A zebra crossing is a form of pedestrian crossing provision point on roads that have significant volumes of traffic. It is one of the safety measures employed to reduce avoidable pedestrian-motorist conflicts and accidents on such roads. In the past several studies have been conducted on the behaviours of road users (pedestrians and motorists) especially on non-signal intersections. Although, various recommendations and solutions have been proffered to the many road-crossing challenges. But there has been little to no change in pedestrians’ perceptions and preferences of zebra crossing. Contemporary researches have tried to rectify this by applying several models to rate the use of pedestrian zebra crossing. This study uses a Regression Model Techniques to analyse factors influencing utilization rate of pedestrian zebra crossing. In this study, 450 samples were collected from 12 locations, covering school, public building, residential and business areas to examine the utilization rate of the zebra crossing by pedestrians. To examine the significance level on the crossing utilization rates by pedestrian at 95% confidence interval, a pedestrian utilization rate (PUR) was acting as the dependent variable and the remaining variables served as the independent variables. The Multiple Linear Regression (MLR) model was also used to determine the utilization rate needed to develop the zebra crossing utilization model. From the findings, the calibrated R2 value was discovered to be at 0.937 and the descriptive statistics of MLR test, t and p-values, were also found within an acceptable range. The result also showed that, out of all the variables which were used, only three have a significant effect on the utilization rates of pedestrian zebra crossing while the remaining variables have an insignificant effect. The study concluded that among the different variables, Guardrail, number of lanes and Width of zebra crossing were the most influential variables. It is believed that the conclusions drawn from this research are expected to be useful to improve the state of pedestrian facilities in Malaysia. According to a report by the United Nations, the global urban population is expected to increase to 68% by 2050, with most of the growth occurring in Africa and Asia . This inPedestrian safety is a crucial aspect of urban planning and transportation infrastructure development. Providing crossing facilities for pedestrians is a common strategy to enhance pedestrian safety . However2This section emphasizes the analysis of the main body of the extant literature namely the pedestrian utilization of crossing facility.2.1Pedestrian crossing choice is influenced by a variety of factors, including infrastructure, environmental factors, social factors, and individual characteristics. When it comes to signalized crosswalks, pedestrian crossing choice is primarily affected by the signal timing, pedestrian volume, and vehicle volume. Signal timing is a crucial factor that determines when and how pedestrians cross the street. According to Ref. , pedestrIn addition to these primary factors, several other factors can also influence pedestrian crossing behavior at signalized crosswalks, including pedestrian age, gender, and destination, as well as weather conditions and time of day. Understanding these factors can help in designing more effective and safer signalized crosswalks . 10] re re10] reSome other literature stated, otherwise, that the choice of pedestrians while crossing road could be a result of other several factors such as condition, location, perceptions and design of the facilities at the intersection . Accordi2.2Numerous incidents of pedestrian fatalities and injuries in road accidents have raised alarm about pedestrian safety, prompting the need for enhanced road safety measures to improve the safety of pedestrians . The uniSeveral research studies have been carried out to address the forgoing concerns of pedestrian safety that are related to their crossing attitude and behaviours . One of Some factors, however, including utilization rates of crossings facility and type of vehicle, among others, are under investigation and need further research. For example, search results of pedestrian utilization of crossing facilities in the ScienceDirect/or Scopus database, with “the utilization rates of pedestrian zebra crossing” in the article title, abstract and/or keywords of indexed articles, showed there has been no detailed investigation on usage of zebra crossing, only a little published data. Also, some of these identified factors have different characteristics, operational and traffic conditions, and work environment that are unique to their selected or study areas ,14,35,36To address the identified gaps, this research focuses on the development of a pedestrian model based on traffic flow density along urban streets in Malaysia, which also covers pedestrian perceptions and behaviours in order to provide a safer and more acceptable ambiance for road users. This will, indeed, be useful for engineers and planners when working on crossing infrastructures in the near future.3In order to achieve this research stated objective, the use of both qualitative and quantitative approaches was employed. For data collection, after several studies and analysis of the literature review, Multiple Linear Regression (MLR) methods was adopted for analyses. Data collections, model development and statistical tests are all showed in 4Adequate information for this research was gathered through the selection of different sites classified in to four categories to have a full evaluation of pedestrians’ behaviours towards zebra crossing. These categories include the following environments  and 12 pedestrian Zebra crossings were observed out of them. The main reason for these 12 selected locations was to measure the level of utilization of available facilities. Videotaping was employed to observe the zebra crossing utilization by pedestrians. Several instruments such as video camera, measuring tape and stopwatch was used for data collection.5In other to analyse factors influencing the usage of pedestrian zebra crossing, data of pedestrians' behaviours were employed. In this research, the pedestrians who used the zebra crossing option while crossing the road section represent the percentage of utilization rate. Video recording called “video data method” was used to retrieve data on pedestrians’ behaviours. This was possible because of the many advantages it has over the manual method. The likes of low cost economic advantage of running video survey on a permanent and continuous record of events makes it more preferable. Also this method was used because, it was very easy and faster to observe within an hour and obtain directly the total number of pedestrians who desired to utilize the zebra crossing compared to those who did eventually. Number of the pedestrians was one of the essential data for this research. The reason was that the volume of pedestrian needed for the study compared to what was available at each site location was lower, hence the need for proper and adequate figure.Lastly, the use of the videotape was targeted to gather information on pedestrians who crossed the road. The following categories of pedestrians were not counted in the samples of this research such as those waiting for the bus and not having intention of crossing, the once walking on the roadside, and those who were done crossing from a distance higher than 50 m.5.1Computation of the descriptive statistics including standard error, t-value, and p-value, under Multiple Linear Regression, Statistical Package for Social Science software (SPSS) version 22 was employed to carry out data analysis. The general functions and steps in Multiple Linear Regression were used for analysis of the data.5.2A multiple linear regression (MLT) analysis was carried out to analyse the contributing factors to the utilization rates of pedestrian zebra crossing. Results showed that 3 out of 5 variables that have been analysed were significant in its association with the pedestrian Zebra crossing utilization. The general model framework is given by Equation 6The variables involved in this section are rate, guardrails, pelican signals, number of lanes, length and width as summarised in Apart from that, the study analysed the zebra crossing utilization rate by calculating the percentage of pedestrians who crossed the road using the zebra crossing as shown in 6.1Multiple regression models were used together with the stepwise method to obtain only the significant variables as shown in Out of the five characteristics being tested, only guardrail, Width and the number of lanes were found to significantly affect the zebra crossing utilization rate. Referring to the table, a B value of 6.85 for the guardrail variable indicated that with the installation of guardrails at the zebra crossing zone, the zebra crossing utilization rate will increase by 6.85%. Moreover, the B value of 3.398 for the Width variable showed that each meter increase in the Width of a zebra crossing (width of the road) will increase the zebra crossing utilization rate by 3.4%. In other words, the wider the road, the riskier it is to cross without zebra crossings. Thus, pedestrians would choose to use the zebra crossing in this case. Next, a B value of 3.233 indicated that when the number of lanes increased by 1 lane, the utilization rate of the zebra crossing will increase by 3.2%Apart from knowing how the characteristics of a zebra crossing affect the utilization rate, the degree of impact was also assessed on the dependent variable. The absolute value of standardised regression weight (BETA) was examined and it was discovered that the Width of a zebra crossing (width of road) has the highest impact on the utilization rate of zebra crossings, followed by guardrail and lastly, the number of lanes.Based on the results presented in To illustrate the relationship of significant zebra crossing characteristics with zebra crossing utilization rate, Equation 7This study focused on the utilization level of zebra crossing along urban streets in Malaysia. The usage rate of the facilities by pedestrians at zebra crossing are peculiar with the characteristics of each area and also related to many other factors and understanding of pedestrian towards the available facility. Survey of users and observing pedestrian movement at different 12 locations was used to obtained information needed for this research. The findings revealed that the pedestrian zebra crossing utilization low level are caused by nonexistence of guardrail, number of lanes and Width of zebra crossing. In order to encourage high utilization rate, placement of the zebra crossing and guardrail at appropriate sites, with large roadway width having more than two lanes, have to be considered when providing this facility. The general belief of the result of this study is that it will inform the regulators, pedestrians, drivers and other road users, thereby reducing the risks at vehicular-pedestrian intersections. More so, the findings hope to serve as a benchmark to perpetually increase and adjust road networks in needs of more accurate estimations to reduce the risk and exposure of pedestrians and other road users to accident in several intersections.81.It is believed from the findings that guardrail installation significantly affects the zebra crossing utilization. Therefore, it is recommended that more guardrails should be installed in areas with high population of pedestrian activities all day long in order to guaranty safety of road users.2.Zebra crossings should be placed in high densely populated areas such as business and high speed streets. With this, more pedestrians will be encouraged to use it in those areas resulting to high utilization level of the facility and also improving the safety of pedestrians on the road.The following recommendations are drawn based upon the results.Walid Abdullah Al Bargi, Basil David Daniel, Nasradeen A Khalifa, Munzilah Md Rohani, Qinaat Hussain & Rafidah Binti Hamdan: Conceived and designed the experiments; Performed the experiments; Analysed and interpreted the data; Contributed reagents, materials, analysis tools or data; Wrote the paper.Data will be made available on request.The authors have no conflicts of interest to declare. All co-authors have seen and agree with the contents of the manuscript and there is no financial interest to report. We certify that the submission is original work and is not under review at any other publication.


This article describes how psychological barriers informed the intervention with these mapped onto relevant components, intervention functions and selected behaviour change techniques, and finally aligned with behaviour change techniques. This article outlines the systematic approach to intervention development within the BCW framework; guiding readers through the practical application of each stage. The use of the BCW framework has ensured the development of the intervention is theory driven, with the research able to be evaluated and validated through replication due to the clarity around processes and tasks completed at each stage.It is estimated among individuals with type 2 diabetes (T2D) requiring injectable therapies to achieve optimal glycaemic control, one-third are reluctant to initiate therapies, with approximately 80% choosing to discontinue or interrupt injectable regimens soon after commencement. Initiation of injectables is a complex issue, with effectiveness of such treatments undermined by non-adherence or poor engagement. Poor engagement and adherence are attributed to psychological aspects such as individuals’ negative perceptions of injectables, depression, anxiety, feelings of shame, distress and perceived lack of control over their condition. The aim of this study was to describe the development of a structured diabetes intervention to address psychological barriers to injectable treatments among a cohort of those with T2D; conducted within a behavioural change framework. An evidence base was developed to inform on key psychological barriers to injectable therapies. A systematic review highlighted the need for theory-based, structured diabetes education focussed on associated psychological constructs to inform effective, patient-centric provisions to improve injectable initiation and persistence. Findings from the focus groups with individuals who had recently commenced injectable therapies, identified patient-centric barriers to initiation and persistence with injectables. Findings from the systematic review and focus groups were translated  Ptients” [–9. Thesetients” [.Non-adherence to medication regimen, medical guidelines or treatment targets can be intentional or not, with people living with diabetes making conscious or sub-conscious determinations about the benefit of the treatment against the potential impact on daily functioning, wellbeing and quality of life . The litAs T2D is a condition that is primarily managed by the individual, efforts to address patient-related challenges of the condition have been recommended to improve self-management, medication adherence and outcomes . HoweverWhen developing a new or novel intervention to change behaviour, few researchers provide a detailed description of the intervention development stages or processes, resulting in a lack of clarity for evaluation or replication of the intervention . Whilst “chronic stressor for patients and families, affecting various life domains” . Accordingly, a behavioural change theory with a singular focus and little consideration for contextual factors may not be the best fit for an intervention to overcome barriers to injectable treatments for those with T2D. Roter et al.  is a comprehensive theoretical model for behaviour change which was developed from a synthesis of 19 existing behavioural change frameworks, in essence ensuring a model that reflects their best practice from those , 30. AccThe National Institute for Health and Care Excellence  guidelin“broad categories by which an intervention can change behaviour”, emphasising an intervention may have “more than one function” [. The BCW, which captures the range of psychosocial and physical mechanisms necessary for optimal behavioural change, was used to provide a theoretical framework for the development of this intervention. The key stages in the design of interventions can be separated into three key aspects: i) Understanding the behaviour; ii) Identifying intervention options and iii) Identifying content and implementation options .In this phase the foundations for successful intervention are laid, with each subsequent phase building on this initial phase. To address this, and in line with the central system in the BCW, the problem behaviour must be defined, then a target behaviour must be selected and specified with identification of the change(s) required , 42.Define the problem in behavioural terms: This step requires definition of the problem, specifying the target group and the behaviour. In developing this intervention, identified gaps in the literature around addressing barriers to uptake and adherence to injectables, coupled with calls to provide interventions to tackle this issue, informed this definition. Therefore, suboptimal uptake and adherence to injectable therapies among T2Ds was defined as the problem to be addressed.Select target behaviour: Although treatment targets exist for HbA1c and related physiological measures, the same consistency is not available for psychological and behavioural aspects. Accordingly, when developing a list of target behaviours for consideration, each should be considered in terms of impact, ease of change and measurement. For this intervention the targeted behaviour was increased uptake of injectable therapies and improved adherence.Specify target behaviour: This aspect requires greater consideration of the target behaviour i.e. Who will perform this behaviour? What do they need to do differently? When will they do this? Where? With whom? How? These questions were addressed in relation to the existing literature and the views gathered from T2Ds using injectables.Behaviour targeted for change: Increased uptake of injectable therapies and improved adherence• When and where is the behaviour performed: Injections to manage T2D are administered by people with T2D in their home within daily routines, in line with prescribed guidance• Identify what needs to change: From the literature, systematic review  were identified: Education, Persuasion, Modelling, Enablement, Training, and Coercion . The use of the BCW framework in this process has ensured the development of the intervention is theory driven, with the research able to be more readily validated through replication due to the clarity around processes and tasks completed at each stage. The BCW responds to the call from the MRC for the use of theoretical frameworks in the development of behavioural change interventions to ensure accurate identification of the mechanisms for behavioural change . At the centre of the model sits a deceptively simple behavioural system that takes cognisance of the key aspects required to engage in a given behaviour . The COMl change . It appeResults, the newly developed ORBIT intervention will allow for delivery of the identified behavioural change techniques to people with diabetes prior to commencing injectable treatment. In line with the translation of the behavioural change techniques, best practice guidelines and clinical guidelines will be used to guide same  and HbAThe raw data supporting the conclusions of this article will be made available by the authors, without undue reservation.Ethical approval was granted by the Office of Research Ethics Committee in Northern Ireland, with governance from the Trust Research Governance Committee prior to the commencement of participant recruitment (15/NI/0091). All participants provided informed consent. The patients/participants provided their written informed consent to participate in this study.DM, AH and VC designed the study. DM, AH, VC, KM, and MO’K were active in the development of the preliminary work. KM and DM guided the development of the intervention via the BCW methodology. KM and DM wrote the first draft of the manuscript. AH and VC critically advised on important intellectual content and contributed to revising of the manuscript. All authors read and approved the manuscript for submission.This work was supported by the HSC Research and Development Division of the Public Health Agency, Northern Ireland (grant number: EAT/4909/13).The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.All claims expressed in this article are solely those of the authors and do not necessarily represent those of their affiliated organizations, or those of the publisher, the editors and the reviewers. Any product that may be evaluated in this article, or claim that may be made by its manufacturer, is not guaranteed or endorsed by the publisher.


Magnetic resonance imaging (MRI) is a non-invasive imaging technique that is commonly used for the visualization of newborn infant brains, both for clinical and research purposes. One of the main challenges with scanning newborn infants, particularly when scanning without sedation in a research setting, is movement. Infant movement can affect MR image quality and therewith reliable image assessment and advanced image analysis. Applying a systematic, stepwise approach to MR scanning during the neonatal period, including the use of the feed-and-bundle technique, is effective in reducing infant motion and ensuring high-quality images. We provide recommendations for one such systematic approach, including the step-by-step preparation and infant immobilization, and highlight safety precautions to minimize any potential risks. The recommendations are primarily focused on scanning newborn infants for research purposes but may be used successfully for clinical purposes as well, granted the infant is medically stable. Using the stepwise approach in our local research setting, our success rate of acquiring high-quality, analyzable infant brain MR images during the neonatal period is as high as 91%. Imaging of a newborn infant’s brain can provide healthcare practitioners with valuable information for diagnosing potential brain lesions and maturational delays, which informs clinical decision making. Infants who are born prematurely at less than 37 weeks’ gestation are at an increased risk of neurological complications, including intraventricular and cerebellar hemorrhage , periventricular hemorrhagic infarction (PVHI), and white matter injury (WMI). In addition, preterm infants may show suboptimal brain growth and maturation . AlthougIn addition to brain imaging in the clinical setting, increasing our understanding of preterm and term-born infant brains through research remains valuable for continued clinical care improvements. At present, the risk factors and underlying mechanisms of brain injury and altered development, and subsequent neurodevelopmental deficits, in newborn infants remain incompletely understood. These knowledge gaps may impede timely diagnosis and intervention as well as the development of new neuroprotective strategies.The preferred, non-invasive tools to image the brain of infants during the neonatal period are cranial ultrasound (cUS) and magnetic resonance imaging (MRI). CUS is a reliable and easily repeatable bedside tool to identify the most common preterm and some term-born brain injury types and to follow the evolution of lesions  ,3,4. HowMRI has proven to be superior to cUS for assessing all brain areas, small and subtle lesions, and maturation ,9,10,11.For clinical brain MR imaging, the administration of sedatives to the infant prior to scanning could be considered. However, sedation should be avoided at any cost when scanning stable newborn infants in the research setting due to the risk of side effects, including respiratory drive depression, seizures, hypotension, and agitation . In addiWe share our local experiences and provide recommendations for brain MRI scanning in preterm and term-born infants during the neonatal period. Our focus is on minimizing infant movement and safety to acquire high-quality MR images from medically stable, non-sedated infants for research purposes, to benefit other research groups planning to develop a neonatal brain MR imaging program.Neonatal brain MRI scanning for research purposes can be performed either when the infant has been discharged home or during admission to the hospital. In both cases, the arrival of the infant to the MR imaging location and scanning times are scheduled around the infant’s feeding routines, with the next feeding most optimally due just prior to the time of the scan. When scanning is performed as an outpatient, the caregivers are encouraged to arrive with their infant about one hour prior to commencing the scan to allow for sufficient time to complete the steps as outlined below. For inpatient scanning, the infant’s arrival time and first steps below may be modified on a case-by-case basis, depending on local resources  and need for transportation between location of admission and MR imaging.After the arrival of the infant and caregiver(s), the following steps are completed sequentially.Caregivers are oriented to the diagnostic imaging department by a research team member and shown to an area which is quiet, private, and allows space for the infant to be fed, changed, and properly bundled. The team member describes the events of the visit, responding to any questions the caregivers may have and ensuring the completion of any required paperwork (such as consent forms or study questionnaires).The infant and any accompanying caregiver are screened for MRI safety. An MRI screening form  is completed by the caregiver to ensure that no MR-incompatible metal implants or devices are or will be present on or in the infant. MRI scanning relies on a strong magnetic field, and presence of metal may put the infant at risk when entering the magnetic field. The same precautions need to be taken for the caregiver should they decide to join the infant in the scanner room (see below). The information collected from the MRI screening form is carefully surveyed by the MRI technician prior to the entrance of the infant and caregiver into the scanner room.While in the waiting area, the caregiver is encouraged to feed and hold the infant. As mentioned above, the non-sedated MRI scan is ideally planned just after a feeding time of the infant. This increases the chances that the infant takes a full feed, falls asleep prior to the scan, and will remain asleep during the scan.After the feeding, the infant is undressed to their diaper and tightly swaddled in a blanket or hospital linen enclosing their arms and legs as a first step to reduce movement. If preferred, the infant’s t-shirt or onesie may be kept on, as long as it is metal-free (such as snaps or zippers). MiniMuffs Neonatal Noise Attenuators  are placed over the infant’s ears to protect them from the noise of the MR system that may affect the infant’s hearing A,B.The above steps 1–4 provide the ideal time for the research staff to address any concerns or questions the caregivers may have regarding the MRI procedure or potential findings from the brain MRI. Caregivers may appear nervous or anxious during the visit. Typical concerns are related to how the infant will tolerate the scan or feeling strongly invested in obtaining interpretable data from the MRI scan. To mitigate any caregiver distress, we provide a careful and thorough explanation of the process that covers the extra time incorporated within the appointment to accommodate the potential needs of the infant and caregiver. We reassure caregivers that the infant will be monitored for waking or crying throughout the scan and explain that most infants will sleep comfortably for a majority of the scan. Should the infant wake up during the scan, the caregiver will be able to hold and soothe the infant.To further minimize movement after swaddling, the infant is positioned supine on an infant-sized Medvac Vacuum Immobilization Bag , a tool that is effectively used for both clinical and research purposes in our institution. Other practices to reduce infant movement may be applied in other centers. The infant is positioned with their head at the top of the bundle bag. The three bottom straps on either side of the bag are fastened in the middle and the straps gently tightened around the infant’s trunk B. SubseqOnce the infant is swaddled and has fallen asleep, the team member and, if applicable, a caregiver carries the infant from the preparation area (or admit unit) to the scanner room. Prior to entering the scanner room, the infant and caregiver are again checked for any metal on or in their bodies.If the MRI scan is performed when the infant is still admitted to the hospital, most of the infant preparation steps, such as feeding and wrapping, can take place on the unit of admission provided there are quiet surroundings.2-saturation from the observation room is strongly recommended. Any evidence of infant distress, presenting as crying (heard through the microphone in the scanner), excessive or persistent motion, or changes in vital signs, should be evaluated immediately.After confirming that both the infant and, if applicable, the accompanying caregiver are safe to enter the scanner room, the infant is placed supine on the MRI table with their head appropriately placed in the coil at the top of the table B. InfantDespite the efficacy of the described preparation steps and bundling technique, movement may still occur during the scan related to waking or movement due to the noise of the MR system. As part of responsible study design, we aim to minimize the scanning time by limiting the protocol to the MR sequences required to answer the research question. In this way, important sequences may be repeated to obtain higher-quality images, when available scan time and infant comfort permit. When available, booking extra scanning time is beneficial. Dependent on the local setting, infrastructure, and patient privacy practices, caregivers may have the option to accompany the infant in the scanner room during the scan. In such cases, they can comfort the infant if they wake up during the scan by providing additional feeding, an MRI-safe soother, or sucrose drops . Additional measures that can be employed to limit infant motion and obtain high-quality images are reducing light and sound as much as possible during the scan.Once the MRI scan is complete, including any appropriate repetition of sequences, the infant and caregiver (if present) are guided back to the quiet area or the unit where the infant is admitted. The secured air valve of the vacuum bag can be opened, allowing air to re-enter the bag and flexibility to be restored. The straps on the vacuum bag can be unclipped, the MiniMuffs removed, and the infant extracted from the bag and bundle. At this time, the infant may be re-dressed and provided another feeding prior to completing the MRI visit. If the scan is performed when the infant is still an inpatient, re-dressing and feeding can be performed in the unit. Notably, the research team member should clearly indicate if (and when) the caregiver receives information regarding the MRI findings, subject to the local institutional and ethics policies.Using the above stepwise approach to neonatal brain MRI, our team has a continuing success rate of as high as 91% for completing the full MRI protocol consisting of eight sequences, with the acquired images being of sufficient quality for assessment and advanced image analyses. For the MR imaging to be successful, occasionally (such as in case of motion artefacts), one or more sequences must be repeated to improve image quality. As sequence repetition adds time to the MRI protocol, repetition is limited to the time available on the MRI system and, most importantly, to the infant’s tolerance. In our opinion, MRI acquisition in a newborn infant should never exceed one hour.n = 92), one or more sequences needed to be repeated to improve image quality due to motion artefacts, with the diffusion and functional sequences with longer scan durations being affected the most frequently. In these infants, the time in the MR system was extended with the scan time of the sequence(s) to be repeated; in all cases, the scan time was limited to a maximum of 60 min. In one infant, the MRI needed to be rescheduled as the infant was unable to settle, with all sequences being obtained successfully on the second attempt. In only 9% of infants, some of the eight sequences were not interpretable or analyzable due to motion corruption. While five infants (4%) in this cohort experienced a temporary increase in skin temperature (see below), no other adverse events  were encountered. Recognizing an overrepresentation of caregivers with completed higher education and professions in the medical field in the cohort, we do not anticipate that the cohort demographics will have substantially influenced our rate of successful scanning. We execute the stepwise approach similarly for all newborn infants, regardless of caregiver demographics.The reported 91% success rate is based on the experiences within our research program including MR imaging in preterm infants around term-equivalent age  using the stepwise approach. In a recently completed study cohort, brain MRI was performed in 121 moderate-to-late preterm infants at a median corrected gestational age of 41.6 weeks. The brain MRI protocol consisted of eight sequences  with a total duration of 36 min. In 76% of the infants . Written caregiver consent must be obtained prior to engaging in any research activities. Regardless of the local approach to neonatal brain MR imaging, the MR safety screening forms must always be completed by trained MRI staff and research team members prior to scanning.MR imaging is not based on ionizing or other types of radiation, like X-ray and Computed Tomography (CT), and therefore does not pose a risk of injurious exposures to the infant. MRI relies on the varying magnetization of protons in different tissues, and uses a strong magnetic field to uniformly align the protons in the target tissue, in this case, the brain. Once aligned, the scanner emits a pulse of energy (radio frequency energy) that causes the protons to re-align to their original position, emitting radio frequency energy in the process. The signals emitted by the protons are measured and used to create the image, referred to as a magnetic resonance image. Given the strong magnetic field in and around the MRI scanner, the presence of metal in the scanner room needs to be avoided at any cost. The strong magnet attracts certain metals to the scanner, putting anyone in or close to the scanner at high risk for injury and causing damage to the scanner. Hence, it is at utmost importance to confirm that any and all equipment, bundle blankets and bags, headphones, and infant clothing are free of metal and are MR-compatible prior to entering the scanner room. All individuals entering the MRI unit must be trained and certified in MR safety and adhere to the safety guidelines put in place by the local diagnostic imaging department.The MRI system emits loud noises to which anyone undergoing an MRI or being in the scanner room during an MRI will be exposed. The noises may negatively impact hearing, particularly in newborn infants. A safety measure that therefore needs to be taken prior to MR scanning is to apply hearing protection. Specifically designed, MR-compatible ear coverings, such as MiniMuffs and infant headphones (see above), can be used for this purpose. Caregivers accompanying the infant during the MRI scan can be provided ear plugs and/or adult headphones.When scanning for research purposes, one needs to ensure that the infant is respiratory and hemodynamically stable, not in need of intensive support, and not sick . Knowledge gains obtained through research should not be prioritized over the risk of scanning a medically unstable infant.The feed-and-bundle technique using the Med-Vac Vacuum Immobilization Bag in addition to swaddling is perfectly suitable and safe to reduce infant motion during the scan. As the vacuum bag is partially open , the infWhen the infant requires supplemental oxygen (without pressure or flow), such as in the case of chronic lung disease in an extremely preterm infant, the MRI can still be performed, provided hospital oxygen and the appropriate connector and tubing are available. Of note, it is of utmost importance to avoid entering the magnetic field with a non-MR-compatible oxygen cylinder. Additionally, orogastric or nasogastric tube feeding, previous ligation of a patent ductus arteriosus or abdominal surgery, or in situ ventricular cerebrospinal fluid drainage device, are themselves not contra-indications for MR scanning, as nowadays MR-compatible devices are primarily used. However, the presence of an experienced MR technologist during the scan, preferably with experience in scanning newborn infants, is strongly recommended in these cases.Newborn infants, particularly preterm infants scanned prior to the expected delivery date and low weight infants, are prone to temperature instability due to the limited ability to regulate and maintain their body temperature . In addiIn our example cohort of 121 moderate-to-late preterm infants who underwent brain MRI using the stepwise approach, we only encountered a change in skin temperature as measured before versus after the MRI in five (4%) infants. Their temperature after the scan had increased either to 37.5 °C or by >1 °C compared to before the scan. However, in all infants, the skin temperature normalized within several minutes of being removed from the vacuum immobilization bag, suggesting that the temperature increase may be related to the bundling and non-breathable material of the bag. None of the infants showed any other clinical signs of infection or illness, such as nasal congestion, wheezing, or sleepiness.Other safety considerations include the cautious positioning of the infant’s head in the coil in the case of a specific anatomical deviation  or device , and monitoring the infant for any regurgitation or signs of discomfort during the scan. Careful positioning by means of MR-safe foam padding is used effectively to elevate the head and prevent choking. In the case of infant discomfort or waking, the scanning team and/or caregiver may soothe the infant by holding and rocking, or providing a soother or sucrose drops. Caregivers or the scanning team may also discontinue the scanning if appropriate. Any signs of infant distress including crying, persistent/erratic motion, or vital sign changes, should result in an immediate halt of the scan and evaluation by the scanning team.Local infrastructure and resources will differ with respect to brand, type, and magnetic field strength of the MR system, availability of a quiet preparation area, and infant immobilization practices. Regardless of local specificities, the above strategies can be, and all above safety precautions, should be applied.A concern that has been raised with regard to MRI scanning of the neonatal brain, both in a clinical and a research setting, is the potential negative impact the MRI results could have on the caregivers’ mental health and well-being ,21. For The research conducted by our team involves brain MR imaging in both preterm and term-born infants during the neonatal period. In order to optimize our approaches with respect to communication style, information provision, and responding to caregiver questions when starting the imaging program in our local center, we assessed caregiver experiences with the brain MRI before and after the scan. The short survey included questions regarding the caregiver’s prior experience with MRI, concerns about their infant’s brain MRI, whether concerns were addressed appropriately by the team members before and during the MRI visit, and suggestions for improvements. The common concerns expressed by caregivers prior to the MRI scan applied to possible harmful exposure to radiation and loud noises from the MR system, and risk of distress of their infant during the scan. The caregiver feedback after scan completion, however, highlighted that caregivers felt sufficiently reassured that no radiation was emitted during the scan, felt that hearing protection was managed appropriately, and that allowing them to accompany their infant in the scanner room eased concerns of distress.With research ongoing, caregivers regularly express their gratitude for the opportunity to learn more about their infant’s brain , with the potential of referral of the infant to appropriate services if deemed necessary based on the MRI results. With proper information provision about MRI safety as well as informed responses to common questions about radiation and noise, caregivers are typically put at ease and enthusiastic for their infant to contribute to scientific research and advancing care and outcomes for future newborn infants.The experiences and recommendations on the approach to neonatal brain MR imaging described in this manuscript are limited to medically stable, non-sedated newborn infants imaged during the neonatal period and up to several months post-term in a setting of a previously established research infrastructure. Brain MR imaging in unstable newborn infants, requiring additional safety considerations that bring more logistical challenges, is beyond the scope of this manuscript. As per the manufacturer’s instructions, the vacuum immobilization bag is only intended for use for newborn infants from 0 to 5 months. In addition, the high rate of success with brain MR imaging in our local setting is partly related to the availability of the MR system. The system is dedicated to research, which allows for the booking of additional scanning time and therewith repetition of sequences in cases of infant motion or waking. The use of clinical MR systems and/or differing institutional policies may inflict local time constraints.While the described stepwise approach has shown to be effective for non-sedated neonatal brain MR imaging, improvements can be sought to further reduce infant movement and waking and therewith image motion artefacts. Studies are ongoing, particularly in view of diffusion and functional imaging, to reduce MR scan times and therewith the time infants need to remain still, while maintaining the high resolution of the images. In addition, developing MR-compatible noise cancelling equipment and a vacuum bag made of a breathable material may reduce infant waking.We describe our local practices and provide recommendations for obtaining high-quality brain MR images in stable newborn infants, primarily focused on non-sedated, elective brain MRI in a research setting. Based on our local experience, applying a systematic, stepwise approach to infant MRI scanning during the neonatal period by use of the feed-and-bundle technique is highly effective in acquiring images with minimal motion. High-quality images are critical in capturing the full extent of brain injury and abnormal brain development, which is important in the early and accurate diagnosis and prognostication of newborn infants. High-quality images also contribute to increasing our knowledge on neonatal brain injury and development, and to improving neuroprotective care, through advanced image analysis to study the developing brain both on a macrostructural and microstructural level. Most importantly, the described approach is safe and well-tolerated by newborn infants, avoiding the use of sedation and any potential risks when appropriate safety precautions are employed. If the newborn infant is medically stable and the MRI is not urgent or time-sensitive for clinical indications, the recommendations can easily be applied in one’s local setting, regardless of differing MR systems and protocols, and if necessary, can be adapted based on local experience, expertise, and infrastructure.


The number of research related to traumatic experiences in people with autism spectrum disorder (ASD) has grown exponentially, yet there are no bibliometric studies in this field. This article aimed to analyze the literature related to trauma and ASD published in Web of Science (WoS). Papers on trauma and ASD were retrieved from the WoS. Analysis and visualization of selected documents were performed using MS Excel (v16.0), VOS viewer (version 1.6.15), and R package . A total of 147 articles were included in this study. The results showed that production has been increasing over the last few years. Among the countries identified, the USA published the largest number of articles. Arvid Nikolai Kildahl, Sissel Berge Helverschou, and Liliana Dell’Osso were the authors with the most number of publications on this topic, and Autism was the most productive journal. The main research topics associated with ASD were post-traumatic stress and traumatic experiences in childhood. This bibliometric study contributes to understanding research trends on trauma and ASD by evaluating relevant publications in the last decades. The results of this bibliometric analysis can serve as a basis and orientation for new studies. Autism Spectrum Disorder (ASD) is characterized by difficulties in social interaction and verbal and nonverbal communication, restricted behaviors, and sensory problems . The etiA trauma or traumatic event can be defined as exposure to actual or threatened death, serious injury, or sexual violence. This type of event may be experienced directly by the person or through witnessing the event occur to another person, learning that the traumatic event occurred to a close family member or close friend, or experiencing repeated exposure or extreme to aversive details of a traumatic event . Such evSome studies have highlighted that people with ASD are exposed to and end up being severely affected by traumatic events, especially abuse ,13. It hAs for the diagnosis of PTSD, the findings of a systematic review conducted by Rumball  highlighAlthough the study of trauma and its consequences has been going on for several decades, its study in people with ASD is quite recent, and apparently, it is not fully systematized; to the best of our knowledge, no bibliometric analysis focused on traumatic experiences and ASD has been performed. The bibliometric analysis involves the mathematical and statistical analysis of the research literature  to highlConsidering the relevance of a bibliometric study to systematize recent research on trauma and ASD, this study aimed to analyze the scientific research published in WoS related to traumatic experiences and ASD. We envisage that results from the study will guide new researchers and experts in this field, as well as practitioners who work with people with ASD. The questions that guided this study were: Q1. What are the general characteristics of the literature on traumatic experiences and ADS? Q2. What is the trajectory of the annual publication? Q3. Who are the most productive authors in this field? Q4. What are the most productive journals? Q5. What were the most cited documents and the main results of each of them? Q6. What are the top keywords, co-occurrence network, and trending topics? Q7 Regarding the social structure, how are the collaboration networks of authors, institutions, and countries organized?In this study, a bibliometric analysis of the literature published on the Web of Science (WoS) on the investigation of traumatic experiences in people with ASD was performed. Bibliometrics is a systematic, direct, and reproducible review method based on mathematics and statistics related to science, scientists, or scientific activity . Due to WoS is a multidisciplinary and selective database that is made up of a variety of specialized indices. The main part of the WoS platform is the Core Collection (WoS CC). Due to its intellectual value, we selected it to analyze the publications related to traumatic experiences and ASD. The search used the advanced search interface: “Article Title, Abstract, Keywords”. Search terms were strategically combined using Boolean operators: “autism spectrum disorder” OR “autism” AND “trauma” OR “post-traumatic stress disorder” OR “traumatic experiences”. The search in WoS included the period (1975–2022). The search was performed by two of the main authors on 13 September 2022. A total of 448 articles potentially relevant to the study were retrieved.Articles studying traumatic experiences in samples of children, adolescents, and adults with ASD, and close people, such as family members and caregivers, were included. No language or publication time restrictions were applied. Articles dealing with traumatic experiences in people with other neurodevelopmental disorders were excluded. Also, we excluded papers that discussed problem behaviors but were not necessarily linked to traumatic experiences.In order to reduce selection bias, the 448 articles collected in the initial search were independently evaluated by two authors. Eligibility and relevance were evaluated for each record, which allowed the exclusion of 301 documents. The double review resulted in 94% agreement. Articles where ratings differed were discussed, and agreement was reached between the two manuscript reviewers. Once the process was completed, 179 records were selected for the bibliometric analysis  and R packages  were used. Data were exported to different file formats for analysis . Analysis indicators included publication number, average citation per publication, countries, institutions, journals, keywords, authors, and main documents. Lokta’s law was applied to see the productivity of authors. According to Ahmad et al. , Lotka’sThis study did not involve the participation of human beings and did not require the approval of an ethics committee to carry it out.After screening, a total of 147 records were identified from the WoSCC Science Citation Index Expanded database. The main information of the sample was distributed as follows: MAIN INFORMATION ABOUT DATA  95, Documents 179, Document Average Age 3.88, Average citations per doc 9.279, References 1); DOCUMENT CONTENTS (Keywords Plus (ID) 419, Author’s Keywords (DE) 369); AUTHORS ; AUTHORS COLLABORATION ; DOCUMENT TYPES . The number of annuals has grown in the last decade. In total, 468 authors were responsible for the analyzed publications. In In the analyzed data, 95 journals were involved with the publication of documents on traumatic experiences and ASD in WoS. Our analysis reveals that core one encompasses 10 journals, among which Autism, Journal of Autism and Developmental Disorders, and Research in Developmental Disabilities are the most prominent see .The Keyword Co-occurrence Network (KCN) provides insight into thematic trends in the field of trauma and ASD. It allows an understanding of the components and structure of a scientific field by examining the links between keywords in the literature, as well as the strength of their connections . In FiguThe thematic map of the data was analyzed in order to obtain an overview of research trends and their sustainability over time. Centrality underlines the importance of a topic in the field of study, and density indicates the development of the topics. The volume of each sphere reflects the number of articles using this keyword. The main collaborative networks are composed of a total of 44 authors. It is possible to observe that the main collaborative network is represented by the red cluster, in which Liliana Dell’Osso, Claudia Carmassi, and Camilla Gesia stand out. The networks represented by the light green cluster composed mainly by Connor Morrow Kerns and Steven J. Berkowitz, and the light pink cluster composed mainly by Arvid Nikolai Kildahl and Sissel Berge follow in importance see .There are 35 institutions participating in ASD and trauma-related scientific production registered with WoS. The United States is the country with the highest number of collaborations, followed by the United Kingdom. The countries that have participated in these studies are mainly European and North American. Two Asian countries (Korea and China), Australia, and Israel are also represented see .The objective of this biometric article was to analyze the literature related to trauma and ASD published in WoS from 1976 to 2022. Our results suggested that the original articles were the main means of scientific dissemination. The fact that the results are presented through this means of scientific dissemination indicates that the research is well established with an adequate theoretical and research base. Also, the number of publications showed a growth trend from 2015, since before that date, it had been a neglected topic in the WoS base. This trend has been verified in other bibliometric analyzes related to ASD ,36. The Based on the analysis of the authors, we found that those with more publications do not necessarily have higher centrality and citation frequency (with the exception of Arvid Nikolai Kildahl), which indicates that the academic influence of the authors may depend on many variables. Regarding the journals that have been published on this topic, the distribution of literature was concentrated in the first 10 journals. These journals can be divided into three categories: ASD journals, disability journals in a general sense, and psychiatry journals. This demonstrates a growing interest in the subject that captures the attention of journals with different scopes, which could imply a favorable projection for this field of study with emphasis on the mentioned topics. However, it should be noted that due to the novelty of the subject, there is not a large volume of articles published in journals on trauma and ASD, but growth has been observed in the last five years. This indicates that in the coming years, these journals could show a growing interest in receiving these types of articles. These journals have also had an important place in other bibliometrics dedicated to ASD ,38.The most cited studies were published between 2011 and 2020. The topics were related to traumatic events in childhood and the prevalence rates of post-traumatic stress related to the victim of an accident, disaster, violence, and/or abuse. According to the criteria of Milojević , the ageThe analysis of the thematic map allowed us to identify which are the driving, specialized, basic, and emerging themes related to the study of trauma and autism. Results evidenced that the study of empathy is an emerging line of research in the field of trauma and autism. These findings are consistent with what was stated by Hume & Burgess , who proThe most productive institutions are located in various countries, such as Norway, the USA, the UK, and Italy. A majority participation of culturally Western countries was observed, with the exception of China and Israel. This suggests that there is room for partnerships to be established with researchers from developing countries that represent cultures other than those mentioned to advance the study of trauma and ASD. Collaborations like these could reveal the specific characteristics of traumatic experiences and their effects on ASD people in contexts other than those studied so far .This study had some limitations that must be considered when interpreting the results. First, only publications from the WoS database were used as units of analysis, which could lead to incomplete literature searches. For future studies, it would be key to use other international databases, such as PubMed. Finally, although the document selection process was carried out by two authors independently and in parallel, a certain bias in the selection of publications cannot be ruled out.The present study highlighted the state of research published in WoS related to traumatic experiences and ASD, as well as current research hotspots and trends. Traumatic experiences in people with ASD is a relatively new field, but the evidence indicates that this line of research will continue to be updated, driven by the need to understand the explanatory bases of the life experience of people with ASD. The research has been developed mainly in Western countries. Traumatic experiences in childhood and post-traumatic stress disorder have consolidated as historical lines of research. The research trends analysis indicated that the study of empathy and its relationship with trauma and PTSD is an emerging line of research relevant to consider in the field of autism. Due to its bibliometric nature, this study can serve as a basis to guide new researchers to find possible collaborators and also guidance to design studies that provide valuable information for researchers and professionals working in the field of ASD.


This study investigates the determinants of the international promotion of the Korean language at the cross-country level. The analysis is based on candidate data drawn from the Test of Proficiency in Korean (TOPIK) and uses a cross-country panel data model to measure how several factors affect Korea's international promotion. To mitigate sample selection bias, we estimated the model using the Heckman two-step method. The findings show that factors such as the Hallyu (or “Korean Wave”), international business, motivation to migrate to South Korea, motivation to study in South Korea, and Korean language learning resources play essential roles in the international promotion of Korean. The development level of the sample countries influenced the importance of each factor. For example, Hallyu, often regarded as important for the international promotion of Korean, was shown to be statistically significant only in the sample of developed countries. In addition, a shortage of Korean language learning resources has been identified as a major impediment to the promotion of Koreans in developing countries. These results provide new insights that can assist in formulating policies to promote the Korean language worldwide. Approximately 2000 institutions outside South Korea offer Korean-language courses to 250,000 students . Moreoven Wave”) , the namn Wave”) . Korean n Wave”) .Hallyu has indeed done much to improve South Korea's image, make people interested in learning Korean, and create a significant demand for Korean language classes . HoweverRQ1At the cross-country level, what factors influence the international promotion of the Korean language?RQ2What are the reasons for variations in Korean language promotion achievements in different countries?RQ3How can we develop effective strategies for the international promotion of the Korean language?This study makes several important contributions to the existing literature. First, our study is the first to combine linguistic and economic research to provide cross-country-level evidence useful for the sustainable international promotion of the Korean language. Prior studies have provided only individual-level evidence from a linguistic perspective, using questionnaires or interviews targeting specific populations in specific countries. Second, research on language promotion has focused on languages with large numbers of speakers, such as English and Chinese . KoreanMost research on the international promotion of the Korean language takes a linguistic perspective on the composition of Korean language learning motivation, and most studies examine specific countries. The lack of comparative analyses across countries makes it challenging to explain international differences in the results of Korean language promotion, which, in turn, makes it difficult to formulate rational promotion policies. International promotion of the Korean language is an important tool by which South Korea can improve its soft power and achieve foreign policy goals  as well 2Currently, research on the international promotion of the Korean language primarily focuses on Korean language learning motivation. Research on Korean language learning motivation can be roughly divided into two categories based on the country in which the research subjects are located. The first category focuses on developed countries, such as Singapore, the United States (US), and Australia. Chan and Chi  sought tThe second type of research, conducted in developing countries, produces different results. Gao  studied The aforementioned studies primarily focused on specific populations within specific countries, such as high school and university students, which may only partially represent the overall population of Korean language learners. By contrast, our study utilizes data on TOPIK candidates, which are not limited to any specific group, thereby contributing to a more comprehensive understanding of Korean language learning motivation composition. Moreover, by comparing studies conducted in developed and developing countries, we discovered the distinct characteristics of each country, making it challenging to simply transfer the experiences and policies for promoting the Korean language from one country to another. We might understand the sources of the differences in the achievements of Korean language promotion among countries to develop language promotion policies that align with the specific characteristics of each country. Our study is not confined to individual countries but to multiple countries to find patterns in the international promotion of the Korean language at the cross-country level, thus providing meaningful suggestions for the international promotion of the Korean language.Regarding the data and methodology, the aforementioned literature relies predominantly on cross-sectional data obtained from questionnaire surveys and interviews. However, cross-sectional data lack the temporal dimension of the variables of interest, resulting in the omission of a substantial amount of information. By contrast, our study utilizes a cross-country panel data model that combines cross-sectional and time-series data. This approach increases the sample size and degrees of freedom and allows for the utilization of fixed effects at different dimensions to mitigate endogeneity issues in regression variables. Furthermore, the data used in this study were sourced from reliable government statistical agencies to ensure credibility.Compared with the aforementioned literature, we provide new insights at the cross-country level, focusing on the economic perspective. First, as a cross-country study, we believe it is essential to consider the development levels, characteristics, and motivations for learning Korean in different countries to provide targeted recommendations for the international promotion of Korean in each country. Second, this study combines linguistics and economics and finds that economic factors significantly influence people's demand to learn Korean. Additionally, in the conclusion section, we provide more detailed explanations of new insights in the economic, cultural, and educational domains.33.1Motivation is a key factor for L2 learning and its maintenance . Motivat3.1.1(1)Benefits of Learning the Korean LanguageInstrumental motivation corresponds to the concept of “foreign-language demand” in economics. It is generally argued that the demand for foreign language learning is motivated by consideration of its costs and benefits . Thus, pThe benefits of learning Korean derive from the income premium gained from acquiring Korean language skills. According to the human capital theory, the positive effect of foreign language skills on wages comes from the increase in productivity they enable . ProductThe demand for labor with foreign language skills is driven by increasing globalization, such as growing international trade and foreign direct investment (FDI) . InternaIn addition to the employment demand created by international trade and FDI from South Korea, part of a nation's labor force can migrate to South Korea in search of employment opportunities. The labor market model of immigration suggests that much of the immigration between source and destination countries may depend on the difference in labor income between the two . If the (2)Cost of Learning the Korean LanguageFurthermore, the motivation for studying in South Korea is instrumental because international students come to South Korea to increase their human capital and improve labor market outcomes . To enteHaving summarized the potential benefits of learning Korean, we should also consider its costs. This cost originates from several sources.The availability of appropriate educational resources is a prerequisite for learning Korean. The King Sejong Institute, established in 2007 and supported by the Korean government, provides Korean language education resources. As of June 2021, the King Sejong Institute had 234 institutions in 82 countries . It offeSecond, the difficulty of learning Korean is an important cost. This difficulty varies depending on the native language of the learner because the nature of the differences between a given language and Korean is language-specific. The greater the difference between the learners' native language and Korean, the greater the time and effort required to learn the language . TherefoFinally, geographic distance is also an important cost of learning the Korean language because the greater the distance, the weaker the desire for cultural exchange and cooperation between countries . At the 3.1.2Learners driven by integrative motivation learn the target language out of a genuine interest in the target language, related cultures, and people . Hallyu 3.2The TOPIK is a Korean language test administered by the National Institute for International Education (NIIED) of the Korean Ministry of Education. It assists foreigners and expatriates whose native language is not Korean in learning the language and helps expand its popularity . The TOPAs We analyzed data on global (non-South Korean) TOPIK candidates from 2016 to 2019. Data from 2020 to 2021 may not be representative because many tests were postponed owing to government control measures during the COVID-19 pandemic and had not been completely restored by 2021. In addition, we excluded countries that began the test between 2016 and 2019 and did not offer the test consecutively because these countries may have accumulated more than two years’ worth of Korean language learners who wished to take the TOPIK test in any given year; using TOPIK candidate data would have overestimated the degree of Korean language promotion measured in these countries for a year.As indicated in Section The TOPIK candidate data were obtained from the National Institute for International Education (NIIED). Data on South Korea's international trade and cultural exports were obtained from the South Korean Customs Service, whereas data on the King Sejong Institute were obtained from the King Sejong Institute Foundation. We also used distance data from Google Maps; international student data from the South Korean Ministry of Education; FTA (Free Trade Agreement) data from the South Korean Ministry of Industry, Trade, and Energy; and other data from the World Bank.3.3Cross-country panel data models have been extensively used to study the international promotion of languages. For example, Xie  used a cAs not all countries held TOPIK exams, our data included many missing values . The TOPIK test data contain two types of information relevant for analyzing the factors affecting the international promotion of the Korean language:1) whether the TOPIK test was held, and 2) the number of TOPIK test applicants. Using ordinary least squares (OLS) regression analysis only for the latter information type would exclude countries that did not conduct TOPIK tests, which would lead to a sample selection bias and affect the consistency of the estimated coefficients. Therefore, the two-step Heckman method was selected . The firThe selection equation for the first stage, estimated using a binary probit regression model, is given in Equation Valid identification of the Heckman model relies on one of two conditions: the presence of a valid exclusion restriction in the selection equation or the presence of data that satisfy the assumption of a normal distribution. Wolfolds and Siegel  demonstrThe outcome equation for the second step is as follows:Because languages within the same language group are similar, learning a foreign language in the same group as the native language is easier than learning a foreign language in a different language group. Korean does not belong to the same language group as the official languages of the sample countries. Therefore, language group fixed effects can effectively control the impact of language distance and language learning difficulty. Thus, we first divided the official languages of the countries in the sample into 21 groups. When a country had multiple official languages, the language with the largest population share was selected as the representative language. The dummy variable 44.1Among the variables describing the benefits of instrumental motivation, the estimated coefficients on iples it ." With tiples it . Xie [12Generally, if the country's average income is lower than that of South Korea, all other things being equal, the country's residents will have a stronger motivation to migrate to South Korea . BecauseSimilarly, the effect of motivation to study in South Korea on the promotion of Korean language proficiency was confirmed.  in Asia . ConsequAmong the variables describing the cost of instrumental motivation, the coefficients of le score . These rle score , we findThe e Hallyu . In addi4.24.2.1To verify the robustness of our results, we replaced the dependent variables with the number of total TOPIK and successful TOPIK test-takers. The results in 4.2.2The high correlation between explanatory variables is known as multicollinearity, which leads to an increase in variance and thus affects confidence intervals and hypothesis testing . We use 4.2.3Hallyu, the King Sejong Institute, and the international promotion of the Korean language are all associated with the characteristics of the Korean language and culture. Therefore, the correlations between them may be attributed to unobserved factors at the Korean language and cultural levels. Thus, if omitted variables are correlated with one or more explanatory variables in the model and correlated with the dependent variable, endogeneity is introduced, leading to biased estimates and potentially spurious correlations between the explanatory and dependent variables . AdditioRegarding the King Sejong Institute, Eom et al.  examinedWe used the ratio of imported cultural goods to GDP as a measure of the sample countries' preferences for consuming foreign cultural products and employed it as an instrumental variable. Logically, the higher the consumer preference for foreign cultural products in the sample countries, the more likely they are to consume greater quantities of cultural goods from South Korea . Moreover, no direct causal relationship exists between consumption preferences for foreign cultural products and the international promotion of the Korean language. This is substantiated by the fact that cultural products from South Korea constituted only 2.48% of global exports of cultural goods in 2019, as reported by UNESCO, despite their remarkable growth.4.2.4If unobserved confounders are correlated with both the explanatory and dependent variables, our estimated relationship may suffer from omitted variable bias. Therefore, we employed the sensitivity analysis framework developed by Cinelli and Hazlett  to assesThe results for trade variables are not robust, which may be attributed to the characteristics of international trade. Although learning Korean can reduce the costs associated with trading with South Korea and lead to economic benefits, international trade is often characterized by its short-term and transactional nature. Consequently, in situations where long-term relationships between buyers and sellers are lacking, buyers tend to opt for a third language, such as English, to facilitate their transactions . Thus, t4.3The results of previous studies on Korean language learning motivation suggest that the factors influencing the international promotion of Koreans may depend on the level of development of the target country. In developed countries, Korean-language learners are more motivated by Hallyu than employment or income. By contrast, Korean language learners in developing countries are more concerned about employment and income. Therefore, to test whether the international promotion of the Korean language is affected by differences in development levels between the sample countries, we divided the sample into two subsamples, representing developed and developing countries, according to the IMF definition of “developed economy.” We then conduct regression analyses on each of the two subsamples. Consistent with expectations, Hallyu's influence was statistically significant only in developed countries, indicating that Hallyu's contribution to the international promotion of Korean is more important in developed countries than in developing countries. For example, in recent years, influenced by Hallyu, there has been a global trend to study the Korean language and culture, and the US is no exception. According to the Modern Language Association of America, the number of students studying Korean at universities in the US was approximately 10,000 in 2002 but increased to 17,100 in 2016, indicating a remarkable growth of 68 % .In terms of employment and income, the effect of income disparity is consistent with expectations because the coefficient of Surprisingly, the ple, Lee  finds thple, Lee . Moreoveple, Lee . TherefoThe coefficient of 5This study is the first to combine linguistics and economics to analyze the factors determining the international promotion of the Korean language at the cross-country level. Using the classification of L2 motivation in linguistics and the concept of “costs and benefits” in economics, we compiled the factors that may affect the international promotion of Korean. We estimate the importance of these factors using TOPIK candidates and economic data from 2016 to 2019. Our estimation analysis uses the Heckman two-step method, which effectively addresses the problem of sample selection bias.Our main findings are as follows: In terms of instrumental motivation, we find that close trade and economic ties with South Korea, motivation to migrate to South Korea, and motivation to study in South Korea are important drivers of the international promotion of Korean, whereas the lack of Korean language learning resources is a significant hindrance. In terms of integrative motivation, we confirmed, for the first time, Hallyu's contribution to the international promotion of the Korean language using econometrics.We ensure the robustness of our main findings through the following efforts. First, we replace the dependent variables with the number of total TOPIK and successful TOPIK test-takers and find that the results remain unchanged. Second, considering that the King Sejong Institute, Hallyu, and the international promotion of the Korean language might all be influenced by factors related to the Korean language and culture, this brings about endogeneity problems, namely spurious correlation and reverse causality. We address this endogeneity by using instrumental variable regression analysis, and the results once again affirm the promotional role of Hallyu and the King Sejong Institute in the international promotion of the Korean language. Third, we employ the variance inflation factor (VIF) to demonstrate that multicollinearity does not affect our results. Fourth, due to data availability, we do not consider other potential determinants that might influence the international promotion of the Korean language, which could lead to an omitted variable bias. We assess the impact of this bias using sensitivity analysis and find that, other than the trade variable, our empirical results are unlikely to be significantly influenced by omitted variable bias.We also find that a nation’s development level affects the importance of the factors influencing Korea’s international promotion. For developed countries, Hallyu is the most significant factor, followed by international business and motivation to study in South Korea. Learning resources and motivation to migrate to South Korea is crucial for developing countries.We believe that the results of this study provide the following insights into the formulation of South Korea's international promotion policies for the Korean language: First, in terms of economic policy, Korea's international promotion relies on the international business activities of Korean companies. Commercial activities between a country and Korean companies can generate demand for Korean language learning among its citizens. The Korean government can provide Korean language education resources to local employees of Korean companies, thereby assisting in the successful implementation of localization strategies while promoting the Korean language. Second, in terms of cultural policy, Hallyu can stimulate foreign interest in learning Korean. South Korea can combine Korean language instruction with Hallyu content by establishing more Sejong Institutes and Korean Cultural Centers in various countries, thus enhancing the efficiency of the international promotion of the Korean language. Third, regarding educational policy, South Korea's international promotion can be combined with policies aimed at attracting international students. We recommend providing Korean language education resources to students who wish to study in South Korea prior to their arrival, especially to students from developing countries where access to online resources may be limited. For example, we suggest opening more Sejong Institutes in additional countries, deploying more excellent teaching staff, and offering a broader range of free Korean language courses. When students with at least a basic level of Korean language proficiency arrive in South Korea, they have better learning and living experiences, which will help enhance South Korea's reputation as a study-abroad destination and attract more international students. Thus, a mutually beneficial relationship can be established between the international promotion of the Korean language and the enhancement of South Korea's national image. Finally, international promotional policies for the Korean language should be formulated to match the characteristics of each country. Taking a developed country, the US, as an example, we suggest continuous efforts to promote the Korean Wave . Specific measures include organizing various cultural promotional activities related to Korean culture and providing policy support for the promotion of Korean TV dramas, movies, and music in the US market. In the case of Vietnam, a developing country, we recommend integrating the promotion of the Korean language with people's instrumental motivation to learn Korean. Specific measures involve providing Korean language learning resources that cater to the particular needs of learners based on their motivations, such as employment, studying abroad, and immigration.This study analyzes the determinants of Korean language international promotion at a cross-country level, makes recommendations for the development of Korean language international promotion policies from an economic perspective, and may have the following implications or new insights: First, in terms of economics, we combine international Korean language promotion with economic factors for the first time. We propose the development of targeted Korean language promotion policies based on different countries' varying levels of economic development, which can contribute to the success of Korean language international promotion. Second, in terms of culture, our findings provide new insights by demonstrating the driving role of the Korean Wave in the internationalization of the Korean language for the first time at the national level. This study contributes to the existing research on the Korean Wave. Third, in Korean language education, we considered language-learning motivations at the national level for the first time. This offers a new perspective for research on Korean language education, especially when studying learners from multiple countries, by incorporating national-level factors into the analysis. Finally, this study has implications for the international promotion of other languages in other countries and can serve as a valuable reference.Our study has several limitations. First, our theoretical component is relatively weak, as we only combined classical language learning and economic theories. Future research could use a deeper combination of cutting-edge language learning and economic theories to advance the development of both theories. Second, the lack of Korean language learner-level data makes it difficult to provide concrete guidance for practice in Korean language education. Therefore, we believe that a combined analysis of macro- and micro-level data in a subsequent study will contribute to Korean language education.Data will be made available on request.Xingong Ding: Writing – original draft, Visualization, Software, Methodology, Investigation, Formal analysis, Conceptualization. Yujiao Wu: Writing – review & editing, Writing – original draft, Validation, Supervision, Resources, Project administration, Funding acquisition, Data curation, Conceptualization.The authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper.