Digital technology and social networks are part of everyday life in the current internet age, especially among young people. To date, few studies have been published worldwide on the pattern of use of digital technology devices and applications in patients with early-stage schizophrenia and even fewer comparing them with healthy participants  from the same demographic areas. In Spain, no such study has been carried out.The aim of this study was to analyze how patients with early-stage schizophrenia use internet and social networks compared with healthy participants matched by age and gender and also to examine which devices are utilized to access internet resources.t test was used for continuous variables and chi-square test for categorical variables. In the case of ordinal variables, nonparametric Mann-Whitney U and Kruskal-Wallis H tests for independent samples were performed to compare groups.A cross-sectional, multicentric study was carried out through a semistructured interview asking about the use of digital technology devices and internet. The sample comprised 90 patients and 90 healthy participants. The semistructured interview was conducted on 30 outpatients and 30 healthy subjects in each of the 3 different cities . Student The results indicated that a large proportion of patients with early-stage schizophrenia have access to different digital devices and use them frequently. In addition, both groups coincide in the order of preference and the purpose for which they use the devices. However, a lower frequency of use of most digital technology devices was detected in patients compared with healthy participants. In the case of some devices, this was due to the impossibility of access and not a lack of interest.To our knowledge, this is the first study to analyze patterns of internet access and use of digital technology devices and applications in Spanish patients with early-stage schizophrenia compared with healthy participants from the same demographic areas. The results on significant access and use of digital technology and internet shown in this cross-sectional study will allow enhanced and more efficient treatment strategies to be planned, utilizing digital technology devices, for patients with early-stage schizophrenia. As indicated in a very recent report by the International Telecommunication Union (ITU) and the United Nations Educational, Scientific and Cultural Organization, the growth in information and communication technologies and the massive use of internet in the last 20 years have influenced the development of human activity in multiple areas such as education and health . In thisMoreover, in 2017, according to the Instituto Nacional de Estadística , 78.4% of households with at least one member, aged between 16 and 74 years, had a computer and 97.4% of households had a landline or mobile phone [According to the same statistics by the INE, the device most commonly used to connect to the internet was by far the smartphone (90.4% of internet users in the last 3 months), followed by laptop (39.3%), desktop computer, and tablet. Smart television (TV), other mobile devices, and game consoles were also mentioned (12%). Regarding participation in social networks, during the previous 3 months, 67.6% of internet users had participated in general nature social networks such as Facebook or Twitter, creating a user profile or sending messages and other contributions, with greater participation by women than by men. The most participative subjects were students (90.4%) and people aged between 16 and 24 years (90.0%).The fact that technology is rapidly changing society, and many activities now require the ability to use digital technology, potentially poses new problems for several population groups, including older adults, the economically disadvantaged, and people with severe mental illness . MoreoveIn the last 10 years, the development and use of mobile devices devoted to health has increased significantly. The main advantage of these devices is that they increase access to medical care, reduce costs, and offer new options for control, prevention, detection of diseases, and basic diagnosis .The literature at the time of this study reports positive effects derived from the use of mobile apps for health in relation to improving hygienic dietary habits such as stopping smoking, losing weight, dieting, and physical activity, as well as increasing therapeutic adherence and preventing and treating sexually transmitted diseases -9.The impact of psychological interventions on mental disorders is unquestionable. However, owing to the limited resources of medical and psychological care and availability of interventions, their enormous potential is restricted -11. UsinSchizophrenia is a chronic psychiatric disorder that affects approximately 1% of the population and severely limits the social and occupational functioning of patients . SymptomSchizophrenia is a mental disorder for which mobile health  offers a tremendous opportunity to provide personalized, innovative, and accessible solutions. A recent systematic review concluded that internet and mobile-based interventions for psychosis seem to be cost-effective, accessible, acceptable, feasible, and have the potential to improve clinical and social outcomes . A subseAt the time of this study, there was limited information on the access and use of digital technology by psychotic patients. Several previous studies have investigated the prevalence of use of technological devices and applications through surveys. In the United States, 2 studies were conducted in patients diagnosed with schizophrenia and schizoaffective disorder. The first interviewed 457 participants by means of a Web-based survey  and the To our knowledge, only 2 studies have been conducted in patients with early-stage schizophrenia. The first study included 71 patients at different stages of their 5-year treatment in a therapeutic program in Montreal (Canada). The patients completed a survey on their access and use of technology and related activities. The authors concluded that a significant proportion of patients with early-stage schizophrenia had access to and were using different technological devices in their daily lives . The secIt should be noted that in the previously mentioned publications, the use of digital technology for internet access was compared with data of use from general population surveys, but not with a sample of controls matched in age, gender, and place of residence. The lack of a control group, as well as a nonmulticentric study design, could be an important source of bias in these publications.To date, no multicentric studies have been carried out that provide information about the use of digital technology to access the internet by patients with early-stage schizophrenia compared with a sample of control participants matched in age, gender, and place of residence. Hence, we conducted a cross-sectional, multicentric study to analyze the use of digital technology in patients with early-stage schizophrenia and to compare the responses with regard to healthy participants matched by age, gender, and place of residence through a semistructured interview. The following 3 main questions were analyzed:Which digital technology devices are most frequently used by patients with early-stage schizophrenia to access the internet? Is there any difference in use by gender, age, education level, or location? And, primarily, is use similar in healthy participants?What is the main purpose of the use of digital technology devices in early-stage schizophrenia patients? Moreover, is there any difference in the purpose of use between patients and healthy participants?Which are the applications more frequently used when patients access the internet? Is their use similar in healthy participants?Hospital Universitario 12 de Octubre (Madrid), Hospital Virgen de la Luz (Cuenca), and Hospital Universitario de San Juan (Alicante). The study was approved by the Clinical Research Ethics Committee.This was a cross-sectional, multicentric study of 6 months’ duration (June to November 2017). The design included 3 recruitment centers: Hospital Universitario 12 de Octubre serves a population of about 450,000 inhabitants and has an integrated psychosis assistance program, including an intensive program for first psychotic episodes. The psychiatric service of the Hospital Virgen de la Luz serves a population of 150,000 inhabitants and also offers an integrated psychosis program. Finally, the psychiatric service of the Hospital de San Juan serves a population of 300,000 inhabitants and manages a program for first psychotic episodes.The psychiatric service of the The patient sample size was established as 90 patients (30 patients from each of the centers). All met the Diagnostic and Statistical Manual of Mental Disorders, fifth edition, (DSM-5) diagnostic criteria for schizophrenia assessed with the Structured Clinical Interview for DSM-5 . All theThe following inclusion criteria were established for patients:Meeting DSM-5 diagnostic criteria for schizophrenia.Staying clinically stabilized during the 3 months before the semistructured interview, according to criteria already used by our group .Being an outpatient.Being aged between 18 and 55 years.Speaking fluent Spanish.Providing signed, informed consent.The following exclusion criteria were considered:Other Axis I major mental disorders of DSM-5.Intellectual disability (IQ <70).Suffering somatic pathology that might interfere with accessing the internet.The patients were screened by their psychiatrist to determine whether they met the inclusion/exclusion criteria and were thus suitable to participate in the study.The patients were recruited consecutively at the clinical appointments of their respective first-episode programs. After the clinical evaluation, the psychiatrist assessed the inclusion and exclusion criteria and proposed their participation in the study on the frequency and purpose of using a series of digital technology devices. t test was used for continuous variables with a normal distribution. For variables found not to be normally distributed after using Levene test (of homogeneity of variance or homoscedasticity) and ordinal variables, nonparametric tests for independent samples were performed.Statistical analysis of all data was conducted using SPSS version 23.0 (IBM Corp). The means and SDs were used to describe continuous variables whereas percentages and chi-square tests were used for categorical variables. Student never (0), including both never, but would like to and never, and would not like to; rarely (1); once a week (2); twice a week (3); and every day (4). Therefore, the P value of nonparametric tests for independent samples is presented as a result. The Mann-Whitney U test  is performed when we have 2 groups of variables whereas the Kruskal-Wallis H  test is conducted for more than 2  groups of variables.The tables described in the section on frequency of use include variables that are considered ordinal variables as they are clearly ordered from The results for the technological devices used by patients and how they used them are presented. We analyze whether there were any differences for several features such as gender, age, education level, and place of residence. In addition, the use of these digital technology devices by patients with early-stage schizophrenia and healthy participants is compared. Subsequently, the purpose of use of these devices is shown, analyzing 4 different domains: entertainment, work, socialization, and shopping. In addition, the websites used to access these internet services and the main applications used for socialization are studied. Finally, the favorite videogames played by both groups are analyzed.A first analysis studied the frequency of use by patients with early-stage schizophrenia of several technological devices that are useful for internet access. In this selection, some devices frequently used for this task such as computers or smartphones and other more novel or not so widely used devices  were included. The inclusion of these latter devices allows possible trends in use to be evaluated. Moreover, this variety of devices was included to cover different domains and usages.every day, twice a week, once a week, and rarely, but also in the case of never for a specific device, an analysis of patients’ interest in their use  was included. This variable reveals the actual motivation of low use of a specific device.smartphone clearly prevails over other devices. More than 80% of patients (75 out of 90 participants) use this device every day and it is very popular among patients. The other type of device most frequently used is the computer. In this case, use is not so frequent but the general use of these devices by patients is similar to that of smartphones.Considering the results shown in In contrast to the devices previously analyzed, the other 3 are used less frequently, but as can be seen in First, we analyzed whether the frequency of use of these devices is similar between schizophrenic patients and healthy participants. As can be seen in game console has a P value higher than .05.As can be seen, there is a significant statistical difference in almost all devices. Only the use of smartphone and computer more frequently and, more remarkably, game console is used by a proportional number of each gender. In contrast, males were more frequent users of smart TV and tablet use was similar between genders.smart TV. Participants aged 30 years or above used smart TV less than younger adults. Although not statistically significant, a trend of greater use of most devices for the age range between 25 and 29 years can be observed across all participants. Nevertheless, it is worth highlighting that the age range in the last interval (≥30) is greater (30 to 53 years), which could affect the results.In terms of age see , this stcomputer; the higher the educational level, the more frequent is the use. In general, participants with a high educational level used the analyzed devices more.For educational level see , the onlrural and urban. In general, the use of digital technology devices is greater in urban than in rural areas. There is, however, a statistically significant difference in the use of game console.The purpose of use was classified into 4 domains: entertainment, work, socialization, and shopping.We analyzed the responses of participants who reported using a specific device. Again, an ordinal variable was assigned to the responses with the following Boolean values: NO=0 and YES=1. This means that the answers of participants who reported never using a specific device were not considered.computer was used by 83 patients versus 89 healthy individuals, tablet by 35 patients versus 55 healthy individuals, smartphone by 84 patients versus 89 healthy individuals, game console by 54 patients versus 61 healthy individuals, and smart TV by 38 patients versus 59 healthy individuals.shopping is the least used domain for all devices. The data show that patients do not frequently shop on the internet. Another relevant result is that the more versatile devices are computer and smartphone, whereas the others are mainly used for entertainment. Regarding socialization, the high value associated with game console is curious. This outcome may show that the games played by patients involve relevant social activity. As expected, the use of smartphone is also noteworthy in this domain.As can be seen, U test for nonparametric variables.However, are there any differences between patients and healthy participants in the purpose of use? entertainment, the mean of healthy participants is higher in general terms and there are significant differences in terms of statistics in the case of smartphone, game console, and smart TV, where healthy participants used these devices for entertainment more than patients.Regarding work, computer was also used more by healthy participants. It is noticeable, although not from a statistical point of view, that tablet was used by patients more than by healthy participants. Nevertheless, the use of this technology was very low for both groups.In the case of socialization should be treated carefully. In fact, smartphone was used for socialization by a high number of patients and healthy participants, although healthy subjects prevail and there is statistical significance. However, on the contrary, game console was much more frequently used by patients than healthy participants.The purpose of shopping, the difference in the use of computer is statistically significant in favor of healthy participants. Moreover, all other devices were found to be less used by patients for this purpose.For smartphone in both groups was socialization, followed by entertainment. Similarly, both game console and smart TV were used in both groups for the main purpose of entertainment. The main purpose of use of tablet was entertainment for both groups.As noted before, both patients and healthy participants used most devices for the same purpose. Thus, the main purpose for using computer, it is noticeable that patients used it preferentially for playing compared with healthy participants who primarily used it as a work tool.Regarding the purpose for using the Regardless of device, what type of website do patients and healthy participants use when they access the internet? Do they use the internet to search for information or socialize? Participants were asked to indicate a maximum of 3 search engines.general , entertainment, knowledge (knowledge sharing), shopping, and work. As can be seen, the percentages are quite similar for patients and healthy participants.Google as a search engine and YouTube for entertainment purposes and the use of specific websites for work and shopping is very low. For work and shopping, the specific search engines were not included, as almost every participant uses a different website. Moreover, the difference in the use of Wikipedia is interesting: 11.1% (10 out of 90 participants) for patients and 3.3% for healthy participants (3 out of 90 participants). When analyzing the number of answers provided by participants, only 5.6% (5 out of 90 participants) of patients did not indicate any search engine, whereas all healthy participants indicated at least one search engine. In addition, the percentage of participants indicating 3 apps was higher for healthy participants than patients.As expected, a great majority of participants use For videogames, never, but would like to responses is striking. This might be because these devices are not economically affordable for this group of the Spanish population despite there being outstanding interest in them.To our knowledge, this is the first multicentric study on the use of digital technology for internet access in patients with early-stage schizophrenia compared with a sample of control participants matched in age, gender, and place of residence. The smartphone is clearly the digital device most widely used by patients (84 out of 90 participants), reaching almost 95% of use at least twice a week. The second most used device is the computer, which reaches a use of almost 75% (67 out of 90 participants) at least twice per week. With regard to the other devices, the low usage indicated and the high number of In any event, although the use of all devices is lower in patients compared with healthy participants, the results indicate that a large proportion of patients with early-stage schizophrenia have access to different technological devices and use them frequently. This finding is of great importance for designing intervention programs including the use of technological devices, especially smartphones and computers. The inclusion of technological devices is being investigated in several areas such as neurocognitive remediation , adherenfrequency of use of digital technology devices between male and female patients, which is interesting in terms of gender equality. In addition, no statistically significant differences were detected in terms of age, except for a lower use of smart TV in older adults. It was also found that frequency of use of computers increased significantly as educational level increased. Although not statistically significant, patients who lived in cities used most digital devices more frequently than those who lived in small towns. To sum up, healthy participants used all digital technology devices more frequently than patients, with this difference between the groups being statistically significant for all devices except for game console.Moreover, no statistically significant differences were found in the purpose of use of digital technology when accessing the internet are described below. Patients and healthy participants coincided in that the main purpose of use for tablet, game console, and smart TV was entertainment and for smartphone, socialization. However, they differ in the purpose for using the computer, with entertainment being the principal motivation for patients and work for healthy participants. In general, most devices are less used by patients for this purpose. These data could indicate a lower interest of patients for this purpose.The main results in terms of Specifically, entertainment seems to be the main objective sought with most devices, both in patients and in healthy participants. For entertainment, patients use smart TV and smartphone more frequently, whereas healthy participants prefer the game console, with this difference being statistically significant. For work, there is a statistically significant difference in favor of healthy participants with respect to computer use. The devices most used to socialize are smartphone  and computer in both groups. Another finding is that patients used the game console more frequently than healthy participants for socialization purposes. Web-based shopping seems to be the least common objective in both groups. Nevertheless, healthy participants engaged more in this type of activity, especially on the computer.search tools, the main finding is the lack of statistically significant differences between the 2 groups. Google is the most important search engine followed by YouTube. The access to social networks is quite similar in both groups, with WhatsApp and Facebook being the most important applications. As expected, the most frequently used domain of social activity was messaging, followed by social media and photo sharing. However, the use of Twitter, another well-known app in this domain, is slightly curious. Here, patients presented a lower use of this app than healthy participants, which was nevertheless mitigated through other messaging apps such as Snapchat and WeChat.With regard to the most used Regarding the number of answers provided by the participants, it is surprising that several patients with early-stage schizophrenia indicated no app, whereas this percentage was null for the other group. Moreover, the percentage of participants reporting a maximum of 3 apps was higher in the case of healthy participants.videogames, both groups knew and played several video games, with FIFA 17 being the favorite for patients and League of Legends for healthy participants. Nonetheless, no single videogame was used by most participants. This means that an accurate analysis cannot be performed by just looking at the results provided in this table. Therefore, a deeper analysis, probably mining the most important features of the videogames, is necessary to give any concluding remarks in this regard.In the case of There are several strengths and limitations in this study.The main strength of this work is that it is the first multicentric study carried out on internet access through digital technology  by patients with early-stage schizophrenia in Spain compared with a sample of controls matched in age, gender, and place of residence.Hospital Virgen de la Luz (Cuenca), Hospital Universitario de San Juan (Alicante), and Hospital Universitario 12 de Octubre (Madrid). The 3 centers of recruitment are related to 3 different types of settlements based on their number of inhabitants. The first could be classified as a large town, the second a large city, and the last a metropolis. Moreover, in terms of rural population, Cuenca has a high percentage, in Alicante the percentage is small, and in Madrid it is practically null.It should also be highlighted that the selection of a multicentric approach representing 3 typical, albeit different, cities is essential to generalize the results to the overall Spanish population. Indeed, this research study involved participants from 3 different recruitment centers (cities): In addition, regarding the statistical analysis, the size of the sample (180 participants) can be considered more than enough to extract important and useful considerations. In this sense, another strength of the study is having a control group of the same sociocultural environment, matched in age and gender.There are some limitations to our study, mainly that socioeconomic status, ethnicity, culture, and working status of participants were not collected, which would have helped enhance the explanation of some results obtained.To the best of our knowledge, no other published multicentric studies have analyzed the access and use of digital technology devices and applications in patients with early-stage schizophrenia in comparison with a sample of healthy participants matched in age, gender, and place of residence.The results of this study indicate that a large proportion of patients have access to different technological devices and use them frequently, although the use of all devices is lower in patients compared with healthy participants. This lower use could be attributed to lower economical level of the patients , lower aBoth patients and healthy participants coincide in the preference for using smartphone over the other devices. The second most used device is the computer, followed by smart TV, game console, and tablet. The preference for the use of smartphone conforms to the Spanish population’s access to this device, as well as the preference of its use to access the internet . ConsideA recent meta-analysis on smartphone ownership in psychotic patients revealed that it was increasing rapidly, with 81.4% ownership among respondents between 2014 and 2015 in the United States . Anotherfrom daily use up to 2 to 3 times per week). This difference in the preference for computer compared with smartphone could be related to 2 circumstances. The first could be cultural difference, as in 2017, the device most frequently used to access the internet was smartphone (76%), followed closely by laptop computer (71%), according to the National Statistics Institute of Canada [In addition, in a previous survey of access and use of technological tools carried out in 2012 in Montreal on 71 patients with a first psychotic episode , a greatf Canada . As can f Canada .Some years ago, an interesting study found that the internet is an influential source of illness-related information for patients with schizophrenia . MoreoveRegarding the most visited search engines, the responses of both groups  were quite similar. Google is the most named search engine by far (with close to 100% use in both groups), which shows the enormous expansion of this tool. The results  were similar for YouTube, the main page visited by both groups for entertainment. It is striking that both patients and healthy participants named these search tools freely, that is, without a list provided by the interviewer. At the time of data collection, both groups coincided in the use of Wikipedia, the use being higher in patients than in healthy participants. With regard to other types of websites related to job searching, the response rate was low in both groups, although higher in the healthy participants, which could be related to the lower employment rates in the psychotic population.With regard to the applications used for socialization, it is striking that around 12% of patients use no application. This is probably related to the difficulties these patients present when socializing. Nevertheless, the patients who responded did so similarly to the healthy participants, with WhatsApp being the favorite app, followed by Facebook and Instagram. As with Google and YouTube, it can be concluded that these applications have expanded enormously in recent years, reaching even young psychotic patients. Both groups agree on the low rate of responses in the use of dating websites, which could be related to inhibition when verbalizing this type of information.This is the first multicentric study carried out that provides information about the access to the internet and use of digital technology devices and applications by patients with early-stage schizophrenia in comparison with healthy participants matched in age, gender, and place of residence.In general terms, the results obtained in our study indicated that a large proportion of patients with early-stage schizophrenia have access to different digital devices and use them frequently. However, a lower frequency of use of most devices was found in patients compared with healthy participants. For some devices, this was due to a lack of access, not an absence of interest. Nevertheless, both groups coincide in the most used devices. In addition, the purpose of using the devices in relation to the internet is highly similar in both groups.This study brings the scientific community closer to the patterns of internet access and use of digital technology in patients with early-stage schizophrenia compared with healthy participants from the same demographic areas. The analysis of this information will be useful to guide the future development of internet technology–based therapeutic applications .


Films illustrate 2 ways that epidemics can affect societies: fear leading to a breakdown in sociability and fear stimulating preservation of tightly held social norms. The first response is often informed by concern over perceived moral failings within society, the second response by the application of arbitrary or excessive controls from outside the community.  Dallas Buyers Club, Philadelphia, And the Band Played On, Kids), often through melodrama, fewer films have dealt with other epidemic diseases, as either direct subject material or background context. Of these more realistic or semirealistic films about epidemics, scholarly literature has focused on the inadequacy of capturing the correct science behind disease transmission, spread, and illness  and a list of “Apocalyptic, epidemic, pandemic and disaster movies” on the Internet Movie Database (https://www.imdb.com/list/ls058975821). We manually selected the films and eliminated those that corresponded to the 3 broad categories mentioned above  and focused on films that pay explicit attention to social responses to disease . Furthermore, the absence of comprehensive indexing of films containing narratives around epidemics makes construction of a systematic sample impractical , to avoid mass panic across the city of New Orleans, the US Public Health Service and the police agree to not notify the press of a death resulting from pneumonic plague. Appearing in the same year, The Killer That Stalked New York  was based on an actual threat of smallpox that occurred in New York in 1947. In the film, public health officials develop a widespread vaccination program, but after the necessary serum runs out, the city descends into mass panic—after the authorities tried to cover up this information. In the UK film 80,000 Suspects , the doctor tackling an outbreak of smallpox uses a quarantining process with the explicitly mentioned goal of reducing the chances of public panic. In Morte a Venezia , a film based on the 1912 novel by German author Thomas Mann, Der Tod in Venedig [Death in Venice], the city authorities do not inform those on vacation of cholera problems within the city for fear they will frantically leave—an approach also taken by town officials in John Ford’s depiction of a community during a typhoid epidemic, Dr. Bull (1933). Another common feature is defiance of the film’s protagonists against a perceived lack of official information. For example, in Quiet Killer , when the doctor realizes that her patient has succumbed to plague, she tries to push authorities to warn the citizens of New York, against considerable reluctance from the mayor, who envisages widespread panic.Many films dealing with epidemics have tended to see panic as an inevitable social response; their main focus has been the process of authorities withholding information to guard against chaos or the circulation of misinformation by the media. For example, in Die Pest in Florenz [The Plague of Florence] , which focused on the real outbreak of the Black Death in Florence in the mid-14th century and portrayed death from plague as a response to immoral behavior and sexual debauchery. The connection between disease and deteriorating social morality came from actual observations of contemporaries at the time, for example, the views of Giovanni Villani (Nuova Cronica) and Giovanni Boccaccio (Decameron). In several films, the plague became used as an explicit punishment for immorality and wrongdoing: The Pied Piper , The Hour of the Pig , and especially Anazapta , in which plague was a supposed consequence of the brutal rape of a lord’s wife by the village. Other films, however, have gone further and tried to examine some of the causes of this fear and panic; in many films, the roots lie in society’s response to perceived declines in social morality. One of the earliest examples is The Seventh Seal (1957), Lars von Trier in Epidemic (1987), Luis Puenzo in The Plague (1992), and Christopher Smith in The Black Death (2010). Those 4 films focus especially on intolerance in the form of scapegoating and persecution of women as witches, but visualization of dread had already appeared earlier in lesser known films, such as Singoalla , Häxan , and Skeleton on Horseback . In the film Trollsyn , set in Norway, the initial stage of the Black Death outbreak is presented as mass hysteria among the villagers: crying and shouting, desperate prayers, suicides, and frantic searching for buboes and panicked movements. Also, in reference to social decline, one scene shows simultaneously the aggressive inquisition of a female scapegoat while amid the chaos a couple are having sex and others have taken off their clothes and are rolling down a grassy hill.Similar kinds of existentialist angst and pessimism over social values in connection with the Black Death were later famously exploited by Ingmar Bergman in The Horseman on the Roof , set during a cholera epidemic in 19th-century Manosque, southern France, the film’s protagonist, Angelo, is captured by a paranoid mob who accuse him of poisoning the town fountain and take him to the authorities. Elsewhere, in the Masque of the Red Death , which focuses on a fictional disease with loose parallels to plague, rural villagers become increasingly desperate and seek to escape the devastating death, only to have soldiers shoot them down by crossbow. In Jezebel , chaotic and violent scenes of 19th-century New Orleans are overlaid with a dramatic, flashing, capitalized “YELLOW FEVER” text across the screen, as if to heighten the emphasis on uncontrolled panic.Many films focusing on outbreaks of epidemic disease focus on outbreaks of senseless violence indicative of a society completely out of control. In Another aspect of declining social morality is linked to scapegoating; stigmatization and blame have long been connected with epidemics. It is well known that the Black Death brought mass persecution of Jews in various parts of Europe (The Giant Rat of Sumatra (not penned by Conan Doyle), Professor Moriarty prepares to import plague to Britain by acquiring infected rats from Southeast Asia , although widely lauded for its accurate depiction of the mechanisms of disease transmission and epidemiology, can be seen to neatly fit within Wald’s outbreak narrative framework, in which a pathogen is brought into the developed world after contact with migrants and visitors from lesser developed areas  was thought to have originated in Africa, whereas in Contagion and The Crazies , the disease originates in Asia , which tries to favorably present Chinese attempts to control a fictional disease (lamanla) based on Ebola in Africa. In The Painted Veil , a 1920s rural village in China is unable to deal with a cholera outbreak until a British bacteriologist comes along to investigate and in the end selflessly gives his own life.In more recent years, however, the othering narrative has also taken new forms, in which an undeveloped or traditional society under threat of an epidemic is heroically saved by outside forces. This narrative can be seen in the popular film set in China, The Citadel , with its scenes of working class miners resisting medical authority during a tuberculosis outbreak, and 1918 , in which residents of a small Texas community resolutely try to continue their normal lives, functions, and networks despite the scale of deaths from influenza.Although epidemics can produce panicked responses that lead to the unraveling of the social fabric, this response is not the only outcome, as the literature  has argued , which deals with a fictional disease that causes epidemic blindness, leading to collective hysteria. Overall, the film considers the human capacity for prejudice, indifference, selfishness, and an easy resort to aggression and violence. As more citizens contract the disease, the normal functioning of society is upturned: strict government quarantines of the infected are imposed by use of physical force. Just as with Contagion, however, this action provokes unrest not connected to the disease but to perceived arbitrary and ruthless actions of elites and authorities. We see scenes in which resources such as food begin to be distributed inequitably, and people begin to exploit their positions by withholding food in exchange for other resources, including coerced sex. Most of the violent confrontation stems from hostilities between those subject to quarantines and those managing the confined environments.Another film demonstrating similar issues is Flu , set in South Korea, which plays on recent experiences with SARS and influenza by focusing on responses to an outbreak of a fictional disease with parallels to the strain of avian influenza A(H5N1) virus. On the one hand, many scenes capture the frenzied breakdown of social norms. As first details of the disease emerge, the film’s protagonist, Ji-goo, is seen in a mall among people frantically making phone calls and rushing to leave the city. After the news is made public on national television, raising the category of the crisis to critical, citizens begin fighting for resources and even exploiting the chaos to loot a supermarket. On the other hand, however, we also see much more focused forms of unrest directed at certain social groups, especially in the process of implementing quarantines. Of note, when infected citizens are forcibly moved to camps, elements of compassion and cohesion develop among camp residents; the most violent reactions come from and are directed toward authorities managing the site. The film also reflects on distrust of elites and authorities with medical knowledge and power; rumors are spread that the infected are killed rather than treated. This same distrust is a theme seen in other films from China, such as Shen yi bian que  and Fall of Ming [Da Ming jie] , about real-life physicians Bian Que and Wu Youke, respectively. This theme again has broad parallels to history and the riots that occurred during 19th- and 20th-century cholera outbreaks, opposing medical staff and governments , Feidian rensheng , and Golden Chicken 2 [Gam gai 2] .These aspects of extreme disdain for the withholding of perceived societal freedoms are not found solely in Western films but in films from Asia too, such as the recent popular movie The Painted Veil, which follows a British bacteriologist working to prevent the spread of cholera in a small village in rural China in the 1920s, set within a broader context of distrust through heightened nationalist tensions. In this film we see no signs of fear or panic from the local population, despite many deaths within the community; the inhabitants are more concerned about maintaining ordinary patterns of living and sociability. The villagers become incensed for the first time when the foreign doctor tries to move bodies from the cemetery to avoid infecting the water; the villagers believe that the deceased must be nearer to the river to move swiftly to the afterlife. The decision to remove all corpses and bury them immediately raises further fury because the villagers expect a certain period to elapse while the bodies are laid out in their homes before burial. Although we must be aware of the potential effects of the orientalist imagination when considering a film such as The Painted Veil, medical history points to its accuracy. In rural China during the 1920s and 1930s, elite medical reformers’ disregard for village internal politics and power dynamics limited the effectiveness of their public health prevention policies, as locals continued the same routines , set during a disease outbreak in Tibet in the 1920s, people living out in the steppe or grasslands continue their very same daily functions, stopping only to pray for the disease to cease.Aside from freedoms and liberties, other films have highlighted how societies sometimes move toward unrest—through either resistance to authorities or physical violence—as a response to perceived infringements on customary and traditional practices that have occurred during an epidemic outbreak. One of the clearest demonstrations of this response appears in the 2006 readaptation of Cinema is not reality, and elements of fear leading to panic and chaos are likely to persist in dramatic representations of disease, purely for entertainment value. These representations may be problematic in 2 interrelated ways. First, “the image of a panicked mob makes exciting footage in disaster movies, but it obscures a broad range of possible public reactions” . In the films mentioned in this article, a recurring lesson is the failure of imposed mass isolation techniques, largely resulting from weak compliance (


Trichoderma reesei is one of the main fungal producers of cellulases and xylanases based on its high production capacity. Its enzymes are applied in food, feed, and textile industry or in lignocellulose hydrolysis in biofuel and biorefinery industry. Over the last years, the demand to expand the molecular toolbox for T. reesei to facilitate genetic engineering and improve the production of heterologous proteins grew. An important instrument to modify the expression of key genes are promoters to initiate and control their transcription. To date, the most commonly used promoter for T. reesei is the strong inducible promoter of the main cellobiohydrolase cel7a. Beside this one, there is a number of alternative inducible promoters derived from other cellulase- and xylanase encoding genes and a few constitutive promoters. With the advances in genomics and transcriptomics the identification of new constitutive and tunable promoters with different expression strength was simplified. In this review, we will discuss new developments in the field of promoters and compare their advantages and disadvantages. Synthetic expression systems constitute a new option to control gene expression and build up complex gene circuits. Therefore, we will address common structural features of promoters and describe options for promoter engineering and synthetic design of promoters. The availability of well-characterized gene expression control tools is essential for the analysis of gene function, detection of bottlenecks in gene networks and yield increase for biotechnology applications.The ascomycete  Trichoderma reesei is a model organism for plant biomass degradation and a production platform for proteins and enzymes  by the US Food and Drug Administration . Another advantage is the cultivation on inexpensive media and the possibility for upscaling to reactor volumes larger than 100 m3 without compromising productivity  annotation CEL7A  from A. niger can be induced by the presence of benzoic acid. It is tightly repressed in the absence of benzoic acid and induced within 10 min upon its addition to the medium , as shown in Figure T. reesei to simultaneously but independently regulate or balance the expression of different genes. Figure In order to realize a metabolism-independent expression and accurate regulation of genes, synthetic expression systems are recommended. Such a well-engineered expression system should respond in a controlled manner to input, for example to an inducing agent, be tightly regulated, cover different expression strength and be non-toxic. In most cases, the controlled gene expression is achieved by the use of a synthetic transactivator, which consists of a fusion of different protein domains. Synthetic transactivators comprise a DNA-binding domain, a heterologous regulatory domain and an activation domain e.g., derived from the S. cerevisiae. It is based on the human estrogen receptor hERα, a member of a family of nuclear receptors for small hydrophobic ligands. The hERα was fused to the DNA-binding domain of LexA or of S. cerevisiae Gal4 and the VP16 activation domain  was successfully applied for  Derntl, .S. cerevisiae light sensitivity toward blue or red light was introduced by fusing photoreceptors of Arabidopsis to the S. cerevisiae GAL1 promoter  light can be applied and removed in an instance, (ii) it is cheap and simple to obtain, (iii) it is easy to control intensity and duration, that means it is fully tunable and (iv) no specific media composition is required. A main drawback is, however, to implement this system on an industrial scale where high biomass concentrations pose clearly a challenge. In tetO operator sequence activating the transcription of the gene of interest. The Tet-off system consists of the tetracycline-controlled transactivator tTA, which allows permanent expression of the gene of interest in the absence of tetracycline. Addition of tetracycline prevents tTA binding to the tetO operator and represses thereby expression. This systems have been adapted for fungi including A. fumigatus  system  and a second one for strong tunable expression of the target gene via an synthetic transcription factor dependent promoter consisting of eight BM3R1 binding sites  approach. For example, a number of activating short sequences are identified and these elements are then arranged in different combination in a backbone. DoE will then help to reduce the number of actual sequences that have to be synthesized and tested. The activity of the new promoter sequences will then be determined and parts with higher or lower impact can be analyzed by Multivariate Data Analysis tools including PCA or PCR (Gagniuc et al., By gaining more and more insights into the regulation of expression, the way leads to the rational design of synthetic promoters optimized for the respective purpose. Several studies were made toward this direction in mammals (Juven-Gershon et al., T. reesei was enhanced for industry by random mutagenesis. To establish T. reesei as recombinant production host, it is more desirable to rationally engineer and optimize the strain for fermentation processes. Many tools are necessary for an efficient modification of the organism, one of them being a broad selection of promoters and expression systems. The choice of the respective promoter depends on the aim of the manipulation, for a simple overexpression a strong inducible promoter does the trick. For complex engineering issues, for example, the manipulation of metabolite pools or the alteration growth parameters toward more favorable characteristics in the fermenter, different promoters and expression systems are needed, that are not interfering with the protein production itself. Finally, synthetic biology offers new avenues and opens the possibility of de novo design of context-specific, customizable promoters. However, to realize these approaches in T. reesei and other fungi, it will be necessary to further increase our understanding of the regulatory networks governing gene expression.For a long time, the natural low cellulase and xylanase production of EF and BS prepared the outline of the manuscript. EF and FW wrote the main part of the manuscript. BS wrote the introduction, read and commented on the ms.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.


Pork has become the number one meat consumed worldwide. Meeting the demand for pork has forced the revolution of swine production from traditional husbandry practices that involved a few pigs or small herds to intensive concentration of swine raised in multisite production systems. This dramatic change has made the production of pork very efficient, but it has also changed the ecology of many swine diseases, may encourage the emergence of new diseases, and amplifies the economic impact of swine diseases. Sustained treatment of diseases in livestock production is not feasible making prevention of disease a priority. Prevention of livestock diseases involves eliminating exposure to pathogens and anti-viral strategies to prevent or reduce clinical disease. For some swine diseases, efficacious vaccines can be made, however, for other diseases the host/pathogen relationship is more complex and efficacious vaccines are not available. Given the increasing demand for pork, the development of new approaches to improve swine anti-viral immunity is critical. Rate-limiting steps to improving vaccines are understanding how the pathogen interacts with the host's immune system, any immunopathology resulting from such interactions and how the host's immune system resolves the infection. Solving this puzzle will require sustained research and may require new technologies to battle contemporary diseases now wreaking havoc in swine production systems around the world. This Special Issue will focus on current swine viral diseases that are the most challenging to the global production of pork with contributions focusing on anti-viral immunity. The quest for food is primal, and for most of mankind's existence, a daily struggle for all. About 15,000 years ago agriculture began to develop with the cultivation of crops and domestication of animals. This lessened the daily burden of searching for food and began providing time for creativity which has led to unimaginable technologic achievements, and to exponential growth in the human population. Despite all contemporary technology, the stability of our food supply is still vulnerable to many challenges that have existed since the beginning of agriculture, and to new ones that are associated with modern agriculture practices that produce massive amounts of food. Although, there are many challenges to meeting our absolute need for food, this review focuses on just one aspect of modern agriculture, the production of pork.In the twenty first century, agriculture reflects a broad spectrum from subsistence farming to single-commodity production systems producing meat, milk, grains, fruits, and vegetables on an unprecedented scale. The increasingly efficient production of pork has made it more readily available and it has become the number one meat consumed worldwide . MeetingDiseases of Swine, 11th edition , a previously unknown swine virus, emerged in the late 1980s and spread around the world within a few years becoming the first of several swine pandemics that would occur over the next 30 years. PRRSV quickly became the number one health problem in major swine producing countries because it is able to affect all stages of production, is highly infectious, has a prolonged shedding duration, and perhaps most importantly, is able to dysregulate the pig's immune response. The economic impact of this virus is substantial, e.g., in 2013 PRRSV was estimated to cost just the US swine industry alone 660 M a year . A numbeFoot and mouth disease virus (FMDV) is a highly infectious virus that affects cloven-hooved animals causing vesicular lesions involving the feet and oral cavity resulting in a crippling disease and loss of production to the extent that this virus is the most important disease concern for livestock producers around the world. Once FMDV has been eradicated from a country, substantial resources are committed to keeping the country FMDV-free that include the regulated movement of livestock, substantial diagnostic testing, and the quest for safe and efficacious vaccines. Similar to PRRSV, FMDV vaccines are available, however, they are serotype specific and lack cross-protection among the 7 FMDV serotypes (The control of influenza A viruses in swine (IAV-S) exemplifies the challenges of passively acquired maternal immunity in modern swine production. In the late 1990s, a novel IAV-S H3 subtype was first detected in the United States, and similar to the then endemic North American H1 subtype, the new virus caused respiratory disease in fattening hogs and sows . In respIAV-S is a swine virus with zoonotic potential . It is uIn 2013, porcine epidemic diarrhea virus (PEDV), one of the swine enteric coronaviruses that causes severe diarrhea in neonatal pigs, was discovered in the Western Hemisphere for the first time. Within 6 months of entry into the US, the virus had spread through all swine dense regions killing about 10% of the pig crop that year. Although, swine can mount a rapid protective immune response to PEDV, young pigs are unable to survive the disease long enough to develop a protective response which makes protecting young pigs the most important step to controlling this disease. The only option to protect the pigs is to provide passive maternal immunity to the suckling pig via colostrum/milk, a strategy that can work but is dependent on the sow having adequate exposure to PEDV to induce mucosal immunity. Although, wild-type PEDV might induce the best lactogenic and colostral immunity for the piglet, immunizing the sow herd with wild-type PEDV has serious safety concerns demonstrating the need for improved PEDV vaccines.Beginning in late 2014 and into 2015, there were outbreaks of idiopathic vesicular disease in Brazil followed by similar outbreaks in the United States. Disease was most often recognized in market-weight swine and sows, and samples from these cases tested positive for Senecavirus A (SVA). Subsequently, the virus has also been identified in Canada, China, Colombia, and Thailand . AlthougThe economic loss from the introduction of a foreign animal disease is multidimensional ranging from the acute direct losses to livestock producers to a chronic loss of production that can diminish an entire industry for extended periods of time, and perhaps permanently. In addition, the increased costs of food and reduced availability of once common products can lead to social instability. In 2018, African Swine Fever virus (ASFV) emerged for the first time in China, the largest producer of pork in the world accounting for over 50% of all production. African Swine Fever was first described in Africa in 1921 causing a fulminating disease in domestic swine . Wild swThe constant need for more food in the world requires each agriculture commodity to be more efficiently produced which includes a perpetual battle against disease in crops and livestock. In the case of swine, the continual evolution of viruses requires sustained research into the basic immunology against these pathogens to provide new mechanistic insights into how pigs, and perhaps other species, respond to pathogens and enable the production of safer and more efficacious vaccines and anti-viral approaches. This knowledge may enable the application of novel technologies that could modulate the pig's immune response in the fight against disease, and ensure the availability of safe and wholesome pork around the globe. In response to the title, it is VERY important to study viral immunity in swine as well as livestock and poultry because more efficient production of meat protein is essential to the quest for more food.KL and AB contributed to and wrote the manuscript.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.


Equity is an important goal for countries in formulating relevant health policies, and research on the equity of health services is more important for China, where the gap between the rich and poor is widening. The aims of this study are to explore to what extent the benefit equity of New Rural Cooperative Medical System enrollees has been achieved and to determine the geographical disparities in Shaanxi province and thus provide suggestions for future policy formulations.Data were obtained from the fifth Health Service Survey of Shaanxi province in 2013. A two-step mode was used to analyse the influencing factors of the inpatient benefit rate and inpatient compensation fee. Concentration indexes and concentration curves were applied to measure the inequity of the inpatient benefit rate and inpatient compensation fee. The decomposition method was employed to explore the source of inequity and horizontal inequity.Based on a sample of 38,032 enrollees, our results showed that there were pro-rich inequities in the inpatient benefit rate and compensation fee. The concentration index of the inpatient benefit rate and compensation fee in 2013 were 0.064 and 0.174, respectively. The economic level (224.62%), self-evaluated health status (− 25.89%) and occupation status (− 12.32%) were the primary three contributors to the inequity of the inpatient benefit rate, and the economic level (106.16%) and age (− 2.88%) were the first two contributors to the inequity of the compensation fee. There were regional differences in the sources of inequities. Moreover, pro-rich horizontal inequity remained after standardizing health care needs.Our results indicated that there were pro-rich inequities in the inpatient benefit rate and compensation fee in the New Rural Cooperative Medical System. The economic levels of enrollees accounted for most of the existing inequity, followed by self-evaluated health scores and age. Efforts should be made to strengthen policies and programmes in the New Rural Cooperative Medical System to achieve basic health services equity, such as implementing hierarchical medical treatments and reducing extra inpatient benefits for the rich. Equity is an important goal as countries perfect relevant health policies. According to the universal health coverage proposed by the World Health Organization in 2013, a well-functioning health insurance system needs to meet both “depth”  and “height”  conditions in addition to providing a wide range of coverage [The New Rural Cooperative Medical System (NCMS) is a basic medical insurance system established by the state to improve the health level of rural residents and solve the problem of “suffering from poverty and returning to poverty by illness”. The Chinese government began to readdress the issue of rural health care and launched the policy of NCMS in 2003 . Last, tRegarding the current status of the NCMS, progress is relatively smooth and its coverage continues to improve, almost achieving the goal of “full coverage in 2010”. To some extent, the issue of rural residents’ medical treatment has been addressed and their economic burdens have been reduced. However, considerable problems and contradictions are highlighted with the development of the NCMS. The NCMS currently features a “low premium, high co-pay rate”. Whether rural residents use health services or not and what the utilization level will be mainly depends on the price of health care services. There is a lower probability of health care utilization with a higher co-payment and price. Some early studies have shown that people with low economic levels have greater flexibility in health services than people with high economic levels, and this high co-pay rate will make the rich who pay more use more health services and thus benefit more from them, implying that the rich will benefit more than the poor. The poor might subsidize the rich with the same level of payment in this case, to some extent, so that the benefits are unequal, which in turn, is contrary to the primary goal of the NCMS.Therefore, based on the situation above, analysing the benefit level of insured NCMS residents and exploring the equity of inpatient benefits and the influencing factors of inequity are of significance to improve residents’ health and benefit status, even in a perfect policy. Some early studies have described the inequity situation in the NCMS. Qingfeng et al. showed that the poor need a large amount of health services, but the rich can gain more benefits than the poor from medical insurance . Zhou etThe NCMS mainly focuses on protecting inpatients from catastrophic expenditures from hospital compensations, but outpatient compensation is relatively limited. Hence, this research only focuses on the inpatient benefit of NCMS enrollees –13.Broad-sense benefits include the increased use of health services, compensation and reduced disease burden; narrow-sense benefits mainly refer to compensation from the NCMS. Indicators, including the general outpatient treatment rate, number of visits, number of hospitalizations and hospitalization rate, are used to describe the residents’ utilization of health services. Compensation can additionally be explained in two aspects: the benefit rate and degree of benefit. This paper analyses the beneficiaries of the NCMS from the perspective of narrow-sense benefits and compensation .From the economic perspective, equity refers to a fundamental criterion for allocating social resources, which means treating various groups with a reasonable and normative standard, despite distinctions between different groups regarding economy and interest. Accordingly, equity in healthcare includes the equity of health status, the equity of health service utilization, the equity of health financing and the equity of health resources allocation. Specifically, equity in the field of health service utilization embodied in the principle of on-demand distribution, which means that health care should be allocated according to health needs. Every member of society with health service needs should have the same opportunity to access appropriate healthcare, gender, race, age, place of residence or purchasing power should not be factors influencing such opportunities . TherefoThe purpose of implementing the NCMS is to cope with the high medical fees and difficulties of attaining medical service, which aims to improve the use of health services, mitigate the economic burden and decrease the inequity of health use caused by income to a minimum. A good policy can be evaluated from the aspects of both equity and effectiveness. Equity should ensure that residents with the same needs attain equal services; effectiveness should improve medical treatment for residents. From the perspective of the benefits of the NCMS, residents should have the same compensation opportunities if they have the same medical needs and they should be able to enjoy the same level of compensation fees on the basis of compensation.In this study, we investigated to what extent the benefit equity of NCMS enrollees has been achieved and the existing geographical disparities in Shaanxi province, which was also determined in other provinces with similar situations in China. An understanding of the nuanced geographical variations and crucial causes of inpatient benefit and compensation inequity is the first step toward reducing equities . FurtherData were obtained from the fifth National Health Service Survey (NHSS) in Shaanxi province in 2013. The NHSS was organized and conducted by the Centre for Health Statistics and Information of the Chinese Ministry of Health. The main aims of this survey were to collect information on health care needs, utilization, quality and expenditures; to evaluate the performance of health reform and development from the previous five years; and to provide evidence for China’s health care planning, targets and action plans –24.Representative samples were obtained through a four-stage stratified random sampling procedure before any individual interviews were conducted . In the The NHSS questionnaire mainly includes household demographics, socioeconomic status, self-reported health status and health care utilization. Data were collected from 57,529 respondents. The adult in-person response rate was 82.1%. Quality control was implemented throughout the survey. The investigators were mainly local medical workers, and the investigation instructors were doctors mainly from township hospitals or health institutions and above. The investigation instructors revisited 5% of the sample households and asked 14 key questions to determine the accuracy of the data recorded by the investigators. The compliance rate after the counter check was more than 97.7%. Various survey data tests, including Myer’s index, goodness-of-fit test, DELTA dissimilarity coefficient and GINI concentration ratio, were applied to check the quality and consistency of the data. The results showed that the survey had no age preference and that the size of the surveyed households was consistent with that of the entire local population.For the purpose of this study, 38,032 samples of NCMS enrollees of age 15 years old and above were selected from the fifth National Health Service Survey in Shaanxi province in 2013.Owing to the reality that the NCMS fund that is mainly used for inpatient compensation and outpatient compensation is rather limited, we selected the following two variables as the main measuring indexes in this study.Inpatient benefit rate: The proportion of enrollees obtaining inpatient compensation from the NCMS during the last year. This rate signifies the probability of obtaining hospitalization compensation.Compensation fee per capita: The amount of the inpatient compensation fee received from the NCMS on the basis of inpatient compensation over the past year. This variable reflects the degree of inpatient benefits.In this study, the factors that affect the hospitalization benefit of the insured include demographic and sociological factors are as follows: Gender, age, marital status, degree of education, occupation, family size, health status , living region, economic level, and access to the nearest medical institution. Among them, gender, age, illness in last two weeks, chronic diseases and self-evaluated health were categorized as need variables; the others were categorized as nonneed variables. , Guanzhong (0.1571) and Shannan (0.1570), implying that there is an inequity slope to the rich in receiving compensation fees in these three areas; the richer the enrollees were, the more they received. When comparing the absolute value of the concentration index of the inpatient compensation fee in the three regions, the largest value in Shanbei implied that enrollees there might have the lowest equity of inpatient compensation fees.The decomposition of the inpatient benefit rate inequity and compensation fee inequity of NCMS enrollees is shown in Table It was observed from the decomposition results that the contribution rate of the known variables to the inequity of inpatient compensation fee was 104.28% and that the residual contribution rate was − 4.28%. The factors that contributed more to inequity included economic levels and age. The contribution rate of the economic level was 106.16%, and its contribution value was positive, indicating that the economic level increased the benefit inequity of the compensation fee to the rich, which enabled the rich to receive more compensation fees. The contribution rate of age was − 2.88% with a negative contribution value, suggesting that age increased the inequity in favour of the poor.The decomposition of inpatient benefit rate inequity and compensation fee inequity of NCMS enrollees in different regions is presented in Table The contributions of the economic level to the inpatient benefit rate inequity of NCMS enrollees in Shaanxi, Shanbei, Shannan and Guanzhong were above the level of the horizontal equity line, which implied that it increased the pro-rich inequity of the inpatient benefit rate; the contributions of need variables and other control variables were below the level of the horizontal equity line, which indicated that it increased pro-poor inequity Fig. . It shouTable The data used in this study were obtained from the fifth National Health Service Survey (NHSS) in Shaanxi province in 2013. The survey was conducted by stratified cluster sampling and indicated sufficient representativeness after the Marye Index test. Regarding the education level, the proportion of enrollees with primary school education or below (44.62%) and junior high school education (41.17%) accounted for the overwhelming majority of enrollees. Only a small number of enrollees (14.21%) had a high school education or above, which was lower than the proportion of rural residents with a senior high school education or above in 2013 (15.40%), implying a relatively low education level of NCMS enrollees.This study also found that women had higher rates of inpatient benefits than men (the sex ratio was 0.94:1) for at least two reasons. First, the relatively poor health status of women prompted their use of hospital services . Women aWe also found an interesting phenomenon: compared to the married, divorced or widowed enrollees, unmarried enrollees mostly aged between 15 to 25 years old maintained good health, used fewer hospital services and had a lower inpatient benefit rate.The inpatient benefit rate of enrollees who were ill in the last two weeks was higher than those who were not, and the rate of inpatient benefit of enrollees with a chronic illness was higher than those who did not have chronic illnesses. The two-week prevalence of disease and the prevalence of chronic diseases can represent the health status of the sample population to some extent. The poor health status of fragile enrollees made their use of hospital services more expensive, leading to a higher rate of hospitalization, which is consistent with most of the previous findings , 27, 28.Another interesting finding was that women received fewer inpatient compensation fees compared with men. One speculation might be that a large proportion of female inpatients were hospitalized for pregnancy, and their hospitalization expenditures were lower than those of other diseases, so less compensation was obtained. Moreover, ideological differences caused by gender differences encourage women to be thriftier in spending money. In the situation of an illness, relatively conservative treatment was preferred by women, which made them less likely to be hospitalized.Inpatient compensation fees were found to be positively related to age. Compared to 15–44 year olds, the inpatient compensation fee was higher for people aged 45–59 and 59 and above. A number of studies have shown that age has a significant effect on the compensation fee under the same conditions and that the compensation fee for older persons is generally higher –33. ThisThe results also showed that NCMS enrollees living in Guanzhong received fewer inpatient compensation fees than those dwelling in Shannan. One explanation for this might be that the rich who live in a more developed area always choose relatively good treatment options or higher levels of hospitalization, resulting in a high-level total expenditure of hospitalization and inpatient compensation fees. Our finding is consistent with most prior studies, where the inpatient compensation fee is positively associated with the socioeconomic level of enrollees, as the rich benefited more from the NCMS , 30–35.We found that there was inequity sloped to the rich in the inpatient benefit rates and compensation fees; the incidence of hospitalization was more concentrated on the population with higher economic levels. Owing to the current compensation model, which was based on “actual medical expenses” in accordance with a certain ratio to be reimbursed, the rich received more inpatient compensation fees. We also found that the inequity in inpatient compensation fees was greater than the inequity in inpatient benefit rates by comparing their concentration indices, implying that the absolute value of the concentration indexes of the inpatient compensation fee was larger than the inpatient benefit rate in Shaannxi province and the other three regions. In addition, we found that Shanbei had the best horizontal equity of the inpatient benefit rate and Shannan had the worst, while Guangzhong had the best horizontal equity of the inpatient compensation fee and Shanbei had the lowest. It is likely that the different physical conditions caused by the geographic environments and economic development of NCMS enrollees may have contributed to the differences in horizontal equity. It is likely that the different physical conditions caused by geographical environment and economic development of the NCMS enrollees may contributed to the differences in horizontal equity. Owning to the different eating habits, customs, topography and climate, there are slight differences in the health status of NCMS enrollees in these three regions. For example, Shanbei is located in the Loess Plateau, the precipitation is relatively less, only drought-tolerant crops could survive here, thus, miscellaneous grains are staple food here. As the Zhai DH & Tao LQ (2004)  highlighThis study revealed that the health status of low-income groups was poor; however, their utilization rate of hospital services and inpatient benefits were low. The benefits of the NCMS were related directly to the utilization of medical services; the more they used medical services, the more benefits they could get. Although most rural residents participated in the NCMS, based on its current compensation policy, low-income enrollees were likely to abandon their use of hospital services due to the handicaps in paying for their own hospitalization needs. The NCMS funding model currently deploys residents’ quota financing, and it is then invested by the government to a certain percentage.For the NCMS, the individual funding and government subsidy standards for different income groups were the same, but according to this payment method, the actual economic capacity of insured residents was not considered. Thereby, under the same circumstances, the inhibition of high-income groups was obviously weaker, helping rich enrollees benefit more. Prior analyses also confirmed this point of view; inequity was found to be in favour of the rich according to the inpatient benefit rates and compensation fees in the NCMS.Our study has several strengths. Initially, current studies on the benefit equity of NCMS enrollees mainly use the concentration indices to measure the degree of inequity of benefits, but very few focus on the sources of inequity and horizontal inequity. We used the decomposition of the concentration index to analyse the sources of inequity and horizontal inequity, providing results and methods as a reference for improving relevant research.This study also has several limitations that should be addressed in future studies. First, the hospital-related expenses and consumer spending data used in this study all were from the respondents themselves; thus, memory bias may be inevitable. Second, with the current data, we were unable to assess how psychological factors were related to inpatient benefits, as most factors in our study were related to physical conditions and socioeconomic characteristics. Third, we only studied the inpatient benefit rate and compensation fee because outpatient compensation is relatively limited in the NCMS. Thus the benefit rate and compensation in this study should be interpreted with caution, as our study mainly focused on NCMS enrollees in China, which may differ from those in other countries and those with different health insurance policies. Last, the fund of NCMS in Shaanxi province started to financed at city level in 2009 , the inpIn conclusion, we found that there was inequity in favour of the rich in the inpatient benefit rate and compensation fee in the NCMS, which implies that wealthy enrollees benefit more. We also substantiated that the economic level, self-evaluated health scores and age contributed to the inequity of the inpatient benefit rate, while the economic level and age were the main contributing factors to the inequity of the inpatient compensation fee. Our findings underlined the need to strengthen the policies and programmes of the NCMS for the equity of basic health services, such as implementing hierarchical medical treatments to encourage patients’ primary diagnosis at the grassroots level. Additional inpatient benefits and compensation for the rich in high-level hospitals might need to be curbed to a relatively equitable level.


Practical independent research projects (IRPs) are a feature of school science in a number of countries. To assess the impact of IRPs on students, a systematic review of the literature was undertaken. Thirty-nine papers met the review inclusion criteria, reporting on work from twelve countries. The review indicates that IRPs are often associated with wider initiatives such as authentic science, problem-based learning, and project-based learning. There is considerable variability in the nature of IRP work in relation to focus, models of provision, assessment, the involvement of external partners such as universities and employers, and funding, and this diversity affects judgements on the quality of the evidence base on impact. The majority of the research reviewed explored areas such as conceptual understanding, motivation to study science once it is no longer compulsory and attitudes to science, and the development of practical skills. Benefits were identified in relation to the learning of science ideas, affective responses to science, views of pursuing careers involving science, and development of a range of skills. Studies focusing on traditionally under-represented groups indicated that such students felt more positive about science as a result of undertaking IRPs. The review findings indicate that further work is needed to enhance the quality of the available evidence, to consider the ways in which IRPs can be validly assessed, to explore more fully the potential benefits for traditionally under-represented groups, and to explore more fully the potential longer-term benefits of participation in IRPs at high school level. This paper presents the findings of a systematic review of the nature and impact of practical independent research projects (IRPs) in high school science, covering their chief characteristics, organisation and assessment, and impact on high school students’ learning of science and affective responses to science.extended investigation or a practical independent research project (IRP). Such projects can take a wide variety of forms, but share several common characteristics. In essence, they are student-led, open-ended research investigations, often supported by a teacher and/or a university-based or industry-based researcher. Students have considerable control in respect of the question(s) they hope the practical work will answer and the way in which the work is undertaken.Practical work in school science can be very diverse: at one end of the spectrum is the ‘recipe’ approach, where a defined list of procedures is followed, while at the other is what can be termed an Typically, though not exclusively, IRPs are undertaken by high school students, and, at the upper high school level, the outcome of the investigation is open in that neither the student nor their teacher knows exactly what the investigation will yield. Beyond this, IRPs may involve external sponsorship, and be associated with science competitions, fairs and award schemes. IRPs can also involve a diversity of assessment techniques, including the production of reports and student presentations. Frequently, they take place outside the formal school science curriculum.For the purposes of this review, IRPs were taken to be student-led, extended open-ended investigations involving practical work, using Millar’s  definitiThere appear to be a number of possible reasons for promoting the use of IRPs in school science lessons. First, the notion of ‘the students as scientist’ is attractive, allowing students to find things out for themselves by pursuing an idea about which they are curious. Second, IRPs are seen as a means of providing students with a realistic taste of scientific research that may motivate them to undertake further study of science. Third, the characteristics of IRPs may be identified in broader, international initiatives of the last twenty years or so, for example ‘inquiry-based science’, ‘problem-based learning’ in science and ‘authentic science’. These approaches have in common the desire to encourage students to engage in activities where at times they behave like scientists, i.e. their work is authentic in that it follows the approaches scientists take when they are trying to solve problems to which there may as yet be no agreed solution. These approaches are primarily aimed at improving cognitive and procedural outcomes for students, though also aspire to have affective benefits.(1) learn in contexts constituted in part by ill-defined problems; (2) experience uncertainties and ambiguities and the social nature of scientific work and knowledge; (3) learning is predicated on, and driven by, their current knowledge state; (4) experience themselves as parts of communities of inquiry in which knowledge, practices, resources and discourse are shared; (5) in these communities, members can draw on the expertise of more knowledgeable others whether they are peers, advisors or teachers. (p1).There are similarities between the features of authentic learning described by Roth and the characteristics associated with problem-based learning (PBL). A PBL approach involves students learning through focusing on the investigation, explanation, and resolution of meaningful problems. PBL has its origins in teaching in medical schools, but has now been used in a variety of subjects, including science. Students work collaboratively in small groups, with the teacher acting as a facilitator to guide student learning through the process of solving the problem presented , including organisation and assessment?What is the quality of the research evidence base on the impact of IRPs?What are the impacts of IRPs on the learning of science and affective responses to science in secondary school students’?The review addressed the following questions:The impetus for the review arose from recent changes in the policy regarding the teaching and assessment of practical work as part of the national examinations for students aged 16 and 18 in England. One outcome of these changes has been a decisive move away from IRPs as part of the core curriculum which, in turn, has led to a concern that there will be a reduction in some of the learning potentially associated with IRPs. While a number of studies have been conducted into the impact of IRPs, to the best of the authors’ knowledge, a review of the associated literature has not been published. Thus the review seeks to bring together recent research into the impact of IRPs, in order to synthesise the existing literature and highlight areas suitable for further investigation.The review took the form of a systematic review. Systematic reviews were introduced as a tool in educational research in the early 2000s to synthesise research findings from a range of related studies , the Education Resources Information Centre (ERIC), PsychINFO and the Social Science Citation Index (SSCI). Additionally, 27 key informants working in the area of IRPs in a range of countries were contacted to identify potentially relevant publications. This was done to add to the robustness of the evidence base, as preliminary electronic searches indicated that there were likely to be a number of publications in the form of grey literature (e.g. reports commissioned by IRP providers) that might not otherwise be identified.In practice, the identification of the relevant literature posed one of the major challenges for the review as IRP activity can be encompassed by a number of other activities. These include: authentic science, independent and/or extended practical work, inquiry-based science, investigative work, practical work, problem-based science and project work. IRP work is also often associated with science competitions and fairs. This diversity in terms necessitated particularly extensive literature searches in order to include all the above terms. Full details may be found in the technical report  addressed by the IRPStudents had major input into the design of the IRPIncluded practical workRequired more than 10 hours of workEntailed production of a report or comparable outputData gathered systematically on students’ learning of science and/or affective responses to scienceSome form of assessment or accreditationPublication written in English.The electronic searches identified 1,403 publications, with a further eleven included based on information from the key informants. To identify the literature that focused specifically on the review questions, the following inclusion criteria were developed:Criteria 3 and 5–7 were set as they encompassed the definition of IRPs used in this review. The review was limited to work undertaken with students aged 11–19 as this covers the high school period where the majority of IRP work takes place in schools. The search covered the period from 2000 onwards in order to focus on recent work. The criterion of an extended period of time for the IRP work was set to avoid the inclusion of short, even single-lesson, investigations which have become common in some countries. The requirement to produce an output of some form was set to yield information on how IRPs might be assessed. When the inclusion criteria were applied, a total of 39 publications resulted.Background information (author(s), year of publication, title, source, country of origin, author details)The aims and research questions of the studyThe name of the associated IRP scheme (if applicable) and a short account of the IRP, including: its aims; principal characteristics ; assessment/accreditation arrangements; associated fundingDesign of the study and sample detailsData collection techniques Methods of data analysis Findings .In addition to the wide range of search terms required and the extensive resulting literature, several other factors contributed to the complexity of the review. A number of different research approaches and data collection techniques were used across the studies as a whole, and this research varied in rigour and detail reported. The studies included in the review took place in a range of contexts within and beyond school settings, and in a range of science disciplines. Thus, a particular challenge for extracting key information from papers was the development of a bespoke data extraction instrument to record systematically the wide range of features and considerable variation in practice associated with IRP work and research into its impact. A pilot version was developed by two of the researchers and independently tested on a subset of papers. Minor modifications were made as a result of this to ensure the instrument captured all the essential information. The resulting bespoke data extraction instrument focused on the following information:The overview is based on 39 publications that report data on impacts of IRPs in enough detail to understand the nature of the IRP and any effects. The publications covered IRP activity in twelve countries, as shown in The majority were from the USA (17 studies) and the UK (8 studies), with two studies coming from each of Australia and Turkey, and single studies from Ireland, Israel, The Netherlands, New Zealand, Qatar, Singapore, Spain and Taiwan.There were three principal contexts in which students engaged in IRPs. In some cases, undertaking IRPs was linked to national policies/agendas. For instance, several USA studies reported on interventions that had secured funding for local initiatives through linking them to policy statements by organisations such as the AAAS (American Association for the Advancement of Science) or the NAS  . Other examples include Symington and Tytler  involved people outside schools. The largest group of these groups comprised university science staff or students, acting as advisers/mentors. Examples in the USA include O’Neill and Polman , Burgin d Tytler  in Austrd Tytler  in Spaind Tytler . Around d Tytler  and Durad Tytler . Less frd Tytler .A small number of publications reported on IRPs undertaken by groups of schools or individual teachers in their own school and not involving any partners: Chin and Chia , Zion etIRPs were most prevalent at upper high school level, i.e. for ages 16–19 (17 studies), as shown in Of the 16 studies focusing on one of the science disciplines, rather than simply being ‘science’, biology IRPs (7) were more common than chemistry (2) or physics (2). Even within a specific science discipline, there was considerable diversity in the topic focus. Biology-related IRPs, for example, explored diet, food and nutrition , participation in the IRP was compulsory. In around half the IRPs (20), students participated as part of a team, with around a quarter (10) requiring individual participation. In a small number of instances, students could choose between team or individual participation.The majority of the IRPs required the generation of one or more products, as shown in Fifteen of the IRP programmes were supported by external funding. Characteristically, this was associated with work involving partnerships with universities, employers or other groups. Where work was required for external examination or specific to one school, it was unfunded. Typically, funding for IRPs came from grants secured from national funding organisations such as government, research councils and charitable bodies with an interest in science education, or from industrial sponsors. Examples included funding from BHP Billiton, a global mining company based in Australia  are already likely to be very sympathetic to the aims of IRPs.A challenge in synthesising the evidence arises from the diversity in provision and execution of IRPs, which is reflected in a corresponding diversity in the aims and range of measures used to assess impact.The main sources of data were students and their teachers, with the most of the work focusing on the impacts on students. Impacts on understanding of concepts, practical skills, cross-disciplinary skills (e.g. working collaboratively in teams), attitudes towards science and motivation to continue with science after it was no longer compulsory were explored. There was also a cluster of studies focusing on impacts on traditionally under-represented groups in relation to gender, socio-economic status and ethnic background. Studies that focused on teachers and others involved  explored views of the impact of IRPs on students together with views on the potential benefits and drawbacks of their own participation in IRPs.None of the studies employed randomised controlled trials; nine adopted some form of experimental design which involved making comparison between participants and non-participants in IRP activities .A wide range of potential impacts of IRPs are reported, particularly on students, with studies reporting on students’ responses to undertaking IRPs, effects on students’ learning and effects on students’ attitudes to science, including attitudes towards pursuing a career in science. Within this, some studies explore elements to do with widening participation issues. Some studies also report on impacts on teachers and, less frequently, impacts on other participating adults such as university scientists and employers.Gains in students’ learning are reported , skills required by teachers and other adults involved in IRPs, and supporting infrastructure. External funding to support IRPs currently comes from a range of sources, including government agencies, charitable bodies, industrial sponsors and other groups that fund research. There are some examples of co-ordinating bodies being established that could play a useful role in supporting IRP work (e.g. the Institute for Research In Schools [IRIS] in the UK), through identifying funding opportunities, training opportunities, and interested external partners.threshold concepts (Land, Meyer, & Smith, In addition to the need for improvement in the quality of the evidence base, the review findings point to three particular areas that would benefit from further research to inform any decision on making more widespread use of IRPs. The first of these is the assessment of IRPs, where there is a dearth of information in the studies in the review. As noted earlier, one of the motives for undertaking IRPs is to give students the opportunity to ‘be like a scientist’. Given this, it would be useful to involve practising scientists in discussions about what being like a scientist means in operational terms, and a consideration of what this means for assessment of IRPs. One avenue of potential utility is that of