The development of locally developed English language teaching (ELT) materials is believed to be conducive to meeting the requirements of local language education policies and practices, and to enhance learners’ agency. In China, in order to implement national educational policy of curriculum-based value education, many locally developed ELT materials have been recently developed. However, there is a paucity of empirical research concerning the actual effects of such materials in practice. This study presents an empirical study of a recently developed set of teaching materials in the context of curriculum-based value education by adopting an approach consisting of questionnaires and interviews to examine the attitudes and experiences of users of these materials. The findings revealed a range of challenges in the use of these materials, including issues related to language and content of the materials, the integration of ideological and value elements, and the development of multi-dimensional teaching materials. The article then proposes possible solutions from the perspectives of optimizing the writing community, carefully selecting teaching materials, innovating the integration of ideological and political elements, and improving the development of multi-dimensional teaching materials. A framework for the evaluation of locally developed ELT materials is also proposed, with the intention of offering a useful benchmark for enhancing the development of such materials. Some researchers examine the western culture and beliefs  in local ELT materials . Forman Previous research results indicate that local material developers have many options at their disposal in the development process. For instance, by investigating three locally developed textbooks that are used in the schools of Chile, Studies also reveal that different stakeholders ought to be included in the development of local materials. In a study by Many studies have discussed the material evaluation. The most frequently mentioned individuals are experts, teachers, and students. For example, 3.3.1.This study seeks to explore the challenges faced by users of locally developed English Language Teaching (ELT) materials and to identify potential strategies for enhancing the effectiveness of such materials. By examining the experiences and perspectives of material users, this research aims to contribute to the development of a comprehensive framework for locally developed ELT materials. This framework will be grounded in the insights gained from the study, offering practical solutions to address challenges and maximize the utility of these materials in educational contexts. The research endeavors to provide valuable guidance for educators and curriculum developers in their efforts to design and implement ELT materials that align with the goals of curriculum-based value education, ultimately benefiting English language learners and the broader educational landscape.3.2.This research was conducted at a distinguished provincial university in China, strategically chosen as the research site due to its notable academic standing and its role as a participant in China’s “Double First-Class” university initiative. Additionally, it serves as an exemplary institution for the Ministry of Education’s university English teaching reform efforts, making its College English education program representative within the Chinese higher education landscape.At the heart of this research lies the implementation of “curriculum-based value education,” a pivotal national educational policy. This policy aspires to infuse Chinese cultural attributes, core socialist values, and traditional Chinese heritage into all facets of higher education. It aims to cultivate not only academic prowess but also moral and intellectual capabilities among students, with the ultimate goal of contributing to China’s ongoing development and construction efforts.One noteworthy facet of this policy is its universal application, spanning all courses offered by the university, including English Language Teaching (ELT) courses. During the time of this study, the university was actively incorporating curriculum-based value education into its College English course, a program catering to non-foreign-language majors. These selected classes utilized a locally developed ELT material, comprising three volumes, each featuring an integrated coursebook accompanied by a corresponding teacher’s guide.The integrated coursebooks, predominantly used by students during their English classes, are distinctively designed to reflect local culture, encompassing elements such as the core socialist values and traditional Chinese cultural nuances. A noteworthy feature highlighted by the developers in the preface of these materials is the deliberate incorporation of various moral education elements into the discourse, subtly infusing students’ learning experiences with underlying moral, ideological values, and cultural connotations.This research, undertaken at this prominent provincial university, not only aligns with national educational policies but also offers a unique vantage point to investigate the development and implementation of teaching materials consistent with these values. It delves into how curriculum-based value education is translated into English language teaching, thereby contributing to a broader understanding of the policy’s implications within the realm of higher education in China. The selected institution’s stature as a “Double First-Class” university and its pioneering role in university English teaching reform make it an ideal location for such an exploration, representative of the changes occurring in Chinese higher education.3.3.The use of a combination of interviews and questionnaire surveys in this research was deliberate and aimed at providing a comprehensive understanding of the challenges associated with locally developed ELT materials, as well as the perspectives and attitudes of material users, including both teachers and students.Interviews played a pivotal role in delving deeper into the attitudes and perspectives of material users. These qualitative interviews allowed for a nuanced exploration of the reasons ELT material users’ attitude and provided a platform for participants to elaborate on their experiences and insights. Through interviews, we gained a rich understanding of the challenges faced and the underlying factors contributing to these challenges.The questionnaire served as a valuable tool for gathering quantitative data to gauge the overall sentiment and experiences of material users. Its design was meticulously crafted to elicit specific information regarding language quality, content appropriateness, the integration of local elements, and multi-dimensional aspects of the materials. The purpose of the questionnaire was to obtain a broad and systematic overview of the challenges faced in using these materials, providing a quantitative foundation for the subsequent qualitative interviews.One of the primary advantages of employing a questionnaire was its ability to collect data from a relatively large sample, allowing for a broader perspective and general trends to emerge. This quantitative data served as a valuable initial step in identifying key challenges and areas of concern related to the locally developed ELT materials. Additionally, the questionnaire’s structured format enabled the systematic collection of information, ensuring that specific aspects of language quality, content, and integration were systematically evaluated.The combined use of interviews and questionnaire surveys provided a balanced approach, combining quantitative data for a broader overview with qualitative insights for a deeper exploration of the research topic. The interviews captured the individual experiences and perspectives of material users with depth. The questionnaire helped identify trends and common challenges. This dual-method approach allowed for a more comprehensive analysis, ensuring that the challenges and potential solutions identified in this research are grounded in both quantitative data and qualitative insights.Overall, the use of questionnaires and interviews was strategic in addressing the research questions comprehensively, blending the advantages of quantitative and qualitative data collection methods to provide a holistic understanding of the challenges and potential solutions associated with locally developed ELT materials.3.4.The author adopted a micro perspective to collect genuine feedback from teachers and students, i.e., the users of the locally developed materials in the context of curriculum-based value education. The selection of participants for this research was guided by several key considerations that align with the research objectives and the specific context of the study. The participants included both teachers and students who were involved in the use and evaluation of locally developed ELT materials.In choosing these participants, the primary aim was to ensure that they possessed direct and first-hand experience in the locally developed materials. This criterion was crucial to gaining insights grounded in real-world usage and challenges. The students who participated in the questionnaire surveys were drawn from the author’s own teaching context, comprising a diverse group of learners from different academic majors and language proficiency levels. These students were selected because they had been exposed to the locally developed materials as part of their English language learning journey.Similarly, the teachers who participated in the interviews were colleagues of the first author and had been actively involved in the development and implementation of the locally produced ELT materials. Their first-hand involvement in the material development process, as well as their roles as instructors using these materials, made them valuable informants to provide deeper insights into the challenges and potential solutions.The sampling procedure for both the questionnaire surveys and interviews followed a convenience sampling approach. Given the contextual nature of this study and the need to access participants directly involved in the use of locally developed ELT materials, this approach was deemed most appropriate. Convenience sampling allowed for the selection of participants who were readily accessible and willing to participate, ensuring a practical and efficient data collection process.Furthermore, it should be noted that the participants in this study were selected based on their relevance to the research objectives, as they represented key stakeholders in the utilization and development of local ELT materials. Their perspectives and experiences were considered essential for addressing the research questions and providing valuable insights into the challenges and potential solutions related to these materials.Overall, the selection of participants and the sampling procedure were carefully considered to align with the research focus, context, and objectives, ensuring that the insights gained from this study are meaningful and contextually relevant.Initially, the authors conducted interviews with those teachers and students, to gain a deep understanding of their experiences and feelings. Details of interview participants are presented in Subsequently, a questionnaire was distributed among the students to further collect relevant data pertaining to their attitudes towards the materials. The questionnaire used in this research was meticulously designed to align with the key themes identified during interviews. These themes encompassed language quality, content appropriateness, the integration of ideological and moral elements into materials, and multi-dimensional aspects of material development. The questionnaire items were crafted to capture participants’ perspectives and experiences related to these dimensions. To ensure the reliability of the questionnaire, several steps were taken. First, a pilot test of the questionnaire was conducted with a small group of participants who were not part of the main study. Their feedback and responses were analyzed to refine the wording and clarity of the questionnaire items. Subsequently, the finalized questionnaire was administered to a larger sample of participants, including both teachers and students, who were directly involved with locally developed ELT materials. The reliability of the questionnaire was further assessed using statistical measures, including Cronbach’s alpha coefficient, which yielded a high level of internal consistency for the questionnaire items. A total of 101 valid questionnaires were obtained from first-year students who were non-foreign-language majors. The respondents comprised 26 male and 75 female students. After conducting a reliability analysis on the questionnaire, the obtained α coefficient of 0.711 indicated that the questionnaire items were reliable in measuring the intended constructs. The quantitative data then underwent descriptive statistical analysis. In this research, our foremost commitment lies in upholding ethical standards and ensuring the trustworthiness of our investigation into locally developed ELT materials. We rigorously obtained informed consent from the teachers and students who participated, underscoring the principles of voluntary involvement and data confidentiality. Additionally, to enhance the reliability of our data, we employed triangulation, which amalgamated information from both interviews and questionnaires.4.4.1.The findings of this survey indicate that the ELT materials, which was locally developed based on the requirements of curriculum-based value education, have exerted a discernible positive influence on the advancement of students’ moral and ideological development, as illustrated in 4.2.4.2.1.The investigation revealed that language in locally developed ELT materials in the context of curriculum-based value education is a significant issue that requires material developers’ attention. All surveyed teachers acknowledged that the language used in the texts and exercises in the set of ELT materials was insufficiently classic and authentic. For instance, T1 pointed out:Extract 1The texts contain some awkward sentence structures, a phenomenon that I find quite prevalent in the materials. It is possible that in certain instances, non-native speakers use distinctive expressions to underscore a particular point, a practice that we can certainly tolerate. Nonetheless, I believe that frequent occurrences of such sentences in the texts are undesirable from a pedagogical standpoint. We should expose students to more classic expressions instead. Teacher T3 expressed a similar view. She believed that it is crucial to use concise and authentic expression so as to tell Chinese stories well, while the language used to discuss Chinese issues in the locally developed ELT materials is verbose and difficult to comprehend. She also pointed out that the same problem occurred in the exercises of the textbook:Extract 2The sentences provided in the textbook exercises are also very pertinent to ‘curriculum-based value education’, and the content expressed in them is lofty, but students cannot understand them. The sentences are too stiff, and there are too many new words. The survey results indicate that only about 20% of students find the language in the locally developed ELT materials easy to understand. As for the causes of the difficulty in understanding the language used in the textbooks , it mainThe “language” problem may stem from the non-classical nature of the selected texts. As T2 suggested:Extract 3After searching for articles featuring the authors’ names, I observed that these authors lack significant influence, and many articles are more likely excerpts from newspapers. In my opinion, we need more literary masterpieces, at least, less newspaper articles.Non-classic texts may not only pose problems in language quality but also affect the learning and interpretative value of the texts. The interviewed teachers all expressed their expectation for students to acquire genuine language skills through material-based learning, including the ability to emulate effective sentence structures and patterns to facilitate communicative and written activities. Nevertheless, if the language utilized in the text in the locally developed ELT materials is not sufficiently authentic, students will find it challenging to effectively carry out such activities.One additional possible cause of the “language” problem is that there were no native speakers in the lists of developers or editors of these locally developed materials. T1 commented:Extract 4I understand that Chinese editors can have a good understanding of the contents of the selected texts, but I still believe it would be advantageous to have native speakers engage in the editorial work to guarantee the quality of the language.4.2.2.The findings of this study disclose particular concerns relating to the content of the locally developed materials, particularly with respect to the complexity, selection of materials, and arrangement.4.2.2.1.The text complexity can be evaluated based on several criteria, of which vocabulary constitutes a vital indicator . In thisExtract 5I perceive that the level of difficulty in the textbook fluctuates, with certain units containing a conspicuous amount of unfamiliar vocabulary compared to others in the same volume.To validate the assertion made by S1, the researchers utilized the vocabulary list appended to the textbook, and conducted a quantitative analysis of the distribution of College English Test Band 4 (CET-4), College English Test Band 6 (CET-6), and more advanced vocabulary across the eight units of the first volume of the textbook, as depicted in During the interview, T2 also shared her thoughts on the vocabulary:Extract 6I believe the design of the vocabulary list could be more scientific. For example, the words drilled in the exercises are not completely consistent with that of the word list, which could affect students’ grasp of key vocabulary and their understanding of course content, thus compromising the effectiveness of the curriculum-based moral education.4.2.2.2.The selection of texts for locally developed ELT materials bears a direct correlation to the integration of ideological and moral elements in the context of curriculum-based moral education. Findings from this study revealed some problems in the process of selecting texts for locally developed materials. The first problem is that the selected texts were deemed too abstruse, and the content was perceived as not interesting and lacking in appeal to students. More than a quarter (26.73%) of the surveyed students (respondents of the questionnaire) expressed that the selected texts were relatively obscure and not germane to their daily lives. Additionally, almost four in ten (38.61%) respondents asserted that the materials’ content was not captivating enough. T3 mentioned that she and her colleagues agreed that the selected texts in the locally developed materials were somewhat tedious. She cited one of her colleague’s comment in the interview:Extract 7I find this textbook difficult and boring. I tried to adapt the material and told my students from the beginning that the purpose of the materials is to evoke more reflection on certain values. In each lesson, I have been encouraging students to share their feelings on the topics in the textbooks by using examples from their own lives. However, the effects have been minimal as students find it challenging to do so as the contents in the selected texts are often very distant from their own lives.This demonstrates that when selecting texts for locally developed ELT materials, it is essential to not only ensure thematic relevance but also consider the suitability for the intended student audience. Given that the goal of the materials is to promote curriculum-based moral education, it would be prudent to conduct a thorough needs analysis among students when developing such materials. The needs analysis will facilitate the selection of texts and make the locally developed materials more likely to be well-received.The second problem pertains to the inadequate coherence between the contents of the texts and the theme of the unit, which results in a lack of profound reflection on pertinent values. According to T2, some of the texts possess a seemingly substantial external presentation but offer little “substance” internally.Extract 8For instance, there is an article on the topic of freedom where the author expresses a desire to be an ordinary researcher instead of a project leader or lab founder. However, the author’s accomplishments as a researcher are unclear. Upon my investigation, no remarkable achievements (of the author) were found.T2’s remarks suggest that there is no clear correlation between this text and the unit theme. Moreover, the author’s achievements are unremarkable, and the case concerned lacks adequacy and typicality, which renders it unconvincing. Such cases often fail to resonate with students and cannot play a good role in value guidance.The third problem is that some of the texts presented in the locally developed materials depict an unfavorable image of China or reflect outdated images of China. For example, both interviewed teachers and students mentioned an article in which the author recounted being bitten by a spider as a child and how her mother treated the wound by using fire. Neither the teachers nor the students considered this text to be morally appropriate. T3 bluntly pointed out:Extract 9The author uses this example to illustrate the backwardness of certain regions in China, and mentions at the end that achieving equal distribution of knowledge and education is necessary to eliminate such backward areas. But I think this plot is completely unnecessary. In this era, how many Chinese students still use fire to treat spider bites?S3 expresses her expectations for materials rich in values:Extract 10I think the original intention of developing local ELT materials like this set of textbooks is to tell good stories about China, so there should be more positive examples. In fact, there are many such examples can be selected, which, I think, is easy to be found in Chinese culture.4.2.2.3.In the preface of the textbook, the authors underscored the significance of maintaining a rough equilibrium between Chinese and foreign cultural content. However, there appears to be no discernible arrangement pattern in this regard. According to our survey conducted among students, 66.34% of them found it challenging to determine whether the textbook achieved a balance between Chinese and foreign cultural content. T2 noted that while the first volume of the textbook usually features Reading A on foreign culture and Reading B on Chinese culture, this pattern is not consistently reflected in the second volume. T2’s perspective, which aligns with the expectations of both teachers and students, suggests that the authors should consider adopting a clear writing pattern to enhance students’ comprehension of the textbook’s content.Additionally, T3 voiced her opinion on the organization of cultural contents in the materials based on the teaching practice. Given that college English courses now have fewer credit hours, T3 suggests:Extract 11Chinese cultural contents should be presented in Reading A, as many universities tend to focus on learning this section, with Reading B only roughly covered or left for after-class study.While T3’s suggestion reveals that there is a need for local ELT materials developer’s to ensure a balance between Chinese and foreign cultural contents in each unit, and, if necessary, reduce the number of units. With the declining credit hours of the college English course, a well-structured arrangement in the ELT materials could prevent an imbalance in students’ exposure to Chinese and foreign culture.4.2.3.According to the notion of curriculum-based moral education, the concrete embodiment of “course-based ideological education” is preferred to be unobtrusive, and therefore the difficulty lies in how to integrate the ideological and moral elements into different courses . In inteExtract 12The  elements are not delivered subtly, I mean, in an implicit way. Instead, these elements are too obvious. It is somewhat difficult for students to get interested.It is apparent that this set of locally developed ELT materials have not yet to achieve the effect of being unobtrusive. The transition from explicitly presenting to implicitly integrating ideological and moral elements have not yet been realized. Clearly, to simply place ideological and moral elements in the texts, or to simply juxtapose different cultures there, is not the original intention of developing local ELT materials and cannot meet the needs of curriculum-based oral education.It seems safe to say that whether the objectives of curriculum-based moral education can be achieved in an implicit way depends largely on teacher’s adaptations. Results from the questionnaire survey indicated that 37.62% of surveyed students reported that their teachers supplemented the locally developed materials with other resources in the teaching practice. In an interview, T1 mentioned that she added Chinese cultural elements to his lesson and tried to avoid preaching:Extract 13For instance, when reading an article about nuclear leakage, which describes foreign scientists sacrificing themselves to protect others, I show a video clip of Chinese scientists to students and guide them in discussing what Chinese scientists have done, gradually inspiring everyone. The main approach is to guide students with something interesting, but I cannot say I excel in this practice.Teachers’ agency and their adaptations of the ELT materials are important in integrating ideological and moral elements into the course, but developing good local ELT materials is still something that cannot be replaced. To achieve better value guidance, local ELT material developers should improve the ways of integration and increase the implicit supply of ideological and moral elements, thereby offering better solutions to users of the materials.4.2.4.The current study has unveiled notable room for enhancement in developing multi-dimensional local ELT materials. Despite the preface of the materials mentioning the reliance on information technology and claiming the integration of mobile learning platforms and teaching resources, both teachers and students perceived the extended resources provided by the material developers to be inadequate. The principal concerns articulated in the feedback from teachers and learners are presented as follows.4.2.4.1.The accompanying reference materials for teaching and learning are indispensable for providing teachers with guidance and enhancing students’ academic achievements. Nevertheless, feedback from both teachers and students indicates that the supplementary reference resources corresponding to the locally developed textbooks fall short of meeting their teaching and learning requirements. For instance, T1 pointed out that:Extract 14Certain crucial questions lack reference answers, and subjective questions lack any answers or basic guidance. While we advocate for students’ independent thinking and self-reflection, a value-driven set of teaching materials cannot fall short of guidance altogether.Additionally, T3 expressed the need to improve the quality of the reference translations in the teacher’s books.Extract 15The reference translation of the texts offered in the teacher’s book is literal and reads like a machine translation. This is, of course, my subjective judgment. But I tell you that the reference translation is not good enough. I understand to express the local things in English is difficult and then translate these texts with local elements may be more challenging. However, I believe that ELT material development is a comprehensive undertaking, that is, apart from the formal textbooks, supporting materials such as reference translations must also be taken into account.The opinions expressed by the aforementioned teachers are quite representative. Besides teachers’ own endeavors, textbook developers should proactively offer “scaffolding” for teachers’ growth in their teaching competence in the new context of curriculum-based education. This includes providing appropriate guidance on some of the crucial or relatively covert value judgments that arise in the texts or exercises in the teaching supporting materials. In addition, students have also raised concerns about the related reference materials for the texts. S2 expressed his frustration:Extract 16The WeChat mini program (that complements the content of the textbook) for vocabulary learning only offers word pronunciations and simple explanations, without any sentences or additional examples from the text. I stopped using it after a few times. Now I simply rely on the textbook and the materials provided by my teacher.S2’s comments indicate that local ELT material development should prioritize not only the form of multi-dimensional construction but also the quality of such construction. In the context of curriculum-based moral education, it is equally vital to pay attention to the inclusion of relevant ideological and moral education resources in the material packages. This approach ensures comprehensive presentation of ideological and moral elements and enables the multi-dimensional local ELT materials to truly enhance students’ learning experiences, thus accomplishing nuanced impacts on cultivating students.4.2.4.2.Besides the necessity for explanatory and guiding learning materials pertaining to the text’s content, the provision of extended digital learning resources related to the theme of the textbook content is also a crucial aspect of multi-dimensional construction for the locally developed ELT materials. Nonetheless, there are certain inadequacies with this series in this regard. Results from the questionnaire reveal that only 37.62% of the surveyed students endorse the digital learning resources provided by the material developers, implying that there is still significant room for improvement in this respect. After exploring the foreign language smart learning platform recommended by the material developers, it turns out that only the relevant electronic lesson plans (PowerPoint slides) for this series of materials were available, and there are no question banks or other resources accessible. Moreover, the digital courses on the learning platform require payment before they can be accessed. Users need to install the corresponding computer client to get access to the courses. However, when the author attempted to install the computer client, it was discovered that the client was no longer available for download. In response, T3 stated in the interview:Extract 17I am currently teaching the second volume of the series this semester. The only resources available to me are the textbook, PowerPoint slides, and a teacher’s book. All other resources need be sought out by myself. It is quite time-consuming and laborious to locate English materials that are properly relevant or aligned with the content on core socialist values and Chinese social culture covered in the textbook, particularly when it comes to audio-visual materials, which are harder to find and require careful screening by myself .The feedback from this teacher indicates that the materials have some deficiencies in terms of the form and content of the multi-dimensional resources. Teachers lack adequate materials that incorporate the ideological and moral elements as a leverage when conducting teaching and students lack them when engaging in extended learning. Hence, they have to compensate for this deficiency by their own efforts. While it is sensible for teachers to adapt the locally developed materials, the scarcity of multi-dimensional resources undoubtedly impairs the materials’ functionality. As an extension of the locally developed textbooks, digital supplementary resources are crucial for teachers to conduct effective curriculum-based moral education in ELT courses. The material developers need to offer practical and efficient support in this regard.5.This study comprehensively investigates the actual use of a series of local ELT materials developed in the context of curriculum-based moral education in China and fully comprehend the feedback from material users (teachers and students) through questionnaires and interviews. Problems of the locally developed materials were identified, including the language quality, content appropriateness, integration of local ideological and moral elements, and the multi-dimensional construction of such materials. Based on these findings, this paper proposes the following solutions to optimize the development of local ELT materials.5.1.The development of language teaching materials is a systematic project that requires the collaborative efforts of different entities , p. 25. 5.2.Drawing upon the findings of this study, we suggest a model for the evaluation of locally development ELT materials, as depicted in Ensuring the quality of language in locally developed ELT materials is of primary significance. It necessitates an authentic representation of language, adherence to English language norms, and clarity in communication. Addressing the problem of language quality in ELT materials requires the joint efforts of both textbook editors and researchers. Firstly, it is suggested that English native speakers  should be included in the community of developing local ELT materials. They can play a vital role in reviewing the language used in the locally developed ELT materials, including texts, exercises, and supplementary materials, to ensure the readability and ease of learning. Secondly, the role of corpora in developing local ELT materials cannot be neglected , p. 5 toThe findings of this study also suggest that developing locally developed ELT materials requires careful consideration of various content-related aspects. It involves controlling the difficulty level, ensuring teachability of selected texts, enhancing relevance to students’ daily lives, appropriate arrangement of local and global elements, and incorporation of positive and educationally significant local elements. Alignment with unit themes is also crucial for effective material development. To -improve the quality of content in locally developed ELT materials, several critical efforts should be undertaken. Firstly, Local material developing experts need to make efforts to incorporate local moral, cultural and ideological elements into the content. It should also be noted that it is crucial to highlight local culture and values in local ELT materials while simultaneously incorporating international and intercultural elements. Scientific organization and arrangement of these elements need to be carefully considered as well. Secondly, by conducting surveys on material users, factors such as learners’ age, major, daily life, cognitive characteristics, teachers’ teaching competence and teaching practice, and school credit hours should be considered; the users’ opinions on language quality, content appropriateness of the materials need to be fully considered and their needs for multi-dimensional local ELT materials should be addressed. Based on the survey results, material developers should aim to maintain a reasonable level of difficulty of the selected texts, and incorporate targeted, varied, interesting, and instructive local ELT materials that can enhance the appeal of the locally developed materials and increase learners’ motivation. In the context of this study, for example, it is recommended that the theoretical and practical research on curriculum-based moral education in ELT be further conducted and the results of such research be closely incorporated into the development of local ELT materials. A third possible solution is to construct a systematic and dynamic local ELT material database full of resources with clear local themes and positive local content, which may need collaborative efforts of policy makers, researchers, material developers and teachers. For instance, the resource database can be shared nationally with the help of policy makers and can be gradually enlarged by other material editors and teachers all over the country, which can make the development of local ELT materials more scientific.The acceptability of the integration approach of local ideological and moral elements to the students is another pivotal factor in the development of locally produced ELT materials. As for how to incorporate local elements into ELT materials, continuous innovation is required in practice. For instance, in the context of this study, many material developers opted for manifesting ideological and moral aspects in an explicit way when developing local ELT materials based on the notion of curriculum-based moral education . It is cThe development of locally produced ELT materials necessitates the availability of ample supporting resources relevant to the teaching material content, as well as an adequate supply of multi-dimensional databases and e-materials for expanding the teaching and learning space. With the continuous development of information technology in language education, the new generation of university ELT materials should break through the flat way of language learning, and the promote multi-dimensional construction of materials and realize the full extension and expansion of classroom learning through the deep integration with various information technology means and online learning platforms . Therefo6.This paper empirically examines the challenges of developing local ELT materials from the micro perspective of material users, including both teachers and students. Drawing upon the concept of a material development community, this study has unearthed valuable insights into the challenges faced in the development and utilization of these materials.One of the significant findings of this investigation pertains to language quality. It has been observed that the language used in local ELT materials often falls short in terms of authenticity and adherence to English language norms. This discovery underscores the importance of incorporating native English speakers, experts in material development, into the process to enhance language quality. Additionally, the utilization of corpora to maintain language standards in the materials has been suggested. Content-related aspects have also been a focal point of this study. The need for a careful balance in terms of content difficulty, teachability, and relevance to students’ daily lives has been emphasized. Furthermore, the strategic incorporation of local cultural, moral, and ideological elements alongside international and intercultural components has been highlighted. The organization and arrangement of these elements have been recognized as critical factors in the effective development of local ELT materials. Addressing the integration of local ideological and moral elements, this study underscores the importance of considering students’ acceptability of such integration. While explicit manifestation of these elements can be valuable, it must be done judiciously to avoid overwhelming students and ensure a balance between language and moral education. Moreover, in the quest for multi-dimensional development, the availability of ample supporting resources relevant to the teaching material content and the existence of comprehensive multi-dimensional databases and e-materials have been identified as pivotal. These resources are crucial for expanding the teaching and learning space, especially in the digital age.In response to these findings, this study proposes a framework for evaluating local ELT materials, offering a systematic approach to material development that encompasses language quality, content appropriateness, the integration of local elements, and multi-dimensional construction. This framework aims to guide future material developers in creating effective and engaging materials aligned with the goals of curriculum-based value education.Future research may involve the examination of a broader range of materials, a deeper exploration of various stakeholders’ attitudes toward material development, and the validation or augmentation of the findings presented in this study. By continuing to delve into these aspects, we can further refine the development and implementation of local ELT materials, ultimately enhancing English language education in the context of curriculum-based value education.In essence, this research not only provides practical solutions for the enhancement of local ELT materials but also contributes to the broader discourse on material development in the evolving landscape of English language education.The original contributions presented in the study are included in the article/supplementary material, further inquiries can be directed to the corresponding author.All authors listed have made a substantial, direct, and intellectual contribution to the work and approved it for publication.


Off-label drug use exists widely in medical practice and is also an area which easily triggers controversy between patients and medical institutions. Previous studies have identified the reasons why off-label drug use long exists. However, there is no multidimensional analysis on real judicial precedents about off-label drug use. This study aimed to investigate the dispute points on off-label drug use based on real cases in China, and proposed suggestions based on newly-leased Physicians Law.Our study is a retrospective study with all the 35 judicial precedents on off-label drug use extracted from China Judgments Online from 2014 to 2019. This study mainly used the methods of statistical analysis, inferential analysis, exemplification, literature summarization and comparative analysis.According to the analysis of the 35 precedents of jurisdictions from 11 different aspects, it can be seen that the second-instance and retrial rates of this kind of cases are high, and the disputes between patients and medical institutions are fierce. In judicial practice of off-label drug use, medical institutions are determined whether to bear civil liability according to the constituent elements of medical tort liability: the rate of medical institutions’ bearing liability for off-label drug use is not high, and medical institutions are not directly identified as infringing acts and they don’t bear tort liability. The clear provisions about off-label drug use in Law of the People’s Republic of China on Physicians which was implemented in March 2022 confirm this at the legislative level.By analyzing the current judicial practice of China’s off-label drug use cases, and summarizing the dispute points between medical institution and patients, the constituent elements of tort liability, and the rules of evidence etc., suggestions are proposed to further regulate off-label drug use and promote safe and rational drug use. Off-label drug use (OLDU) refers to the inconsistency of the patient’s age, indications, administration method, dose, and route of administration with the drug instruction provided by the manufacturer . OLDU inBefore 2022, there was no specific legislation for OLDU in China. The “Drug Administration Law” clearly stipulates the accuracy of drug instructions and the strict verification of drug dispensers in medical institutions. Paragraph 9 of Article 6 of the “Prescription Administrative Policy” stipulates that drugs can be used in excess doses under special circumstances, but the reasons should be indicated and signed again. Although the law does not expressly prohibit the prescribing right of OLDU, there is no positive regulation either. Therefore, in clinical practice, there are inconsistencies about whether or not to use off-label drugs, the responsibility of using off-label drugs, under what circumstances can off-label drugs be used, and what procedures and rules need to be followed. In view of this, professional societies in various provinces and cities have also launched a series of consensuses from the perspective of clinical guidance. For example, the “Expert Consensus on Drugs’ Unregistered Use” launched by Guangdong Pharmaceutical Association in March 2010 is the first industry norms for OLDU issued by a professional association in China [It is worth noting that 2022 Law of the People’s Republic of China on Physicians regulates OLDU for the first time, making China a country that legislates and regulates OLDU after the United States, France, Germany, the Netherlands, Italy, New Zealand, Japan, and India . The ArtWhen analyzing the lawsuits involving OLDU, this paper uses several terms. Here are their brief definitions: (1) Tort liability refers to the liability that arises as the result of one person’s causing property damage to another according to civil law. (2) First instance means the first court hearing. (3) Second instance means that when either party of a lawsuit refuses to accept the judgement of first instance, he can appellate to a higher court before the judgement takes legal effect. (4) A new trial in which issues already litigated and to which the court has already rendered a verdict or decision are reexamined by the same court. (5) The burden of proof means the duty of presenting a certain amount of evidence in order to meet the legal requirements for establishing the entitlement of the party in a case to the outcome sought.By searching precedents of jurisdictions published on China Judgments Online, an authority site run by the Supreme People’s Court of the People’s Republic of China, there were 35 lawsuits involving OLDU, and the time span of judgments was 2014–2019. This study analyzed these 35 cases from 11 different dimensions to investigate the current condition of juridical precedents caused by OLDU. The 35 cases were comprehensively analyzed from 11 different aspects, such as the cause of the cases, the trial procedure, trial results, distribution of involved medical institutions, involved drugs and departments, etc. When analyzing and discussing about these cases, this paper uses the method of inferential analysis; when reviewing China’s legislation on the regulation of OLDU, and proposing suggestions, this paper also uses the methods of exemplification, literature summarization and comparative analysis.Since one dimension is to analyze the medical institutions involved in these 35 lawsuits, it is necessary to introduce the classification of Chinese medical institutions. Generally, according to whether they are owned and funded by the government, Chinese medical institutions can be divided into public and private hospitals. Public hospitals in China are organized according to a 3-tier system that recognizes a hospital’s ability to provide medical care, medical education, and conduct medical research. Based on this, public hospitals are designated as Primary, Secondary and Tertiary institutions (Tertiary is better than Primary). Further, based on the level of service provision, size, medical technology, medical equipment, and management and medical quality, these 3 grades are further subdivided into 3 subsidiary levels: A, B and C (A is better than C). This results in a total of 9 levels.Judging from the cause of the cases, there were mainly 34 cases of medical damage liability disputes, in addition to 1 case of medical service contract dispute. Judging from the trial procedure, there were 20 cases in the first instance, 14 cases in the second instance, and 1 case in the retrial . They believe that medical institutions should be responsible for OLDU are mainly concentrated on: (1) The instructions have been approved through legal procedures and are highly effective. OLDU violates diagnosis and treatment norms, and causes medication errors. (2) Medical institutions failed to fulfill their obligation to fully inform patients and violated patient’s right to know. In 20 cases, the patients or their families claimed that the medical institutions’ notification was not standardized, and they did not fulfill the obligation of special risk notification, violating patients’ rights to know and to choose. (3) Medical institutions had the behavior of modifying or concealing medical records. In 19 cases, the patients or their families claimed that the medical records of the medical institutions were incomplete, the behavior of OLDU was not recorded, the contents of the medical records were modified, relevant contents were concealed, the writing was incomplete, and there was no physician’s signature, etc. Medical institutions’ main reasons to refute are: (1) There are clinical indications to prove that OLDU is reasonable, and there are many supporting evidence, including domestic and foreign guidelines, foreign drug instructions, expert consensus, professional textbooks, or evidence-based medicine evidences, such as authoritative literature reports and case reports. (2) The development of patients’ condition is based on his own situation and has nothing to do with drug use behavior.The medical damage caused by OLDU is applicable to the constituent elements of general medical damage, namely: the medical institution has medical behaviors that violate the routine of diagnosis and treatment ; there are facts of damage, that is, the patients are harmed; there is a causal relationship between the medical behavior and the damage; the medical practice has fault or negligence. Among the 35 cases, judging from fact-finding, the court identified that OLDU in medical institutions constituted medical damage in 17 cases, did not constitute medical damage in 15 cases, and 3 cases were not clearly identified Table . JudgingAlthough the 35 cases of judicial precedents analyzed in this paper occurred before the legislation, the judgments of judicial practice are consistent with the spirit of 2022 Law of the People’s Republic of China on Physicians.According to the provisions of the Civil Code of China, medical damage liability can be divided into the liability for medical technology damage, the liability for medical ethics damage and the liability for medical product damage. OLDU refers that medical institutions and their medical personnel violate the usage of instruction, and fail to provide patients with “the required medical level”, resulting in personal or property damage to patients. The imputation principle of medical damage liability caused by OLDU belongs to principle of fault liability. However, from the cases’ analysis, it can be seen that patients are naturally in weak position in terms of burden of proof, including medical records stored in medical institutions and patients’ weakness in professional knowledge. The evidence provided by patients is often only the provisions of the medical record and the instructions. Therefore, in terms of the effectiveness of proof, it can only prove the existence of OLDU behavior, but as to whether the medical behavior causes damage, whether there is subjective negligence, and whether there is a causal relationship between the actual damage result and the behavior, it cannot meet the proof standards required for medical damage liability. It is suggested to introduce relief system of burden of proof, and transfer the burden to the defendant  on the basis of the patient’s initial performance of the burden of proof. This transfer can help to balance the medical institution-patient gap .In daily diagnosis and treatment activities, OLDU behavior is inevitable in medical institutions. From the perspective of judicial and legislative practice, OLDU behavior may cause adverse consequences to medical institutions and physicians themselves, which to a certain extent will cause the following condition in medical practice: physicians tend to conservatively and strictly implement the instructions in order to avoid disputes and practice risks, rather than break through the instruction limits for disease diagnosis and treatment and patients’ benefits. From the perspective of contributing to the treatment of patients and promoting the development of medicine, OLDU has its rationality and it is inevitable; In order to avoid disputes between patients and medical institutions, and protect the rights and interests of patients , it is nring database for the adverse reactions of OLDU.It is suggested to standardize the management process of OLDU in medical institutions, establish internal institutional norms and approval procedures for OLDU, and conduct appropriateness review of physician’s prescriptions and orders , timely In view of the fact that most of the current OLDU information is reported in literature, and there is no unified information platform nationwide, it is suggested to establish a nationwide OLDU data system, including reporting, adverse reaction monitoring, etc., so as to promote specification formulation and improvement, providing a resource platform for rational supervision . In viewMany cases of judicial precedents show that disputes about OLDU exist in practice. The newly revised Law of the People’s Republic of China on Physicians in 2022 explicitly allows OLDU in certain conditions from the legislative level, and although the judicial precedents in practice all occurred before the new Law of the People’s Republic of China on Physicians came into effect, it is also confirmed from the level of judicial practice that OLDU is not necessarily equivalent to an unreasonable prescription, and OLDU does not necessarily constitute infringement. In clinical practice, what really needs to be avoided is the damage caused to patients by drug misuse and other mistakes. OLDU behaviors that can benefit patients’ treatment should be encouraged and supported, but at the same time, the prerequisites should be strictly limited, that is, there is no effective or better treatment means, and there are evidence-based medicine evidences, such as clinical application guidelines, clinical diagnosis and treatment guidelines, etc. If the medical institution causes damage due to medical negligence, it shall still bear tort liability . In addiAccording to the statistics of judicial cases, it can be seen that patients’ believing that medical institutions did not fulfill the obligation of informed consent accounts for a large proportion (57%). Article 29 of the Law of the People’s Republic of China on Physicians stipulates that the explicit informed consent of the patient is required for OLDU. According to Article 1219 of the Civil Code of China, medical personnel shall promptly explain to patients the medical risks, alternative medical solutions, etc., and obtain their explicit consent; if they cannot or should not explain to the patient, they shall explain to the patient’s close relatives and obtain their explicit consent. The Civil Code of China changes obtaining written consent in the original Tort Liability Law to obtaining explicit consent, so that the form of notification by medical institutions is no longer limited to written consent, instead the content of the notification should reach the full understanding of patients and their families. Although explicit informed consent is not the same as written consent, in the practice of diagnosis and treatment, written consent has evidentiary effect and helps to avoid or deal with disputes between patients and medical institutions. It is recommended that medical institutions formulate a specific informed consent template for OLDU and standardize relevant content of informing. The elements of the standardized template include: the explanation for OLDU, the evidence-based medicine evidences, possible medical risks, alternatives and the explanations of related reasons, and obtaining the confirming signature of the patient or their families. International studies indicate that when written information is provided to patients as part of the informed consent process, it should be fully understandable to the patient, regardless of their degree of literacy . FirstlyIn the process of studying judicial precedents related to OLDU, relevant information of some precedents is incomplete, and the extracted subjective and objective factors affecting the decision of the cases are not comprehensive enough. In addition, in China’s legal practice, there are not many cases of OLDU entering judicial procedure, which leads to the small sample size of this study. Further studies need to increase the sample size in the future, and try to expand to cases that have not yet entered judicial procedure, but do have disputes between hospitals and patients, so as to carry out a larger range of sampling and research.


The prevalence of diabetes mellitus (DM), which affects people of all socioeconomic backgrounds, continues to climb at an alarming rate. Diabetes affects nearly half a billion people worldwide, and it is anticipated that this statistic will soar by more than 50% over the upcoming quarter of a century. Because of how ubiquitous it is all throughout the world, DM has become a cause of massive concern for the population’s health. People who have diabetes have a higher risk of developing chronic conditions that are linked to damage to either the microvascular or macrovascular systems. Complications involving the lower extremities, such as peripheral artery disease (PAD), are becoming more prevalent worldwide. This has a substantial impact on the mortality and morbidity rates of diabetic patientsPAD is known as the narrowing or occlusion of the arteries in the lower extremities as a consequence of atherosclerosis. Some of the most prominent atherosclerotic risk factors for the development of PAD include smoking, DM, increasing age, and dyslipidemia. DM has been associated with a two-fold to four-fold increase in the incidence of PAD. Undeterred by the fact that PAD remains significant both epidemiologically and clinically, it still falls prey to the vicious cycle of being unattended, underdiagnosed and thus, undertreated. This may be due to the fact that a mere 10% of the patients exhibit typical symptoms of the diseaseThe ankle-brachial index (ABI) is a valuable test for assessing atherosclerotic disease of the lower extremities. This test evaluates a decline in the systemic arterial pressure of the lower limb. Patients who have aberrant ABI values, that is either less than 0.9 or greater than 1.3, have an increased likelihood of suffering from cardiovascular eventsIn Asia, in particular, the brachial-ankle pulse wave velocity (baPWV) is frequently used owing to its benefits of ease of use, high reproducibility, and significant correlation with aortic PWV. A high baPWV is linked to an elevated risk of all-cause and cardiovascular mortalityet al. intended to determine the cumulative, interactive, and independent correlations of ABI and baPWV with mortality from all-cause and expanded cardiovascular disease in type 2 DM patients. The results of this study disclosed that ABI and baPWV are critical determinants that can assist in predicting all-cause and expanded cardiovascular disease mortality in type 2 DM patients and in identifying high-risk patients who would benefit from diabetes therapy in comparison to ABI or baPWV alone. This practical approach has the potential to be implemented into mainstream clinical practices in order to customize risk assessment and direct clinical decisionsBoth baPWV and ABI are prominent noninvasive indicators that are utilized in the process of diagnosing atherosclerosis. In a recent study carried out in Taiwan, Lin Not applicable.The authors declare no conflicts of interest.Externally peer-reviewed, not commissioned.


Rubella is a leading vaccine-preventable cause of birth defects. We conducted this study to evaluate the rubella surveillance system in South Africa from 2016 to 2018. The rubella surveillance system had not been evaluated since its inception; therefore, a formal evaluation is necessary to assess key attributes and to ascertain the extent to which the system achieves its objectives.We conducted a cross-sectional study to assess the usefulness, simplicity, positive predictive value, timeliness, and data quality of the rubella surveillance system from 2016 to 2018. We reviewed retrospective rubella surveillance data and conducted a survey with key stakeholders of the system. We compiled a summary report from the survey and calculated the annualized detection rate of rubella and non-rubella febrile rash, positive predictive value, the proportion of complete records, and timeliness between the surveillance steps. We compared our results with recommended performance indicators from the 2015 revised World Health Organization African regional guidelines for measles and rubella surveillance.The rubella surveillance system was useful but weak in terms of simplicity. The annualized detection rate of rubella febrile rash was 1.5 per 100,000 populations in 2016, 4.4 in 2017, and 2.1 in 2018. The positive predictive value was 29.1% in 2016, 40.9% in 2017, and 32.9% in 2018. The system did not meet the timeliness goal in the health facility component but met this goal in the laboratory component. The system had poor data quality, particularly in the health facility component.The rubella surveillance system was useful, although it was not simple to use and had low PPV, poor timeliness, and poor data quality. Efforts should be made to improve the system’s simplicity, PPV, timeliness, and data quality at the facility level. Rubivirus in the Togaviridae family. Rubella is transmitted through airborne droplets when infected individuals cough or sneeze [Rubella is a contagious infection caused by a virus of the genus r sneeze . Althougr sneeze , 2. CRS r sneeze , 4. Womer sneeze . Althougr sneeze . Due to r sneeze . Over thr sneeze , 6. The r sneeze , 8. Soutr sneeze .It is estimated that more than 100 000 babies are born with CRS globally each year . Africa To accelerate rubella elimination and control goals, WHO recommends that countries conduct rubella surveillance to keep track of cases . SurveilWe conducted a cross-sectional study from 2016 to 2018 that entailed retrospective rubella data analysis and a survey that collected data from stakeholders in South Africa. South Africa has nine provinces and 52 districts and a total population size of 59.6 million was recorded in 2018 . The pubRubella surveillance is entirely laboratory-based and is coordinated by the Center for Vaccines and Immunology (CVI), NICD, a division of the National Health Laboratory Services (NHLS). The NHLS is the largest diagnostic pathology service provider in South Africa, and provides laboratory services to more than 80% of the population, through a network of over 260 laboratories distributed across all provinces of the country . All labRubella symptoms are like those that are caused by measles virus. Therefore, the practice is that blood samples are collected from suspected measles cases within all four tiers of health facilities and sent to CVI, NICD for measles and rubella serological testing. Samples are collected in health facilities using suspected measles case definition adopted from WHO. A suspected measles case is any person with fever (≥38°C) and maculopapular (non-vesicular) generalized rash and any of the three C’s: cough, coryza or conjunctivitis or anyone whom a clinician suspect measles infection . A confiFor each suspected case, healthcare workers complete surveillance tools  with epidemiological data . CompletWe evaluated this surveillance system using the Updated Guidelines for Evaluating a Public Health Surveillance System published by the Centers for Disease Control and Prevention (CDC), Atlanta, United States of America . The CDCFor the survey, we included healthcare workers involved in coordinating measles and rubella surveillance systems at WHO South Africa, NICD, national, provincial and district DoH and those involved in diagnosing, recording, and notifying health authorities of suspected measles cases in public health facilities of Gauteng and Limpopo provinces. We conveniently selected Gauteng and Limpopo provinces because they were easily accessible to the study team. We purposively selected districts and health facilities that were included in the 2017 WHO comprehensive EPI, data quality, essential vaccines management and in-depth surveillance review. We conducted survey in seven health facilities, including hospitals and community health centres, from Gauteng and Limpopo provinces that were included in 2017 WHO review. We interviewed measles and rubella laboratory manager, data administrator, and personnel who test samples at CVI and EPI managers at the selected districts. We also targeted to interview measles and rubella surveillance coordinators at WHO South Africa country office, NDoH, and Gauteng and Limpopo EPI provincial managers. At the facility-level, we purposively included all medical doctors and nurses at outpatient department and paediatric ward.We measured key attributes of the surveillance system through survey and analysis of the rubella surveillance database .For retrospective rubella database analysis, we included all records of individuals who were tested for rubella infection from 2016 to 2018 in South Africa and excluded records that did not have test results.We conducted face-to-face interview with individual participants using a structured paper-based questionnaire. The questionnaire had a mixture of close and open-ended questions and was comprised of two sections. First section included socio-demographic information and second one had questions based on each measured key attribute. Data collection took place over a two-week period. We explained the study and handed information sheet to the participants. Those who were interested to be part of the survey signed a written consent form before the interview.Version 15. StataCorp LLC, College Station, TX, United States of America, 2017).We received the rubella surveillance database from the CDW of the NHLS in a Microsoft Excel (2016) format. We analyzed the rubella surveillance data using Microsoft Excel and Stata , we divided the total number of rubella IgM positive cases by the total number of suspect cases that were tested for rubella infection.To assess system timeliness, we calculated facility and laboratory turnaround times and determined the proportion of samples that met the WHO desired turnaround times. WHO defines desired turnaround times as at least 80% of samples collected from the facilities arriving at the laboratory within three days, and at least 80% of the test results being disseminated to the national level from the laboratory within seven days of receipt of samples . SpecifiTo determine the overall data quality of the system, we divided the total number of complete rubella records on the database by the total number of rubella records from 2016 to 2018. To determine the data quality of each variable on the database, we divided the total number of records with complete information for each variable by the total number of rubella records.We assessed the system’s adequacy performance indicators by calculating rubella febrile rash detection rate for each year as the total number of rubella IgM positive cases divided by the South African mid-year population estimates of each year. We also calculated non-rubella febrile rash detection rate for each year as the total number of rubella negative cases divided by the South African mid-year population estimates. We obtained number of rubella cases from the rubella surveillance database and mid-year population estimates from statistics South Africa reports. We then compared the annual detection rates with the desired WHO rubella febrile rash and non-rubella febrile rash which is at least two cases per 100,000 population per year .The attributes usefulness and simplicity were assessed based on participants responses to the relevant survey questions. We captured and processed survey response in Microsoft Excel. We compiled a summary report following information that we obtained from the participants.The study was approved by the Faculty of Health Sciences Research Ethics Committee of the University of Pretoria (Ethic No 40/2019). We obtained approvals from Gauteng and Limpopo provincial DoH and management of all included health facilities. Rubella surveillance is part of the NICD’s routine surveillance activities and ethics approval for this was granted by the Human Ethics Research Committee  of the University of Witwatersrand (M210752). Survey participants read an information letter and signed a written consent form before participating in the study.A total of 12,858 samples were received and tested for rubella at the NICD laboratory from January 2016 to December 2018 . We exclPositive predictive value: The overall PPV was 35.9% (4540/12633). The PPV was 29.1% (819/2816) in 2016, 40.9% (2512/6143) in 2017 and 32.9% (1209/3672) in 2018.We described timeliness in terms of facility and laboratory turnaround times. The facility component had 70.5% (8903/12631) of timely reports, which is below the WHO target of 80% . The labThe data management process starts at the health facilities continuing to the national level. Analysis of the rubella national database revealed that data quality of the system is poor, particularly information gathered at the facility-level. For the period under review, only 12.1% (1528/12633) of the records in the database were complete . Data quRubella surveillance system adequacy performance indicators: Our findings showed that the system achieved the adequate surveillance indicator target since it was able to detect rubella and non-rubella febrile rash, apart from 2016 where the detection of rubella cases fell below the WHO-recommended targets .The analysis and interpretation of the surveillance data in the years under review and information gathered through the survey showed that the surveillance system was able to meet its stipulated goals . ParticiData for the rubella surveillance system is collected using tools such as notifiable medical conditions forms, case investigation forms, laboratory forms, and an electronic application. Surveillance information collected at the facilities is sent to the district, provincial, and national level daily using a combination of these tools. The national level does not send real time notification of rubella cases but sends weekly reports summarizing the surveillance data back to the provincial and district levels. Participants in both facility, district, and national levels were not certain if the system is simple. Our findings suggest that the system is not simple as there were several challenges raised regarding the operation of the system. Participants from the district and national level indicated that they receive incomplete information on cases from the facility level. The other aspect raised was that most of the rubella cases are asymptomatic, making it difficult for health care workers to identify all cases, and hindering the system from detecting all true cases. One participant said, “It is not simple to detect all rubella cases since we are currently dependent on measles case definitions for rubella surveillance”. Rubella surveillance is currently done concurrently with measles, and some cases could be missed as healthcare workers identify cases based on measles case definition”.At the facility level, most of the participants did not know case definitions that are used and whether their facilities were conducting rubella surveillance. Participants also raised challenges regarding centralized laboratories and designation of personnel for sample collection. They said they are unable to send samples to laboratories over the weekend, and samples are not collected when designated personnel are off duty. Another issue raised was the confusion between the measles and rubella surveillance as these systems are operated concurrently. Participants from the district and facility level further raised challenges regarding data sharing. Participants indicated that they struggle to communicate with other stakeholders due to a poor or complete lack of internet connectivity at their facilities. As a result, they use their personal resources such as cellphones, data, and WhatsApp to communicate with other stakeholders. Participants at the national level (NICD) did not raise any challenges regarding sending rubella surveillance data to stakeholders and mentioned that the use of emails as means of communication is feasible and sustainable, since they are able to reach many people in a short period of the time.We evaluated the rubella surveillance system in South Africa and found that the system was useful but not simple and had low PPV, poor timeliness and poor data quality at the health facility level. The surveillance system had a low PPV for the years under review. Since rubella is endemic in South Africa, we would expect to see a higher test positivity for cases reported to this surveillance system. The low PPV observed in our study could be because of the low sensitivity of the case definition that is used to identify cases in rubella surveillance in South Africa. This may imply that some rubella cases are missed given that samples tested for rubella are based on suspected measles case definition. This should be worrisome as the system may miss rubella outbreaks and underestimate incidence and prevalence.The laboratory-component of the system showed commendable timeliness between the receipt of the samples in the laboratory and dissemination of results. The timeliness was higher than the WHO standard (80%) . HoweverAnalysis of the national rubella surveillance database showed poor data quality, particularly on the information that is gathered at the facility level. This is likely due to the facilities providing incomplete surveillance tools to both district, provincial and national levels. The provision of incomplete surveillance tools could be because healthcare workers at this level are not completely aware of the necessity of providing complete details of the suspect cases for surveillance system operation. Poor data quality at health facility level has been reported previously in South Africa , 30, andRegarding the usefulness of the rubella surveillance system, although stakeholders at national level (NICD) knew the importance of the system, those at district and facility levels did not know. Nonetheless, when comparing objectives of the system with the data provided in this study, and that of the national database, the system seems to be serving its purpose. For instance, the rubella national database can provide stakeholders with useful data to estimate the incidence and prevalence of rubella. The system also provides guidance to users for rubella prevention and control strategies. For example, the data collected by the rubella surveillance system were used to inform CRS sentinel surveillance in South Africa. As South Africa is preparing for the introduction of the rubella vaccine in the EPI, data from the rubella surveillance system may be useful in guiding authorities to prioritize vaccination of at-risk populations. The system met WHO-recommended surveillance indicators   for the Our findings showed that stakeholders do not find the system simple to engage with. This is likely because rubella surveillance is solely laboratory-based and integrated into the measles surveillance system. Stakeholders are unable to differentiate the two systems, particularly those who are working at district- and facility-levels. Given the fact that confirmed rubella cases are only identified in the laboratory, there are no clear pathways for collecting and sharing data across the facility- and district-level. Most healthcare workers at the facility-level do not know case definitions that are used for this surveillance system. The facility-level timeliness that was below the WHO standard (80%) and a lack of knowledge about rubella surveillance case definitions support our conclusion that the system is not simple. Developing a clinical case definition for rubella would simplify the rubella surveillance system.The system has several limitations that should be taken into consideration. The system is laboratory-based; therefore, healthcare workers at the facility-level do not know much about it. The system is conducted using measles case definitions; hence, some cases might be missed as healthcare workers focus on signs and symptoms of measles. Health facilities are not notified of the cases that test positive for rubella on real time and this might cause reluctance of healthcare workers to be involved in the system as they may not see the value of reporting suspected cases. Our study limitation was the inability to evaluate the system at WHO, provincial and national DoH levels as we were unable to reach key participants for interviews.We found that the system was useful based on the information gathered from the participants, analysis of rubella surveillance database and WHO indicators. However, the system was not simple, and had low PPV, poor timeliness and poor data quality at the facility level. Our findings highlighted the need to raise awareness among healthcare workers, particularly at the facility level to strengthen the functioning of this surveillance system. The use of rubella case definition and real-time notification of cases could improve PPV, timeliness and simplicity of the system. Future studies should assess factors that affect timeliness and data quality at the facility level. As South Africa considers introduction of the rubella vaccine in EPI schedule, it is essential that this surveillance system perform optimally.S1 File(XLSX)Click here for additional data file.S2 File(XLSX)Click here for additional data file.


Lung cancer is one of the malignant tumors with the fastest growth in incidence and mortality and the greatest threat to human health and life. Non-small cell lung cancer (NSCLC) accounts for approximately 80% of all lung cancers, with approximately 75% of patients diagnosed in the advanced stage, and the 5-year survival rate of advanced patients is less than 5% . ImportaLong et al.).Compared with previous diagnostic methods, nanotechnology has advantages such as small size, good biocompatibility, and strong organ targeting ability, providing a new multifunctional platform for biomedical research . NanotecPeng et al. believed that with the novel engineering avenues of nanomedicine, there is a possibility to overcome the inherent limitations derived from conventional and emerging treatments, such as off-site drug cytotoxicity, drug resistance, and administration methods. Combining nanotechnology with the convergence points of current therapies could open up new avenues for meeting the unmet needs of NSCLC treatment.Nanotechnology has emerged as a modality for the treatment of cancer. Combination therapies with high efficacy and low toxicity are required to extend the clinical benefit to a wider patient population and improve the prognosis of NSCLC . FunctioHolder et al.).Nanocarriers can greatly improve the dosage and accuracy of targeted drug release, as well as reduce toxicity and side effects, thus treating tumors more effectively in a non-invasive state in the human body. In combination with nanoparticles, it is possible to improve the pharmacokinetic and pharmacodynamic profiles of pre-existing drugs used in cancer treatment. Nanoparticles have physiochemical properties such as small size, allowing passage through challenging areas of the body, and a large surface area allows for higher doses of drugs to be brought to the tumor site. Nanoparticles can be functionalized, which involves modifying the surface chemistry of the particles and allows for the conjugation of ligands . Ligands can be chosen for their ability to target components that are specific to or are upregulated in cancer cells, such as targeting receptors on the tumor surface that are highly expressed in the cancer. This ability to precisely target the tumor can improve the efficacy of drugs and decrease toxic side effects. This review will discuss approaches used for targeting drugs to tumors using nanoparticles, provide examples of how this has been applied in the clinic, and highlight future prospects for this technology , to influence tumor-associated inflammation. In addition, a combination of active ingredients of herbal medicine and modern nanotechnology alters the tumor immune microenvironment. In recent years, immunological antitumor therapy in TCM has been applied on a reasonably large scale both nationally and internationally, and there is potential for further clinical expansion. Investigation of immune modulation mechanisms in Chinese herbal medicine will provide novel perspectives of how herbal medicine controls tumor growth and metastasis, which will contribute to the evolution of tumor research.Therefore, we expect nanotechnology to bring precise diagnosis and treatment to patients with NSCLC, improving their overall survival rate and quality of life.QS drafted the manuscript; QS, LP, YZ, and RW reviewed and edited the manuscript. All authors contributed to the article and approved the submitted version.