The increasing burden of depression and noncommunicable disease (NCD) is a global challenge, especially in low- and middle-income countries, considering the resource constraints and lack of trained human resources in these settings. Effective treatment of depression in people with NCDs has the potential to enhance both the mental and physical well-being of this population. It will also result in the effective use of the available health care resources. Brief psychological therapies, such as behavioral activation (BA), are effective for the treatment of depression. BA has not been adapted in the community health care services of India, and the feasibility of using BA as an intervention for depression in NCD and its effectiveness in these settings have not been systematically evaluated.Our objective is to adapt BA for the Indian NCD context and test the acceptability, feasibility, and implementation of the adapted BA intervention (BEACON intervention package [BIP]). Additionally, we aim to test the feasibility of a randomized controlled trial evaluation of BIP for the treatment of depression compared with enhanced usual care.Following well-established frameworks for intervention adaptation, we first adapted BA  for delivery in India. The intervention was also adapted for potential remote delivery by telephone. In a randomized controlled trial, we will be testing the acceptability, feasibility, and implementation of the adapted BA intervention (BIP). We shall also test if a randomized controlled feasibility trial can be delivered effectively and estimate important parameters  needed to design a future definitive trial.Following the receipt of approval from all the relevant agencies, the development of the BIP was started on November 28, 2020, and completed on August 18, 2021, and the quantitative data collection was started on August 23, 2021, and completed on December 10, 2021. Process evaluation  collection is ongoing. Both the qualitative and quantitative data analyses are ongoing.This study may offer insights that could help in closing the gap in the treatment of common mental illness, particularly in nations with limited resources, infrastructure, and systems such as India. To close this gap, BEACON tries to provide BA for depression in NCDs through qualified NCD (BA) counselors integrated within the state-run NCD clinics. The results of this study may aid in understanding whether BA as an intervention is acceptable for the population and how feasible it will be to deliver such interventions for depression in NCD in South Asian countries such as India. The BIP may also be used in the future by Indian community clinics as a brief intervention program.Clinical Trials Registry of India CTRI/2020/05/025048; https://tinyurl.com/mpt33jv5DERR1-10.2196/41127 Noncommunicable diseases (NCDs), also known as chronic diseases, tend to be of long duration and are the result of a combination of genetic, physiological, environmental, and behavioral factors. NCDs are the leading cause of mortality in the world, much of which is premature and avoidable ,2. The lThe presence of depression worsens NCD symptoms, adversely impacts the quality of life, and increases the financial burden for patients and their families . TherefoThere is an identified need to integrate mental health care in NCD care settings to help address the high burden of comorbid depression with NCDs. However, there is a notable gap worldwide between the number of people in need of mental health care and those who receive treatment. This “treatment gap” is especially high in low- and middle-income countries (LMICs) ,8. It isAnother reason for this treatment gap would be that in developing nations, stigma is a significant barrier to people seeking care for mental health issues. Those who are stigmatized may expect to be treated unfairly and with contempt by others, which may encourage them to use unhealthy coping techniques such as withdrawal or secrecy. This tendency has been noted in research conducted in LMICs, such as Ethiopia and India. One option would be to incorporate areas of mental health treatment that influence the development of stigma, such as successful task-shifting programs, peer and health worker-delivered therapy, and case management . Task shBehavioral activation (BA) is an evidence-based, simple, structured psychotherapy for the treatment of depression, initially developed in the 1970s. BA aims to break the negative cycle of aversive behaviors and low mood by increasing engagement in activities that are associated with positive reinforcement. BA therapy is delivered by a trained practitioner, usually over a series of face-to-face therapy sessions, with “homework” tasks that are agreed upon with the person with depression to be undertaken between sessions. BA can be delivered through a number of sessions over digital and telephone platforms as well as in person ,12,13.Although there is interest in using BA for depression in people with NCDs, evidence for the effectiveness of this approach has not been clearly established. A systematic review conducted in 2011 found only 8 randomized controlled trials of BA in long-term conditions (with study sample sizes ranging from 20 to 105) . A totalThis study aims to address this evidence gap by (1) adapting BA for the Indian NCD context; (2) testing the acceptability, feasibility, and implementation of the adapted BA intervention (BEACON intervention package [BIP]); and (3) testing the feasibility of a randomized controlled trial evaluation of BIP for the treatment of depression compared with an enhanced usual care (EUC) package.The purpose of this step was to ensure the BA intervention content and delivery were appropriate for the Indian NCD’s cultural, linguistic, and resource context. The initial content was based on treatment manuals and workbooks from previous adaptations of BA for multimorbidity and delivery by lay counselors in the United Kingdom  and IndiFollowing adaptation frameworks, including cultural adaptation ,20, and The finalized BIP comprised a BA counselor’s manual, a session log, and a flipbook for the patient participants. The intervention could be delivered remotely by telephone over 6 sessions lasting approximately 30-40 minutes each. The training of the BA counselors focused on developing skills in communication, establishing therapeutic relationships, and using the manual and materials to deliver therapy sessions. The task of adapting BA for the Indian NCD context has already been completed.The objectives of the feasibility trial are to (1) test the acceptability, feasibility, and implementation of the adapted BA intervention (BIP) and (2) test if a randomized controlled feasibility trial can be delivered effectively and estimate important parameters needed to design a future definitive trial.This will be achieved by answering the following research questions (RQs): (1) what are the recruitment and retention rates for participants in the trial? (2) What is the feasibility and acceptability of the proposed randomization and data collection procedures? (3) To what degree can the BIP be implemented as planned? (4) What is the acceptability of the BIP from the perspective of study participants and BA counselors?A randomized controlled feasibility trial with the nested process and economic evaluations was conducted over 12 months. The Gantt chart can be found in The 2 trial arms are the intervention arm (BIP) and the control arm (EUC).In 2010, the Ministry of Health and Family Welfare, Government of India, launched the National Programme for Prevention and Control of Cancer, Diabetes, Cardiovascular Diseases, and Stroke (NPCDCS). This includes the prevention and management of NCDs at district and subdistrict-level facilities. These facilities provide services for screening, treatment, or referral of patients with NCD but do not, at present, include the integrated detection and management of mental disorders. They do not yet cover all districts in the country .The setting for the BEACON study is a district in Kolar, Karnataka, South India, where it was possible to explore the integration of mental and physical health care based on several pragmatic considerations, including the availability of NCD services that are part of the government health system and the engagement of key stakeholders. Therefore, to better understand the health system at the study site, a survey of the organizational capacity in the study area was conducted, along with interviews with the NCD counselors and the patients who visit the health facility. Following this, the selection of health care facilities was based on (1) the provision of NCD services, (2) the availability of health care staff such as NCD counselors and nurses to identify the patient participants for the study  , a screeSince most NCD services are limited to providing care for cardiovascular and chronic lung diseases and diabetes (excluding cancer), the study focused on these disorders. Finally, a total of 6 NCD clinics were chosen for data collection.The eligibility criteria for this study are given in Inclusion criteriaAged 18 years or older.Diagnosed with cardiovascular disease, chronic respiratory disease, or diabetes (type 1 or 2).Current diagnosis of depression  who will be specifically recruited for the study. BA counselors will be supervised by a mental health specialist.The BIP will be delivered over 6 sessions lasting 30-40 minutes over a period of 6-12 weeks, with a minimum of one week between sessions. All sessions will be delivered remotely, by telephone. An alternate telephone number will be collected at the time of recruitment to ensure the unhindered delivery of BA sessions to the client.The components of BIP include structured sessions where participants, with the BA counselors, plan and identify 3 types of activities. The first one includes routine and necessary activities that are done either regularly or on a daily basis, for example, getting fresh, taking a bath, cooking, doing household chores, etc. Second, social activities involve interacting with other people, for example, meeting or chatting with people from the neighborhood, etc. And third, pleasurable activities include activities that one enjoys and has fun with. For example, reading a newspaper or book, watching television , etc. The BA counselor and the participant will both have a flipbook for guidance and a better understanding of the activities during the session, as it contains a pictorial representation of each type of activity. The BA counselor will follow a manual and maintain the session logs of the participants. The BA counselor in the session log will not only maintain the session details but also keep a record of the daily activities done by the participants and the mood associated with doing these activities through telephonic follow-up in between the sessions. Another reason this is done is to check if the participants are doing the activities or if they are facing any challenges while doing them.Participants in the control arm will receive an EUC leaflet describing depression and its treatment and signposting, including providing contact details (addresses and telephone numbers) to help access usual care for depression. They will also be provided with 1-time brief advice on the same from the research assistants (RAs) remotely.The outcomes for the feasibility trial relate to (1) the acceptability and feasibility of recruitment and data collection and (2) the acceptability, feasibility, and implementation of the BIP.Outcomes relating to the feasibility and acceptability of recruitment and data collection are (1) the rates of recruitment into the trial and retention at 3 months (RQ1), (2) the proportion of participants recruited who are randomized (RQ2), and (3) the completeness of data collection (percentage of planned measures completed) (RQ2) at:Baseline: demographic data, depression symptoms—PHQ-9 , negativ3 months: depression symptoms—PHQ-9 , negativOutcomes relating to the acceptability, feasibility, and implementation of the BIP are described below in the process evaluation.The sample size is set to enable reliable estimation of recruitment and retention rates and to adequately explore the feasibility of data collection and intervention delivery in this feasibility trial. A total of 56 participants will be recruited for this study. This should be adequate to estimate a participation rate of 20% and a follow-up rate of 80% to within a 95% CI .The BEACON study flowchart can be found in Participating sites were asked to implement depression screening by NCD health care staff, such as NCD counselors and nurses, using the PHQ-2 , as partStaff (NCD counselors and nurses) will be asked to give information about the study and screen the patients for PHQ-2  after obRecruitment of the willing participants by RAs was done remotely by telephone, mobile phone, internet, or video calling, as was convenient for the participant. Accordingly, verbal informed consent will be obtained before administering the PHQ-9, along with consent for participation in the feasibility trial. Those screening positive for depression on PHQ-9 (score ≥10) were invited to participate in the feasibility trial and provided detailed information about the purpose of the study and trial procedures either face-to-face or remotely. Furthermore, a suicide risk assessment was conducted at this point, where the participant was asked whether they have had thoughts of harming themselves or wished they were dead in the past week. If they say no, then the recruitment process will continue. Final verbal consent for participating in the trial will be obtained. The BEACON patient information sheet and consent forms can be found in But if the answer is yes to the question of whether they have had thoughts of harming themselves or wished they were dead in the past week, then further questions on plans, actions, and prevention are to be asked, and based on the responses, the participants will be categorized into level A (mild), level B (moderate), and level C (severe). Three-week follow-ups by the RAs will be done, and then the decision on whether to recruit the patient or not will be made by the research team. The details about the safety considerations followed in the trial can be found in Participants were free to withdraw consent and leave the trial at any time without giving a reason. They were able to withdraw by letting any member of the research team know that they wished to do so. If a participant withdrew consent to participate, no further data were collected from them. However, data collected up to the point of withdrawal were retained and used in the analysis, except where withdrawal of consent for the use of this data is explicit, in which case all data will be destroyed.Once consent has been secured, eligible participants complete a baseline questionnaire and are then randomized (BIP or EUC) by the trial manager or research fellow who will be based at the central office. Participants will be allocated in a 1:1 ratio using simple randomization without stratification. Treatment allocation was concealed from the study team at the point of recruitment using an automated computer data entry system, administered remotely by York Trials Unit, and using a computer-generated randomization sequence generated by an independent statistician .Baseline and 3-month follow-up data were collected by RAs. The SPIRIT  schedule of enrollment, interventions, and assessments can be found in Analyses will be conducted using Stata software. The number of participants who were screened, randomized, treated, and followed up for the primary outcome (PHQ-9)  will be t test or Mann-Whitney U test will be used to compare the intervention and the EUC arm.The proportion of baseline and outcome measures completed out of those planned and presented by the treatment allocation arm will also be calculated. The normality of the data will be assessed, and based on that, an independent The 3 key functions of a process evaluation  will underpin our approach for the feasibility trial . The quaTo capture the views and experiences of participants, all participants will complete a brief quantitative survey at a 3-month follow-up. Participants in the intervention arm will be asked about their engagement with and acceptability of BIP, views on remote delivery, as well as the perceived impact on their depression symptoms. Control arm participants will answer these questions in relation to the EUC leaflet. Participants in both trial arms will also complete some questions to assess the acceptability of trial processes.Potential mediators of intervention impact will be measured at baseline and 3 months: intentions, beliefs about capabilities, and beliefs about outcomes. These have been selected to reflect the hypothesized mechanisms of action of BA .A subsample of 16 participants will be interviewed. We will purposively sample to ensure a mix of participants . The interviews will seek in-depth feedback on the topics explored in the brief survey as well as explore individual and context barriers and drivers to performing the 3 types of activities .Once delivery of the BIP is completed, a group interview will be conducted with the 4 BA counselors to explore their experiences, including the acceptability of the interventions and the barriers and drivers to delivery, including contextual factors such as remote delivery.All interviews will be conducted in the local language, face-to-face using topic guides, and digitally audio-recorded. A hermeneutics approach, which encourages participants to discuss features of the intervention to elicit data on their experience and evaluation of its delivery or receipt, will be used with trial participants, family members, and health care staff .Trial participants will provide written informed consent for these interviews within their trial consent.Fidelity in delivering BIP will be assessed using a fidelity index. This index consists of 2 subindices, namely, the adherence index, which assesses adherence to delivering the content of the 6 BIP sessions, and the interaction index, which assesses the level of counselor-participant with which the intervention was delivered. Both indices are scored on a 3-point Likert scale .All BIP sessions will be audio-recorded. We will then perform the fidelity checks by reviewing the audio recording of a subsample (n=18) of sessions. These sessions will be purposefully selected to include a mix of sessions 1-6, delivered by all BA counselors early and late in the feasibility trial.The quantitative data from the fidelity index and questionnaire will be analyzed using descriptive statistics, including means and SD for continuous variables and absolute and relative frequencies for categorical variables.Interviews will be transcribed verbatim, translated into English, and analyzed using the Framework Approach , which iIntegration of interview findings with respective questionnaire data will be done using a “triangulation protocol” . MethodoThe feasibility of undertaking a full cost-effectiveness analysis will be assessed. This will primarily investigate the acceptability and resource use associated with capturing data for a cost-effectiveness evaluation in the full trial.The team will capture costs associated with depression in NCD, such as delivery or receipt of the BIP. Costs will include the time to deliver the BIP and the cost of the materials used. And the costs of training the BA counselors to deliver the BIP will be calculated. Training requires the “staff time” of the trainer plus staff travel costs. Staff time is based on the salary of the trainer and allocated on a cost-per-minute basis, plus costs of materials.Diaries to capture resource use, to be completed by patients and BA counselors, will be developed by the research team. Participants will be asked to complete these on a monthly basis for 3 months.A pro forma to capture the costs of delivering the BIP incurred by the host organization will be completed by service managers, including staff salaries, time, and costs of estates and materials. An average cost per case per trial arm for treatment and the control group will be calculated.Health service use will be assessed by asking pretested questions on contacts with doctors and nurses, hospital admissions, pharmacy visits, drug use, etc.Quality of life will be assessed using a quality of life questionnaire (EQ-5D-5L) at baseline and 3 months. This information can be used as a quantitative measure of health outcomes as judged by the individual respondents. A higher score represents a better-perceived health state. The data will be checked for completeness.The following data will be collected from feasibility trial participants (at baseline and 3-month follow-up): demographic data and validated instrument measurements of mental and physical health. The process evaluation of the feasibility trial will collect data from interviews with trial participants and BA counselors, a sample of audio-recorded BIP sessions, and drop-out data. Health economic data will be collected to provide evidence of the costs of providing the BIP in the host institution.All study data will be stored in accordance with the General Data Protection Regulation and the University of York data management policies. Electronic data will be password-protected and stored on secure servers at the country’s partner institutions and the University of York.Unique study identification (ID) numbers, allocated by the research team, will be used to anonymize data on electronic documents containing data from the trial and interviews. Paper-based documents, for example, consent forms and hard copies of transcripts, as well as any research participant personal data collected, will be stored in locked filing cabinets at the partner institutions.Study documents (paper and electronic) at the research sites will be retained in a secure (locked when not in use) location during and after the study finishes. Interview recordings will be transferred from the digital recorder to a secure server as soon as possible after the interview has taken place. Once the transferred recording has been checked to ensure audibility, the original will be deleted from the digital recorder. All essential documents, including source documents , will be retained for a minimum period of 10 years after study completion, in accordance with the University of York Research Data Management Policy. This is deemed to be sufficient time for any queries arising from the findings to be answered, for example, queries arising from the publication of the findings. They will be retained in secure locations (locked when not in use) at the University of York and at the partner institutions.The Department of Health Sciences at the University of York has a backup procedure approved by auditors for disaster recovery. There will be a separate archive of electronic data performed at the end of the study to safeguard the data and comply with regulatory requirements. The access, use, and storage of sensitive or confidential data will be conducted in accordance with the University of York Data Security Policy and Handling Sensitive Data Guidance. All sensitive or confidential data used for BEACON will be encrypted.Data will be monitored for quality and completeness by the delegated researchers at the study site, followed by a second check by researchers at the University of York using verification, validation and checking processes. Missing data will be pursued until the study’s end unless it causes any distress to the participant contacted. Data will be reported to the Health Ministry Screening Committee and Ethics Committee as required.Working with a potentially vulnerable group of participants has many ethical implications. We have addressed them in our ethics application. The main adverse events anticipated in this study, both during the recruitment phase and during the delivery of the BIP, are self-harm and suicide risk. Therefore, standard operating procedures to address these adverse events will be adapted by the study team.As the recruitment is done at 2 levels, written consent will be obtained at first-level screening using PHQ-2  by the sData will be anonymized, replacing identifiable personal data with unique study participant identification numbers, with the key only available to the local research team and the principal investigator.A community advisory panel will provide community engagement and involvement for the duration of the study. This panel consists of patient and family representatives and community and voluntary sector advocates interested in improving the care of common mental disorders and NCDs. The panel has already given feedback on:The accessibility and feasibility for patients of the proposed BIP intervention, including remote delivery.Delivery of BA counseling by the NCD counselors.The acceptability of proposed methods for the feasibility trial.The feedback and suggestions were incorporated into the intervention development and delivery plans of the study. The panel will continue to provide feedback, providing an important perspective on the delivery of the study and its findings.Feasibility study results will be disseminated by engaging end users of our research, including policy makers and commissioners, by holding knowledge transfer and dissemination events at key stages. Lay summaries and fact sheets of findings are distributed using social media, newspapers, and a project website, alongside publications in academic journals, to reach a range of audiences.Ethics and other relevant approvals on the protocol have been secured from the University of York Health Sciences Research Governance Committee ; the Health Ministry Screening Committee, India ; and the ethics committee, NIMHANS’s Behavioral Sciences Division . The trial is also registered under the Clinical Trial Registry of India .Approvals for necessary amendments adjusting to the COVID-19 pandemic situation have been provided by the institutional ethics committee, Behavioral Sciences Division, NIMHANS.The following amendments are made to the protocol:In the first amendment to the protocol dated September 25, 2020, the focus group discussions and interviews as part of the survey of organizational capacity were shifted from face-to-face to telephonic mode.In the second amendment to the protocol dated May 15, 2021, the recruitment process was shifted from face-to-face to telephonic mode, and NCD counselors were involved in preliminary screening. A total of 4 BA counselors of the same cadre as the NCD counselors were recruited into the study to deliver the BA sessions.In the third amendment to the protocol dated January 27, 2022, process evaluation interviews are to be conducted at 8 weeks instead of 12 weeks, that is, immediately after the participants in the intervention group complete their 6 BA sessions and in the control group at 8 weeks after the participants receive their brief advice from the RAs postbaseline assessment.Participants in the intervention group will receive INR 250 (US $3.01) per session, and participants in the EUC group will receive INR 250 (US $3.01) for attending the one-time brief advice.The BIP was developed beginning on November 28, 2020, and it was finished on August 18, 2021. The quantitative data-gathering process began on August 23, 2021, and was finished on December 10, 2021, following the acquisition of approval from all pertinent agencies. Process evaluation  collection is ongoing. Both the qualitative and quantitative data analyses are ongoing.This research study overall aims to address the evidence gap regarding the use of BA for depression in people with NCDs by adapting BA interventions to the Indian context, testing the acceptability, feasibility, and implementation of adapted BA intervention, and testing the feasibility of a randomized controlled trial evaluation of BIP for the treatment of depression compared with EUC.Effective treatment of depression in NCDs offers the potential to improve mental and physical outcomes for this population and, additionally, maximize the efficient use of health care resources. To bridge the treatment gap globally, psychological therapies must be scaled up, which necessitates their effective use in many cultural contexts. An increasing number of studies have examined the degree to which cultural adaptation enhances the acceptability and effectiveness of psychological therapies among populations from various cultural backgrounds. The data are still unclear at this stage because there are not enough studies that analyze the many types of changes involved in cultural adaptation . If showSeveral of the issues with conventional psychological therapy may be resolved through remote therapy. Because of their accessibility and simplicity, telephone-based therapies are a popular research topic in the field of therapeutic communication and may provide important advantages. Data suggests that a therapeutic connection and successful treatment outcomes may not require the colocation of a patient and therapist. Nonetheless, the evidence is scant in both amount and quality . TherefoIf the feasibility trial demonstrates that the BIP is feasible and potentially beneficial, we will be able to make further adaptations to the BIP and test the intervention in a full trial.Given the COVID-19 situation, BA counselors of the same cadre as the NCD counselors were recruited into the study to deliver the BA sessions, which can be a drawback as there is no sense of familiarity, which might affect intervention delivery.This work will support a future definitive trial evaluation of BA for depression in NCD in India.This study has the potential to provide evidence that would be useful to bridge the treatment gap for mental disorders, especially in resource-, infrastructure-, and system-constraint countries such as India. BEACON attempts to deliver BA for depression in NCDs through trained NCD (BA) counselors integrated within the NCD clinics to reduce this gap. The findings from this study will help understand the impact of the BA intervention for depression in NCD in countries such as India. Also, the BIP may serve as a culturally validated intervention package for the Indian population for future use.


Climate change is a key threat to human health worldwide. Accordingly, medical education should prepare future physicians for climate-associated hazards and corresponding professional challenges. Currently, this is not yet implemented across the board. The aim of this review is to present (I) the knowledge and (II) the attitudes of medical students and physicians towards climate change and (III) the expectations of medical education as formulated by medical students. In addition, the available literature will be used to look at (IV) global teaching activities, (V) international learning goals and learning goal catalogues, and (VI) applied teaching methods and formats. This review should simplify and, considering the urgency of the topic, accelerate the design of future teaching activities.The paper is based on a selective literature search supplemented by a topic-guided internet search. Knowledge about the causes and concrete health consequences of climate change seems to be incomplete. The majority of medical students consider human health to be at risk from climate change and the health sector to be inadequately prepared. A majority of surveyed medical students would like to see teaching about climate change. It is evident that internationally, teaching projects on climate change and climate health, as well as topic-specific learning objectives and learning goal catalogues, have been developed and integrated into medical education.There is a need for and acceptance of teaching climate change in the medical curriculum. This literature review can assist in the development and implementation of new teaching formats. Climate change threatens the health, well-being, and lives of countless people , 2]. Th. Th2]. THealth systems worldwide are being confronted with the resulting health problems, which is why there is an urgent need and responsibility for medical professionals to educate themselves in this regard. Their responsibility includes at least four levels: as physicians, they must be able to recognize, prevent and treat so-called climate-sensitive and climate-induced diseases ; as scieMedical students' knowledge and attitudes about climate change should be known, as well as their expectations in this regard, to tailor teaching to the actual needs of the target group.In addition, knowledge about pilot projects, already established courses or published learning objective catalogues is helpful to benefit from this preliminary work.Furthermore, adequate teaching methods adapted to the content should be used.All these points have already been addressed in international publications, the results of which are the focus of this review.The objective of this review is to present the state of international medical education on climate change and health. For this purpose, findings on prior knowledge, attitudes and expectations of medical students on climate change and climate science were collected. Current teaching activities were considered, and possible content and design options for specific courses were identified.A three-step approach was followed for the literature review. First, areas were identified on which to focus the research, namely, (I) knowledge, (II) attitudes of medical students and physicians and related disciplines towards climate change, (III) expectations of medical students regarding medical teaching, (IV) a global representation of existing teaching activities, (V) formulated learning objectives, and (VI) applied methods and formats in teaching climate-related content. The search for relevant publications was conducted in the PubMed and Google Scholar databases in April 2021. The search strategy is presented in figure 1 2 concentration in the atmosphere, and the increase in the Earth's temperature. The questions were answered correctly by 60% of the students. It was further revealed that a majority of the respondents (79%) considered humans to be mainly responsible for climate change . T. T2 conc50 years .Surveys of the current state of knowledge on climate change among already licenced physicians is also informative to derive which teaching approaches medical students – as tomorrow's physicians – could benefit from. For example, in 2015 and 2016, the American Thoracic Society (ATS) surveyed its international members regarding their knowledge of the links between climate change and health. In 2015, 89% of physicians agreed that global temperatures had risen in the past, would continue to rise, and would change the world's climate. Sixty-eight percent saw humans as the cause of these changes . One yeaOne group that is particularly confronted with the health impacts of climate change is rural physicians. In 2014, a survey of rural physicians was conducted in Australia. Among them, 71% considered climate change to be real, and 66% attributed such change to greenhouse gas emissions .The majority of German medical students in a 2021 study considered themselves to be role models regarding climate change, while less than half of the respondents reported having either a particular social responsibility or informative or educational role . Among YSince the number of studies focusing on medical students is small, the attitudes of already licenced physicians will be considered comparatively. In the 2015 and 2016 ATS studies, medical students from various disciplines were surveyed , [15]. CIn most of the identified studies, most medical students showed positive attitudes towards the introduction of climate change coursework and content. In a study based in the United States, Ryan et al. showed that nearly 60% of medical students surveyed wanted the topic of climate change to be integrated into their curriculum . HoweverDue to the very limited number of studies on the desire to address climate change in the human medical curriculum, it is also recommended to look at studies in other health professions. In 2014, nursing trainees in four European countries were asked whether they wanted climate change events to be integrated into their curriculum. German nursing trainees were significantly more likely to agree than those from the United Kingdom . In 2016In many places, courses that teach climate change have already been piloted or permanently implemented in medical education. A 2019 survey of members of the International Federation of Medical Students Associations (IFSMA) showed that 73 of 107 countries had integrated climate change teaching into their national curricula . T. T32]. TOne possible goal of teaching climate change can be to give the participating students an impression of the diversity of this topic. In addition to knowledge and skills, attitudes and values come to the fore in the field of climate change education, which cannot be “learned” in the conventional sense. Therefore, ethical case work and discussions, group work involving diverse perspectives, and reflection exercises are particularly helpful in teaching attitudes and values .The involvement of committed students takes on a special significance in the field of climate teaching, since individual medical students have a profound knowledge of climate change and its health consequences, for example, due to a previous commitment to Fridays For Future. To profitably incorporate these competencies into courses, the “flipped classroom” technique, discussion rounds and debates are particularly suitable . Peer-toIn addition to the aforementioned teaching methods and formats, clear lesson structure, concise instructions, and approaches that demonstrate the relevance of scholarship to clinical practice also contribute to greater student engagement . For exaDepending on the university setting, the focus and the teaching method used , it can also be useful to provide evidence of achievement in the field of climate science . InternaThe aim of this paper is to present the state of the art of climate science within medical education. On an international level, there are already some projects focused on the integration of this complex of topics into medical curricula. For example, learning objective catalogues and handouts for the design of specific courses exist, which are freely available and represent an important inspiration. The field of teaching climate-related content is rapidly evolving; for example, as this article goes to press, a topic-based extension of the National Competence Based Catalogue of Learning Objectives for Undergraduate Medical Education (NKLM) is already underway in Germany. Despite all the attention to detail and the dedication that medical educators sometimes display on the way to obtain the best possible course, one thing must not be forgotten: time is of the essence. Therefore, according to the authors of this review, just as important as considering the literature presented herein is the willingness to “get started”. The relative pressure of time and action, in turn, underscores the importance of an accompanying seminar evaluation to be able to make adjustments as the seminar progresses. Physicians practising today and in the future will be confronted with the health effects of climate change. Adaptation strategies must therefore be taught, as well as ways to minimize the negative ecological impacts of the health sector.Of course, this work is also subject to certain limitations that restrict its informative value; due to its narrative character, no claim to completeness can be made. The actual knowledge of medical students about the health consequences of climate change can only be approximated. Regarding the low level of willingness of today’s medical students to act as social role models for future patients, it must be critically questioned whether this lack of willingness is due to an ignorance of the health effects of climate change or whether this responsibility is seen to lie with other professions. Few teaching projects seem to have been developed or scientifically described within human medicine thus far; therefore, studies from neighbouring disciplines are often used. This makes it difficult to make a statement specifically related to medical students. Ultimately, however, teaching on the links between climate change and health seems to have depended heavily on the initiative of individual student groups, lecturers, faculties or universities. It is therefore necessary to expand the medical curriculum to include content on climate change on a mandatory and comprehensive basis to take the importance of this topic into account.https://networks.sustainablehealthcare.org.uk/The Sustainable Healthcare Education Network (SHE) of the Centre of Sustainable Healthcare (CSH Networks) provides a peer network to support teaching about sustainable health care. CSH Networks: https://phreportcard.org/ is a student-led initiative to encourage universities and faculties to become more involved in teaching about climate change. It features an interactive map of teaching opportunities, currently particularly in the U.S. and England. The Planetary Health Report Card Initiative https://www.cfms.org/what-we-do/global-health/heart-competencies. The Canadian Federation of Medical Students (CFMS) has published a catalogue of learning objectives with recommendations on which topics to cover on climate change and into which existing subjects they can be integrated: Funded by the Baden-Württemberg Stiftung.The authors declare that they have no competing interests.


The aim of the research was to evaluate the traditional exodontia block course. The objectives were to explore the experiences and views of students, clinical teachers and dental practitioners of the various elements of the course curriculum.The study was a qualitative, participatory action research study using descriptive analysis. The study was conducted at a Dental Faculty in South Africa. A purposive sample of students, clinical teachers and dental practitioners were invited to participate. Focus group discussions were used to collect data which was analysed by an external coder.The study population consisted of 15 undergraduate dentistry students, 10 clinical teachers and seven dental practitioners. Four broad themes with sub-themes emerged from the study. The main themes identified strengths and deficiencies of the traditional course and made recommendations for its improvement. The themes identified were i) Integration of knowledge and skills, ii) Block course structure, iii) Challenges associated, and iv) Recommendations for improvement. Overall, the participants were satisfied that the course met its objectives. The results pertaining to clinical skills acquisition identified that teaching the use of elevators and luxators in the course, and standardisation of terminology among all clinical teachers as areas requiring attention. Teaching and learning strategies such as community-based learning, peer learning, case reviews, feedback and visual technology were viewed by the student, as well as clinical teacher samples, as strategies most beneficial to clinical learning.The review of the curriculum for exodontia skills acquisition and development, provided several benefits. Firstly, this research served as a quality assurance indicator. It further highlighted many teaching and learning strategies that would improve clinical skills development, reduce stress and anxiety, and support student learning. To a large extent, pertinent information was obtained that served to inform the subsequent redesigning of the course. The findings of the study augment the literature currently available on the best practice for exodontia skills acquisition and development and provide baseline information for the planning and redesign of related courses. Tooth extraction [exodontia] is a commonly performed dental procedure worldwide , 2. PrimCompetence has been defined as a measure of performance that is the active, behavioural expression of expertise lying on a continuum from novice to expert . The jouClinical teaching and training, an inherent feature of health professions curriculum  enables The commencement of acquiring a new clinical skill often starts in a simulated clinic or a skills laboratory; recognised as preclinical teaching and learning. The preclinical environment may include demonstrations and practice on bench models or simulators. Once a level of readiness has been achieved by the student, he/she may progress to the next level, that of training on the clinical platform. In this study, the ‘service learning’ model most accurately resembles the clinical training aspect experienced by the students of the programme in this study. By definition, service learning combines educational goals with service to the community whereby the community and the training institution are equal partners. The three main goals of service learning are improving learning, promoting civic engagement, and strengthening communities . AlthougFor this research, the exodontia curriculum with its various facets is reviewed. Detailed information on the topic is sparse. The existing literature largely focuses on content delivery and assessing competence , 26–30 aIn this research, at a dentistry school in South Africa, a learning unit in a Maxillofacial and Oral Surgery module focusing on the teaching and learning of tooth removal (exodontia) was evaluated. The Exodontia Block Course is presented in a three-and-a-half-day (3.8) contact session in the third year of study. Due to the traditional block course not having been systematically reviewed for an extended period, the module coordinator (the primary researcher) decided to review the course and redesign it by incorporating a teaching and learning strategy (deliberate practice) aimed at improving the procedural skill of tooth extraction. As part of a larger study evaluating the traditional exodontia block course, this paper aims to describe the experiences and perceptions of CTs, dentistry students, and dentists in practice of the preclinical component of the tooth extraction procedure with emphasis on the strategies employed, the instruments or equipment used, and the logistics of the course. Furthermore, the challenges and recommendations for improvement of both the preclinical component and the clinical training aspect are reported.This was a qualitative study using descriptive analysis. Participatory action research (PAR) was used as the research methodology and appreciative inquiry (AI) as the framework for data collection and analysis.rd, 4th and 5th year students via the class representatives and through the ‘announcement’ tool of the learning management site. The DP sample were general dentists from various private and public settings. These participants were recruited using a snowballing approach through contacts of the primary investigator (PI). Information pertaining to the nature of the research was shared with participants, and consent for the research was collected via a Google Form.The research was conducted at a dentistry school in South Africa. A purposive sample consisted of undergraduate dentistry students, CTs and dental practitioners (DPs). Only students who had completed the Exodontia Block Course, CTs who taught in the Maxillofacial and Oral Surgery Department, and DPs who completed the course at the institution as undergraduate students were eligible to participate. Invitations to participate in the research were sent to the 3The Biomedical Research Ethics Committee of the institution granted ethics approval (BM19/10/23). Focus group confidentiality binding forms were completed by all participants. The research assistants involved in the research where reminded of the protection of data act. Data were stored on Google Drive and a password-protected laptop. The participants were de-identified by replacing their names with a participant identifier thus ensuring anonymity. Participation was voluntary and no monetary or other incentives were provided.Data collection commenced in July 2020 and was completed in March 2021. A Google Form was sent to participants to collect demographic information. The PI conducted the first focus group discussions (FDGs), initially with a group of two students and in a separate session, with a group of six CTs. These FGDs were conducted in-person (face-to-face) and constituted the pilot study. As a means of eliminating any measure of bias, an external facilitator was used thereafter to conduct the remaining FGDs. Because of the COVID-19 pandemic, these FGDs were conducted online using the Zoom and Google Meet platforms. Data from the pilot study were added to the study data and included in the analysis since there were no significant differences. A semi-structured interview guide informed by the AI framework  was usedFocus groups were used as a data collection instrument because it allowed for the collection of rich data and a reduction in potential researcher bias . These dThe recordings were transcribed verbatim and ‘cleaned’ for better flow. Filler words such as ‘the’ and ‘so’ were removed. A research assistance was employed to do the transcriptions, and the data analysis was conducted by an independent coder and analyst who was familiar with qualitative data. After preparing the raw data for analysis, Tesch’s eight steps for analysing data was employed. The eight steps were i) gaining a sense of the whole by reading through all the transcribed interviews, ii) searching for underlying meanings, iii) compiling a list of all the topics and grouping them together into clusters, iv) abbreviating the topics in view of data coding, v) transforming the topics into themes and reducing the list of themes, vi) deciding on the themes and alphabetising the final themes, vii) performing a preliminary analysis, and viii) recoding existing data where required . Only thThe inclusion of various stakeholders in the research in addition to member checking improved the trustworthiness of the outcomes of the research. The researcher was aware of her role within the research and the potential for bias stemming from her experience in the field. The researcher endeavoured to remain reflexive throughout the research through debriefing sessions with one of her supervisors.I mean, supervisors know their stuff. We just don’t necessarily grasp it the minute they give it to us (SIV3), and a group of younger CTs who were able to identify with the current generation of students upervisors, obviously they’ve been doing it, they’ve got years of experience. but we don’t learn the same—and they teach us, they’ll teach us once, like, they’ll cover a lecture and everyone is listening, but we don’t learn the same. So then you’ll go to someone else in your class, who will kind of demonstrate or teach you, or just rephrase what the supervisor said in their way, or their explanation makes more sense to you. Because, I mean, this is someone who’s your age. This is someone who processes similar to you.Clinical teachers were predominantly part-time faculty, primarily from the private sector, who spent between 8 hours and 20 hours per week teaching on the clinical platform and a mean of 33.1 hours per week practising as general dentists. In addition, 80% of the CTs held postgraduate qualifications, which included an honours degree in oral surgery, master’s degrees in dentistry, postgraduate diplomas in oral surgery, and a law degree. The two faculty members who did not have a postgraduate qualification were enrolled for a postgraduate diploma in oral surgery at the time of the research. Furthermore, three of the participants were no longer employed at the school at the time of the research. One participant had emigrated, one had moved to the public sector, and the remaining participant had started training as a specialist maxillofacial surgeon.Of the DP sample, all participants were employed in private practice, the public sector, an academic institution, or the National Defence Force. The age range was between 23 years and 33 years (mean age: 28 years). The time from qualification to the current research was between one year and nine years. Demographic information and characteristics of these samples are presented in Integration of knowledge and skills; ii) Block course structure; iii) Challenges associated, and iv) Recommendations for improvement. The first two themes reflected the strengths of the course. The themes and sub-themes that are described and discussed in this paper relate primarily to clinical teaching and training or clinical skills development. The four phases of the AI framework are used to present these findings  and the coder. The main themes identified the strengths, deficiencies, and recommendations for improvement of the traditional block course as experienced by the participants of the research . The thefindings . These pThe use of the AI framework allowed for a comprehensive presentation of the findings pertaining to the clinical skills development component of the traditional course. The phases of the framework are not necessarily explicit, and possibly due to the generative nature of the process, crossover of the themes and sub-themes resulted. The authors mapped the information pertaining to the clinical skills component from the master table of findings  to the vIntegration of knowledge and skills and Block course structure. The sub-themes provided a more detailed view of the strengths of the course. The integration of the course content, didactic teaching, course presentation (layout), complemented by the incorporation of clinical practice and chairside teaching, contributed to the success of the course, as evidenced by the emerging sub-theme Student confidence  really do think it’s because of that episode I had with the syncope patient, that could just, like deflated my confidence a whole lot. I’m not saying I’m a needy person, but if the supervisor/someone told me, you know, it’s gonna be fine, … maybe I just had the wrong supervisor on the wrong day, but just that debriefing, or just to let you know that it’s normal, it’s gonna happen and you’re only gonna grow from here…The debriefing activity not only supports experiential learning, but is also used as a tool to reach consensus on the teaching content of CTs who teach in teams. Qualitative studies, literature reviews, and expert opinion papers have identified several characteristics for successful debriefing; these include structure, positive faculty demeanour, cueing questions, debriefing immediately after simulation, honest forthright feedback on performance, a safe learning environment, and adequate time to debrief learners .clinical skills or simulation laboratory is used in medical education for students to train in a simulated clinical environment. This development became necessary when the access to patients for clinical teaching and training was reduced for a number of reasons including an increase in student numbers and an increase in litigious claims. Whilst the skills laboratory is not conducive for teaching of exodontia in its current state, a skills laboratory allows for an increase in opportunity for students to view, to participate in demonstrations , and to handle real instruments such as extraction forceps. The opportunities for practising clinical procedures in a simulated clinical environment with the correct instrumentation act as a form of scaffolding. Students are able to practise patient and operator positions and orientate themselves in terms of anatomical structures in the mouth in a low-risk environment. This helps in gaining confidence and reducing the stress that students endure when engaging with an invasive procedure such as the removal of a tooth. Less-stressed students may engage more confidently on the clinical training platform, enhancing their learning and ultimately resulting in improved patient outcomes. Owing to resource constraints, the traditional block course did not take place in a clinical skills laboratory equipped for oral surgery procedures. The suggestion to incorporate a clinical skills or simulation laboratory into the course in the future requires significant planning. The design and construction of a clinical skills laboratory requires resources in terms of finance and space together with buy-in from the relevant authorities.The Community-based learning or education, also referred to as ‘community outreach’, was viewed very favourably by the samples comprising students and DPs and was considered an opportunity to improve and accelerate clinical skills and to serve as an introduction to the ‘real world’. The practice of working in communities provides insight into the inner workings of communities, including their culture, health practices, and challenges. According to DP5:Comm-serve [community service], but I think it was in final year. We didn’t do outreach programmes, and I was part of the group that went to Gugulethu clinic. A group of us went there, and we got introduced to the real world, the real part of dentistry, and our clinical patient… was the government. And, you know, [you] see all those patients outside and you having a certain timeframe to complete it, you learn to work really well, and you learn to gain that confidence.A concern raised by the CT sample was that the content presented in the course was too expansive and was not focused specifically on skills acquisition. The content pertaining to the use of drugs within Oral Surgery and prescription writing was beyond the parameters of the course and this possibly distracted the student from the task of skills acquisition. It was suggested that the time spent on delivering this content be used in developing the psychomotor skill by increasing the time spent on clinical practice.Peer learning in medical education has become increasingly popular in part due to the increase in the number of medical students. Its benefits are well established in the literature , 55. TheFeedback is an important contributor to learning and forms part of the experiential learning cycle. SIII1 shared this view:… where you get some sort of feedback to say, ‘Okay, this is where you went wrong. I would have given you this mark if you had done so and so’.From the above response, there appears to be a mis-interpretation or misunderstanding between the provision of feedback and the link between assessment and feedback. Shrivastava et al (2022) indicate that faculty find it a challenge to provide feedback to students . Many divisual technology) in supporting learning was strongly supported in the research. Although a blended learning approach has been in use within the module, alternative applications of technology were described. The use of visual technology in the form of videos was found to be the most useful form of clinical teaching [The benefits and value of technology , andThe theme The third-year students are very fresh. So you basically hold their hand the whole way from beginning to end as soon as they walk into the cubicle until they leave. So, and that makes it difficult when it’s a big class because they need the individual attention. (CT8)Block course duration’ encompasses the host of challenges that were encountered, particularly by the CT sample. The results suggest that better clinical teaching with the consequent student learning could take place if more time were spent on individual students. The following were viewed as hindrances to optimal clinical skills teaching and training: i) high student to clinical teacher ratio; ii) inadequate time per clinical session to teach; iii) disproportionate focus on clinical service delivery versus clinical chairside teaching; iv) an over teach may be taking place, breaching the objectives of the course; and v) too much emphasis on the clinical assessment (assessment of learning) of the junior student, thus negatively affecting student learning. Clinical teachers expressed that increased opportunity to engage with students on an individual basis would allow them to impart skills teaching to novice clinicians. Contemporaneously, the students sample expressed an increase in the duration of the course to allow them more time for practice. With the luxury of having adequate patients requiring treatment (opportunity for practice), increasing the duration of the block course or recommending block teaching to the institution may address the issue of time constraints and aid in meaningful clinical teaching and learning. Of the recommendations for improvement of the block course suggested by the student sample, teaching and learning strategies such as community-based education, peer learning, feedback, case reviews during clinical practice, and visual technologies featured prominently.An increase in the number of students within a group rotating through the course appeared to affect student learning negatively. Smaller group sizes were favoured by both students and CTs. A smaller number of students per group improved the student to clinical teacher ratio. This appeared to favour interaction between student and faculty member. The potential for opportunity for students to engage with faculty members increases when the student number decreases. In addition, demonstrations can be viewed more easily by students when there are fewer students in the group. In terms of redesigning (co-constructing) the course, a reduction in the number of students in the course rotation will have to be considered. Human resources, physical infrastructure, and time availability will also have to be taken into account. The sub-theme ‘Integration of knowledge and skills and Challenges associated.This phase is represented by the themes: The sub-theme, the layout of the course is well planned, as evident by the quotation:There is nothing I would change about the block, it was lovely (SIII1)Reliance on teachers, may require the exploration of strategies which foster independent, adult learning. Self-directed learning (SDL) is an example of a strategy that can be explored in an attempt to address the lack of ownership for learning by some students, as expressed by the CTs in this research. Self-directed learning has been suggested as a promising methodology for lifelong learning in medicine [Because the overall view of the traditional block course was positive, the retention of the aspects which were both well received and well perceived by the participants are important when developing the revised course. A consideration in addressing the sub-theme, medicine . This stmedicine . Additiomedicine . The graThe number of student participants in the research can viewed as a limitation. An increase in the amount of student participation may add further depth to the themes generated by the data. Students learning are diverse and there may possibly be an outlier in terms of student learner styles which has not been included in the research. An analysis more specific to the elements of the curriculum may have resulted in themes for pointed to these elements.The evaluation process brought to light the strengths and concerns of the course from the perspectives of three stakeholder groups. Moving forward, it would be necessary to interrogate and cross-match the views of each sample on specific focus areas of the curriculum. It is important to note that the proposed changes to the curriculum would have a knock-on effect across the elements. Because the tooth extraction procedure is fairly invasive, it is worth investing in instructional methods and learning strategies which support the journey from novice to competent in particular those suggested by the student and CT samples. The evaluation of the course clearly describes a continuum of learning of the tooth extraction procedure whereby the block course stems the starting point for skills development, with the continuation of clinical learning throughout the fourth and fifth years providing the opportunity to gain proficiency and ultimately reaching mastery if the correct instructional methods being applied. Although the research made use of only the subjective, personal views and experiences of the stakeholders, the nature of the qualitative data collection approach allowed for the retrieval of rich data that were able to inform the status of the course and provide a basis for its redesign. The information that was obtained can be considered when planning and developing the course curriculum to promote effective clinical rotations and student learning. There have been significant technological advances in both dental extraction techniques and in the education sphere. Adding to this, the COVID-19 pandemic has opened up a space for online activities which supports a student-centred, adult learning approach. A convergence of these three factors could potentially result in a revised course which meets the needs of the majority of diverse students. The findings of this research provide a baseline allowing for comparison of the course with similar oral surgery modules at other dental schools. Further, the results of this research augment the literature currently available on best practice for exodontia skills acquisition and provide important baseline information for the planning and redesign of related courses.


The circular economy reshapes the linear “take, make, and dispose” approach and evolves around minimizing waste and recapturing resources in a closed-loop system. The health sector accounts for 4.6% of global greenhouse gas emissions and has, over the decades, been built to rely on single-use devices and deal with high volumes of medical waste. With the increase in the adoption of digital health solutions in the health care industry, leading the industry into a new paradigm of how we provide health care, a focus must be put on the amount of waste that will follow. Digital health solutions will shape health care through the use of technology and lead to improved patient care, but they will also make medical waste more complex to deal with due to the e-waste component. Therefore, a transformation of the health care industry to a circular economy is a crucial cornerstone in decreasing the impact on the environment.This study aims to address the lack of direction in the current literature on circular business models. It will consider micro, meso, and macro factors that would impact the operational validity of circular models using the digital health solutions ePaper label , smart wearable sensor , smart pill box (medication management), and endo-cutter  as examples.The study will systematically perform a scoping review through a database and snowball search. We will analyze and classify the studies from a predetermined set of categories and then summarize them into an evidence map. Based on the review, the study will develop a 2D framework for businesses to follow or for future research to take a standpoint from.Preliminarily, the review has analyzed 26 studies in total. The results are close to equally distributed among the micro , meso , and macro  levels. Circular economy studies emphasize several circular practices such as recycling , reusing , reducing , and remanufacturing . The value proposition in the examined business model is mostly dominated by stand-alone products  compared to product as a service , involving stakeholders such as health care professionals or hospitals , manufacturers , and consumers . All studies encompass societal , economic , and environmental  viewpoints.The study argues that each digital health solution would have to be accessed individually to find the optimal business model to follow. This is due to their differing life cycles and complexity. The manufacturer will need a layered value proposition, implementing several business models dependent on their respective product portfolios. The need to incorporate several business models implies an ecosystem perspective that is relevant to consider.DERR1-10.2196/47874 A circular economy is a system that has been evolving in theory and practice for decades, with a core focus on minimizing waste and reprocessing products in a closed-loop system -4. GrounAs global technological advancement continues, the health care industry has witnessed a surge in the adoption of digital health solutions across hospitals, health care professionals, and patients . Given tThe current literature landscape’s lack of consensus on how to develop a circular business model in health care does not arise due to disagreements on how circular waste management should be introduced but rather stems from a lack of knowledge and research on the topic. This conundrum could hint toward current circular business model solutions being too generalized and not considering the specificities of the health care industry and digital health to be implemented. Circularity must thus be implemented on a product- or industry-specific level to succeed .2 emissions due to electricity use and the continuous use as well as the repurposing of data. Even within digital health solutions, a distinction must also be made between the different types of life cycles the solutions have due to their varying use. Some digital health solutions never leave the hospital, in which case it can be easier to control their reprocessing, while other solutions are owned by the patients, which can leave uncertainties on take-back schemes in a circular business model. Second, the contamination risk of medical solutions adds an additional layer of regulatory and operational complexity that also must be considered in the operations of the circular model. You need to ensure the product does not spread or contain harmful elements impacting human health and the environment. The motivation behind developing an industry-specific model forms the purpose of this scoping review: to theoretically develop a framework that businesses can take as a standpoint [For instance, 2 crucial characteristics of digital health solutions would make the implementation of a generic circular model fail. First, the term digital health “solution” is used on purpose instead of “device” because the product not only contains hardware but also software and data components . Apart fandpoint . This fiTo develop concepts for tailored circular business models for digital health solutions, this scoping review examines existing circular models in the health care industry and of other similar products in other industries. To make the analysis concrete, 4 product categories will be used as examples: medical packaging (ePaper label), health monitoring devices (smart wearable sensor), medication management (smart pill box), and surgical equipment (endo-cutter). These 4 products are representative of medical versus nonmedical, as well as single-use versus recurrent-use products.The unit of analysis in the scoping review is the circular business model. This is due to it being the core concept that motivates and justifies the performance of the study. The units of analysis can be broken down into circular and business models. Circularity will be defined through the concept of the 4 R’s  and the MacArthur butterfly model  and hencA set of theoretical boundaries will guide the scoping review. First, as the research on circular business models in health care is limited, the search does not solely focus on the health care industry but also related industries such as wellness. To avoid a scope that is too broad, it is important to narrow down the types of solutions to be examined and only include products that have similar components  or businThe scoping review will provide valuable information for future research in the circular economy as well as within the European Union (EU)–funded Digital Health in Circular Economy (DiCE) project and the stakeholders involved . The adoThe scoping review will follow a systematic framework and best practices developed by Arksey and O’Malley , Durach The scoping review and its research question will be built around the unit of analysis and on the defined research boundaries listed. As the research question has an exploratory objective as well as an evaluation perspective on current circular business models, the following research question has been formulated: “How can circular business models be adapted and remodeled to digital health solutions?”The research question will synthesize the literature on circular business models with a health care–oriented lens. To support the research question, a set of subquestions has been created to guide the analysis.What are the barriers and enablers of implementing circular economy practices in the digital health market, and how can they be addressed? How are value and cost both negatively and positively redistributed in implementing a circular business model and impacting its key targets and performance indicators? How would operating systems and data gathered by the solutions be affected positively or negatively by circularity? To identify a relevant set of studies, the following inclusion and exclusion criteria  have beeInclusion criteriaStudies focusing on one or more of the components in the solutions being hardware, software, and dataStudies including health care or related industries such as fitness and wellnessStudies including one or several stakeholders in a circular business modelStudies illustrating environmental or societal impact by implementing circular business modelsExclusion criteriaStudies that do not focus on economical, societal, or consumer outcomeStudies published before the year 2010 ,20Non–peer-reviewed articlesEditorials and commentariesNon-English studiesIn the literature search, 2 search strategies will be implemented: keyword search and snowball search. The keyword search will be performed in Scopus and Web of Science. Furthermore, a separate cross-checking search in PubMed has been done to ensure the databases include studies within the industry of interest, health care. Scopus and Web of Science have been chosen for several reasons. First, they both cover interdisciplinary results, thus fitting the scope of the scoping review into circularity, business model, and health care. Second, the databases have similar search functions, making the standard search protocol easier to follow without too much adaptation from one database to another. Third, they are some of the biggest databases and have a broad reach. Following the research protocol, a set of search criteria and search strategies have been applied when searching in the mentioned databases.The snowball search will be performed by screening the reference list of selected studies and their references. The dual search approach will help ensure a more comprehensive scoping review and provide a complete understanding of the topic. The keywords have been chosen by testing the number of hits for each keyword and using the snowball search technique to choose relevant keywords.A total of 3 search queries have been created to enlighten the different layers of the research question . One topIn the study selection, all duplication of records is removed before a screening of the topic is performed. Furthermore, the inclusion and exclusion criteria will be used to reduce the final selection of studies. The results from the keyword search will be manually screened by 2 independent researchers to be able to compare and discuss the final study selection. The tool Rayyan (Qatar Computing Research Institute) will be used for this procedure. This method ensures the screening is less biased by the researchers’ different fields of expertise. In the data extraction process, the data will be inserted into the reference manager Zotero .Both empirical qualitative and quantitative studies, as well as literature reviews, conceptual pieces, and modeling research, will be considered to enlighten the topic from different methodological perspectives. The selected studies will be coded through an emerging and a priori coding structure to find relevant relationships between variables. With a priori code, we mean predetermined categories will be screened for when reporting the results. It will in addition extract relevant details on the studies such as title, author, publication details, and methods.The results will be analyzed and summarized through a statistical view in tables and graphs as well as a narrative method. An evidence map will be created, with the set of categories that have been chosen below to categorize the data and find similarities and differences among the results to discuss . The catIn addition to the categories chosen in the evidence map, the 3 levels, micro, meso, and macro, will be the structure of the discussion and help find the current research gaps in the literature.This scoping review does not require ethical approval as it solely uses published articles with no research involving humans, medical records, patient information, or observations of public behaviors. Therefore, the term “not applicable” applies. Any deviations from this protocol will be disclosed in the following scoping review publication. Additionally, the outcomes will be disseminated in the research community, such as through conference participation.A preliminary description of the results has been performed. The results have been ranked according to the hierarchy of evidence to assess how likely they are to incorporate a systematic bias. There are 7/26 (27%) systematic reviews, 18/26 (69%) controlled studies, and 1/26 (4%) expert opinion. The results are well distributed among the 3 levels that will be analyzed: micro , meso , and macro . The reporting of results is divided into the unit of analysis, the circular business models, and the type of product analyzed in the studies.Most studies incorporate 2 or more R’s in their analysis . Reuse , recycle , and reduce  are covered in most studies, with remanufacture being the least covered .Most studies focused on a stand-alone value proposition . Product as a service is mentioned in 27% (7/26) of the results. The main stakeholders covered by the studies are health care professionals or hospitals , manufacturers , and consumers .The majority  of the studies have a product-specific focus, and 9/26 (35%) studies have a system-oriented focus. Out of the 17 studies that focus on a product, most of these are single-use devices  and medicine .A more in-depth report of the results will be performed.The review outlined will serve to understand and offer insights into the factors that influence the adoption of circular business models in health care. The findings within the micro level are expected to shed light on the product design and principles to design after. The findings within the meso level will focus on the role of stakeholders, the set of skills they must have, and key factors when collaborating. At last, the macro level will adopt broader legislation and guideline perspectives on the circular economy within health care at the national and EU levels. The findings from the review will be disseminated through a peer-reviewed scientific journal and conference presentations.A total of 2 main limitations have been identified. First, as the review’s macro level focuses partially on EU legislation, there may be an overrepresentation of European studies, and the review might oversee interesting legislative initiatives in a global context. Second, in the literature search, the review only focuses on studies from 2010 onward. Therefore, older, important articles might be missed and not included in the review, which the readers should be aware of.The conclusion and outcome of the review will show that a circular business model for digital health solutions will be very specific to what kind of product it is. This will in the future require manufacturers to have a clear end-of-life management plan for their product and incorporate a layered value proposition. Furthermore, to make the value proposition and end-of-life management of the products successful, the review implies they must engage in an ecosystem with several actors to close the circular loop.


Conducting on-site surveys to assess tourists' spatial visitation patterns and preferences is both time and labor intensive. However, an assessment of regional visitation patterns based on social media data can be an important decision-making tool for tourism management. In this study, an assessment of the visitation patterns of Chinese mainland tourists in Sabah is conducted to identify high-visitation hotspots and their changes, as well as large-scale and small-scale temporal characteristics. The data is sourced from the Sina Weibo platform using web crawler technology. In this work, a spatial overlay analysis was used to identify the hotspots of Chinese tourists' visits and the spatial and temporal variations. The results of the study revealed that the hotspots visited by Chinese tourists prior to 2016 have shifted from the southeast coast of Sabah, to the west coast of Sabah. At a small scale, Chinese tourists' visitation hotspots were mainly concentrated in the urban area along the southwest coast of Kota Kinabalu, shifting to the southeast of the urban area in 2018. This study provides insights into the applicability of social media big data in regional tourism management and its potential to enhance fieldwork. However, due to fears of another Covid-19 wave, several parties have called for the government not to allow entry for travellers from China There are no studies that have applied social media data to evaluate tourist visitation patterns in Sabah, Malaysia. Although the applicability and validity of data needs to be considered in applying social media data for tourism research, social media data can be a good remedy for the lack of survey data. The work of this research has been motivated by several studies that have shown the spatial–temporal-based big data can provide new insights gained from location-based social media data and understand human spatial–temporal behavior patterns The aim of this study is to apply and validate a modeling method for mining key information about tourist destinations in Sabah, Malaysia using social media big data. Based on the aim of this research, here are three research questions that will be addressed in this work; 1) Is it feasible to collect the appropriate data on social media platforms and store in a geo-database? 2) What indicators of tourist interest are reflected and how these hotspots are distributed in space and time?Thus, the objectives of this work are firstly, to investigate the best practice available to design and create a geo-database to store tourist data captured from social media platform, and then to adapt and implement the Kernel Density Analysis (KDA), Spatial Overlay Analysis (SOA) and Standard Deviation Ellipse Analysis (SDE) to visualize the tourist data and perform spatial analysis.The contributions of this work include the findings related to the distribution of tourist destinations and related facilities in Sabah, Malaysia, and also the identification of high-traffic areas of Chinese tourists on both large and small scales.http://www.weibo.com), we collected relevant information about Chinese tourists visiting Sabah, and explored the time and space visiting patterns of Chinese tourists. In addition, according to the time series, spatial overlay analysis is used to discover the preference characteristics of tourists in different periods. Finally, differences in existing tourist destinations and related facilities and spatial access patterns of tourists are analyzed. This study applies social media big data to provide new perspectives and insights into the application of Malaysian Sabah managers in tourism planning, development and management, while also including the effectiveness and limitations of their use. The findings are expected to help Sabah managers use social media big data to develop healthy and sustainable regional tourism destinations with limited field data.Sabah, Malaysia is a famous tourist destination in Asia and even the world. Through Sina Weibo . OpenStreetMap provides a variety of ways for users to download map resources, where the geographic information is provided voluntarily and contains accurate spatial data for users to use Property location data in Sabah is mainly provided by OpenStreetMap  generated according to the timestamp from April 2014 to July 2019. However, only 48 months (N) will be used (data aggregated monthly for year 2015 to 2018) out of 64 months to verify the number of microblogs that reflect the number or inbound Chinese tourists in Sabah.2.3Previous scholars that have conducted studies related to spatial-temporal analysis of tourists include investigating the spatial associations of urban tourism phenomena by using GIS and statistical methods to examine the relationships between hotels and land use types, attractions, transportation facilities, and the economic variables of the tertiary planning units in which the hotels are located In contrast, in this work, three methods are combined to analyze visitation patterns in Sabah based on Weibo Social Big Data to determine the spatial and temporal distribution of the visitor's area of interest, to identify high-traffic areas of Chinese tourists on both large and small scales, and to study the equilibrium degree of regional spatial distribution of tourist destinations in Sabah. These methods are Spatial Overlay Analysis (SOA) 2.3.1In this study, the collected Weibo data has precise location coordinates, so the number of Weibo is used as an indicator to identify tourists' spatial-temporal visiting patterns. The number of Weibo is considered here as a surrogate indicator of tourists.At different spatial scales, the number of Weibo is calculated according to grids of different areas. On a large scale, the number of Weibo is calculated according to a grid of 11 km × 11 km. On a small scale, the number of Weibo is calculated according to a grid of 1 km × 1 km. The collected Weibo data was visualized using ArcGIS software based on the location information in the data. Sabah, Malaysia is divided into 1400 grids according to a grid of 11 km × 11 km. Kota Kinabalu is divided into 928 grids according to a grid of 1 km × 1 km.2.3.2Tourists' visiting preference features are mined and analyzed through spatial overlay analysis by using ArcGIS 10.2. The distribution of natural attractions, cultural attractions and tourism-related facilities in Sabah, using the kernel density to mine the spatial distribution pattern of tourist destinations. Differences in tourist spatial access patterns and the distribution of tourist destinations and related settings are revealed by standard deviation ellipse analysis.In GIS, it is often necessary to extract spatial implicit information to obtain more valuable information. Superposition analysis is one of the common methods to extract spatial implicit information. Unlike location queries, overlay analysis generates new layers, and with overlay analysis, some features in the input layer are split by the boundaries of features in the overlay layer 2.3.3h has a great influence on the results of the kernel density analysis. In applications, the value of the bandwidth h is flexible, and different bandwidths can be selected for testing to explore the smoothness of the estimated point-dense surface Kernel Density Analysis (KDA) uses a kernel function to calculate the size of each unit area of a point or line feature to fit each point or line to a smooth conical surface. Commonly used kernel functions include quadratic kernel function, normal kernel function and fourth-order polynomial kernel function 2.3.4Standard Deviation Ellipse Analysis (SDE) is often used to describe the directional distribution of geographic features and is one of the commonly used methods in geostatistical analysis 33.1Due to the differences in socio-economic development level and natural geographical conditions in Sabah, Malaysia, the distribution of tourist destinations and related facilities in various regions is uneven. In order to more accurately and scientifically reveal the distribution of tourist destinations and related facilities in Sabah, Malaysia in different regions, the 25 cities in Sabah, Malaysia, the surrounding islands and the Federal Territory of Labuan are taken as regional geographical units. Destinations and facilities are listed in descending order, as shown in 3.2By comparing the statistics of the arrival of international tourists from Sabah, Malaysia with the number of Weibo collected, it is verified whether the number of Weibo reflects the number of Chinese tourists visiting Sabah, Malaysia. The number of Chinese tourist arrivals among them is counted and summarized on a monthly basis. The collected Weibo data is from March 2014 to July 2019, and the entire year of Weibo data is selected for statistics and aggregation on a monthly basis, which are 2015, 2016, 2017, and 2018 respectively. Pearson correlation analysis of the number of Chinese tourists visiting Sabah and Weibo data using SPSS software, the following results are obtained.N is the sample size.The correlation between the number of Chinese tourists visiting Sabah and the number of Weibo was fitted by SPSS regression analysis, as shown in 3.3Based on the social media big data of Sina Weibo, the number of Weibo accounts reveals the tourist destinations in Sabah visited by Chinese tourists . CombiniSmall-scale social media data mining can help reveal the preferences and changes of tourist visiting patterns within tourist destinations. As the capital of Sabah, Kota Kinabalu is an important hub for international tourists visiting Sabah. And on a grand scale, Kota Kinabalu is also a hot spot for Chinese tourists to visit. After 2016, the number of Chinese tourists visiting Kota Kinabalu and surrounding areas has increased significantly, as shown in In this study, Weibo-based spatial visitation patterns of Chinese tourists are matched with local knowledge of visiting hotspots. Semporna is a famous diving destination in Sabah, and both Pulau Mantanani Besar and Pulau Mantanani Besar have rich island tourism resources. South of Kota Belud is the location of Mount Kinabalu National Park. As the capital of Sabah, Kota Kinabalu not only includes abundant tourism resources, but also has convenient transportation conditions and sound tourism-related facilities. The city of Kota Kinabalu and the famous Tanjung Aru Beach are concentrated in the southwest area of Kota Kinabalu.3.4The spatial distribution of tourist destinations in Sabah has some similarities to the preferences of Chinese tourists visiting Sabah, but also shows more significant differences. Standard deviation ellipse analysis can reveal more accurately the relationship between the spatial distribution of tourist destinations in Sabah and the visitation preferences of Chinese tourists.∘29'57.9'E, 5∘52'33.2'N. The center of the distribution of Chinese tourist visitation patterns is located at 116∘29'16.4'E, 5∘48'12.5'N . The analysis results show that social media big data can effectively identify tourists' visiting preferences and spatial differences in tourist hotspots.Although the application of social media big data in tourism requires a large amount of observational data to verify, the number of Chinese tourists visiting Sabah and the collected Weibo data are statistically significant . Since 2016, the number of visits to the urban area of Kota Kinabalu has been decreasing year by year.This paper has proposed the application of social media data to identify the visitation patterns and preferences of mainland Chinese tourists in Sabah. The secondary objective is to also identify high-visit hotspots and their changes through the temporal attributes of social media data. Based on the findings obtained in this work, the Weibo dataset can be used to extract entities required to be stored in the geo-database. Furthermore, based on the data analysis conducted in this work, the following conclusions can be drawn related to the indicators of tourist interest and how these hotspots are distributed in space and time;The association of tourist sites and related facilities with tourist visitation hotspots at different scales is also discussed. At large scales, Sabah tourist sites and related facilities show variability in terms of distribution direction, distribution extent, and distribution dispersion from tourist visitation hotspot areas. At small scales, tourist sites and related facilities in Kota Kinabalu show variability in terms of distribution range and dispersion of distribution.In addition, this study also discusses the applicability of social media big data in the tourism industry. Although data from social media platforms is limited, this type of data is effective in mining and assessing tourism within an area. Through social media data, visitor visit patterns and preferences can be identified, and managers can develop policies to control visitor flow and behavioral changes. It is also an innovative tool for social media data to support destination management and the development of sustainable tourism. Finally, the field survey results combined with the advantages of social media data can provide managers with reliable information to promote the healthy and sustainable development of tourism in the region.Data obtained from social media platforms may be biased. In addition, in different tourism activities, tourists' willingness to post content or photos is also different. For example, when tourists explore the island by speedboat, they may not like to take pictures in the process although they have a device connected to the Internet. The data quality of social media big data is affected by the GPS capabilities of tourists' mobile devices and internet access. Finally, there are differences in the access patterns shown by different social media platforms. Therefore, in future research, consider using social media big data from different platforms to mine tourists' visiting preferences and visiting degrees. In addition, this study collected 100,365 Weibo data from April 2014 to July 2019, which requires sufficient field data to verify the credibility of social media big data. Despite these limitations and obstacles, the findings of this study are still able to demonstrate the effectiveness of social media big data in mining tourists' visit preferences and degree of visit. The above issues still need further consideration and evaluation to improve the applicability of social media big data.Rayner Alfred: Conceived and designed the experiments; Performed the experiments; Analyzed and interpreted the data; Contributed reagents, materials, analysis tools or data; Wrote the paper.Zhu Chen: Conceived and designed the experiments; Performed the experiments; Analyzed and interpreted the data; Contributed reagents, materials, analysis tools or data; Wrote the paper.Oliver Valentine Eboy: Analyzed and interpreted the data.Zhang Luxuan: Performed the experiments.Li Renjie: Contributed reagents, materials, analysis tools or data.The authors declare no conflict of interest.