Chronic disease burdens continue to rise in highly dense urban environments where clustering of type II diabetes mellitus, acute myocardial infarction, stroke, or any combination of these three conditions is occurring. Many individuals suffering from these conditions will require longer-term care and access to clinics which specialize in managing their illness. With Singapore as a case study, we utilized census data in an agent-modeling approach at an individual level to estimate prevalence in 2020 and found high-risk clusters with >14,000 type II diabetes mellitus cases and 2000–2500 estimated stroke cases. For comorbidities, 10% of those with type II diabetes mellitus had a past acute myocardial infarction episode, while 6% had a past stroke. The western region of Singapore had the highest number of high-risk individuals at 173,000 with at least one chronic condition, followed by the east at 169,000 and the north with the least at 137,000. Such estimates can assist in healthcare resource planning, which requires these spatial distributions for evidence-based policymaking and to investigate why such heterogeneities exist. The methodologies presented can be utilized within any urban setting where census data exists. Chronic diseases are the main cause of mortality and morbidity in developed countries, and constitute a large proportion of the healthcare burden . The dirTo evaluate accessibility and capacity planning, health systems need to identify where cases are in physical space. A method to perform such an analysis would be to use electronic medical records, registries, or other databases that record incident cases . AnotherAs computing power improves, computational simulation models are becoming more widely used in public health research. Specifically, chronic diseases develop over a long period of time, and as repeated epidemiological studies are costly and infeasible, computational approaches are useful tools to obtain preliminary estimates, a statement echoed by Barhak et al. . Models In this study, we aimed to estimate the present health risk of the resident population of Singapore, an island city state measuring 50 by 27 kilometers, for DM, specifically type II DM, AMI, and stroke using an individual-based model and identify where cases are located geospatially. This model allows us to investigate the presence of comorbidities in the local population quickly without the need to link up patient identifiers between different registries while at the same time provide information as to where these cases are concentrated in physical space. Given that individuals with multiple comorbidities are high-risk and are most likely to seek medical care, we aggregated the number of high-risk individuals by regional health system to generate estimates that are useful for capacity planning in local health institutions.To perform spatial imputation for a given population, information on the demographic breakdown of the population and the relationship between demographics and geography is required. In this study, we used a temporally explicit agent-based model of the population of Singapore with the demographic attributes of ethnicity, gender, and age by Phan et al. to create a synthetic population of Singapore . This moThe General Household Survey 2015 contains census tables that correlate demographic attributes such as ethnicity, gender and age with physical location . HoweverSeed random initial physical locations for the synthetic population;Calculate the chi-square statistic for each census table using the synthetic population as the observed values and the census as the expected values;Select two random individuals in the population and swap their physical locations;Calculate the new chi-square statistic for each census table. If the new chi-square statistic is lower than the previous one, accept the swap. If not, reject the swap and revert the physical locations to their original values;Repeat steps 2–4 until improvement in the chi-square statistic is marginal, implying optimal convergence.A hill climbing algorithm was chosen to optimize across the multiple dimensions. The steps of the algorithm within the context of the study are as follows:This process can be repeated for multiple attributes so long as aggregate statistics relating the imputed attribute with existing attributes in the synthetic population are present. For this study, imputing physical location took 10 million iterations to reach convergence. To obtain robust estimates, we performed spatial imputation with 100 copies of the synthetic population and reported the means.Using this method, specific outcomes of interest were chosen for validation and exploratory purposes. The National Health Survey 2010 is a population health survey for Singaporean citizens and permanent residents aged 18–69. In the National Health Survey 2010, the prevalence of DM was reported by ethnicity and gender in one table and by age group. We recreated these tables using the synthetic population for 2020, reporting the prevalence and the expected number of cases for validation purposes, and did the same for the chronic conditions of AMI and stroke where there are currently limited reported estimates at a population level. Registry data only reports annual incident cases which is insufficient to estimate the total chronic disease burden in the entire population. To estimate prevalence, a temporal element is required, hence our modelling approach. With a cross-section of the population in 2020, we can then obtain prevalent cases in the community. Singapore aggregates population statistics by planning areas, so we aggregated and visualized these case numbers on a map at the planning area level as a simple way to quickly assess the spatial distribution of health. Additionally, this model consolidates all health conditions by individual and allows for detailed reporting of comorbidities at a population level while simultaneously identifying where these high-risk individuals are likely to be located. To understand the spatial distribution of comorbidities, we investigated the number of individuals with DM and AMI, DM and stroke, AMI and stroke as well as all three chronic conditions and visualized the results on a map of Singapore. In Singapore, healthcare providers are organized into three regional health systems in the western, northern, and eastern parts of Singapore, thus for capacity planning, we aggregated our results by health system, a superset of physical location. We presented the total number of high-risk individuals with at least one chronic condition in each of the three regional health systems as these individuals are most likely to seek medical care for chronic conditions.After stratifying by age , we obseBeyond the scope of estimating prevalence of individual conditions, we also investigated comorbidities . DM withThe other application of the model is to visualize aggregate data which would otherwise require some coordination to obtain across different healthcare providers. Applying our model to the population of Singapore, we obtained quick estimates of the case numbers and prevalence of DM, AMI, and stroke in Singapore. Our results suggest that prevalence varies greatly by age, gender, and ethnicity, reinforcing previous findings that in Singapore, disease risk is heavily influenced by demographics . These eApart from access to timely medical care, urban planners choosing potential locations of homes for the elderly, dialysis centers, or other primary care facilities would benefit from information on the spatial distribution of chronic disease risk. Healthy Urban Planning is one of the themes of the World Health Organization ; the objGlobally, there is increased awareness as to the connection between urban planning and the health of communities . Our metPotential improvements to this study would be obtaining the actual anonymized geographic distribution of the population with detailed health information as opposed to a synthetically reconstructed population for additional validation, although this was not possible due to issues of data privacy. We also were not able to compare prevalence of AMI and stroke with actual numbers as registry reports primarily report incidence, and the last estimate of stroke prevalence was in 2006. In the evaluation of access to hospitals and healthcare facilities, it is common to define catchment areas based on geography ; howeverGeographical distributions of chronic disease risk are instrumental in understanding differences in community health at a national level and identifying high-risk communities which is critical for evidence-based policymaking. Using Singapore as a case study, we estimated the prevalence of DM, AMI, and stroke to be 12.7%, 3.0%, and 1.9%, respectively. In terms of comorbidities, approximately 10.0% and 6.0% of individuals with DM had AMI. To inform urban planning, we provided estimates of the number of high-risk cases by regional health system in order to ensure adequate access to healthcare and to minimise geographical disparities in health outcomes.


In the original article, the abstract was incorrect. Unfortunately, an older version of the abstract was included in the final proof. In the following, the correct abstract referring to the above mentioned article is presented.Introduction, Results, Methods, and Conclusion:Corrections have been made to the Introduction: It has not yet been possible to demonstrate the well-established increased bleeding risk related to antidepressants (ADs) with methods of pharmacovigilance as disproportionality analysis. As bleeding events related to ADs often occur under comedication with antithrombotics, ADs might not be considered causative of, but merely “linked” with the bleeding event. Therefore, we hypothesized that causality assessment of bleeding events related to ADs and the competitive impact of antithrombotics are factors contributing to the mentioned previous non-findings.Methods: We performed a case/non-case study based on data from VigiBase™ and calculated reporting odds ratios (RORs) for 25 ADs. We used individual case safety reports (ICSRs) that were differently categorized in the database regarding the type of association between drug and event. Furthermore, we investigated the competitive impact of antithrombotics by comparing RORs calculated with and without ICSRs related to antithrombotics.Results: Analysis of ICSRs that were categorized as causally associated with ADs resulted in detection of only 2 signals . Analysis of ICSRs irrespective of the type of association resulted in detection of 8 signals . In our analysis, consideration of ICSRs associated with antithrombotics as competitive substances did not have significant impact on signal detection.Conclusion: Categorization of the type of association between drug and event may affect quantitative signal detection toward reduced sensitivity. Causality assessment seems to significantly impact signal detection, probably particularly in rare, unknown, or clinically unremarkable adverse drug reactions. ADs appear to increase the bleeding risk considerably, even independent of antithrombotic comedication.The authors apologize for this error and state that this does not change the scientific conclusions of the article in any way. The original article has been updated.All authors listed have made a substantial, direct, and intellectual contribution to the work and approved it for publication.All claims expressed in this article are solely those of the authors and do not necessarily represent those of their affiliated organizations, or those of the publisher, the editors and the reviewers. Any product that may be evaluated in this article, or claim that may be made by its manufacturer, is not guaranteed or endorsed by the publisher.


Electronic health records (EHRs) represent an important aspect of digital health care, and to promote their use further, we need to better understand the drivers of their acceptance among health care professionals. EHRs are not simple computer applications; they should be considered as a highly integrated set of systems. Technology acceptance theories can be used to better understand users’ intentions to use EHRs. It is recommended to assess factors that determine the future acceptance of a system before it is implemented.This study uses a modified version of the Unified Theory of Acceptance and Use of Technology with the aim of examining the factors associated with intentions to use an EHR application among general practitioners (GPs) in the Republic of North Macedonia, a country that has been underrepresented in extant literature. More specifically, this study aims to assess the role of technology acceptance predictors such as performance expectancy, effort expectancy, social influence, facilitating conditions, job relevance, descriptive norms, and satisfaction with existing eHealth systems already implemented in the country.A web-based invitation was sent to 1174 GPs, of whom 458 completed the questionnaire (response rate=40.2%). The research instrument assessed performance expectancy, effort expectancy, facilitating conditions, and social influence in relation to the GPs’ intentions to use future EHR systems. Job relevance, descriptive norms, satisfaction with currently used eHealth systems in the country, and computer/internet use were also measured.z=2.64; P<.001), facilitating conditions , descriptive norms , and effort expectancy  mediated the association between job relevance and intentions. Finally, moderated regression analysis showed that the association between social influence and usage intention was significantly moderated (P=.02) by experience . In addition, the association between social influence and intentions was significantly moderated (P=.02) by age .Hierarchical linear regression analysis showed that effort expectancy, descriptive norms, social influence, facilitating conditions, and job relevance were significantly associated with intentions to use the future EHR system, but performance expectance was not. Multiple mediation modeling analyses further showed that social influence (Expectations of less effort in using EHRs and perceptions on supportive infrastructures for enabling EHR use were significantly associated with the greater acceptance of EHRs among GPs. Social norms were also associated with intentions, even more so among older GPs and those with less work experience. The theoretical and practical implications of these findings are also discussed. The development and implementation of eHealth and digital technologies in health care have become widespread in recent decades. However, there have been numerous failures in eHealth systems because of the lack of adoption and use of these technologies and systems by health care professionals and other staff in health care systems ,2. The uElectronic health record (EHR) systems are an essential part of information and communication technologies (ICTs) within health care settings and organizations. In primary health care, EHR systems have been developed to support the storage, retrieval, and use of patient data over the life course of a patient by general practitioners (GPs) and other health care professionals in primary care.Different theories have been developed to assess the factors that influence the adoption and use of ICTs in health care, including the Unified Theory of Acceptance and Use of Technology UTAUT;  8], whi, whi8], Although the application of early technology acceptance models in health care settings started in the late 1990s , there iThis study is a part of a PhD thesis and is published for the first time in a journal. A national EHR system has been proposed for the Republic of North Macedonia, and the aim of this study is to examine the factors that influence the adoption of such a system among GPs within the country. All GPs in the country worked in private settings, but they had active contracts with the National Health Insurance Fund and were obliged to follow the work instructions proposed by the fund. The proposed EHR system was not implemented in the country when this research was conducted. The technology acceptance assessment was conducted before the implementation of the EHR system in the country with the aim of identifying the factors that determine intentions for future use. However, the “Health Smart Card” system  and the “My term system” (a web-based scheduling system) were implemented in the country at the time when this research was conducted.The main objective of this research is to assess the readiness of GPs in the country for the future acceptance of EHR systems. Other objectives are to address the role of the basic predictors of the original UTAUT model on EHR use; to assess the effect of other technology acceptance predictors such as job relevance, descriptive norm, and satisfaction ; and to identify the moderating effect of basic moderation variables such as age, gender, and previous work experience.Adding new technology acceptance constructs to the basic UTAUT model was an opportunity to develop a better understanding of the factors influencing the use of ICTs in a large sample of GPs within a country. However, some technology acceptance constructs, such as descriptive norm , computeThe following hypotheses were developed:H1: the original UTAUT constructs  will be associated with intentions to use the EHR system in the future.H2: other technology acceptance constructs—job relevance, satisfaction, and the use of other technology—will be indirectly associated with intentions to use the EHR system in the future through the effects of performance expectancy.H3: the association between the basic UTAUT constructs and intentions to use the future EHR system will be moderated by age, gender, and previous work experience (moderation effect according to the UTAUT model).H4: descriptive norms will be significantly associated with intentions to use the EHR system in the future, over and above the effects of other predictor constructs.The assessment of the hypotheses identifies the effects of technology acceptance variables on user intentions. Therefore, this research aims to establish the most important technology acceptance predictors for future EHR systems among GPs in the country.The target population was the GPs in the country; all GPs who had contracts with the National Health Insurance Fund were included in the study. Participants’ email addresses were provided by the National Health Insurance Fund List. According to the list, there were 1631 active GPs in the country at the time of the study, with 1174 active email addresses of GPs registered in the list. A web-based survey was created on the SharePoint (TM) platform, and an invitation email was sent to all email addresses. General information on the future EHR system is included in a short introduction to the survey. The email was sent on July 1, 2014, followed by 2 reminder emails on July 15, 2014, and August 1, 2014. However, 35 emails were returned, as they did not reach valid email addresses.The original UTAUT model was modified with other technology acceptance extensions for this study. The following technology acceptance items were added to the questionnaire: job relevance , descripPerformance expectancy ,15 was mQuestions relating to the 3 UTAUT moderators  were alt tests, Spearman rank correlations, internal consistency reliability (Cronbach α), hierarchical linear regression, moderated regression analyses, and mediation analyses were applied to analyze the collected data.Various approaches such as descriptive statistics, two-tailed independent sample Research ethics approval was obtained in accordance with the Research Ethics Policy of the University of Sheffield before commencement of the study . The queA total of 458 completed questionnaires were eligible for analysis, yielding a response rate of 40.2%. The age of the respondents who took part in the study ranged from 24 to 65 years . Two-thirds of the participants in the study  were females and one-third  were males. The work experience of the participants ranged from <1 year to 38 years of experience .The internal consistency reliability of the technology acceptance constructs used in the questionnaire was assessed using Cronbach α ,30. The Bivariate correlations were estimated using Spearman rank-order correlation coefficients before the regression analyses. R coefficients=0.52-0.71) included in the study.The Spearman correlation showed that usage intention  correlated significantly and positively with all the technology acceptance constructs  was not favored. Around 18%-24% of the participants were neutral. Respondents also reported high effort expectancy from the system. They reported a positive effort expectancy of over 50% from future EHRs. A small minority (between 7% and 15%) appeared to have a negative attitude, and the neutral responses were higher (between 22% and 31%). Participants reported more than 50% positive agreement with statements on social influence constructs. A smaller minority (between 11% and 13%) reported that they did not agree with the statement, and a consistent proportion (between 30% and 33%) of participants were neutral. Participants reported that facilitating conditions are important for future use of the system. They reported over 50% positive agreement with the statements. A smaller minority of participants (between 6% and 18%) appeared not to be in favor, and 14% to 25% of respondents were neutral. Participants reported over 50% positive agreement with intention statements. A smaller minority (between 4% and 5%) appeared to have low intentions, and between 11% and 14% gave neutral scores on intentions for future use.t tests were used to assess gender differences with respect to the technology acceptance constructs. The results indicated that only significant differences were identified in performance expectancy , wherein male GPs reported significantly higher scores  than their female colleagues .Independent sample R2) 65.4% of the variance in intention to use the future EHR system F445=106.77; P<.001. In the first step of the analysis, only the use of other technology variables  predicted intention to use the future EHR system. In the second step of the analysis, the addition of the UTAUT constructs significantly increased the predicted variance in intention to use the future EHR system by 63.2%. The significant predictors of intention to use the EHR system at the final step of the analysis included facilitating conditions , effort expectancy , descriptive norms , job relevance , and social influence . The results of the hierarchical regression analysis are presented in Hierarchical linear regression was used to assess the multivariate association between intentions to use the EHR system and UTAUT constructs. The analysis was completed in 2 steps to differentially assess the effects of demographic and information technology use/work-related constructs  and the effects of technology acceptance constructs . The overall model predicted (z) was used to enable effect size comparisons between the mediators [We used a multiple mediation methodology  to assesediators .z=5.81; P<.001), social influence , descriptive norms , and facilitating conditions . The mediation effect of effort expectancy was significantly higher (P=.02) than the effects of social influence and descriptive norms.The mediation analysis showed that the association between job relevance and intentions was mediated by effort expectancy (β weights (B) and 95% CIs were estimated [In total, 8 moderated regression analyses were used to assess the interactive effects of gender, age, and working experience on the relationships between the UTAUT constructs  on intentions to use the EHR system. Technology acceptance predictors were mean-centered to avoid multicollinearity . As the stimated .P=.02) with social influence , showing that when age was higher, the association between social influence and intentions was stronger (P=.02) by experience , showing that among GPs in the early stages of work experience, there was a stronger relationship between the social influence and intentions to use the EHR system.The analyses identified only 2 significant moderation effects. Age significantly interacted , it was hypothesized that UTAUT constructs  would be associated with intentions to use the EHR system in the future and mediate the relationship of intentions with job relevance, satisfaction with using the eHealth systems in the country, and use of other  technology. On the basis of the UTAUT premises [, it was H1 was accepted, as effort expectancy, social influence, and facilitating conditions constructs were significantly associated with GPs’ intention to use the future EHR system in the multivariate model, which accounted for 65.4% of the variance in intentions. However, although performance expectancy was significantly associated with intentions in the bivariate correlation analysis , this asThese findings are in line with previous research ,14,20, iThe significant multivariate association between effort expectancy and EHR use intentions corroborates previous research on health care professionals in the Republic of North Macedonia . Taken tThe moderated regression analyses indicated that age and experience moderated the effects of social influence construct on intentions to use the future EHR system. However, no previous studies in these areas have used moderated regression analyses. The mediation analyses showed that the effect of job relevance was mediated by effort expectancy, social influence, descriptive norms, and facilitating conditions. This means that perceiving the use of the EHR system as relevant to GP work can only partially explain the GPs’ decision to use the system. Other, more relevant considerations, such as the perceived effort in using it and the existence of relevant technical support and infrastructure, as well as the perceived use by other GPs, appear to be more prominent considerations in the decision-making process and further explain the association between job relevance and usage intentions. In other words, GPs would be willing to use health care technology that appears relevant to their job, to the extent that this technology is seen as less effortful to use, supported by relevant infrastructure, and endorsed by more colleagues.GPs’ decision to use job-relevant health care technology, such as an EHR system, is multifaceted and based on several considerations. Primarily, the perceived effortless use and the existence of supportive infrastructure appear to be highly relevant to the decision to use the EHR system in question, followed by perceptions of endorsed  use by colleagues. Taken together, these considerations appear to be more important than the perceived benefits of the EHR system in daily practice.The findings of this study may be useful for policy makers and managers when developing and implementing new ICTs in health care. The contextualized technology acceptance model developed for this study contributes to understanding the drivers of the acceptance of new technology in this country in Southeast Europe. The emphasis on the design and development of future EHRs should be easy to use. The effect of social influence on intentions to use the EHR system may be moderated by the age and experience (moderators) of the GPs.Managers and policy makers should use workshops and tools that will persuade end users about the ease of use of EHR systems. Future EHR systems should provide effective technical support (facilitating conditions). The influence of key colleagues may facilitate the implementation of EHR systems .A quantitative approach was applied in this study, and it is possible that a qualitative approach may have provided a more in-depth explanation of participants’ attitudes. GPs who use ICT less in their professional roles may have been underrepresented in this study, which may have created a response bias in this sample. It is also possible that the views in the research, in relation to readiness to adopt the EHR system, reflect those GPs who were more familiar with using ICT. The response rate of 40.2% is not ideal for generalizing the findings of this research to the whole GP population in the country. Although the research instrument was applied to a large sample of GPs, there was a self-selection bias among respondents. The EHR system in 2020, although planned, was not implemented in the Republic of North Macedonia. However, it is possible that the views of health care professionals, such as performance expectancy and various forms of computer and internet use, have changed over time.Gender split and other demographic data in the GP population in the country were not available through the National Fund of Health Insurance. The gender distribution in the respondents  of this research cannot be compared with the GPs’ gender split. Data for this research were collected in 2014, and there is a time gap with its presentation in this study.The application of a newer technology acceptance model, such as UTAUT2, was considered a possible limitation. However, the newly added variables to the UTAUT2, such as hedonic motivation (enjoyment derived from using the technology) and price value (trade-off between perceived benefits and monetary costs) were less relevant to the planned EHR (proposed mandatory use of the EHR system reimbursed by the government).The UTAUT model has been applied in a few studies in health care settings to assess the intentions to use the EHR system. Performance expectancy and effort expectancy were found to be strong predictors, which is different from the findings of this study. The main finding of this study that only effort expectancy (not performance expectancy) was established as a predictor of intention to use the EHR system is different from those in the relevant literature ,14. Job The modified version of the UTAUT applied in this study is a useful tool for researchers to assess attitudes and intentions to use new eHealth systems. The main findings from this study indicated that effort expectancy (not performance expectancy) and facilitating conditions  were the strongest predictors of intentions for the future use of the EHR system among GPs. Taken together, the main findings of our study suggest that health care technology acceptance can be explained by models, such as the UTAUT model. However, different variables appear to predict intentions to use health care technology in different countries, suggesting that future research may address cultural and contextual influences in health care technology acceptance and that modified versions of the UTAUT may be relevant in different countries.


The objective of this study was to analyze gender inequalities and intersectionality experienced by rural-indigenous women who produce and sell native maize tortillas at three different markets-tianguis in central Mexico, facing the COVID-19 pandemic.This was a qualitative study based on 36 in-depth interviews before pandemic (2018), as well as 16 interviews during pandemic (2020) of women engaged in this work.Making corn tortillas by hand is one of the culturally assigned gender roles in the indigenous population of the Mazahua region, which is why their sale in local markets as a female strategy to have access to income for household sustenance has been widely by the communities. The configuration of the different market-space for the sale of handmade tortillas, reflects the inequalities of gender and intersectionality . The women in conditions of poverty, landlessness, and with school-age children, have met greater disadvantages in continuing to sell tortillas in the face of the experience of pandemic restrictions.The women who were already disadvantaged by their intersectional relationships continue to experience the same inequalities that conditioned their position in the marketplaces before the pandemic, sustaining a marginal but constant market. It has been recognized that rural women worldwide are not only responsible for feeding their families and contributing to the production of food, but also for helping preserve much of the biodiversity of their localities. However, few are represented at the managerial level and in decision-making in the public spaces in which they participate , such asIn Mexico, maize is a food of ancestral ethnic origin. Besides being the basic cereal in the Food Security and Food Sovereignty policy, it is the most deeply rooted grain in the Mexican food culture due to its diversity, as well as its culinary, ecological, spiritual, and nutritional versatility . With thThroughout history, tortillas have been the main form of maize consumption in Mexico. Tortillas are high in carbohydrates; they provide energy, as well as dietary fiber, proteins, and some vitamins. Through the nixtamalization process Fig. , tortilltianguis , where women offered them in woven baskets in order to keep them warm [Tortillas emerged in the Late Formative stage (400 BC to 100 AD) . Since Phem warm .tortillerias (tortilla bakeries), using basic technology. Starting with the Mexican urbanization and industrialization process in the 1960s, tortillas have also been produced in different food systems, gaining space in national and international markets. Despite this, the handmade tortilla market continues to coexist, albeit with great disadvantages with regard to the multinational maize and tortilla agroindustry that favors intensive monoculture of agrochemical-dependent hybrid maize [Until 5 decades ago, native maize varieties were used in the production of tortillas, which were exclusively handmade by rural and indigenous women or else prepared in id maize .tianguis [The weak but growing demand for handmade tortillas by the urban middle and upper classes is due to the emergence of consumers who are conscious of the importance of rescuing native maize varieties, which are associated with healthy ethnic foods and reinforce their Mexican identity  Fig. 3)3). Despitianguis . Even sotianguis , due to tianguis .Fig. 3Vatianguis has surely generated new questions about the strategies that rural women carry out to supply these markets, formerly frequented by groups of regular consumers [As a staple food, maize is still produced in different systems. Consequently, tortillas continue to be present in the diet of Mexican families, before and during the pandemic. The uncertainty of selling handmade tortillas at marketplaces and onsumers .tianguis and on the streets  [Corn tortillas are consumed to accompany the meals of the Mexican population and are used to make tacos and more than 300 dishes throughout the several cultural regions of the country. Others foods derived from nixtamalized corn dough are also considered ethnic foods and are sold like tortillas in local markets, s, etc.) .tianguis in a medium-sized city renowned for its regional and national trade at Mazahua Region in Central Mexico, are considered as a case study. The Mazahua region is one of the five indigenous regions situated in central Mexico  [Recently, the different types of handmade tortilla markets have begun to be studied , as wellopoloca) , 22.Gender inequalities are understood from different approaches. The UN refers to the disadvantages suffered by women compared to men in the social, cultural, political, knowledge, spatial, economic and environmental spheres . For som.Among these roots, they point out those derived from the forms of racial domination to which indigenous peoples were subjected; the division of social classes that came with colonialism and the progress of capitalism; and the cultural assignments of traditional gender roles. These forms of domination caused indigenous women to be doubly excluded from political and economic access to a free and dignified life .A few decades ago, feminist studies had reported the triple oppression of sexism, classism, and racism experienced by women . HoweverWomen who sell ethnic foods under these conditions have begun to be studied in anthropological and sociological research , 26, 27.The Class category is defined by their peasant lifestyles with or without access to land to produce maize for self-consumption. Generally, their production only supplies up to 6 months of their food needs . This coThe ethnicity category is defined in the relations of domination imposed in colonization and non-indigenous modernity-civilizing progress, through mechanisms of social exclusion and discrimination and intolerance to the identities of native peoples .Age is understood as belonging to a generational group. The family life cycle is positioned as an important analysis category to understand the workloads of women in the home, the period of biological reproduction and childcare. Depending on it, women manage their time to do income-generating jobs .The level of education is considered more as a social condition that generates inequality than an analytical category . HoweverAn analysis from this perspective also allows recognizing women’s work as the basis for the continuity of food culture . It highTianguis (weekly street markets on strategic locations in town’s streets). It goes back to more than 100 years. The diversity of ethnic food is great, and it includes mushrooms, insects, reptiles and Pigweed [A qualitative study  was perf Pigweed , 22.The results of a first qualitative study done from October 2016 to July 2018, carried out with the objective of getting to know the feminine strategies in the making and selling of artisan corn tortillas in these three unique markets in Ixtlahuaca , led to In that first study, all the women that sold tortillas in those three markets were initially identified and invited (73 women). Thirty-six of them accepted to participate in the investigation. Accompanied by ethnographic research technics , each one of them accepted to talk in Spanish. An in-depth interview was carried out. In average it lasted between 10 and 15 h (an interview was completed in 5 to 8 visits). The audio was recorded and transcribed manually. The interviews dealt with the following subjects, besides of the sociodemographic identification file Table ; distribThe second stage of the investigation took place from June to August 2020. Our search was for the 36 women who had participated in the previous study, but only 16 of them were found, and they were interviewed again. It is worth mentioning that no new saleswomen were recognized during this field work. The direct interviews were structured using open questions related to the difficulties encountered in making a living by doing the same activity within the context of government-imposed confinements and restrictions. Adding both interviews, the narratives were coded by intersectional categories to differentiate coping strategies of women that continue to work in the markets.Tianguis that takes place on Mondays, where the making and selling of tortillas is performed in open spaces in the central streets of the municipal capital  where tortillas made at home are sold from straw baskets covered with a cloth napkin to keep them warm, as was done in Precolumbian times [At the different marketplaces, local products, but also regional and imported products are found, many of them of Asian origin . In the tal Fig. ; (2) La an times  Fig. 5)Tianguis tianguis that maintain the configuration of the Prehispanic markets. A great diversity of ethnic products associated with the gastronomy of the Mazahua culture can be found there, such as quelites (Pigweed), mushrooms, pulque (fermented agave drink), handicrafts, and tortillas of various colors and sizes. Products continue to be exchanged through barter (trueque in Spanish) [tianguis have been considered as reservoirs of natural and human biodiversity [At present, the first two marketplaces are Spanish) , thus reiversity .Fiestas, also went to the marketplaces to sell them thus contributing to the family income. Finally, the third factor is their access to native maize varieties. Their experience has helped women develop an extensive knowledge of the use and handling of different varieties. This knowledge is vital for the understanding and conservation of the native maize diversity [In the Mazahua culture, the remnant of the umbilical cord of a newborn girl is thrown into the stove as a symbol of her responsibility of maintaining the family unity, both through reproduction and through the livelihood related to the preparation of tortillas and other traditional foods . Followiiversity .In general, trade carried out by women in local markets is restricted to the surroundings of the community of origin, in order not to “neglect” household responsibilities . These sIt is nonetheless common for indigenous merchant women to trade and barter wild harvest produce such as mushrooms, edible and medicinal plants, agricultural leftovers, and maize-based products, along with selling tortillas. Moreover, tortillas not sold by the end of the day may serve as barter to secure other products they need. It is worth noting that male merchants can usually sell at more distant places, and also products not necessarily derived from maize diversity .La Placita often sell tortillas sitting on the sidewalk, without minimum safety conditions. They usually sit in small groups of three to four women as an implicit socialization strategy in these small spaces. Many of them are in the “empty nest” stage of the family life cycle. In contrast, women who sell at the Travelling Tianguis and the Municipality Market are usually in the “consolidation” stage of the family life cycle. The differences between these women are manifested in female support networks that help out with the care of children under the age of 11. As those who sell at the Travelling Tianguis lack these support networks, they have opted to sell only one day per week to reconcile their commercial ventures with their household and parenting activities, even if this means a reduction in income.Women at La Placita, the average age is 57 years. These women grew up in a time when, although all children had access to secular, compulsory, and free primary education (established in 1867), families favored giving boys better educational opportunities, as they were considered to be the future earners [Age marks a specific cultural and social context that defines the insertion into a specific market type Table . In the  earners . This exTianguis, women were 41 years old on average, and all of them had completed elementary school. In turn, at the Municipality Market women were 38 years old on average, with higher levels of education.In the case of the Traveling The access to education for a greater number of women generates positive and significant relationships. Still, women are not yet concretely engaged in local political participation where they can influence decision making, at least in the areas where they work.La Placita and at the Travelling Tianguis) indicated that they do not own agricultural land, but that their husbands do and can decide what type of maize to plant , which represents the lowest rung on the energy ladder. Admittedly, fuel inequality and the use of inefficient technologies is an understudied indicator of energy poverty [Paradoxically, until the restrictions on activities due to the pandemic were set in place, the women who earned the highest income were those who sold at a permanent store and bought this hybrid maize. On average, they made the biggest sales volume, and hired at least one employee. They also had the capacity to pay the monthly rent of the store, the land use fees collected by the Municipality Market administration, and other expenses such as gas, water, and electricity. In contrast, women who produce tortillas at home and sell them at  poverty .Table tianguis was left to the interpretation of local  governments. These measures changed over the course of the pandemic and adjusted to the social, economic, and political demands of society to cope with the different waves of COVID-19 infection rates in Mexico.Throughout 2020, the global COVID-19 pandemic has forced countries to put in place extraordinary health, social, and economic measures to reduce the massive spread and lethality of SARS-CoV2 . Among tTianguis to continue operating during the first 3 months of the quarantine period in Mexico (March to May 2020). By contrast the La Placita and Municipal Markets did not stop their commercial activities during the entire period.The second phase of this study was conducted precisely after the first measures were implemented. They kept the population in restrictive confinement (June to August 2020). The municipal government of Ixtlahuaca did not allow the Travelling La Placita. Before the pandemic, we observe that they experience very significant inequalities marked by old social structures. Their lives are lived in subordination because of their gender, class, ethnicity, age, and family life circle. Recent studies have shown that the predominance of norms, values and cultural beliefs regulating the social structures in traditional communities, are factors that undergo few or no transformation in the relations and roles of gender when facing economic crises or instability [This situation did not translate into greater advantages for the women who continued to sell their tortillas in tability , 39.La Placita did not develop alternative strategies to the production and sale of tortillas that would provide them with other means of sustenance. In consequence, they risked continuing to sell every day at the marketplace and on the sidewalks, despite the risk of SARS-CoV-2 infection that this represented.Under such rigid structure, the conditions of vulnerability in which many Mazahua women live  , 37, becDuring this timeframe (March–July) the poorest and oldest women experienced a marginal increase in tortilla sales, since the restrictions that conditioned them before the pandemic  continued to persist and briefly acted in their favor.Those who do not produce their own maize were forced to increase the price of handmade tortillas by 30% Table . This waOn the other hand, who have school-age children have experienced other limitations that have subjected them to further class and family life cycle (reproductive period). For example, they encountered drastically reduced times at their disposal for the preparation and selling of tortillas. Some even had to abandon this activity altogether, particularly if the burden of household activities (chores and care of children or family members suffering from COVID-19) had increased. Indeed, online education and at-home learning, means they now must devote more time to their children’s learning, which restricts the ability to leave home to earn a living. As a result, many have impoverished themselves and gone into debt to have access to computers, cell phones, internet, and electricity. These debts increase with the purchase of medicines and expenses for private medical consultations to treat infected family members or themselves.It would have been expected that women established in the Municipal Market would have faced this restrictive period with better performance due to their economic capabilities. However, they have been unable to either sustain the cost of renting and nor securing jobs. The municipal administration has not stopped collecting fees. This has subjected sellers to a new economic crisis, with debts accumulating. Some have been threatened by the marketplace management with not renewing selling permits, or even canceling valid ones.Among the limitations of this study, besides the challenge of doing field work amid mobility restrictions, is that it was not possible to investigate an emerging market that took on importance. The sale from door of door is in fact the least explored market that appears to be a more recurrent strategy in the region of Central Mexico in the face of the health crisis.Tianguis, they resorted to selling their tortillas in this mode to be able to obtain an income and cover the new expenses that increased at home .Although this market was not analyzed due to its own mobility dynamics from door to door, two women who previously had their stalls in the Traveling Tortillas are essential in the Mexican food, and they are part of the eating habits of most people in the Mexican society, besides, the tortillas are used to prepare a great variety of Mexican  dishes , 10. ManCertainly, food anthropology has been interest to analyze the markets where the rural and poor women sell the traditional tortillas: on the sidewalks of the cities’ streets and in the markets of Mexico , as wellA few studies show that in this large-scale cultural movement, it is the chefs promoting the Mexican cuisine at the international level who have benefited from the work, experience, knowledge, and vulnerability conditions experienced by women who produce tortillas by hand in such kitchens as employees with the lowest staff salaries, as well as by the direct or indirect purchase of those tortillas at much lower prices than in the formal market . Even soGovernment decisions to slow down the country's economy in order to contain the contagion did not completely stop the informal economy , where aTianguis meant a twofold blow for women that used to sell their tortillas there. In this context, these women had no income during the 3 months the market was closed. The lack of any other source of income, supplies, health services, the lack of ability to access financial resources, among other means to acquire corn or sow it, have reduced the possibilities of returning and recovering their spaces to sell in this market, which was rehabilitated since the month of August in 2020. Coupled with the increase in the prices of inputs, it is inferred that their return will demand long-term indebtedness and pre-existing gender inequalities in rural areas will deepen.At the beginning of the quarantine and the mobility restrictions, the intermediaries in the sale of tortillas disappeared in the markets researched. This along with the closure of the Traveling The exacerbation of inequalities in Mexico before and during the COVID-19 Pandemic has made visible the problems of making quality health care accessible, the ability to sustain employment and to provide continuity in education. This study made it possible to analyze the structural gender inequalities that existed before the pandemic, which deepened, making it evident that power structures remain immovable to the detriment of women who make and sell handmade corn tortillas in different markets in central Mexico. However, this research also showed that through the intersectionality perspective, slight differences are observed among these women. It was revealed that having higher levels of education, consolidated women's networks, and being in a family life cycle childless, increase the possibilities of recovering from the health crisis and reactivating their economic activities.It is hoped that this paper will be useful for decision-makers in their domestic and international agendas that seek to re-establish food systems tied to local traditions. In essence, ethnic foods contribute to food security with short food supply chains, not only before and during, but also after the pandemic. Undoubtedly, these decisions should focus on the rescue and strengthening of biodiversity, be it through its promotion as culinary heritage or as a domestic food security policy, but always considering the valuable and essential female contribution, where equal opportunities are guaranteed to women who live in rural areas and who sustain the native corn tortillas, as one of the most important ethnic foods in the Mexican diet.


Then, the groups were compared: the overall difference between LOS of the groups was not statistically significant, but some insights were provided by comparing the LOS of the groups according to each variable. In conclusion, in light of the insights provided by this study regarding the comparison of two antibiotic protocols, the utilization of DMAIC cycle and Six Sigma tools to perform HTA studies could be considered in future research.Squamous cell carcinoma represents the most common cancer affecting the oral cavity. At the University of Naples “Federico II”, two different antibiotic protocols were used in patients undergoing oral mucosa cancer surgery from 2006 to 2018. From 2011, there was a shift; the combination of Cefazolin plus Clindamycin as a postoperative prophylactic protocol was chosen. In this paper, a health technology assessment (HTA) is performed by using the Six Sigma and DMAIC  cycle in order to compare the performance of the antibiotic protocols according to the length of hospital stay (LOS). The data (13 variables) of two groups were collected and analysed; overall, 136 patients were involved. The American Society of Anaesthesiologist score, use of lymphadenectomy or tracheotomy and the presence of infections influenced LOS significantly ( Cancer of the oral cavity is one of the most common malignant neoplasms worldwide  and can Multiple variables influence the incidence of oral cancer, including poor oral hygiene, smoking , alcoholThis study is based on the analysis of clinical outcomes of patients treated for oral cancer involving oral mucosa, excluding other cancers deriving from the tongue, gum, muscles and bones. In our study, we considered all surgeries performed with the removal of oral mucosa with or without reconstruction. The surgical management of oral cancer is complex because of different aspects. First, the mouth is involved in various important physiological functions, such as speech breathing, deglutition and mastication , but it Regarding the operations involving removal and reconstruction of oral mucosa, surgical options preview primary closure or the use of local or free flaps. Depending on tumor stage and lymph nodes involvement, some more surgical procedure may be considered, such as neck dissection and tracheotomy. Neck dissection consists in the removal of lymph nodes of the neck to prevent metastatic evolution. The need of prophylactic neck dissection where there is no evidence of cervical lymph nodes involvement is still under discussion . DespiteAt the Department of Maxillofacial Surgery of the University of Naples “Federico II”, two different antibiotic protocols were used in patients undergoing oral mucosa cancer surgery from 2006 to 2018, according to internal guidelines. A postoperative antibiotic protocol with Ceftriaxone was used for patients without allergy from 2006 to 2018. From 2011, there was a shift to the use of the combination of Cefazolin plus Clindamycin as a postoperative prophylactic protocol.The aim of this work was to perform a health technology assessment (HTA) in order to compare the performance of the above-mentioned antibiotics by studying the postoperative length of stay (LOS), measured in days. The Six Sigma (SS), by using the DMAIC  cycle, was used as a tool of the HTA: the influence of some variables on the postoperative LOS was analysed, and patients’ hospitalization time from surgery until discharge was the focus.SS is an innovative quality management method that focuses on reducing variations, measuring defects and improving the quality of products, processes and services. It was first introduced by Bill Smith to the Motorola Corporation in the 1980s and further developed by General Electric in the late 1990s .The Define phase identifies the project, the problem and the objective.In the Measure phase, the current process that needs improvement is quantitatively described.In the Analyse phase, the statistical analysis is used to understand causes and effects in relation to the current process.The Improve phase allows users to develop a plan that can be validated by statistical data to improve the process. In this research, this phase will be used to compare the two analysed approaches.The Control phase establishes a monitoring tool or mechanisms to ensure that the process is supported and to design effective quality controls ,17; in tDMAIC structure is one of the quality improvement methods used in the SS concept considered by many professionals to be the main reason for its success:Research studies in the healthcare sector confirm the validity of the methodology and several studies in literature discussed the administration of drugs analysed through DMAIC cycle.Yousef N. and Yousef F. studied the medication use process by using the DMAIC approach in order to find out the real reasons behind drug administration errors with the aim of reducing errors to 1% . Other aThe purpose of the study carried out Downen J. and Jaeger C. was to decrease the rate of missed intravenous to oral medication conversion opportunities for eligible patients, which aligns with the strategic plan for quality improvement of resource utilization and reduces delays when using the LSS approach and DMAIC .Today, healthcare is constantly evolving, and it seeks to offer improvements in technology and patient treatment. It is a complex network in which resource limitations, errors and complications threaten the security of patient care and service provision . TherefoA methodology based on reducing variations, measuring defects and improving the quality of products, processes and services turns out to be SS. It has been recognized globally in the service sector, and the use and the success of the SS in healthcare in the last decade have been very significant as a practice of continuous improvement . SS projHowever, this methodology, as emerged from scientific studies, is often associated with lean thinking. The combination of these two methodologies aims to improve services to meet customer needs by eliminating waste and reducing costs ,40. ReceHTA has been used in combination with other methods as well; several studies performed HTA by using techniques and methodologies such as analytical hierarchical process, Likert scale, modelling and simulations ,26,27.The SS framework has not been formally applied to the comparison of the performance of two antibiotic protocols until last year: For the first time, SS has been used as a tool of HTA to compare two drugs recently with good results ,43. SimiAll data analysed in this study were based on surgeries performed at the Maxillofacial Surgery Unit of the University Hospital of Naples “Federico II”. The Unit is divided in two different floors. At the ground floor, there is the day hospital part of the ward with two desks and the possibility to visit two different patients at the same time, the day surgery ambulatory where minor surgeries are performed daily, the direction and some medical offices. The hospital ward, the operating rooms, the nursery, the pharmacy and some rooms for the medical and nursing teams are located on the first floor. The Maxillofacial Surgery Unit of “Federico II” consists also in an acceptance office, a library and the residency office. In the hospital ward, there are 9 rooms with 22 beds for the patients and some rooms for surgeons and nurses. Near the hospital ward, there are two operating rooms that work at the same time.Patients with postoperative LOS ≤ 2 because the target of the study was ordinary hospitalization.Patients who underwent an antibiotic shift during their hospital stay (8 treated with Ceftriaxone and 15 with Cefazolin plus Clindamycin).Patients with missing data because they could have compromised the result of the analyses.In this study, two groups of patients were analysed, and the data were collected from the Department of Maxillofacial Surgery of the University of Naples “Federico II”. The first one was treated with Cefazolin plus Clindamycin from 2011 to 2018, while the second one was treated with Ceftriaxone since 2006 to 2017. The first group includes 51 patients, while the second one includes 85 patients. The data were collected from medical records, and statistical tests were performed by using IBM SPSS Statistics version 25 (United States). The following exclusion criteria were applied:All patients were included without exclusion due to clinical history.Gender;Age;American Society of Anaesthesiologists (ASA) score;Oral hygiene;Diabetes;Cardiovascular diseases;Surgical intervention;Flap;Lymphadenectomy;Tracheotomy;Surgical site infections;Dehiscence;Fistulae.Each patient was analysed according to the following variables:The aim of the Define phase is to determine a working group and to divide tasks for analysis. The multidisciplinary team is composed of clinicians, an economist, biomedical engineers and two biologists with experience in health management. The team was responsible for collecting data from patients with oral cancer from medical records and consecutive data analyses considering the influence of some variables. The leader supervised and coordinated the study and interpretation of the data. The critical quality of the research was the LOS. A project charter was created  to show Then, a SIPOC (Suppliers-Inputs-Processes-Output-Customers) diagram was designed by the team to show the main actors of the projects. This tool is very useful for identifying all relevant elements of a process improvement project before the work begins .The purpose of this phase is to measure the performance of the antibiotics studied.The dataset is made up of two groups of patients: The first includes 51 patients treated with Cefazolin plus Clindamycin, while the second includes 85 patients treated with Ceftriaxone. The time frame in which they were collected is from 2011 to 2018 for patients treated with Cefazolin plus Clindamycin and from 2006 to 2018 for those treated with Ceftriaxone. All the collected variables were analysed, and patients undergoing an antibiotic shift during their hospitalization or had missing data were not included in the analysis because they could have compromised the results.In the descriptive analysis, the postoperative LOS of both antibiotics was reported according to each variable. The results show that, in patients treated with Cefazolin plus Clindamycin, the mean LOS is 1600 days with a standard deviation of 982 days, whereas for Ceftriaxone the mean is 1471 days with a standard deviation of 1147 days. In this phase, the data were analysed in order to evaluate which variables can influence postoperative LOS. First, the Kolmogorov–Smirnov test was used in order to evaluate the data distribution.p-value < 0.001; thus, the Mann–Whitney U test was used to study dichotomous variables and Kruskal–Wallis was used for non-dichotomous variables (age). The normality Kolmogorov–Smirnov test on patients treated with Cefazolin plus Clindamycin distinctly showed a p-value 0.196 ; therefore, t-test and ANOVA (only for age) were employed.Patients treated with Ceftriaxone showed a non-normal trend with a The results regarding Ceftriaxone are shown in As shown below in The workflow of the activities carried on in the ward has already been shown in previous research ; the actTo date, a correct antibiotic prophylactic protocol for head and neck cancer surgery has not been clearly defined yet .We divided our population of patients into two groups depending on the use of Ceftriaxon, a third-generation cephalosporin, and on the use of the association of Cefazolin and Clindamycin, our second antibiotic protocol.Ceftriaxone is a third-generation cephalosporin antibiotic belonging to the beta lactam family. It operates by inhibiting the synthesis of the bacterial cell wall. For this reason, antibiotics belonging to the class of cephalosporins are bactericides. In clinical practice, Ceftriaxon is generally used to treat most of the infections sustained by antibiotic resistant bacteria. It is active on Gram-positive bacteria with a tropism to skin and soft tissues infection because of its action on the bacterial cell wall. Due to the increased risk of antibiotic resistance from bacteria, Ceftriaxon should not be used as a first-choice antibiotic, despite the fact that it represents the main choice for empiric antibiotic therapy due to its wide spectrum antibiotic coverage.Cefazolin is a semi-synthetic beta-lactam antibiotic belonging to first-generation cephalosporins. This antibiotic is active against a large population of bacteria, including Methicillin-sensible Staphylococcus Aureus, Streptocococcus Pneumoniae, Clostridium perfringens and Lysteria monocytogenes. It is less active on Gram-negative bacteria and not active against viruses. As antibiotic protocol in maxillofacial surgery, Cefazolin is used for infections that affect the upper respiratory and the upper aerodigestive tracts and soft tissues.Clindamycin is an antibiotic belonging to the lincosamide class that acts with a bacteriostatic mechanism by interfering in the replication of different bacteria. Clindamycin act in inhibiting the synthesis of the proteins of the bacterial cells. It is used against the infections sustained by anaerobic bacteria and Methicillin-resistant Staphylococcous Aureus. In clinical practice, it is used for bacterial infections involving bones, oral cavity, teeth, upper respiratory and digestive tracts. It is active also on soft tissue, especially to treat infections affecting the oral floor and the neck. Clindamycin is also used as an alternative when the patient is allergic to beta lactam antibiotics.In the Maxillofacial Unit of University Hospital “Federico II”, an association of Cefazolin and Clindamycin has been used since 2011 as an antibiotic postoperative protocol against the main classes of bacteria affecting the head and neck district. The sections may be divided by subheadings. It should provide a concise and precise description of the experimental results, their interpretation and the experimental conclusions that can be drawn.Control charts were used to monitor the performance of the key variable. After implementing the actions described in the improve phase, a decrease in the mean of the postoperative LOS of the patients treated with Ceftriaxone was observed, as shown in the control charts before and after the implementation of the new postoperative antibiotic protocol with Cefazolin plus Clindamycin in Following the guidelines to improve administration, drawn up according to the influence of clinical characteristics and complications, as from the analyses carried out in this study;Periodic review meetings to evaluate the maxillofacial surgery process;Internal audit and production of reports that highlight the trend of patients’ LOS measured in days.A control plan was established to ensure continuous improvements in the future in terms of the performance of both antibiotics:p-value lower than 0.01; thus, each category was studied by using non-parametric statistical tests. Dichotomous groups were analysed with a Mann–Whitney U test, while groups with more than two categories (only age) were analysed with a Kruskal–Wallis test. The percentage difference in the average of the postoperative LOS is calculated between the initial value of Cefazolin plus Clindamycin and the final value Ceftriaxone. p-value 0.197). With respect to the categories of the variables, patients with lymphadenectomy  and tracheotomy  treated with Cefazolin plus Clindamycin have, on average, a lower postoperative LOS in a statistically significant manner. The percentage differences explain that, on average, postoperative LOS does not follow a trend line in favour of a single antibiotic. The most relevant percentage differences indicate that patients under the age of 50 treated with Ceftriaxone had an increase in LOS of 60.1% compared to those treated with Cefazolin plus Clindamycinl; on the contrary, patients with diabetes treated with Cefazolin plus Clindamycin had a decrease in LOS of −30.3%.The Kolmogorov–Smirnov test for the normality of data showed a The chi-square test was conducted for a population demographic study; the results are shown in At the Department of Maxillofacial Surgery of the University of Naples “Federico II”, a comparison study was carried out between two antibiotics Ceftriaxone and Cefazolin plus Clindamycin, investigating the problem of prolonging postoperative LOS in patients undergoing oral mucosa cancer surgery.t-test and ANOVA).As shown by previous studies, the SS methodology was found to be useful for improving decision making in healthcare . In partFrom the analysis in Depending on the type of surgery, we observed that the need of reconstruction, especially when the use of a flap is required, causes an increase in the incidence of surgical site infections and, consequently, LOS . A simplOther factors that seem to reduce LOS when referred to the Cefazolin/Clindamycin protocols are a low ASA score and an age lower than 50 years. Reduced times of hospitalization for patients with low ASA scores and age lower than 50 can be explained because young patients present less comorbidities in comparison to older people. Young people are generally healthier and present better healing process. They are also more compliant to therapies, and their health status can be better managed. Older people have a major incidence of comorbidities because the senescence process determines body weakness and the appearance of chronicle pathologies that need to be considered for their management.Moreover, from The other facets of HTA need to be discussed too: the two drugs are equally approved, have similar costs and are both currently used in clinical practice without requiring different organizational pathways. Therefore, it appears that the two antibiotic protocols are almost equivalent with respect to the number of complications  and the LOS.In conclusion, this study proved the utility of applying SS methodology using the DMAIC cycle for comparing the performance of the two antibiotics administered after surgery for cancer of the oral mucosa. Obviously, SS is a management and non-medical tool from the beginning; however, it could be a good method for analysing clinical and surgical variables to support the decision-making process of the doctors.


By adopting the 2009 "pesticide package," the EU proposed a common approach to limiting the harmful effects of pesticides, promoting Integrated Pest Management, and the progressive replacement of the most dangerous pesticides with low-risk alternatives through a comprehensive but flexible framework for all EU Member States. Each EU Member State had to develop a National Action Plan that would propose measures to achieve the package’s goals. Nevertheless, the choice of actions and indicators remained to be established at the national level. A series of recent evaluations of how Directive 2009/128/EC of the European Parliament and the Council on the Sustainable Use of Pesticides Directive (SUD), a central piece of the "pesticide package," was implemented showed limited success in achieving its goals. Aiming to explain these failures, we compare the National Action Plans eight EU Member States adopted after the SUD. We assess the degree to which the countries’ proposed measures and indicators would achieve the Directive’s three overarching objectives . We develop the comparative analysis along three dimensions: the promotion of measures to achieve SUD’s three goals; the evolution of the pre-and post-Directive action plans of some of the old EU Member States; and the differences between old and the new EU Member States. The comparison along ten variables shows that the SUD had a minimal effect in homogenizing different states’ approaches to develop their National Action Plans to systematically treat problems, propose measures, and timetables for implementation and indicators. Given that the overall effect in generating a common EU approach to raise the sustainability of pesticide use and agriculture, in general, was still limited, as no common measures, indicators, or process to planning were identified, we discuss some suggestions to improve the situation. Directive 2009/128/EC of the European Parliament and of the Council of Oct 21 2009 establishing a framework for Community action to achieve the sustainable use of pesticides (Sustainable Use Directive or SUD), focused on promoting alternative approaches or techniques to reduce dependency on the use of pesticides, mainly by increasing the availability and usage of low-risk pesticides and the development of organic agriculture [Despite the ever-increasing awareness of the harmful effects of pesticides and continuous efforts to eliminate the most damaging substances and to promote low-risk alternatives , the faciculture  and Inteiculture . The Euriculture .Regulation (EC) No 1107/2009 of the European Parliament and of the Council of Oct 21, 2009, concerning the placing of plant protection products on the market [Part of the "pesticide package," e market  introduc"Accelerate the evaluation, authorization, registration, and monitoring of the use of low-risk plant protection products of biological origin while maintaining risk assessment at a high level;Include the use of low-risk pesticides of biological origin in their national action plans on the protection of the environment and of human health;Encourages the Member States to exchange information and good practices deriving from research results into pest control, enabling the provision of alternative solutions viable in environmental, health, and economic terms."Furthermore, the SUD’s efficient application is vital as Eurostat data shows that pesticides sales across the EU have not decreased after 2011 when the SUD should have been fully transposed . The pesUnlike EU treaties, regulations, or decisions, EU Directives propose a series of results but leaves the means to achieve those results to the Member States. The Sustainable Use Directive, adopted in October 2009, required the Member States to draw up National Action Plans (NAPs) to implement the Directive by November 2012. To achieve the objective of the SUD, each NAP (under Article 4) needed to: (a) propose measurable goals, targets, and indicators to decrease the potential and proved effects of pesticide use on humans and the environment; (b) stimulate the expansion of IPM and alternative approaches or methods to reduce reliance on pesticides . The actFurthermore, while the SUD Directive called at Article 15 for the establishment of EU-level harmonized risk indicators that would allow a comparison of progress among the EU Member States, this process stalled and only restarted in 2019 through the adoption of the 2019/782/EC Directive, which amended the SUD Directive . A 2014 A first evaluation of the SUD Directive implementation was based on a questionnaire completed by the Member States in 2016. The report  was alsoFour years later, the 2020 European Court of Auditors’ report underlined the limited progress in measuring and reducing pesticide risks in the EU. EC’s limited monitoring capacities caused this, along with the limited incentives for farmers to implement IPM . The 202Given the limited positive evolutions shown by the two HRI, the Commission pledged to increase its efforts to press EU MS to implement "rules on pesticides by Member States (including launching infringement actions if necessary); ensure the full implementation of Integrated Pest Management (IPM)." Another pledge aimed to link the Common Agricultural Policy (CAP) with the progress of pesticides and to evaluate and revise the SUD  and external issues  . A signiIn this article, we aim to contribute to the explanation of the observed limiting success in achieving the aims of the SUD by performing the first comprehensive analysis of the content of the NAPs of five old Member States  and three new Member States . While they belong to different authorization zones for PPPs according to Regulation EC 1107/2009, the SUD 2009/128/EC does not include specific requirements for states, depending on the zone to which they belong. While the NAPs do not necessarily present an accurate picture of the measures taken after the plan was adopted, they represent the best-case scenario proposed by each MS. Their comparative analysis offers thus an in-depth view of the EU Member States’ differences in the level of ambition and planning their actions. Unlike the Commission’s evaluation, based on questionnaires completed by the EU MS, in this article, we are directly analyzing the NAPs and thus avoid the biases caused by the tendency of each MS to present measures in the best light. The 2017 evaluation focuses on limiting the negative effects of pesticides but offers no comparative assessment and no cross-temporal comparison. These reports, however, focused only on whether the Member States’ NAPs covered specific technical requirements. Our study goes to more advanced points than the 2017 reports in that we analyze the comprehensiveness of different sections or whether the objectives of the NAPs had indicators and timetables. Our study fits within the Europeanisation of public policies and compliance with EU regulations literature. It is also part of the wider research area of compliance with international institutions . Thus ouTo allow us a cross-temporal analysis, we build on the analytic structure proposed for the first comparison of NAPs designed for five Member States by Barzman and Dachbrodt-Saaydeh  before DRQ1: To what extent did the EU Member States NAP’s respect the SUD obligations to propose quantifiable objectives, targets, measures, and indicators to achieve the three goals of the SUD: (1) reduce risks and impacts of pesticide use on human health and the environment; (2) encourage the development and introduction of Integrated Pest Management, and (3) propose alternative approaches or techniques to reduce dependency on pesticides?RQ2: What are the effects of SUD 2009/128/EC on the NAPs of the countries that voluntarily developed them before adopting the Directive?RQ3: To what extent did SUD 2009/128/EC drive homogenization in the approach to sustainable use of pesticides among the old and new Member States?For this analysis, we have studied the NAPs  of the eRegarding the first research question, the eight countries’ NAPs contain references to encourage IPM , low-risk products, and organic farming . Instead, the proposed measures and emphasis vary widely. IPM plays a central role in the drive towards agricultural sustainability in Germany. Also, France has developed the DEPHY network that included experimental farms (DEPHY FERME) and experiments with cropping schemes aiming to reduce reliance on chemical PPPs  and an oMeasures to promote SUD’s third goal by promoting low-risk pesticides (first dimension) are discussed to decrease reliance on synthetic pesticides, but without concrete targets . In contrast, there are measures to increase their usage , while others treat them as central to a new approach to agriculture (Denmark and France). For example, Denmark focuses on a detailed set of measures to promote low-risk products. All eight NAPs support organic farming . Some propose comprehensive measures to stimulate it . Other NAPs mention steps to encourage it , while Romania’s NAP does not discuss it.Regarding our second research question, the effects of Directive 2009/128/EC on those countries that had already voluntarily developed NAPs, the data in All states had to reduce pesticide use in specific areas . Still, their treatment of the actions varies significantly. Germany and Poland have strict prohibitions on PPP use in public areas, while France, the UK, and Hungary do not discuss this issue in their NAP. Romania’s NAP presents the relevant national legislation that regulates PPP’s use but contains no specific evaluation of the situation or specific measures. As this problem has been addressed since 1998, and the first NAP was developed in 1986, Denmark is one of the most advanced countries in achieving success in this area.While all the Member States’ NAPs refer to websites that contain information and raise awareness on pesticide use and their effects, Germany, UK, and Hungary do not go beyond these minimal measures. In contrast, Poland and Romania are proactive in proposing information campaigns, and Denmark, the Netherlands, and France have a more comprehensive and participatory approach. In the Netherlands and Hungary, farmers are obliged to inform their neighbors before using pesticides.Regarding the third research question, the extent to which Directive 2009/128/EC has homogenized the approach to ameliorate the sustainability of pesticide use in particular and of agriculture in general, the answer is that in practice, the NAPs are far from homogenous. Still, no division of the old versus the new EU Member States could be identified. The UK’s NAP is the least comprehensive and detailed along the dimensions we have analyzed, a situation that has persisted from the last NAP. While it contains a complete list of indicators used to assess the evolutions in PPP usage and their impact, no clear targets and timetables are elaborated.The NAPs of the three new EU Member States  treat some dimensions comprehensively and ignore others. Still, they generally do not contain indicators and quantifiable targets. Romania is one of only two Member States with planned public information measures but had no proposed concrete steps to reduce pesticides in specific areas or promote IPM and the use of low-risk products, and no mention of organic farming. By 2013, Poland had a more comprehensive approach to IPM, as it proposed measures to disseminate knowledge and proactive measures to encourage the development of an IPM production system. Meanwhile, Hungary advanced a comprehensive analysis of the sector and stressed the need for future growth.Furthermore, Hungary’s approach to the role of low-risk products was already more advanced in 2012, as its NAP noted the importance of promoting the use of low-risk PPP, especially for minor crops. Poland went even further with a set of proposed measures to encourage the use of IPM to decrease dependency on chemical PPP. Poland had already recognized the importance of developing organic farming in 2013 and proposed measures for the sector’s encouragement.The current article is, to our knowledge, the first qualitative comparative analysis of EU Member State NAPs as drawn following the goals outlined in the SUD 2009/128/EC, while looking at the evolution over time of five Member State NAPs. Based on the comparative analysis of the NAPs of eight countries, we have shown that they are highly heterogeneous and vary significantly in their complexity. Although they have some common chapters, they are challenging to assess, as the depth of treatment of various dimensions differs dramatically. They do not use the same quantitative indicators or logic for proposing timetables.Unlike other EU legislation, we reiterate that directives propose goals but leave the means to achieve them to the EU Member States. The SUD defined an overarching objective (the sustainable use of pesticides), three goals , and a set of compulsory action areas. Still, SUD proposed no quantifiable means to assess progress and no mandatory targets. Instead, each EU Member State was supposed to propose measurable objectives, targets, measures, and indicators that would allow for verifying its NAP implementation.Regarding the first research question (RQ1), the most important conclusion from our analysis is that except for Denmark, France, and, partially, Netherlands, the analyzed NAPs do not meet the goals set in Article 4 of the SUD to "advance quantifiable objectives, targets, measures and indicators," defined as ++++ in The second research question (RQ2) investigates the incremental approach in developing NAPs from the pre-SUD to the post-SUD period. The analysis along the third research question (RQ3) brings the positive discovery that at least some of the EU’s new Member States appear to have advanced reasonably quickly in their approach to their NAP. All in all, the first-generation NAPs following the adoption of the Directive 2009/128/EC are very difficult to compare, as they lack a standard logical structure, treatment of measures, common indicators, or approach to developing timetables. Implicitly, they do not lead to a truly common approach to achieving sustainability of pesticide usage, thus improving agriculture’s sustainability.Given that SUD contained no targets and compulsory measures, most EU MS chose the most accessible route: develop NAP’s that would discuss various issues and avoid committing to clear measures, timetables, and indicators. The second (IPM) and third  SUD goals were discussed but not operationalized. Also, most NAPs did not contain some elements deemed compulsory: timetables and targets, provisions regarding the application of IPM by all professional users by 2014, and crop and sector-specific guidelines. The conclusions of the European Court of Auditors’ and RISE Foundation reports are of no surprise, as the NAPs analysis, which represents the best-case-scenario, show that most MS did not even bother actually to plan and implement measures to achieve these goals, and the European Commission did not put any relevant pressures on them to do so.While our analysis and EC’s 2017 reports focused on the same topic, our conclusions are sensible about the second and third SUD goals. These differences underline the added value of independently analyzing the original documents instead of using questionnaires completed by the MS. Regarding the SUD’s second goal, the European Commission’s evaluation depicted a rosy picture, indicating the presence of a mix of tools to support IPM in all MS and the availability of CAP funds to promote organic agriculture. The report was also based on a field visit in six EU MS, out of which four are also analyzed in this article  . The EC’Given the difficulties in comparatively assessing the harmful effects of pesticides across the EU, the 2019 calculation of the Harmonized Risk Indicators represents excellent progress. As soon as possible, detailed data for EU MS should be calculated, and clear and compulsory targets should be set. Without such comparable metrics, it would be difficult to compare different countries’ evolution or allow the potential and systematic transfer of good practices with proven positive impact.In order to achieve a truly European approach to the sustainable use of pesticides, more uniformity in the Member States’ NAPs should be encouraged, especially in terms of proposing a set of comparable indicators to assess progress in the various areas. While our analysis does not reveal the SUD Directive’s total ineffectiveness, the main limitation is that it did not create any mechanisms to assess progress. The adoption of the 2019/782/EC Directive amending the SUD Directive (12) to speed the adoption of harmonized indicators to compare progress across the EU Member States, objectively represents the first step in this direction. While the NAPs are just plans and do not reflect all the efforts in this area, it is hardly believable that the EU Member States would go beyond the efforts they propose in these plans. To become more effective in generating a common EU approach to the sustainable use of pesticides, more standardization of NAPs should be required. This would imply asking each Member State to comprehensively treat each dimension in terms of the measures, timetable, and indicators they use and to encourage a pan-EU exchange of information, a good practices exchange mechanism, and a joint research agenda.


The Spanish Civil War (1936–1939) is an example of a historic event involving nurses, with the participation of professional and volunteer nurses from Spain and other countries. In this context, nurses were trained over short periods of time and recruited to work at hospitals serving the two warring camps.To identify the characteristics of the training received by volunteer nurses on both sides in the Spanish Civil War and compare it with previous experiences in the history.Historical research.ABC and La Vanguardia. The following variables were analysed: duration, entry requirements, and theoretical content of the training courses. Consolidated Criteria for Reporting Qualitative Research (COREQ) has been used.Heuristic and hermeneutical analysis of nurse training manuals and news articles from 1936 to 1939. Spanish primary sources were consulted at the Red Cross Documentation Centre Archive in Madrid, the General Military Archive in Ávila, the Municipal Newspaper Archive in Madrid, and the archives of Spanish daily newspapers Both sides in the conflict offered a varied training programme, which was supported by official institutions and private initiatives. The courses lasted between one week and two months. Entry requirements were influenced by education level, age, moral conduct, health status, and social and political background. Training content focused on the techniques needed in conflict settings and covered specific moral values.Despite the different social and political characteristics of the two warring factions, the variety of training programmes on offer, the entry requirements, and the theoretical content of volunteer nurse training were similar on both sides. At the end of the Spanish Civil War, volunteer nurses on the Republican side suffered reprisals or had to go into exile. We now know that some countries involved in World War II provided training courses for volunteer nurses. It would therefore be interesting to ascertain whether Spanish volunteer nurses contributed their experience to these courses. Like any other social or health emergency, armed conflict has shaped the role played by nurses in healthcare delivery , forgingThroughout the 20th century, nurses participated in a number of armed conflicts around the world, tackling physical, psychological, and clinical problems. Training for civilian nurses differs in a number of ways from specific training allowing nurses to work in military hospitals, where specific preparation for ethical and care dilemmas is vital . ResearcNurse training is crucial in preparing nurses for the challenges of working in a conflict setting, where their theoretical knowledge, ethical commitment, and social responsibility are put to the test as they provide care in hostile, unpredictable, and challenging environments . Public Public health emergencies have shaped the development of the nursing profession, imbuing it with the social, political, and economic values of each historical context and influencing and modifying its image over time. It is important to study these emergencies and their incorporation into training programmes in order to understand nurses’ influence and contribution to society .practicante (practitioner). The nurse was a professional related to the woman-caregiver-salaried duality and the practitioner with the male-healer-autonomous duality  and translated from the French by María de Corral, a nurse with the Spanish Red Cross, was available  despite the fact that the rules state that the minimum age is 20 years old and she is 16. It’s nonsense that these girls hang around in hospitals instead of school, so they can’t be given the [training] card! Not being mobilised or on night shift, we cannot be indulgent until 18, but not less in any way. I don’t know what these parents are thinking about!” .Continuing with the Nationalist zone, applicants were asked to submit a certificate of good conduct, their birth certificate, and their academic qualifications with their application . In otheThe conflict situation led to a change in training content see , which fAs well as new training manuals focusing on knowledge relating to the conflict situation, some existing manuals also added sections for this purpose, including nursing, chemical warfare, and military administration .Theory lessons covered the spirit of sacrifice, sense of duty, caution, patience, and charity . VolunteTraining manuals also addressed matters relating to public perceptions of nurses, encouraging specific moral qualities. Their humanitarian work was expected to be characterised by kindness, gentleness, and altruism, as well as warmth, which nurses were required to display to all patients while remaining discreet and respecting patient confidentiality .In the training provided for nurses on the Nationalist side of the conflict, a sense of vocation and Christian charity  were presented as the model of perfection that nurses should strive to attain, with no expectation of professional recognition beyond that of God. Religious indoctrination became more entrenched as the war went on and nurses were asked to profess their love of God “by practising a Christian life of meditation and piety” that would allow them to care for the sick .The contribution of volunteer nurses during World War I is widely recognised , raisingAlthough dependence on the medical profession waned during World War I , doctorsIn World War II, the countries involved were already equipped with professional nurses, albeit in insufficient numbers. Nurses had to be mobilised from different countries , 69, stuDuring the Spanish Civil War, training courses lasted for a short period of time as their purpose was to provide intensive training for volunteers, including World War II volunteer nurses from Brazil  and FinlWe have identified that although the courses provided by both sides in the Spanish Civil War varied in terms of the training provided, their duration, and their entry requirements, the theoretical content was similar in all of them. The aim was to prepare volunteer nurses to provide healthcare in conflict settings. In such settings, knowledge and professional skills are extremely important. Studies such as Firouzkouhi et al. provide evidence of this, focusing on the need to include specific training in triage to ensure adequate healthcare .As we have seen, comprehensive, targeted training was needed during the Spanish Civil War to meet healthcare needs. The volunteers’ lack of experience and training were compensated by their eagerness to help and their good intentions, but these were not always sufficient to enable them to cope with the emotional distress caused by working in a war zone. None of the lessons in the manuals referred to the pain and suffering that the nurses would witness. They were asked to be kind, pious, and caring, but they were not prepared for the mental fatigue that they would face when providing compassionate care . These pThe training provided by the Spanish Civil War courses contributed to the public image of what a nurse should be, emphasising the moral qualities that nurses were expected to possess in particular. As well shaping their image, training courses also helped to foment a sense of belonging to a group and served as a way of homogenising attitudes and practices, as well as highlighting gender issues in this context . In thisWe have not found any cases of training courses for male nurses (practitioners) during the Spanish Civil War. This is related to the sexualisation of care that was present in the early 20th century . It woulAs well as theory lessons on providing healthcare and assistance to the wounded, the training manuals also contained recommendations on rest, diet, and exercise for nurses to ensure that they remained healthy and able to carry out their work to the best of their abilities. Recent studies have demonstrated the importance of self-care among nurses. Clinical training, rest, recuperation, exercise, and diet are all important factors in reducing psychological stress in war zones .During the Spanish Civil War, volunteers nurses were trained in the ethics of care, twinned with vocation and humanitarianism, which are essential in any conflict setting . Both siThe outcome of the Spanish Civil War and the first few decades of the Franco dictatorship (1939–1975) shaped the development of the nursing profession in Spain. The dictatorship revoked nursing diplomas issued by the Republican side , retaliaLey de Sanidad), nursing, midwifery, and nursing assistant studies were unified in Spain in 1953 under a new qualification named ayudante técnico sanitario  [Under the 1944 Spanish Health Law (sistant) . For decsistant)  and focusistant) .The health emergency caused by the Spanish Civil War gave rise to a need for greater numbers of nurses, leading to the emergence of courses aiming to train volunteers on both sides in a pattern that would be repeated in World War II years later. The variety of training programmes, entry requirements, and theoretical content were similar in both factions, although they were shaped by different sociopolitical contexts. The outcome of the war was pivotal in the lives of the volunteers. Volunteer nurses on the Republican side went into exile, so it is difficult to know how their experiences in the Spanish Civil War may have influenced volunteer nurse training systems in World War II or their integration into the workforce in their destination countries. The volunteer nurses on the winning Nationalist side helped to consolidate the nursing profession and nurses’ professional identity, which were shaped by the values of the Franco dictatorship.