Community participation is the core of sustainable tourism development; however, it encounters obstacles at government-controlled heritage sites in China. This paper examines the status quo of community participation and residents’ empowerment perception through 25 in-depth interviews and 168 questionnaires in the Miao ethnic heritage site of Xijiang Village in southwest China, the findings reveal that: (a) The phenomenon of disempowerment focuses on the political and economic aspects, rather than the social and psychological aspects; (b) Spatial difference affects empowerment perception; and (c) Residents desire more political and education empowerment. On this basis, the present research puts forward a comprehensive empowerment system consists of system, information, and education empowerment which contributes to the theorization of community empowerment between Chinese and Western scholars and provides an alternative path to sustainable tourism development for developing countries’ cultural heritage sites. Community participation is the key issue for tourism development of heritage sites and is a process that is vital to enhance long-term sustainable heritage management . The parIn recent years, most scholars have begun to pay attention to the specific issues of community tourism empowerment: the empowerment of vulnerable groups of women in the community ; the speHowever, community participation faces a variety of challenges in China, such as focus on economic interests, residents’ passive and ineffective participation, and the distribution of tourism profits and gains unfairly . These pAlthough the practice of community tourism empowerment in China has encountered many problems, it has still achieved positive impact on community participation and justice perception and promote the economic growth of heritage sites, which varies from the different management models and the state-owned private heritage management model has the highest performance . In ChinThe previous studies have innovated ways to achieve empowerment in tourism communities and paid special attention to system empowerment . Most stTherefore, the author believes that empowerment in tourism communities is a systematic project, which cannot be accomplished through a single method. It requires multilevel paths to achieve sustainable development of tourism empowerment. In order to effectively realize community participation, community empowerment must be carried out, especially, in western minority areas of China which are facing the reality of backward economic foundation, imperfect legal system, lack of democratic consciousness, and low quality of residents. The present research examines the status quo of community participation and explores the challenges and difficulties community empowerment has met in a government-controlled heritage site, Xijiang Miao Village, through the lens of both local and global tourism empowerment literature, as also as digs the reasons behind these obstacles deeply. With that, a reasonable and effective mechanism has been constructed to solve these problems in government-controlled heritage sites which is suit the Chinese situation.We hope to contribute to the literature on tourism community empowerment for government-controlled heritage sites in the following ways. First, our research reaffirms the significance of western empowerment theory, while suggesting a comprehensive framework based on the features of Chinese society, which helps to enrich the theoretical system of tourism community empowerment. At the same time, We puts forward a comprehensive empowerment system consists of system, information, and education empowerment, which contributes to the theorization of community empowerment between Chinese and Western scholars and provides an alternative path to sustainable tourism development for developing countries’ cultural heritage sites. Last but not least, based on the case of Xijiang, we not only put forward a specific path for the community tourism empowerment in Xijiang Miao Village, but also provide a choice way to develop tourism in similar tourism heritage sites.In the West, community empowerment theory is a result of the democratic political, economic, and cultural system, which advocates human rights, private property ownership, and stakeholder theory. However, the concept was amended in China due to the public land ownership system, weak democratic awareness and participation, and the lack of Non-Governmental Organizations NGOs; . It is dFirstly, the connotation of community empowerment differs. The western community tourism empowerment theory limits “empowerment “to “power” and “capability,” advocates the promotion of “power and capability” of community residents to participate in tourism through community empowerment, and defines this “power” as the improvement of “power” and “capability” of community residents . WesternSecondly, the object of empowerment is different. Western theory views individuals as participants in social organizations, fighting for personal right as the main method of community empowerment . HoweverFinally, there are various paths to realize community empowerment. Western scholars emphasize educational and informational empowerment , which iIt can be seen based on the above discussion: (1) Formulating right, power, capability, and interest into a four-in-one component system to differentiate the connotation of empowerment; (2) Incorporating empowerment framework of Xijiang Miao Village, locates in the Qiangdongnan Miao and Dong Autonomous Prefecture, Guizhou Province. The Miao, an ancient cultural group and now the fourth largest ethnic minority in China, lives primarily in the mountainous areas of Guizhou, Yunnan, Sichuan, and other provinces in the southwest. Some sub-groups of the Miao, most notably the Hmong, have migrated out of China into southeast Asia and other western countries. They have their own languages, religious beliefs, and other folks. As the largest Miao inhabited area in China, Xijiang village developed during the third migration of the Miao people and now has a history of about 2,000 years and 1,288 households with a total population of nearly 6,000 accounting for 98.5% Miao globally. It is the largest Miao majority region in the world. The entire Miao habitation was built in the mountains and along water with a magnificent view of layers of terraced buildings, the typical style of Miao architecture see . The setXijiang is an essential location to learn Miao history and experience Miao culture and scenery where the Miao culture is well preserved. For example, every year in the Miao calendar New Year will hold a long table banquet, a time-honored guest reception. It is reserved for special occasions, such as weddings, a baby’s first-month celebration, and important social activities among villages. At that time, each household brings out their tables and benches to be arranged in a stream on the village street, as well as provides their own hand-cooked food freely, sometimes stretching several 100 m. To the left is the host seat, while on the right is the guest seat, the host and guest sit opposite each other and sing to the wine. The host and guest are equal, and all the guests are treated equally see . Now, LoSince its inception, it has received considerable attention from the outside world. Looking from the history of tourism development in Xijiang Miao Village, it followed a typical government power intervention path. In the first stage, the village officials took the lead to develop tourism independently, while the government took over later on and formed a new pattern which comprises of the lead of government, the intervention of enterprises and community participation. In terms of operation and management, it seems to be commercialized. However, the “Scenic Authority” and “Scenery Development Company” are both established by the government. The local residents formed the defacto ownership of tourist resources by owning their dwellings and the right to use the surrounding land. However, due to the complex interests relationships, most community residents turned from support for tourism development in the early stage to complaint about its unfairness and it is getting worse.Xijiang Miao Village, as a typical heritage tourism destination in western ethnic areas of China, has strong representativeness in the process of interest conflict and empowerment perception. How to solve the interest conflict phenomenon of heritage tourism destination under the strong power of the government and build a harmonious and stable win-win interest mechanism are the common problems to be solved in the development of heritage tourism destination in western ethnic areas of China and other developing areas.To reduce the impact of common method variance, the research group conducted two-stages surveys. In order to make the interview more meaningful and realistic and provide basic guidance for the compilation of the survey items, the research team went through expert consultation and group discussion before the investigation from July 23 to 30, 2017, and further optimized interview subjects to eventually form the in-depth interview topics of involvement, impact of tourism development, awareness, and capability which in the following Since our research is funded by the National Social Science Project, the survey was welcomed and facilitated by the manager of Xijiang heritage tourism company and the “Guzangtou” who has no real power but is the informal spiritual leader of the Miao village. Our survey was led and translated by the “Guzangtou” since most interviewees cannot read or speak Mandarin. We obtained their consent orally to make sure they understood the survey was purely for research purposes, would not be released to any third-party, and conducted anonymously to protect their rights and privacy.Based on the in-depth interviews and predecessors’ research , a questWe used software SPSS 20.0 for mean and SD of the measurement items and Cronbach’s alpha indicator to test the reliability and validity of the survey. The overall Cronbach’s α coefficient was 0.8868, and the Cronbach’s α coefficients of economic, psychology, social, and political dimensions 0.8178, 0.8973, 0.9125, and 0.9198, respectively. Reliability is generally acceptable if Cronbach’s α coefficient value is greater than 0.7, high if greater than 0.9. The results of our survey are greater than 0.7 and close to 0.9 standard, indicating a high reliability.With the guidance of local village leaders and cadres, residents participated in tourism independently and autonomously. Constrained by underdeveloped infrastructure, local tourism evolved fairly slowly. In 2007, local government became fully involved in its tourism development and funded planning, infrastructure construction, marketing, and personnel training. It is undeniable that local tourism developed rapidly after governmental involvement. By 2017, the number of tourists had reached 7.5 million. There are currently more than 100 Miao restaurants, 500 hotels and inns, and 160 souvenir shops in Xijiang.Significantly, the government is the main investor, marketer, and manager at the same time in Xijiang. The tourism development company and the heritage site administration committee take charge of Xijiang’s tourism, which are set up by the government with the same staff. Therefore, the government takes care of all the issues of the development of the scenic spot and determines the development direction of the scenic spot. But the actual owners of the cultural and scenic capital of Xijiang are residents, so their ownership position has been taken away by the government.Their development goals and rights are not fully satisfied in three main ways. First, residents lost ownership of their land due to the mandatory land transfer system. In order to expand the commercial space within the heritage site, the management company, in the name of government, forced the requisition of several acres of fertile land along the Baishui River (the main river channel in Xijiang), and they converted it into commercial buildings for rental and tax purposes . High prSecond, residents have little access to information and few rights to express themselves. During the development, all information related to planning, construction, financing, and personnel are completely closed to the community. Even income distribution is formulated by the government without notice. Finally, residents’ right to education is not well-protected either. Training and education are important guarantees for the development rights of community residents; however, survey statistics show that 60% of interviewees only have primary and secondary education and that 80% of villagers do not directly participate in tourism management or service work. As the residents say:“Can we have any opinions on the scenic spot? Even if we do, who can we report to and who will listen to us?”—(Pingzhai-05).“Let the local people participate in the management of our scenic area? Why should they be involved? Do they understand heritage protection? Do they understand how to promote the scenic area?”—(Admin-02).These statements coincide with arguments of The research on the perception of political empowerment further confirms this problem, which results show that community organization participation contributes the most to political empowerment perception, while limited opportunity to participate in decision-making is the biggest obstacle for empowerment in all four villages . In geneBased on a comprehensive analysis of interview and survey results, the study found that the more residents are dependent on the tourism economy and exposed to the outside world, the more they know about their rights and thus have more conflicts with the government. On the contrary, the less participation and access to information, the less the conflicts with the government. Ironically, this situation makes them believe that they have higher political empowerment.Xijiang residents profited more following the increase in tourism. There are mainly four ways to make money: (1) Independent investment and operation: residents use their own property to run ethnic restaurants, inns, stores, etc.; (2) Rental: most residents rent their property to tourists for accommodation due to a lack of funds and skills to produce other revenue; (3) Selling local products and ethnic handicrafts such as Miao medicine, embroidery, silverware, etc.; and (4) Participating in labor-intensive services, such as song and dance performances, cleaning, car battery transportation, etc.However, conflicts appear gradually accompanied by the distribution of interests. As the government is not an “economic entity” in a complete sense, it needs financial support to achieve some of its political goals. Hence, it is inevitable that the government fights with community residents for economic resources.For example, the government claimed that it stipulated the cost of infrastructure construction and marketing expenses for the development of scenic spot, so most of the ticket income (90%) is obtained by the scenic spot management company on behalf of the government, while only 10% of the profit went to the residents in the form of a completed heritage preservation project. What is more serious is that residents have very little agency in the way of income distribution, which will certainly arouse the dissatisfaction of the community residents. Just like the residents say:“We do have better income and better living standard than before. We receive thousands of RMB Yuans each year from the government, but most of the money is earned by the outside business owners. My family only collects some rent every year.”—(Dong Yin-04).“Yes, we can make more money than just working in the farm in the past. But our family is on the mountain, the business is only good on holidays and during July and August. We can make more money during these times but the business is much worse at other times. The outside business owners are not willing to rent our house.”—(Yangpai-03).Local residents gain continuous economic benefits from tourism industry and their living standards are significantly improved. But they have obtained only a small amount of unstable income while community elites, foreign tourism developers, and local governments have obtained most of the benefits. This phenomenon is the economic disempowerment described by Even with the internal and external conflicts of interests, most respondents agree that tourism development in Xijiang has brought real benefits to the local community, such as increased income, more job opportunities, and better standards of living .A phenomenon worthy of attention is that compared to Pingzhai and Dongyin Villages which are closer to the core tourism area, Nangui Village and Yangpai Village have relatively lower perceptions of economic empowerment. But Pingzhai and Dongyin benefit more due to their advantageous location. In this case, spatial differences influence residents’ perception of economic empowerment, but behind the scenes, the imbalanced income distribution system is key.The social empowerment in tourism is realized when tourism maintains or improves the balance of the local community; when individuals and families work together to build a successful tourism company and the degree of integration of the community is improved; when partial tourism proceeds are used on community development . TourismNevertheless, most touristic activities happen along the main street of the most scenic area in the region. Thus, the two villages in the core area, Pingzhai and Dongyin, have increased chances to receive tourists, while the other two villages, Nangui and Yangpai, have less opportunities see . For exa“We are old and we are female. We sweep the streets for living. Most of the time we sell things here. The money is definitely less, but we can only do this!”—(Yangpai-05).“We have more income and better living standard than before, but the relationship between relatives and neighbors is not as good as it used to be. We used to practice Long Table Banquets in the stockades before. It was not for outsiders. It is for our a good relationship. Now everyone is money-driven and often quarreled.”—(Nangui-04).As indicated in “Who would have known in the past that we will engage in tourism in this place. Some of them (tourists) like our shabby houses. We must thank the government for developing tourism!”—(Pingzhai-03).“There are more time to dance and sing, and host festivals. People outside like to watch us dance and hear us sing. We also like it.”—(Dongyin-05).Every informant confirmed that with the increase of family income and the improvement of living standards, residents’ self-confidence in the future was strengthened. According to They actively seek various education and training programs to increase employment opportunities. In the process of tourism development, local women gained more income from tourism development than traditional agriculture and demonstrated their capabilities by participating in singing or dancing performances. Thus, their family status has also been improved.From the above analysis, Xijiang Miao Village, as a typical government-controlled ethnic heritage site in western China, manifests the features of compulsory government-led tourism development. The results for field research demonstrated that: (1) The disempowerment phenomenon concentrate on the political and economic aspects not on social and psychological aspects. Most interviewees showed great respect of local culture and satisfaction of their job arrangements in the administration bureau, and they has shared the economic benefits and improved living standards through tourism development, but complaints about imbalanced interests distribution still exist and the lack of political participation has become the biggest obstacle to the empowerment of residents’ communities. (2) Spatial difference affects the degree of participation and further influence empowerment perception. Pingzhai and Dongyin Villages, which are closer to the main street and have more opportunities to participate in the tourism development, have a lower perception of political empowerment, while have higher economical, social, and psychological empowerment perception, but it does not work in the villages of Nangui and Yangpai. (3) Residents desire more political and education empowerment. Residents’ weaker perception of political empowerment reflects the potential growth and necessity of political empowerment in government-controlled heritage sites like Xijiang Miao Village. This shows a stronger desire for political empowerment in villages that are more economically active, while education empowerment is the fundamental way to achieve it.Such research conclusions have been drawn in other similar settings, Studies and practices have proved the importance of taking residents’ will and interest into consideration during tourism development in ethnic areas . The curXijiang Miao Village demonstrates the common phenomenon that many ethnic heritage sites in western China face. With the development of tourism, the economic, social, and psychological empowerment of community residents has been realized partly, but this kind of government-led top-down mandatory supply system of tourism empowerment has not fundamentally solved the contradictions in the process of community tourism development in ethnic areas. From the case of tourism empowerment in the Xijiang Miao village, we have found a path to from the contents to achieve “empowerment” in the community, that is, to achieve political empowerment from institutional empowerment and to achieve autonomous empowerment through education empowerment and information empowerment.In recent years, Chinese scholars have also explored the reasons for the failure of community participation in China from the perspective of laws and regulations, and they have proposed a basic path for system empowerment. It is apparent that current laws and regulations fail to ensure the right to community participation and cannot define, regulated or protect it . HoweverFirst of all, land ownership reform is the foundation of system empowerment. In recent years, the survival and livelihood of farmers who have lost land due to tourism development have been a matter of common concern for the Chinese government. Some experts and scholars advocate returning land ownership to farmers; that is, privatizing the land . HoweverWhat is more, property laws governing tourist attraction should be promulgated. Research has found that there were two basic interest conflicts between community residents, governments, and outside developers: under-compensated land price and deliberately neglected compensation of future gain of assets during the land transfer process . In XijiLast but not least, a mutual benefit mechanism between local residents and developers should be established in any land management system. In the existing way of tourism development, land is often purchased or rent by outside investors at one time to obtain more long-term profits. It is neither fair nor sustainable for developers to benefit the most while residents receive only limited rent from land-leasing. The biggest dissatisfaction among the community residents where we surveyed is the profit imbalance. It is not poverty but inequality that caused sharp conflicts in community tourism development.Thus, instead of renting or transferring their land, community residents should invest their land in the tourism industry for future gains which the innovative forms of land transfer are also the guidance of government. The use of land shares is a new and effective, yet rarely adopted, method to resolve conflicts of interest in land transfer which allows residents to lease their land to enterprises and also to invest their property—with tourist attractions attached to that land—into the share capital of the enterprises.In that case, community residents can obtain stable income as well as dividends from the development of the heritage site according to the number of shares converted from tourist attractions. Besides, as a shareholder of the tourism enterprise, community residents can also exercise real rights to participate in tourism development, such as planning, decision-making, and management of tourism areas.Information is the key to navigating decision-making among various stakeholders. Information asymmetry is the leading cause of the tragedy of the commons. Under the influence of a planned economy, with its policies and bureaucracy, local governments avoid informing local residents of their decisions in case any unpredictable incidents will jeopardize upcoming investments. Although China has achieved rapid development during economic transition, democratization, and civil rights awareness have not yet reached the same level.The lack of a communication platform and mechanism puts residents in a vulnerable position. In order to change that, the government should first recognize residents as the main body of tourism development and increase their self-awareness. It is the government’s responsibility to initiate effective communication and truly benefit local people instead of taking advantage of them. Next, the government needs to set up a long-term mechanism for information disclosure on tourism development which specifies the time, periodicity, and content of information to be released. Finally, a platform for information exchange and communication should be built; for example, the village committee or tourism professional associations could act as liaisons so that information related to tourism development can be delivered to each community inhabitant.In the survey data from Xijiang Miao Village, family income and community tourism participation are positively related to education level. Households that have received junior high school education and above have a higher family income and more members participating in community tourism than those who only have junior high degrees or below. It is helpful for residents to obtain more information, but this requires residents do have awareness of their rights and the ability to fight for them. Thus, education empowerment is extremely important to realize that.Education empowerment includes three components. At first, community residents must improve their legal awareness to understand national policies on land expropriation, resources protection, and traditional culture protection. Then, modern tourists have an ever-increasing higher demand of quality from tourism professionals, which stimulate the community residents to improve their operating abilities, management abilities, and service skills. In Western developed countries, third-party civic organizations take charge of the educational and training functions for most community residents. However, in China, these organizations develop relatively slowly and lack the necessary financial support due to constraints of the social system. Therefore, it is the governments’ responsibility and obligation to provide education and professional skill training. Local governments should allocate a proportion from tourist gains to provide education and training or establish a special training fund for this purpose.In the end, abundant cultural practices in heritage sites in western China have become important tourist attractions, such as folk songs and dances, arts, and crafts. Local governments should also allocate special funds to educate and train residents to maintain craftsmanship in the intangible cultural heritage of these peoples, such as certifying inheritors of non-material cultural heritage and providing training on cultural heritage inheritance education, especially to the younger generation so that they find confidence and recognition from their own culture. Additionally, local governments in ethnic regions should strengthen cooperation with tourism colleges and research institutions. In that case, colleges and research institutions find research places, and the voluntary lectures of experts and students’ internships in the community can greatly improve the residents’ awareness of their rights and ability to participate in local tourism development.This work measures the residents’ empowerment of power in social, political, and other aspects from the perspective of psychological perception. However, the means and methods of measurement have certain limitations, which cannot relieve the influence of cultural traditions and individual differences, and the source of analysis and conclusions of the Chinese political framework will inevitably lack rigor.In the course of the study, we also found that the degree of tourism participation is different from the occupations of residents, and then the perception of residents’ empowerment varies. In the future, we can further study the differences in the perception of empowerment and government satisfaction in different professions.Obviously, it is not possible for community residents alone to realize true empowerment in government-controlled heritage sites. So combine the research results and previous studies, this paper forms a comprehensive empowerment system consists of system, information, and education empowerment. The core components of system empowerment are reform of collective land ownership, the land leasing system, and property rights law. Additionally, we need to establish a mechanism and platform for residents to express themselves, discuss tourism related affairs, exchange information, and access policy announcements. Education empowerment is equally important which improve their capability to become fully engaged in tourism.This research reaffirms the significance of western empowerment theory, while suggesting alterations should be made based on the features of Chinese society. The implication from the Xijiang case is thus meaningful and can be replicated at many other government-controlled heritage sites.The original contributions presented in the study are included in the article/supplementary material, further inquiries can be directed to the corresponding author.The studies involving human participants were reviewed and approved by the Academic Committee of Guizhou University of Finance and Economics. Written informed consent to participate in this study was provided by the participants’ legal guardian/next of kin. Written informed consent was obtained from the individual(s) for the publication of any identifiable images or data included in this article.BH conceived the research and wrote the original draft. FH participated in the revision of the manuscript. LH collated the data. All authors contributed to the article and approved the submitted version.This research was funded by China National Social Science Fund Project (17BMZ130) and Graduate Project of Guizhou University of Finance and Economics (2020ZXSY24).The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.All claims expressed in this article are solely those of the authors and do not necessarily represent those of their affiliated organizations, or those of the publisher, the editors and the reviewers. Any product that may be evaluated in this article, or claim that may be made by its manufacturer, is not guaranteed or endorsed by the publisher.


The Non-Pneumatic Anti-Shock Garment (NASG) is a first aid tool that can halt and reverse hypovolemic shock secondary to obstetric hemorrhage. The World Health Organization recommended the NASG for use as a temporizing measure in 2012, but uptake of the recommendation has been slow, partially because operational experience is limited. The study is a process evaluation of the introduction of NASG in a public sector health facility network in rural Zimbabwe utilizing an adapted RE-AIM, categorizing observations into the domains of: reach, effectiveness, adoption, implementation and maintenance. The location of the study was Hurungwe district, where staff members of 34 health facilities at primary (31), secondary (2) and tertiary (1) levels of care participated. We found that all facilities became skilled in using the NASG, and that the NASG was used in 10 of 11 instances of severe hemorrhage. In the cases of hypovolemic shock where the NASG was used, there were no maternal deaths and no extreme adverse outcomes related to obstetric hemorrhage in the study period. Among the 10 NASG uses, the garment was used correctly in each case. Fidelity to processes was high, especially in regard to training and cascading skills, but revisions of the NASG rotation and replacement operating procedures were required to keep clean garments stocked. Clinical documentation was also a key challenge. NASG introduction dovetailed very well with pre-existing systems for obstetric emergency response, and improved clinical outcomes. Scale-up of the NASG in the Zimbabwean public health system can be undertaken with careful attention to mentorship, drills, documentation and logistics. Preventable maternal death remains a seemingly intractable problem globally, despite availability of a wide spectrum of interventions to address the key drivers in maternal mortality, including obstetric hemorrhage (OH), one of the most common causes of maternal mortality in the world . In 2019Encouraging facility deliveries has been a mainstay of the global strategy to reduce maternal mortality, which Zimbabwe has promoted. While there has been a notable increase in deliveries occurring in health facilities in Zimbabwe, from 65% in 2011 to 85% in 2019 . OH in pThe lens of the “three delays” provides insight by sorting obstacles in access to emergency obstetric care into three categories; 1) time taken in deciding to seek appropriate medical help for an obstetric emergency, 2) time taken in reaching an appropriate obstetric facility, and 3) time taken in receiving adequate care when a facility is reached . In ZimbThe Non-Pneumatic Anti-Shock Garment (NASG) is a first aid tool that can halt and reverse hypovolemic shock secondary to OH. NASG is a lightweight compression wrap that is reusable and reasonably simple to apply, making it quite suitable for low-resource settings. While the NASG alone is not a treatment for OH, it buys essential time to transport a woman to a facility that can provide the services she needs, and within facilities that can provide those services, to assure that adequate time is available to prepare and deliver life-saving obstetric emergency care.Numerous studies have shown the clinical effectiveness of NASG in reducing blood loss, improving recovery time from shock, decreasing mortality, and reducing incidence of extreme adverse outcomes (EAOs) –10. In 2Once an intervention is shown to have efficacy, cost is one of the next factors given priority for evaluation. Use of the NASG in management of hypovolemic shock secondary to OH has been shown to reduce poor clinical outcomes, but also to be highly cost-effective . “Cost-eIn order to better translate the clinical and economic evidence supporting the NASG into practical action in the public health system of a lower income country, the NASG was introduced in a naturalistic setting and the process was documented through a multi-dimensional evaluation, including incremental costs associated with the introduction. Private sector, for-profit facilities were not included in the evaluation because their experiences were not seen as directly relevant to questions about how the public health system in Zimbabwe could fare in introducing the NASG.The Institutional Review Board of The Medical Research Council of Zimbabwe approved this study in December 2018. The approval number is: MRCZ/A/2400. Written informed consent was obtained from participating health workers and oral informed consent was obtained from participating patients. This decision was made in collaboration with the Medical Research Council of Zimbabwe. Two key points considered were: 1) Hypovolemic Shock from obstetric hemorrhage is a medical emergency that requires fast action to save lives. In that context, obtaining written consent seemed like a potential risk to safety of patients; 2) the Medical Research Council of Zimbabwe had prior positive experience with the NASG randomized control trial in Zimbabwe, where verbal consent using a very similar script was obtained from enrolled patients.This was an observational study to evaluate the process of incorporating the NASG into the obstetric emergency response within the Zimbabwe public health system using an explicit implementation strategy. Study sites were facilities within a discrete geographical area of Zimbabwe, comprising the public health system of Hurungwe Province and its referral hospital in the adjacent district. The study was conducted prior to national introduction of NASG, with the intent of providing operational guidance for future policy and program planning. Data collection was aligned to the RE-AIM framework, looking at the process of the intervention in terms of its reach, effectiveness, adoption, implementation and maintenance .Originally presented in 1999, the RE-AIM framework organizes evaluation into five domains, which, examined together, estimate an intervention’s public health impact . While iIn consultation with government stakeholders, Hurungwe District of Mashonaland West Province in north central Zimbabwe, bordering Zambia, was selected for this process evaluation. Reasons for this choice were multi-factorial, including non-urban or peri-urban setting, relative lack of implementation partners, burden of maternal morbidity and mortality, and feasibility of access by road. Hurungwe, with a population of 358,000, is a predominantly rural district in the province; 92% of people reside in rural settings where in general, only primary care is accessed. 13,674 births were reported in Hurungwe district in 2018. Of the 13,476 live births reported, 93.3% were institutional, the largest proportion of which (41.4%) were conducted at primary care facilities; 34.1% of facility births occurred at district and mission hospitals, 11.3% at rural health centers, and 13.1% at rural hospitals. Staff from the provincial health administration, Hurungwe District health management staff and those providing obstetric care at the primary, secondary and tertiary levels participated in the process evaluation. NASG was introduced for use in 34 health facilities: 1 tertiary level, 2 secondary, and 31 primary level facilities. The study area is depicted in the map displayed in Over the course of three months, NASG was introduced into Hurungwe District through didactic and practical training in a ‘training of trainers’ style, where NASG trainers from the study team trained selected health workers from the participating facilities, and those trainees were expected to cascade NASG knowledge to co-workers at their facilities. The training demonstrated the use of the NASG, the theory behind it, and the necessary steps to introduce it, including how to fill in the study-specific OH case and transfer form, and data and logistics registers. Deployment of NASGs and data and logistics tools was done at the time of the training. For the remainder of the study period, participants were followed up at their facilities. Further, mentorship was delivered through a pre-existing provincial-district level supportive supervisory program. During those visits, NASG skills were observed in health workers through simulated obstetric hemorrhage response, data collection tools were reviewed, mentorship was provided, and informal qualitative feedback from health workers who were trained in NASG. Answers and comments from the health workers were recorded on supervisory visit forms.Non-medical janitorial staff were also selected to receive training in cleaning and storage of the garments; their role in successful incorporation of the NASG into obstetric emergency response was critical, as the logistics of cleaning, rotating, and tracking garments was paramount to its success in a clinical network. Standard operating procedures for emergency transport and NASG logistics were developed by District staff, supported by the research team. Availability of ambulances, informal arrangements for emergency transport, contact phone numbers and suggested troubleshooting were assessed and mapped in the referral tree of District facilities.All data collection was paper-based and done continuously throughout the three-month period, from 7 January 2019 to 31 March 2019. To capture as much detail about how the district system responded to OH after NASG introduction, each case of OH presenting to participating facilities was documented, regardless of whether hypovolemic shock developed from the OH, or whether the NASG was used as part of treatment. In addition to clinical details, communication and transportation details were documented: which facility was called at what time, and how long it took for transport to arrive once called.Other data was collected through NASG logs and clinical registers, and through documentation of supportive supervision that assessed retention and feedback of NASG skills among facility workers. Supportive supervisory visits were conducted by two District clinical supervisors, who were accompanied by two midwives on the study team who are NASG trainers. The pairings were not always the same, and the four debriefed on the findings of each supervisory visit, in order to minimize interobserver variation. In addition to assessing NASG skills, District supervisors also collected informal qualitative data, asking open-ended questions during visits, and recording some comments health workers made about the experience of learning how to use NASG and incorporating it into their pre-existing obstetric emergency response protocols. This einfomral qualitative data was collected from health workers who were trained, regardless of whether or not they had used NASG clinically yet. Clinical registers were augmented by study-specific forms to document clinical details of obstetric hemorrhage cases, such as estimated blood loss, signs of hypovolemic shock, treatments provided, if NASG was applied, if applied when and where removed, and clinical outcomes, such as shock recovery. Incremental costing was done through monitoring of expenses related to NASG introduction, including district sensitization, NASG and sundries procurements, service provider training, as well as post training follow up and supportive supervision visits.Reach, or penetration of the intervention within the study area, had two key aspects in this study: saturation of NASG skills and units throughout the district, and clinical use of the NASG. Saturation of NASG and skills for its use among the participating facilities was impressive, with 100% of participating facilities demonstrating both basic command of NASG use and cascaded training on the NASG to providers who did not attend the NASG introduction training. This aspect of reach is also represented by distribution of the garments within the district network: 9 garments to the tertiary care referral hospital, 6 each to the two secondary care hospitals, and 3 each to 2 rural hospitals and 29 rural primary health facilities. Numbers of garments at the higher level facilities had to be adjusted up soon after introduction, after it became clear to staff at those facilities that the NASG was as useful internally in both comprehensive and basic emergency obstetric care facilities as for facilities referring patients up, given the high volume of deliveries, inward referrals, and utility of the NASG to stabilize a woman while preparing for definitive treatment made.Reach was also assessed through the lens of NASG availability, accessibility and equity. Availability of the NASG in the selected facilities ensured that the intervention was an option for the women who may have needed it during the study period. Access to the intervention was assured by the availability of service providers skilled in use of the NASG in all the participating facilities. One detractor to this aspect of reach was that, due to scheduling conflicts, the intervention commenced two weeks later at the tertiary facility than at the rest of the participating facilities, which was consequential in terms of OH response at that facility during the lag period. Equity in access to the NASG was achieved by the high level of reach of the NASG. To increase equity and offset the unpredictable nature of OH, the NASG was availed to all participating facilities, regardless of volume of births occurring at the facility, so that the intervention was available for all women who needed it, regardless of the social context or geographic location of the woman or facility within the catchment area.When examining reach of the NASG as evidenced by appropriate clinical application, the results were promising but less universal. Among the 11 cases of hypovolemic shock that were reported during the study, the NASG was applied in 10 cases. The case where NASG was not used, despite documented hypovolemic shock secondary to OH, occurred at a referral level facility. Nonuse of the NASG at that facility may have resulted from the impression that the NASG could only be used for stabilization in preparation for and during transport, applied at facilities where the needed definitive treatment was not available. This scenario for use was emphasized during NASG training, to highlight that the NASG is a first aid device useful while transferring patients from lower to higher levels of care. The case of nonuse suggests a need to clarify the utility of applying the NASG as a clinical management tool in any facility, regardless of patient transfer, to gain time to prepare for and deliver definitive treatment, facilitating a quick recovery from shock. The types of OH that led to the NASG uses, shown in One finding of interest related to the clinical use aspect of reach related to the observed incidence of OH. While the true rate of OH in Hurungwe District is unknown, estimation of the anticipated number of OH cases was made using reported rates from the global literature alongside 2018 Hurungwe statistics. This led to an estimation that 69 cases of OH were anticipated to occur during the study period, with approximately 15% progressing to hypovolemic shock. During the study, 78 cases of OH did occur, 113% of the anticipated total, with 14, 17.9% of them resulting in documented hypovolemic shock. A caveat to note is that there were 3 OH cases that were not documented as hypovolemic shock, but were flagged by clinical reviewers as potentially undiagnosed shock cases. If those 3 cases were indeed hypovolemic shock, the rate would have been 21.7%. These figures contribute to and help validate current thinking about estimation of OH in resource-constrained settings.The 3 cases of potentially undiagnosed hypovolemic shock mentioned above received definitive treatment at the facilities without the benefit of NASG application, and all three women recovered. These potential NASG cases received surgical care to arrest hemorrhage immediately without the NASG and were referred or managed post operatively without the NASG. This finding indicates the need to strengthen identification of early signs of hypovolemic shock. Since hypovolemic shock was not diagnosed in those three cases of potentially missed opportunities for NASG, not using the NASG in those cases technically was appropriate. While staff at rural facilities did use NASG for stabilization during transfer, the district hospital did not use NASG in one case where it would have been appropriate while preparing for definitive care within the hospital, indicating the need to reinforce use of the NASG within a facility at referral level.In two of the NASG cases, women received definitive treatment, but the management was varied, providing insight into the contextual importance of NASG. In one case, the NASG was applied and treatment given, but there was also need for blood transfusion. Due to lack of availability of blood, the woman was managed with hematinic medication in the intensive care unit while wrapped in a NASG, until she became stable. In a similar case at secondary level, stabilizing treatment was provided, and the patient was referred to the next level for blood transfusion after removal of the NASG.Effectiveness, as defined for the NASG introduction to Hurungwe District, is measured by the number of maternal deaths or extreme adverse outcomes (EAO), including emergency hysterectomy, and organ failure. Based on 2018 data from Hurungwe District, 3–4 EAO secondary to OH and 2–3 maternal deaths from OH were anticipated. Among the 10 of 11 hypovolemic shock cases where a NASG was utilized, all were cases in which NASG was used appropriately, resulting in zero deaths or EAO. With correct clinical use, zero mortality and zero other EAO, effectiveness as defined in the RE-AIM framework for this process evaluation was high.The estimate of expected all-cause maternal death during the study period, was 4–5. During the same time period in the year prior to the study, six maternal deaths, three of which were from PPH were reported in Hurungwe; during the study period after NASG was introduced, there were no deaths from OH. This analysis excludes maternal deaths that occurred at the tertiary hospital during the two-week period in January 2019 when NASG had been introduced to participating Hurungwe facilities, but not yet introduced to the tertiary facility. Two of the maternal deaths from the tertiary hospital that occurred in that time period were attributed to PPH, and therefore may have been averted if introduction of the NASG had been done at the same time for all participating facilities. After NASG was introduced in all participating facilities, there were two maternal deaths before the end of the study period, both from indirect causes. Perspectives of participating health workers were also considered as a reflection of effectiveness, because without acceptance of the new tool it will not be used, in which case it could not be considered effective. Overwhelmingly, the comments by health workers made and documented during supervisory visits were positive, and reflected appreciation of how practical the NASG can be. Not all feedback was without concern, however. One health worker expressed doubt that everyone would remember the correct way to apply the NASG, mentioning that it would be difficult for everyone to apply it, “without forgetting to do a snap test.” Another nurse was concerned about, “lack of knowledge to those not trained, especially at a hospital with a big number of staff. Also, it is a challenge to apply the NASG when you are alone.”Positive feedback was more common. One nurse from a primary level rural facility pointed out that the NASG doesn’t interact with drugs, and “has no after effects as long as it is used on the right patient at the right time.” Another expressed commitment to exploit the stabilizing effects of the NASG while preparing treatment: “NASG is a first priority before giving all other required medicine, soon after quick check and observations; it’s one of the major devices for preventing shock.” Another nurse recognized the potential impact of expanding availability of NASG: “My hope is for NASGs to start from the village to prevent maternal death.”All levels of care used the garment at least once during the study, however, due to the limited timeframe, not all of the 34 facilities demonstrated clinical use of the garment. However, through mentorship visits, all facilities demonstrated NASG integration into OH response planning. Among the 10 NASG uses that occurred during the study period, the garment was used correctly in each case.Among providers, the commitment to incorporating the NASG, regardless of whether it had been used in obstetric emergency response yet, was evident. One primary care nurse from a rural health center that did use the NASG commented that, “the NASG can be applied by anyone as long as they are trained on how to do it correctly. OH is not easy to predict. NASGs being applied early leads to the best outcomes.”High fidelity to implementation plans was observed overall, especially in terms of training workers from all cadres involved in a range of service delivery, including anesthesiologists, drivers and cleaning staff. The most challenging points in implementation were related to operational issues: access to emergency transport for women in shock and logistics for NASG replacement. The approach to introduction of the NASG involved allowing the health workers themselves to create the networking procedures such as how to secure transport, who to call for referrals and garment replacement. For example, the NASG rotation and replacement system was established by the District administrative and health worker team, making plans that they felt would work best in their practice environment. The standard procedure as planned was for the replacement NASG to be sent in the ambulance that collected the patient from the basic emergency obstetric and newborn care (BEmONC) facility, through communication between the nurse managers of the Maternity Wards. The practical experience proved that these procedures were difficult to adhere to, and required ad hoc adjustments. Qualitative feedback during supervisory visits highlighted transport access issues related to shortages of vehicles and fuel availability, but rather than referring to those factors as implementation challenges, providers referred to those chronic challenges as motivational factors to incorporate use of the NASG to buy time to execute a safe emergency transport. One health worker talked about how incorporating NASG allows less skilled workers to assist in immediate response to a patient who has gone into hypovolemic shock from obstetric hemorrhage: “it can be used by any other staff available at the facility who are trained to use it, as compared to drug administration which can only be done by a nurse or doctor.” Another primary level provider alluded to utility of NASG while arranging referrals, remarking: “A NASG is an effective device at grass root level that can be used while awaiting further management of patient to a higher level of care.” None of the implementation challenges were out of the ordinary for the introduction of a new tool that required a coordinated network of providers.Despite the brevity of the study period, important signals related to maintenance of the NASG were clear. For example, use of the NASG was formally integrated into the District PPH management package, both in policy and in practice. One NASG was dedicated to the PPH management emergency kits at all facilities. Similarly, NASG was integrated into the antenatal health education sessions as a topic, promoting acceptance and longevity of NASG use by familiarizing all users of maternal services in Hurungwe District with its appearance and purpose.NASG logbooks remained available and filled in at facilities. The standard referral forms were easily annotated to include NASG information in lieu of the separate OH case and transfer form created for use in the process evaluation. Most facilities conducted in-service training on the NASG for their co-workers, adding 127 trained workers to the 119 trained through the introduction sessions, more than doubling the NASG-skilled workforce through cascade learning.Through pre-existing district mentorship and supportive supervision, OH response drills that include NASG application became regular practice sessions, both reinforcing skills, teamwork, and extending capacity. Additionally, a mission hospital, one of the secondary care facilities and the only non-government facility in the study, took the initiative to plan for training and equipping a remote clinic that refers in to their hospital with NASG training and garments. This is a clinic which is outside of Hurungwe District, but from which the hospital receives most of their OH clients. The long distance and poor roads between these two facilities resulted in six-hour referral times, thus the need for the NASG was critical and was proactively addressed by this participating facility.The maintenance costs were also encouraging. The price of the garments used in the introduction was far lower than in previous years, while the quality of garment is greatly improved, allowing for 144 washes without loss of compression. The budgetary needs for replacing garments in the district were therefore quite low . Cost ofDemonstration and evaluation of the process the national health system of a low-income country would need to undertake in order to avail the proven clinical and economic benefits of the NASG has been missing in the global literature. Evidence from controlled study environments, taking place in largely urban areas, has not been intended to provide insight into introduction of NASG in real-world low- and middle-income public health systems settings, rather, these efforts were more focused on the previous step, showing that NASG is efficacious and valuable clinically and is cost-effective –10. DocuBecause use of NASG mostly involved referral of a patient to another facility, the need to replace used NASGs at the facility where it was applied brought to light the common difficulty of providers from different facilities being able to exchange material goods. While the ideal protocol, as laid out by the participating providers, was to have a clean NASG on the ambulance to give to the referring facility when the patient in a NASG was picked up, the reality was that ambulances and fuel were in short supply. Often relatives secured private transport in lieu of continuing to wait hours for the ambulance to arrive, or ambulances may come from another call, without the opportunity to pick up the replacement NASG from the referral facility first. It is also possible that being early on the learning curve of NASG incorporation, practical solutions, such as having a clean NASG aboard every ambulance, did not have time to gain traction. Flow of the NASG between Departments in the tertiary care Provincial Hospital was another difficulty noted. It became clear that wider sensitization, among many wards within the hospital, was needed to ensure that garments did not become lost. We did not observe any NASG replacement difficulty related to a sense of ownership of garments; each NASG was labeled with a provincial ID number, which was used in the NASG logbooks to indicate intake and outflow of each individual garment.Another important lessoned learned was that as much as NASG proved very useful in buying time to wait for emergency transport that was difficult to obtain in the study area, there were at least two NASG uses where life-saving time was provided by the NASG while access to definitive treatment, in these cases, blood transfusion, was secured. Non-application of the NASG in preparation for surgical or medical intervention at the tertiary facility as well as varied use of the NASG as a management tool in cases where the definitive treatment was provided in phases, suggested a gap in the appropriate use of the NASG. While the application of NASG to patient in need of treatment only available elsewhere was consistent, only one facility demonstrated use of NASG when definitive treatment was available on site, and referral of the patient was not expected. Further, it is notable that in no case was the NASG removed before definitive treatment for the OH was provided and the patient was stable as per NASG removal clinical guidance.The incremental costs associated with NASG introduction were modest and affordable with respect to the District health budget. However, it was noted that the cost of introduction of the NASG was interrelated with the health system’s strength in the sense that where basic commodities for obstetric service delivery, such as blood pressure cuffs or cleaning supplies were lacking, the cost of introduction increased.The way health workers embraced integration of the NASG into their emergency response standard operating procedures, both in preparation and practice, indicated a clear understanding of the theory behind NASG use, and increased the likelihood that the intervention would become normalized in obstetric practice. The improved clinical outcomes observed during the study period further confirmed this assertion. No resistance to use of the NASG from managers or frontline health workers was apparent.This process evaluation had several limitations to note. Due to the brief time period of the study, the public health impact score of NASG introduction could not be calculated as proposed in the original RE-AIM evaluation model. Duration of 6 to 12 months is recommended before calculating public health impact score, which is the product of the five RE-AIM dimensions . The durIn the first process evaluation of NASG introduction to a natural public health setting in rural Zimbabwe, it was found that in the domains of reach, effectiveness, adoption, implementation, and maintenance, NASG introduction dovetailed very well with pre-existing systems for obstetric emergency response, and improved clinical outcomes for women who suffered from hypovolemic shock secondary to OH. Uptake of NASG was nearly universal and feedback from trained health workers was positive. Further, the cost of introduction was affordable, despite the need for extra expenditure on basic commodities used in delivery of all obstetric care. Scale-up of the NASG in the Zimbabwe public health system can be undertaken with careful attention to buttressing systems such as mentorship, drills, documentation and logistics.S1 Fig(JPG)Click here for additional data file.S1 Data(XLSX)Click here for additional data file.


The relationship between environmental regulation, technology spillover, and economic performance has been the subject of intense scholarly debate in environmental economics for many years. The famous Porter hypothesis states that environmental regulation promotes both the economic performance and the environmental performance of corporations. However, the existing literature has paid relatively little attention to micro-level research and spatial spillover effects. This article endeavors to fill this gap by an empirical analysis of a sample of 900 of China’s heavily polluting listed corporations for the period of 2013–2016. By utilizing spatial econometric methods to measure spatial direct and indirect effects and decomposing total factor productivity change into technical change, pure efficiency change, and scale efficiency change, we find that environmental regulation promotes corporate total factor productivity but widens the disparity between profitable and unprofitable corporations. Our results also suggest that the direct and indirect effects of environmental regulation and corporate profitability on promoting total factor productivity rely heavily on the efficiency changes, while the contribution of the key component, technical change, is insignificant. China has undergone rapid economic development for many years, but it also suffers from severe environmental pollution. According to the 2016 China Environmental Status Bulletin released by the Ministry of Environmental Protection of the People’s Republic of China [The Chinese economy has transformed from a stage of rapid growth to a stage of high-quality development. Improving environmental quality and developing a green economy are the keys to improving the quality of China’s economy. Therefore, environmental regulation is necessary to optimize China’s economic development mechanism. However, enhancing environmental regulation requires high costs, including financial pressure for the governments, regulatory costs for the regulatory authorities, and tax burdens for corporations, among others. On the other hand, heavily polluting corporations may need to abandon existing production models, update equipment, and invest in research and development activities to make them comply with environmental regulatory requirements, which means high explicit costs for those corporations that may harm profitability.Is economic development incompatible with the improvement of environmental quality? Numerous scholars have done a lot of investigation in this field. The conclusions are presented in the literature review. Most studies adopt macro-level data, such as country-level, sector-level, and industry-level data, because collecting micro-level data, i.e., firm-level, is relatively difficult. Macro-level data contain more information, but micro-level data are more targeted and specific. Corporation-level data can thus be of great significance in terms of examining how corporations respond to environmental regulation because corporations are the recipients of environmental regulation, and their reactions are the basis for policymakers to adjust their environmental policies to achieve certain goals. Moreover, the environmental regulation measurement also has to match the data scale. With respect to this, the utilization of corporation-level single indices outnumbers that of the multidimensional indices. However, the latter can be a better approach because these indices are comprehensive and can more accurately measure how much environmental regulation burdens each corporation. Currently, there is only a very small proportion of the studies that possess both of the features above, namely the adoption of micro-level data and the construction of environmental regulation via multidimensional indices.In addition, some researchers in this field have also considered spatial correlation, but in a more general way. Environmental regulation in one province can be influenced by that of other provinces because local governments are more or less involved in competition against each other or are influenced by the overall strategy of the country, which can cause them to make adjustments in their development strategies accordingly, including in environmental policymaking. For example, in order to clean up the capital’s environmental problems, the Chinese Government has introduced policies to limit production capacity in the provinces surrounding Beijing in order to improve the capital’s environmental conditions. In addition, China has introduced regional coordinated development policies, such as the Beijing-Tianjin-Hebei integration and the Yangtze River Delta integration, which enhance the regional relevance of the environmental regulations and other related policies and lead to more obvious spatial spillover effects. Similarly, competition among corporations is more obvious, leading to the spatial interaction of corporations in their technology spillovers and economic performances. As a result, it is of great value to study the spatial interaction of environmental regulation.The greatest difference between this article and the previous literature is that our research simultaneously combines the three features mentioned above, namely the elaboration of the environmental regulation variable via multidimensional indices, the adoption of micro-level data, and the use of spatial econometric methods. To investigate the mechanism of how each component of total factor productivity (TFP) affects the overall TFP, this study decomposes TFP through the DEA-Malmquist index and conducts empirical analyses via the instrumental-variables two-stage least-squares (IV-2SLS) regression model and the spatial Durbin model, which can measure direct and indirect effects. Using the panel data of 900 of China’s heavily polluting listed corporations from 2013 to 2016, we discover that environmental regulation has a positive direct effect and a negative indirect effect on TFP; most of these effects are due to pure efficiency change and scale efficiency change. Corporate profitability exerts negative direct and indirect effects on TFP; most of these effects are due to pure efficiency change and scale efficiency change. Moreover, these effects may vary between profitable and unprofitable corporations.Scholars have already been making contributions to studies on the relationship between environmental regulation, technological improvement, and economic performance for many years. Michael Porter  proposedWhen it comes to the spatial spillover effects of environmental regulation, competition between local governments gives local environmental regulation policies the power to impact the environmental regulation policymakers in other regions. Likewise, technological improvement in one corporation can easily affect other corporations due to the spillover effect of technologies. With respect to financial performance, the influences are even stronger in an environment with fierce competition because corporations are forced to react to the performances of their rivals.Many studies diverge on how they choose sample data for research on the above issue. Some investigations are based on macro-level data ,14,15. HA major difference between those studies in this field is how a proxy was chosen for the environmental regulation. Brunel and Levinson  thoroughThere is limited literature at a spatial level which can help us to investigate our subject matter spatially as the stringency of the environmental regulation in a certain area may influence that in other areas. The spatial econometric method was not introduced into the relevant research for the first time until this century, by Maddison , who triIn summary, the present study shows insufficient consideration in terms of sample size and environmental regulation measurement, as well as technological space spillover. The most important thing is that the application of spatial econometric methods has not yet been fully popularized. In a few studies involving this aspect, the authors prefer to use macro-level data. Compared with the existing research, we have made progress mainly in the aspect of the measurement of environmental regulation and the spatial spillover effects of the technology. This article represents the first application of the spatial econometric method to explore the nexus between environmental regulation, corporate profitability, and TFP in the micro-level field. First, we employ the quasi-environmental tax, a multidimensional index combining many administrative charges and taxes related to the environment, instead of a single index that has been used in many previous studies, to construct a more comprehensive environmental regulation index that may provide more convincing conclusions . Second,The effects of environmental regulation on the efficiency of corporations, especially heavily polluting corporations, have not yet been concluded. Zhou et al.  proposedTheoretically, environmental regulation puts forward higher requirements for the production activities of corporations, especially for the heavily polluting ones, which are the first-line targets of environmental governance. The reasons are as follows: firstly, environmental regulation has lower supervision intensity for non-heavily polluting corporations, whose effects are not as obvious as those of the heavily polluting corporations. In addition, non-heavily polluting corporations have fewer cost burdens in paying quasi-environmental taxes; so, they have no reasons to take measures which have the risk of increasing costs and destroying efficiency to change the status quo in order to reduce environmental pollution in the production process. In summary, it is less likely that environmental regulation spillover will penetrate into the non-heavily polluting corporations. As a result, compared with the non-heavily polluting corporations, the heavily polluting ones may achieve a greater degree of technical efficiency improvement through environmental regulation. Under such circumstances, heavily polluting corporations are forced to improve technology and innovate production methods to meet regulatory requirements. At the same time, the improvement of corporate technical efficiency will make the operating level and profitability more promising and ultimately boost the corporations’ overall efficiency.Additionally, compared to the more profitable corporations, the unprofitable corporations are in more difficult situations under strict environmental regulation, which makes them bear more losses. Instead of suffering from continuous costs due to high fines or frequent restrictions, technical improvements should be made without interruption. Although it causes large expenses in the initial stage of research and development, the services of the new technology and equipment can not only eliminate environmental burdens but can also enhance operating efficiency. The above two reasons both prompt corporations to choose to improve technical efficiency.According to the above literature analysis and theoretical analysis, we propose the following hypotheses:Hypothesis 1 (H1).Environmental regulation has positive effects on the heavily polluting corporations’ efficiency.Hypothesis 2 (H2).Environmental regulation improves the efficiency of unprofitable corporations compared with profitable ones.The spatial interaction of environmental regulation is also a noteworthy topic. Recently, a few researchers have begun to consider it and to try to verify it quantitatively at the macro-level. The empirical results of Wu et al.  indicateSuppose that the regional division is based on the provinces. When environmental regulation is implemented in one province, the technical efficiency and operating performance of the corporations over there will be improved. Due to fierce competition, the corporations in the other provinces will introduce the advanced technology to make their own performance better. On the other hand, the governments will also compete for environmental quality. When a province has made an achievement through the environmental regulation, others will implement similar measures. Therefore, the technical efficiency of the corporations located in the other provinces will increase accordingly.Based on the above analysis, we propose the third hypothesis:Hypothesis 3 (H3).Environmental regulation leads to the spatial interaction of corporations in their technology spillovers.With respect to how environmental regulation affects TFP, decomposing it into several components is a common practice. Most studies use the three decomposed components from TFP to illustrate how much each contributes to the growth rate of TFP ,33. In tDEA modeln = 2), which are the labor input t to period t + 1:t + 1 and period t, which represent the change of TFP.This study intends to calculate the TFP of 900 corporations for the period of 2013–2016, referring to the DEA-Malmquist index methodology used by Fare et al. . Initials et al. , we built + 1, under the technical condition of period t + 1, can be presented as:In the same way, the Malmquist index of the change in TFP from period t to period t + 1:To avoid the biased error resulting from the arbitrariness of period choice, we take the geometric mean of the two Malmquist indices, Malmquist indexReleasing the assumption of constant returns to scale, we further transform the formula above and obtain:t + 1 into three parts: technical change (TC), pure efficiency change (PE), and scale efficiency change (SE).In Formula (6), the subscript CRS implies constant returns to scale, and VRS implies variable returns to scale. Then, we decompose the change in TFP from period t to period Overall, the growth of total factor productivity is defined as the product of TC, PE, and SE. We interpret our components as follows: the improvement in technical change results from innovation, and pure efficiency indicates the ability to utilize and allocate resources with a static technical level, while scale efficiency reflects the extent of the achievement of economies of scale.t + 1, and the efficiency is improved. When they are equal to 1, it means that TFP remains unchanged, as well as the efficiency. When they are less than 1, it means that TFP and the efficiency decrease from period t to period t + 1.When the Malmquist indices are greater than 1, it means that TFP rises from period t to period Technology endogeneity model of new growth theorySince the middle of the 1980s, new growth theory has developed rapidly; it argues that technology is endogenous, overturning the assumption of the new classic growth theory that technology is exogenous. Since then, a great deal of literature has sprung up in this field. Page , Jaffe , and GayIn Formula (8), Y denotes corporate business income; SIZE denotes the corporate size; CLR denotes the capital–labor ratio ; RD denotes the regional economic development level; t denotes time; A(·) denotes the efficiency function of Hicks-neutral technical progress; and F(·) denotes the combination of K  and L (labor input).The effects of environmental regulation and corporate profitability on technologyThe relationship between environmental regulation and technological improvement has been intensively investigated. Hamamoto , Cole etProfit is an important source for corporations to invest in R&D. Fagerberg and Godinho  and CainReferring to the practice of Hulten et al. , we assui indicates the corporation; t indicates the year; In Formula (11), By substituting Formula (11) for Formula (10) and dividing both sides by By taking the natural logarithm on both sides of Formula (12), we attain the linear equation:Ultimately, we postulate that the effect of environmental regulation on corporate TFP is contingent on corporate profitability and vice versa. Facing environmental regulation, corporations with different levels of profits might respond to it distinctly. For example, even with the regulation imposed, corporations may stop technological improvements as long as they are earning profits. In addition, the demand for technological improvement can differ for stringently and laxly regulated corporations given the same level of profits earned. Therefore, we add an interaction term between the two variables into Formula (13):Technology has spillover effects. However, by introducing distance into our analyses, i.e., spatial econometric methods, we can measure the spatial technology spillover that is more precise than the spillover measured by classic econometric approaches.Spatial panel econometric modelThe general form of the spatial panel econometric model is as follows:In practice, there are three forms of spatial econometric models that are commonly used: the spatial autoregressive model (SAR), the spatial error model (SEM), and the spatial Durbin model (SDM). SDM simultaneously takes into account the spatial correlations of the explained and explanatory variables. Given this, we adopt SDM to carry out the spatial econometric analyses. When Measurement of spatial spillover effectsBecause of the utilization of the spatial econometric method, we can easily measure the spatial spillover effects by calculating the average total effect, the average direct effect, and the average indirect effect. The average total effect indicates the average effect of the explanatory variable A simpler interpretation is that the direct effect of an explanatory variable in region j measures its average effect on the explained variable in region j, while the indirect effect of an explanatory variable in region j measures its average effect on the explained variable in region -j . These interpretations are employed in Based on Formula (14), we place initial production efficiency Similarly, we can obtain the econometric model of the spatial Durbin model:To explore how environmental regulation and corporate profitability affect corporate TFP and the mechanism thereof, we need to choose three other variables, TC, PE, and SE, as explained variables to estimate the equations. Consequently, three additional equations are needed:Likewise, when carrying out the spatial econometric estimations, we also estimate a system of four equations:To calculate the TFP of each corporation in the sample from 2013 to 2016, the data of the input element and output element for the period of 2012–2016 are needed. We measure output by business income, capital input by the total assets, and labor input by the number of employees ,51,52. The existing studies mainly measure environmental regulation by pollution abatement fees or pollution abatement and control expenditures, while this article replaces the conventional environmental regulation variable with the quasi-environmental tax. Referring to the methodology of Bi and Yu  and Liu Corporate profitability in this article is a binary indicator that indicates whether a corporation can earn a positive profit. An unprofitable corporation earns a negative profit and vice versa. Corporate profit (in CNY 10 billion) is measured by the total profit extracted from the corporate annual report. If it is positive, lnPRO is equal to 1, and it equals 0 if the corporation incurs a negative profit. Although profitable corporations can vary widely in their profitability, the value of lnPRO can still be classified with the same value of 1.With regard to the control variables, the corporate size is computed by taking the natural logarithm of the corporate total assets. The capital–labor ratio is the year-end total assets divided by the year-end number of employees. The regional economic development level is represented by the gross domestic product  of the province in which the corporate address is registered. In terms of the instrumental variable, we use the business income of each firm, denoted by BI (in CNY 10 billion).The data sources are as follows: (1) total profit, business income, number of employees, and the total assets data are from the Qianzhan database; (2) the GDP data originate from the China National Bureau of Statistics; (3) the data of the quasi-environmental tax breakdowns are extracted from corporate annual reports by manual sorting by the authors.The State Council of the People’s Republic of China promulgated the National "12th Five-Year Plan" For Environmental Protection on 15 December 2011, which marked a new round of environmental protection campaigns. To examine how environmental regulation has affected corporations since the campaign commenced, our sample interval starts in 2012. However, the sample interval in this article is from 2013 to 2016 because the method of calculating TFP requires eliminating 2012 from the interval. All the corporations in our sample are China’s heavily polluting listed corporations. The reason why we selected these types of corporations are as follows: first, the environmental information disclosures of the heavily polluting listed corporations are more complete than the other types of corporations, which helps us gain the relevant data on the environmental regulation burden. Second, it is more difficult to collect data on the non-listed corporations. In order to test the possible survivor bias caused by the lack of samples of the non-listed corporations, we counted the number of listed corporations in China’s heavily polluting industries from 2013 to 2016. According to the statistics, among the 27 heavily polluting industries, only four of them have seen a slightly decrease in the number of listed corporations compared with other industries, with increasing number of corporations, as is shown in At present, there is no academically specific definition of heavily polluting industries. The criteria of heavily polluting industries in China are stated in The Guide to Environmental Information Disclosures of Listed Corporations (Draft Version) released by the Ministry of Environmental Protection of the People’s Republic of China in 2010, namely the industries of thermal power, steel, cement, electrolytic aluminum, coal, metallurgy, chemicals, petrochemicals, building materials, paper, brewing, pharmaceuticals, fermentation, textile, leather, and mining. Heavily polluting listed corporations are listed corporations classified into heavily polluting industries. In addition, the industry categories of listed corporations are set by the China Securities Regulatory Commission. According to the classification outcome of the industries of listed corporations in Q2 of 2017, we selected 1167 heavily polluting listed corporations. To acquire the relative data of each corporation from 2012 to 2016, we eliminated 252 corporations whose annual reports were published for less than five years, and 15 corporations were also removed from our sample whose data disclosures had faults or missing items. Finally, we obtained a sample of 900 heavily polluting listed corporations, most of which are located in the southeastern coastal area. Environmental regulation mainly affects corporations in the secondary industry, while the primary industry and the tertiary industry are little affected because of their relatively low pollution emissions. In light of the three industry classification provisions released by the National Bureau of Statistics and the classification outcome of the industries of the listed corporations in Q2 of 2017, announced by the China Securities Regulatory Commission, the secondary industry includes 43 industries and 2325 listed corporations. Regardless of the sample interval, our sample contains 27 industries and 1167 listed corporations, which means that the sample covers 62.79% of the industries and 50.19% of the listed corporations that are affected by environmental regulations in China. Thus, the representativeness of our sample is relatively high. We also report summary statistics for the sample in the In order to verify Hypothesis 1 and Hypothesis 2, we will use TFP and its Malmquist indexes as explained variables and perform regressions, shown as Equations (17), (19)–(21). In order to make the regression result more robust, we normalized the interaction term There might be a bidirectional causality issue between the environmental regulations and the corporate technological levels; so, we adopt fixed-effect IV-2SLS regression to reduce the estimation biases and make causal inferences. We use business income as the instrumental variable for the environmental regulations because business income is highly correlated to the environmental regulation burden as many taxes and fees are based on corporate income, while it is less likely to correlate to the corporate technological levels (and the error term). The Limited Information Maximum Likelihood (LIML) method is also used to test the validity of the instrumental variable. Anderson and Rubin ,55 introThe coefficients of lnER in Based on the properties of the interaction terms in these models, the results show that for unprofitable corporations, environmental regulations can increase corporate TFP at the significance level of 5%. This effect is weaker for profitable corporations, while corporate profitability may lead to a decrease in corporate TFP, and this impact is amplified by intensifying environmental regulations. With regard to the TFP components, for unprofitable corporations, environmental regulation would decrease TC and increase PE and SE, and the increase in PE is undermined for profitable corporations; the effect on SE is insignificantly different between the two types of corporations. Profitability exerts no impact on TC and SE.The spatial spillover effects of the corporations’ technology, which is expressed as Hypothesis 3, will be examined by the regressions shown as Equations (18) and (22)–(24).The premise of applying spatial econometrics is that there is a spatial correlation among the explained variables. In spatial statistics, we usually utilize Moran’s I  index anBefore we embark on calculating the two indices, the spatial weight matrix of sample In the formulae above, The usual endogeneity considered in classic econometrics is often ignored in spatial econometrics, but an attempt to control for endogeneity can make the estimation less biased and allows us to obtain causality. Our spatial estimation is divided into two stages. In the first stage, we regress the endogenous variables on their instruments and the other exogenous variables to gain the linear predictions of the endogenous variables. In the second stage, we substitute the endogenous variables in the original model with their predicted values in the first stage and run the spatial regression. Note that the spatial Durbin model includes the spatial lagged terms of the explained variables and the explanatory variables, and the impacts of the explanatory variables on the explained variables are not simply reflected by the regressive coefficients. Therefore, we only report the direct, indirect, and total effects and the total effect. The time fixed effect is controlled. The results of the four estimations are shown in As is shown in Among the results in A notable point to make is that the results of the IV-2SLS regression are nearly consistent with the total effects of the spatial regression. However, the application of spatial econometrics allows us to distinguish the direct effect and the indirect effect that can differ greatly from the results of the standard linear model. We then examine the direct and indirect effects of each variable below.Environmental regulation may have positive direct effects on TFP. Compared to the unprofitable corporations, this effect is weaker for profitable corporations. It also exerts positive direct effects on PE and SE at the 1% level of significance, although these effects do not differ for different types of corporations and their direct effect on TC is insignificant. Moreover, environmental regulation exhibits no indirect effect on TFP for unprofitable corporations but has a negative indirect effect on TFP for profitable corporations. It also has a positive indirect effect on SE at the 5% level of significance that does not differ for the profitable and unprofitable corporations.Corporate profitability exerts negative direct effects on TFP that may increase as the environmental regulation intensifies. It also has negative direct effects on PE and SE that do not differ between corporations and has no significant direct effect on TC. In terms of the indirect effect, profitability possibly has a negative indirect effect on TFP that increases as the environmental regulation becomes more stringent. It also has a negative indirect effect on PE at the 5% level of significance, which does not differ for the profitable and unprofitable corporations.Compared with most existing research, this article pays more attention to the research of individual corporations. Through the results interpretation of the spatial Dubin model, it is a concept of relative distance to explore the direct and indirect effects of technology spillover among Chinese corporations under environmental regulation. Furthermore, we further classify corporations according to whether they are profitable or not in order to research the different effects of environmental regulation.Based on the variable-by-variable results, there are several remarkable points to make.First, from the perspective of the total effect, it seems that the effects of the explanatory variables are mostly imposed on the pure efficiency change and the scale efficiency change, leading to the change in TFP, while TC is statistically insensitive to all explanatory variables. Basically, it means that, overall, technical change plays no role in affecting TFP in our analyses. However, most of the literature suggests that technical change is positively correlated to TFP ,62,63. OTo save space, we omit the regression results of environmental regulation and the other control variables. As is shown in the second column of Second, environmental regulation may increase the TFP of the unprofitable corporations more than the profitable corporations, and this gap broadens as environmental regulation becomes more stringent. The implication of this phenomenon is that facing an intensifying environmental regulation, unprofitable corporations are forced to increase their technological levels to avoid more losses resulting from taking on more environmental burden. This proposition is based on our observation from the data that the TFP of profitable corporations has a lower mean and variance than unprofitable corporations. This direct effect on TFP is mostly due to efficiency changes. When turning to the indirect effect, environmental regulation exhibits a similar feature that, as it intensifies, the TFP gap between the profitable and unprofitable corporations widens, which suggests that environmental regulation in one province can impact corporate TFP in itself and the other provinces. This indirect effect is also attributed to efficiency changes.Third, regional economic development contributes to an “outflow” of TFP, i.e., a decrease in the TFP of corporations in the region itself and an increase in corporate TFP in all the other regions, all of which is due to its effect on scale efficiency change; that is, it would increase the scale efficiency in the region per se and decrease the scale efficiency in all the other regions. A possible explanation is that a booming regional economy provides corporations a good opportunity to raise their scale efficiency because the economy of the whole region is in expansion, which may lead to the decrease in scale efficiency for corporations in other regions as their regional economies become comparatively small. Regional economic expansion brings pressure to the management of corporations. For example, it can attract more workers into the region, which makes the pure efficiency of the corporations in this region decrease but contributes to the increase in that of the corporations in the other regions because fewer workers make it easier to manage, which can explain its effect on the TFP of corporations in the local and neighboring regions. However, the changes in TFP resulting from the pure efficiency change are not significant at the 5% level.The ongoing debate on the nexus between environmental regulation, corporate economic performance, and technology spillover has attracted many scholars. By decomposing TFP change into technical change, pure efficiency change, and scale efficiency change and applying spatial econometric methods to measure the spatial effects, we find that the direct and indirect effects of environmental regulation and corporate profitability on promoting TFP partly rely on the pure and scale efficiency changes, while the contribution of the predominant component, technical change, is insignificant. As each coin has two sides, environmental regulation acts as a spur to technological improvement but may widen the TFP disparity between profitable and unprofitable corporations. The contribution of this article is mainly reflected in three aspects. Firstly, the quasi-environmental tax is used as the indicator of environmental regulations, which introduces a method of micro-level data measurement for subsequent, related research. Secondly, we proved that environmental regulation would promote the corporations’ TFP and have a more significant effect on unprofitable corporations, which provides guidance for the implementation of environmental regulations. Finally, the research found that the direct effect of spatial spillover is most obvious among the three effects, which reminds policymakers to consider the policy reaction of governments and corporations in the neighboring regions, as well as the countereffects brought by competition.Based on our findings, we can suggest some policy implications. First, current environmental regulation in China can contribute to the increase in corporate TFP, which provides empirical evidence of an unconflicted relationship between environmental regulation and corporate productivity in China. Thus, in the long run, the existence and improvement of environmental policies can help achieve the improvement of environmental quality and economic growth simultaneously. Second, facing environmental regulation, to increase productivity, corporations in China are inclined to increase their efficiencies instead of technical change, i.e., innovation. For example, many heavily polluting corporations in Beijing have moved to the suburbs of Beijing or even the surrounding provinces because they have little desire to develop and adopt new technologies. Therefore, to enable corporate TFP to increase consistently, governments should design policies that guide or facilitate the corporate innovation that is predominant in the business environment. Third, a provincial environmental regulation can influence the region per se and the other neighboring provinces, which requires the provincial policymakers to adjust their environmental policies according to those from other provinces, instead of regarding their province as an isolated system. Moreover, although environmental regulation incentivizes corporate technological improvement, it also contributes to technological disparities between profitable and unprofitable corporations, implying that the policymaking should strive to reach a balance between the positive and negative sides of environmental regulation.In the end, we should point out the limitations of this article. When dealing with the endogeneity in our models, we use business income as the instrumental variable for environmental regulation. Even though it passes certain instrument validity tests, it is not the most ideal one and probably brings some biases to our empirical estimations. Additionally, the spatial weight matrix only employs geographical information, ignoring the influences of economic factors. For instance, there is to some extent industrial agglomeration in each province, or the stringencies of environmental regulations vary from province to province. In addition, the value of Moran’s I indices and Geary’s C indices, which are utilized to test the existence of spatial correlation, may be optimized with increasing sample size or observable data. Moreover, taking practicality into consideration when researching spatial spillover at the corporation level, we chose the location of the headquarters as the main activity location of the sample corporations in this article, which can be misleading as the headquarters can be different from the location of the actual activity for tax or prestige reasons. Due to the limitations of this article, some perspectives have not been considered, such as spillover by the industry or pollution type, the influence of the international context on competition and regulatory differences, the inclusion of non-heavily polluting corporations in the research scope, and so on. The above content could be new directions for future research in this field.