Multimodal approaches have been shown to be a promising way to collect data on child development at high frequency, combining different data inputs  to understand children’s health and development outcomes more integrally from multiple perspectives.The aim of this work was to describe an implementation study using a multimodal approach combining noninvasive biomarkers, social contact patterns, mobile surveying, and face-to-face interviews in order to validate technologies that help us better understand child development in poor countries at a high frequency.We carried out a mixed study based on a transversal descriptive analysis and a longitudinal prospective analysis in Malawi. In each village, children were sampled to participate in weekly sessions in which data signals were collected through wearable devices . Additionally, wearable proximity sensors to elicit the social network were deployed among children and their caregivers. Mobile surveys using interactive voice response calls were also used as an additional layer of data collection. An end-line face-to-face survey was conducted at the end of the study.During the implementation, 82 EEG/ECG data entry points were collected across four villages. The sampled children for EEG/ECG were 0 to 5 years old. EEG/ECG data were collected once a week. In every session, children wore the EEG headband for 5 minutes and the ECG hand pad for 3 minutes. In total, 3531 calls were sent over 5 weeks, with 2291 participants picking up the calls and 984 of those answering the consent question. In total, 585 people completed the surveys over the course of 5 weeks.This study achieved its objective of demonstrating the feasibility of generating data through the unprecedented use of a multimodal approach for tracking child development in Malawi, which is one of the poorest countries in the world. Above and beyond its multiple dimensions, the dynamics of child development are complex. It is the case not only that no data stream in isolation can accurately characterize it, but also that even if combined, infrequent data might miss critical inflection points and interactions between different conditions and behaviors. In turn, combining different modes at a sufficiently high frequency allows researchers to make progress by considering contact patterns, reported symptoms and behaviors, and critical biomarkers all at once. This application showcases that even in developing countries facing multiple constraints, complementary technologies can leverage and accelerate the digitalization of health, bringing benefits to populations that lack new tools for understanding child well-being and development. Research on many determinants of child development, including its underlying biological mechanisms, has accelerated at a fast pace over the last decade. It is now well known that early childhood development is a maturational and interactive process, resulting in an ordered progression of perceptual motor, cognitive, language, socioemotional, and self-regulation skills ,2. It isIn addition, knowledge on the impacts of disease outbreaks on child development is still scarce, particularly when it comes to infection susceptibility disrupting the environment in which children grow . SpecifiPanel studies in developing countries typically employ face-to-face data collection , which happens at a low frequency ,13. The Today’s technologies allow collecting a multiplicity of users’ features at scale and at a higher frequency and lower cost than face-to-face data collection, even if typically restrained to developed country settings. If their application could be extended to poor countries to track child development throughout different stages of their lives, such data could give us more power to evaluate interventions and improve causal inferences, and could help identify underlying mechanisms . In partWhile some of those technologies, including wearables, have been applied to track children’s conditions in developing country settings, this has typically been done either (1) in isolation, rather than combining multiple data streams, or (2) at a low frequency. The problem of the former is that each data stream in isolation has important limitations, for example, symptoms might be underreported in phone surveys, wearable readings might correspond to a multiplicity of states when considered in isolation, and contact patterns might be insufficient to characterize disease transmission dynamics. The problem of the latter is that above and beyond being multidimensional, the dynamics of child development are complex. It is the case not only that no data stream in isolation can accurately characterize it, but also that even if combined, infrequent data might miss critical inflection points and interactions between different conditions and behaviors.Instead, multimodal approaches have been shown to be a promising alternative for high-frequency monitoring, combining different inputs of noninvasive biomarkers and creating multiple angles to understand health and clinical outcomes ,19. ThesThe aim of this study was to describe a multimodal approach combining noninvasive biomarkers, social contact patterns, mobile surveying, and face-to-face interviews in order to validate technologies that help us better understand child development, as well as epidemiological events at the community level.We carried out a mixed study based on a transversal descriptive analysis and a longitudinal prospective analysis in Malawi. The field work took place in the following four villages in Dowa District: Mdoliro, Chidothi, Mtalanje, and Mkuwani. A pilot was run from October 1 to October 31, 2019. In this pilot, the team sampled villagers and users as described in In each village, children were sampled to use wearable devices. Additionally, wearable proximity sensors to elicit the social network were deployed in one village. A key ethical concern is the protection of human subjects from physical or psychological harm. All participants in the study were fully informed about the nature and purpose of the research and their requested involvement. Only participants who provided written consent (documented) were included in the research. In the case of children (subjects under 10 years old), consent was obtained from their guardians. In the case of adolescents (subjects between 10 and 19 years old), consent was obtained from both themselves and their guardians. Specific safeguards were in place to protect the safety  of respondents and those collecting the data. Personal identification information, including the names of the children, the names of the caregivers, and the phone numbers of the caregivers, were only accessible to local field workers and to one research associate in Malawi. No researcher was able to see any personal identification information as data sets were anonymized. Before the study, every participant was informed about the content of the study, including the objective of the study and the different types of data collected. Thereafter, every participant read a consent form (in both Chichewa and English) and signed it to indicate that they agreed to participate or let their children participate in this study. For those who could not read and write, our field workers read the content of the consent form to the participant and the participant provided his/her fingerprint to indicate consent. Enumerators were trained in collecting sensitive information, including information about children and health. Data collection tools, including wearable devices, were tested and designed in a way that was culturally appropriate  and did not create distress for respondents . Data collection visits were organized at the appropriate time  and place to minimize the risk to respondents. Enumerators were able to provide information on how individuals in situations of risk can seek support. Respondents were always given the option to withdraw from the study at any time. All data from the study were kept without identifiers to protect subject privacy. No data generated by this study, even if deidentified, can be exploited for commercial purposes by any of the counterparts involved. For the inception phase, two institutional review board (IRB) approvals were obtained. One was obtained from the Ethics Committee at the University of Zurich (OEC IRB #2018-046), and the other was obtained from the College of Medicine Research and Ethics Committee at the University of Malawi (P.10/19/2825).Electrocardiography (ECG) pads  collect During data collection, the study participants held the pad with their hands in a resting state and placed their thumbs on the metal electrodes for around 3 minutes. For small children who could not hold the pad, the health surveillance assistants and volunteers put two clips with electrodes on the child’s wrists, connected the clips to the pad with a cable, and waited for 3 minutes. The ECG data appeared on an app on a tablet, and the data were stored on the tablet, which could be later uploaded to the cloud.Muse headbands  were useThe main research question that we were interested in is whether EEG data can show proxies that could be related to cerebral malaria, which has a high incidence in the country or whether those metrics could be related to cognitive development, enabling systematic long-term monitoring in children at the community level.During recording sessions, health surveillance assistants and volunteers placed the headband on the child’s head, fitting the frontal electrodes above the eyebrow bridge and adjusting the posterior electrodes behind each mastoid. A block of 5 minutes of EEG data was recorded for each child while in a resting state with eyes open. The size of the headband could be adjusted to fit the size of the child’s head. For very young children whose head circumferences were too small to fit the headband, an elastic gauze material was used to wrap up around the headband to maintain firm connectivity. The EEG data were shown on an app on a tablet, and the data were stored on the tablet and later synced to an encrypted server for retrieval and analysis.Both EEG and ECG signals were integrated in a mobile app used on a tablet by health surveillance assistants and community watchers. Additionally, portable solar power kits were distributed to make sure the devices would be recharged when necessary without relying on local electricity availability.Proximity sensors  using loAs a research aspect, we were interested in social network structures at the community level to help understand when and how a disease would spread through the villages. Additionally, we wanted to assess if it is possible to rely on network sensing to evaluate the effect of nudges sent during the study.A mobile-based system of data collection, where individuals were asked to participate in a survey via IVR, was used as an additional data collection layer . RespondDuring the 1-month implementation, the selected participants received a call on their mobile phones every Friday for 5 weeks. One day before the phone call, they received an SMS text message that reminded them of the upcoming call -37. If tBesides mobile surveying by IVR, we sent nudges by SMS text message to the participants. By sending nudges on different topics, we wanted to test how participants react to the messages and whether there is any change in their behavior in response to the provided information . It was decided to randomly split each of the four villages into two equal groups (control and treatment). The individuals in the treatment group received the nudges every week for 4 weeks. Conversely, the individuals in the control group did not receive the nudges. The weekly nudges asked caregivers to take their children to the health or nutrition clinic for check-ups, requested households to talk with other households about handwashing behavior, or asked caregivers to take their children on play dates with children from other households.This study included the administration of (1) a light census and (2) a follow-up survey. These two data collections facilitated the interpretation of data coming from the devices.First, in order to figure out who is eligible for the study and sample participants, the team performed a census survey in the four selected villages before the inception phase started. The survey only collected data about demographic information of the households and information about the medical situation of the children in the past 4 weeks, as well as their functioning mobile phone number and their willingness to receive SMS text messages/IVR calls.After the fieldwork activities, the team deployed another face-to-face survey to collect information about child development, including health, wash, nutrition, education, child protection, and environmental data. Similarly, this follow-up survey collected reported information on device usability and acceptability, and similar ethical concerns that the population might raise because of the deployment of technological devices. We were interested to understand how the population receives a mobile message and if individuals share this information within the household and with neighbors. For this, we measured the ratio of information received through phone messages during the face-to-face data collection among segments of the target population that were not sent phone messages.The follow-up survey contained the following four sections: demographics of the households and measured children; questions about the Child Development Study, including the reactions of the participants toward the study and the ethical concerns of the study; questions about the user experiences of the different wearable devices; and questions about the medical symptoms and medical treatments of the targeted children.Descriptive analyses were undertaken showcasing the adherence and number of sessions involving wearable devices. For EEG data, we performed a grand average frequency spectra analysis evaluating the frequency range distribution. For proximity sensor data, we created a social contact matrix to evaluate relevant contacts during the study period. In addition, the contact patterns were compared with nudges sent by the IVR through a time series. For the end-line survey, we performed linear regression for medical symptoms. In-depth analyses were not the objective in this study and will be covered in future publications.During the implementation, 82 EEG/ECG data entry points were collected in the four villages . The samRegarding EEG data collection, the goal of this study was to measure the feasibility of the Muse headband in recording the signal from the children. For the proximity sensors, the matrix  shows thIn total, 3531 calls were sent over the 5 weeks the project was live, with 2291 people picking up the calls and 984 answering the consent question. In total, 585 people completed the surveys over the 5 weeks. This implies a pickup rate of 64.88% (2291/3531), a completion rate after pickup of 25.53% (585/2291), and a completion rate after answering the consent question of 59.5% (585/984). Completion rates dropped for each village after the first week, regardless of the incentive provided both in that week and the following weeks.First, in order to understand if IVR surveys are feasible, we studied phone ownership in the reference area. Phone ownership ranges from 56% in Mkuwani to 81% in Mdoliro. The probability of owning a phone might be related to other characteristics of a household.Regarding the symptoms collected during the mobile surveying, Besides symptoms, we collected data on some dimensions of child development, including information on nutrition  and earlFinally, This study demonstrated the feasibility of the unprecedented use of a multimodal approach for collecting data related to child development in Malawi settings. The preliminary data collected through our different data streams showcase a feasible methodology for tracking children’s health and development in poor country settings at a high frequency.While several studies applied in developing countries have already proven the feasibility of using wearable devices to understand how diseases behave and affect certain populations -41, inclThe execution of studies like this is still a challenge owing to the logistical and infrastructure issues that need to be overcome. However, the portability of the devices used favored the measurement of noninvasive biomarkers, such as EEG and ECG data, in environments without any structure, which is an important finding that was demonstrated. The EEG and ECG data showed that in addition to the feasibility of collection, the quality achieved has great potential for scaling interventions that previously did not consider these types of biomarkers. As seen in The syndromic approach seems to be an important tool for assessing the risk and existence of outbreaks of infectious diseases in the studied region owing to the self-report of symptoms present in the children informed by their caregivers. The alignment of syndromic approaches with participatory surveillance plays an important role in understanding epidemiological settings at the community level , and eveThe development of research that uses different technologies for data collection in children in the context of underdeveloped countries is challenging, requiring a recurrent search for instruments and strategies that enable and balance the needs and potential of certain areas . Wearabl


Research has shown that academic success is strongly associated with positive academic self-efficacy beliefs and that individuals with learning disabilities (LDs) usually report a lower perception of competence than their peers in most learning domains. The aim of this study was two-fold: (1) To compare the performance of inaccurate writers who were not diagnosed with an LD with that of students who were diagnosed with an LD, in order to identify which tasks were the most challenging for individuals with LDs, and (2) to investigate whether inaccurate writers with and without a diagnosis differ in terms of self-perceived difficulties. Two groups were selected from a total sample of 639 students attending seven Italian universities: The first group included 48 participants  with scores on writing tasks below the 5th percentile, and the second included 51 participants  who were diagnosed with an LD. The results showed that the two groups significantly differed in the articulatory suppression condition tasks, but not in the standard condition tasks. When groups were matched for performance on writing tasks, students who were diagnosed with an LD reported significantly more perceived difficulties than students without an LD. The implications of these results in terms of the self-efficacy beliefs of students with an LD are discussed. A nonnegligible proportion of students in mainstream higher education have learning difficulties . Learninlate diagnostic evaluation. Specifically, regarding the ability of reading and writing, it has been observed how crucial aspects such as difficulties in decoding single words and in applying the rules for a correct grapheme-phoneme conversion tend to decrease through different developmental stages ). When we performed PSA to test net group differences in self-perceived difficulties, we found a large difference in pre-matching distance scores  , who were considered the reference group and thus assigned a weight of 1 by the procedure, and 21 participants from the LD group, who were considered the focal group and were assigned a weight ranging from 0.42 to 3.33 (median = 0.62) to reach an adequate balance. After matching, the difference in distance scores was no longer significant  = 0.20, p = 0.845, d = 0.05 ), and the groups were adequately balanced in terms of the writing task scores  might interfere with the LDs participants’ performance and result in a more inaccurate outcome. Interestingly, when considering standard tasks, such as word dictation and grapheme production, students with LDs did not seem to make more errors than students who were within the tails of the normal distribution. The tasks performed under the articulatory suppression condition cannot be classified as standard everyday tasks that were familiar to the student, but were specifically created to discriminate the specific characteristics of LDs . The differences between the two groups registered in the Vinegrad+ questionnaire are particularly interesting. This self-report measure specifically focuses on the perception of difficulty, and the results clearly indicate that participants who were already diagnosed with LDs tended to report significantly more perceived difficulties compared to inaccurate writers who had never been evaluated for or diagnosed with LDs.The analysis performed on the matched samples allowed us to test whether the differences found between the perceptions of the two groups were linked to the actual differences found in the performance of specific tasks that we described above. The results confirmed that even when balancing the performance of the two groups for all tasks under the articulatory suppression condition, which emerged as the most discriminative for students with a diagnosis of LDs, participants with LDs reported significantly more perceived difficulties than students identified as inaccurate writers—who, in some cases, possibly had an LD that had not yet been detected. This result, in particular, may be of specific interest in discussing the all-around implications of being diagnosed with LDs and the need to work not only on the learning cognitive mechanism, but also on more general aspects, such as self-esteem, self-efficacy, and self-worth. The literature indicates how students with LDs benefit more from specific activities, such as first-year preparation courses, before entering university , as theyThe emerged enhanced perception of difficulty is a finding consistent with the limited existing literature on the topic. The results from a comprehensive study on the efficacy of university preparation courses by Reed et al.  outlinedThe results presented in the current study show that the enhanced perception of difficulty concerns not only specific difficulties related to writing skills, but also general learning features  and the overall learning experience assessed by the Vinegrad+ total score. These results suggest important areas for intervention that not only take into account the cognitive features and challenges that individuals with LDs face, but also the emotional impact of a diagnosis on the general perception of ability that, in turn, may influence future outcomes, such as career choice and the drop-out rate in higher levels of education . This atIn conclusion, the results of the present study are consistent with previous findings on the compensation that university students with LDs are able to implement, on one hand, and on the tendency of these students to internalize an experience of difficulty and fatigue with regard to learning, on the other hand ,31.Some limitations of this study warrant mentioning. First, as students with LDs are relatively rare in Italian universities, the sample size was inevitably not very large, and this might have impacted the statistical power. Future research in this domain should attempt to replicate these results using larger samples. Second, we only used one self-report measure for perceived difficulties: The use of multiple measures and the collection of data from observers, such as peers, teachers, tutors, and/or parents, will help to provide a more comprehensive assessment of the phenomenon. Despite these limitations, this study adds knowledge to a relatively less investigated stage of development and the features of LDs in young adulthood. In addition, it provides evidence of differences in the individuals’ perception of difficulties while controlling for performance, suggesting important areas for intervention. From this perspective, these results address the crucial role that receiving a diagnosis has in guaranteeing that students with LDs have access to all the instruments and tutelage that can allow them to proficiently experience learning at university. Moreover, the results provided by the present study highlight the importance of investing in practices that support students emotionally, with a specific focus on self-efficacy and self-esteem beliefs, which, together with the above mentioned tutelages and instruments, constitute a core protective factor for preventing drop-out, allowing students to confidently persevere in their careers. An important advancement in this regard would be the implementation of a specific support service at university to work with LD students on both the emotional impact of diagnosis and specific strategies and methodologies for supporting them in studying. These practices would increase and support student’s self-efficacy and self-esteem, working on both performance and academic “identity” at the same time.Overall, in this study, we showed how students with LDs and writing difficulties can reach a certain level of efficient compensation. Nevertheless, students with LDs perceived significantly more difficulties with respect to their undiagnosed peers. This result was also confirmed when matching the two groups in terms of writing task scores, suggesting the importance of addressing self-perception and self-efficacy issues in these students.


It is crucial to actively encourage the development of agriculture green technology, which has been regarded as one of the most effective solutions to the environmental degradation caused by agricultural activities. However, agriculture green technology diffusion is indeed a challenging task and still faces numerous barriers. The stakeholders who can potentially deal with these barriers, however, have been overlooked by previous studies. To address these issues, social network analysis was performed to identify critical stakeholders and barriers. Their interactions in agriculture green technology diffusion were analyzed based on the literature, a questionnaire survey and expert judgments. A two-mode network and two one-mode networks were used to analyze the relationships among the identified 12 barriers and 14 stakeholders who can influence these 12 barriers identified. The results show that agricultural research institutes, universities, agribusiness, agencies of township promotion, the government and farmers’ relatives are key stakeholders and that the limited market demand for green technology and the high cost of its diffusion are two main barriers. However, poor green technology operability and farmer families in distress are factors that are not as important as previously perceived. Finally, some recommendations and suggestions are provided to promote agriculture green technology diffusion in China. With the implementation of the rural revitalization strategy, China has experienced rapid development of agriculture and realized socialized etiquette and civility, effective governance and prosperous life. However, agriculture is the second-largest contributor to greenhouse gas emissions. To a large extent, its high-energy-consuming production technology has caused various environmental problems, which have greatly affected the development of agriculture . TherefoAs a result of the numerous sustainable benefits of agriculture green technology, many governments and organizations have taken measures to promote its diffusion and adoption. However, it is still a challenging task. Based on the experience of diffusing green agricultural technology—such as green pest control, soil nutrient management (such as soil testing formula technology), conservation tillage and precision agriculture—it has been concluded that, even if a technology is useful, there are different factors that limit its effectiveness . In reseIn the process of promoting the diffusion of agriculture green technology, stakeholders play a vital role. Collaboration among stakeholders is an important step and integral in promoting the diffusion of agriculture green technology . HoweverAt present, a limited amount of research has been conducted on stakeholder collaboration in the diffusion of agriculture green technology and the removal of barriers to diffusion by stakeholders. Researchers and practitioners agree that the diffusion of agriculture green technology is more complex and challenging because agriculture is “traditionally very conservative” and changes slowly. Therefore, it is of vital importance to clearly identify the relationship between stakeholders and diffusion barriers and identify crucial factors that affect the diffusion. In order to fill the gap in this aspect, this paper first analyzes barriers to the diffusion of agriculture green technology from the perspective of stakeholders. Then, a comprehensive analysis of stakeholders and barriers is provided, and their impact on the diffusion of agriculture green technology is quantified through the social network analysis (SNA) method. Finally, the relationship between different stakeholders and barriers is explored, and key stakeholders and barriers, as well as their impact, are also identified. To the best of our knowledge, this paper fills gaps in previous studies on green agriculture, which have rarely involved the relationship between different stakeholders and barriers. In our research, in contrast to traditional social network analysis, the one-mode network analysis examines the internal relationship in the same group of entities, while the two-mode network analysis explores the relationship between two different groups. The results of these analyses reveal interlinked stakeholders through the barriers they can jointly address and interlinked barriers through the stakeholders who have the power to influence them. Furthermore, the analysis of barrier factors from the perspective of stakeholders provides a useful reference for future research. In the process of agriculture green technology diffusion, the relationship between barriers and stakeholders, as well as the network characteristics of stakeholder collaboration, can be understood through this network model, and the cooperative relationship between stakeholders who overcome these barriers is also determined. Innovative viewpoints in this research can guide stakeholders to make correct decisions. This research not only enriches the theory of agriculture green technology diffusion and adoption but also provides insights into how China can effectively promote it and thereby facilitate agriculture development.The rest of the paper is structured as follows: The diffusion of green technologies refers to the process in which the source of innovation disseminates innovative green technologies among individuals and diffuses them throughout all of society . It is aAt present, excessive consumption of the Earth’s resources, a deteriorating environment and severe ecological damage have led to an increasing demand for agriculture green technology . AlthougThe speed and effect of the diffusion of agriculture technologies are closely related to their nature. Currently, developing countries are putting more effort into innovating single agriculture technologies, while having relatively few supporting technical achievements and lacking effective technological support . TherefoDuring the diffusion of agriculture green technology, quite a few technology research institutes, limited by their own problems , do not The diffusion of agriculture green technology involves the active organization and participation of different stakeholders. Decisions made by enterprises and governments are of great significance to the spread of agriculture green technology. Relevant policies under implementation lack substantive supporting policies that could effectively promote the diffusion of green technologies , which hDemonstration, application and promotion by agriculture technology workers are needed to transform agriculture green technology into productivity. As the work to promote agriculture technologies is not fully implemented by the associated government departments, promotion personnel have not received complete training in promoting agriculture green technology or in providing the necessary education. As a result of the aging of knowledge and a low level of personnel quality, farmers could not receive adequate technical guidance and technological upgrades, which will have an influence on the diffusion of agriculture green technology . MoreoveDeveloping countries are still lagging behind in the market of agriculture green technology. On the one hand, farmers in these regions have a relatively low level of literacy . They arThe diffusion of agriculture green technology is also subject to the market environment. Great market risks and uncertainties in the innovation of agriculture green technology  make it With the transition of stakeholder theory from the dyadic perspective to the network perspective, cooperation among stakeholders has become a new goal in the field of stakeholder management . StakehoPower is one of the most salient attributes of stakeholders . Power mIn terms of research methods, the past decade has witnessed a number of studies that examined the factors of agriculture technology adoption using social network analysis. Wang et al. analyzed the efficiency of farmers’ agricultural technology adoption and the interaction effect between the social network and extension service . In theiPrevious studies have shown that various barriers related to technologies, organizations, markets and social environments in the spread of agriculture green technology have inhibited the adoption and diffusion of agriculture green technology. At the same time, the diffusion of green technologies involves many stakeholders. Prior research and studies on the power and collaboration of stakeholders have suggested that the more powerful these stakeholders are, the more influence they have on the spread of green technologies. Effective collaboration among stakeholders will definitely have positive effects on the efficiency and performance of the diffusion of agriculture green technology. The existing research has barely explored how to effectively eliminate barriers to the diffusion of agriculture green technology from the perspective of stakeholders. Different resources provided by different stakeholders are needed to overcome these barriers. As a matter of fact, it is essential to study the influence of stakeholders on barriers to the diffusion of agriculture green technology, so as to improve the performance of this process.This paper analyzes the complicated relationship between stakeholders and adoption barriers during the diffusion of agriculture green technology through social network analysis. Social network analysis is applied to examine the existence and strength of the relationship between a pair of stakeholders and adoption barriers. This theory emphasizes the “structure and mode” of the relationship and tries to identify the reasons behind adoption constraints and their corresponding influence .The establishment of social networks is based on nodes and links. This step mainly focuses on recognizing the network nodes, that is, finding the stakeholders of and barriers to the spread of agriculture green technology. First, the literature research method was used to define stakeholders and barriers . Then, tIn order to verify the validity and reliability of the chosen barriers and stakeholders, the experts interviewed all have rich research experience in this field and have unique insights into green technologies and the stakeholders involved. S* represents stakeholders and F# represents barriers, where * denotes the number of stakeholders and # is the number of barriers.In order to analyze the influence of stakeholders on barriers to the spread of agriculture green technology, the snowball sampling technique, as well as questionnaires and expert seminars, were used to determine the relationship between stakeholders and barriers. Snowball sampling is particularly designed for cases that require professionals to give relevant opinions on issues in their field . The queAn element in the stakeholder–barrier matrix refers to the condition in which a stakeholder handles barriers. It is composed of a group of stakeholders (X) and a group of barriers (Y). If If The stakeholder–barrier matrix was transformed into a stakeholder–stakeholder matrix and a barrier–barrier matrix. This can highlight the key stakeholders and barriers and evaluate the strength of the correlation on a quantitative basis.In contrast to traditional social network analysis, both the two-mode and one-mode network analysis were used to analyze the relationships between stakeholders and barriers, as well as the interrelationships between stakeholders or barriers, so as to build a good collaboration among stakeholders to address those barriers that are hard to solve.In this study, the stakeholders can be regarded as the subject of the action of the network, and different kinds of barriers can be seen as the “organization” or the “case” affiliated to it. The two-mode social network analysis method analyzes the power of stakeholders in the social network to determine its impact and the means of overcoming obstacles. Using a two-mode social network analysis, Gan et al. provided a creative perspective on overcoming barriers to off-site construction by engaging stakeholders . HoweverCentrality analysis(1)Degree centralityK represents the key node, j represents other nodes and N represents the total number of nodes. Degree centrality measures the number of nodes directly linked to one node. It focuses on the degree of the power of nodes only. In the stakeholder–barrier network, this implies that stakeholders have the power to handle the number of barriers. As for barriers, the degree centrality is equal to the number of involved stakeholders . The deg(2)Closeness centralityg represents the number of stakeholders, h represents the number of barriers, k represents the barrier affected by a stakeholder, j represents some other stakeholder or barrier and k and j.The closeness centrality indicates the proximity of a network node to other nodes. The closeness centrality of a stakeholder refers to a function that represents the shortest network distance from the affected barrier to other stakeholders and barriers , which cThe closeness centrality of a barrier refers to a function that represents the shortest network distance from the affected stakeholder to other stakeholders and barriers , as showg represents the number of stakeholders, h represents the number of barriers, j represents some other stakeholder or barrier and i and j.Generally speaking, the closeness centrality reflects the proximity of members of the network. The shorter the distance, the more likely it is to be at the center of the whole network. In Equation (3), (3)Betweenness centralityg + h + 2.Betweenness centrality demonstrates the ability of a participant to play an intermediary role in the network , as is sCore–periphery analysisi, j and The core–periphery network has an ideal structure in which the rows and columns are divided into two categories. The block in the main diagonal represents the core, and the other one is the periphery . In the During the process of agriculture green technology diffusion, the analysis of the stakeholder-barrier network can help identify the power of stakeholders over the barriers. Furthermore, it is a challenge for stakeholders to address multiple barriers as their resources are limited. By analyzing the stakeholder-stakeholder network and barrier-barrier network, the main stakeholders and barriers can be observed more clearly. The powerful stakeholders can be identified through the stakeholder-stakeholder network, thus the effective collaboration among them can be established to maximize their resources, so as to better address the barriers of agriculture green technology diffusion. While the barrier-barrier network can help stakeholders have a full understanding of the relationships between the barriers, and make the contributes to the decision making of agriculture green technology diffusion.Network measures(1)Density analysis of the stakeholder/barrier networkG, K indicates the number of existing relationships and N represents the total node number of network G.Density indicates the closeness of network members . When th(2)Cohesion analysis of the stakeholder/barrier networkN represents the total node number of the network.Cohesion indicates the relationship between two contacts of an action provider . When coIn/out-degree analysisi and node j, j and node i. If there is a correlation, then the value is 1; if there is no correlation, then the value is 0.In/out-degree analysis reflects the strength of the influence of nodes. It divides the correlation strength between two nodes into outdegree and indegree. The outdegree of a node indicates the total number of nodes that it directly points to, while indegree indicates the total number of dots that other nodes point to . The calStructural Hole analysis of the stakeholder/barrier networkThe structural hole indicates a non-redundant connection among actors. It offers opportunities for holders to obtain an “information benefit” and “control benefit”, so as to make them more competitive than members in another position of the network . The par(1)Effective sizet represents the number of correlations in the network, and i.The effective size of an actor equals the non-redundant factors of the network in which the actor’s individual network deducts the redundancy of the network. It can measure the overall strength of the influence and the importance of nodes and indicates the control that a node has over the relationship between other nodes. The more effective the size of a node, the freer its action. The calculation of effective size is shown in Equation (11), with effective size > 0.(2)Efficiencyi is calculated by Equation (12), with 0 ≤ efficiency ≤ 1.n represents the number of nodes and Efficiency can be used to describe the influence of a node on other related nodes in the network. The efficiency of a node is equal to the ratio of its effective size to its actual size. The higher the efficiency of the node, the greater its influence in the control process. The efficiency of node (3)Aggregate constraintAggregate constraint indicates the ability of a node to use a structural hole. When a node of a single network is directly or indirectly connected to another one, it causes an aggregate constraint. The more aggregate constraint that a node has, the greater constraint that it has over the node, with 0 ≤ aggregate constraint ≤ 1. The aggregate constraint can be calculated by Equation (13):i and node j both adjoin node q, j among all the neighboring points of node i, and q among all neighboring points of node i and node j, respectively.In this formula, node In this study, we performed a literature review and expert interviews to screen out stakeholders and barrier factors for agriculture green technology diffusion after two rounds of the Delphi survey. We invited 20 experts to attend the discussion group, including eight scholars who excel in green agriculture and 12 experts in green production and management of agriculture and agriculture technology. In round I, the background and purpose of this research was sent to respondents by e-mail. The respondents were instructed to screen out the stakeholders and barrier factors of agriculture green technology diffusion that had been collected and to list their reasons. In round II, all the data and information collected in round I were analyzed, and the results were provided to these experts to allow them to re-evaluate and judge the influencing factors. A total of 15 barriers and 20 stakeholders were determined preliminarily, but after documentary review and expert selection, a total of 12 barriers and 14 stakeholders remained, which are listed in From the results of questionnaires and symposiums, the stakeholder–barrier network of agriculture green technology diffusion can be established by analyzing a relationships matrix between stakeholders and barriers and can be visualized through software , which iAs shown in Furthermore, the degree centrality, betweenness centrality and closeness centrality of F10 (high cost of green technology diffusion) and F11 (limited market demand for green technology) are the top two factors in the centrality analysis of barriers. This signifies that these two barriers are key difficulties in agriculture green technology diffusion and should be paid more attention to in future research and development. In addition, other barriers, such as F4 (non-significant benefits of green technology), F6 (limited knowledge of farmer), F7 (unscientific green technology promotion) and F12 , are among the top barriers, which indicates that more stakeholders are needed to address these barriers together.The core–periphery analysis result of the stakeholder–barrier network is displayed in a density matrix , and theThe core stakeholders and barriers  are deteThe core–periphery structure in this study can provide guidance for establishing an active collaboration network for stakeholders. For instance, S10 (government), located in the core, is able to solve 11 barriers, among which eight are in the core and four are in the periphery. As shown in It is indispensable to transform the two-mode stakeholder–barrier network into two one-mode networks of barrier–barrier and stakeholder–stakeholder. The density and cohesion of the one-mode networks of barrier–barrier and stakeholder–stakeholder are analyzed to understand the characteristics of the whole networks.The density of the barrier network and stakeholder network is 0.999 and 0.967, respectively, indicating that they have relatively high density and that the relationships between barriers and stakeholders are complicated. The cohesion index of the barrier network is 0.985, signifying a close and complicated relationship among barriers. The cohesion index of the stakeholder network is 0.973, showing that stakeholders can contact each other. When a barrier emerges, stakeholders participating in the program of agriculture green technology may all be involved. Statistics of the cohesion index show that the relationship among stakeholders is close and intricate.As a result of the symmetrical nature of the barrier network, the indegree of each node equals the outdegree. In addition, the standard deviation is 0.373, indicating that the influence of each barrier is relatively concentrated. Similar to the barrier network, the in/out-degree of each node of the stakeholder network remains the same. The overall degree is 176, while the average degree of the stakeholders is 12.57. Thus, a given stakeholder will influence an average of 12.57 stakeholders, including the original stakeholder, and, in turn, these stakeholders will also influence the original stakeholder. The influence of a particular stakeholder on others is relatively concentrated and vice versa. The standard deviation is 0.821.The measurement of a structural hole will help identify barriers that have a great impact on other non-associated barriers in the barrier–barrier network, as well as stakeholders that have a stronger influence on other non-associated stakeholders in the stakeholder–stakeholder network.The measurement results of the structural holes in the stakeholder network are shown in Agriculture is being upgraded with the advancement of the era. Green agriculture has gained unprecedented attention in China. Quite a few scholars have conducted research into agriculture green technology diffusion from different perspectives. However, most of them only analyzed barriers or stakeholders and put forward advice in this regard. Only a few of them have focused on the key subject of stakeholders overcoming barriers. This study offers new perspectives for exploring collaboration among stakeholders in agriculture green technology diffusion. The results of this analysis are discussed in this section.The core and most important stakeholders identified in the two-mode network analysis are agricultural research institutes, universities, agribusiness, the government, agencies of township promotion and farmers’ relatives, which can influence other stakeholders with their power and reputation, and they are more likely to address core barriers. The key barriers are the limited market demand for green technology and the high cost of its diffusion, which are also found in the one-mode network analysis. Furthermore, the results of the one-mode network analysis also show that poor green technology operability and farmer families in distress are factors that are not as important as previously perceived, and the relatives of farmers and township promotion agencies are becoming very important in social networks. From the analysis of both the two-mode and one-mode networks, it is apparent that the government has the strongest power over the barriers and can affect other stakeholders. Therefore, it is important for the government to use its power to establish collaboration among the stakeholders, especially those who are in the core position and can best address the barriers.(1)Survey results and findings show that “high cost of green technology diffusion” and “limited market demand for green technology” are deemed important barriers in the social network. Although agriculture green technology has gained increasing attention from all walks of society, it is still developing slowly. The majority of stakeholders are accustomed to traditional agriculture technologies. Many of them, such as agribusinesses and farmers, hold a negative attitude toward adopting agriculture green technology. They pay considerable attention to the cost of agriculture green technology diffusion during the research, innovation, production, promotion and application process , which c(2)As a key stakeholder in the agriculture green technology diffusion in China, the “government” has a clear central position in the network and has a strong influence. It can influence more barriers than other stakeholders and plays an important role in promoting stakeholder collaboration. Although the Chinese government has attached great importance to the development and diffusion of agriculture green technology in recent years, it has not diffused as well as expected. As a result of externalities and the path dependence effect , the inn(3)Two barriers—poor green technology operability and farmer families in distress—are not as important as previously perceived, which can be seen from the results of social network analysis. In recent years, China has attached great importance to the development of green agriculture , and the(4)As expected, six core stakeholders, namely, agricultural research institutes, universities, agribusiness, government, agencies of township promotion and farmers’ relatives, can influence other stakeholders with their power and reputation, and they are more likely to address core barriers. Whether the core stakeholders can achieve effective cooperation and collaboration has greatly affected the development of agriculture green technology. The entire process of the diffusion of agriculture green technology, from the establishment of goals to the realization of technology and the determination of the final operational flow, requires effective coordination among multiple stakeholders. The information exchange, intensive interaction and cooperation among the core stakeholders, including agricultural research institutes, universities, agribusiness, government, agencies of township promotion and farmers’ relatives, will facilitate common values, attitudes and interests in agriculture green technology, thus improving its acceptance by other stakeholders and further promote its diffusion . Further(5)An interesting finding is that relatives of farmers and township promotion agencies are becoming very important in social networks. At present, farmers’ relatives and township promotion agencies need to further deepen their understanding of agriculture green technology. Although an increasing number of adopters and farmers realize that ecological and environmental damage is a serious problem, they often consider it to be an issue that needs to be addressed by the government, and few farmers are concerned about the adoption of agriculture green technology. As a result of the structure of rural society, a relatively fixed social network is established in relatively closed spaces, social norms are relatively easy to form, and the social relationship between individuals is more affected by factors such as blood kinship and geographical scope, which can significantly affect the adoption of green technology by farmers ,54. At tAgriculture green technology is considered to be a useful tool to address various development issues, but it is still in its infancy in many countries, especially in developing countries like China. In the process of studying agriculture green technology diffusion, stakeholder collaboration as a key factor has been neglected by scholars, and it is not clear who among the stakeholders can solve which barrier. Through the analysis of the stakeholder–barrier network, this paper links the identified barriers to stakeholders and provides an innovative perspective for exploring stakeholder collaboration in the process of agriculture green technology diffusion.With the results of the social network analysis method, this paper discusses the influence of stakeholders on various barriers to agriculture green technology diffusion. Two-mode social networks, one-mode stakeholder networks and one-mode barrier networks are all used to study the relationship between stakeholders and barriers. This expands the traditional research model on stakeholders and barriers and provides theoretical and practical significance for promoting the diffusion of agriculture green technology. The following important findings are drawn from this study: (1) Compared with other barriers, “high cost of green technology diffusion” and “limited market demand of green technology” have more serious impacts on the diffusion of agriculture green technology. (2) The government, as the most influential stakeholder, plays an important role in overcoming barriers to the diffusion of agriculture green technology and promoting stakeholder collaboration. (3) Some barriers, such as poor green technology operability and farmer families in distress, are not as important as usually perceived. (4) Collaboration among core stakeholders, such as agricultural research institutes, universities, agribusiness, the government, agencies of township promotion and farmers’ relatives, can influence other stakeholders and facilitate the resolution of barriers. Effective promotion of collaboration among core stakeholders plays an extremely important role in overcoming barriers to the diffusion of agriculture green technology. (5) Farmers’ relatives and agencies of township promotion are becoming very important in social networks. Although these research results need to be tested with more in-depth practical investigations and academic research, the results of this study can provide stakeholders with new ideas to remove barriers to the diffusion of agriculture green technology, and can serve as a policy- and decision-making reference for government management departments and enterprises to facilitate this diffusion.On the basis of the results of the analysis, this paper proposes some suggestions for promoting the diffusion of agriculture green technology. First, in order to successfully diffuse and widely implement agriculture green technologies in China, it is necessary to further actively respond to and implement the two strategic decisions of rural revitalization and poverty alleviation, continuously improve the living standards of farmers’ families, promote the development of green agriculture as a whole, boost the performance of agriculture green technology diffusion, reduce the cost of diffusion and vigorously tap the green technology market, thereby increasing the demand for agriculture green technology.Second, as the main advocate of agriculture green technology, the government’s environmental policies can help encourage many stakeholders to cooperate in the diffusion of green technology innovation, thus addressing many diffusion barriers. If environmental policy tools, such as carbon tax and subsidies, can be integrated and synergistically combined, then the results will be better.Third, the government should actively respond to the trend of agricultural development and promote collaboration among core stakeholders, such as agricultural research institutes, universities, agribusiness, government, agencies of township promotion and farmers’ relatives through policy incentives and regulation design, and it should give full play to the basic role of market mechanisms in resource allocation, build an innovation and diffusion system of agriculture green technology based on stakeholder coordination, promote the supply of green technology innovation, reduce the cost, improve efficiency and further promote the diffusion of agriculture green technology.Finally, it is necessary to attach importance to the role of farmers’ relatives and agencies of township promotion in the diffusion of agriculture green technology, raise farmers’ awareness of green development, promote awareness of agriculture green technology among farmers’ relatives and township promotion agencies and strengthen their communication to promote barrier removal with policy guidance and social education. Farmers’ relatives and township promotion agencies should be encouraged to actively participate in the diffusion of agriculture green technology with policy incentives and benefit-sharing mechanisms.This study also has some limitations. First, one limitation of this study is that the data are from China, where agriculture green technology is in its initial stage of development, so the results of this study can only reflect the role of stakeholders in the diffusion of agricultural green technology in China, and not in countries in which the development of agriculture green technology is relatively mature.For future research, international comparison research can be conducted in these countries in order to establish international benchmarks for the acceptance of agriculture green technology. As the diffusion of agricultural green technology is a complex process, involving basic research, applied research and on-farm research to adapt new techniques to local conditions, participatory extension strategies, the establishment of farmer-to-farmer networks and the acquisition of an in-depth understanding of household dynamics, decision-making and community socioeconomic conditions, a modeling approach can be considered the first step to assess the dynamics of technology transfer and adoption. Future research may place a focus on carrying out follow-up on-farm research and surveys to validate, strengthen or fine-tune the findings from a valuable modeling approach, so as to better understand interactions among stakeholders and barriers to diffusion. Additionally, agriculture green technologies may be better adopted among some groups of farmers compared with those with less education or more limited resources. Future research can be carried out on target farm groups with similar socioeconomic backgrounds, to clarify the relationship between stakeholders and diffusion barriers and identify crucial factors that affect adoption and diffusion among groups of farmers with different socioeconomic backgrounds.


Approximately 90% of currently published clinical and public health research is in the form of observational studies. Having a detailed and registered study protocol prior to data collection is important in any empirical study. Without this, there is no reliable way to assess the occurrence of publication bias, outcome reporting bias, and other protocol deviations. However, there is currently no solid guidance available on the information that a protocol for an observational study should contain.The aim of this study is to formulate the Standardized Protocol Items Recommendations for Observational Studies (SPIROS) reporting guidelines, which focus on 3 main study designs of analytical epidemiology: cohort, case-control, and cross-sectional studies.A scoping review of published protocol papers of observational studies in epidemiology will identify candidate items for the SPIROS reporting guidelines. The list of items will be extended with the Strengthening the Reporting of Observational Studies in Epidemiology (STROBE) checklist items and recommendations from the SPIROS steering committee. This long list serves as the basis for a 2-round Delphi survey among experts to obtain consensus on which items to include. Each candidate item from the long list will be rated on a 5-point Likert scale to assess relevance for inclusion in the SPIROS reporting guidelines. Following the Delphi survey, an expert-driven consensus workshop will be convened to finalize the reporting guidelines.A scoping review of published observational study protocols has been completed, with 59 candidate items identified for inclusion into the Delphi survey, itself launched in early 2020.This project aims to improve the timeliness, completeness, and clarity of study protocols of observational studies in analytical epidemiology by producing expert-based recommendations of items to be addressed. These reporting guidelines will facilitate and encourage researchers to prepare and register study protocols of sufficient quality prior to data collection in order to improve the transparency, reproducibility, and quality of observational studies.PRR1-10.2196/17864 The protocol of any empirical study offers the researcher practical guidance in data collection, analysis, and reporting. It also forms the basis for subsequent replication of the study and detection of publication bias, outcome reporting bias, and other protocol deviations. A well-formulated study protocol uploaded prior to data collection through a time-stamped registry will allow a robust audit trail. This improves the chances that the study is appropriately planned, executed, and well documented, thus promoting optimal conduct, accountability, replicability, and overall research integrity. In summary, ensuring a high level of transparency in the research planning phase facilitates replicability of the study and fosters good research practices ,2.Although the value of registered study protocols and reporting guidelines on how to write them are widely recognized in the field of randomized control trials (RCTs) -5, reporAn estimated 90% of currently published clinical or public health–related research is in the form of observational studies . In partWhen protocols of observational studies do not provide sufficient details concerning the conduct of their preplanned study and are not preregistered or made openly available prior to data collection initiation, the scientific community is left with an incomplete picture of what the researchers intended to do and whether undisclosed protocol deviations and reporting biases occurred. Consequently, in the absence of registered protocols for observational studies, we are insufficiently able to judge the validity and reliability of the results. As such, interpretation of the results within the context of the study limitations becomes a potential major issue .The objective of this study is to develop reporting guidelines to be used in the design of observational study protocols. Our initiative has been given the acronym SPIROS . The project aims to improve the completeness and utility of study protocols for observational studies by producing expert-based recommendations for a minimum set of items these study protocols need to address. An item is defined as an important section, heading, or subheading within the study protocol, with each item describing an important methodological feature of the study. Our study is designed to meet three objectives.Objective 1 is to conduct a scoping review of items addressed in study protocols of observational studies in epidemiology. The purpose of objective 1 is to develop a long list of candidate items that could a priori be incorporated in the draft reporting guidelines. This would serve as the basis for the first round of the Delphi survey (Objective 2).Objective 2 is to conduct a Delphi survey with participants who are selected based on a prespecified range of expertise, with the intention of obtaining consensus on which items to include in the SPIROS reporting guidelines.Objective 3 is to conduct a face-to-face consensus workshop to finalize the SPIROS reporting guidelines and then disseminate the results with an associated manual.A scoping review of published study protocols of observational studies will be conducted, in which every item mentioned more than once will be listed ,12. The Up to 100 protocols of observational studies  published in indexed journals from the Web of Science will be included in the present review. To ensure the most current state of affairs is assessed, only papers published between January 1, 2016, and May 1, 2018, will be included because, based on a preliminary assessment, the target number of studies is expected to be reached within this time range.Data for this scoping review will be identified by searching the Web of Science Core Collection and references from relevant papers using the search terms “protocol” PLUS “observational study” AND/OR “cohort study” AND/OR “case control study” AND/OR “cross sectional study” AND/OR “prevalence study” AND/OR “survey” in the advanced search mode. A senior clinical librarian will be engaged to ensure that the search strategy is valid.All the protocol items present in the headings, subheadings, or text of protocol papers will then be presented in the form of a table, following the structure of the STROBE checklist. Initially, all items will be categorized into the following themes: general information, introduction, methods, ethical considerations, reporting, dissemination, and others. However, if different themes emerge, this structure will be accordingly iteratively adapted.The long list of candidate items for the protocols of observational studies identified in the scoping review will be evaluated by experts. For this purpose, we will conduct a 2-round Delphi study -19. We wEach panelist will be asked to rate every candidate item from the long list on a 5-point Likert scale for relevance for inclusion in the reporting guidelines for protocols of observational studies .A field for adding free text will be provided for comments on comprehensiveness and comprehensibility for each item and to suggest alterations or additional items. Round 1 will also collect core demographic information (panelists’ working field and place of employment) and panelists’ self-rated level of expertise on the particular topic.A threshold of 67% agreement among participants on a score of 4 or 5 for each candidate item will be considered to indicate consensus among the expert panel for consideration of inclusion in the SPIROS checklist. If agreement among participants is less than 67% scoring 4 or 5, the item will be considered discordant. The survey will be structured to last no more than 30 minutes and will be pretested and approved by the expert steering committee. The study protocol with any amendments will be uploaded in the Open Science Framework (OSF), as will the Delphi survey format, which will be updated, if needed, before the second round.Round 2 will contain all original candidate items plus additional items nominated or identified during the first round. For each item, panelists will be provided with percentage agreement from the first round, while the themes of each item´s free text comments will be merged into an anonymized executive summary.The participants will be asked to rerate the items and consider the comment themes. Once collated, all items reaching a 67% consensus agreement ranking of 4 or 5 on the Likert score will be included in the short list for the reporting guidelines and advance to the next stage of the process.A preset online survey questionnaire will be developed on the Google Forms online survey platform and uploaded to OSF before being sent out to expert panelists via email. Medians, interquartile range, and percentage of agreement will be calculated for each item.Following completion of the Delphi survey, the steering committee will convene a consensus workshop consisting of the steering committee plus 10 others previously involved in developing guidelines. Experts will review and adapt the draft reporting guidelines into a format appropriate for wider dissemination. A further workshop around dissemination strategy planning will also be convened, comprising experts involved with previous guideline dissemination, to ensure that a robust uptake mechanism is defined for widespread adoption of SPIROS, including choice of journal for publication of the final manuscript and content of a website exclusively for the initiative.The ultimate objective of this initiative is to facilitate widespread adoption of the SPIROS reporting guidelines. Therefore, all outputs of this initiative will be published as preprints and in open access journals or open choice access. This will include a detailed manual that explains and justifies the recommendations and includes examples of good reporting. We aim to have the SPIROS reporting guidelines adopted by journals and funders. The SPIROS protocol and final reporting guidelines will be published on a dedicated website (spiros-statement.org) and will be included in the Enhancing the Quality and Transparency of Health Research (EQUATOR) Network.The study will comply with the EU General Data Protection Regulation. Prior to data collection, the study protocol and all appendices will be registered and made openly available on the OSF, and links will be provided to reviewers and readers of the paper. This will include the complete data management and data analysis plan, and on completion of the study, all anonymized data will additionally be made available on OSF with no restrictions.Ethics approval has been obtained from the Ethics Review Committee of Maastricht University. The study will not collect any sensitive information, and the identity of each panel member will be fully protected and blinded to other panel members and the research group (except for the corresponding researcher). The burden for the panelists includes a maximum of 30 minutes for each of the Delphi survey rounds.Online informed consent will be obtained from all panel members, which will comprise an introductory page and completion of the survey as consent. Participants of the Delphi consensus survey will be provided with a summary of the overall aim of the SPIROS project and a link to the complete protocol. The consent for the Delphi survey will explain the specific aim of the survey and an outline of the procedures involved, as well as the benefits, risks, and burdens involved in participating. If consent is given, panels member will be acknowledged in the publication of the SPIROS reporting guidelines. However, the option to not be mentioned in the acknowledgments will also be given.The scoping review of published protocols of observational studies has been completed, with 59 candidate items identified. This long list of candidate items has formed the basis of the 2-round Delphi survey launched in early 2020.Over the last decade, there has been an increasing call for prospective registration of observational study protocols ,20-22. WThere are several recent projects, such as the Reproducible Evidence: Practices to Enhance and Achieve Transparency (REPEAT) initiative, that aim to improve transparency, reproducibility, and validity of database research . At the However, the absence of guidelines to develop protocols has historically resulted in a large proportion of observational research being conducted without quality-assured study protocols. Existing protocols are often not fit for purpose, and the proportion of researchers ensuring registration of protocols for observational studies prior to data collection remains negligible. Therefore, our study aims to develop reporting guidelines for protocols of observational studies by launching SPIROS. We expect this initiative to increase transparency of methods used in observational studies, and through standardizing protocols, we hope that study designs will be improved and more often be registered and published in a journal or in a repository.The main limitation of our study is that SPIROS reporting guidelines will be developed primarily for cohort, case-control, and cross-sectional study designs but not for other observational research designs. Because of the wide scope of observational study designs, it is difficult to prepare standard reporting guidelines that cover all observational study designs.Nevertheless, as the first attempt to develop a guiding document for observational study protocols, our guidelines will fill an important gap. Once widely available, an impact assessment should be conducted after a 4- to 5-year period to determine whether more and higher-quality protocols have become available, similar to the approach adopted by other reporting guidelines .


This aim of this study was to explore the role of regulation on the quality of care of older people living with depression in LTC, which in this paper is a domestic environment providing 24-h care for people with complex health needs and increased vulnerability.We conducted a systematic scoping review. A peer reviewed search strategy was developed in consultation with a specialist librarian. Several databases were searched to identify relevant studies including: Embase (using the OVID platform); MEDLINE (using the OVID platform); Psych info (using the OVID platform); Ageline (using the EBSCO platform); and CINHAL (using the EBSCO platform). Articles were screened by three reviewers with conflicts resolved in consultation with authors. Data charting was completed by one reviewer, with a quality check performed by a second reviewer. Key themes were then derived from the included studies.The search yielded 778 unique articles, of which 20 were included. Articles were grouped by themes: regulatory requirements, funding issues, and organizational issues.The highly regulated environment of LTC poses significant challenges which can influence the quality of care of residents with depression. Despite existing evidence around prevalence and improved treatment regimens, regulation appears to have failed to capture the best practice and contemporary knowledge available. This scoping review has identified a need for further empirical research to explore these issues. The prevalence of depression in older people living in long-term care (LTC) is high –4. RecogRegulation in LTC has been linked to quality –19, althMany frameworks, models of care and evidence-based practices have been described in the literature to improve the quality of care for older people living with depression in LTC. Furthermore, multi-disciplinary approaches to care  which inRecognition of depression in LTC residents is a crucial aspect of quality , with asThere are risks from failing to recognize depression in LTC. Podgorski et al.  studied Although a deterrence approach to regulation dominates the LTC sector , other sAn expert panel, which included leaders and stakeholders in the field of LTC, systematically reviewed the literature and made recommendations that families, residents, and ‘substitute decision makers’ (where capacity is an issue) should be actively involved in decision making in the LTC environment, as stakeholders . LTC is In summary, the treatment of older people with depression living in LTC is hindered by several factors including, a lack of recognition of depression, an increased prevalence of depression and a reduced access to treatment for depression. The literature also shows that whilst LTC quality is driven by regulation across the sector, there remains concerns about quality. It appears there is strong evidence that collaboration and partnership is an effective way to deliver care in this setting. The concepts of regulation, long-term care and depression, have been extensively addressed in the literature in isolation, however, there is a paucity of literature examining the relationship between the role of regulation and the care of older people with depression who are living in LTC. The aim of this systematic scoping review was to describe and analyze published studies and relevant grey literature, to explore the role of regulation on the quality of care of older people with depression living in LTC. Whilst the authors acknowledge the aim of this scoping review may be somewhat ‘lofty’ and hard to address, beginning with a scoping review of the literature to examine what evidence is available, is a worthwhile starting point. A scoping review of the existing literature will allow us to be better able to identify gaps and inform future research in this area.This systematic scoping review is based on the Arskey & O’Malley’s Methodological Framework for Scoping Studies . The comA search strategy was developed in consultation with experts in both scoping reviews, and in the topic area, along with consultations with a specialist librarian who had knowledge of the health literature. Search terms were developed by capturing a broad notion of the different concepts of regulation, older people, depression, and LTC. LTC and nursing homes are terms often used interchangeably in the literature but for this scoping review only LTC facilities or nursing homes that provided “a domestic-styled environment that provides 24-hour functional support and care for persons who require assistance with ADLs and who often have complex health needs and increased vulnerability.”  were incTo enhance the quality of the search strategy it was peer-reviewed by the specialist librarian using the ‘Peer Review of Electronic Search Strategies’ evidence-based guidelines , with suSeveral databases were searched to identify relevant studies , using search terms which are listed in supplementary document 1. A search of the grey literature was also undertaken from various sources, using the concepts already described. The websites that were searched included Health Canada, Care Quality Commission, National Institute of Clinical Excellence, Manitoba Centre for Health Policy and Evaluation, health ministries, and the Canadian Institute for Health Information.Using the broad concepts in the search strategy to identify items which were relevant, handsearching of relevant key journals, relevant reference lists and relevant grey literature identified from the systematic searches were also conducted. The Preferred Reporting System for Systematic Reviews and Meta-Analysis  was utilA two-stage screening process was conducted using the pre-defined inclusion criteria. Any qualitative, quantitative, or mixed method studies focused on regulation, LTC, and depression were included. The inclusion criteria at the screening of title and abstract stage did not include age as a concept. This decision was reached in consultation with a specialist librarian, who agreed that adding age, as a concept, in the initial phase of the scoping review might limit results. Therefore, the concept of age was applied during the screening of full text articles only. Articles written in English and French were included in the study.We excluded editorials, study protocols, and commentaries which only described policy or initiatives. Articles related to quality of life measurement, pain, palliative care, and cancer services were also excluded unless they were specifically linked to depression in LTC settings. There were no limitations placed on the dates of publications or the location of the studies in the search strategy. Covidence, an online systematic review software application, was used for this process.A total of 1946 articles were retrieved from the search, with 778 remaining following removal of duplicates. In the first phase, three researchers  independently examined the 778 titles and abstracts produced from the systematic search. Six hundred forty-two articles were excluded in this initial screening based on information within the title and abstract of the article. Where this was unclear, or if the title and abstract did not provide enough information to decide, these articles were included in the full text arties which were assessed for eligibility in the second stage of the screening process.Conflicts were noted in the outcome of this initial screening were resolved by consultation between the three reviewers  and other authors (CB & DA).During the second stage of the process, the same group of researchers examined 134 full text articles, adding the concept of ‘older people’ (in this study described as 65 years or older). An article was included if it was related to regulation, older people, depression, and LTC.Data was charted using a tool based on Booth, Sutton & Papaionannou , which cThree of the articles were randomly selected and reviewed by a second reviewer (RDB) and checked for consistency and quality. Results were charted using an excel spreadsheet. A narrative synthesis was conducted which consisted of extracting key themes from the scoping review studies as well as exploring the relationships between the themes.Of the final 20 articles included in this scoping review, there was 1 article each from France, Canada, the UK and New Zealand; 2 from the Netherlands; and 14 from the USA. This might be explained by the strong relationships in the USA between quality assessment and remuneration for health benefits, Medicare, and Medicaid which has required regulatory processes and an attempt at standardization with the RAI/MDS .Chart Eleven of the studies had a quantitative design; 1 study was qualitative; 3 were reviews; and 5 had a mixed methodology approach.Regulatory requirements; funding and organizational issues were identified as key themes in this scoping review.There are several different approaches to quality described in the literature, which suggest accreditation and regulation are linked to quality outcomes in care . In manyThe extent to which systems which are governed by regulation in the LTC sector make a difference to the quality of care that is delivered has been studied. In the USA, OBRA (1987) was enacted with the goal of helping improve LTC residents’ quality of life by mandating standardized assessments; by prescribing a policy of psychotropic drugs; and by enacting care planning requirements . This acIn Hanlon et al.  they notIncorporating assessment in mental health care has been shown to have a positive impact on care , 30. MolVarious studies retrieved in this scoping review suggest there is variability in how such mandated tools are implemented across different areas. For instance, in a national study in the USA, Linkins et al.  noted thHoltkamp et al.  concludeIn this scoping review, almost one fifth of the articles were related to Medicare and Medicaid funding, the RAI, and legislation, which was not surprising since in many jurisdictions, performance, quality and funding are inter-related. In a study of over 88,000 residents in over 2000 facilities across 6 states in the USA, Lapane & Hughes  exploredWagenaar et al.  suggest Most researchers argue that improved quality of care is linked to improvements in staffing levels , and theLinkins et al.  assessedTaylor et al.  suggestsThis systematic scoping review explored the role of regulation, and the care of older people with depression living in LTC. There is evidence that regulation in LTC does not necessarily have a positive role in the care of older people with depression. It could be argued that inspection processes result in LTC facilities being so concerned with what they need to demonstrate in relation to meeting standards, it results in a preoccupation with inspections leaving no time to think about quality , 59. SucMany of the studies retrieved have presented issues relating to Medicare and Medicaid, which was not surprising since many articles in this scoping review were based in the USA. Although the articles explore the links between certain mandated requirements in different jurisdictions and depression in LTC, they did not explore the direct role of regulation on the care of people with depression living in LTC facilities.Many of the articles in this scoping review have shown LTC to be a complex and highly regulated environment which has significant challenges due to funding constraints, and has many structures and processes in place which can influence the care of residents with depression. Despite existing evidence around prevalence and improved ways to manage depression in this population, generally regulation continues to adopt a deterrence-based approach , but whiThe widely used deterrence approach to regulation , may alsThis systematic scoping review showed that in many cases decisions regarding regulation and legislative requirements in the LTC sector, have a direct influence on the structures and processes of care delivered to residents, but which staff, who are accountable for the provision of care, have little influence over. We have found a paucity of literature exploring the role of regulation on the care of older people living with depression in long term care. This suggests there is scope for further research which explores the role of the concepts of regulation on the care of older people with depression living in long-term care. The authors propose a study which can explore the relationships between these concepts in the long-term care setting and offer alternative models of regulation in the sector which could contribute to the policy direction of regulation.Additional file 1: Chart 1. Overview of Articles – details of all full text articles which were reviewed in this study.


Teaching medical students is a central part of being a doctor, and is essential for the training of the next generation of physicians and for maintaining the quality of medicine. Our research reviews the training that physicians in Israel receive as teachers of clinical clerkships, and their thoughts regarding teaching students. The importance of faculty development cannot be overstated, for securing quality medicine and physician empowerment.This study was based on a survey conducted among physicians teaching at Israeli medical schools. The survey was conducted using an online questionnaire sent to clinical teachers according to lists received from the teaching units of the faculties, department heads, and other clinical teachers. Participation in the study was anonymous.Of 433 invited physicians, 245 (56%) from three departments  of four faculties of medicine in Israel, out of five total, completed the questionnaire. Only 35% of the physicians reported having received training for their role as teachers, most of these participated in a short course of up to 2 days. There were significant differences between the Technion and the other schools. Technion teachers without academic appointment had higher rates of pedagogic training. The same was true in regard to Technion teachers, either residents or young specialist. Significant gaps were reported between the content covered in the training and the topics the doctors felt they would want to learn. The clinicians who participated in the survey expressed that clinical teaching was less valued and more poorly remunerated than research, and that improved compensation and perceived appreciation would likely improve the quality of clinical teaching.Of the one-third of the physicians surveyed who had received some training in clinical teaching, the training was perceived as inadequate and not aligned with their needs. There was a significant difference in rates of pedagogic training between the Technion and other medical schools. In addition, most clinical teachers surveyed felt that teaching students is inadequately valued. Due to its focus on just three disciplines, and higher relative number participants from the Technion faculty of medicine, our survey may not fully represent the activities of the faculties of medicine in Israel. Nevertheless, given the importance of clinical teaching of medical students, our findings argue for increasing faculty development and educational training of physicians in clinical settings, for recognizing the importance of teaching in academic and professional promotion processes.The online version contains supplementary material available at 10.1186/s13584-021-00438-0. Beyond the role of clinician, a significant and integral part of a doctor’s profession is to teach, and to educate the next generation of doctors. The term “doctor” derives from the Latin word to teach, and the importance of teaching in medicine is featured even in the Hippocratic oath .High quality teaching is recognized as a precondition for quality medicine. Good clinical teachers  and the Comprehensive training of physicians as teachers, with an emphasis on professionalism and clinical teaching methods, is essential to faculty development programs , 9. The Despite the centrality of education in medicine, most teaching physicians do not receive sufficient training , 12 and Various models have been developed for improving teaching skills. These range from comprehensive programs over months or years, to short training courses of 1–3 days .These inMedical education in Israel has been evolving significantly in recent years –25, but In this context, we conducted a research project whose main purpose was to evaluate and characterize the perceptions of clinical teachers of medical students about the training they received in clinical teaching. The findings of our study should be used in planning the future of medical education in Israel.This study consisted of an online survey of physicians who are responsible for teaching medical students in in-hospital clinical clerkships in internal medicine, paediatrics, and obstetrics and gynaecology. Participants were identified based on recommendations from medical faculties’ clinical education units, heads of clinical departments and clinician educator colleagues. The survey aimed to assess the training the participants received to perform their roles as medical teachers, their perceptions of this training, and their attitudes toward teaching. The questionnaire included demographic information, 87 closed questions , and one open question. The data were analysed according to sub-populations, such as medical specialty, holders of an official academic appointment, and quantity of clinical and teaching experience. We focused on three disciplines and in-hospital teaching, as most teaching in Israel is still conducted in hospitals.The questionnaire was developed by the authors of this manuscript and is based on their experience in teaching, managing faculty educational systems, and running faculty development programs. The format is adapted from that of Foster et al. , as suitwww.jotform.com) and quantitative data processing was performed in SPSS v21 and Microsoft Excel 15.24. Tests of statistical significance included χ2, the one-sided t-test, and one-sided ANOVA as appropriate.Participation in the survey was anonymous and was preceded by each participant’s “signing” an online informed consent form. The questionnaire was built using Jotform  comparing rates of pedagogic training, content of training and the length.The study was planned as a survey and thus no primary outcome was defined for the purpose of calculating the number of participants required. The survey was open to respondents between June and December 2017.The study was carried out with the approval of the Ethics Committee for Social and Behavioural Sciences of the Technion, Israel Institute of Technology.p < 0.002). Eight doctors from Bar Ilan University Medical Faculty completed the questionnaire without knowing that their faculty refused to participate, and were subsequently removed from the analysis. Table Of the 433 physicians invited to participate in the survey 253 (58.4%) completed the questionnaire. The rate of participation in the survey out of those approached from the Technion faculty of medicine was 104/152 (68.4%) and from the other universities 149/281 (53%) reported receiving formal training as a teacher . In terms of the content of the training received, respondents reported more of a focus on Giving Feedback at the Technion than other schools , and Role Modeling , and less emphasis on teaching about Small Group Teaching . Statistically significant differences between the Technion and the other schools were not found regarding other topics of study.In regard to content of training, there were differences in responses between the Technion and the other schools amongst those who had undertaken educational training as reflected in the replies in the survey  were rated as having more influence in increasing motivation to teach than were external factors . This concurs with previous studies , 37, 38.The reported improvement in motivation following pedagogic training is an additional reason for medical schools to provide pedagogic training to their teaching staff. This suggests that tailoring training programs to the needs of clinician-teachers may further increase their motivation.As we observed, regardless of faculty development programs, self-confidence may be short-lived. This is because lack of investment in training and personal and professional development usually leads to burnout and loss of empathy and self-confidence .Participants’ perception that medical education is poorly recognized and remunerated is an important finding. Notably, such opinions did not vary by specialty, by educational or professional experience, or by academic appointment. Differences were found between medical schools in attitudes to the statement: “I believe that good teaching is appropriately recognized and rewarded”. However, we suppose that this is not a true finding, but rather represents sampling bias due to the low number of participants from two of the medical schools. The sentiments expressed by the survey participants seem to reflect a situation that has been previously described . SpecifiVarious methods have been described for encouraging and improving medical instruction. These include the establishment of academic advancement tracks on the basis of teaching and educational activity , the devResponses to the open question “What are the aspects of greatest importance in your opinion regarding the training of doctors for teaching in the clinical environment?” generally reflect responses to the Likert-scale questions, and strengthen the quantitative results. As noted, there was a tendency for junior and more experienced teachers to give qualitatively different responses. Veteran teachers commented more on systemic factors and more advanced aspects of medical education. In contrast, younger teachers expressed more basic needs, such as guidance in clerkship requirements, lesson planning and teaching methods. These results highlight young teachers’ struggles with even the most basic topics related to teaching, and stress the need for training before beginning their role as clinical teachers. This also underscores the changing needs of clinical teachers throughout their careers, and the need to adapt training to differing needs over the course of physicians’ careers.The methodology of this survey subjects it to potential sources of bias. No mechanism was implemented to secure equal representation of the participating medical schools. The were significant differences between the Technion and the other 3 universities in rates, length and content of pedagogic training. In the Technion many physicians with no academic appointment received short pedagogic training. These caveats aside, the data provide a basis for understanding the needs of clinical teachers in Israel. In light of reports of the inadequacy of training clinical teachers from other regions , 11–13, The findings of our survey should serve for planning the future of medical education in Israel. The major issues that should be addressed are inadequate training and the content of training, and the recognition and rewards of teaching medical students in academic promotion and in material benefits. These issues were also raised by the international committee which performed an external review of the medical schools in Israel in 2014   / similarly  / more poorly  rewarded and appreciated” by variables. Table S8. Representative examples of responses to the open question “What are the aspects of greatest importance in your opinion regarding the training of doctors for teaching in the clinical environment?” broadly categorized by theme. n = 126.Additional file 2.