Studies of past forest use traditions are crucial in both understanding the present state of the oldest European forests, and in guiding decisions on future forest conservation and management. Current management of Poland’s Białowieża Forest (BF), one of the best-preserved forests of the European lowlands, is heavily influenced by anecdotal knowledge on forest history. Therefore, it is important to gain knowledge of the forest’s past in order to answer questions about its historical administration, utilisation, and associated anthropogenic changes. Such understanding can then inform future management. This study, based on surveys in Belarussian and Russian archives and a preliminary field survey in ten forest compartments of Białowieża National Park, focuses on culturally-modified trees (CMTs), which in this case are by-products of different forms of traditional forest use. Information about the formation of the CMTs can then be used to provide insight into former forest usage. Two types of CMTs were discovered to be still present in the contemporary BF. One type found in two forms was of 1) pine trees scorched and chopped in the bottom part of the trunk and 2) pine trees with carved beehives. A second type based on written accounts, and therefore known to be present in the past , was of 3) lime-trees with strips of bark peeled from the trunk. Written accounts cover the period of transition between the traditional forest management  and modern, “scientific” forestry . These accounts document that both types of CMTs and the traditional forest uses responsible for their creation were considered harmful to “rational forestry” by the nineteenth-century forest administration. Thus the practices which created CMTs were banned and the trees gradually removed from the forest. Indeed, these activities drew the attention of forest administrators for several decades, and in our view delayed the introduction of new, timber-oriented, forest management in the BF. One of the main requirements for understanding the currently observed state of any natural environment is the knowledge of its history, and especially of past anthropogenic activities. Studying past interactions between humans and the environment is of utmost importance in the case of ancient forests with continual tree cover for perhaps several centuries. One such area is Białowieża Forest (BF), which has persisted in some form since the end of the last glaciation –2.The scale, extent and meaning of anthropogenic modification of the BF are currently not only a matter of scientific interest but have been incorporated in political discussions as part of the long-term conflict around the need to protect the forest. It is crucial then to maximise opportunities to better understand the forest’s past in order to answer questions concerning its historical administration, utilisation and change. Former traditions of forest use can be and are studied in many ways. Up to the present time, different approaches were used and these include: quantification of the impact of traditional forest use, both singular, e.g. cattle pasturing  and cumuMost studies, apart from collecting information on presently-existing CMTs and analysing their chronology and spatial distribution, raise issues of their protection for cultural heritage reasons. The durability of such remnants of past forest use is generally limited by the trees’ lifespans and the additional time they can persist in dead form. Any case in which historical, archival data of CMTs are available is therefore a unique opportunity to overcome the limitations set by the life-time of a tree’s existence.Centuries of traditional forest use created different types of CMT in BF, and these were observed and noted on different occasions since the eighteenth century. This paper explores the idea of wooded landscapes carrying the memory of past traditional uses and human-nature interactions in the form of scarred, modified or “worked” trees. Furthermore, this is in the context of introduction of modern, “scientific” forestry undertaken by the Russian administration of the Forest in the nineteenth century. The clash between the centuries-long, multifunctional use of BF and the demands of the new timber- and later game-oriented approach to “rational” forest management was observed in the case of cattle pasturing in the forest , and traThis research aimed to collect information about types of culturally modified trees in the BF and to analyse spatial and temporal patterns of the presence of different types of CMTs in the forest. The nineteenth-century data on CMT allow quantification of the intensity of traditional types of forest use that survived in the BF even after the introduction of modern, “scientific” forestry under Russian rule. Official accounts facilitate estimation of the extent of those traditional uses and allow an assessment of the efficiency of the forest administration’s fight to control  these types of utilisation.2, is a continuous region of temperate mixed lowland forest divided between Poland and Belarus. The Polish part, covering 600 km2, incorporates an area of 47.5 km2 of old-growth forest strictly protected since 1921 , and forests managed under state forestry by means of timber extraction and tree planting. The managed part is studded with smaller nature reserves with different protection regimes, but in general has a younger age class-distribution of tree stands compared with the National Park . Th. Th43]. Written sources concerning CMTs allowed the allocation of their numbers to twelve forest sections—administrative units, into which BF was divided until the 1840s . This adData on villages and settlements inside, on the border of the forest, and in the buffer zone of approximately one kilometre around the border, were extracted from the map “Białowieża Forest. Administrative division according to the Description of the Forest from 1796…” . This maAnalysis of correlation between the number of CMT, type of the forest habitat and land use, and number of villages was conducted using the Pearson correlation coefficient in R, version 3.2.3 .Archival survey and literature search, along with field survey, generated information on two forms of CMTs that still exist in BF nowadays and allowed the conceptualisation of one other form of CMT. This latter form is not now present but potentially was there in the forest historically .Pinus sylvestris trees were traditionally used for a source of resinous wood for kindling. The material was produced by scorching the lower part of the trunk, which caused increased production of resin in the damaged area. This effect is shown by studies on different Pinus species [Scots pine  species –48. The  species ). Howeve species . For com species . AcquisiAfter a short period of chaotic acquisition of BF and adjacent villages by the Russian administration, tsar Alexander’s decrees from 1802 and 1803 brought back the protection of the forest and of European bison based on a model from the previous, Polish period. For the next four decades the established traditional forest management was employed, with selective cutting in the years 1813–1821. However, from 1821, the forest, as a habitat of European bison was conserved and no timber felling allowed. It was only in 1838 that the Russian Navy started to acquire and extract oaks and pine trees for the purposes of shipbuilding . MisapprTraditional use of pine trees to collect resinous wood was no longer welcome, and was prohibited. Those trees which had been used were recorded as wasted timber described as trees “spoiled in the lower part of the trunk by chopping pieces of wood” . This laIn the period between 1843 and 1846, the forest inventory team worked in BF to produce forest management plans, including location of clear-cuts and amounts of timber to be produced. Such plans were accepted by the Special Forestry Committee in Petersburg, yet before they were realized, the Grodno Chamber of the Ministry of State Domains reported that there were still 83,704 large pine trees damaged in the lower part of the trunk by chopping pieces of wood inventoried in BF. Since these trees were mostly healthy and could be still sold as timber, the Grodno Chamber proposed to exploit them immediately rather than waiting for their turn in the forest management plan. It was argued that any delay might cause their further deterioration, and soon they would be barely useful even as firewood or for wood tar production , 53. In Damaged pine trees were stamped and selected for felling in the first instance, yet this raised several problems for the forest administration. The trees were located in different parts of the BF, with no transportation routes nearby. Eventually, a merchant C.F.L. Buggenhagen from Berlin and his Russian representative S.A. Simund were contracted in 1854 to extract 60,000 pine trees “damaged in the bottom part of the trunk” in the course of the next 5 years . ArchivaSince Buggenhagen’s contract did not end the problems of tree destruction by established uses, forest management was still looking for ways to remove both the trees and the traditions of their use from BF. In 1861, the head forester of the province Eichwald attempted to solve the problem of damaged trees present in BF whilst at the same time satisfying the constant demand from local peasants for kindling material. By clear-cutting compartment lines in the forest (first marked in 1843–1846) , he plan2 (most probably the density of such CMTs would be lower in the managed part of BF). Most registered trees were dead , and most had burning marks. Only in rare cases was the chopping off of resinous wood not accompanied by scorching of the trunk  was used but only for illustrative purposes , ownership marks, and protective measures against animals . The first two modifications are rarely observed in the forest nowadays, as usually only the beehive hollow (sometimes overgrown by layers of new wood) survives . The thiIn 1936, Karpiński described sixty-eight beehive trees in Białowieża National Park . It was Based on the historical information, another type of CMT (No. 3 below) was expected to be encountered in the forest.Tilia cordata was used on an everyday basis by the local people for a variety of uses. These uses included: bast tearing , charcoal burning, making bee-hives, collecting flowers and seeds for medicinal use, and in producing a variety of objects from lime wood [Since at least the sixteenth century, small-leaved lime ime wood . In the ime wood . In 1567ime wood . In the ime wood . The widime wood . Howeverime wood .According to nineteenth-century descriptions, two types of lime bark were stripped (in May and June): 1) large mats  from the bottom part of the trunk and 2) long strips (up to 4 metres in length) from the upper part of the trunk and branches. The first type was used to produce roof covers, chests and crates, and the second to weave mats (used mainly for transportation of goods), baskets, ropes, bags and shoes –71. BastIn an 1816 report about illegal hunting by a leaseholder of Białowieża property called Pusłowski, lime bast is mentioned as one of the advantages derived from the forest without permission by his men. The report contains information about a search conducted among dwellers of Białowieża village, which revealed thirteen fresh sheaves of lime bast .The importance of lime bast products was observed across much of the Russian Empire with Keppen noting in the Journal of the Ministry of State Domains , that whilst peasants use a lot of lime, the resource is so important for this social class that it is impossible to restrict it . In 1862The central Russian administration noted the problem and in 1859 ordered an inventory of the popularity and extent of lime use among peasants in all provinces of the empire. It was explained that “manufacturing lime products allows for the poorest peasants to earn their livelihood and pay taxes” . AnswersAlongside the official view that there was no commercial use of lime wood in BF, other sources confirm that lime bast was being used  until the end of the nineteenth century. Tearing bast from young lime trees was reported to be such a widespread activity in the 1880s Grodno Province, that lime trees were almost absent in private forests, and were to be found only in better protected state forests (including BF) . AccordiSuch widespread and long-lasting peeling of lime bark might be expected to leave a visible trace in the form of culturally-modified, scarred small-leaved lime trees, yet none were found during the preliminary survey in BF. Scars on lime trees associated with peeling should therefore be considered “ghost CMTs”, and their absence in BF is discussed below.Two types of CMT were discovered in BF and three identified in historical sources. Based on the results above these were: 1) scorched pine trees chopped in the bottom part of the trunk; 2) pine trees with carved beehives; and 3) “ghost CMTs” of peeled lime. All three can be treated as an evidence of centuries-old, traditional, multi-functional utilisation of the BF surviving well into the era of modern forestry. Modified trees are not the only case of historical, low-intensity forest use since cattle pasturing, for example, was present in the forest until the mid-twentieth century . What isAs described above, removal of damaged pine trees was not completed even by the early 1860s. Indeed, indicated by the remaining CMTs, the goal of removing modified trees from the forest was never achieved. Furthermore, as noted, after the Tsar’s hunt in 1860 the entire management of BF started shifting from timber production to game for the chase. This again halted attempts at introducing full-scale timber production. Without the disputes over CMTs, maybe the Russian administration would have had fewer problems in introducing clear-cuts in BF at an earlier date. In that case, it can be argued that the nineteenth- and twentieth-century history of the forest could have taken a very different route, with much earlier introduction of large-scale clear-cuts. It is likely that much of the conservation interest and cultural value of the forest found today would have been seriously compromised.Bison bonasus) in BF and the Tsars’ special interest in preserving this unique animal was also. In many cases, this goal conflicted with forest management, e.g. reports that sounds of timber felling scared the bison away led to temporary stoppage of felling [“Damaged” trees were not the only factor that hindered the introduction of modern forestry to BF: the presence of the last population of European bison ( felling . CMTs ca felling –33). It  felling , 78.The fact that peeled lime tree CMTs are not today found in BF can be explained in a number of possible ways. Firstly, lime trees carrying scars from bark peeling may simply be absent from the forest because other local uses resulted in the removal of the entire tree. Bark peeling was only one of many uses this particular tree species. Indeed, all parts of the tree were used, from bark and wood, to leaves, and flowers. It might be that this intensive utilisation could have led to increased pressure on lime and the cumulative effect resulting in a decrease of the share of lime in tree-stands of BF . It was Results of the analysis of the presence of nineteenth-century scorched and chopped pine trees in relation to forest habitats, land-use types and number of villages inside and on the border of the forest, are interesting. The research showed that none of these factors was decisive in determining the present spatial distribution of CMTs. This is informative and suggests that the traditional use of pine trees was common and more-or-less equally spread over the entire BF. Interestingly, even in the more coniferous parts of the forest, the number of CMTs remained similar to the deciduous areas. This might suggest that: (1) there were some mechanisms preventing overuse of certain, pine-rich parts of the forest, (2) pine chopping and scorching never reached an industrial scale, and it was not a commercial utilisation, or 3) the nineteenth-century BF generally had higher proportions of pine and spruce. Maybe these trees were abundant in all forest types.The reliability of the historical data is always an important factor in environmental history work, and our paper is not an exception. There is a possibility of bias resulting from the selection of documents for preservation by historical actors. However, in the case of the Russian forest administration this seems unlikely for two reasons. Firstly, the administration itself was strictly hierarchical and bureaucratic, and all aspects of forest management were reported to at least two levels of higher authorities. Not reporting cases like the presence of “spoiled trees” or removing archival documentation of such on a large scale was highly unlikely. Secondly, archives visited during preparation for this work contained continuous series of documents concerning the management of BF from 1830s until the end of Russian rule over the forest in 1915, and we did not find any significant gaps in archival information in that period.The history of CMTs in this particular Polish example illustrates processes of much wider relevance i.e. the process of disenfranchisement of local dwellers from their traditional uses of the forest. This has strong similarities to colonial processes in eighteenth- and nineteenth-century Australia and North America. There, European colonization impacted the indigenous forest management, disturbing or even entirely stopping the traditional stewardship of resources. Similarly to such cases, CMTs in BF record the prior system of land use often erased by modern management systems. CMTs are a visible, persisting evidence of different forest management regimes from several centuries ago. As such they are a cultural component of the forest landscape. On the other hand, these trees are still a part of living nature and of the natural forest life-cycle, in which competition between trees and natural dynamics accelerate the exchange of tree generations. Aging and decaying CMTs will eventually vanish from BF, but before they do, it is important to record and analyse them in order to gain insight into the forest’s history and to address questions that otherwise could not be answered based on historical sources alone.Ips typographus) followed by mass-scale logging using heavy machinery ignited the discussion on the future of the forest. Many foresters and forestry experts favour turning BF into intensively managed and regulated forest, and most of the scientific community urging the strengthening of the protection of natural processes in BF [Our findings help inform the on-going debate surrounding the management of BF . The rees in BF , 86. OneA systematic inventory of all CMTs in the entire forest (Polish and Belarussian parts).More detailed analysis of spatial distribution, age and chronology of use of surviving CMTs and introduction of new methods of analysis .Creation of a conservation plan for the most important veteran trees with a plan for their use in education .Comparison with other sites where CMTs were studied in search for common global patterns of different aspects of past life of traditional populations and their expression in the form of CMTs.The culturally modified trees of BF remain an interesting topic with much still to be discovered. There are several opportunities for future research:


In the last few years, several studies have focused on describing and understanding how virtual coaches  could be key drivers for health promotion in home care settings. As there has been enormous technological progress in the field of artificial intelligence and data processing in the past decade, the use of virtual coaches gains an augmented attention in the considerations of medical innovations.This scoping review aimed at providing an overview of the applications of a virtual coach in the clinical field. In particular, the review focused on the papers that provide tangible information for coaching activities with an active implication for engaging and guiding patients who have an ongoing plan of care.virtual coach in the clinical field performing a methodical review of the relevant literature indexed on PubMed, Scopus, and Embase databases to find virtual coach papers focused on specific activities dealing with clinical or medical contexts, excluding those aimed at surgical settings or electronic learning purposes.We aimed to investigate the use of the term After a careful revision of the inclusion and exclusion criteria, 46 records were selected for the full-text review. Most of the identified articles directly or indirectly addressed the topic of physical activity. Some papers were focused on the use of virtual coaching (VC) to manage overweight or nutritional issues. Other papers dealt with technological interfaces to facilitate interactions with patients suffering from different chronic clinical conditions such as heart failure, chronic obstructive pulmonary disease, depression, and chronic pain.Although physical activity is a healthy practice that is most encouraged by a virtual coach system, in the current scenario, rehabilitation is the great absentee. This paper gives an overview of the tangible applications of this tool in the medical field and may inspire new ideas for future research on VC. Virtual coaches are seen as key drivers for health promotion in home care settings. Concurrently, against the background of demographic development, the continuity of care from the professional environment into the home has become critical to ensure patients’ quality of life and to optimize the economics of medical and social treatments. Nowadays, 1 out of 6 people in the European Union (EU) has a disability . Acute dAs there has been enormous progress in the fields of artificial intelligence (AI) and data processing in the past decade, the use of virtual coaches has gained increasing attention in the considerations of medical innovations. The term virtual coach refers to a coaching program or smart device aimed at providing coaching support through a variety of applications. The virtual coach will be able to personalize and adapt goals according to the progress achieved by the user in their recovery from their impairments or disabilities. It is broadly defined as any form of coaching using electronic media, including or excluding input from a real (human) coach. The virtual coaches guide and train users through a set of tasks, with the aim of supporting positive actions or assisting in learning new skills. For example, virtual coaches could help users to define and preserve a fitness program, suggest problem-solving skills training, or advise patients with specific medical conditions -8.The latest technological developments have shown promise as effective, accessible, and cost-effective solutions. Recent research about the use of embodied conversational agents  has shown that users can efficaciously form a working alliance relationship with a nonhuman agent  .Virtual coaching (VC) is becoming increasingly important in medical care and in health-related research investments. For example, the recent EU’s Horizon 2020 research framework program funded several projects on VC through a specific call entitled “Personalised coaching for well-being and care of people as they age” . The priCurrently, VC for rehabilitation support in the home environment is still in its initial phases of development from the technical, organizational, medical, and ethical points of view. It is of the foremost importance to provide a terminological and conceptual foundation for this new field. Therefore, we sought to investigate the use of the term virtual coach in the clinical field by performing a methodical review of the relevant literature on VC. Pretests of the body of literature for finding a suitable review method revealed a variety of VC approaches, conversational agents and avatar applications, study designs, diseases, and outcome measures, such that the approach of a traditional systematic review appeared inappropriate. We decided to use the scoping review method  to map tThis review can be used as a starting point by clinical researchers and clinicians interested in VC, revealing the potential of VC systems in the clinical domain, and supporting the understanding of the essential components of such interventions.We chose to adopt and follow the Arksey and O'Malley scoping review methodology . The litConsidering the main key concept for our research, specifically a coaching program or smart device aimed at providing coaching support through a variety of applications, we identified the relevant key words  for an initial search strategy. These keywords were then refined and used for the identification of related terms. Thus, the final keywords were as follows (syntax was adjusted for each database as necessary): “virtual coach” ; “virtual trainer”; “virtual training” ; “virtual therapist”; “virtual nurse”; “virtual agent”; “embodied conversational agent”; “avatar assisted therapy” (OR “avatar mediated training” OR “avatar therapy”); “e coach.”Medicine, Health Professions, and Psychology. Only published journal papers written in English were included, but there was no limitation regarding the publication date.In addition, wildcard symbols, such as hyphens or inverted commas, were used to consider all possible variations of root words . Limiting categorical area terms were used for the Scopus database: In addition to the electronic database search, a manual search was performed in JMIR for issues dated up to July 2019. Moreover, we carefully checked references to each article we found to avoid missing relevant papers not identified in the electronic search . Two authors (PT and IS) conducted the literature search, and they stored the references in a spreadsheet program, removing duplicates.In a second step, after electronic searching and handsearching, we used the titles and abstracts of the identified articles to check their pertinence to the medical domain. At this step, we selected papers that focused on specific VC activities dealing with clinical or medical contexts, excluding those aimed at surgical settings or electronic learning (e-learning) purposes.The preselected abstracts were considered for full-text analysis if the related VC had a reasonable sense of agency, with some extent of autonomous behavior able to exhibit some form of reasoning. Furthermore, 3 reviewers  independently examined the search results of possible relevant papers. Consensus rounds were used to solve disagreements in the selection.Publications that satisfied the initial inclusion and exclusion criteria were downloaded into bibliography manager software  for furtData were summarized in a descriptive form. A quantitative assessment was attempted, but the wide heterogeneity in the study design, instrumental technologies, characteristics of the studied subjects, and analytical methods adopted in the studies prevented any type of meta-analysis of data.After reading the titles and the abstracts, 309 records clearly did not meet our eligibility criteria; the 89 remaining records were selected to undergo further analysis. Several articles were related to clinical aspects; however, they were not focused on specific coaching activities. Therefore, we further excluded 49 records that did not meet the inclusion and exclusion criteria for full-text assessment. In detail, 27 papers were excluded because they were related to mere virtual training approaches, without any implication on coaching activities or clinical applications, 8 analyzed e-learning platforms, and 6 were related to emotional aspects of ECA . In addition, 3 were excluded because they presented a model of user-interface communication services, 2 were only related to reminder or agenda services, 2 presented the analysis of interactions between users and commercial virtual environments, and 1 was a review on behavioral changes. In addition, using handsearching, we retrieved 6 additional records, 1 of which was a conference paper previously not included by automatic research.After a careful revision of inclusion and exclusion criteria, a total of 49 records were finally selected to undergo the full-text review. In addition, 16 of the 46 studies selected were clustered as randomized controlled trials (RCTs), 21 as exploratory studies, 5 as review articles, and 5 as theoretical studies. We identified 5 reviews on VC. To define the fundamentals and elementary components of the term virtual coach, we first analyzed the reference paper by Ding et al . RecentlRegarding their clinical fields of application for VC, most of the identified articles classified as RCTs directly or indirectly addressed the topic of physical activity -26,30,32Conversely, we identified several scientific articles that highlighted the growing interest in the use of computer-based ECAs for clinical purposes, both in the context of physical activity ,41,43,51ad hoc platforms comprised of one or more devices with a dedicated software that are used for training and coaching interventions. VC platforms use several tasks to support the learning of new activities and encourage positive or correct behavior. According to Ding et al, 4 components  define the space of action of such interventions and address when, how, and what message, feedback, and stimuli to deliver.The term virtual coach was firstly used in the athletic context during the 1950s, in reference to sporting coaches that were leading the teams behind the scenes or over distance. The earliest medically oriented usage of Virtual Coach was in 1997 in an operating room for guiding a nonstandard surgical procedure. Nowadays, the term virtual coach is a specific technological concept referring to This could be defined as the observation and recording of a specific activity or a specific condition, related to personal and physical information . Self-monitoring is performed  with a wide variety of sensors that allow the tracking of the user performance, triggering messages to the user only when they are necessary and relevant.This consists of a collection of specific contextual parameters  and of the responsiveness to an interruption of a task based on that contextual information. However, many more factors, such as the emotional state of the user and the reason and modality of the interruption, are crucially linked to the responsiveness . Sensor A coaching strategy selects which kind of content should be contained in each message delivered to the user, distinguishing general versus specific messages and the incorporation of proper emotional effects within them. The strategy also aims to perform a dynamic adaptation of the activities to the needs, performance, and improvements of the user, which are collected through the two self-monitoring and context awareness phases. Due to the adaptation, the annoying effect could be avoided and the user may be more confident in their use of the system. Moreover, positive messages may help to reinforce the performance, comfort, and interest in using the system. Conversely, the use of negative feedback and messages should be limited as they are normally inappropriate and the aim is to decrease errors.This includes the different kinds of interfaces  that can be used to deliver coaching messages to users. As matter of fact, ECAs have become the most popular interface because of increasing innovations in the field of computer graphics. ECA interfaces could be very different, ranging from simple animated characters to humanlike or animal-like entities, talking animals, or many other varying forms. One of the common trends is to design animated humanlike agents and then characterize them with a great heterogeneity of features, from its gender, aesthetics, and voice to its personality and behavioral patterns.As previously mentioned, the ability to provide coaching messages in a way that is personalized both to the user and the situation will likely develop a trustworthy relationship between the VC platform and the user, improving the acceptance and effectiveness of the technology. In this context, the interaction between the virtual coach and the user acquires a priority role. From the analyses of the literature, a description of the interaction between VC and users was found as the relevant topic. Several articles examined this theme in depth ,49,53,55Moreover, the structure and format of the dialogue, together with the content of individual expressions, needs to be personalized according to the users’ progress in the system, their current status, and the speech context . An acceAccording to Kreps et al , the sucA group of 20 out of 46 revised papers see  used thethe interface that allows users to communicate with the ECA ;the algorithm that consists of the mental capacities of the ECA, allowing the ECA to react empathically with users;the so-called embodiment  of the ECA, meaning how it appears . The look of the ECA is also defined by the way in which it communicates with users .The authors also categorized the way in which information was conveyed: ECA and users could communicate with each other through speech, facial expressions and eye gaze, hand and body gestures, or simply text . The negSimulating facial expressions and eye gaze (face-to-face conversation) is particularly important in health care when dealing with users with low literacy because in those cases, face-to-face encounters with health providers remain the most effective interaction modalities . RegardiRegarding the social aspects of ECAs, it is worth mentioning that one of the selected articles described 4 social roles for ECAs : (1) theIn addition, a pilot study evaluated how older adults could interact with a pet avatar . This stIn conclusion, studies indicate that ECAs have the following benefits:Social interaction: relations between a human being and a machine are social; an avatar supports contact in a natural way, like with other human beings.User attention: animated characters can attract the user’s attention.Real simulation: embodied relational agents provide the illusion of liveliness and interacting with a real person.Body language information: facial expressions of the avatar contain a lot of information.Trustworthiness and believability: the level of trustworthiness is amplified by the humanization of the ECA; a realistic face seems to be rated as more intelligent, engaging, and likeable.The analysis of the literature showed that the application of the VC has involved different areas of the medical domain, which allowed us to address the problem from different angles. In particular, the studies evaluated specific topics, such as physical activity and nutritional regimen, or wider contexts linked to the reduction of the risk of illness. The following are the main topics covered.The physical activity of adults and elderly people is increasingly recognized as an essential lifestyle behavior in maintaining health and preventing diseases. Therefore, it is not surprising that many articles have tried to introduce an automated exercise promotion system to support motor activity in healthy or overweight elderly subjects.At the beginning of this decade, Segerståhl and Oinas-Kukkonen  supporteAmong the elderly population, Bickmore et al ,22 evaluIn addition, a Web-based physical activity intervention was proposed to increase health and reduce risk factors in the elderly population. In several studies from the same group ,25,26, aSimilarly, in a preclinical exploratory trial , an infoWatson et al  demonstrTo provide guidelines for the design of persuasive technologies for promoting regular exercise behavior, Oyibo et al  conducteIn a cohort of 10 patients with prediabetes, Srivastava et al  recentlyVC could play a fundamental role for people with chronic diseases, providing them with support for the self-management of their problems at home. This explains why some authors have begun to evaluate the use of e-coaches in communities of no longer healthy subjects. In 2008, Allen et al  developeRitchie et al  conducteRegarding the neurological diseases, Ellis et al  conducteWith a virtual therapist designed for speech therapy that works across devices, and built-in Web monitoring, scheduling, and communication technologies, van Vuuren et al  recruiteWith the role of virtual nursing avatars (VNAs) considered to be promising and evolving  in the cIn a 3-month pre- to postdesign pilot study, the promotion of HIV medication adherence was also explored in 43 patients using a theory-based, mobile-delivered, ECA to provide information and behavioral skills. They showed good acceptability and preliminary efficacy in improving drug adherence .The promotion of therapy adherence in other chronic diseases was also described through a Web-based nursing intervention in some pilot RCTs ,31, whosThe use of VC has also involved the field of, both in offering new educational approaches or psychotherapeutic support, and in trying to understand the relationship between ECA and user. In 2013, Hudlicka  reportedECAs and VC services with an integrated cognitive training system, interactive clinical scales and tests to identify chewing and swallowing difficulties, with integrated pedometers and other wearable sensors , as well as a home-based interactive information environment can be used to identify and prevent disease-related complications at home or outdoors. This type of coaching system has been demonstrated in health problems such as obesity and a sedentary lifestyle ,22,27. TAny implemented VC service such as ECA should also take specific care of treatment adherence monitoring. In this sense, the creation of a virtual social environment may include that patients could exchange information with other patients or could directly contact their reference health care professionals for treatment-related inquiries . HoweverThis scoping review shows that in the last 10 years, there has been a growing interest in implementing VC programs aimed at stimulating and guiding users toward positive behaviors in the various sectors of the health care world. In the review, we evaluated all available evidence on the use of VC, defined a coaching program, and suggested problem-solving strategies helping users to face specific medical conditions. In most cases, a successful VC approach must consist of participant-involving methods, with a focus on the individual patient’s lifestyle conditions. In addition, the review allowed us to map the key concepts currently tied to the users’ or patients’ VC, such as function and symptoms, medication, dietary recommendations, recognition and coping with alarm signals of worsening of the disease, psychological and emotional reactions in connection with the disease, and exercise strategies. The patients’ relatives or other acquaintances can be involved depending on the patients’ needs and requests, and education must be conducted in a combined individual and group-based setting.Recently, another review examined eHealth interventions with the combined use of self-tracking and persuasive e-Coaching . It is iRegarding the medical care context, to date, the use of virtual coach technology–assisted care seems to be more represented but it has mainly been implemented for healthy subjects with the aim of improving their health behaviors and reducing the risk factors for cardio- and cerebrovascular diseases, such as obesity or physical inactivity. On the contrary, only 7 studies considered groups of patients with chronic diseases  with the intent of demonstrating the usefulness of different internet-based health coaching interventions. These were aimed, for example, at improving communication with nursing staff, reducing the rate of rehospitalization of patients, or promoting their daily physical activity.It is noteworthy that this review found 16 RCT studies among the 46 articles selected for concrete coaching interventions in the medical health field in the last 10 years. However, although this may represent an interesting fact for a topic that has appeared over the last 15 years, it deserves some specific considerations. First, as the majority of RCT studies involved healthy subjects, although often constitutionally overweight or in old age, their primary aim was often to promote healthy behavior. Moreover, with particular reference to this type of intervention on a healthy population, RCT studies have so far preferentially evaluated the use of VC for the purposes of primary prevention ,29,30,32In relation to the ambitious goal of helping with the implementation of primary prevention, it is obvious that both the limited number of subjects studied and the short time of use of the technological solutions have not yet allowed research to sustain the absolute effectiveness of VC in producing a change in harmful behavior or maintaining good habits that can positively affect people’s health. Conversely, it is known that studies related to lifestyles and how these can be modified in a positive and healthy way require several years of monitoring of a large population. Second, although 6 RCT studies evaluating physical activity and 3 being overweight are present, the comparability of results within each of the two groups is inadequate for differences in average age and sample size of the studied populations, in the types of interface, and in the used outcome measures.Most of the remaining studies, definable as exploratory, return little information beyond the interest of some authors in evaluating the application of VC in the management of some pathological conditions.Health promotion can be achieved by using ECA or IVR systems, as the usability and acceptance of these devices is usually high ,30,46. TThe therapeutic alliance between the patient and the health professional has also been considered an integrative element in all forms of therapy, regarding both the efficacy of treatment and the improvement of adherence. Interestingly, ECAs, especially those exhibiting empathic behaviors, can potentially deliver nonjudgmental support like real face to-face communication, and thus may compensate for clinical failures in some groups of patients. ECA might also be used to promote healthy eating habits specific to neurologic and cardiologic patients. In addition, taking care of nutrition in patients is very important, particularly during pharmacological treatments as many nutrients may interact with drugs , thus interfering with their intestinal absorption. Although the ideal characteristics of an ECA developing an empathic relationship with the user are still under study, this interface seems to bring good acceptability in many studies and could be the best solution today in terms of an interface for controlling the regular intake of drugs in patients with chronic diseases.The review has revealed a certain interest in cardiological and neurological diseases which, as is well known, often require changes in lifestyle, adherence to drug therapies, and specific rehabilitation programs. Specifically, cardiological and neurological diseases are especially relevant for people as they age. They include cardiovascular diseases, such as heart attack and heart failure, cerebrovascular diseases, such as stroke, or neurodegenerative disorders such as PD. Admittedly, these diseases have quite different pathogenic mechanisms and therapeutic treatment, with an acute onset or a chronic course. However, the structure of the rehabilitation programs is quite similar, even if the care plans and their basis might differ at some points. Their main objective is to help the patients in improving their quality of life as much as possible through recovery of their fitness levels and motor and cognitive disabilities. People should be supported in relearning or regaining the ability to deal with their home environment without (extensive) help. Thanks to the progress in acute treatment , most people survive acute pathological events but they are often affected by long-term disability.Consequently, rehabilitation (mainly as organized inpatient multidisciplinary rehabilitation) remains one of the cornerstones of disability treatment. Rehabilitation strategies help survivors to relearn skills that are lost. In the literature, there are models ,68 that The lack of continuity of care leads to a gap between the real patient’s condition and the level of recovery that they could reach with a constant, well-structured rehabilitation process ,52. To mad hoc VC systems could be the answer to these problems.In addition to improving motor and cognitive manifestations by proper monitoring and rehabilitation programs, one of the main elements determining quality of life is related to rehabilitation strategies oriented to promote independence in basic and instrumental activities of daily living. For all these reasons, it is time to design and implement coaching systems capable of activating the appropriate strategies to improve the motor and cognitive disabilities of patients, including those promoting independence in personal hygiene, dressing, self-feeding, using the telephone or other forms of communication, and taking prescribed medications. Thus, continuously applied and personalized rehabilitation programs help people with disabilities to improve the body functions that limit reinsertion into their home or community, living independently, and participating in education, the labor market, and civic life . CurrentThe review of the VC literature confirms an increased diffusion of technologies with strong interaction with human beings in the world of health and medicine. The increase in interest on this issue is evident not only in the number of publications since the beginning of the current year but also in the guiding vision of the EU’s Horizon 2020 research framework program.If up to now most studies have tested the goodness of the technological interlocutor and the availability of the human one, in the future, we will try to strengthen this relationship in the medical sector as we are working to foster patients’ engagement toward a process of self-awareness and self-confidence in health management. Nevertheless, advanced modes of presence will lead to ubiquity of the VC and allow further interaction modes. Integrating the VC within the real world in terms of an augmented reality  will broaden its abilities to guide the user and therefore increase the literacy of the suggested actions. Advanced sensing and acting levels allow seamless adaptation in relation to the people’s conditions. Prospectively, multiple linked coaches will allow better monitoring and guidance of the user. Furthermore, the to-be virtual coach will not only improve basic treatment scenarios, but the advanced AI may also infer new treatment strategies.Hopefully, these changes will allow us to deal with increasingly complex clinical situations, mainly belonging to the world of chronic diseases and disabilities. The lesson acquired so far, aimed at promoting coaching interventions often on healthy subjects, independent thinking, and acting, represents an important step in transferring the experience of the interventions on the major themes of primary prevention to the more complicated and specific ones of secondary prevention.Thus, the future of VC for frail or sick people is expected to provide solid evidence about the usefulness and effectiveness in preserving physical, cognitive, mental, and social well-being for as long as possible. More specifically, the VC will educate and finally empower patients to increase their adherence to drug therapy and to pursue physical and cognitive rehabilitation programs to regain independence with a healthier lifestyle and a better quality of life.This scoping review was guided by a protocol reviewed by a research team that adopted Arksey and O’Malley’s definition for scoping reviews at the outset of the study and found that their simple definition was generally useful in guiding study selection. To ensure a broad search of the literature, the search strategy included 3 electronic bibliographic databases, the reference list of different articles, the websites of relevant journals, and the snowball technique. Each citation and article were then reviewed by 3 independent reviewers belonging to different disciplines (medicine and bioengineering) who met at regular intervals to resolve conflicts.For several reasons, this review brings new information to the reader’s attention. First, it revised the definition of virtual coach, demonstrating the current validity of the first description made by Ding and how it can still include the technological developments of recent years aimed at improving interaction between virtual coach and user. Second, with an innovative approach, the review significantly aimed at highlighting which medical care sectors were considered to apply VC. Considering this extensive analysis, the review aimed to return useful information to bioengineers regarding the current potentialities of the medical application of VC and look at its possible future uses.Nevertheless, some limitations are worth noting. First, because of variability in the conduct of scoping reviews, we are aware that there is a need for methodological standardization to ensure the strength of evidence. Second, this review may not have identified all the papers in the published literature despite attempts to be as comprehensive as possible. Our search algorithm included 9 different terms (and their declination) previously used to describe the VC devices and services; however, other terms may also exist. Although our search included 3 databases , the overall search strategy may have been biased toward health and sciences. Moreover, we may have missed some papers in the gray literature.The continuous technological progress is changing the impact on users of the use of a humanoid avatar, which is an artificial figure apparently substitutive for a health professional. This relationship could entail numerous preconceptions, such as the lack of a direct dialogue between doctor and patient. As already underlined, a trusty relationship will be based on the good interaction between the user and the avatar and on how much the latter is recognized as an element of a high-quality medical care process. However, the psychological implications of this relationship can only be known through the concrete application of these technologies. Based on our analysis, we must look forward with confidence, aware that there are still several open questions. In a broader vision, many articles on VC have directly or indirectly addressed medical aspects of utmost importance in both primary  and secondary  prevention.However, the review gained evidence that VC is more rarely applied in medical care for secondary prevention. As a matter of fact, although physical activity is mostly encouraged by a VC system, we know that it cannot be compared with a real rehabilitation program, whose indication is of extreme importance in patients suffering from acute disabling events or motor functional impairments because of several chronic conditions. Therefore, in the current scenario of VC application, rehabilitation is the great absentee. Thus, looking at a secondary prevention of chronic diseases, VC has a concrete potential to improve medication adherence and to extend existing rehabilitation programs for patients, providing a great opportunity to guarantee the continuity of care between hospital and home. Considering these considerations, it is essential that the constructive dialogue between bioengineers and clinicians in creating innovative technological platforms continues and improves to deal synergistically with new challenges in the world of medical care.


This paper explores the phenomenon of international servicification of manufacturing from the period 1995 to 2011. By applying empirical techniques of Social Network Analysis and graph theory, we find that the network of flows of intermediate services embodied in manufacturing exports is still slightly dense and would not correspond to a traditional centre-periphery structure. The mapping shows a numerous, highly cohesive group of countries, with China, the USA and Germany as central economies and an increasing leading role of Asian economies, which would indicate their commitment to upgrading within global value chains. We go a step further by empirically analysing the impact of the countries’ centrality in the global network of intermediate services on manufacturing competitiveness. Our findings reveal that, together with the level of embodiment of intermediate services into manufacturing exports, who the providers of those services inputs are is a key determining factor for manufacturing competitiveness. The growing importance of services in international trade is widely supported by the empirical literature. The phenomenon becomes even more evident when trade flows are measured in terms of value added. Services account for around 50 percent of world exports according to the OECD-WTO Trade in Value Added (TiVA) database. One of the possible explanations for this expansion could be the ever more segmented and geographically dispersed production processes, as long as efficient and high-quality services are key elements for the proper functioning of these global value chains (GVCs). At the same time, advances in information and communication technologies and fewer obstacles to their international exchanges have enabled services to be more tradable. The whole is a virtuous circle which leads not only to the cheapening and upgrading of these services but also to driving the international fragmentation of production forward.This growing dependence on services is most clearly addressed in the manufacturing industry –5. In anThose interdependent dynamics are configuring a world inter-sectoral network in which services are playing an ever more prominent role. Also, the level, intensity and function of countries which participate in the network are not trivial. The role of different countries as demanders or suppliers of intermediate services embodied in manufacturing will largely depend on their comparative advantages, which, in turn, will determine their type of GVC participation. Countries with low labour costs often integrate into GVCs by focusing on manufacturing and assembly phases. For that, they require access to high-quality, highly specialised services in order to maintain and improve their position in the network. In the absence of domestic supply, these services are generally demanded abroad. Therefore, in parallel to GVCs in manufacturing sectors, a global network of suppliers and users of intermediate services to be incorporated into manufacturing has emerged.The aim of this paper is twofold. The first is to identify the “expert suppliers” within the global network formed by cross-border exchanges of intermediate services embodied in manufacturing exports, and the evolution of the network over time. To do this analysis, we will use data from TiVA database and will apply Social Network Analysis  tools and graph theory to this world network. Secondly, based on the results obtained in the previous analysis, we will go a step further by empirically studying how countries’ expertise in the global network of embodied intermediate services affects manufacturing competitiveness. Our hypothesis is that, together with the level of embodiment of those services, who the providers of those intermediate inputs embodied in manufacturing exports are matters: the higher the performance of services suppliers, the more intense the competitiveness-enhancing effect.The second part of the analysis is the main contribution to the existing literature. While the effect of using foreign material inputs on manufacturing competitiveness has been widely investigated in recent empirical literature –14, the The article is structured as follows. After this introduction, the second section explains the data and indicators used in the analysis of the characteristics of the network and the role of the countries that form it. This analysis is carried out in Section 3. Section 4 presents the empirical model to test the role of embodied intermediate services in manufacturing competitiveness and discusses the results. Final considerations are reported in Section 5.As mentioned in the Introduction, our main goal is to test whether or not, together with the level of embodiment of services inputs into manufacturing exports, a higher performance of services suppliers has a competitiveness-enhancing effect on manufacturing exports. Data to construct those explanatory variables as well as the dependent variable (manufacturing competitiveness) come from the TiVA database, December 2016 edition. It offers information for the period 1995–2011 for 64 countries (see Table A.1 in i’s manufacturing sector at time t (RCAMDVAit for short) is calculated as follows:DVAMit denotes the forward linkage-based measure of value added that originates from the manufacturing sector of country i and is embedded in the gross exports from all sectors of that country i, at time t. Then, RCAMDVAit is the ratio between the share of domestic manufacturing value added embodied in country i’s gross exports in the country’s total domestic value added embodied in gross exports at time t, and the corresponding share for the world. As in the traditional RCA, an RCAMDVAit index greater than one would indicate that the country has a revealed comparative advantage in that sector. Conversely, a value lower than one means a revealed comparative disadvantage for that country-sector.Manufacturing competitiveness is measured by a modified version of revealed comparative advantage (RCA). The traditional RCA is the share of a country-sector’s gross exports in the country’s total gross exports, relative to the share of that sector in world gross exports. Instead, the modified RCA indicator takes into account both domestic and international production fragmentation and is based on domestic value added (DVA) embodied in gross exports , 21. SpeRCAMDVA in 1995 and 2011. It is divided into four quadrants. There are more countries located in the bottom left quadrant, where comparative disadvantage prevails in both periods, than in the upper right quadrant, where comparative advantage exists in both periods. This is an expected result since most countries in the sample are high or upper-middle income level economies, with specialisation in the service sector. Additionally, countries located along the diagonal line are those with improvements in manufacturing competitiveness between 1995 and 2011, while those below the diagonal line have seen their manufacturing competitiveness decline. The number of countries in each area is quite similar. The farther the country is from the main diagonal, the greater the change. Advanced countries such as Finland, Ireland, Sweden, Canada, the United Kingdom, Belgium, Denmark, Austria, Luxemburg and Hong Kong exhibit a substantial worsening in manufacturing competitiveness. The first three countries still show comparative advantage in 2011, while Canada has lost it. On the other hand, other advanced countries such as Germany, Japan and Korea show the largest improvements in manufacturing competitiveness. Finally, emerging Asian countries such as China, Thailand, Cambodia and Vietnam and Eastern European countries such as Romania, Slovakia, the Czech Republic, Hungary and Bulgaria have also significantly strengthened their comparative advantage over time.FSVAoinXMi, where o is the origin or source country of the foreign services value added (FSVA) and i is the destination country whose manufacturing exports (XMi) embody that foreign services value added content.To measure the expertise of suppliers of intermediate services embodied in manufacturing exports, we apply SNA methodology to data on foreign value added which comes from services sectors and is incorporated into manufacturing exports. This information comes from the TiVA database and is calculated using OECD Inter-Country Input-Output (ICIO) tables. Specifically, it is based on the Leontief inverse matrix to capture those final foreign value-added flows in exports after all stages of production have propagated through the world . In thisSince it is reasonable to expect a varying impact of different intermediate services on the competitiveness of manufacturing exports, in addition to aggregate services, we consider four types of services separately in our analysis, according to the ISIC classification: Trade and distribution services (ISIC Rev. 3.1. codes 50–55); Transport and communication services (ISIC codes 60–64); Financial services (ISIC codes 65–67) and Computer, R&D and other business services (ISIC codes 72–74).oinXMi) in world services value added embodied in world manufacturing exports values (∑o ∑i FSVAoinXMi). Those shares are denoted by woi and measured as:SNA methodology is based on mathematical graph theory and thus we must start with the construction of a network with nodes and edges. In our analysis, the nodes are the 64 economies included in the TiVA database, and the edges are the countries’ shares of foreign services value added embodied in their manufacturing exports  threshold is set.As we are interested in comparing the network at two different moments in time, by using these shares, trend effects are eliminated and we obtain adimensional weights that are automatically deflated, allowing for consistent comparisons across different years and country types . Additiowoi. Additionally, we also explore the properties of the binary projection of the weighted generic matrix (W) by analysing the mere presence or absence of a flow of services value added embodied in manufacturing exports between two countries. The elements of this binary matrix (A) will be: aoi = 1, when woi>0; and aoi = 0, when woi = 0.While we are interested in evaluating the network from both a qualitative and quantitative point of view, we consider it from two complementary standpoints. First, we build a directed weighted network where each directed link is woi for any pair of connected economies. As an illustration, woi with a value of 0.33  would correspond to the services value added from source country 1 embodied in manufacturing exports of destination country 2  divided by world services value added embodied in world manufacturing exports . We would have to construct four separate data tables , and the total amount of services value added that each country provides to all destination countries to be embodied in their manufacturing exports  will be its outstrength (∑iwoi). Conversely, the backward links (column links in oaoi), and the total amount of foreign services value added that each manufacturing exporting country embodies from all its provider countries  will be its instrength (∑owoi).As long as the network is directed, we can consider the flows of embodied services valued added from two different perspectives: outgoing edges or forward links, and incoming edges or backward links. The first ones (row links in As the increasing role of those embodied intermediate services has resulted in changes in the network structure (and vice versa), SNA is an appropriate methodology since it enables us to measure the nature and evolution of these intermediate services-manufacturing relations between countries in ways that other measurements do not capture. These changes comprise a double dimension: (i) How many, which, and how countries participate in the network; and (ii) With what intensity, in terms of volume of embodied services value added, they will do it. By analysing the changes in these dynamics and identifying those countries that have played a prominent role in them, we will be able to detect the expertise suppliers of embodied services value added within the network.mutual enhancement effect. Examples of these third iterative refinement centralities in which every node gets support from its neighbours are eigenvector centrality and cumulative nomination algorithm for undirected networks, and page rank and Hyperlink-Induced Topic Search (HITS) algorithms (and their variants) for directed networks.Of course, the influence of a node in the network is largely affected and reflected by the topological structure of the network it belongs to, and the interpretation of what is meant by “important” in a network depends on what the aim of the analysis is. Accordingly, many different measures of node-centrality have been developed. All of them assign a value to each node ranking the nodes subject to their importance. Roughly, three kinds of node-centrality indicators have been developed in the related literature : (i) cenauthorities and hubs. In its original meaning, a node with a high authority value is indicated by many other nodes with high hub values, and a node with a high hub value indicates many nodes with high authority values. In a directed network, the authority score of a node equals the summation of the hub scores of all the nodes that point to this node while the hub score of a node equals the summation of the authority scores of all the nodes which this node points to. As is well known, in the PageRank algorithm the importance of a node is determined only by the importance of the nodes pointing to it, i.e., as an authority. Thus, in the case of our network, the weighted HITS is more nontrivial, as it reflects the two-links network structure [The HITS algorithm was originally introduced by Kleinberg  to rate tructure . Althougtructure .hubs and authorities, to clarify the network topology changes more exactly in terms of network science than the original HITS does [hubs will be those economies that not only supply services value added to other economies which do not produce them domestically, but also are the origin of a very intense flow from them towards other countries which are sophisticated recipients themselves, central countries within the network as suppliers, i.e., the more discerning customers that choose the best suppliers.Since we are interested in identifying those high-quality, highly specialised services providers within the network, i.e., those countries considered by their partners to be “expert suppliers”, in this paper we will specifically apply the weighted HITS algorithm, that is, the quantitative measures of ITS does , 28. AltIn SNA, the within-sample dynamics of the network and its main characteristics can be summarised by topological measures and paths. Before identifying who the expert suppliers in the embodied services value added network are, it is necessary to contextualise these measures, i.e., to provide evidence for the structural properties of the whole network and its evolution: the number of partners and the interaction intensity of countries (its density); the volume of embodied services value added exchanged; the shape of the network, more centred or more regular; the heterogeneity of the role of its members as intermediaries in the network; and whether or not and to what extent there exist relatively dense subnetworks and thus cohesive subgroups within the whole network. These measures can consider both first-order relations between countries, i.e., direct link with their partners and second-order relations, which indicate how and how much each country’s partners are themselves connected within the network.first-order indicators, from 1995–2011. average node degree. Considering the binary network from a double perspective, suppliers and recipients, we observe that the differences between both networks are not significant.We start the analysis by studying the evolution of aggregate statistics of the binary network, specifically, the degree centralisation indexes, i.e., the extent to which a network is centred on one or several important nodes, are fairly moderate and decreasing, which would indicate that the network exhibits a poorly integrated structure. However, these results  must be considered with certain caution, as they can be influenced by the low number of countries included in the sample (64 countries). Moreover, most of those countries play a leading role in the international economy. In outdegree and the indegree centralisation indexes are low. However, it is remarkable that while providers increasingly diversify, the network of recipients becomes more concentrated over time. The rest of the indexes calculated ratify the irregular shape of the network. The low average random walk betweenness centrality (RWBC) index would signal the small number of countries with a crucial role as intermediaries in the network in both periods of analysis. It also implies a certain symmetry in the relationship of countries since their function as gatekeepers in the network is quite homogeneous. Nevertheless, according to the closeness centrality index, the geodesic distances between countries seem to have shrunk, and, in both years, more links seem to imply more direct links, which would suggest that the central countries within the network will be the ones that bolster their integration. The clustering coefficient is relatively high, and basically constant over time.According to the results for aggregate centrality measures  has remained almost unaltered over time. By interacting the binary and the weighted network, we have detected that the most connected and integrated countries are also the most intensely connected. Consequently, the role of these countries in the future development of the network is reinforced.When we go a step further and consider the intensity of flows of the intermediate services (weighted network), we observe that average contribution that exchanges maintained by countries with their partners to the world trade of embodied services inputs (average instrength) and suppliers (outstrength), we observe different although convergent dynamics between them over time. While in 1995 the importers’ intermediate services network was more homogenous, with countries contributing in a more symmetric way to the world added value, in 2011 some countries concentrated foreign intermediate services demand to a greater extent. In particular, in 1995, the United States was the country with the highest instrength, with 8.2; in 2011, China was the first country in the ranking, with a share of 16.5, practically double. From the supply side, the dynamic is fairly different. In 1995, there were fewer important providers than recipients, with a more concentrated contribution. However, in 2011, we observe a more diversified supply. These results would suggest that some economies are boosting the international terciarisation of manufactures in a firmer way than others. The weighted centrality measures reinforced the results of the binary analysis. Nevertheless, considering both, the increasing tendency of these indexes and the results obtained when we correlate the betweenness binary indexes (RWBC) with the strengths of countries would indicate that those economies with the most intense links would presumably be the ones that will gain a more central role as intermediaries within the network. Consequently, the performance of those leading countries (in terms of volume or share) related to their productive, legal, organisational and property development of intermediate services will be crucial for the future evolution of this world network.When the weighted network distinguishes recipients  is much higher than the average node degree in both periods, and that these differences have increased. Therefore, we infer that the central countries within the network are extending their links towards other poorly connected economies. Additionally, the correlation between node strength and average nearest-neighbour strength (ANNS) is strongly negative in both periods, indicating that only one group of countries has intensified their flows, enhancing their leading role within the network.Finally, when we consider the Transport and communication services the densest section in both periods and Computer, R&D and other business services the least connected. Similarly, all four sectional networks are modestly extensive, and all of them have increased their average node degree: the highest average degree is shown by Transport and communication services and the lowest by Computer, R&D and other business services in both periods, but all of them are analogous to the average of the total network.As we mentioned in the Introduction, it is interesting to analyse the performance of the network for the different types of services. When we do that, we observe that all of them show structural characteristics similar to those of the total network: very moderate connectivity, with degree centralisation index is moderate in all sectional networks. In 1995, the figures were even lower for the sectional networks than for the total network, while in 2011, the results were more aligned. The most centred sectional network is that of Financial services. It is also interesting to observe that only in the Transport and communication services section has the number of direct links between nodes increased, as we have seen for the total services network.Besides, as for the total network, all centralisation coefficients would indicate regular networks for the four sections. The average strength was higher for all sectional networks than for the total network, and was especially higher for Trade and distribution services in 2011. In fact, the average strength has increased noticeably in this section, which would indicate that the average contribution of countries to the world trade of these intermediate services has grown. We also observe a higher concentration of supply, with the five principal economies (excluding ROW) concentrating half of the world share in 2011 (40 percent in 1995). The contrary situation is depicted in the other three sections, especially in Computer, R&D and other business services, for which the average contribution of economies has decreased over time and the concentration has diminished.Considering the weighted network, in both periods, the hubs, 14 were also authorities (15 if we include the rest of the world). It is likely that transnational companies’ operations from these countries are behind this shared leading role from the demand and supply perspective.We examine in more detail the composition of the network centre by analysing the node-specific measures, focusing on the analysis of the results of the weighted HITS algorithm. Firstly, it is important to note that, in both periods, out of the top 20 countries considered node degree), the most intensely connected economies (with the highest node strength), the most easily reachable  and with the most prominent role as intermediaries (RWWC). However, significant changes can be appreciated in some of them with respect to their position.From 1995 to 2011, we can observe interesting changes in the role that these central countries play within the network. The most remarkable change is the spectacular variation in China’s hub score. It almost tripled since 1995, allowing this economy to rise three positions in the ranking to become the first world intermediate services hub, with a value very far from that of other countries. Among the first positions, also noteworthy is the advance of Korea, which has increased its hub score until occupying the third position, when it ranked eighth in 1995. Also in Asia, we observe that, by maintaining their hub scores, Malaysia and Thailand have risen markedly since 1995. India, in the middle part of the ranking, has also made remarkable improvement, multiplying its score (13.7) to be amongst the top twenty in the ranking (19). Also noteworthy is the progress of some East European countries such as the Czech Republic, Poland, Hungary and Russia, which have managed to position themselves better in the ranking. Finally, it is worth mentioning the cases of Turkey and Vietnam, which have certainly progressed since 1995. On the other hand, the three North American economies have reduced their hub scores, but while Mexico has improved its relative position, Canada and the USA have fallen in the ranking, especially Canada, which dropped five positions. In Europe, Belgium, Sweden, Austria, the United Kingdom and the Netherlands have seen their scores substantially worsen, falling in the classification. In addition, in Asia, Singapore is the economy with the worst evolution, losing eight positions.Computer, R&D and other business services section and the other three. However, we do not observe the same patterns when we consider the evolution of hub scores in the different sections, as they are not significantly correlated, which would indicate that differentiated dynamics can be observed in each of the four sectional networks.When we disaggregate the network of embodied services value added by services sections, we observe in 2011 a very high correlation between the positions that countries occupy in the ranking of hubs: the same countries are at the top of the list of hubs in all of the four sections. The lowest correlation in the ranking is observed between the Trade and distribution services, Transport and communication services and Financial services sections, among the top five are China, Korea, the USA and Germany, with great distance between China’s hub score and the rest of the countries’. However, in the Computer, R&D and other business services section, China, Germany and Korea are also among the top five, but not the USA: Ireland and France occupy the third and fifth positions, respectively. Another significant difference with the other three networks is that China’s hub score in this section network is much closer to the rest of the countries’ and it is lower. Therefore, it is a more diversified network, less concentrated than the other three. In this section, we observe in the top ten positions countries that are not present in the other networks, such as the Netherlands, the United Kingdom and Italy.Going further in the analysis of these sectional networks, we observe that for the Trade and distribution services, Transport and communication services and Financial services sections, and it multiplies by more than four its score in the Computer, R&D and other business services section. Korea improves its scores in all sections but Financial services, although it rises in position in all four networks. Thailand increases its scores in Trade and distribution services, Transport and communication services and Computer, R&D and other business services, achieving better positions only in the two first; however, it rises in Financial services even though its score is worse than in 1995. Japan increases its hub score slightly in Trade and distribution services, rising six positions, and rises in Financial services in spite of recording a lower score in 2011. As for the total services network, India and Turkey are the countries which present the strongest advance, multiplying their scores intensely in each of the four sections, especially in Trade and distribution services and Computer, R&D and other business services. These improvements mean significant ascents in the rankings. As in the total network, we observe in the four sections notable improvements in some Eastern European countries  and, to a lesser extent, Russia, which jump in the rankings. However, the progress is especially significant in the Trade and distribution services section for Poland and Hungary, while in the Transport and communication services and Computer, R&D and other business services sections, Poland records the most important advances by far. Also remarkable are the improvement of Switzerland in the Computer, R&D and other business services section in both score and position and the advance of Spain which maintained its score.As we have mentioned above, the evolution of the four networks has been relatively uneven. China is the country which presents a better evolution in its performance in the four sectional networks: it more than doubles its score in the Trade and distribution services, and France in Computer, R&D and other business services. Other European economies have also reduced their scores and lost positions in some specific sections. For example, Ireland has reduced its scores dramatically in the Trade and distribution services and Transport and communication services sections; Denmark in Transport and communication services and Computer, R&D and other business services; and Finland in Computer, R&D and other business services. Noteworthy is the case of some other European economies, such as Germany, Spain and Switzerland, which in this highly competitive context have reduced their scores in the majority of sections, but have managed to maintain their positions in the ranking or even improved them slightly.By contrast, we observe that the majority of central European economies have reduced their hub scores substantially over time in the four sectional networks, and some of them have seen their position in the ranking of expert providers drop sharply. That is the case of Belgium, Sweden, Austria, the Netherlands and the United Kingdom. Italy and France have reduced their scores in all sections but Italy has maintained and even improved its position in Financial services has maintained its position and in Computer, R&D and other business services has fallen only one position. Canada, on the contrary, has lost positions in all sections. In this area, Mexico is the only economy, which has improved its positions in the four sections, in spite of reducing its scores in all of them but Computer, R&D and other business services. Finally, in Asia, Singapore is the economy, which has lost positions in the four sections, especially in Trade and distribution services and Financial services. Japan has fallen only in Transport and communication services, although it has reduced its scores in Financial services and Computer, R&D and other business services.Beyond Europe, we observe other interesting dynamics. For instance, the USA has reduced its hub scores in the four sections, but in hubs in the network, while some of the most advanced economies in Europe and North America have lost impulse in playing this role under the pressure of those new actors. All sectional networks have incorporated to a greater or lesser extent new countries which are moving up the ranking of expert intermediate services suppliers.All in all, we have observed that some emerging economies, especially Asian and Eastern European economies, have gained momentum over time as Once we have examined the structural configuration of the network of embodied services value added and detected the central countries within it, we go a step further by empirically analysing the impact of this centrality on manufacturing competitiveness. The list and definition of variables included in the model are provided in Table A.3 in RCAMDVA of a country i in a year t is foreign services value added embodied in country i’s gross manufacturing exports in that year (FSVAoinXMit) as a share of those gross manufacturing exports. We have seen how the literature has shown that, in addition to being key enablers of GVCs, intermediate services may enhance manufacturing competitiveness by raising productivity, reducing costs and contributing to product differentiation. As is shown in Table A.4 in As we explained in the Introduction, a variable that should positively affect the hub score. As we noted, a country is considered a prominent hub within the network when it links prominent authorities, i.e., when it supplies intermediate services to countries that are provided by many other prominent suppliers. Therefore, it supplies “expert” buyers. The variable hub ranks in our sample between 0  and 0.79 (China). Our hypothesis is that the higher the hub score of a country’s suppliers is, the higher its RCAMDVA is. Then, we propose to calculate a provider-weighted indicator of foreign services value added content of manufacturing exports (o_Weighted_FSVAoinXMit), where the share of the embodied services value added from each source or supplier country is weighted by each hub score. The average of this weighted indicator is 2.8  is also relevant: the higher the level of expertise of the embodied services suppliers, the more intense the competitiveness-enhancing effect is. As we observed in Section 3.2, a suitable indicator for proxying the level of a country as a specialised (“expert”) provider is its hub score itself (Hubit) positively affects the country’s manufacturing competitiveness. Consequently, we should control for it in the model. Moreover, we control for the share of domestic services embodied in a country’s manufacturing exports (DSVAinXMit). According to the descriptive statistics from Table A.4 in i-weighted indicator of domestic services value added content of manufacturing exports (i_weighted_DSVAinXMit), where the share of those domestic services is weighted by the exporting country’s hub score. With this measure, we try to quantify the combined effect of incorporating more or less domestic intermediate services in manufacturing exports and the role of the exporting country itself as a hub on that country’s manufacturing competitiveness. The average of this indicator, which ranges from 0 (Cyprus) to 10.54 (China), is 1.26.Furthermore, services value added to be incorporated in manufacturing exports can be supplied by domestic providers and not only by foreign providers. When a country’s domestic providers are highly specialized, that country will play a prominent role as a hub within the network of embodied services value added. It can also be presumed that the country RCA analysis, are included in the model as control variables (Zit denotes the vector for these control variables). Firstly, we have considered labour productivity in the manufacturing sector in order to account for price and non-price factors of competitiveness. Labour productivity is measured as real value added divided by total employment. We also control for the size of the exporting country’s manufacturing sector, measured by its manufacturing employment, and for the country’s development level, using GDP per capita, both of them in logarithms. We add country fixed effects to control for unobserved time-invariant country characteristics (ai) and time fixed effects to control for unobserved factors that are common to all countries (at). Robust standard errors are clustered by country to control for potential heteroscedasticity and country-level serial correlation in the error terms.Additional variables, those most commonly used in empirical In line with the aforementioned arguments and the availability of data, we estimate the following specifications:RCAMDVA model. In all of them, “services” refers to total aggregate services. In column (1), the variable FSVAoinXMi  is the only one included (included . The coeIn column (2), we introduce the provider-weighted indicator of foreign services value added content of manufacturing exports . As expeZit), are reported in columns (3) and (4), respectively. The first one includes the unweighted FSVAoinXMi and the second one the weighted one. It is relevant to note that by doing so we lose many observations because of missing values for some countries and years. We observe that, in these estimations, both the unweighted and the weighted share of embodied foreign services value added are statistically significant in explaining manufacturing competitiveness with a positive effect. That is, both how much foreign services value added content and who the providers of those services are matter. The control variables included in the estimations show the expected signs. Labour productivity and size of the exporting country’s manufacturing sector are positively related to competitiveness. The effect of the country’s development level on comparative advantage in manufacturing is also positive although it is not statistically significant.Results from estimating the specification in Eqs  and 6),,6), wherFSVAoinXMit remain positive and statistically significant.In columns (5) and (6), we add the hub score of the exporting country whose manufactures embody the foreign services value added (specifications in Eqs DSVAinXMit) as an explanatory variable (specifications in Eqs In columns (7) and (8), we add the share of domestic services value added embodied in a country’s manufacturing exports  is found for both the unweighted (column 9) and the provider-weighted (column 10) indicator of foreign services. Furthermore, the higher magnitude of the coefficients of those variables suggests a stronger effect on manufacturing competitiveness compared with that of the country-weighted indicator of domestic services.Columns (9) and (10) display the results when the combined variable of quantity of domestic intermediate services in manufacturing exports and exporting country hub score is included in the specifications Eqs  and 12. FSVAoinXM is estimated. The results which correspond to Eqs (FSVAoinXM is reported. In columns (c) and (d), the weighted DVSAinXM is also estimated.We go one step further and divide embodied services value added into types of services. As the share of value added content from different services categories is highly correlated among these categories, we estimate the effect of each category of services separately. Estimation results are reported in d to Eqs  and 12)FSVAoinXMWholesale and retail services and Transport and telecommunications services, the share of embodied foreign services value added affects manufacturing competitiveness positively, and the effect is statistically significant (columns 1a and 2a). The effect is similar  to that of the provider-weighted foreign services value added (columns 1b and 2b). That is, for these two services categories, which are considered traditional services, both how much foreign services content and who the providers of those services are matter.For both Financial services and Computer, R&D and other business services), no statistically significant association between manufacturing RCA and embodied foreign services value added is observed (columns 3a and 4a). However, a positive and statistically significant association is found when the provider-weighted indicator of embodied foreign services value added is used (columns 3b and 4b). This result implies that a higher foreign services value added content from more central providers tends to increase manufacturing competitiveness. For these modern services, which are dynamic, internationally traded services and more complex services sectors [However, for the other two services categories , except for Computer, R&D and other business services, where the coefficient is not statistically significant (columns 4c-4d). Furthermore, in the estimations where the unweighted indicator of embodied foreign services value added is included (columns c), this variable positively and significantly affects manufacturing competitiveness only when the embodied services are Wholesale and retail services and Transport and telecommunications services. However, for the four types of services, the provider-weighted indicator of FSVAoinXM shows a positive and statistically significant coefficient (columns d), although the magnitude of its effect on manufacturing RCA is slightly lower compared with that of previous estimates. That is, again the level of expertise of the services suppliers more than the quantity of those embodied services is relevant for manufacturing competitiveness in the case of modern services. From these estimations, an additional conclusion can be drawn: except for the last type of service, Computer, R&D and other business services, improvements in manufacturing competitiveness are associated with higher shares of both foreign and domestic services content of manufacturing exports when the centrality of the country provider is taken into account.The last two columns for each services category (columns c and d) show that revealed comparative advantage in manufacturing increases with the share of domestic services value added weighted by the exporting country’s Computer, R&D and other business services with the same intensity. The use of these modern services is more intensive in manufactures with a higher technological content. Consequently, only in manufacturing sectors with a high degree of embodied business services, would improvements in manufacturing competitiveness be associated with higher intermediate services provided by suppliers that are more expert. In fact, in Section 3.2, we detected that this sectional network is the least connected and integrated, the most diversified and the one in which the contribution of each country’s exchanged flows has diminished to the highest extent.The different behaviour of the last services category may be related to the fact that they are knowledge-intensive services and hence more exclusive. Not all manufacturing industries incorporate Therefore, our findings reveal the importance of the source country of foreign intermediate services in manufacturing exports for manufacturing competitiveness. While previous literature has focused on the quantity of foreign services inputs, according to the estimations above, the centrality of the country provider of those embodied foreign services inputs is also a key determining factor for improvements in manufacturing RCA.In this paper we have analysed the importance of the source-country of foreign services value added embodied in manufacturing exports for manufacturing competitiveness. In order to do this, we have examined the characteristics of the inter-sectoral global network formed by flows of embodied services value added, paying special attention to the role that countries play within that network.We have observed that the network exhibits a low density, with a connectivity that could be considered incipient as the number of countries that do not participate within the network in a significant way is still relatively high. The structure of the network is regular (not a centre-periphery) with a numerous group of highly connected countries in the centre with trade relationships with many other countries. New countries have been incorporated into this centre over time, playing a prominent role: China is the most evident case. Other countries, still poorly connected, are becoming incorporated into the network little by little, spreading it out. We have also detected that the most connected and integrated countries are also the most intensely connected, and that those countries are the ones which have strengthened their links over time. Therefore, the analysis suggests that the network can still become more developed, connected and cohesive in the future and that those central countries within the network will be the ones that bolster their future integration.Three relevant centres have been detected within the network, with a regional scope and connected themselves: the European Factory, with the central EU economies as leaders, particularly with Germany at the forefront; the North American Factory, with the United States as the principal country; and the Asian Factory, with China at the head. Within those three centres, there are both “expert suppliers” and “expert recipients”, meaning countries that supply embodied services value added not only to other economies which do not produce them themselves, but also to other countries which are significant providers, themselves central countries within the network as suppliers.These hubs are able to provide highly specialised intermediate services to their partners, which, in turn, are sophisticated recipients themselves. In this regard, we have showed that for manufacturing competitiveness, together with the level of embodiment of services value added into manufacturing exports, expertise as providers of countries’ suppliers is also relevant: the higher the centrality of intermediate services suppliers, the more intense the competitiveness-enhancing effect is. Therefore, who the providers of those embodied services inputs are is also a key determining factor for manufacturing competitiveness.These findings would suggest that, in the near future, this inter-sectoral network will continue to develop and widen, deepening the servicification of manufactures, especially those destined for exports. In this process, we have seen how the network of embodied services value added is increasingly incorporating new emerging economies, which are, hand in hand with GVCs of manufactures, becoming crucial actors within the inter-sectoral world network. Although the most advanced economies remain at the top of the hubs ranking, now and even more in the near future, they will have to share their positions with these new economies and others, which presumably will become integrated within the network, especially in those more traditional services. It seems undoubtable that in this process, the current central countries and the ones which will be incorporated into the network centre will be the driving forces of this process, playing a crucial role in the improvement of industry competitiveness. They will be the economies which will provide the global manufacturing sector with the most specialised and advanced services; in turn, this specialisation will imply that those same economies will also demand other sophisticated services from other partners. This interdependence will knit an increasingly denser and more integrated network.S1 Appendix(DOCX)Click here for additional data file.