity to hospitals can be applied to other cities. Their distribution should also be considered in the future urban planning of these cities. Under the background of nationwide promotion of nearby medical treatment, the identified measures that promote nearby medical treatment can be promoted in other cities. China has experienced rapid urbanization over the past few decades. Relevant standards and norms may have been lagging behind the social and economic changes in Chinese society. For example, existing urban planning norms mainly consider land use and population ratio in the provision of public medical services but ignore the demands of gender, age, and socio-economic conditions. Moreover, the construction of public services cannot keep pace with urban expansion, so the urban transport system is in urgent need of renewal. Those are common problems in most Chinese cities. More critically, the ageing population has been the main issue of Chinese society. However, the demands of the elderly, especially accessibility, have not yet been considered key elements in planning for the provision of health and medical service facilities as a component of urban development. The proposals and suggestions in this research will contribute to academic debate and professional practice in Chinese urban planning and development, having strong social significance and practical value.In our research, the one-to-one interviews to the elderly were conducted before COVID-19, and the telephone follow-ups were about their behavior and evaluation before the epidemic. COVID-19 was not considered in the scope of this study; however, it does have a certain degree of influence on elderly patients’ medical decisions, personal consciousness, and concept of health. Future studies could conduct surveys on elderly hospital patients to compare their medical decisions before and after the pandemic and determine the adjustments that they need to make with regard to choosing medical facilities in the context of epidemic prevention and control. In addition, future studies should no longer be limited to tertiary hospitals, but should also include other levels of medical facilities. Since the services provided by low-level medical facilities can be replaced by those of high-level medical facilities, including more levels of medical facilities, future research will more accurately capture the decision-making process of elderly patients choosing a hospital to visit.


Clinical trials on pediatric oncology use therapeutic techniques with the overwhelming majority of children's cancer patients obtaining therapy via clinical investigation procedures. Medical treatment is scheduled according to a specific protocol for enrolled patients. These protocols often do not refer to nursing care. Nursing care, on the other hand, must complement the medical care specified in the medical research protocol. Safe treatment administration, assessment of treatment responses, patients' and families' education, and communication with the whole medical team are just a few of the critical nursing tasks that should be properly managed. Nursing care standards have been developed in this study to strike a good balance between the procedure for clinical research and the nursing care connected with it. These recommendations outline the nursing activities and considerations that must be made while caring for pediatric cancer patients who are engaged in a specific clinical investigation procedure. The objective of this study is to outline the procedure through which nursing care guidelines could be developed and evaluated. The goal of this study was to find out the involvement of nurses in the process of health education for osteosarcoma and family patients. The role of the nurse in the care of osteosarcoma patients is crucial. From the moment the patient and the patient's family are informed about the sickness, the nurse gives support and comfort and also clarifies the information of the medical doctor to them. All elements of medical treatment are handled, and the nursing care provider is typically the first point of contact for patients who call the physician's office seeking information or reporting a problem. The nursing care provider schedules and organizes appointments in accordance with the patient's health and, in certain cases, social requirements to give complete treatment with meticulous attention. This message will offer context for the nurse's role in ensuring the patient's and family's entire care. The most common primary bone cancer in children is osteosarcoma, originating from primitive bone-forming (osteoid generating) mesenchymal cells. It is classified as primary or secondary based on other underline conditions and accounts for roughly 20 percent of all primary bone cancers. Osteosarcoma is quite diverse in its presentation, allowing for classification into various subgroups based on the degree of differentiation, location within the bone, and histological profile. These categories exhibit a range of imaging characteristics, demographic characteristics, and biological behavior. Treatment choices and survivorship have significantly improved in recent years because of the tireless efforts of medical, surgical, and scientific advancements –3. Althost-century merging of the pediatric oncology cooperative organizations to establish the Children's Oncology Group (COG), a Children's Cancer Group or Pediatric Oncology Group facility was responsible for around 94 percent of pediatric oncology patients [http://www.childrensoncologygroup.org/). These procedures are thorough blueprints outlining the medical care that will be provided to the kid or teenager during their therapy. Treatments are becoming more complicated, and administration of treatment is becoming more difficult as a result of differences in pharmaceutical preparation, dose, infusion rate, and duration, as well as the use of diverse medications in different procedures [Numerous advancements have been achieved in the delivery of curative medicines to children and adolescents with cancer during the last decade. The majority of advancements in this field are due to the predominance of clinical trials since the majority of pediatric oncology patients are treated according to medical research procedures. Protocol-directed therapy is used in pediatric oncology to discover the best successful treatment for groups of pediatric oncology patients. Additionally, protocols allow health care practitioners to identify treatment response differences that are associated with individuals' genetic makeup, sex, age, and ethnicity . Prior tpatients . The COGocedures , 12. Chiocedures –15. ThroThe interaction between the medical staff, the patient, the patient's friends, and family is critical. Our institution has adopted family-centered care as a method to define such interaction. “Family-centred care is a philosophy of health care that influences health care policy, programs, facility design, and daily interactions between patients, families, doctors, and other health care providers.” Family-centered care is built on the premise that the family is the real master in their child's care, as well as the primary source of courage and strength. Dignity and respect are essential values, as are cooperation, involvement, and information sharing , 17. We When our pediatric patients are diagnosed with osteosarcoma, they embark on an unfamiliar and sometimes dangerous road. Our responsibility as advocates and educators for patients and families cannot be overstated. Developing strategies to assist patients in comprehending their sickness and therapy, as well as organizing and expanding on preliminary information, involves sensitivity, visual information, and imagination –21.To maintain a high quality of life throughout management, it is critical to avoid and/or reduce illness symptoms and treatment side effects. Pain is the most common and probably utmost distressing symptom. Pain is a symptom that requires attention at several places throughout the continuum of treatment. Vomiting, nausea, lethargy, constipation, and decreased appetite are all common treatment side effects .Pain is typically the most prevalent symptom in individuals with osteosarcoma, and it poses a significant danger to the quality of life unless managed properly. When pain is caused by the formation of a localized tumor, which is usually exacerbated with pathologic fracture and over-the-counter painkillers, for example, ibuprofen and acetaminophen become ineffective. Drugs combining a pain killer and the use of oral opioids are typically the next stage. The most successful method for tumor pain reduction is to start therapy as soon as feasible. A self-report should be included in the first pain assessment , physiologic measures/diagnostic results, parent input, physical examination, and behavioral observation . Future Postoperative pain is somewhat expectable. The pain treatment regimen often includes intravenous (IV) or epidural analgesia. The need to continuously evaluate therapy effectiveness cannot be overstated, since pain is a subjective sensation. Patients will heal far faster if they are not restricted by discomfort . With prPain caused by progressive illness is a complicated issue that needs collaboration with professionals. Patients and their families have a right to believe we offer the resources necessary to manage their suffering –30. We pIn 1999, Nursing Fellowship Program was developed by our hospital's Office of Nursing. Nurses should be better promoted in the institution's study objectives. The first batch of nursing research fellows consisted of ten staff nurses. To encourage nurse participation in the research assignment, we examined our institution's and our Office of Nursing's research missions in depth, exposed nurses to a variety of research programs as well as the study infrastructure at our hospital, focused on the goal and kinds of oncology trials in the clinic, and practiced selected research skills , 32. To The term nursing care guidelines is defined as a self-contained paper developed in conjunction with a curative investigation procedure. The guidelines detail the activities taken in nursing care and the reasons behind those actions necessary for administering the medical treatment as well as educating, monitoring, and supporting the patient throughout the protocol's therapy phases. The recommendations provided nurses with a concise basis of protocol-specific information about direct care. The goals of the recommendations are (1) to boost a medical nurse's belief in himself and capacity to deliver good quality hospital care by explaining why certain nursing care activities are taken, (2) to improve the nurse's comprehension and expertise of the clinical investigation procedure, (3) to improve the nurse's capacity to educate patients and their families about the protocols and clinical testing in general, (4) to reduce the possibility of clinical mistakes, and (5) to improve the nurse's capability to inform patients and their families regarding the process and clinical testing in particular , 25.Nursing upkeep recommendations must be comprehensible. The OS99 recommendations were organized into seven pieces dubbed the “remember box” to accomplish this goal. The seven pieces were general protocol goals, risk assessment, diagnostic imaging, chemotherapeutic treatment plans, rehabilitation services, and surgical nursing care after surgery. While every element serves a distinct function, collectively, they offer nurses the whole breadth of nursing care necessary to deliver to patients registered in the OS99 protocol . AdditioThe “remember box” serves as a reminder to the nurse about the purpose and limitations of the nursing care standards , 36. ThiThe chemotherapy treatment schema section discusses the administration of chemotherapy. Additionally, the medical and hematological laboratory values are stated in this section that must be obtained before the start of the chemotherapy, the kind of patient monitoring that must be performed prior to and following chemotherapy administration, significant toxicities, and precise links to the methodology for clinical research . Due to The investigation colleagues developed an education strategy to familiarise medical nurses with the idea and contents of the nursing care standards. The coworkers then defined the intended audience and devised procedures for assessing the recommendations' robustness as assessed by staff nurses. Even though staff nurses caring for osteosarcoma patients were the major target audience, other employees of the medical team were educated about the guidelines at educational inservices . The 03 The educational workshop included three primary topics: (1) the aim and objective of developing nursing care standards, (2) the information unique to management plan principles, and (3) the nursing care that is provided to patients who are part of the OS99 procedure .The research fellows underlined the recognized difficulties of protocol-driven treatment, as well as how the recommendations might be used to help the nurse and uncover critical nursing behaviors that are not specified in the protocol manuscript. The emphasis was subsequently directed to specific parts of the OS99 method. Throughout this phase of the teaching session, participants were introduced to and taught the fundamental ideas of the medical research procedure , 38.The nursing research fellows explained to the participants that critical components of the medical research protocol were included in the nursing care recommendations to help nurses better comprehend the OS99 procedure , though Family-centered treatment is intended to encourage patients and their families to confront the disease's problems head-on to grow in strength. Our objective is to educate family members of patients about the condition and its cure, while also finding out how to tailor the strategy for their requirements and objectives. Refining a large amount of data into digestible pieces allows the art of nursing to flourish. By preserving as much “normal” as possible via outpatient and home chemotherapy, we can promote normal growth and family life. Management of symptoms is crucial for overall health and usually needs a collaborative approach. Our patients now have access to a greater variety of new drugs, pharmaceutical combinations, and therapy modalities than ever before , 46.


Worldwide there is an alarming increase in the caesarean delivery rate which has become a controversial topic. However, the reasons for this tendency are not clear. For example, in Greece alone, rates increased by almost 50% from 1983 to 1996. In order to better understand the causes of this phenomenon, we need to examine closely what groups of women undergo caesarean section (CS). To achieve this, it is essential to use a system that will enable us to monitor and compare caesarean delivery rates. Such a classification system should be easily adopted by obstetricians, midwives, and public health services.A review search of electronic databases concerning medical care was held from December 2020 to January 2021 in order to find systematic reviews which describe either theoretical or practical CS classification systems.The most common classification systems fall into three main categories based on indication, urgency and maternal-based characteristics. According to users the highest rated classification system was women-based classifications in general. In particular the Robson Ten Group Classification System was considered to be the most valid to meet current local and international standards. The Robson classification system is praised for its robustness, simplicity, flexibility, and reproducibility.The right implementation of the Robson Ten Group Classification System can facilitate an in-depth analysis of the main groups that increase CS rates and can be used to both review and monitor delivery practices both in Greece and abroad. The World Health Organization (WHO) together with the International Federation of Obstetrics and Gynecology (FIGO) have expressed their concern at this steady increase, considering this international trend an ‘epidemic’4. Since 1985, the World Health Organization (WHO) has considered that there should be no justification for CS rates over 10–15% , for whatever region. Since then, the validity of this threshold has been questioned and the international community has increasingly referenced the need to revise the 1985 recommended rate4. According to the latest research, this threshold has been raised to around 19%, with no significant change on maternal and neonatal mortality5. Strictly speaking, worldwide caesarean section rates have risen from about 6% in 1990 to 19% in 20146. In the northern part of Europe, rates are still under 20% while in the southeastern part of Europe, China and South America they have climbed to or above 50% of total births5. In northern African countries the rates have risen from 5% to 28%. In Egypt this rate has reached 50%1. Caesarean section rates have remained very low in rural areas of low-income and middle-income countries. However, there has been an increase in urban areas. This can be easily understood, as there is a visible lack of access to medical services in certain regions while there is an overuse of interventions in other parts of the world or in other areas of the same country7. Those large variations in caesarean birth rates have become a major, controversial public health concern9 and rising CS rates give rise to international debates owing to possible perinatal risks associated with this rise, limited access and issues related to cost13. Consequences include direct and indirect perinatal morbidity and mortality caused by bleeding, aesthetic and urological complications, thromboembolism and infection, respiratory neonatal problems14. Moreover, the increase in CS rates negatively affects future pregnancies as there is a related rise in preterm birth and abnormalities of the placenta, which may lead to excessive vaginal bleeding and as a result to hysterectomy15.Worldwide there is an alarming increase in caesarean delivery rates but the reasons for this phenomenon are not fully understood16. In their 2005 study, Mosialos et al.17 reported a 41.6% CS rate in two public hospitals and a 53% CS rate in a private hospital. In the same study, authors investigated the factors that increased the likelihood of undergoing CS. Results of this study led to the conclusion that obstetricians tend to perform a CS for financial and convenience reasons.In Greece, the situation is even worse, over half of the births occur by CS, making it one of the countries with the highest CS rates in the world. In Greece, rates increased by almost 50% from 1983 to 199618.In order to better understand the causes of this phenomenon, it is first imperative to examine closely the groups of women who are undergoing CS. This requires using a classification system which could best monitor and compare CS rates in a uniform, dependable, and consistent manner. Such a system should be ‘simple, accountable, clinically relevant, verifiable and replicable’ and globally applicable and useful for healthcare providers and public health servicesThe aim of this review is to identify the most reliable classification system which is appropriate, and that could monitor, assess and compare the ever-increasing caesarean section rates.A review search of electronic databases concerning medical care  was conducted from December 2020 to January 2021 in order to detect systematic reviews which presented either a theoretical or a practical caesarean delivery classification system, published in English from inception to 2021. For the systematic search of the databases the MeSH terms, PICO and PICO management elements were used, depending on the database, with the following search terms: caesarean section, classification or taxonomy, and optimal rate of caesarean section. Additional methods of searching included a search of the reference list of articles selected from the primary search, in order to identify studies which had not surfaced from the initial search.The included studies were systematic reviews, published from inception to January 2021, in the English language. The included studies assessed any type of classification systems for CS which gave a clear description. The review included studies based on the use of a classification system for CS in various groups of low-risk women, regardless of their perinatal, medical or other demographic characteristics.Data collection and analysis was conducted by two authors simultaneously. The initial search generated 24 titles from the database systematic search. The study selection flow diagram is shown in 19, the most highly rated classification system was women-based in general and Robson classification system in particular. The latter is acknowledged to be the most appropriate to meet current regional and international standards19. According to the Robson system all deliveries can be categorized into one of the ten groups based on five parameters: obstetric history, (parity and previous caesarean section), onset of labor , fetal presentation or lie , number of neonates and gestational age20. The classification categorizes all women admitted for delivery into one of ten groups, which are mutually exclusive and totally inclusive. In other words, adopted based on a few basic obstetric parameters. All women admitted for delivery in any hospital can be classified into only one of the ten groups and no woman is excluded20.In a 2011 WHO systematic review several classification methods were examined. These classifications can be divided into three main categories: 1) indication-based, 2) urgency-based, and 3) women-based. Of these, the indication-based system was the most commonly used. The main question answered by this type of classification is ‘why’ the CS is performed. These data are recorded routinely in all maternity hospitals therefore it is easy to implement. However, the weakness of this taxonomy was that women giving birth with CS could fall into more than one category (could be >1 primary indication). Another weakness is that there are no uniform definitions for frequent indications . Moreover, the indications could only be reviewed after the performance of the CS, rendering implementation difficult and not very useful for the reformation of clinical practice. Classifications according to the degree of urgency for caesarean births were easy to interpret and implement owing to the limited number of the proposed categories. Thus, providing valuable information regarding ‘when’ the CS is performed. The main strength of this type of classification is that it could improve the communication among health professionals and in this way have a positive impact on maternal– neonatal outcomes. However, in this type of group similar problems were noted with indication-based classifications. Classifications according to the level of urgency do not provide accurate definitions for each of the categories. They have poor reproducibility unless clearer definitions are provided and medical staff are better trained. Also, they possess limited value for health policy makers, epidemiologists and public health authorities. Women-based classifications essentially inform us who is to undergo CS, according to maternal and pregnancy characteristics and are considered as the most advanced approach. These classification systems allow prospective categorization into mutually exclusive, completely inclusive categories and are highly dependable. Also, they have been performed in various countries and in large parts of the population. Robson Ten Group Classification System and the Denk 8 group classification system were given the highest overall ratings. Specifically, they have been characterized as flexible enough to been employed in different clinical settings. One of the advantages is that they offer the opportunity to implement modifications in clinical practices in order to manage CS rates. The only drawback of women-based classifications is that they fail to mention why (indications) or when (degree of urgency) the CS was conducted. According to a 2011 systematic review by Torloni et al.10 carried out a systematic review in order to synthesize the experience of the users of the Robson classification system regarding the advantages and disadvantages of the adopting, implementing and interpreting of this particular classification system, together with their modifications or recommendations regarding this classification. According to the author, the Robson classification system is praised for its robustness, simplicity, flexibility and reproducibility and the fact that it categorizes women prospectively allowing the adoption and assessment of interventions directed at specific groups. According to the users, the classification is capable of overcoming the main weaknesses of those systems that are not mutually exclusive and have low reproducibility for frequent reasons such as dystocia or fetal distress. In a systematic review21 of the Robson classification which examines its use in over 33 million women from 31 countries, out of 58 studies, 34 studies produce data according to the Robson ten groups without subdivisions and 18 studies provide their data according to subgroups or even adding new groups. Moreover, they report that the classification is clinically applicable and it can be employed as a tool to lower CS rates by itself. They concluded that several authors proposed relevant modifications that could pave the way for their implementation by medical facilities worldwide and suggest that assessing maternal and fetal outcomes in relation to CS rates would be the next critical step towards establishing an optimal caesarean section rate.In 2015, Betran et al.22, examined the increase in the number of CSs performed in Italy from the perspective of a healthcare system. They reported that CS rates in Italy are influenced by complex interrelationships, by several involved and specific circumstances and factors such as the over-medicalization of delivery, legal and social issues, variations in practice and policies across healthcare institutions and national nations, and women’s point of view regarding pregnancy and childbirth. Authors recommended that the high CS rate in Italy justifies a close monitoring of epidemiological data and hospital practices relevant to CS. Although they did not apply any classification system in their research, they suggested the implementation of Robson classification, especially in less centralized hospitals and private units, for a better insight into the causes of the growing CS rates and for the development of interventions to safely curb this phenomenon.A 2020 systematic review by Longo et al.4. According to the WHO experts, the use of the Robson classification will enable hospitals to identify and analyze the groups of women which influence to a greater or lesser extent the overall CS rates. Robson classification could compare delivery practices in these groups of women with other hospitals which have more covetable results and consider changes accordingly. Moreover, Robson classification will help healthcare facilities to evaluate the effectiveness of interventions or the strategies employed at optimizing the use of CS. Also, it will be able to evaluate the quality of clinical care and management of clinical practices by analyzing outcomes within groups of women. Furthermore, it could appraise the validity of the data collected and alter the staff about their importance, interpretation and use20.Our findings show that worldwide, there is a rapid increase in the use of the Robson classification. Unlike previous classifications based on indication for CS, the Robson classification is a comprehensive system including all women, regardless of the mode of birth or circumstances . WHO proposes the Robson classification system ‘as a global standard for assessing, monitoring and comparing caesarean section rates within healthcare facilities over time, and between facilities’24. According to WHO, sub-classifications are particularly appropriate when deciding the kind of clinical interventions that will be implemented in specific subgroups. WHO specifically emphasizes that all subdivisions must be analyzed in relation to one another, and not by themselves, in order to arrive at a valid outcome20. According to WHO, According to our review, many authors who used the Robson classification proposed subdivisions in the basic 10 groups. The aim of proposed subdivisions is to raise consistency and homogeneity of the groups by categorizing women within groups according to certain relevant criteria. In 2012, the Society of Obstetrics and Gynecology, Canada (SOGC), published the modified Robson criteria . This moThe right implementation of the Robson classification can contribute to a better understanding of the main groups that increase caesarean birth rates in Greece and to use it as a useful tool to both audit and monitor our practice in our country and/or between countries. Itself, the Robson classification could be used as a tool intervention for the monitoring and reduction of CS rates. Also, Robson classification could help individual populations with the impact of caesarean section on both maternal and neonatal morbidity and mortality rates. Moreover, it could help customize our practice for optimum perinatal health. However, the Robson system does not take account for other maternal and perinatal aspects such as: maternal age, pre-existing conditions, body mass index (BMI), type of labor, oxytocin, indications for caesarean section or non-clinical variables that influence the CS rate, concluding that more variables could be included and analyzed regarding each and every group of Robson classification in the Greek population.


Over recent years, food safety has garnered widespread attention and concern from society. Concurrently, social media sites and online forums have become popular platforms to disseminate news, share opinions, and connect with one’s social network. In this research, we focus on the intersection of food safety and online social networking by utilizing natural language processing techniques and social network analysis to study public opinions related to food safety. Using real data collected from a popular Chinese question-and-answer platform, we first identify hot topics related to food safety, and then analyze the emotional state of users in each community  to understand the public’s sentiment related to different food safety topics. We proceed by forming semantic networks to analyze the characteristics of food safety opinion networks. Our results show that Internet users form modular communities, each with differences in topics of concern and emotional states of community users. Users focus on a wide range of topics, showing that overall, food safety awareness is increasing. This paper provides novel insights that can help interested stakeholders monitor the discussions and opinions related to food safety. According to the 49th Statistical Report on the Development Status of the Internet in China released by the China Internet Network Information Center, as of December 2021, there were 1.032 billion Internet users in China. With 42.96 million new Internet users compared to December 2020, the Internet penetration rate reached 73%, an increase of 2.6 percentage points compared to December 2020. The per capita weekly online time is 26.9 h for Chinese citizens .Group 1’s focus is on the sanitation scandal of Laotan pickled cabbage. Negative emotions accounted for a large proportion of the users (66.2%), and 35% of users had an emotional value of , reflecting their extreme dissatisfaction with the incident.Group 3’s focus is on the topic of CCTV exposure, and they have a relatively large share of positive emotions (71.9%), with a high percentage of users whose emotion value is at , with 43% of users with sentiment values at , close to half of the users. This result indicates that most users are likely to face food safety problems when eating at restaurants or ordering take-out and feel angry and dissatisfied with their experiences.The distribution of emotions between the overall user base and the subgroups that we identified shows that there are differences in emotional states between users in each subgroup and in the overall group. The overall number of users in the highly positive and highly negative emotional states is almost the same, showing a divide in overall user experiences and opinions regarding food safety. However, within the grouped data, it is shown that, except for the science topics, users’ emotions tend to be extremely negative or extremely positive in response to food safety topics.A radar chart, also known as a spider plot, is a chart showing the strength of multidimensional data. It maps the data of multiple dimensions onto the coordinate axis. Based on the personal information of users in each community, the study obtained information about their industries and selected the top 15 industries with the highest number to draw a radar chart. Users on the Internet, computer software, and higher education industries post the most content on the topic of food safety within Zhihu’s platform see . In receInternet or computer software industry ranks first in each group, there are still some differences across the five groups.banking, real estate, automotive, communications, and other industries. Clearly, netizens from all walks of life are sharing their comments and opinions on food safety topics.The topics discussed in Groups 1 and 3 are hot topics of food safety exposed by CCTV. The industries of their users are widely and evenly distributed, including catering industry and the food and beverage industry have participated in these discussions. The catering industry pays more attention to the evaluation of cooking oils, and the food and beverage industry pays more attention to the issue of food shelf life. This indicates that more food safety topics that are discussed on Zhihu are likely to attract users from related fields of employment, which is likely to lead to stronger subject-matter expertise being shared within related Q&A conversations. Users in the catering industry and food and beverage industry can bring more professional answers, help, and gain more knowledge in discussions in the online community.The topics discussed in Groups 2 and 4 are popular science topics in the field of food safety. Many users in the legal industry in this group, and they help other users from a professional point of view. Netizens in the legal circle believe that when consumers encounter food safety problems, they should have the courage to defend their rights, protect themselves through legal means, and reasonably strive for their rights and interests.The topic discussed in Group 5 focuses on whether consumers should protect their rights when food safety problems occur and what are the means and ways to protect their rights. Correspondingly, there are many employees in the In all, there are differences in the industry characteristics of users among the groups. Hot topics on the Internet for food safety attract the attention of various industries, but under targeted topics, more users from related industries are involved in the discussion.The traditional LDA topic model is not effective when dealing with short texts because the words in the text are sparse. BTM is an unsupervised statistical learning model that is proposed for short texts and improves upon the traditional LDA model. BTM reveals the correlation between words through a two-word-based word co-occurrence pattern, which is then applied for topic analysis .n_iter = 10, and save_step = 100. This figure shows that the confusion degree is lowest when the number of topics, K, is 5.Perplexity is the standard to measure the number of topics selected by natural language models. When the model is more capable of generating complexity, the complexity value is smaller. Under the BTM model, five topics are classified according to perplexity, and the topic intensities are 0.67, 0.13, 0.09, 0.08, and 0.02, respectively. The intensity of Topic 1 is much higher than the others.The keywords such as “merchant,” “shelf life,” and “complaint” in Topic 1 demonstrates users’ concerns about food safety issues such as expired food and Laotan pickled cabbage. When these food safety issues occur, consumers should pursue merchants in a timely manner and use formal means to defend their rights. Topic 2 is about food safety science knowledge. Topic 3 shows the current situation that supermarkets often sell bread, milk, and other expired discounted food. Topic 4 concerns brands with food safety problems, such as Yili, Mengniu, and Yang Guofu, where consumers are prone to long-term rejection of brands that have had food safety problems. Topic 5 discusses whether consumers should apply for refunds, compensation, or even file complaints to fight for their legal rights when food safety problems occur when they dine out or take out.The subject terms extracted by the BTM model are mainly based on word co-occurrence, where the subject terms are discrete, and the correlation between the subject terms is not considered. The PMI index is applied to measure the correlation between two subject terms (keywords). Topic 1 focuses on the information available on food packaging, including the shelf life and ingredient list, the best “before date” of the food, and the ingredients and additives in the ingredient list, all of which reflect users’ concerns.Topic 2 focuses on the participants in the food industry, including consumers, merchants, and regulators. Users express that consumers should use legal means to defend their rights when they encounter food safety problems, while regulators should also increase the frequency and intensity of food safety supervision and punishment.Topic 3 focuses on the controversial topic of imported and exported food products. Whether it is milk or Laotan pickled cabbage, the quality of imported and exported foods is generally higher than that of domestic foods.Topic 4 focuses on science topics about the nutritional value of food. Users discuss the ingredients and nutritional content in food, especially caring about the nutritional value of cooking oil.Domestic food safety incidents have occurred frequently throughout China, triggering great public concern regarding food safety issues. In order to explore the public’s awareness and help improve the current state of food safety and build a harmonious online community, the hot events under the topic of “food safety” on the Zhihu platform are studied in this research. An overall food safety user network is constructed, where key users in the group are identified based on degree centrality and eigenvector centrality. Further, the user network is divided into multiple communities to analyze community-specific topics and conduct sentiment analyses on the posting within each community.The TF-IDF and TextRank algorithms are used to determine high-frequency keywords in each community. The python SnowNLP library is used to analyze the sentiment status of users in each community. The BTM model is applied to identify the discussion topics under food safety topics on the Zhihu platform. Further, Gephi is used to map the semantic network and identify the topics through the community segmentation algorithm. Finally, based on the results of user network and opinion network analysis, our conclusions are as follows:(1) Internet users in the field of food safety form virtual communities with a wide range of diverse topics of concern. It is found that users form distinct community divisions. Most of the users in the community have the same interests. The opinions of the core users in the community have a certain guiding effect on the general users, and the topics concerned by each community are different, which is mainly divided into three aspects. One is the major food safety issues exposed by the official media such as CCTV, which can easily lead to heated discussions among netizens, expressing their emotions and putting forward their own opinions. The other is food safety, a popular science topic under the Zhihu platform. These topics have been widely welcomed by netizens, and users all expressed their appreciation for the popular science experts in the food industry. The third is the food safety problems experienced when dining out and ordering food to go. Users often share and discuss personal experiences on these topics. It is noteworthy that netizens concern more about news reports of failed food safety tests and problems with unclean food encountered in their lives than about actual disease risks, which is consistent with the findings of existing food safety opinion studies ,36.(2) The formation of online communities is related to users’ concerns, emotional states, and industry characteristics. It is found that there are significant differences in the hot topics and emotional characteristics of users in different online communities, and users in each online community have the same tendency to pay attention to or feel the same way. The industry differences among groups are reflected in the fact that users are more likely to express their opinions and participate in discussions on topics in which they hold subject-matter expertise.(3) Consumers’ awareness of food safety is increasing, and awareness of rights is strengthening. Multiple methods are used to classify the text data into topics, among which those about consumer complaints and rights protection are of high intensity. With the growth of social and economic activity, consumers are now more aware of their rights, and their demands tend to be more reasonable and legitimate . There are more diverse channels of complaint and reporting, such as through 12,315, 12,345, and other complaint hotlines, or online platforms such as takeaway platforms and review platforms. The increased awareness of consumer self-protection plays a good regulatory role for food industry producers and sellers, and the timely resolution of any problems found helps to promote food safety governance.(1) Increase food safety supervision to enhance food quality assurance. Held on 27 April 2022, the “national food safety work conference of the market supervision system” emphasized that the food safety defense line should be steadily guarded against the height of politics, with extreme responsibility and with the strength of the whole system and tough violation measures. Therefore, in view of the frequent occurrence of food safety problems in China in recent years, the relevant regulatory authorities should implement the important instructions of General Secretary Xi Jinping on food safety and production safety, enhance the unity and professionalism of food safety supervision, improve the level and capacity of food safety supervision, solve the concerns and confusion of the general public, and guarantee “safety on the tip of the tongue”.(2) Enhance the quality and safety of local food and improve the influence of national brands. According to the Laotan pickled cabbage topic, the phenomenon of “double standards” in food safety has been widely discussed recently. The CHAQICAIYE Company treats domestic consumers and exported consumers differently with different quality products, disregarding the health of domestic consumers. Similar issues have led to more and more domestic consumers preferring imported products with quality assurance guarantees, safety, and security. Such preference towards imported goods is not a good sign for domestic food production and the related economical effects.As early as 2016, China has been promoting and encouraging the “same line, same standard, same quality” project for domestic and foreign products. Companies should produce domestic and export goods according to the same standard on the same production line so that products supplied to the domestic market meet the same quality standards as those in the international market. Domestic manufacturers and sellers should improve the quality control and supervision of domestic products to meet consumers’ expectations as much as possible and continuously improve the brand quality and influence of national brands.(3) Strengthen the awareness of consumers’ rights so that consumers can better defend and protect such rights. With the development and growth of China’s market economy, the food industry has seen an increase in the number of merchants, which has to a certain extent, led to an increase in violations, and consumers are prone to encounter infringements. Firstly, information related to the protection of rights should be better publicized throughout the media to help consumers establish a reasonable and legal awareness of their rights. Secondly, the popularization of the Consumer Rights law and other related laws would help to eliminate the legal blind spots for consumers and therefore protect their rights as needed. Finally, policy needs to urge the relevant departments to actively accept and resolve food safety disputes, effectively solve problems for the people, and encourage consumers to report food quality/safety problems.(1) Attention should be paid to the cluster effects within the online community, which can help to promote the healthy development of the network environment. It is found that the topic of food safety shows a strong cluster effect, with multiple virtual communities that have unique interests and emotional tendencies. The emergence of online communities makes it easy for users to find like-minded partners and discuss hot issues, but clusters can lead to extreme emotional tendencies, exaggerate real-life conflicts, and generate and spread irrational emotions . In order to purify the current situation of online platforms and promote the healthy development of online environments, platform managers should pay attention to the cluster effect, which would likely help in controlling the spread of false information and radical emotions . (2) Monitor the statements of key community users to effectively guide the platform’s public opinion. The statements of key users in the online community have a strong guiding effect on other general users and the overall discussions. Further, given that key network users cannot always guarantee the accuracy and reliability of their published information, this could lead to the spread of online rumors and false information. Online platforms should establish a more complete and effective network information supervision system, monitor the content posted by key users in the community as much as possible, reduce the spread of false information, and guide positive platform public opinion orientation.(3) Strengthen the science of food safety knowledge to help raise food safety awareness. According to the data, most users of the Zhihu platform are interested in food safety knowledge and respond to comments under topics related to food science and nutrition. Online platforms can take advantage of users’ positive psychology and sense of knowledge to enhance food safety knowledge. There are some limitations in the research. For example, only the Zhihu platform is selected, and the number of Internet users who are concerned about food safety topics is not comprehensive enough. In future research, it would be interesting to apply the methodology used in this paper to analyze other platforms where food safety issues are likely discussed, such as Yelp. In addition, the depth and breadth of data collection can be further expanded, such as by selecting more relevant topics in this field for research and lengthening the period of data collection.