Despite a strong evidence base for developing interventions to reduce child mortality and morbidity related to pregnancy and delivery, major knowledge–implementation gaps remain. The Action Leveraging Evidence to Reduce perinatal morTality and morbidity (ALERT) in sub-Saharan Africa project aims to overcome these gaps through strengthening the capacity of multidisciplinary teams that provide maternity care. The intervention includes competency-based midwife training, community engagement for study design, mentoring and quality improvement cycles. The realist process evaluation of ALERT aims at identifying and testing the causal pathway through which the intervention achieves its impact.This realist process evaluation complements the effectiveness evaluation and the economic evaluation of the ALERT intervention. Following the realist evaluation cycle, we will first elicit the initial programme theory on the basis of the ALERT theory of change, a review of the evidence on adoption and diffusion of innovations and the perspectives of the stakeholders. Second, we will use a multiple embedded case study design to empirically test the initial programme theory in two hospitals in each of the four intervention countries. Qualitative and quantitative data will be collected, using in-depth interviews with hospital staff and mothers, observations, patient exit interviews and  document reviews. Analysis will be guided by the Intervention-Actors-Context-Mechanism-Outcome configuration heuristic. We will use thematic coding to analyse the qualitative data. The quantitative data will be analysed descriptively and integrated in the analysis using a retroductive approach. Each case study will end with a refined programme theory . Third, we will carry out a cross-case comparison within and between the four countries. Comparison between study countries should enable identifying relevant context factors that influence effectiveness and implementation, leading to a mid-range theory that may inform the scaling up the intervention.do no harm principle, confidentiality and non-attribution. We received ethical approval from the local and national institutional review boards in Tanzania, Uganda, Malawi, Benin, Sweden and Belgium. Written or verbal consent of respondents will be secured after explaining the purpose, potential benefits and potential harms of the study using an information sheet. The results will be disseminated through workshops with the hospital staff and national policymakers, and scientific publications and conferences.In developing this protocol, we paid specific attention to cultural sensitivity, the PACTR202006793783148. Realist evaluation enhances the explanatory power of process evaluations by providing an analytical approach that starts from an intervention theory and explains the outcome in terms of a configuration of intervention, context, actors and mechanisms of change.The approach furthermore allows testing and developing the theoretical basis of implementation and scaling up of effective interventions.Study limitations include social desirability bias and potential risks presented by cross-cultural differences, power imbalances and western-dominated theories in realist research.Child mortality and mortality related to pregnancy and childbirth remain major public health priorities. Globally, 5 million children die before their second birthdayThe project aims to (1) overcome the knowledge–implementation gap at the level of multidisciplinary teams providing maternity care and (2) promote implementation of evidence-based interventions in hospitals with a target primary outcome of reduced in-facility perinatal  mortality. The ALERT project will develop an intervention that includes four main components :Codesign of the intervention via end-user participation, involving narratives of women, families and midwifery providers. These include nurses, nurse-midwives, midwives, auxiliary staff, physicians and obstetricians.Competency-based training for midwivesQuality improvement (QI) cycles to help providers identify and overcome problems, supported by data from a clinical perinatal e-registry.Mentoring maternity unit leaders to foster empowerment and leadership, complemented by biannual coordination and accountability meetings at district level.et alet alThe intervention is based on a framework that builds on many years of experience working in the respective settings and the literature on QI and learning . Four district-level hospitals were selected in each country, representing a mix of public and private not-for-profit facilities. Each hospital has at least 2.500 births per year and this selection should provide sufficient power (75%–80%) to detect a 25% reduction in early perinatal mortality with 95% CIs. We refer to the overall study protocol paper for more details.10.1136/bmjopen-2021-057414.supp1Supplementary dataAn implementation science approach is at the heart of this study. Since the implementation of evidence-based guidelines (and arguably any QI strategy) is both determined by providers, funding and healthcare system capacity,(i) A stepped-wedge design to evaluate the effect of the intervention on in-facility perinatal mortality with a primary outcome of reduced in-facility perinatal  mortality. (ii) A realist process evaluation (PE) to understand what works, for whom and under which conditions, complemented by an economic evaluation. (iii) Economic evaluation focused on scalability including costing studies in the countries.In this paper, we present the research protocol of the realist PE, which is part of a stepped wedge trial. PEs are often carried out in implementation research, both to address the issue of the black box between an intervention and its results, and also because they are considered as useful in the design and testing of complex interventions.10.1136/bmjopen-2021-057414.supp2Supplementary datawhat works, for whom, in what respect, to what extent, in what context and how? From the perspective of RE, programmes work (or not) because actors make decisions in response to the opportunities or resources that the programme provides. According to Pawson and Tilley, programmes or interventions can be viewed as theories or assumptions held by people  who are embedded in the open social systems in which they operate. Therefore, it is not the programme, but the actors who are engaged in it who bring about the results. To understand how that happens, RE explores the context in which the programme operates and the mechanisms that are underlying the observed change (or the lack thereof). Mechanisms refer to psychological, social, cultural or organisational factors that explain why actors respond to a programme the way they do. This response, however, does not happen in isolation; the context in which the programme takes place influences the way actors respond to it: mechanisms (and thus the programmes that trigger them) only work if the context conditions are right. Summarily, not every programme works identically in different settings. Realist evaluators use the term programme theory (PT) to describe the explanation of how a programme has contributed to observed results. The PT is both the end product of a RE, and it is also a hypothesis that serves as the starting point of any RE. The initial PT shapes the study design, data collection, analysis and synthesis.In the quest to open the ‘black-box’ of complex programmes, Pawson and Tilley developed RE, a theory-driven research approach that seeks to understand the links between context, outcomes and mechanisms.We structured the PE of ALERT according to the steps of the realist research cycle.initial PT on existing evidence , interviews with key actors and/or exploratory research.In consideration of the topic being researched, realists build the study design is chosen as a function of the PT that needs to be assessed.The Data collection tools and methods are selected based on the components of the initial PT to be tested: all data required to test the initial PT should be collected. Often mixed methods  of data collection are used.Data analysis: the Intervention-Context-Actor-Mechanism-Outcome (ICAMO) configuration heuristic is often used in the analysis of data.synthesis based on a comparison of the findings of the study with the initial PT, which is adapted as needed, leading to a refined PT.Each study ends with a Which components of the ALERT intervention work, how, for whom and in which contexts?The main objective of the ALERT PE is to identify and test the causal pathway through which the intervention achieves its impact. Summarily, it aims to answer the question There are four specific objectives:(i) To collaboratively elicit the initial PT of the ALERT intervention. (ii) To test the initial PT through a multiple embedded case study. (iii) To refine the PT of the ALERT intervention using cross-case analysis. (iv) To summarise and disseminate findings in the form of recommendations to inform implementation and practice  at hospital and country levels.In the following sections, each of the four core objectives and the corresponding data collection and analysis methods are presented.We will formulate the initial ALERT PT based on its theory of change (TOC) see , a reviewhat ; the who or recipients ; the where or context  and the how . The TOC implies that end-user participation ensures that the needs of women, families and midwifery providers  are identified and addressed in the form of training and QI. Also, better trained and supported midwifery providers will provide better care, including improved foetal monitoring, improved emergency care and client-centred support during labour. Furthermore, better skilled and empowered midwifery providers will also be better able to quickly make decisions. Finally, improved hospital processes leading to timely access to caesarean section or operative vaginal delivery will reduce hypoxic–ischaemic events and thus reduce stillbirths and neonatal deaths.ALERT’s TOC is informed by the integrated Promoting Action on Research Implementation in Health Services (i-PARIHS) framework.In order to move the TOC to the level of an initial PT, we would need to identify the context elements and mechanisms that would explain how and why the ALERT intervention would achieve the expected results. We plan to carry out the following steps:We will summarise existing evidence to identify any theories that may explain how and in which conditions the ALERT intervention will be effective. More concretely, we will focus on the adoption, diffusion and maintenance of the intervention (components) by healthcare providers and hospital managers and the role of multistakeholder co-production in these processes.We will draw on health facility assessment data, stakeholder mapping data and the national context assessment data collected by other WPs in the intervention, to describe the national and facility context, and the views and perspectives of national stakeholders.We will organise participatory stakeholder workshops to elicit the assumptions of the ALERT consortium members.We will use the opportunity of online and face-to-face monthly coordination meetings, consortia meetings, discussions and feedback sessions to present and discuss the evolving initial PT to our colleague-researchers and stakeholders from each country.The end product of these is the initial PT that will guide the further steps of the PE.To test the initial PT, we will use a case study design. Investigating the intervention’s implementation through case studies in hospitals in four countries will allow us to monitor the actual implementation of the intervention and how it progressively evolves  across the study sites.We will carry out a multiple embedded case study.In each country, the first site selected for the realist PE is the hospital where the ALERT intervention will start at step 1 (Month 19 (M19)–M24) of the stepped wedge intervention design . In thesWe will use the following data collection methods and tools:In each site, we will carry out in-depth interviews with health stakeholders , focusing on their view on the reasons the ALERT intervention works (or not).This will be complemented by opportunistic observations and review of relevant hospital documents.We will draw on data collected by WP3 (training module development), WP4 , WP5  and WP 6  to describe the planned intervention (end product of WP3), the actual implementation of the intervention (WP6), as well as the context and the actors (WP4) and the processes triggered by the intervention (WP6). For more details about these WPs, we refer to the overall protocol paper.We will carry out in-depth interviews with mothers and their families to document their views on the design and implementation of the ALERT intervention.We will draw on the data from patient exit interviews carried out by another ALERT WP to obtain additional information on the views of patients on the care they received and the  influence of the ALERT intervention.Intervals between data collection offer time to analyse data and refine the IPT based on emerging patterns which will be presented at the subsequent consortium meetings. For each data collection method described above, specific tools will be used: a facilitator guide for the participatory stakeholder workshops for ALERT consortium members; in-depth interview guides for hospital managers/in-charges, midwives and district directors of health and in-depth interview guides for mothers and families (the latter interviews will be carried out within another WP). Local research assistants will collect data in each country. To bridge gaps in technical capacity, especially with respect to realist interviewing techniques,Audio files (and handwritten notes) will be translated, transcribed verbatim and managed for analysis using NVIVO qualitative data analysis software. Translation will aim to retain technical and cultural meaning in order to minimise interpretation gaps resulting from cross-cultural differences.As mentioned above, RE is method-neutral: discipline-specific and appropriate techniques are adopted during data analysis. In general, the analysis will be guided by the ICAMO configuration. Analysis of the qualitative data will be guided by the primary elements and themes identified in the initial ALERT PT. Analysis of transcripts will begin immediately following transcription, allowing for early identification of ICAMO configurations and patterns. In line with realist principles, a thematic coding approach will be used that is based on the core elements of the initial PT. The framework analysis methodThe data will be categorised in a first round of analysis using the ICAMO configuration.New interpretations will emerge in subsequent rounds of coding, leading to a refined analysis.Next, a retroduction approach will be adopted, whereby the observed outcomes are explained by looking into the mechanisms, actual intervention modalities, actors and context elements. This results in descriptions of the actual intervention, its effects , the context elements and the underlying mechanisms (ICAMO configurations), which offer the most plausible explanations of the observed outcomes.During this analytical process, we will also draw on data and findings from other WPs and integrate participatory reflection and feedback from the ALERT consortium annual meetings. Data triangulation and verification will be ensured by comparing responses from different respondents and from other data sources in order to identify similar and divergent views. This will contribute to the internal validity of the analysis.The site-specific ICAMO configuration(s) will be compared with the initial PT, and in a process of abstraction, the initial PT will be modified when and where needed.The above described ‘in-case’ analysis will be followed by cross-case analysis within and between the countries. Comparing between the study countries should enable identifying relevant context factors at country level and assessing their influence on intervention implementation and scale up. In practice, we will develop tables presenting the different ICAMO configurations by country. We will look for patterns of similarity and difference and see how these challenge, refute or confirm the initial PT. Prior to the finalisation of the refined PT, the results of the PE will be discussed in a final round of participatory workshops with ALERT partners and in-country stakeholders directly involved in the project. This will provide an opportunity to contextualise, reflect on and improve the PT.In summary, the final round of PT development will occur iteratively during the cross-case analysis, leading to a final PT that may reach the level of a mid-range theory, which indicates what it is about the ALERT intervention that works for whom and in which circumstances. The results may both inform the formulation of recommendations for scaling up the intervention in the study countries, and may also allow tailoring of similar interventions to different contexts.To summarise and disseminate findings in the form of recommendations at study site and country level, we will leverage the annual consortium project meetings. This also serves as an opportunity for cross-pollination of experiences and learning between intervention countries, and for presenting and discussing the research findings within the broader findings of the project. Feedback meetings will adopt a participatory open discussion approach with the aim to discuss potential and critical action points for improving implementation and scaling up to other locations, as well as the possible implications (positive and negative) of such efforts.In addition to the final country reports on the RE from each country, findings will be further disseminated through at least two open-access publications and two international conferences. We expect that the doctoral student working on this PE will provide additional avenues for dissemination at country and international level (conferences and peer-reviewed publications).In this component of the ALERT project, which in essence is an evaluation of a QI intervention, patients nor members of the public were involved in the design and they will not be involved in the actual evaluation and analysis. However, during the formative phase of the project, the ALERT intervention will be codesigned with women and families living in the study sites. Their narratives regarding pregnancy, birth and their health seeking behaviour in general will be documented and analysed in order to inform the intervention design. They will be included in feedback meetings at the end of the project.The research team recognises the ethical implications of any form of research. The realist PE will be carried out in line with the principles of the Declaration of Helsinki as amended in 2013, and any further versions.The study team will place particular emphasis on:Data collection modalities will be aligned to the sociocultural norms and preferences of people in their daily life and within organisational settings . All personnel on the study team will be bound to the code of conduct and ethical restrictions of the research.Respondents will be well informed of their rights to withdraw from the study at any point in time and all efforts will be made to ensure that no discomfort or stress is experienced by respondents as a result of the research. This includes allowing respondents to choose their preferred location and time for interviews with care taken to ensure privacy to the greatest degree possible. Informed consent, privacy and confidentiality, as well as respect for participants’ time will be prioritised.Only ALERT team members will have access to raw data. All documents, completed questionnaires and audio-recordings will be treated with the strictest care for confidentiality. Reports will be compiled with the intention to protect the identity of respondents while representing their views and opinions as accurately and fairly as possible.The views and experiences of respondents for the realist PE are primarily collected through participatory sessions and in-depth interviews . We consider that the issues to be discussed in interviews are of a non-sensitive nature and we do not foresee any harmful risks or adverse outcomes . Due to the nature of health workers’ jobs, interviews will be conducted at a place and time of their convenience without hindering their service delivery tasks. Respondents will, however, be making a sacrifice of their time in order to participate in the interviews. They will be compensated in line with the country standards for transportation reimbursement and provision of refreshments .Written or verbal consent of respondents will be secured after explaining the purpose, potential benefits and potential harms of the study using an information sheet. Copies of informed consent will be available in the local language of the participants  and where applicable, English. Data collectors will explain the informed consent form and respondents will be encouraged to ask for clarification or ask any questions. Respondents able to read and write will be required to sign the consent form themselves. In case of illiterate study participants, the data collectors will read the form carefully to them and they will countersign the form using their thumb impression. Where participants prefer to provide verbal consent in place of written consent, the consent will be audio-recorded. In this case, the participant or the researcher will read the paragraph granting consent aloud while being audio-recorded. Interviews conducted under verbal consent can only proceed if there is at least an audio-recording of the consent. The respondent can still decline audio-recording for the full interview. Where the respondent does not give consent for audio-recording, only handwritten notes will be taken during the interview.The consent procedures make it clear to research participants that they have the right to withdraw from the study at any point, and to refuse to answer questions without any negative consequences.Possibilities for study withdrawal would include the following:Where respondents have identified that they would be at risk from participating in the studyWhere a respondent self-reports that there has been a threat, verbal abuse or attempts to restrict their access to care or other services due to their participation in the data collection.When the research team identifies that there has been an incident, where recriminations have been levelled against respondents due to their participation in the study.Where a potential respondent declines providing any type of documented consent .We received ethical approval from the local and national institutional review boards as follows: Karolinska Institutet, Sweden (Etikprövningsmyndigheten Dnr 2020-01587); Uganda National Council for Science and Technology (UNCST) (HS1324ES); Muhimbili University of Health And Allied Sciences (MUHAS) Research and Ethics Committee, Tanzania (MUHAS-REC-04-2020-118) and The Aga Khan University Ethical Review Committee, Tanzania (AKU/2019/044/fb); College of Medicine Research and Ethics Committee (COMREC), Malawi (COMREC P.04/20/3038); Comité National d’Ethique pour la Recherche en Santé, Cotonou, Bénin (83/MS/DC/SGM/CNERS/ST); The Institutional Review Board at the Institute of Tropical Medicine Antwerp and The Ethics Committee at the University Hospital Antwerp, Belgium (ITG 1375/20. B3002020000116).The results of this study will be published following the European Union’s open-access policy. As mentioned above, we will use several avenues. First, we will organise workshops at hospital-level, district-level and national level in the four study countries. Second, we will draft and submit scientific publications to open access journals and submit our work for presentation at conferences. Third, all publications and products will be published in a website .In implementation science, finding heterogeneity in results across different settings and types of organisations and by different actors is common. This variation may often be explained by the dynamic interplay between the intervention, its context, the implementation process and the agency of involved actors. When these interactions are not accounted for in an evaluation, the result is a ‘black box’ of knowledge that provides little or no explanatory insight on causal factors that explain how interventions lead to outcomes. In response to the evaluation approaches dominant in the 1970s and which focused almost exclusively on effectiveness, theory-driven inquiry methods were developed.et al call for using mid-range theories of implementation, referring to Merton’s definition of middle-range theories as theories that are situated between minor working hypotheses (nowadays often referred to as programme theories) and the all-inclusive unified theory (or grand theories).The 2015 guidance on the conduct of PE developed by the UK Medical Research Council (MRC) calls for paying more attention to the intervention theory.Previous studies have shown that realist principles can be adapted and applied to all phases of the PE cycle.As with any study, there are some limitations to this study. Social desirability bias can occur when respondents answer to questions based on what they believe the interviewer wants to hear, or when specific responses are assumed to be more socially acceptable. Attempts to minimise this bias will be made by asking to view documentation where appropriate and triangulating data from multiple sources across WPs. The challenges of cross-cultural differences, power imbalances and western-dominated theories in realist research are additional recognised risks.


Monkeypox was first diagnosed in humans while enhanced surveillance for smallpox was carried out during the eradication programme.3 Smallpox was declared eradicated on 08 May 1980 and smallpox vaccination discontinued globally. Given the serological cross-reactivity of orthopox viruses, the effect of cessation of smallpox vaccination on the possible emergence of MPX was anticipated. Arguments on the theory of ‘vacated niches’ have been ongoing since the eradication of smallpox.4 The theory explains how the vacated niche left by the eradicated pathogen presents a vacuum that may be filled by pathogens which have gained a competitive advantage.Monkeypox (MPX), a zoonotic viral infection, presents as a febrile illness with a typical vesicular-pustular rash. The disease is rarely fatal but may be temporarily debilitating, with a few experiencing severe pain and complications observed as an exception.5 More than 80% occurred in children under 10 years of age who were unvaccinated for smallpox. Monkeypox hit the news in 2003, when a MPX outbreak was reported in the United States (US).6 This outbreak involved the importation of rodents from West Africa for the exotic pet trade. When brought under control, an increased appreciation remained for the possible risk of similar events in the future, as well as the use of MPX as a bioweapon, not only in populations with waning smallpox immunity but also in a growing population of individuals not vaccinated for smallpox. In 2004, a list of priority MPX research needs was published and included the re-establishment and strengthening of human MPX surveillance in endemic countries; studies of the characteristics of MPX and other pox-like illnesses in patients living with HIV; ecological and natural history studies; population-based studies to define the clinical, epidemiological and ecological characteristics; and improvement of laboratory diagnosis of human MPX.7 Regardless of the appreciation of the possible future risks associated with MPX, it remained a neglected disease in the years that followed.In the years following the eradication of smallpox, MPX cases remained rare. From 1970 to 1979, 47 cases of MPX were reported from five countries in West and Central Africa.5 Many argue that the orthopox-immunity gap following cessation of smallpox vaccination is a contributing factor. It should, however, be observed that little is understood about the natural ecology of MPX, and so it is not possible to determine other factors at this time that may have been driving the emergence of the zoonotic disease in endemic countries. Since the re-emergence of MPX in Nigeria, cases in travellers returning from Nigeria were reported annually from 2018 to 2021.8 In May 2022, the confirmation of MPX in the United Kingdom (UK) in a traveller from Nigeria was quickly evolved, and by August 2022, more than 40 000 cases of MPX was reported from nearly 100 countries.10 Men have been affected disproportionately, notably men who have sex with men, with heightened risk in individuals with multiple partners.10 From June 2022 to August 2022, five cases of MPX were confirmed in South Africa, all male patients, some with a history of recent travel to Europe . The World Health Organization declared this outbreak a public health emergency of international concern to escalate and coordinate public health responses and scale up production of, and increase access to, countermeasures. This is because of the concern that unless the epidemic can be controlled at an early stage, the disease may remain as a widespread human-to-human transmitted infectious burden. The epidemic is fraught with complexities, including stigma associated with the unfortunate naming of the disease and the fact that currently, it is primarily a vulnerable community, subjected to many years of social injustice and discrimination, that is being affected. Given the often mild presentation of the disease, those affected may not seek medical attention, evading surveillance and the health responses intended to break chains of transmission. A scramble for access to vaccines has also ensued, and questions of equity in vaccine access are raised once again.A steady rise in the number of MPX cases was reported in Africa for the past two decades, notably in the Democratic Republic of Congo (DRC) and in Nigeria .In retrospect, the smouldering MPX risk has taken flame in a way that was not foreseen. The epidemic has produced a complex and urgent public health dilemma in a world that is fatigued by the COVID-19 pandemic. This fatigue, complicated social issues and a disease that has many scientific gaps and unknowns pose real risks for attempts to disrupt the transmission of MPXV during the 2022 multicountry outbreak. Intensified public health measures are urgently required, including equity and access to vaccination for those at risk. A key question is whether MPX, as a disease that is now transmitted from human to human rather than as a zoonosis, is here to fill the ‘vacated niche’.


The circular economy is an emerging paradigm with important economic, environmental, and societal implications. As the world faces such paradigm shifts, new and radical technologies are urgently needed to enable it; blockchain technology can assist to accomplish the aforementioned circular economy shift given its decentralization and distributiveness principles as well as its smart contract capability. This study represents one of the first attempts to analyze those academic research domains together adopting a science mapping technique. By adopting such approach, the study envisages research challenges, highlights important research gaps, and proposes future paths in the blockchain and circular economy fields. Among the others, key findings show that blockchain technology as a tool for promoting the circular economy has been extensively researched at the micro  and meso levels  more effort on how blockchain can support the development of circular smart cites and measurement tools for providing information to stakeholders and assisting in policy creation expresses the greatest potential in terms of novel research. Moreover, the research suggests that another possible stream of research might be dealing on how blockchain together with physical technologies , can support the transition towards the circular economy. The established linear production and consumption economic model has been recently argued by the circular economy (CE) paradigm . This evIn this context, the aims of this paper are to analyze the use of the BT as the backbone for the development of the CE describing the main areas of research, visualize the most recent trends, and envisage how research in this field can evolve in the near future. Considering that literature in this field is fast emerging, it makes critical to capture the implications of BT development and propose a new stream of research also with bibliometric methods able to deal with a consistent amount of scientific papers. While this method does not provide a comprehensive analysis of all papers of interest, it does provide a systematic and replicable way to map knowledge developments over time and trends of topics of interest in the research literature . MoreoveThe paper is organized as follows: the next section provides an overview of the blockchain and the CE paradigm. The third section presents how data were collected and treated. Then the fourth section presents the results and pathways for further research. Finally, in the conclusions, the study’s most important contributions are emphasized.Blockchain is a technology allowing the creation and management of a large distributed database for arranging transactions between multiple nodes on a network . The bloIn general, many types of blockchains exist based on the data that is handled, the availability of that data, and the activities that can be performed by the user. The public, consortium, and private are examples of this.According to Zheng et al. , a publiOn the other hand, only a limited number of users may participate in the distributed consensus process in a consortium blockchain . Those uFinally, only selected nodes can join a private blockchain network. As a result, it is a decentralized yet centralized network , 28. PriThe blockchain appeared together with the idea behind a decentralized network to process and verify monetary transactions named Bitcoin . The BitIn the last years, the use of the BT moved away from its original application  to embrace wider applications –31. SmarDefining CE in not easy; indeed, there is currently a lack of agreement on this subject. As Kirchherr et al.  showed tThe CE has been also defined as a cycle of resource extraction, transformation, distribution, use, and recovery of materials , 45. To However, many authors underline also other relevant aspects that define CE. For instance, Howard et al.  and MorsOther authors identified CE with a closed-loop system , 50. RecWhen we expand the research of a definition to the grey literature, it gets even more diverse. The Ellen MacArthur Foundation, a non-profit organization committed to the comprehensive development and implementation of the CE, has proposed three circular value creation principles to define CE . FirstlyIn addition to definitory aspects, literature on CE dedicated much attention to drivers towards the CE and barriers impeding a full transition towards this paradigm. For instance, De Jesus and Mendonça  identifiIn regard to the preceding description of CE, BT can efficiently cater to the aspects of sharing, optimization, and virtualization. As a result, a wide range of regenerative digital alternatives for the CE’s objective of sustainability become available. For instance, by using a decentralized approach of value production and circulation rather than the traditional value creation approach, the CE can profit from simultaneous collaboration . ThroughAt present time, only Böckel et al.  conductea visual representation of the state of the art in a research area;an orientation for scientists and practitioners in expanding their area of interest on the topic;a comprehensive analysis of future approaches in developing a field of research.The methodology adopted in order to perform the analysis is a bibliometric mapping approach. The main objective of this approach is to visually represent relationships between items of interest. In detail, such methodology has been used in several fields –67 in orAlthough a few recent bibliometric researches have addressed the CE research field , et al.,In order to address the study’s research aims, the first step was to identify the appropriate papers dealing with BT and CE. In more detail, the research design depicted in Fig. Data were gathered from the two main scientific citation and indexing services, namely, Web of Science (WoS) and Scopus. In comparison to EBSCO, Google Scholar, or others, Scopus and WoS databases ensure a greater range of high-quality, peer-reviewed journals on the subject under investigation .Because this analysis aims at understanding a relatively recent phenomenon, no precise time frame has been selected. For the same reason, it was decided to not limit the search just to articles published in academic journals, but also those presented in conferences and available into books that were indexed on the two citation and indexing services. Only English-language publications were considered.Publications were selected through a keyword filtering criterion as both WoS and Scopus allow for keyword search. In more detail, to retrieve all relevant papers, the Scopus and WoS keyword searches were adjusted to include titles, abstracts, and keywords.“blockchain” OR “block chain” OR “cryptocurrenc*” OR “distributed ledger” OR “shared ledger” OR “smart contract*” AND “circular economy”Firstly, a shortlist of keywords has been selected after having drafted the first outline of publications on the topic , 45, 71.The initial search generated 221 publications (124 from Scopus and 97 from WoS), but when the results were refined by removing duplicates, the Scopus and WoS databases yielded 137 papers.Table The chosen methodological approach aims at identifying the structure of all the available contributions related to the field of BT. In particular, by producing a visual representation of this research field, the paper aims at providing an overview of the whole research area, the different subtopics, how those subtopics are linked together, and especially a temporal trend of those researches. The fundamental assumption is that word co-occurrences reveal the underlying intellectual structures of research dynamics and consequently can represent a useful technique for assessing real word applications. This analysis represents a useful means to investigate the orientation of future research lines and business application within this field. In detail, VOSviewer  has beenFinally, a term map representing the whole research field composed by the 137 papers collected has been produced.In order to examine the interrelations in the field of BT and CE, we used an overlay framework that allows to represent the set of retrieved papers on a global map of science based on 20.554 academic journals . This prThe Rao-Stirling diversity index was developed as a measure of interdisciplinarity in the BT and CE research field , 79. TheThe map shown in Fig. The green cluster groups business-related keywords and researches conducted with the aim of exploring the use of BT to organize the supply chain according to CE principles but also how BT can be a useful tool to revise the business model to adopt a more circular one. Studies exploring the use BTs in circular supply chains aim mostly at introducing novel models based on BT aiming at solving traditional supply chain problem such as the relationships between supply chain members or the absence of information for consumers regarding product origins.For instance, Zhang , adoptinNowadays, the COVID-19 pandemic has brought to light the flaws in supply chains as well as the limitations of present technologies. Interestingly to notice, some of the researches related to keywords belonging to this cluster explored also how businesses create new skills and abilities by grounding on CE principles and BT in responses to supply chain disruptions during COVID-19 , 82, 83.Finally, the cluster suggests the application of the BT in supporting reverse logistics operations for returned, damaged products and products reaching the end of life as an enabling technology to implement take-back programs by firms  .According to Narayan and Tidström , one of The red cluster at the bottom left of the map is connected with issues related to the end-of-life management of products . Topics on this cluster are strongly connected with the Internet of things technology (IoT). The IoT is a fast-growing industrial field aiming at transforming business activities, cities, and homes making them smarter by embedding them with electronics, software, sensors, and connectivity that enable a wide variety of objects to collect and exchange data. According to Biswas and Muthukkumarasamy , embeddiOne of the most important bottlenecks for the uptake of CE strategies is a lack of trustworthy information on the availability, amount, quality, and compatibility of recycled feedstocks. Manufacturers are not incentivized to purchase recycled feedstock without such trustworthy information .In such a framework, researches addressed some of the structural challenges emerging due to the lack of technologies in plastic waste collection and recycling processes and the lack of reliable data about recycled plastics . In partThe yellow cluster groups issue is strictly connected with energy generation and management in the context of CE. The transition towards CE call for the adoption of natural energy resources and for reducing energy consumption. Energy distribution networks have become increasingly sophisticated as the trend toward the utilization of renewable energy resources has grown. As a result, efficient energy distribution, unlawful energy consumption, and individual energy producers’ entry into the market are some of the most pressing concerns nowadays. In this context, BT and its integration with renewable energy systems are discussed widely in the literature , 94, 95.The blue cluster groups issue is mostly connected with exchanging of information of products all along their life cycle, from the design phase through the usage of consumers including the condition of the product after the first use and or reuse potential. The cluster is thus strictly shaped by the topic of Industry 4.0 a paradigm that was first introduced in Germany in 2011 at the Hannover Messe . IndustrFinally, the purple cluster groups keywords dealing with problems and drawbacks in using the BT for supporting the CE. While BT has huge potential to help in the transition to the CE, the term map shows that the technology faces a number of technical problems also connected to CE. Security, such as cyber-attacks and issues related to BT use in CE contexts, were highly debated in research , as wellOther technical challenges include high development costs and limited scalability; all of those are also largely mentioned in researches . MoreoveSeveral researchers find an agreement that CE is divided into three stages of study and implementation: micro, meso, and macro . CompaniSome recent research in the field of CE suggest that it is vital to build a measuring mechanism in order to determine if CE adoption is contributing to meaningful change , 126. InAnother possible stream of research arises from the fact that analysis of how BT together with physical technologies can support the transition towards the CE is also under-dimensioned at present time. According to Lacy et al. , physicaConsidering that from the analysis emerge that BT for supporting the CE is not immune from problems and drawbacks , future research can focus on addressing those existing issues and new ones. For instance, one recent issue acknowledged by Caldarelli  is the sMoreover, several keywords in the term map suggest that the benefits of BT for the CE were largely explored in academic research. In particular, a focus on the business and environmental advantages is assessed in researches dealing with the supply chain and business models. This field of research seems thus evolving similarly to most of CE-related researches that have primarily focused on the environmental and economic dimensions, while social aspects such as have only been tangentially and sporadically incorporated into the CE concept . In suchFinally, in order to deeper investigate the research field and formulate future research avenues, an overlay representation of journals in a global map of science has been produced. Even if the papers presented in this map are only 66 , this approach can be useful to deeper assess the research domain at this initial stage. As presented in Fig. The transition to the CE is also supported by material science, chemical, and biological science , 133, anBT and the CE are two new paradigms with significant consequences for business and society. This research represents one of the first attempts to analyze those research domains together by adopting a science mapping technique. Moreover, the research examined research issues, identified significant research gaps, and suggested future directions in the BT and CE domains.The clusters identified in the term map suggest that BT as a tool for supporting CE has been widely explored on a micro  and meso level . On a macro level, academic researchers are merely dealing with waste management activities that can be supported by BT and other technologies such as IoT. Thus, fostering researches on the potential usage of the BT on a macro level  represents one of the most promising avenues for future researches.Other researches focused on how BT can support the exchange of product information all along their life cycle also with the help of other typical Industry 4.0 digital technologies. Thus, another possible stream of research is connected with understanding how BT together with physical technologies can support the transition towards the CE . Finally, results show also a low level of interdisciplinarity of the research domain at present time, thus would be necessary also to connect more with other disciplines such as material science, chemical, and biological science.Despite the importance of the results, some possible limitations should be mentioned. Firstly, a limitation could be inherent in the assumptions taken during the keyword selection process; even if the keyword were validated by international experts on the topic, some distortion could be still caused by the data selection process. Secondly, as suggested by Heersmink et al. , a map i


Residents' high medical expenses is the core challenge that needs to be solved urgently in China's medical reform for a long time. Based on the panel data of 30 provinces in Chinese Mainland during 2011–2019, we evaluate the impact of China's national comprehensive medical reform pilot policy on residents' medical expenses by using the difference-in-differences model. The results show that the pilot policy was generally conducive to reducing residents' medical expenses, resulting in a reduction of 2.13% in per capita medical expenses for inpatients, but the effect on per capita medical expenses for outpatients was insignificant. Mechanism analysis shows that hospital competition and institutional environment played a moderating role in the effect of the pilot policy on residents' medical expenses reduction. The more intense the hospital competition and the better the institutional environment, the more significant of the reduction effect. In addition, the reduction effect of the pilot policy was greater in the central provinces, the provinces with poor medical infrastructure, and the provinces with strong financial strength. This study provides useful policy insights for deepening medical reform and reducing residents' medical expenses. The rapid rise of medical expenses will crowd out residents' consumption in other fields, bring about a loss of social welfare, and thus affecting the sustainable development of macro-economy , 2. TherAs the largest developing country in the world, China realized the incremental expansion of medical and health service supply since the market-oriented reform of medical and health services in the late 1990s. It greatly contributed to the rapid development of the medical service industry . Howeverthe Opinions on Deepening the Reform of the Medical and Health System.” The “New Medical Reform” thereafter beginning, which aims to effectively reduce the burden of residents' medical expenses  issued “expenses , 8. On tAgainst this contextual backdrop, we use the exogenous shock of China's NCMR pilot policy, and build a difference-in-differences (DID) model to test the impact of the pilot policy on residents' medical expenses. Compared with existing literature, the marginal contributions of this study are mainly in the following three aspects. First, in terms of research topics, although the NCMR pilot policy has been implemented for more than seven years, there was little literature on the quantitative evaluation of the policy's implementation effects. Although a few studies focused on the policy , they maThe remainder of this study is organized as follows: the second section is the literature review, the third section introduces the methods and data, the fourth section is empirical results and analyses, the fifth section is further analyses, the sixth section is discussion, and the seventh section is conclusion.The rapid rise of residents' medical expenses is a common problem in medical reform around the world, and also a hot topic in academic research. In general, the existing literature comprehensively investigated the influencing factors of residents' medical expenses from multiple perspectives. Some studies believed that serious air pollution is not conducive to residents' health, which may increase residents' medical expenses –14, whilIn addition, many literatures discussed the impact of medical reform on residents' medical expenses. Kuroki  used theAs for China, many scholars also paid attention to this topic. Based on the China Health and Retirement Longitudinal Study (CHARLS) database in 2013, 2015 and 2018, Liu and Hu  assessedThroughout the existing literature, we can find that the existing literature comprehensively analyzed the effects of many medical reform policies. However, China's NCMR pilot policy has received less attention. Wu et al.  took ZheThe pilot governance is a typical governance mode with Chinese characteristics, which was widely used in economy, ecology, public service and other reform fields . Since tWe will comprehensively investigate the impact of China's NCMR pilot policy on residents' medical expenses from two aspects: the direct effect and the moderating effect. Among them, the analysis of the moderating effect will be carried out from both the micro and the macro levels. The problem of “expensive medical expenses” is the primary issue that China's NCMR pilot policy striving to address. In practice, the pilot provinces have adhered to the basic principles of public welfare, full coverage and synergy, and also innovated a number of policy measures to reduce residents' medical expenses . First, Hypothesis 1:China's NCMR pilot policy was conducive to reducing residents' medical expenses.In theory, whether the effect of China's NCMR pilot policy to reduce residents' medical expenses can be fully realized is affected by many factors at the micro and macro levels.On the one hand, at the micro-level, hospital competition is an important factor. For a long time, China's access to the medical service market is relatively strict, adhering to the policy of public institutions taking the lead and private institutions as the supplement . As a reOn the other hand, at the macro-level, institutional environment is also an important factor. Market-oriented reform is an important direction of China's NCMR pilot policy , 30. ForHypothesis 2:The effect of China's NCMR pilot policy on residents' medical expenses reduction was affected by hospital competition and institutional environment. The more intense the hospital competition and the better the institutional environment, the more significant the effect of the pilot policy on residents' medical expenses reduction.Based on the analysis framework of DID, we examine the impact of the NCMR on residents' medical expenses. The benchmark model is constructed as follows:i and t represent the province and year, lnME is the explained variable, indicating residents' medical expenses; Policy is the core explanatory variable, referring to China's NCMR pilot policy; X denotes a series of control variables that may affect residents' medical expenses. In the benchmark model, we also control for the province fixed effects (Province FE) μi and the year fixed effects (Year FE) ηtto capture the unobservable factors of provinces and years. εit represents the error term.Where the subscript 1 of Policy. A significantly negative β1 indicates that China's NCMR pilot policy is conducive to reducing residents' medical expenses. On the contrary, if β1 is positive significant or insignificant, it indicates that the pilot policy fails to effectively solve the problem of “expensive medical expenses.”Our main concern is the regression coefficient βIn order to explore the mechanisms of China's NCMR pilot policy affecting residents' medical expenses, we further construct the following moderating effect model :M represents the moderating variables. Corresponding to Hypothesis 2, we construct the moderating variables from both the micro and the macro levels, and the definitions of other variables in this model are consistent with the benchmark model.Where, 2 of the interaction term Policy × M, a significant α2 indicates that the moderating variables do play a moderating role in the process of China's NCMR pilot policy affecting residents' medical expenses.In model (2), we mainly focus on the regression coefficient αME_outpatient represents the logarithm of per capita medical expenses of outpatients, and (2) lnME_inpatient denotes the logarithm of per capita medical expenses of inpatients.We use per capita medical expenses to measure the residents' medical expenses, which is specifically divided into two categories: outpatients and inpatients. To ensure that medical expenses are comparable across years, we convert the per capita medical expenses to constant 2011 prices. On this basis, we take logarithm of the per capita medical expenses to mitigate the effect of heteroskedasticity. Therefore, there are two explained variables in this study: (1) lni was identified as the pilot in year t, the value of Policyit in and after year t is set to 1, otherwise the value is set to 0. In 2015 and 2016, four and seven provinces were selected as pilot provinces, respectively, constituting the experimental group, and the remaining 19 provinces constitute the control group.We take China's NCMR pilot policy as a quasi-natural experiment and use the dummy variable to reflect the pilot policy. Specifically, if province Hypothesis 2, we construct the moderating variables from both the micro and the macro levels.According to Competition). Referring to the existing research ((1) Hospital competition . We apply the Marketization Index to measure the institutional environment, which is widely used in existing literature  Institutional environment . Economic development level is an important factor affects residents' medical expenses ((1) Economic development level . Industry structure affects the quality and level of healthcare services ((2) Industry structure . Residents' health status is another important factor that affects medical expenses ((3) Residents' health status . Numerous studies showed that severe air pollution can cause various diseases and affect residents' physical and mental health ((4) Environmental pollution . Ecological endowment may indirectly affect residents' medical expenses by affecting their health. Therefore, we also introduce this as a control variable, which is measured by forest coverage ((5) Ecological endowment . The total health expense is an important variable reflecting medical support of local governments and has a significant impact on residents' medical expenses. In this study, we use the logarithm of the total health expenses per capita to reflect medical support.(6) Medical support . Medical infrastructure is another important factor that determines residents' medical expenditure ((7) Medical infrastructure  in Chinese Mainland during 2011–2019 as the research sample to evaluate the net effect of China's NCMR pilot policy on residents' medical expenses. The data are mainly obtained from the Policy is 0.0044 but not significant, indicating that China's NCMR pilot policy had no significant impact on residents' medical expenses of outpatients. Column (2) presents that the estimated coefficient of Policy is−0.0213 and significant at the 1% level, indicating that the pilot policy significantly reduced residents' medical expenses of inpatients. In terms of economic significance, the pilot policy resulted in a reduction of approximately 2.13% in per capita medical expenses of inpatients. Since residents' medical expenses for inpatients is much higher than that for outpatients  being included in the pilot scope, then beforeit (afterit) takes the value of 1, and the other cases take the value of 0. In the empirical analysis, we use the year before implementation (t = −1) as the comparison period to avoid the influence of multiple collinearities.Where ME_outpatient or lnME_inpatient is the explained variable, the estimated coefficient of beforeit is not significant, indicating that there is no systematic difference in the change trend of the per capita medical expenses between the experimental and control group samples before the implementation of China's NCMR pilot policy. Therefore, the parallel trend hypothesis is verified, and they DID model adopted in this study is reasonable.ME_outpatient is used as the explained variable, none of the estimated coefficients of afterit are significant, indicating that there is no significant effect of the pilot policy on residents' medical expenses of outpatients. When lnME_inpatient is used as the explained variable, the estimated coefficients of afterit are significantly negative at 2 and 3 years after the policy implementation (t = 2 & t = 3), indicating that there is a significant negative effect of the pilot policy on residents' medical expenses of inpatients, which is consistent with the results of the benchmark regression.Meanwhile, when lnPollution), which reaches 10.8%. At the same time, the mean value difference of all covariates after matching is not significant, indicating that the experimental and the control group are very close. Therefore, the matching result is good.Considering that the identification of experimental group provinces may not be random, it may lead to the problem of “selection bias” in the model estimation process. In order to overcome this issue, we further employ the PSM-DID to conduct the basic regression. Specifically, we choose the explained variables in the benchmark model as outcome variables and the seven control variables as the covariates, and use the kernel matching method to match the experimental and control groups. The PSM balance test results are shown in Policy in column (1) is−0.004 but insignificant, while the coefficient of Policy in column (2) is−0.0237 and significant at the level of 1%, which further supports the benchmark regression results.Based on the matched samples, the DID estimation is performed again based on Equation (1), and the regression results are shown in Policy in column (1) is−0.0178 and insignificant, and the coefficient of Policy in column (2) is significantly negative, which demonstrates the robustness of the core research findings again.Compared with the PSM method, the entropy balancing method can achieve sample balance of the control and experimental group in a higher dimension without causing sample loss . TherefoPolicy, and plot the kernel density curve , when lnME_inpatient is taken as the explained variable, only 75 coefficients are smaller than the benchmark regression coefficient (-0.0213), and none of the regression coefficients of Policy is significant, indicating that the pilot policy has no significant impact on the medical expenses of outpatients, but it can significantly reduce the medical expenses of inpatients.In order to exclude the interference of other random factors on the regression results, we further conduct a placebo test for robustness. Specifically, among the 30 provinces, we randomly select four provinces as the pilot provinces in 2015 and other seven provinces as the pilot provinces in 2016, and construct a virtual policy variable for regression. We repeat the above process for 1,000 times to obtain 1,000 “spurious” regression coefficients of urve see . AccordiRandom factors such as the time trend of the control variables may also have an impact on the regression results . TherefoThe selection of the sample interval may also have an impact on the empirical results . For thiCompetition is used as the moderating variable, the interaction item Policy × Competition are all significantly negative, indicating that hospital competition does play a moderating role. Specifically, the more intense the competition among hospitals , the stronger the reduction effect of China's NCMR pilot policy on residents' medical expenses. As can be seen in columns (3) and (4), when Market is used as the moderating variable, the interaction item Policy × Market are all negative, and column (3) is significantly negative at the 1% level, which partly reflects the moderating role of institutional environment. Specifically, with a better institutional environment , the reduction effect of the pilot policy on residents' medical expenses becomes greater, thereby basically confirming Hypothesis 2.In order to further explore the mechanisms of China's NCMR pilot policy to reduce residents' medical expenses, we estimate the moderating effect model of Equation (2). The regression results are shown in ME_outpatient or lnME_inpatient is the explained variable, the confidence interval  of Policy covers value zero in the eastern and western regions, but not in the central region, indicating that the reduction effect of China's NCMR pilot policy on residents' medical expenses is significant in the central region but not in the eastern and western regions. The reason may be that the eastern region has a higher level of economic development, so that the residents there have a stronger awareness of health, and a higher ability and willingness to pay for medical expenses, which leads to the failure of the pilot policy to effectively reduce residents' medical expenses. On the contrary, in the western region, due to the low degree of marketization, the relevant reform is still dominated by the administration, and thus failing to effectively stimulate the reduction effect of the pilot policy on residents' medical expenses.According to different locations, the sample are divided into three sub-samples: eastern, central and western regionsME_outpatient is used as the explained variable, the estimated coefficient of Policy is significantly negative in provinces with poor medical infrastructure, but significantly positive in provinces with good medical infrastructure, indicating that the pilot policy can effectively reduce medical expenses of outpatients in provinces with poor medical infrastructure, but increase medical expenses of outpatients in provinces with good medical infrastructure. When lnME_inpatient is used as the explained variable, the estimated coefficient of Policy is significantly negative in provinces with poor medical infrastructure, but not significant in provinces with good medical infrastructure, which indicates that the pilot policy can effectively reduce medical expenses of inpatients in provinces with poor medical infrastructure, but has no significant effect on medical expenses of inpatients in provinces with good medical infrastructure. In brief, the reduction effect of the pilot policy on residents' medical expenses is significant only in provinces with poor medical infrastructure. The reason may be that the pilot policy can effectively improve access to medical services and reduce medical expenditure in provinces with poor medical infrastructure. This conclusion also indicates that China's NCMR pilot policy has the nature of “supporting the weak” to some extent.The medical infrastructure status is an important factor influencing the effectiveness of the pilot policy. For this reason, we divide the sample into two sub-samples based on the median of hospital beds per capita: provinces with poor medical infrastructure and provinces with good medical infrastructure. The regression results are shown in ME_outpatient is used as the explained variable, the estimated coefficient of Policy is not significant in provinces with both weak financial strength and strong financial strength. When lnME_inpatient is used as the explained variable, the estimated coefficient of Policy is significantly negative in provinces with strong financial strength, but not significant in provinces with weak financial strength. Therefore, overall, the reduction effect of the pilot policy on residents' medical expenses is significant only in provinces with strong financial strength. The reason may be that provinces with stronger financial strength can invest more resources and funds into medical services, which can fully guarantee the effectiveness of the pilot policy.Financial strength is an important guarantee for the effective implementation of medical reform. Therefore, we divide the sample into two sub-samples based on the median of general budgetary revenue: provinces with weak financial strength and provinces with strong financial strength. The estimation results are shown in High medical expense is not conducive to the improvement of residents' welfare and the realization of the common prosperity goal. Therefore, the influencing factors of residents' medical expenses are important topics that scholars have paid attention to for a long time. For example, the existing literature investigated the above issue from the perspective of air pollution –14, enviAs a new attempt of China's medical reform, the NCMR pilot policy also attracted the attention of scholars. However, there were few quantitative evaluations on the effect of the policy in the existing literature, and these studies mainly used the case study  or only Using the exogenous shock of China's NCMR pilot policy in 2015 and 2016, we construct a DID model to comprehensively investigate the impact and the mechanisms of the pilot policy on residents' medical expenses. The conclusions are as follows: first, the pilot policy effectively reduced residents' medical expenses, but mainly for inpatients other than outpatient patients. This research conclusion is still valid after a series of robustness tests such as the parallel trend test, the PSM-DID estimation, the entropy balancing estimation, the placebo test, controlling the time trend, and changing the sample interval. Second, hospital competition and institutional environment are important for the fully realizing of the policy effect. The more intense the hospital competition and the better the institutional environment, the greater the effect of the pilot policy on reducing residents' medical expenses. Third, the effect of the pilot policy on residents' medical expenses is heterogeneous. Specifically, the residents' medical expenses reduction effect is more effective in the central provinces, the provinces with poor medical infrastructure, and the provinces with strong financial strength.Based on the above research conclusions, the following policy recommendations are proposed: first, we should further promote medical reform and expand the coverage of the pilot policy. In the horizontal dimension, further pilot provinces can be added on the basis of summarizing the successful experience of existing pilot provinces; in the vertical dimension, pilot policies can be tried to be implemented at the municipal or county level. Second, we should take relevant measures to support private health care institutions to provide basic health care services and strengthen hospital competition. At the same time, we should improve the regional institutional environment and promote the market-oriented reform of medical care to ensure the full play of the policy effect. Finally, in the further implementation of the pilot policy, it is important to tailor the policy to local conditions to ensure that the policy effects can be effectively implemented. Especially in those regions the policy effects have not been fully realized, relevant policy measures can be designed to adapt their actual situations.Although this study is meaningful to understand the importance of medical reform in reducing residents' medical expenses, there are still some limitations. On the one hand, due to the availability of data, this study uses provincial panel data rather than city-level data or micro data of hospitals or individuals. Therefore, it is difficult for this study to effectively solve the problem of high sensitivity to costs in the field of medical management . On the The original contributions presented in the study are included in the article/supplementary material, further inquiries can be directed to the corresponding author.CN was responsible for the overall design and writing of the article. YF was responsible for collecting data and establishing model. All authors contributed to the article and approved the submitted version.


Methods. The student group and class took the advanced simulator training as the experimental group, applied the advanced integrated simulator and other systems of the Norwegian company, referred to the international guidelines for cardiopulmonary resuscitation and cardiovascular first aid in 2005, and practiced in the emergency department during the clinical internship and “emergency clinical simulation training” course. The course includes basic life support, advanced life support, and comprehensive training of CPR (cardiopulmonary resuscitation) and endotracheal intubation. Results. The passing rate of simulated first aid practice was 94.4%; 100% of the students think it is necessary to set up the course, 91% of the students think it is practical, 91% of the students think the course content is reasonable and perfect, and 77%–100% of the students think the course has improved their first aid operation ability, comprehensive application of knowledge, and clinical thinking ability. Conclusion. Carrying out the course of “clinical simulated first aid training” through the advanced simulator system can effectively improve the interns' clinical first aid operation ability, teamwork ability, and self-confidence, improve the students' clinical thinking and judgment ability, and improve the service level to patients.Anesthesiology is a subject with strong practicality and application. Undergraduate anesthesiology teaching needs to strike a balance between theoretical knowledge, clinical skill training, and clinical thinking development. Clinical probation and practice are an important part of undergraduate anesthesia teaching. Traditional clinical teaching uses real patients for demonstration and training, but as patients become more self-protective and less cooperative, there are not enough patients for clinical skill training. Simulation is to teach medical scenes in real life under the control of standardized technical guidelines and parameters. Since then, with the rapid development of computer technology, simulation technology and simulation teaching have been greatly developed and are more and more used in clinical teaching, skill evaluation, and scientific research. This study explores the effective methods of clinical teaching in anesthesiology by comparing the effectiveness of traditional teaching methods and simulation teaching methods in undergraduate clinical teaching. It is difficult to combine theory and practice in first aid, which does not allow them to directly receive and deal with emergency medical treatment and resuscitation. In China's current medical environment and patients' high demand for medical services, it is imperative to vigorously carry out simulated medical education. In the eastern part of Inner Mongolia, according to the advantages of teaching hospitals, our hospital took the lead in carrying out the simulation education project, which is still in the exploratory stage and not systematic enough. This study will help us to better carry out simulation teaching and improve the clinical skills of medical students in the future.  Medical simulation is a branch of simulation technology, which is used for education, training, and research on various topics in the medical field. Medical simulation education is an educational method that uses simulation technology to replace real patients and create simulated patients and simulated clinical scenes for clinical teaching and practice . The purThe development of modern medicine has made emergency medicine an independent medical discipline. Emergency medicine has become one of the important symbols reflecting the level of clinical medical science . It is iThe application of simulation systems is of great significance to cultivate medical students' clinical practical ability, clinical comprehensive diagnosis and treatment ability, and team cooperation ability . In the P > 0.05).A total of 102 trainees and clinical postgraduate students from the department of respiratory medicine in 2021 were divided into two groups by batch. There were 42 males and 60 females, with a mean age of 24.3 years. There was no statistically significant difference between the two groups in terms of age, gender, admission score, and examination results of undergraduate courses  operation and analysis, medical record analysis, and other basic skills. After completing the learning objectives, evaluate the two groups of students. A questionnaire survey was conducted on the teaching methods of the two groups of students and the learning methods of the experimental group of the intelligent medical comprehensive simulation system.t-test.The data were statistically analyzed using SPSS  15.0 software, and the measurement data were expressed as (mean ± standard deviation) using the P < 0.01), as given in The theoretical knowledge, clinical skills, and general ability were assessed for both groups, as given in Traditional medicine is based on knowledge inculcation and pays insufficient attention to clinical skill teaching, which makes it difficult to meet the requirements of clinical professional posts, resulting in students' low interest in learning, poor mastery of theoretical knowledge, poor practical ability, and the separation of “learning” and “use” . In the This experiment uses an intelligent medical comprehensive simulation system for clinical teaching and explores a new method of respiratory first aid teaching. The results show that compared with the control group, the theoretical test, clinical skill test, and comprehensive ability evaluation of the experimental group are highly statistically significant . This isThere is still a gap between the intelligent medical integrated simulation system and the actual clinical environment, and most of the clinical cases designed are typical cases, which may cause students' perceptions to be biased, as the actual occurrence of cases in the clinic is affected by many factors and the clinical situation is highly variable. It is more difficult to complete face-to-face doctor-patient communication training in the teaching of intelligent medical integrated simulation systems. Due to human body differences, simulated patients cannot completely replace real people as clinical training objects nor can simulated instruments simulate certain complex emergencies that occur in real environments. It is necessary to combine the teaching of the intelligent medical integrated simulation system with traditional clinical teaching, so as to achieve twice the result with half the effort , 22.In conclusion, intelligent medical integrated simulation system teaching solves the problem of poor practical ability of medical students due to the lack of clinical practice opportunities and is an important and effective supplement to traditional clinical teaching methods, as well as a bridge to apply theoretical and practical knowledge to clinical practice. By reasonably integrating intelligent medical simulation system teaching into the traditional clinical teaching process, it can deepen medical students' understanding and application of theoretical knowledge, improve their clinical practice ability, and cultivate more practical clinical talents.Foreign research on simulation education is relatively mature. In our hospital, we took the lead in developing the simulation education project according to the advantages of the teaching hospital. The project is still in the exploratory stage and not systematic enough. This study has accumulated preliminary experience for better carrying out medical simulation education and improving the first aid skills of medical students in our hospital in the future. Through the training of advanced intelligent simulator systems, students' mastery of theoretical knowledge of first aid, practical operation ability, and clinical cooperation ability have been significantly improved. Students can accept the application of the advanced intelligent simulation system in teaching, and the teaching effect is significantly improved.


The 2009 “pesticide package” changed the European Union’s approach to increasing its resilience to synthetic pesticides’ detrimental effects and health risks. It promoted the common goals of reducing volumes, reducing treatment frequency, improving efficacy, reducing risks of pesticide usage, reducing impact, reducing pesticide use in specific areas, and increasing public knowledge and awareness of plant protection products (PPP) usage and effects. Part of the “pesticide package,” Directive 2009/128/EC demanded that each EU MS crystalize by 2012 their approach to these goals in National Action Plans (NAPs) designed to systematically assess the situation and propose objectives and measures to achieve the Directive’s aims. This article presents a dynamic analysis of the changes that took place between the first (by 2012) and second (by 2019) generation of NAPs and evaluates in measures and a timetable the observed progress in achieving the first goal of Directive 2009/128/EC We assess how the EU MS approach to minimizing risks to public health has changed in this intrinsically environmental policy. We show that improvements-proposing measures designed to achieve the Directive’s first goal in all EU MS can be observed, but increasing coherence in measures, timetables, and indicators is needed to accomplish the SUD and EU Green Deal goals. Persistent negative effects of pesticides on biodiversity and biological control potential on European farmland [The increasing population of the planet requires an ever-increasing agricultural productivity that depends on intensive usage of plant protection products (PPPs) mainly obtained through synthetic methods—products that have, in many cases, harmful effects on the environment and humans. Recent literature shows the importance of approaching comprehensively the general issue of managing risks associated with synthetic pesticide usage in various situations. An extensive evaluation by a broad collective on the farmland  showed tfarmland  For examfarmland , while afarmland . A studyfarmland . In the farmland . This isfarmland . The oveBy adopting the “pesticide package,” a four-piece legislative package, the EU aimed to integrate its approach on the whole life span of PPPs, starting with evaluating, approving, authorizing, and finalizing their use. Regulation (EC) No 1107/2009  modifiedFollowing the requirement of the SUD, by 2012, most EU MS had adopted their NAP and began to implement the measures forecasted in them. Starting in 2019, some of the EU MS have adopted updated forms of the NAPs or adopted new NAPs. As the NAPs are roadmaps but do not necessarily accurately describe the steps each EU MS had taken in terms of timetables, targets, and their implementation, the usefulness of this analysis might be questioned. Nevertheless, we stress that a comparative analysis of NAPs can reveal significant differences between how different countries approach the “pesticide package” goals, especially those related to public health, which is more politically sensitive. Also, the NAPs represent the best-case scenario assumed by each country and, thus, the level of ambition. Also, since each plan is implicitly built on evaluating the current state of affairs, dynamic analysis can reveal the progress obtained in implementing the previous NAP. Overall, since no systematic data exist on the implemented measures, as EU MS does not have any obligation to report on this, this comparative analysis gives us the best estimate of the overall trend.An initial evaluation of the first generation of NAPs was published in 2013 by the Pesticide Action Network Europe (PAN) . The revThe second evaluation of the NAPs implementation is the 2017 Overview Report on the Implementation of Member State’s Measures to Achieve the Sustainable Use of Pesticides under Directive 2009/128/EC . In 80% Sustainable use of plant protection products: limited progress in measuring and reducing risks by the European Court of Auditors assessed the EU’s approach to minimizing risks to public health and the environment related to PPP use [Subsequently, the 2020 report  PPP use . The rep PPP use  The repoThe reports offer only general overviews of EU MS’s NAPs and, because they focus only on a few issues, lack a comparative and dynamic perspective. In our 2021 evaluation of the implementation of the first NAPs adopted after the SUD, we discovered that only a third of the NAPs partially met the requirements set in article 4 of the SUD, intending to “advance quantifiable objectives, targets, measures, and indicators” .Based on our initial article and the two evaluation reports, in this article we highlight a more sensitive methodological approach to the changes that occurred after the adoption of the SUD by evaluating not so much the NAPs, but the changes between the first and second NAP, within the measures detailed under the first aim of the SUD, risk reduction. The importance of decreasing the EU’s dependence on synthetic pesticides is underlined in the 2020 EU Green Deal, which explicitly embarked on reducing both the use and the risks caused by synthetic pesticides by 2030% . As the To overcome the limitations of the approach used by these reports and better assess the evolution of the measures proposed by the EU MS for mitigating the risks generated by synthetic pesticides on human health and the environment, we have analyzed the first (2012–2018) and second (2019) NAPs submitted to the European Commission by six EU MS with significant agricultural sectors: France, Sweden, Spain, Romania, Hungary, and Poland. Given that Germany, Denmark, and the Netherlands have not submitted their second NAP and that UK left the European Union, we have eliminated those countries from the analysis performed in our previous article . Also, wEU policy for a sustainable use of pesticide: the story behind the strategy [In evaluating the strength of the NAPs regarding each of these six types of measures, we have summarized and ranked the content of each NAP along a scale that assessed the degree to which they cumulatively contain a series of elements. We were interested in whether a measure is mentioned or not, how many times, and in how many sections. We also assessed if specific measures are analyzed in designated sections or only mentioned. Furthermore, we assessed if the discussion of a measure is operationalized in concrete steps to be undertaken and if the NAP advances quantifiable timelines for implementing the measure. Finally, we searched for indicators associated with different measures which would allow for quantifying the success in implementing them. Following the methodological approach in our previous article, we comprehensively analyzed all the documents and performed a search using keywords for each dimension. Overall, progress on each measure is ranked along a summative ordinal scale with five levels: − No mention or discussion of the measure; + Mention—a type of measure is discussed in the document, but it is not operationalized; ++ Systematic presence and measures; +++ Measures and timetable; ++++ Measures, timetable, and indicators . In the second step, we compared the results from the first and second generation of NAPs to assess if there is a cumulative change that leads to improvements along the five levels of the scale. Thus, if the initial NAP was already ranked highly on a type of measure, the second NAP measure would be assessed cumulatively with the first one. While initially we aimed to identify a purely quantitative method to compare the NAPs, our attempts led to misleading results. This partial impossibility comes from the absence of any unique structure in the NAPs. While already in 2007 a document by the European Commission strategy  elaboratThus, unlike our previous work, when we developed our investigation along with three research questions (RQs), one of them following the cross-temporal differences between the NAPs adopted before and after the adoption of SUD, in this article we focus on one cross-temporal RQ: What are the main changes between the first and second NAPs regarding the reduction of risks associated with pesticide use in terms of quantifiable objectives, targets, measures, and indicators? Above all, we are interested in whether the public health and environmental concerns caused by the usage of PPP are better addressed in the second generation of NAPs than in the first generation. Furthermore, to increase our assessment’s precision, we have also analyzed the core goals or priorities advanced in each country’s NAPs.The results of applying the methodological guidelines of the first and second NAP of France, Sweden, Spain, Romania, Hungary, and Poland are summarized in The analysis of the objectives set in the second NAPs of France, Sweden, Spain, Romania, Hungary, and Poland, as presented in Sweden’s first, fourth, and sixth NAP objectives mention risk reduction, while the second, third, and sixth refer to reducing levels of PPP usage in various areas, but not a total volume reduction. Instead, Spain’s objective set different order priorities. The first objective refers to improving training and information. The second aims at promoting research, innovation, and technology transfer in integrated pest management and the sustainable use of plant protection products. The third focuses on IPM to ensure “rational” use of PPP. The fourth objective focuses on promoting the availability of effective PPP, while the fifth to ninth are focused on reducing risks and increasing monitoring and control of PPP.the replacement of plant protection products of particular concern, suppression of their use, while the subsequent targets refer to eliminating problematic PPP and limiting usage to minimally required levels. Hungary’s NAP is the first to explicitly target increasing low-risk plant PPP availability but does not mention IPM. Poland’s nine actions forecasted in its NAP start with promoting IPM and continue with measures for more effective use of PPP . By contrast, only one target mentions risks, and it requires an analysis of the risks but proposes no measures to reduce them.Romania’s objectives start with improving the training and certification of professional users, distributors, and advisors; the continued monitoring of PPP marketing; and compliance with requirements on PPP usage across the entire cycle (c). The following objectives focus on risk reduction, impact, and use in specific areas. Hungary’s NAP starts with the aim to apply the minimum amount of PPP and continues by limiting the risks from PPP in various usages. The fifth focus mentions a reduction of pollution by PPP. The seventh requires Analyzing the goals set in the NAPs of the six countries reveals that while some elements appear in most of these documents, significant differences exist among countries in terms of ordering and the emphasis put on various measures. France’s NAP is the only one to emphasize total volume reduction, while Sweden and Spain emphasize reducing PPP in specific areas. Reduction of risks is present in several goals in all NAPs except for Poland’s. Instead, Hungary’s NAP is the only one to emphasize eliminating some PPP and reducing pollution. Also, technical measures on treatment efficiency are present in the NAPs of France and Spain but not directly addressed in the objectives of the rest of the NAPs. Overall, with varying frequencies, the impact of reduction is present in the goals of all the NAPs, as underlined in Data showed a decrease of 17% in HRI 1 in the use and risk of pesticides but a 56% increase in HRI 2 in the evolution of emergency authorization. This objective evaluation reveals mild progress and raises important questions about the overall capacity of the EU MS to achieve notable success in decreasing the risks to public health and the environment posed by synthetic pesticides. Here we use one angle of investigation to understand these evolutions. One of the most important implications of the systematic differences in structuring the goals of the NAPs and not following an EU-level coherent approach in structuring, measures, timetables, and measure-level indicators is that it makes it difficult to identify the best practices that allow faster progress toward improving a country’s scores in Harmonized Risk Indicators and the overall goals of the EU Green Deal.EU’s efforts to improve resilience to health and environmental risks associated with pesticide use have been systematically approached, starting with the 2009 “pesticides package,” which came at the top of the EU’s policy agenda within the EU Green Deal. Each EU MS’s efforts toward these aims are structured in its NAP. This research evaluates the progress achieved in reaching the first goal of Directive 2009/128/EC in some EU MS with relevant agricultural sectors. Data synthesized in In line with the European Commission and European Court of Auditors’ assessment, our analysis confirms that despite progress, even the second generation of NAPs does not fully address the limitations identified in the report. Promoting IPM is present in some of the objectives. There is no systematic approach to monitoring progress by using a clear set of harmonized risk indicators that would allow us to monitor and compare the progress toward the policy objectives of SUD. Overall, the progress achieved in the second generation of NAPs indicates that the third generation of NAPs would incorporate the recommendation in the European Commission and European Court of Auditors Report in their objectives.The environmental effects of PPP and their impact on health are more comprehensively treated in the NAPs of the six new and old EU MS when comparing the plans’ first and second generations. While substantial progress is still needed, the current analysis shows that imposing an approach that only sets general goals without a clear quantification and clear requirements for a common approach to the measures, timetables, and indicators has yet to achieve the goals of SUD. Besides steps in proposing an EU-level coherent methodology for creating the NAPs, creating a set of comparable indicators to assess progress on each measure proposed in the NAPs could also enhance comparability and allow for better identification and transfer of best practices among EU MS.