Population aging and rural–urban migration have posed challenges to the elderly support system in developing countries that lack social safety net and services. Given that there is no consistent conclusion in the literature on whether adult children's internal migration can improve or impair their left-behind parents' health, little is known about the effect mechanisms. This paper investigates the comprehensive impact of adult children's migration on the health of their parents in rural China by analyzing the income effect and time allocation effect. The empirical analysis uses the rural sample of the China Health and Retirement Longitudinal Study (CHARLS) in 2013, 2015, and 2018. We found that adult children migration can improve parents' physical health, mainly thanks to the income effect. The analysis of the mechanism found that although the income effect has a positive effect on parents' health, the time allocation effect has a negative effect on parents' health because of the lack of care and increased working hours of parents. Our findings suggest that providing social care services and enhancing intergenerational communication can be practical strategies to mitigate the negative effect of children's migration to rural left-behind elderly parents. Population aging and rural–urban migration have posed potential challenges to the elderly support system in developing countries that lack institutional support. As the largest developing country in the world, China has been experiencing rapid population aging, which is more rapid in rural areas than that in urban areas , 2. In 2In China, internal migration for a better job is an important way to increase income for many rural households , 9. RuraScholars have increasingly been interested in the influence of adult children's internal migration on their left-behind parents' health, but their conclusions are not consistent. Some literature found that adult children migration can improve the left-behind elderly parents' physical and mental health –20. OppoThis paper contributes to the literature by empirically demonstrating there are two mechanisms, the income effect and the time allocation effect, of adult children's migration on parents' health. Meanwhile, this paper explores the interaction impact of these two mechanisms on parental health. Although the interaction impact of the two mechanisms is of importance to understand exactly how adult children's migration affects parents' physical and mental health, many existing studies have ignored it. This paper intends to fill the gap. In this study, we investigate the comprehensive impact of adult children migration on the health of their elderly parents in rural China by analyzing the income effect and the time allocation effect, and their interaction.The aged social security system of rural China has not yet been perfected , 19. RurAdult children's migration may affect their parents' health in two ways. The first way is parents may adjust their time arrangements for agricultural production and domestic labor after the children's migration, which is referred to as the “time allocation effect” . As an iThe second way is that parents may receive more remittances from their migrant children, which could have a positive effect on their parents. This effect is referred to as the “income effect” . The migThese two ways can influence each other. On the one hand, migrant children's remittance can reduce the parents' labor supply time and, to a certain extent, alleviate the negative impact of “time allocation effect.” The reason is that the employment income of the migrant children can replace or compensate for agricultural income and reduce their family's dependence on agricultural production. Families can reduce the agricultural working time of the elderly parents through land transfer. On the other hand, parents who take care of their grandchildren not only need to input time and energy but also need to bear economic costs, which weakens the positive impact of the “income effect.” Babysitting grandchildren is highly correlated with obtaining financial support from the offspring. Migrant children may increase their financial support to their parents because their parents help to take care of their children , and parObviously, adult children's migration affects parents' health through two opposing mechanisms. The overall health effect of children's migration depends on the respective strengths of these two mechanisms. That is, if the positive impact of the “income effect” is greater than the negative impact of the “time allocation effect,” children migration will improve the health of their parents. Conversely, adult children migration will worsen the health of their parents. The data in this paper are from the China Health and Retirement Longitudinal Study (CHARLS) organized by Peking University. The CHARLS is a nationwide social panel survey project that is specifically aimed at aging individuals in the Chinese population. The survey subjects are middle-aged and elderly people who are 45 years old and older. The project collects data at three levels: the individual, family, and community (village) levels. The CHARLS gathers data on personal health status, medical care, work and retirement, family income, population information, and intergenerational support for children, as well as the community (village) economy and population information. The sample covers 28 provinces in China. Since the 2011 national baseline survey, the CHARLS has been collecting data every 2 or 3 years. This article mainly used the mixed cross-sectional data from the 2013, 2015, and 2018 CHARLS. The response samples in the 2013, 2015, and 2018 CHARLS are 18,264, 20,284, and 19,816, respectively.People who live in rural areas and have at least one adult child who is 45 years old and older were selected as the research sample. The CHARLS defines the urban and rural samples according to the urban–rural division code of the National Bureau of Statistics. After excluding the urban sample and childless sample, the sample size was 33,460. To obtain village-level information to control the influence of village-level economic and social factors, participants in the sample described above were matched with the data at the community (village) level from the 2011 CHARLS. After matching, there were a total of 30,261 participants.To evaluate the total effect of adult children migration behavior on their parents' physical and mental health, this paper used the following constructed econometric model:Hi is parent i's health level; Mi is an indicator of children's migration situation of parent i; Zi indicates control variables, specifically including the variables of parental characteristics, children and family characteristics, and village-level characteristics, as well as year dummy variables and province dummy variables; and εi is an error term.where The model may have the problem of endogeneity because of the reverse causation between children's migration and the health of their parents. For instance, the poorer health of the parents is, the less likely the children are to work outside the home because they need to stay with their parents to provide care and support. Alternatively, parents with poor health may have a low economic income, which requires their children to migrate for work to earn income. This means that parents' health status affects their children's decision to migrate, which may lead to biased and inconsistent estimation results of the variables for children's migration. The abovementioned endogeneity problem has been fully discussed in existing studies and is usually dealt with by the instrumental variable method , 39. DraTheoretically, these two instrumental variables meet the conditions of correlation and exogenous. In terms of correlation, in a rural area, the migrant network in the village is an important source of information and social capital for farmers to seek jobs outside of the village. It can not only effectively reduce the cost of employment outside the village but also improve the probability of employment. Generally, the higher the rate of village-level migration is, the greater the possibility of their children's migrating for work. There are two possible effects of the urban unemployment rate on rural employment. The first is that the high unemployment rate in the local city promotes the transfer of rural labor workers to other cities to engage in non-agricultural work; the other is that the high urban unemployment rate causes the labor workers to stay in the countryside to engage in agricultural production. We do not discuss which of the two influences is dominant, but the above analysis shows that the urban unemployment rate is related to rural labor migration. In terms of exogeneity, village-level rate of migration and urban unemployment rate usually do not directly affect an individual's health. In fact, the village-level rate of migration and urban unemployment rate is related to the levels of economic and social development of a region, which may affect an individual's health. Therefore, we controlled for parental income, village-level characteristics, and province dummy variables in the econometric model, which could largely eliminate the endogeneity of instrumental variables.To evaluate “time allocation effect” and “income effect,” this paper used a multiple-step multiple mediator model. Hayes (2009) stated that when there are multiple mediation variables and the mediation variables interact with each other, a multiple-step multiple mediator model needs to be constructed to test for mediating effects . The folCi is intergenerational care, Si is children's financial support, and εi1, εi2, and εi3 are random disturbance terms. It should be noted that the mediating effect of time allocation adjustments is analyzed in this paper using intergenerational care time as an example. The reasons are as follows: First, in terms of labor time allocation, intergenerational care time is more affected by children's migrating behaviors; second, grandparenting is also caused by the “incompleteness” of labor transfer, and in rural areas, intergenerational care is becoming increasingly common, so it is significant to study the impact of intergenerational care on parents' health , the same instrumental variables used above were selected, and Equation (2) was estimated using 2SLS. In Equation (3), migration and grandparenting time were also potentially endogenous variables, and the theoretical analysis partially suggested that the financial support provided by migrant children also influences parents' grandparenting behaviors. To this end, drawing on existing research, the number of grandchildren under 16 years of age and the average grandparenting time at the village level excluding the subject himself/herself were selected as the instrumental variables for grandparenting time , 29. EquSince health is multidimensional , this paWe chose the degree of depression and subjective well-being to measure the parents' mental health. The degree of depression was measured by the Depression Scale developed by the Center for Epidemiological Survey (CES-D) , 46. TheMigration was the key independent variable. Children's rural–urban migration is often expressed as long-distance geographical migration, that is, children's working and living places are transferred from rural areas to urban areas or to places that are far away from their hometowns. Migration is also manifested in the employment sector, that is, the transfer from the agricultural sector to the non-agricultural sector. Based on the existing literature, migration is defined as having non-agricultural employment with their habitual residence outside of the county where their parents habitually reside. The migration variable was set as a dummy variable , 25, 39.Considering that there are many factors that affect parents' health, we controlled for three types of independent variables: parental characteristics, children and family characteristics, and village-level characteristics , 19–22. In addition, this paper also examines the effects of the “income effect” and “time allocation effect” on parents' health. Two types of mediation variables were used in the article: One is the remittance provided by the children to their parents, and another is the grandparenting time variable from the perspective of labor supply The empirical results show, in terms of physical health, the estimated coefficient of migration variable was significantly positive in the SRH equation, IADL equation, and physical activity ability equation. The results show that parents' SRH, IADL, and physical activity ability were significantly increased when their children migrated for work. In terms of mental health, the migration variable's coefficient was negative in the CES-D equation and positive in SWB equation. The results show that parents' depression degree was decreased, and subjective well-being was improved when their children migrated for work, but these two coefficients were not statistically significant. This indicates that children's migration does not significantly improve the mental health of their parents.The estimated results of other control variables were basically consistent with the theoretical and realistic expectations. As the parents grew older, their health gradually declined. There were obvious differences between fathers and mothers. Both the physical and mental health of fathers were significantly better than those of mothers. The higher the status level of childhood health was, the higher the level of physical health and mental health. Chronic diseases have a significant negative impact on parents' health. Income has a significant positive effect on parental health. Furthermore, the more children the parents had, the worse their physical health level was, which indicates, to some extent, that increased child-rearing tasks are not good for parents' physical health. In contrast, with the aging of their children, the health level of parents increased correspondingly. A possible reason is that, after the children have grown, the care burden of parents is reduced on the one hand, and on the other hand, children can also help their parents by sharing labor. From the estimation results of the village-level characteristic variables, it can be seen that village economic and social development levels had a positive impact on the physical and mental health of middle-aged and elderly people.The previous analysis found that children's migration was conducive to improving parents' health. Is there any difference in this effect for parents with different characteristics? Next, we look into the heterogeneous effects on several important dimensions: gender, number of children, and region. Panel A shows results separately by male and female. The results based on separated samples show significant differences between father and mother. In the mother group, we can see that most of the absolute values of the estimated coefficients are smaller than those of the father group, and most of the estimated coefficients are insignificant. This indicates that child migration can improve fathers' health, but the improvement in maternal health is not significant. Panel B shows results separately by parents with one child and parents with more than one child. The results show that for parents with one child, children's migration did not have a positive impact on parents' health. But for parents with more than one child, children's migration had a significant positive impact on parents' physical health. Panel C shows results separately by region. According to the standard of the National Bureau of Statistics on the division of administrative regions, the samples are divided into three groups: east, middle, and west. The results of group regression showed that children's migration had a significant positive impact on the health of parents who are living in central rural China and little to no effect on the health of eastern parents. However, it has a significant negative impact on the self-rated health and life satisfaction of parents who are living in western rural China. Overall, our results suggest that children's migration has larger beneficial effects on parents who are male, have more than one child, and live in central rural China.Columns (1) and (2) in The mediation effects of grandparenting time and remittance were further calculated and compared. The mediation effect of the independent role of grandparenting time could be obtained by calculating the product of a_1 and b_1. Similarly, the mediation effect of the independent role of remittance could be obtained by calculating the product of a_2 and b_2. In addition, grandparenting time also plays a role in the chain-mediated effect by affecting adult children's economic support, which could be obtained by calculating the product of a_1, d, and b_2. The calculated results are shown in This study examined the question of how adult children's rural–urban migration influences left-behind parents' health using the rural sample of the China Health and Retirement Longitudinal Study (CHARLS) in 2013, 2015, and 2018. This study found that children's migration can improve left-behind parents' physical health, but has no significant impact on parents' mental health, while some previous studies also found adult children's outmigration has positive associations between children's migration and parents' physical health , and no The mediation impact mechanism of children's migration on parents' health is analyzed. The study demonstrated time allocation and children's financial support mediated the relationship between children migration and parents' physical and mental health in opposite directions. The empirical analysis showed that children rural–urban migration negatively affected parents' health by increasing the burden of intergenerational care but positively affected parents' health by increasing financial support, and the positive effect of children's financial support was greater than the negative effect of intergenerational care. In addition, intergenerational care also exerted a positive chain mediating effect by affecting children's financial support; that is, children's financial support could mitigate the negative effects of intergenerational care on parents' health.This study also found that there were obvious heterogeneous effects on gender, the number of children, and region. Children's migration improved fathers' health but did not improve mothers' health. There are two possible reasons: One is female health is more fragile and easily affected by changes in the external environment; the other is the female has an advantage in the role of caregiver, and mothers are more likely to bear family labor and the task of caring for grandchildren when their children go out to work. Therefore, compared to fathers, mothers' health is more severely negatively affected. We found that there is an adverse effect on parents who are living in western rural China. The possible reason is that in the western regions of China, the labor usually migrates to the eastern coastal areas to work, and the family income may improve after the children migrate. However, due to the distance, the frequency of children returning to their hometown is generally relatively low. Parents lack care and spiritual support and need to undertake more family labor. The income effect of migration cannot compensate for the time allocation effect. Meanwhile, in western rural China, public resources, such as medical and elderly support, are relatively insufficient. Parents need more support from their children.In this study, we found that adult children migration can improve parents' physical health, mainly thanks to the income effect. We also found although the income effect has a positive effect on parents' health, the time allocation effect has a negative effect on parents' health because of the lack of care and increased working hours of parents. Meanwhile, the positive income effect can partly offset such negative effects in health caused by the absence of migrant children.The findings of this study have important implications. First, it is of great importance to promote the free movement of migrant workers. Rural labor mobility can optimize resource allocation, transfer surplus labor, significantly increase farmers' income, and subsequently, has a positive effect on the physical health of the rural elderly population through the income effect. Therefore, the policy needs to be improved to promote rural surplus labor transfer, including enhancing labor training, rights and interest protection, and welfare and household registration system reform. Second, intergenerational communication and relevant social care services for the rural left-behind elderly population should be enhanced furtherly. Although the transfer payment from migrant children can mitigate the negative effect of children's migration, it is quite limited to parents' mental health. Currently, the mental health of the rural left-behind elderly population in China is easily overlooked, this population's mental health problems are more serious. Giving financial support cannot completely substitute for the absence of children, and the communication between migrate children and left-behind parents should be enhanced with the application of modern information technology. Moreover, the social care system also should be constructed to provide excellent care service for the left-behind parents in rural areas.The original contributions presented in the study are included in the article/supplementary material, further inquiries can be directed to the corresponding author.ChiZ designed the study, carried out the data collection and analysis, and participated in drafting the manuscript. ChoZ was involved in data analysis and drafting the manuscript. KL and XC participated in drafting the manuscript. All authors contributed to reviewing the manuscript and have read and agreed to the published version of the manuscript.This research was funded by the Soft Science General Program of Zhejiang Province, China (Grant Number: 2022C35096) and the National Natural Science Foundation of China (Grant Number: 72003186).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.


This study aimed to describe the effect of the COVID-19 pandemic, combined with the Korean government’s response to the pandemic on tobacco consumption and national smoking cessation services among the Korean population. We obtained tobacco sale data from the Ministry of Finance and analysed the data on smokers’ visits to national smoking cessation clinics during the pandemic from a member of the National Assembly. We also conducted an online search to understand smokers’ thoughts about their tobacco use during the pandemic. We found that after the emergence of COVID-19 in 2020, the sale of conventional cigarettes increased from 3063.70 to 3209.70 million packs (4.77%). The number of smokers who visited clinics sharply decreased in the first half of 2020. The six-month quit rate decreased from 38.5% in 2017 to 22.3% in early 2020. We also found that smokers increased their consumption and began to switch from conventional cigarettes to heated tobacco products. The COVID-19 pandemic has threatened tobacco control policies and programs in Korea in the last two years; however, based on our experience during this period and considering the WHO recommendation, we should sustain and reinforce tobacco control policies and national smoking cessation services today and in the future. During the first half of 2020, more than one million smokers in the United Kingdom (UK) successfully quit smoking because of the COVID-19 pandemic . In HongIn the Republic of Korea (hereafter Korea), President Jae-in Moon raised the first issue related to COVID-19 and smoking. On 2 February 2020, a Korean evacuation plane returned to Seoul from Wuhan, China, and 360 evacuated Korean citizens were isolated at two different public facilities in Asan and Jincheon, the country’s central region. A week later, President Moon visited Jincheon to comfort the evacuees. During his visit, the Minister of Public Administration and Security, who served as the Minister of Health and Welfare in 2013, reported that smokers vehemently protested against not being allowed to smoke in the rooms of the smoke-free buildings, as well as not being allowed to go out of their rooms to smoke. President Moon addressed this issue by emphasizing the need to do the right thing and offered support to the smokers to quit smoking during such a difficult time .The message from President Moon seemed to have provided a good opportunity to sustain tobacco control policies and comprehensive smoking cessation services during the pandemic. However, unlike President Moon’s thoughts about smoking during the pandemic, the Ministry of Health and Welfare (MOHW) frequently sent official documents to 254 public health centers that provided smoking cessation services all over the country and other national smoking cessation facilities, suggesting that all smoking cessation services be stopped, in order to focus on fighting the spread of COVID-19 [Nevertheless, the recommendation from the WHO was to sustain and reinforce tobacco control policies and comprehensive smoking cessation services during the COVID-19 pandemic, in order to protect smokers, who are more vulnerable to COVID-19 . On the https://www.moef.go.kr/ (accessed on 1 April 2020). The tobacco sales data included the sales of conventional cigarettes and heated tobacco products . HTPs are treated as tobacco products, based on the tobacco definition in Tobacco Business Act [The ideal approach to examine the impact of the COVID-19 pandemic and MOHW’s response to the pandemic on tobacco sales or consumption and smoking behavior in Korea is to observe the changes in smoking prevalence before and after the pandemic. However, given that the data on smoking prevalence in 2020 had not yet been released, as of November 2021, we tried to obtain data from three different data sources and triangulate the information to achieve the research aim. Firstly, we considered tobacco sales data as an alternative source to determine the impact of COVID-19. Specifically, we visited the official website of the Ministry of Finance and obtained quarterly tobacco sales data for the 10-year period of 2011–2020, which was the longitudinal quantitative data. The data are publicly available at Secondly, in order to obtain the data on the number of smokers who visited national smoking cessation clinics in public health centers during the pandemic, we worked with Mr. Young-in Koh, a member of the National Assembly. The MOHW has a data collecting system for the national smoking cessation services. All the smoking cessation counselors who work for the smoking cessation clinic in public health centers should upload their records during the smoking cessation counselling. This data has been used to evaluate the national smoking cessation service; thus, they are official and accurate. This data has not been regularly opened to the public, and the MOHW normally releases this data to the public for their purpose or upon the request from news reporters or any members of the National Assembly. In these circumstances, we had contacted a member of the National Assembly. There is a particular system in which the National Assembly requests any kind of information and data from the government. Working with a member of the National Assembly, Mr. Koh’s office, we requested to the MOHW the number of visitors in smoking cessation clinics in public health centers between 2017 and 2020, and the six-month success rate of quitting, all of which can be important criteria for smoking cessation evaluation. Before the COVID-19 pandemic, the six-month success rate of quitting in smoking cessation clinics in public health centers was defined as carbon monoxide (CO) verified abstinence or self-reported abstinence from all tobacco products. This was based on point-prevalent abstinence. However, after the pandemic, the public health centers collected self-reported abstinence. In the context of the pandemic, the smoking cessation clinics were not able to conduct CO monitoring.www.naver.com), by using keywords such as “COVID-19 and smoking”, as well as on Internet blogs that had any communication about the COVID-19 and smoking, to understand smokers’ thoughts about smoking and their tobacco use during the COVID-19 pandemic. Throughout the first week of October 2021, we searched news articles that were publicly released from April 2020 to September 2021, smokers’ comments from the news articles that we selected, and Internet blogs related to our research topics. We first reviewed the titles of the news articles and excluded duplicated articles, as well as the articles with titles that were not related to our research topics. Afterwards, we read the news articles and looked through the public comments located under the new articles. Anyone can add their comment to most new articles released on the Internet, and it is very common culture to attach their thoughts and opinion to new articles in Korea. This is a popular method to understand public opinion in Korea. This method was not a systematic and comprehensive search, and we tried to briefly collect public opinion related to the COVID-19 pandemic and smoking in Korea. Without any funding source, we were not able to conduct any former survey, which might be a better way to collect public views; thus, we decided to identify smokers’ views, related to the pandemic and their smoking behavior, with this method.Thirdly, we conducted an broad online search on the biggest internet portal in Korea, Naver  did not represent the majority views of Korean smokers; thus, the finding should be carefully interpreted. In addition, as the findings were collected in the cross-sectional analysis, there was a limitation to infer real changes to smoking patterns at the population level.This study aimed to describe the effect of the COVID-19 pandemic, combined with the Korean government’s response to the pandemic on tobacco consumption and national smoking cessation services among the Korean population. We found that, after the COVID-19 pandemic, the tobacco sales increased and the number of smokers who visited smoking cessation clinics sharply decreased in the first half of 2020. We also found that smokers increased their tobacco consumption and began to switch from conventional cigarettes to HTPs. Consistent with Article 14 of the WHO FCTC, the ninth session of the COP to the WHO FCTC aimed to explore health system adaptations to support alternative service delivery options, such as e-health and telemedicine consultations, for tobacco dependence and cessation services . Similar


Sustainable mobility is a current challenge in our society. Research shows that carpooling systems are potential solutions that could mitigate environmental pollution and urban congestion and provide cost savings for their users. Despite their potential benefits, the levels of carpooling practices among some occupations could be improved. Teachers are suitable for carpooling experiences due to their specific working conditions ; however, there is no research solely focused on teachers. Thus, the current research aimed to analyze the barriers and incentives for teachers using carpooling systems for commuting. A panel member was selected following the staticized group technique. Panelists were surveyed to evaluate the advantages and disadvantages of carpooling. Results showed that fuel savings were considered by the expert panel as the most important incentive for carpooling. For short distances, carpooling was not considered the best commuting option. Additionally, the increase in travel time and loss of personal independence were identified as relevant barriers. Based on the opinions of experts, it can be concluded that carpooling barriers outweigh the incentives for the commuting of teachers. To promote carpooling practices, institutional mobility plans with advantages for carpoolers could improve the teachers’ perceptions about carpooling. Future carpooling strategies should consider these results to promote incentives and address the identified barriers. Transportation and mobility are key factors in societal development . Sustain2 emissions through climate change adaptations and mitigation measures, to minimize the effects of CO2 emissions. For the success of the eco-friendly programs, profound changes are also required in the consumption patterns of citizens, as well as their participation in communities. Individual sustainability describes the potential of actions that enable and lead to attitudes and practices according to sustainability. The involvement of citizens, in an active way, in the sustainable development process, is the key to success [In the European Union, institutions, enterprises, and governments are committed to increasing their knowledge, performance, and management of sustainable development. In this context, many communities are focused on limiting CO success .Deep changes are needed for sustainable mobility, where the behaviors of citizens are determinant. Shared mobility, associated with the emerging ‘collaborative and sharing economy’ expressed in the European agenda , is one One of the most simple examples of shared mobility is car-pooling, where people can offer free rides in their vehicles . ResearcCarpooling can be defined as people—with similar origins and destinations—who share the same car (owned by one of the carpoolers) ,12,13. ICarpooling practices present several advantages from different perspectives. On the one hand, carpooling is an efficient way to reduce fuel consumption. In the 1970s, casual carpooling clubs (motivated by the oil crisis) were habitual in the USA ; howeverSome authors have studied the impacts of this fuel reduction in different countries, such as the United States of America , China , and IraCommuting carpoolers will more likely address some of the cited potential problems ,30,39, bNowadays, the importance of carpooling programs has motivated the study of their effectiveness . The citIn the particular case of Spanish teachers, their specific labor conditions provide good opportunities to practice carpooling. For the majority of teachers, they could change their habitual schools each year, if they agree to participate in an official procedure. In this procedure, teachers are ranked according to the length of service and some additional achievements. Based on these ranks, they can choose among the available destinations. Thus, once a year, many teachers are relocated according to the results of the cited procedure. According to that, the distance that a teacher must cover each academic year may vary. In addition, they share the same workplace with several colleagues, they have similar timetables, and in many cases, they match paths from their city of residence to their habitual workplace. However, the use of private cars by solo drivers is the most extended practice.As previously described, several research studies can be found on the incentives and barriers of carpooling in the literature ,44,45,46Thus, the current research aimed to analyze the barriers and incentives of carpooling systems (for teachers who commute). The paper is structured as follows. In We used the Delphi Method (a single round), called the staticized group technique. The Delphi method is demonstrated to be an effective group-based judgment and decision-making method . AccordiThe staticized group technique is very similar to the Delphi Method. The only methodological difference is the absence of feedback or additional rounds in the staticized group technique. The Delphi methodology was carried out in fields, such as information systems  or workeIt was not possible to generalize the results obtained from a small number of participants from a larger population . However one of the main strengths of the staticized group methodology is that it takes advantage of the knowledge of experts in a specific topic. Experts selected were considered to have knowledge beyond a representative group. Then, the results obtained from the panel produced benefits for research and practice.In the methodology applied, expert selection is a key factor in the quality of the research. The majority of previous studies incorporated between 8 and 16 panelists and a minimum of 8 was suggested, while the authors suggested between 12 and 15 members . The autThe level of expertise was defined by the previous authors  as the mAll members of the panel scored at least 30 points in addition to the 4 achievements . Three oRegarding the personal conditions of the participants, the panel of experts was finally made up of 6 female professors and 6 male professors. Their ages ranged from 30 to 55 years. Ten of them were married with children, and only two were single. They all obtained a bachelor’s or baster’s degree before they started teaching.2. Its extension is larger than some countries, such as Denmark, Holland, or Belgium, and is similar to Portugal. The number of teachers officially employed in Andalusia in the education sector (excluding universities) was higher than 125,000 in 2021. They daily commuted to one of the 3500 schools and high schools located in the region. Women represented 65% of teachers and men 35%.The region studied in the current research was Andalusia (Spain). It has a total area of 87.268 kmOnce a year, many teachers are relocated to a different school or high school; the distance that a teacher must commute varies. However, there are no official data available about their mobility patterns and transportation alternatives.The items selected for the questionnaire were chosen after a literature review focused on carpooling practices. In the first approach, 35 factors were considered. Then, the carpooling factors were classified as incentives or barriers. Finally, they were grouped and reduced to 20 items.Vehicle: includes the advantages and disadvantages related to the vehicle (such as fuel consumption or maintenance costs).Time: includes aspects related to the length of the commute (such as delay or length of displacement).Personal: individual factors, such as the genders of the carpoolers, or physical and mental fatigue.Social: human factors related to the social aspects of sharing a car.Environmental: reduction of emissions was considered in this category.The following items were evaluated by the members of the expert panel. Items were classified into two main groups. In the first group, incentives for using the carpooler system were included . The othThe order of the questions was randomized for each participant to reduce the contrast effect and primacy effect.The anonymity of each panel member was ensured.A digital survey was used to collect the participants’ opinions. The following strategies were integrated into the survey to reduce the bias and to improve the quality of the research:A Likert scale was proposed to the experts to evaluate the items. The Likert scale can be defined as a psychometric tool with a set of statements of the study’s hypothesis . PanelisDifferent benefits and barriers of carpooling practices have been evaluated in the research. Some of them were previously studied in the literature. A consensus was not required for the staticized group methodology; variance and standard deviations were calculated to compare the results obtained with a Delphi method approach with additional rounds of feedback. On the one hand, all incentive items obtained values under 10% variance and deviation. On the other hand, some barrier items did not reach consensus values under the cited 10%. Thus, it can be said that consensus is lower regarding the barriers to adopting carpooling. Questionnaire reliability was calculated with Cronbach’s alpha values. Items classified as incentives obtained a Cronbach’s alpha of 0.67. This value is considered a satisfactory level of consistency . For theOne of the most studied incentives is the impact of cost-saving (regarding attitude toward carpooling) ,44,54,55Different types of costs associated with the use of the vehicle, such as fuel, parking, or maintenance, were similarly rated in our research. The difference between fuel-saving and maintenance saving  was very low. Regarding cost savings (fuel and maintenance), there were no significant differences between male and female opinions. In the literature, the differences were not significant. Cost of parking (41.3%) and cost of fuel (40.1%) were noted as relevant factors by habitual carpoolers . AlignedThe impact of fuel-saving decreases when the commuting distance is low . In the The group of personal factors was scored as the second group of highest values. Mental and physical fatigue reduction were scored with values near to 8 and over 10 in the Likert scale. Aligned with that results, previous researches revealed a positive relationship between carpooling and well-being during commuting . SimilarRegarding the social advantages of carpooling, they obtained values over 7, but they were the lowest-rated group of advantages when compared with the rest of the items. Then, social advantages were the less important group in the sector studied. Similarly, other research found that socializing was the least popular motive to carpool. Only 5.7% of the participants noted that reason as an incentive .Finally, environmental reasons, such as a reduction in emissions, obtained an average value of 8.08. Although the value could be considered high, it was lower than fuel saving (9.83). Results associated with environmental concerns varied. On the one hand, previous research ranked low environmental reasons for carpooling . On the Once the perceptions of incentives were analyzed, the next step was to analyze the barriers to adopting carpooling with the aim to understand the low levels of carpooling practices in the sector.According to the experts , the maiSpending time waiting for workmates  and a bigger probability of delay  were identified as second and third barriers in weight. In research carried out in the USA , it was The increase in travel time and waiting time were previously noted as important disadvantages to carpooling . Some auAnother relevant barrier in the opinions of experts was the need for displacement to the meeting points . This problem was addressed in previous studies ,36. TheyIn real-world carpooling, an extra displacement to the hub is considered a disadvantage by carpoolers when they decide between carpooling or solo-driving; however, optimized hubs can promote carpooling practices . A higheRegarding personal variables, they scored relevant values. Loss of personal independence to travel was considered an important barrier. The results are aligned with previous studies ,38. In aFinally, the group of social barriers obtained the lowest values of importance, but the higher values of variance and deviation. In the case of social awkwardness , the low values can be motivated because teaching is a team task, and teachers are in constant communication with their colleagues. Therefore, most of them know each other. This factor contributes to increased trust in potential carpooler mates ,39. The Based on the results obtained, it can be concluded that the barriers to carpooling outweigh the incentives for teachers to travel. Most of the specific results obtained for teachers were aligned with previous general results obtained by other authors. Despite the specific working conditions of teachers, their attitudes toward carpooling were not particularly different compared to other groups of people previously studied, such as students and industry workers.Cost savings related to fuel consumption were identified as the main incentives (or advantages) of practicing carpooling. However, the importance (or weight) of these incentives decrease if the length of the displacement is short because cost savings are poor.Psycho-social factors related to personal and social variables were regarded as obstacles to performing carpooling practices. These barriers were difficult to change according to the existing literature. The most effective way to reduce the weight of these disadvantages is to increase the efficiency of carpooling systems because the weight of cost savings will increase too.In the group of female experts, the items related to barriers obtained higher results than the group of male participants. Females placed different genders of coworkers as the more relevant barrier compared to males for the same item. A possible solution to reduce this barrier could be the management of some vehicles exclusively for women. This solution would allow the group of women with less confidence to share their cars in conditions that are desirable for them. In this sense, some previous experience based on “pink transportation” has been developed in some countries .In contrast, male and female panelists scored similar values regarding the incentives for carpooling.According to the results obtained, the regional government could develop a carpooling system for teachers in Andalusia based on the main incentives found. An institutional carpooling program would increase the number of possible combinations to carpooling among users and improve their matching possibilities. This could reduce some barriers, such as the need for displacements to meeting points, earlier beginnings of journeys, and the genders of coworkers.Additionally, a formal carpooling system with real-time information about cost savings and emission reductions could encourage potential carpoolers to carpool.Future carpooling strategies should consider the results achieved to promote incentives and address the identified barriers.The current research was focused on teachers from a specific region of Spain. Different labor conditions for teachers in other regions or countries might change the opinion of experts. Similarly, different cultures, safety levels, or social habits could change the opinions of potential carpooling users.In future research, a combination of experts from different countries could increase the scope of the results.The design and assessment of a real carpooling system by the same group of experts combined with a questionnaire for users could improve their knowledge about the real problems of carpooling systems and create new solutions to mitigate existing barriers.


Patient and Public Involvement and Engagement (PPIE) – sometimes called CommunityEngagement and Involvement (CEI) – comes as a big challenge but one that can bevery helpful for health care professionals and stakeholders in planning betterhealth policies for attending to the main needs of the community. PPIE involvesthree pillars: public involvement, public engagement, and participation. Publicinvolvement occurs when members of the general population are actively involvedin developing the research question, designing, and conducting the research.Public engagement tells people about new studies, why they are important, theimpact of results, the possible implication of the main findings for thecommunity, and the possible impact of these new findings in society, as well as,in the dissemination of knowledge to the general population. Participation isbeing a volunteer in the study. Our experience with PPIE, to the best of ourknowledge the first initiative in Brazil, is a partnership with the Universityof Birmingham, the University of Liverpool, and the NIHR Global Health Group onAtrial Fibrillation (AF) Management focusing on the AF care pathway exploringthe important aspects of diagnosis and treatment in the primary care system froma low-middle income area in São Paulo. The involvement of patients/public in theresearch represents a new step in the process of inclusion of all segments ofour society based on patient illness and the gaps in knowledge aiming to opennew horizons for continuous improvement and better acceptance of researchprojects. In the first two decades of the 21st century, society has been repeatedly encouraged tobe more participative in processes that might benefit populations. This global movementis directed toward building a more inclusive and egalitarian society that involves andrespects minorities. Brazil has a very mixed population that faces major socialinequalities. The socioeconomic disadvantage of our minority populations and of thedifferent regions of the country is huge, particularly with regard to public health andeducation.In this context, Patient and Public Involvement and Engagement (PPIE) – sometimes calledCommunity Engagement and Involvement (CEI) – is a big challenge, but one that can bevery helpful to health care professionals and stakeholders in planning better healthpolicies to meet the main needs of the community ,2.PPIE in scientific research refers to an active partnership involving people from thegeneral population and patients with community leaders or representative entities andstakeholders in a comprehensive way. Together, researchers and the community co-produceclinical research that follows scientific principles and respects community wishes. At firsInvolving patients and the public in research teams will therefore provide importantinformation that would not be considered if only researchers were part of the team.Ideally, patients and the public need to be involved as members of the research team atall stages, from developing the research hypothesis/question to helping tailor theresearch by prioritizing studies about certain diseases that impact society, decreasingthe individual burden of the disease. Involving patients/public in developing theresearch question, designing and managing the study, assisting with data collection andanalysis, and disseminating the main findings from their own perspectives are just someof the important contributions envisioned ,2.Public involvement occurs when members of the generalpopulation are actively involved in developing the research question, and designing andconducting the research  Management that focuses on the AFcare pathway and explores the important aspects of diagnosis and treatment in primarycare in a low-to-middle-income area in the western region of the city of São Paulo.In fact, we are still learning. In developing the project, we interviewed patients andcommunity members . An inteHow can we incorporate PPIE in research? We should try to be open-minded about thesechanges and ask people how they want to be involved in the research, i.e., helping theresearcher reach out to new perspectives that were not previously considered in theoriginal project, building new relationships, listening to community members, and askingthem if they want to participate as co-applicants. The researcher may find peopleinterested in participating in the study in workshops and meetings with patients and thecommunity. Community co-applicants with equal opinion weight and rights as researchersensure minority representation and diversity in society, which is the main goal of PPIE.Remember that it can be daunting for a member of the public/patient to voice theiropinion to a group of academics and clinicians. The public/patient members need to feelrelaxed, encouraged to participate, and know that their contribution will be takenseriously. Public co-applicants may bring new perspectives and experiences to thedevelopment of the study.According to this new perspective, information from research projects must not only reachthe scientific community, but also be disseminated within the community and health caresystems to ensure a positive, timely impact. Involving patients/public in researchrepresents a new step in the process of including all segments of our society, based onthe patient’s illness and knowledge gaps, aiming to open new horizons for continuousimprovement and better acceptance of research projects in the country.To learn more about PPIE, see reference 2 for the PPIE Pocket Guide.


Water conservation, soil conservation, biodiversity importance, and sandstorm prevention are important ecosystem services (ES) and the core challenges to sustainable economic and societal development in the Beijing–Tianjin–Hebei (BTH) region. Using the Integrated Valuation of Ecosystem Services and Tradeoffs (InVEST) model and observation data, we identified high-value ES areas in the BTH region. The high-value ES areas were mainly found in the northern and southwestern parts of the region, like the Yanshan Mountain Range and the Taihang Mountain Range. The ecosystem in the northern mountains is dominated by forest and grassland, and generally provides more valuable ES than does the eastern agricultural plain. Greater species richness was mainly found in the northern mountains with low human activity intensity. Due to its proximity, the Yanshan Mountain Range is critical to the health of the local ecosystem of Beijing. High biodiversity was present in the vicinity of the national nature reserves. Compared with other regions of China, changes in the BTH region are highly intense. Reinforcement of biodiversity conservation and ecosystem restoration in areas with a high degree of ES in the BTH region are capable of effectively improving habitat quality and regional ES. Ecosystem services (ES) refer to the products and services provided by ecosystem structures and processes for human society so that humans may obtain the benefits from an ecosystem, directly or indirectly . ES are ES are crucial for human wellbeing . EvaluatThe biodiversity of organisms and their environment is complex, involving the synthesis of various related ecological processes and an understanding of the relations of organisms to one another and to their physical surroundings . BiodiveThe relationship between ES provided by the natural ecosystem and the ecological response to human activities may extend beyond the carrying capacity of the ecosystem and include natural disasters, heat island effects, and pollution . ConversEcological restoration is a process to help a degraded ecosystem recover, with the goal to return to a state similar to the original state. In China, ecological restoration has become particularly important as a result of large-scale land degradation due to climate change and unsustainable human use. Artificial recovery emphasizes the positive role of humans in the recovery process, but natural processes such as succession that affect recovery success over time also must be taken into account. Recovery also can be primarily natural: natural processes may be sufficient to restore the ecosystem to its original state if an ecosystem is protected from further degradation .Beijing is the capital of China and is rich in many resources, however, the BTH region currently faces a double threat from water and mineral resource shortages . Few stuThe weakness of the study on ecological vulnerability will be addressed through analysis of the important areas of biodiversity and ES in the BHT Nature Reserve. We overlay the threatened biodiversity map with other maps that primarily regulate ES. We have chosen these four ES  because they are the national priorities of policymakers and the foundation of human wellbeing. Then, we propose the establishment of the BHT protected area to address the deficiencies of the existing protection in the BHT region. It is hoped that this method can alleviate the serious ecological problems in the BTH area to a certain extent.The BTH region includes two province-level municipalities (Beijing in the center and Tianjin in the east) and one province (Hebei)  Fig. 1)Fig. 1). The terrain is tilted from northwest to southeast and is high in the north and west and low in the south and east . The TaiThe increasing intensity of human activities exerts pressure on an ecosystem. Environmental degradation has not been effectively curbed. The local government has not taken effective measures to slow the trend of environmental declines. In cities other than Beijing and Tianjin, urban pollution is serious, and soil erosion in the Taihang and Yanshan mountains is increasing. Further, the plains are shrinking and disappearing, coastal and estuarine ecosystems are degrading, the land is subsiding, and seawater is intruding, causing increasing threats to habitat quality and sustainable ecological development .Land coverage data of the BTH region in 2000 and 2010 were obtained from a global land coverage product with 30-m resolution (GlobeLand30) . The imaThe data for this work came from national ecosystem assessment projects and national key infrastructure projects. Water yield was calculated and defined as water conservation capacity . The watP is the dimensionless conservation practice  was calculated using the InVEST model as follows : \documl runoff .LP) minus that in current land use/land cover type . We used the revised wind erosion equation (RWEQ) model to estimate the sandstorm prevention service. The formulas are as follows: Sandstorm prevention (wind erosion control service) refers to the sand retained in an ecosystem within a certain period. Sandstorm prevention capacity was calculated as sand loss from areas without vegetation cover  is sand control capacity, SL (kg m−2) is soil erosion caused by wind, SLP (kg m−2) is the potential soil erosion caused by wind, WF (kg m−1) is a climate factor, K’ is the surface roughness factor, and S (m) is the critical field length , is calculated as follows (j is the chosen conservation objective based on land use/land cover (LULC) user type, which mainly provides habitat for the selected protection targets in the study. In the parameter Dxj is described in the InVEST user guide.The biodiversity model has inherent spatial features, and biodiversity can be evaluated by analyzing the threat to biodiversity in the land coverage map . For exa follows : \documIn order to examine the relationship between simulation results and observational data, Pearson correlation analysis was used to analyze county, quadrat and watershed as statistical units respectively. We used the statistical analysis in SPSS 17.0.The importance of ES in a given region depends on the importance of individual ES within the region. Considering the irreplaceable role of each ES function in ensuring regional ecological security and supporting social and economic development, it is considered that only one ES function is very important in a given region, so this area is an important area of that ES function. The maximum value of the importance of each individual ES function is assigned to the comprehensive evaluation of the importance of ES functions, based on this principle.Grid maps of different types of ES were obtained based on the model calculations. We used the Raster Calculator in ArcGIS to obtain a raster map of the normalized ES function values. We exported the raster data attribute table, which records the ES value of each raster pixel; arranged the service value in descending order; and calculated the cumulative service value. The raster values corresponding to 50% and 80% of the total ES value are used as the demarcation points of ES evaluation and classification. The reclassification tool of ArcGIS software is used to divide the importance of of each ES into four levels, as the top 50% (extremely important), 50–75% (important), 75–90% (moderately important), and 90–100% . The spatial distribution pattern of the importance of ES functions in the BHT region was obtained.Using soil conservation as an example, the grading steps were as follows: first, calculate the soil holding capacity of each sorted grid; then sort the grids in descending order of soil holding capacity, and calculate the cumulative ratio of soil holding across the grid unit. The importance of each service function was superimposed and integrated by importance into comprehensive ES indexes .z-score. Z-scores are measures of standard deviation, and p values are probabilities.In the study of ES hotspots, hotspot areas are those with high service aggregation, so spatial correlation analysis can be used to identify hotspots and establish protected areas for these hotspots, which can effectively protect biodiversity and ES. The Gi* statistic represents the amount of spatial clustering within a local sample and can be calculated as the sum of the differences between the local sample value and the mean. The Gi* coefficient is a commonly used local spatial autocorrelation index based on the full distance matrix. It can detect which areas in the study area are highly clustered, that is, hotspot areas . The staz-score, p-value, and confidence. Features with high z-scores and small p-values represent statistically significant hotspots. The magnitude of the absolute value of the z-score explains the strength of the clustering. This approach can help identify hotspots with different levels of prominence, so stakeholders can prioritize accordingly based on actual needs.In this work, the spatial autocorrelation analysis of ArcGIS software was used to calculate the aggregation degree of biodiversity changes. As a tool integrated in ArcGIS 10.2, this method takes each raster pixel in the context of adjacent elements into the calculation and outputs a new feature class with i* (z-score) is as follows: i is a z-score of patch i. xj is the attribute value for patch j; wij is the spatial weight between patch i and patch j, if the distance from a neighbor j to the feature i is within the distance, wij = 1; otherwise wij = 0; n is the total number of grid cells and identifying and mapping the hotspots can visualize priority areas spatial-explicitly, which is helpful for targeted policy making.To simplify the analysis, the BTH region was divided into a number of small areas with polygon sizes of 10,000 hectares as hotspot analysis statistical units. The degree of aggregation of biodiversity change was calculated with spatial autocorrelation analysis in ArcGIS software . The comWe used the Pearson correlation coefficient and observation-based data to validate the model. The results showed that the modeled values were highly correlated with measurement data, indicating that the ES model in this research simulated those in the study .−2, and average sandstorm prevention capacity of shrubs of 1,703.06 t km−2  by the method described above. Our results show that the higher the regional vegetation coverage rate is, the stronger the function of ES in hotspot areas is. Areas of important distribution stretched through the Taihang and Yanshan Mountains . The Yani*.A high concentration of ES hotspots was found mainly in the northern and southwestern parts of the BTH region, due primarily to the presence of national nature reserves with high biodiversity . CompareThe soil retention service function was mainly distributed in the Yanshan Mountains in the northern part of the BTH region and the Taihang Mountains in the southwestern part of the region. The distribution of the water conservation function was basically the same as that of the soil retention function. Areas with high importance of ES were mainly distributed in the northwestern part of China . These aThe spatial distributions of ES and biodiversity were notably different. Overall, the northern mountain forest and grassland ecosystems typically provide more valuable soil and water conservation, water retention, and sandstorm prevention services than the eastern agricultural plains. Species are more abundant in the northern high mountains with less human interference than elsewhere. Important distribution areas of the northern mountain ecosystems were mainly in the northwestern part of China, with grassland as the main ecosystem type in the area. The possible reason for that is the dominant wind direction in the area is northwesterly and mainly prevalent in autumn and winter; at those time, vegetation plays an important role as sandstorm prevention even though vegetation cover is low.The northern and western mountains of the BHT region often have extremely rich species diversity due to their unique and complicated environmental and climatic conditions. Habitats for species to spread and distribute often ranges in large mountain. However, due to increasing human activities, habitats are gradually shrinking, which is insufficient to protect species populations and natural ecological processes in the long run. Therefore, there is an urgent need to integrate habitat into a larger spatial scale and to protect, restore and strengthen ecological connectivity between habitats. The construction and restoration of habitats are considered to be the key to the fundamental realization of ES management. The spatial distribution of existing habitat protection systems is not well matched with the spatial distribution of biodiversity. So there is a huge gap in the adequate representation of biodiversity in habitat protection. To address this shortcoming, we propose the creation of a new type of protected area to improve biodiversity and habitat quality. In order to expand the political viability of habitats, it is essential to allow some allowable use of natural resources as long as it does not compromise biodiversity and habitat quality goals.ES hotspot maps can be used as a visual and vivid tool to initiate communication with stakeholders on management planning. Identifying hotspots can help prioritize the maintenance of basic ES in limited financial resources. ES hotspots should be reserved first to avoid being destroyed. In this paper, hotspots mainly appear in the western and northern regions of BHT with high vegetation coverage. While our ecosystems are often complex and a landscape often has multiple services, multiple ESs should be considered at once to preserve multifunctional hotspots. Gi* statistical-based hotspot analysis works well for this situation as well. Ecological restoration is the process by which humans help restore a degraded ecosystem, with the goal of restoring it to its original state or a new state. In the BHT region, ecological restoration has become especially important to limit the human influence and protect the geographical space of nature. Now that ecological restoration is undergoing a major shift, expanding the goal from focusing primarily on biodiversity to also including the provision of ES for human wellbeing, how to achieve both biodiversity and ES is a top priority.Additional areas with high importance of ES were the Taihang and Yanshan Mountains. The Yanshan Mountains in the northern BTH region play an important role in the maintenance of ecological security of the Beijing area. The southern and eastern parts of the region are mainly farmland with little ecological importance . The stri*. Given the misalignment between biodiversity and regulatory services, expanding existing nature reserves and establishing new ones is an important step. In short, the expansion of existing nature reserves and the establishment of new nature reserves in these areas will also protect more areas of important ES. Based on experiences in China and in other regions, biodiversity and ES are useful measures for determining important areas for the expansion of ecological reserves, which will improve local and national support for conservation investment, effectiveness, and sustainability  is output when the computed local sum is completely different than expected, and the difference exceeds random chance, so Gi * Statistic is a more robust method for identifying hotspots. Additionally, geostatistical analyses such as Moran’s I, Getis-Ord Gi* statistics can also be used to identify hotspots, but in practice, Getis-Ord Gi* statistics (or simply Gi* statistics) have proven to be a superior alternative.Gi* statistics is one of the spatial clustering methods that works by computing the local sum of a feature and its neighbors, and then comparing the initial result proportionally to the sum of all features. A statistically significant i* statistical data could be used to identify hotspots, because this method considers all adjacent features and the value of hotspots of different statistical significance. The hotspot output can display ranking of sufficient landscape connectivity in succession  may show the location of centralized points or line features. In addition, Getis–Ord Gccession .Reinforcement of biodiversity conservation and ecosystem restoration in ES hotspots in the BTH region may effectively improve habitat quality and ES, support agriculture and economic development in the southeastern part of the region, and enable the coexistence of development and environmental protection . Areas tThis study provides a spatial framework for addressing priorities in ES protection. Stakeholders can integrate this approach into their own frameworks to identify and preserve multiple functional hotspots of ES or biodiversity, thus supporting targeted ES policy making. Our results show that the key ES areas are mainly distributed in the Yanshan and Taihang Mountains in the southwestern BTH region. Our work discusses the spatial features of ES in related areas. The spatial distribution of soil and water conservation areas is in line with that of biodiversity, and the mountainous areas northwest of Beijing play a critical role in that biodiversity. The main ecosystem types in Tianjin and Hebei are forests and shrubs.The lower slopes of the Yanshan Mountains in the BTH region are important to protect the ecosystem of the capital region. Hotspots rich in biodiversity are concentrated in the northern and southwestern parts of the BTH region, which are close to national nature reserves. Biodiversity changes are more intense and concentrated in those areas than in other regions. This study establishes the importance of multiservice ES areas in the BTH region, and shows that intensification of biodiversity conservation and ecosystem restoration in the region can effectively improve habitat quality and ES, support agricultural and economic development in the southeastern part of the region, and help in achieving the coexistence of development and environmental protection.10.7717/peerj.13881/supp-1Supplemental Information 1Beijing-Tianjin-Hebei Region and distribution of land use in year 2015 (Arcgis Desktop software).Click here for additional data file.10.7717/peerj.13881/supp-2Supplemental Information 2Arcgis software.Click here for additional data file.10.7717/peerj.13881/supp-3Supplemental Information 3Click here for additional data file.10.7717/peerj.13881/supp-4Supplemental Information 4Click here for additional data file.


Africa is home to many countries with the highest incidence of cervical cancer in the world. It is encouraging to see that the efforts to prevent and manage this disease are intensifying across the continent. The World Health Organization (WHO) has, in the last years, led a world-wide initiative to eliminate cervical cancer as a public health problem, starting by setting clear targets for 2030.To assist those African countries with the largest burden of cervical cancer, to reach the set targets, as a first step, WHO initiated a baseline capacity assessment in African high burden countries. We present and discuss the results thereof in this paper.The countries selected for the baseline evaluation were Eswatini, Guinea, Malawi, Rwanda, Uganda and Zambia. The data were collected by a mailed questionnaire in English, with 129 questions, most of them with preset answer options. It was answered by national coordinators of non-communicable diseases, cancer control or reproductive health programmes in the ministries of health and by the WHO country representatives. Based on the answers, suggestions were made towards optimising the efforts for cancer control.Except for Eswatini and Guinea, vaccination against the human papilloma virus (HPV) has reached between 74% and 98% of girls in the age bracket. The main method for cervical screening is still inspection with acid acetic. HPV testing, recommended by WHO, is being introduced slowly. The numbers of women screened are not yet nearing the required levels. Between 30% and 70% of the cervical cancers diagnosed are being treated with palliative intent. A deficit of personnel was reported for all professions involved in cervical cancer care.Guinea will need assistance to implement HPV immunisations and expand screening. In all six countries surveyed, steps should be taken to introduce or scale up the more precise HPV screening instead of acid acetic inspection of the cervix, to replace the current cryoablation of the preinvasive lesions of the cervix with thermal ablation and to increase the capacity for screening. Solutions need to be found for covering the dearth in gynaecological oncologists and radiotherapy installations and personnel. Cancer of the cervix was the world’s fourth most frequent cause of death from malignant disease in women in 2020 . What diThis is an evaluation of the readiness of six African countries to implement progressive changes leading to the elimination of the cancer of the uterine cervix as a public health problem. As a first step on the path to this global objective, announced in 2018, The World Health Organization (WHO) has set attainable targets for 2030: to vaccinate 90% of girls by 15 years of age against the HPV, to screen 70% of women by 30 years of age and again by 45 years, with a high-performance test, and to treat 90% of pre-invasive cervical cancers, as well as manage 90% of invasive cancers [The African countries selected by WHO for a baseline evaluation, to assist them to develop the required capacity for cervical cancer control: Eswatini, Guinea, Malawi, Rwanda, Uganda and Zambia, constituted a ‘first wave’, with evaluations of other countries to follow. The choice was based on the paucity of actionable information in the available research, which was focusing on isolated aspects of cervical cancer prevention and management. It was decided therefore to obtain a detailed set of data, via the WHO country representatives, on the significant components of the cervical cancer burden, its prevention and management. The findings will be used to devise solutions to assist these countries, as well as other African countries which will be evaluated in the future, to implement and scale up the appropriate solutions on the path to eliminating the cervical cancer as a public health problem.The data published here contribute to create a clear, comprehensive and true image of the cervical cancer prevention and management situation in these countries. They will be used as baseline to evaluate progress towards the goals set by WHO. They also offer an information platform, on which further research projects may be designed.The data for this study were collected with a survey by mailed questionnaire in English, with 129 questions, most of them with preset answer options. The questionnaire was answered by national coordinators of non-communicable diseases, cancer control or reproductive health programmes in the ministries of health, as well as by the WHO country representatives. To clarify some answers or obtain information where questions were left unanswered, interviews were held via the Internet with the respondents. Most of the 2020 data on HPV vaccination were extracted from WHO subsequent publications, as they were not available at the time of the survey. The results were grouped in comparative tables for ease of analysis –5.At the time of data collection, Eswatini and Guinea had not introduced HPV vaccination in their immunisation programmes. Eswatini was not eligible for GAVI support; however, in May this year, the country announced the start of its vaccination programme from September , 6. GuinMalawi has introduced HPV vaccination in the national immunisation programme in 2019. It is estimated that 84% coverage of the targeted population was achieved in 2020 [In Rwanda, 98% of the eligible population group was vaccinated during the 2011–2018 period. Presently, the vaccination is administered only to the 12 years age group, with an estimated coverage of 89% [In Uganda, the country-wide roll-out of HPV vaccination started in 2015, with the aim of covering 80% of the target group. The estimated coverage of the targeted population (girls by the age of 15) in 2020 is 74% .Zambia has entered the vaccination in its national immunisation programme in 2019. The estimated coverage with two doses was 70% in 2020 .The prevailing method of screening for cervical cancer is VIA in all six countries, practiced at public health institutions at all levels of care. It is also used in private centres in Malawi and Zambia. Cytology is offered at secondary and tertiary centres in Malawi and Zambia, while in Rwanda and Uganda only at tertiary centres. HPV testing is done in public facilities at all levels in Zambia, and at primary and secondary level in Malawi, if part of research studies. Private units offer HPV testing only in Malawi and Zambia.The numbers of screening facilities of primary and secondary levels per 100,000 women of 35–49 years of age are varied, from 1.5 in Guinea to 7.6 in Uganda to 13.6 in Rwanda.Colposcopy, biopsy and histology are offered mainly in tertiary hospitals. At secondary level, colposcopy and biopsy are available at some units in Malawi, Rwanda and Uganda. Some private and NGO units are offering these services in Eswatini, Guinea, Rwanda and Zambia, while for the other countries the information on private facilities is missing.Cryotherapy is widely used for treating precancerous lesions at all three levels of public facilities, mostly in a screen-and-treat setting. Thermal ablation is used in secondary units in Guinea, Malawi and Zambia, and in all tertiary units except in Eswatini. Tertiary centres also practice Large Loop Excision of the Transformation Zone (LLETZ), cervical conization and hysterectomy. There is little information on the services offered by private centres or by other non-governmental facilities.Only Uganda and Zambia offer all therapeutic modalities for invasive cancer. However, while in Zambia around 70% of patients are treated with curative intent, in Uganda the figure is only 30%–40%. As the waiting time from diagnosis to beginning of therapy is just 1 month in Uganda, the difference may be due to a massive late-stage presentation of patients in this country.It is notable that radical hysterectomy is not offered in Eswatini and Rwanda, indicating the need to train gynaecologists in those countries.Finally, neither radiotherapy nor brachytherapy is available in Eswatini, Guinea and Malawi. Brachytherapy is also not available in Rwanda.The vaccination of pre-adolescent girls against the HPV at the low price per dose negotiated by Gavi is a highly cost-effective method of prevention of the cervical cancer in the countries surveyed , 13. RecA potentially highly effective tool might be included in the vaccination programme: mobile phone messaging, driven by the e-health teams at the ministries of health, could be devised within a short time, reach a large audience and contribute to mobilising parents to bring their daughters to be immunised. The messages could offer to the parents, at a minimum, the essential information for understanding the threat of cervical cancer, its origin in the chronic infection with HPV, the benefits of vaccination and information on the age group targeted, as well as on the location and opening hours of the vaccination centres.Another important success in primary prevention of cervical cancer was registered this year in Eswatini. The country is on the list of those with highest incidence of the disease in the world , associaThere is very little available information on the state of prevention of cervical cancer in Guinea. A study of 831 women from Conakry , publishThe age-standardised incidence rate of cervical cancer in 2021 was estimated to be 50.1 . Guinea Apart from HPV vaccination, condom usage and circumcision, advised on a populational scale for reducing the spread of HIV, have a complementary benefit of significantly preventing the transmission of HPV , and infOur data confirm that the visual inspection of the cervix after application of acetic acid (VIA) is the main method of screening for dysplasia of the cervix in the countries surveyed, even in tertiary level and private care institutions. HPV testing, strongly supported by WHO as being more accurate than VIA, is not yet widespread. In Zambia, HPV screening is offered at all levels of public healthcare as well as in private healthcare. It is estimated that some 10% of screenings will be done by this method in 2023. The cost of screening one person with HPV detection is 23 USD, i.e. ten times higher than the cost of VIA. Zambia’s experience in HPV testing on a larger scale should be studied, for possible solutions applicable in other African countries [WHO has updated the guidelines for screening and treatment of cervical pre-cancer lesions  at the eThe planning of infrastructure, material resources, human resources and budget necessary to achieve the screening proposed by WHO needs to consider the – often large – size of the population targeted. To exemplify the magnitude of the effort waiting ahead, we may consider the case of Uganda. By using the population pyramid of Uganda  for instA recent study of HPV prevalence in rural Uganda , using aThe planning should also consider the investigations and treatment procedures, like cryo- or thermal ablations, LLETZ and cervical conization histopathology specimens generated by the screening, and the management of the additional invasive cancers discovered. For realistic planning, estimating the prevalence of cervical infection with HPV and its main oncogenic variants, by testing a representative sample of the population targeted, should be done in the countries surveyed, as soon as possible.An important component of the migration to a large-scale HPV screening would be point-of-care testing, rather than processing the samples in centralised laboratories. As the technology of testing evolves, it may become possible to screen and treat during a single visit.This survey indicated that cryotherapy is still the most widely used method of cervical dysplasia ablation, at primary and secondary levels of healthcare, in the countries surveyed. The notorious inconvenient of this method is that it is plagued by insufficient stocks of freezing agent. WHO encouraged replacing it by thermal ablation powered by electricity, either from a desktop source or from rechargeable batteries . LLETZ tOur data  shows thIn three of the countries surveyed, no radiotherapy is available. Rwanda has linear accelerators but no brachytherapy. Some of the patients from countries where no irradiation treatment is possible, are referred to facilities beyond borders, which incurs additional expenses for travel and subsistence, above the cost of treatment. Presumably most of the patients meant only for palliative treatment do not receive any irradiation under the present circumstances. This group constitutes more than half of the newly diagnosed cases, in some of the countries studied.The solution requires the involvement of governments, in partnership with financial institutions, donors and the African Commission on Nuclear Energy, in drawing and finalising projects for new radiotherapy facilities and personnel recruitment and training. The International Agency for Atomic Energy has established that one linear accelerator can treat around 450 cases of cancer annually, meaning that calculating with an average cancer incidence and distribution of various cancers, five facilities would be necessary for 1 million of inhabitants. According to these norms, Rwanda would need 52 radiation therapy units, Uganda 228 and Zambia 89. Such coverage has not yet been attained on the African continent, but the figures are supported by thorough studies, and constitute a clear target for planning, over a longer perspective .This study also shows discordant numbers of cases diagnosed versus cases treated versus distribution of cases per stages. These reflect a problem with cancer registration and extraction of data. It may be necessary to review the nature of captured data on cervical cancer, to ensure that they provide adequate information for planning, and digitise the recording and storing of the respective information.A few data on palliative management have been collected. The relatively small numbers of palliation specialists reported are contrasting with the significant percentages of cases managed with palliative intent. Out of the six countries studied, only Uganda reported that specialised accredited training in palliation is available. However, the existence of primary healthcare personnel trained in morphine administration is documented only in Eswatini; no data were received from the other countries, although the literature mentions the existence of home palliative care services .The consumption of morphine  is reported in milligrams per capita, for ease of comparison. A large discrepancy exists between the figures reported and published data from high-income countries: in the countries surveyed, the morphine use varies from less than 1 mg per capita to 3 mg; the literature shows consumptions of 241 mg per capita in UK, 213 mg in France and 204 in Italy .This report contains information provided by the national coordinators of various governmental institutions and programmes whose purpose is to control the cancer of the cervix, in the six countries surveyed. Together with its complementary report , it depiOur data highlight truthfully the progress of HPV immunisation in the countries studied, the challenging dimensions of the cervical cancer screening lying ahead and the need to urgently train or acquire more pathologists, surgical and radiation oncologists and to build more radiotherapy facilities. They clearly indicate that strong leadership, international cooperation and innovative solutions are needed for protecting African women and their families from this disease, which is at present highly preventable and curable.We could only formulate a few reasonable and realistic suggestions towards addressing the problems we identified. We are highly aware that only someone that is directly and permanently leading health care activities at various levels would be able to find adequate and effective answers. However, our synthesis may help to formulate strategies and to better prepare for the challenges ahead, going towards the elimination of cervical cancer as a public health problem. Of particular interest in this respect is the experience of Zambia, where HPV testing is being offered at all public facilities. A future analysis of that activity might extract useful lessons for the introduction or scaling up of HPV screening in other African countries. Unfortunately, we did not obtain data on the number of facilities already offering HPV screening in the countries surveyed.Another shortcoming of the analysis of secondary prevention activities was that the actual coverage of the target population through opportunistic screening is not known; the figure is necessary for estimating the necessary escalation of the service to reach the 2030 target. It remains to be determined or estimated by the health authorities in each country.Four of the six countries surveyed have active vaccination programmes. Guinea should be supported towards starting her own vaccination programmes.The migration from the almost ubiquitous VIA primary screening method to HPV testing will happen gradually. The main advantage of a negative HPV test is that one can be highly confident that the patient can be recalled according to the appropriate testing schedule without risk. The main disadvantage right now is that if a treatment of dysplasia is needed, the patient must travel for a second visit. However, techniques of self-sampling may obviate the need for many visits at the health centres.Scaling up the screening and its associated medical interventions will require many more testing points and personnel but will be rewarded by a reduction in the costs of cervical cancer care and substantially improved survival rates. To improve the numbers of patients treated with curative intent, it is the responsibility of governments to plan and budget for the training of the necessary specialists in gynaecologic oncology and for establishing radiotherapy facilities.However, a large proportion of the diagnosed cases is managed at present with palliative intent, due to late presentation, but also because of limited capacity to perform radical hysterectomies or radiotherapy, in those cases where they would be indicated. The patients in palliative care receive limited pain therapy, judging from the consumption of morphine equivalent per capita. We should not neglect the suffering of the many patients who presently are beyond cure, while working to improve our curative capabilities.To monitor the progress towards the 2030 targets set by WHO, the cancer registries should be improved, both with regard to data collection and ease of data retrieval and analysis.None.None declared.


We need to increase the awareness about disease transmission, signs and symptoms, and how to prevent ourselves from this emerging infection. Lessons from research on past infectious disease outbreaks have taught us that stigma will pose a significant hurdle to health and wellness during any pandemic.Monkeypox is an emerging viral zoonotic disease that is endemic in Central and West Africa. The first cases outside the African continent were detected in the United States of America (USA) in 2003 following the importation of infected animals. On July 23, 2022, the World Health Organization (WHO) declared monkeypox a Public Health Emergency of International Concern (PHIEC), following the rapid spreading into multiple continents in short time . Since Jvia air and droplet are invariably associated with high social stigma, and COVID-19 is a perfect example of that. Healthcare workers and patients who survived COVID-19 faced substantial social stigma and discrimination worldwide. It created unprecedented panic in people's minds, with several socially stigmatized. Such discrimination resulted in affected people hiding their illness, prevented them from visiting hospitals and ultimately led to certain psychological problems such as anxiety and depression and grave complications from the diseases due to lack of proper health care . It must be clear to people that everyone can acquire monkeypox, regardless of gender identity or sexual orientation, or age. Proper emphasis regarding the different modes of transmission, including direct contact with the infectious rash, respiratory secretions during face-to-face contact and touching infected objects, is also being given. We also should not stigmatize the gay and bisexual community  by holding them responsible for spreading the disease. They should be reached using targeted channels like specific websites, dating apps, or media programs, with a holistic approach. Reliable sources such as the CDC and WHO should be sought to obtain correct information about the disease. Any sign or symptom of the disease should be reported at the earliest, knowing that it is associated with a good prognosis in most cases. Besides all of the above, effective and impactful communication about monkeypox is critical to combat the disease and avoid fueling fear and stigma. It includes using friendly words with the patients, promoting the general population to participate in the spread of accurate scientific news and especially the social influencers whose voices have an impact (Addressing stigma is fundamental in healthcare sector. Numerous studies during the COVID-19 pandemic have highlighted stigma and discrimination among healthcare workers. Lessons from COVID-19, which showed healthcare workers are vulnerable to such kind of emerging infections –7. Healtn impact –7. It isRS: draw and draft the manuscript. BP, AM, AR, and AR-M: review the literature, finalize, and edit the manuscript. All authors have read and approve for the final manuscript.The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest. The handling editor SB declared a shared affiliation with the author AM at the time of review.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.