Rabies is endemic in the Philippines. To support the rabies campaign in the Bicol region at the southeastern part of Luzon, the BAI-OIE Stop Transboundary Animal Diseases and Zoonoses (STANDZ) Rabies project was implemented in the pilot provinces of Camarines Norte, Camarines Sur, Albay, and Masbate. A community awareness survey was conducted with the residents of these provinces to determine their knowledge, attitude, and practices (KAP) on rabies during the start and end of the project. Qualitative, descriptive research was done with a structured KAP questionnaire. Pet owners in the pilot provinces were chosen as respondents. Results showed that respondents know that they can acquire rabies in animals through the bite of a rabid dog (pre-project implementation (PRI): 19.6%, post-project implementation (POI): 38.0%). Vaccination was the top rabies preventive measure . Biting incidents were noted in some respondents, and observing the dog and killing it immediately were some of the actions taken by bite victims. If a supposed rabid dog was seen, respondents would either: immediately kill the dog , report it to authorities , and capture and observe the dog concerned . Pet owners increased their KAP about rabies prevention and control as compared to the pre-implementation study. However, certain gaps in their KAP need to be given attention; thus continuous education of pet owners must be done. Rabies is considered a neglected tropical disease and is responsible for claiming the lives of 59,000 humans annually, mainly in developing countries of Asia and Africa . Once clIn the Philippines, rabies remains endemic with 200–300 human fatalities annually (an average of 2.13 deaths per million) and 635 animal rabies cases  since 2012 .Financial provision to facilitate these activities is a crucial factor in program implementation. In many developing countries, rabies control programs are not a high priority on the government’s agenda. The delineation of responsibility and budget allocation between ministries of agriculture and health seems to be unclear . FurtherA critical component of a successful rabies program is a community that is well-educated on the risk factors associated with, and the control of, rabies . The lacIn September 2014, several provinces in Bicol were selected to be pilot areas for an internationally-funded project for rabies elimination. Through the World Organisation for Animal Health (OIE), with funding support from Australia’s Department of Foreign Affairs and Trade (DFAT) Stop Transboundary Animal Diseases and Zoonoses (STANDZ) initiative, together with Philippines’ Department of Agriculture-Bureau of Animal Industry (DA-BAI), an agreement was made to support rabies elimination in two priority areas, Masbate and Albay, as well as to provide vaccination support to Camarines Norte and Camarines Sur. From September 2014 to June 2017, the OIE STANDZ Rabies Project provided technical support for aligning the National Rabies Prevention and Control Program (NRPCP) with international standards, provided vaccines from the OIE Bank, conducted capacity building for new vaccinators, supported rabies information dissemination campaigns, and conducted multi-sectoral meetings, among others.Rabies awareness in the community is very important in creating effective control measures in the Philippines; however, very little information has been published about this. The conduct of the KAP survey provided additional information to the implementers on which areas of the Rabies program should be improved  based on the pet owners’ response. This study aimed to compare and assess the general knowledge, determine the attitude, and identify the practices of respondents on rabies and its related issues, including biting incidents and RPO, during the pre-implementation (PRI) and post-implementation (POI) stages of the OIE STANDZ Rabies Project in its pilot areas.A community-based study was conducted by the OIE STANDZ Rabies Project in pilot areas of Camarines Norte , Camarines Sur , Albay , and Masbate . The study was conducted in two periods, namely: April to May 2015 (PRI) and February to April 2017 (POI).A quantitative descriptive method was employed in this study to determine the knowledge, attitudes, and practices (KAP) of pet owners concerning rabies, including dog bites. In every village in a municipality, respondents were selected, depending on the presence of pets in their household. The same set of municipalities was involved in both PRI and POI studies but not necessarily the same set of pet owners. Municipalities chosen were either 3rd- or 4th-class municipalities. Each district in a province was represented by at least two municipalities. A total of 1088 respondents was included in the PRI study and 1380 in the POI. The study was limited to dog owners of the four provinces aforementioned, since dogs are the primary reservoir host of rabies in the country. Bikolano  to ensure good comprehension of the questions. One adult in each household was selected to be a respondent in the study. Respondents were briefed before the start of the interview about the purpose of the study. The questionnaire included items regarding the respondent’s profile, vaccination history of their dog/s, the presence of biting incidents and first aid adopted, and other general questions regarding rabies, including its transmission and symptoms. The data were collated in Microsoft Excel and presented using descriptive statistics. Frequency and percentages were used for analysis, including PRI and POI percentages. A statistical analysis using Statistical Analysis System (SAS) was performed to compare the PRI and POI proportions.With coordination from the City Veterinary/Municipal Agriculture Office (CVO/MAO), researchers were accompanied by a staff member from the mentioned offices. Personal interviews were carried out using a structured questionnaire. The questionnaire was developed in English but translated to Tagalog  or Most of the respondents were female , a mother , and married . The majority graduated from at least high school level . Most pet owners had heard about rabies, mostly from radio , health workers , television , neighbors , and veterinarians . Dogs  and humans  were the usual species affected with rabies according to the respondents. They identified fear of water , aggressiveness , and salivation  as the most common signs of dog rabies. Common signs reported in humans were also fear of water  and salivation . Others admitted that they did not know anything about the signs of rabies in humans . Respondents were asked for their knowledge on how dogs acquire rabies. Common answers were bite of another rabid dog  and scavenging garbage . There were also respondents who did not know anything on how rabies is being transmitted . Others mentioned that dirty food and environment can be reasons why dogs acquire rabies . On the other hand, rabid dog bite  and eating dog meat  are usual responses on how humans get infected with rabies. Similar to dog rabies transmission, there were people who did not know how the virus can be transferred to humans . Meanwhile, to prevent rabies, pet owners believed that the best measures to prevent rabies in dogs are vaccination  and confinement of dogs . Some pet owners also mentioned that proper feeding, regular bathing, and maintaining a clean habitat  are important rabies preventive measures. A majority of them know that pets should be vaccinated every year . The data also indicated that the majority had heard about rabies-related local ordinance  within their municipality  or a legal mandate regarding RPO . The majority felt the presence of rabies-related programs , such as dog vaccination  and rabies seminars , during both study periods. tandok’ , and consulting an Animal Bite Treatment Center (ABTC) . Observing the biting dog within the observation period  and the immediate killing of the biting dog  were some of the actions taken by bite victims toward the biting dog. Most of the respondents had at least 1–2 dogs in their household . Totals of 2193 and 2421 dogs were owned by the respondents, with an average of 1.83 and 1.75 dogs per household in the PRI study and the POI study, respectively. Vaccination history of dogs was noted from the respondents. During the PRI period, 58% were vaccinated (1272 of 2193) while in the POI, the history reflected dog vaccination coverage of 37% (890 of 2421) in 2015, 54% (1300 of 2421) in 2016, and 37% (890 of 2421) in 2017. Some of the household members incurred dog bites , where bite victims were usually bitten by their own household dogs  or roaming dogs with an owner . A few first aid measures which were adopted by the bite victims were washing with soap , visiting ‘Respondents were asked about the actions to be done should they see animals with rabies-like symptoms. The answers included immediate killing of the dog , capturing and observing the dog , doing nothing , and others, such as walking away from the suspect rabid animal . A notable increase has been noted in people who responded to report rabid dog sighting to authorities in POI (63%) than PRI (26%). Of the people who answered that they reported to authorities, most of them mentioned that they will report suspect animals to village officials . Pet owners were also asked questions on common practices in taking care of pets. Overall, the most common answers were submitting of dogs for vaccination, confining dogs, and providing dogs with shelter and food. There was improvement (more than twofold) in the response of pet owners to submit their dogs for vaccination, from the PRI to the POI. Community awareness is crucial in rabies prevention and control. In many parts of the study, the pet owners’ level of rabies awareness was seen to improve during the post-implementation study. However, there were still some questions which were answered incorrectly; thus, rabies information dissemination must continue at the community level. Females, including mothers, represented the majority of dog owners and respondents for this study. In the Philippines, mothers are the primary care-givers for the children and are thus well-placed to also care for the household dogs . The majConsidering all platforms through which respondents have obtained knowledge on rabies, the common clinical signs recognized by pet owners in both dogs and humans were fear of water, aggressiveness, and drooling. Both humans and animals exhibit a fear of water or ‘hydrophobia’ when the animal is trying to drink water due to the spasm of the accessory respiratory muscles of the neck, pharyngeal muscles, and diaphragm followed by extension of the neck and a feeling of dyspnea . When thkilawin’, as a delicacy, especially during alcohol drinking sessions. These people are at risk to exposure to rabies if the dog happens to be infected. Even though the risk of transmission varies, all possible modes of transmission, including through bite, contact with saliva, and consumption of animal products from diseased animals should be avoided [The number of pet owners in the POI who knew that dog rabies can be transmitted through a bite doubled compared to the PRI. However, there were still a considerable number of people who believed that scavenging garbage can infect dogs with rabies. This belief could be related to the traditional beliefs about stray dogs that are often observed scavenging. Some people believed that dogs become sick through a dirty environment and eventually become rabid. Others stated that stray dogs are at greater risk to receive a bite from rabid dogs; therefore, this study suggests to program implementers to strictly implement stray dog control to reduce the spread of rabies or other diseases through contact with infected dogs. More people are becoming aware of rabies transmission, with a twofold decrease in people who did not know anything about this. There were a few respondents during both PRI and POI who believed that eating dog meat is a potential source in acquiring rabies. Eating cooked dog meat which is suspected to come from a rabid animal cannot transmit the disease to humans, since the virus is killed by the high temperature of cooking. However, the danger of eating dog meat lies with the person who killed the dog and prepared the meat as contact with the infected saliva via broken skin or mucous membrane, the consumption of uncooked meat and meat preparation are risks for the transmission of rabies . In the  avoided .During the POI, an overwhelming response was noted with regard to vaccination being reported as the most important rabies control measure. While vaccination is the most effective measure to control rabies, restricting dogs from roaming freely, bathing dogs, and cleaning their cages were also mentioned. This does not have a direct impact on the transmission of the virus but are components of RPO which should also be improved. Almost all pet owners knew that vaccinations should be carried out every year in the POI period compared to pet owners during the previous study. This could be a direct result of the MDV initiated by most agriculture/veterinary offices. Most respondents were aware of the local ordinances that had been implemented by cities and municipalities within each territorial jurisdiction. There was an increase in the number of pet owners who were aware of the rabies program in their municipality in the POI, compared to the PRI, particularly to dog vaccination.The number of dogs owned in each household remained almost the same, at 1–2 dogs, in both study periods. Unfortunately, upon checking the vaccination history of the dogs in the POI, out of the 2421 dogs surveyed, there was a 54% (2016) and 36.8% (2017) vaccination coverage, values which are below the 70% vaccination rate recommended for effective control of the disease. Since the data from the POI were only collected in February to April 2017, this might be too early to notice an impact because the MAO/CVO may have only just started its campaign. There may be an increase in awareness observed in many areas during the POI; however, this does not correlate with the number of dogs submitted for vaccination. This result should be considered by program implementers because many of the vaccination reports in the pilot area indicated that the 70% vaccination rate has been reached. MDV might have only reached urban villages but not the remote areas; thus, there is a lower reporting of vaccination in this survey as the study was conducted in both urban and rural villages. Furthermore, there might have been a low turn-out because dogs under the age bracket of 1 year  were included in the POI study. Unfortunately, data on the age bracket was not gathered in the PRI.MDVs are often performed in a city/municipality over a two-to-three month period depending on its area size. In the Philippines, if few dogs are submitted to a central vaccination site, then house-to-house MDV is also done. If a pet owner has dogs which are not three months of age, they will not yet be vaccinated. Vaccinators advise them to visit the MAO/CVO once the dog reaches the recommended age. However, pet owners, especially in rural areas, will not bother to bring their dogs to the MAO/CVO because of transportation-related expenses and a lack of household members to handle the dogs in these offices. With the presumption that maternal antibody will interfere with the immune response before three months of age, vaccination is not recommended in this age group . HoweverSome areas in the Bicol region have refined their strategies in the conduct of MDV. Good practices that were documented include the hiring of a community animal health worker (CAHW) or CAHW per village (recommended by their village leader), who would be responsible to conduct an initial census of the dog population and to vaccinate the whole village within a certain period of time dictated by the MAO/CVO. Some CAHWs learned that it was better to vaccinate after office hours and weekends so that owners will be present to handle their pets during vaccination. In other municipalities, socio-civic organizations were tapped as volunteers to augment the needed manpower in MDV. An increase in vaccination accomplishment is achieved through well-informed pet owners willing to cooperate with the government’s rabies-related activities.tandok’ or traditional faith healers and the application of garlic as a topical first aid were still adopted by some bite victims from both study periods. This is not unique to the Philippines, as bite victims from countries such as India and Bangladesh also applied chili oil and turmeric powder as home remedies in their bite wounds [At least one bite incident in the household was documented in twenty percent (20%) of the respondents. Usually, pet owners have been bitten by their own dogs. There was an increase in the number of biting dogs that are roaming but are owned; thus, there was no improvement seen in the control of stray dogs in between the two study periods. Most of the bite victims performed washing of the wound with soap, which is one of the most important first aid measures in any bite injury; however, there was a decrease in the number of people performing this during the POI. Consulting ABTCs to seek medical attention was also carried out by bite victims, but a decrease in the number of people doing this was documented in the POI. Consulting ‘e wounds ,21.Observation of the biting dog was carried out in most biting incidents. There were less people in the POI who did nothing, and an increase in bite victims immediately killing the dog, was noted. In many of the animal rabies cases investigated within the pilot areas, a rabid dog bit more than two people. In worst cases, rabid dogs bit at least ten people. If situations such as these arise, the community comes together to find and kill the aggressive dog and stop the series of biting. In cultures where they are not familiar with dog handling and restraint, the practice of killing is very common . A studyThere was a significant improvement in the POI with regard to the reporting of rabid dog sightings to authorities, more specifically to village officials. This may be a result of the STANDZ initiative to support community-based orientation on the Anti-Rabies Act. Aside from the human health, animal health, and education counterparts, village officials were also invited to participate in this meeting. In this forum, the roles and responsibilities of each agency towards the implementation of rabies control programs were discussed. Since village officials are considered the frontline in small communities, they must be educated on the importance of their role in preventing and controlling rabies. By underscoring the importance of their position in the program, they will feel empowered and are more likely to effectively perform their job in educating their constituents. Following protocols such as capturing the dog involved, observing them for the next 14 days, and submitting the head sample (if the biting dog dies within 14 days) would be very helpful in preventing the spread of virus from its source. During the PRI, most pet owners replied that they would just walk away from suspect rabid dogs. This reply decreased significantly in the POI, which signifies that pet owners are becoming more conscious of their responsibility as a pet owner to report suspect rabid dogs to authorities.Pet owners have also recognized their responsibility of submitting their dogs for vaccination. Improvement was realized in the POI study, where more respondents chose this practice as a way to take care of their pets. Meanwhile, almost the same number of people across both studies answered that they should not allow dogs to roam freely. This should prompt the implementing agencies to place more emphasis on education and to create policies that would strengthen the control of stray dogs in the community, since most rabid dogs are strays.The Bicol Region has gained substantial knowledge, attitude, and practices on rabies prevention and control and other related issues since the initial PRI study was conducted. Previously, most of the respondents knew very little about rabies and would do nothing upon seeing rabid dogs. After the support given by OIE STANDZ Rabies Project to the pilot provinces, many are now actively reporting sightings of suspect rabid dogs and properly managing dog bite cases. Most respondents have agreed that vaccination is an effective preventive measure to control rabies. However, there are still certain management practices that need to be improved, such as reducing reliance on traditional faith healers for bite wounds, improving rabies vaccination coverage in both rural and urban villages, and controlling stray dogs.Now that the OIE STANDZ Rabies Project has come to a close, municipalities and cities should institutionalize the implementation of self-sustaining rabies programs, building upon the lessons learned from the project, such as: (1) continuous regular information campaigns directed towards the pet owners (up to the village level) in order to increase the public’s awareness on rabies and related issues; (2) implement ordinances and strictly impose penalties for violators; (3) collaborate with other relevant agencies and organizations, and create strategies to increase MDV coverage in cities and municipalities; (4) design programs to regulate traditional faith healers, and discourage the public from consulting them; (5) involve village officials in the rabies program; and (6) establish a proper referral system for dog bite incidents.Strategies and tools for a more holistic rabies program implementation are widely available at the international level, yet its operationalization at the community remains as a challenge. Many pet owners actively participated in different information dissemination activities organized by the project. As a result, the knowledge gained by the residents of the community was translated into actions. In the pilot areas, coordination across all sectors  has greatly improved during the reporting of those suspect rabid dogs which have eventually turned out to be rabies positive. Behavioral change in the community is reflected by their active response to biting incidents and rabid dog sightings, which coincided with the results in the POI phase. This shows that efforts can effectively be focused first at the community level (which includes empowering village officers) and can serve as a model for implementation at a larger scale as a sound program starts at this level.Government efforts should likewise be complemented by a cooperative community willing to support activities to promote rabies awareness and responsible pet ownership. A harmonious relationship between the government and its communities and the education of its constituents on this disease will help reduce the incidence of rabies.


Background: Haemophilia is a disease of genetic origin, which causes a defect in blood coagulation. Under normal conditions, in the case of leakage from the blood vessels, the blood forms a clot that reduces or blocks the bleeding. This process involves the activation of several plasma proteins in a cascade-like species. Two of these proteins, produced in the liver, factor VIII and factor IX, are deficient or present a functional defect in people with haemophilia. Because of this deficit, the haemophiliacs easily suffer external and internal bleeding. Surgical treatment of these patients is to be observed, and often their treatment is delayed due to unclear guidelines and risks in treating these patients. The aim is to provide clear guidelines in the case of surgical treatment of these patients. Methods: In this study, we have considered all the guidelines that refer to the gold-maxillofacial surgery, focusing on the literature of the last 10 years. Results: Surely, this collection of guidelines will favor the choice of the clinician towards safer and predictable protocols. This study does not want to create a guideline but evaluates the literature of the last 10 years, and highlights the latest for the treatment of these patients., with the aim of informing the pathology and at the same time making the surgical maneuvers safer. Conclusions: Despite the research of literature has produced few results, it was nevertheless possible to draw up a guideline thanks to additional information extrapolated from textbooks and other scientific articles. According to the guidelines, it is possible to proceed to the treatment of these patients, if with appropriate therapy in a safe and risk-free manner. Haemophilias are hereditary coagulopathies whose basic anomaly consists of the quantitative or qualitative alteration of one or more plasma proteins in the coagulation system. The entities most frequent nosological diseases are represented by: haemophilia A, haemophilia B and angioemophilia of von Willebrand. Haemophilia A has an incidence estimated at 1: 20,000–100,000 male births per year, of which the 30% of cases without familiarity (largely attributable to new mutations). It is a hereditary recessive coagulopathy linked to the X chromosome, in which the male is ill and has variously reduced plasma levels, while the female is usually a healthy carrier. The haemostatic defect derives from the lack of factor VIII to which follows a reduced generation of thrombin through the way intrinsic coagulation. The severity of the clinical picture is related to the degree of deficiency: a normal haemostasis requires a residual activity of >25%; the majority of patients have levels below 5% and have spontaneous symptoms and complications ,5. SurgiWhat are the surgical guidelines for patients with coagulopathies, especially those with haemophiliacs?The following focus question was developed according to the population, intervention, comparison, and outcome (PICO) study design:The search strategy incorporated examinations of electronic databases, supplemented by hand searches. A search of four electronic databases, including Ovid MEDLINE, PubMed, EMBASE, and Dentistry and Oral Sciences Source, Biomaterials source for relevant studies published in the English language from January 2009 to January 2019 was carried out.A hand search was also performed in Internal Medicine and Haematology journals. The search was limited to English language articles. A hand search of the reference lists in the articles retrieved was carried out to source additional relevant publications and to improve the sensitivity of the search.The keywords used in the search of the selected electronic databases included the following: “haemophiliac” OR “coagulopathies” AND “surgical” OR “oral” AND “guidelines”.The choice of keywords was intended to collect and to record as much relevant data as possible without relying on electronic means alone to refine the search results.Two researcher of University of Messina and University of Naples, singularly analysed the obtaining papers in order to select inclusion and exclusion criteria as follows. Reviewers compared decisions and resolved differences through comparing the manuscripts. For the stage of reviewing of full-text articles, a complete independent dual revision was performed.The review included studies published in the English language. Letters and Editorials were excluded.The review included all human studies and literature review published between January 2009 and January 2019, on haemophiliac patients undergoing to maxilla-facial district surgery.Haemophiliac patients.Surgery and haemophiliac patients.Surgery on patients with coagulopathies.The full text of all studies of possible relevance was obtained for assessment against the following inclusion criteria:Studies involving patients with other specific diseases, immunologic disorders, uncontrolled diabetes mellitus, osteoporosis, or systemic conditions.Not enough information regarding the selected topic.Surgeon guidelines not for dentistry or maxillofacial fields.Articles published prior to 1 January 2009.No access to the title and abstract in English language.The applied exclusion criteria for studies were as follows:After the first literature analysis, all article titles were screened to exclude irrelevant publications, case reports and the no English language publications. Then, researches were not selected based on data obtained from screening the abstracts. The final stage of screening involved reading the full texts to confirm each study’s eligibility, based on the inclusion and exclusion criteria.The data were independently extracted from studies in the form of variables, according to the aims and themes of the topic.This type of work brings together all the studies in the literature in the last ten years presenting a technique for nanosurface realization and analyzing their biological interaction. The risk of bias in this case is present because each author convinced of his own study could have influenced the results. For this reason, the works taken into consideration and all those with a high risk of bias or with conflicts of interest have been carefully evaluated.Perspective study and data extraction were performed according to PRISMA flow diagram . The iniAs already mentioned in the introduction, haemophilia is a recessive hereditary disorder that causes a serious deficiency in blood coagulation due to the total or partial lack of factor VIII  or of coagulation factor IX (The rarer is the factor IX (e.B), given by the total or partial lack of the XI factor. The hemophilic subject may be affected by spontaneous bleeding, or caused by trauma, these with outcomes that are more serious. In haemophilia type A the deficit can be quantitatively variable, so as to induce different clinical pictures: with functional levels of factor VIII up to 2%  haematomas are frequent  and, in childhood, the spontaneous hemarthrosis (hemorrhages of the joint cavities); with factor VIII levels ranging from 2 to 5% , hemarthrosis are rare and bleeding occurs only after surgery.In haemophilia type B, the genetic anomaly determines a functional factor IX deficiency, which corresponds to a deficiency of the antigenic part in 70% of cases, and of only the functional part in 30%. Substitutive therapy rarely involves the infusion of prothrombin complex concentrates, the factor IX or VFIX is used frequently. Factor IX (e.B) (Haemophilia C) is even more rare and the defect, which affects the factor XI, is transmitted as an autosomal recessive deficit. The manifestations are more rare and milder than the previous defects: there are bleeding after surgery and after important traumas. Von Willebrand’s disease (VWD) is an inherited haemorrhagic disease caused by a genetic defect that determines a quantitative structural or functional anomaly of the Willebrand factor (VWF). The disease is classified into two main groups, based on the VWF deficiency: the form with a partial quantitative defect type 1) or total (type 3), and the form with a qualitative defect type 2). The clinical symptomatology includes the bleeding, of variable entity, that can arise spontaneously or during the use of invasive techniques. Bleeding abnormalities are usually characterized by muco-cutaneous haemorrhages [ or total. The cliCurrently, the treatment of haemophilia occurs through the administration of the drug (hemoderivative or recombinant) containing the deficient coagulation factor. The two main therapeutic regimens for haemophilia are “on demand” therapy  and prophylaxis, which instead involves the constant administration of the deficiency factor to prevent serious bleeding and protect patients. These are infusions that must be done about three times a week. For several months, recombinant drugs with a prolonged half-life are also available for prophylaxis therapy, which entail numerous advantages, allowing a lower number of infusions with equal protection for patients. In the future, gene therapy may be available for haemophilia ,14,15.Perioperative risk surgical interventions and the same injections of anesthetic (both intramucose or truncular) may cause prolonged bleeding that can not be controlled with local measures and may cause serious consequences: hemorrhage with anemia until hypovolaemic shock ; HaematoSurgical treatment should be referred to hospital facilities and it is always necessary to request haematological advice to establish the severity of haemophilia, the presence of inhibitor VIII, the type of replacement therapy and the dosage, according to Planning elective surgery in people with haemophilia is always a challenge for the clinician. Haematology consultations are often requested and in many cases, the therapies, especially in the case of pain, are based only on a pharmacological phase that is repeated without ever reaching surgical therapy. Despite this, however, the guidelines and studies examined below are clear. According to Escobar et al., the planning phase should ensure that surgery proceeds without incident in a multidisciplinary surgery team, and it is very important that postoperative rehabilitation begin soon after surgery. The importance according to these authors therefore, lies entirely in the correct planning of the intervention, with a multidisciplinary team ready to handle any kind of complication . In anotDespite the limited scientific support available in the literature, this study is able to represent a guideline for the surgery of these patients. Surely, the patient must be framed and carefully evaluated even by haematological counselling. The guidelines analyzed in this study, and therefore proposed by the authors, should in any case be re-evaluated according to the new biomedical technologies. it is necessary to remember that in the course of the literature analysis, no guideline taken into consideration mentioned the use of biomaterials or other factors such as micro-crystallization collagen, anti-fibrinolytic and factor replacement. The guidelines, however, inform us of a low risk towards patients’ health.This article is intended to be a report of the articles and guidelines in literature over the last 10 years regarding this topic. The results appear to be satisfactory and to offer surgeons’ risk-free guidelines. in any case, the patient must be considered with a multidisciplinary approach and be attentive during the intra and post-operative phases.


Repurchasing intention of agricultural materials is a key to a sustainable food business system. The novel contribution of this study is that we go beyond technical aspect and look into human capital dynamics in a general context, by examining how different dimensions of ‘guanxi’  between farmers and agricultural retailers affect trust between the two and, in turn, repeated purchase intention of agricultural materials by farmers in China. To further generate implications for food system as a whole, we also examined how dynamic environment moderates the effects mentioned above. Adopting survey method and multivariate analyses, this study tests the hypotheses with a collected data set of 578 farmers from representative rural areas of China. The results show that guanxi between farmers and agricultural retailers has a positive effect on trust between them and on repeated purchase intentions of farmers. While instrumentality has a negative effect on trust between them and on repeated purchase intentions of farmers. The trust between farmers and agricultural retailers promotes farmers’ repeated purchase intentions. The intensity of competition negatively moderates the positive relation between trust and repeated purchases. Demand uncertainty does not moderate the positive effect of trust on repeated purchases. The results and discussion shed light on agricultural food system sustainability from a dynamic environment embedded business relationship perspective.  The competition in the agricultural material market of China is becoming more intense in recent years as the market economy in this sector is developing very fast. A saying that is popular among marketing practitioners is that “the cost of attracting new customers is five times that of maintaining old ones”. Agricultural retailers must focus on cultivating farmers’ repeated purchase intentions to generate satisfactory sales. Thus, exploring the factors that stimulate farmers’ repeated purchase intentions is of great importance for agricultural retailers, and this question also deserves more research attention from academia.Previous studies on customer repeated purchase intentions show that factors such as perceived value ,2, custoIn a business-to-business (B2B) context, trust is also important in establishing a stable, continuous, and good supplier relationship, thereby enhancing the role of corporate customer share and customer retention . MoreoveHowever, this research on guanxi, trust, and repeated purchase intentions is mostly based on B2B or online marketing scenarios. The purchase of agricultural materials in rural area of China is business-to-customer (B2C) and mostly offline transactions. In addition, the agricultural materials market in China is very unique. Most farmers in China have very limited knowledge of agricultural materials such as pesticides, seeds, and fertilizers. They do not know the components or usage of them . TherefoDifferent from western countries, research shows that the relationship between the business parties in China is of great importance in business transactions. It is a stepping stone of making a deal successfully. The level of trust between the buyers and sellers determines the way in which business is done . More spIn addition, given the importance of environment in determining business activities, it is necessary to ask the question that will the relationship between guanxi, trust, and repeated purchase intentions be affected by the boundary conditions, and ‘what are the implications for the food system?’. Besides being embedded deeply with Chinese traditional culture of relationship-based “acquaintance” society, the agricultural materials market in China is emerging and developing. The number of agricultural retailers is growing rapidly, and farmers increasingly enjoy more choices. In a dynamic environment such as this, can trust, as a marketing tool, still significantly increase repeat purchase intentions? This is also a question that needs to be addressed.In view of the above questions, based on relationship marketing and social exchange theory, from a perspective of Chinese ‘relationships’, this paper investigates firstly, the impact of the two dimensions of guanxi  on trust. An emotional relationship is a relationship based on human emotions and established by a person to satisfy the emotional needs of both parties . The insThe following section will review the relevant literature and theories, develop the conceptual framework, and propose the hypotheses. The research methods and results are given in the third section. The conclusions, limitation of the research, and the direction of further studies are discussed in the last section.‘Guanxi’ in China refers to the interrelationship between people that is based on personal emotions and interests, and established in the process of social activities in the context of Chinese culture . China iGuanxi, as a culturally embedded variable, is complex and contains multiple dimensions . Some stA combination of the traditional ‘relationship-based’ and a modernized ‘commercial economy’ type of purchasing behavior is spearing in the rural area in China in recent years. The purchase behavior of farmers is increasingly instrumental. The purchase decision of agricultural materials is no longer simply based on the emotional relationship of blood, kinship, or geography, but increasingly reflects the instrumental orientation of pursuing economic and utilitarian ends . It is tAn emotional relationship is a relationship based on human emotions and established by a person to satisfy the emotional needs of both parties . In the The instrumental relationship refers to the social relationship established by individuals with others in order to achieve some goals . In the Trust refers to the confidence of one party in the transaction relationship to the reliability and integrity of the other party . Trust iThe influencing factors of repeated purchase intentions have been a hot topic in the research of marketing. In the mid-1980s, customer perceived value was considered to be the most important factor affecting customers’ repeated purchase intentions, and it was also one of the important methods to measure whether enterprises have competitive advantage in service . CustomeIn the mid-to-late 1990s, customer trust stood out among the influencing factors of repeated purchase intentions and was highly valued by research scholars. It believed that trust had a significant effect on the generation of repeated purchase intentions ,6. SinceWhile agricultural marketing has its uniqueness compared to B2B or online marketing. Firstly, agricultural materials are distinguished from consumer products and living materials by their high aftereffect—i.e., the cost of purchasing fake and shoddy products is very high—and the effect of the use of agricultural materials can only be identified in the middle, late, or end of the agricultural production process. Secondly, the main body of purchase of agricultural materials in China is thousands of individual farmers with small farms. The expertise to purchase agricultural materials is poor. Most of them make the purchase according to previous farming and purchasing experience, and are easily affected by the surrounding voices. Thirdly, different from other trading networks, farmers are at the edge of the rural social network; their ability to effectively obtain information and resources is weak. Agricultural retailers often deal with supply and marketing companies, and have many channels to obtain information. Therefore, they occupy a central position in the agricultural social network, and have control over information and resources. Thus, farmers depend heavily on agricultural retailers for information and suggestions . TherefoSocial exchange theory believes that interpersonal interaction is a process that both parties follow the principle of reciprocity ,30. The In agricultural trading, repeated purchase intentions reflect the desire and inclination of farmers to maintain a relationship with a certain agricultural retailer. Due to the cyclical nature of agricultural production and the characteristics of dedicated asset investment, farmers will have a strong motivation in cooperation with agricultural retailers to ensure a desirable result of farming. The relatively closed and acquaintance-driven society gives guanxi a key position in influencing the repeated purchase intention of farmers. The trust in agricultural retailers is the guarantee for farmers to deal with the purchase risk. Guanxi positively influences farmers’ repeated purchase intention through establishing trust between agricultural retailers and farmers. A dynamic environment is the most prominent feature of an enterprise’s external environment. The economic behavior of both seller and purchaser is always embedded in a certain social environment, and is bound to be affected by environmental factors . A dynamFarmers and other retailers are the two most important market players in the agricultural market for agricultural retailers. The rapid and ever-changing demand of farmers has put pressure on agricultural retailers. The huge group of competitors and the fierce competition in the industry has clearly formed a big obstacle for the retailers to achieve competitive advantages and business expansion. Therefore, this study considers that demand and competition are the two most important aspects of environmental factors that influence the repeated purchase intentions of farmers ,32. DemaThe demand of agricultural materials is vulnerable to fluctuations in market conditions during the sales process. Therefore, compared with general consumer goods and industrial products, agricultural product marketing faces higher demand uncertainty and changes in competition intensity . The dynIn summary, we propose a conceptual model in which guanxi between farmers and agricultural retailers improves the trust between them and the repeated purchase intentions of farmers, trust promotes the repeated purchase intention of farmers, and this effect is moderated by environmental dynamics. The conceptual framework is depicted in • Guanxi and TrustThe close guanxi between farmers and retailers indicates that the relationship has been tested for a long time and the two sides believe that the other party is a friend of their own. Agricultural retailers will not forge the information on quality and other aspects of agricultural materials. Instead, they will really care about the agricultural harvest and benefits of farmers and provide quality products and services that meet the needs of farmers. This will increase farmers’ confidence of agricultural retailers in fulfilling their responsibilities and maintaining credibility. Therefore, farmers believe that agricultural retailers with good guanxi are worthy of trust and have the ability to recommend suitable products for them. In addition, in the acquaintance society of Chinese rural area, the close guanxi indicating that the two parties will not only be friendly and mutually supportive at work, but also extend the friendship to non-work issues, and the two sides will maintain contact. Frequent communication and interaction play a role of mutual benefit and eliminates contradictions. Thus, farmers have higher trust in agricultural retailers. As Huang (2015) argued that in the context of micro-marketing, guanxi can promote the generation of trust . TherefoHypothesis 1.The closer the personal relations  between farmers and agricultural retailers are, the higher the trust between them.• Instrumentality and TrustOn the contrary, if farmers only contact agricultural retailers when they want to buy agricultural materials, the relationship is established by the farmers solely to meet their goals, to achieve possible benefits, to do things smoothly and obtain internal information. In other words, both the farmers and the agricultural retailers treat the relationship as an instrumentality and will not trust each other. Based on this short-term trading relationship, it is difficult for agricultural retailers to truly care about the agricultural harvest and interests of farmers. Naturally, the reliability of agricultural retailers perceived by farmers will be reduced. In addition, the trust established within the instrumental relationship is short-lived and unstable, or misplaced. Once other agricultural retailers can offer more favorable prices, more considerate services or more adequate agricultural information, the trust relationship is likely to collapse. Therefore, it is proposed that, all else being equal, Hypothesis 2.The more instrumental the relationship between farmers and agricultural retailers is, the less possible the trust between them will be established.• Personal Relations and Repeated Purchase IntentionThe emotional elements of guanxi established a foundation of cooperation between farmers and agricultural retailers. The better the personal relations, the more likely they form an ‘inside circle’. In this circumstance, even if they do not consider doing business with the other side, the two parties will care about each other’s private affairs and help each other, showing the responsibility and support between the members of the ‘inside circle’. This kind of responsibility and affection not only weakens the motivation of agricultural retailers to pursue profit at the expense of morality, but also enables farmers to generate more business contacts with agricultural retailers in the future, which in turn will stabilize the personal relations between the two. The long-term stable relationship plays an important role in retaining customers and improving customers’ repeated purchase intentions. In addition, better personal relations also mean that farmers will get more price concessions, credit sales services, and agricultural materials information in the actual purchase process. Thus, farmers are willing to buy again because of the perception of ‘returning the favor’. Therefore, it is proposed that all else being equal,Hypothesis 3.The better the personal relations between farmers and agricultural retailers, the stronger the intention to repeat purchases.• Instrumentality and Repeated Purchase IntentionIn the rural society of China, the role of instrumental rationality is apparent in the purchase decision of farmers choosing agricultural retailers . The conHypothesis 4.The more instrumental that farmers are in their relationship with agricultural retailers, the lower their intention to repeat purchases.Individual consumers purchasing decisions are closely related to their trust in the seller . The truHypothesis 5.Farmers’ trust in agricultural retailers positively affects farmers’ repeated purchase intentions.• Moderation Effect of Demand UncertaintyIn an environment with high demand uncertainty, farmers’ trust in agricultural retailers will be more effective in promoting repurchase intention. In the condition of high demand uncertainty, farmers’ demand preferences for agricultural materials appear inconstant and always seek something new and different, which indicates some risks in transferring from one brand or type to another brand or type of fertilizer, pesticides, and seeds. Therefore, farmers will choose a trusted agricultural retailer to avoid potential risks and provide protection for their replacement options. Firstly, farmers believe that the agricultural retailers they trust will guarantee the quality of newly purchased agricultural materials and provide corresponding technical services. Secondly, they believe that retailers will not exaggerate the quality of new agricultural materials to induce farmers to buy. Thirdly, farmers believe that retailers will really care about the agricultural harvest after farmers use new agricultural materials. This will further enhance farmers’ intention to repeatedly purchase agricultural materials. Therefore, it is proposed that all else being equal, Hypothesis 6.Demand uncertainty positively moderates the relationship between trust and repeated purchase intentions.• The Moderation of Competition IntensityA highly competitive environment reduces the incentives for trust to promote repeat purchase intentions. On the one hand, the increase in competition intensity indicates that many agricultural retail stores are in the market which providing similar agricultural materials, and the change of agricultural materials is very fast. In this situation, in order to be competitive, agricultural retailers will try their best to improve service, e.g., keep their promises in agricultural materials transactions, provide preferential prices and professional technical services, and go deep into the fields to actively support farmers of the use of agricultural materials and actual harvest. Farmers will thus not worry about the provision of false information or inferior agricultural materials by a certain agricultural retailer, and they can compare and replace agricultural retailers more easily. On the other hand, in order to cope with fierce competition, agricultural retailers will adopt strategies such as low-cost concessions, home delivery, and technical services. These concessions and convenience services will attract farmers to switch from formerly trusted agricultural retailers to new agricultural retailers. Therefore, it is proposed that all else being equal,Hypothesis 7.The intensity of competition will negatively moderate the relationship between trust and the repeated purchase intention of agricultural materials.A questionnaire approach is adopted by the study to collect data. The questionnaire collectors are mainly university students who were born and grow up in rural areas of China, so that they were familiar with the production and life in rural areas. They were trained on the skills required for the survey before going to do the data collection. In order to ensure the recovery rate and efficiency of the questionnaire, from July to September 2016, a stratified sampling method was adopted to select the samples. Firstly, a province with developed agriculture was randomly selected from the provinces and autonomous regions in the eastern, central, and western regions of China. Hebei province was drawn from the eastern region; the central region was drawn to Henan Province, and the western region was drawn to Guizhou Province. Because agriculture is a pillar industry in the western region, in order to make the research questions of this paper more thorough, Ningxia Province was selected from the west. The agricultural development conditions of the four provinces are as follows: Most of Hebei Province belongs to the North China, with more arable land and better sunshine. It is one of the national grain and cotton oil production areas and one of the country’s 13 commodity grain production bases. Located in the middle and lower reaches of the Yellow River in central China, Henan Province has a humid climate, abundant rainfall and long sunshine hours. It is an important agricultural production base and agricultural province in China. The climate of Guizhou Province is mild, humid, rich in heat, and the conditions for agricultural development are good. Ningxia belongs to the plain area, with long sunshine hours, high effective accumulated temperature, sufficient precipitation and long frost-free period, and the agricultural foundation is unique.Secondly, from the four provinces of Henan, Hebei, Ningxia and Guizhou, 10 cities with relatively developed agriculture—such as Luohe City, Baoding City, Yinchuan City, and Zunyi City—were randomly selected. Among them, Luohe City is located in Henan Province. In the south, warm and humid monsoon climate, four distinct seasons, more precipitation, better agricultural development foundation; Baoding City has four distinct seasons, sufficient sunshine, heat, and rain in the same season; Yinchuan City is located in Hetao Plain, an important irrigated agricultural area. Zunyi City has a large cultivated land and distinctive industries. Thirdly, 13 counties were selected with strong agricultural development advantages such as Linyi County, Tang County, Xixia District, and Wuchuan County from these 10 cities. Finally, in these counties, select some representative villages and farmers were selected in these counties. Door-to-door visits were used to issue and collect questionnaires. The respondents selected are the farmers who are mainly engaged in agricultural production in each family and have experience in purchasing agricultural materials. A total of 605 households were selected for the survey, and 605 questionnaires were collected. After eliminating 27 invalid questionnaires, the effective questionnaire was 578. The effective recovery rate is 95.5%. The main reason for the invalidity is that it is not completed and/or there are extensive default values in the purification process of the questionnaire. A profile of the samples is shown in A pilot study was firstly conducted in a typical agricultural village in Henan Province in June 2016. 80 questionnaires were collected, of which 75 were valid, and the effective recovery rate is 93.75%. According to the information feedback of the interviewees and the data analysis results of the 75 answers of the pilot study, the questionnaire was further revised, and a formal questionnaire was finally formulated. To ensure the authenticity and validity of the survey data, all data collected in the pilot survey is not used as a final sample.Harman’s single factor test was conducted to ensure that common methods variance is not a threat to the study. All items in the questionnaire were put together for un-rotated factor analysis and a total of six principal component factors were extracted. The first factor explains 25.2% of the total variance, much lower than the threshold value of 40%, which means that the common method variance is not significant and will not affect the conclusion of the study.The measurement of the variables is based on extant literature ,31,32,35To ensure the reliability and accuracy of the measurement results, this study firstly tested the reliability and validity of the data. Using internal consistency as a measure of reliability, As shown in Except for the AVE of all variables, the mean, standard deviation, and correlation coefficient of each variable are shown in In order to ensure the accuracy of the empirical results, the variables are sequentially placed into the regression equation model by the hierarchical regression method, and the influence of the predicted independent variables on the dependent variables is analyzed by comparing the changes of the regression coefficients. The results are shown in 2 = 0.190). In the regression results, the personal relations are significantly positively related with trust , thus Hypothesis 1 is supported. Instrumentality is significantly negatively related with trust , thus Hypothesis 2 is supported. For the effect of personal relations and instrumentality on repeated purchase intention, it is known from model 2 that the fit is better (R2 = 0.343). In the regression results, the personal relations are significantly and positively related with the repeated purchase intention , thus the Hypothesis 3 is supported. The instrumentality is significantly and negatively related with the repeated purchase intention , thus Hypothesis 4 is supported. The effect of trust on repeated purchase intentions is also shown in model 2. In the regression results, trust is significantly and positively related with the repeated purchase intention , thus Hypothesis 5 is supported.For the influence of personal relations and instrumentality on trust, model 1 of 2 = 0.350). Trust has a significant impact on repeated purchase intentions , but the effect of demand uncertainty on repeated purchase intentions is not significant. Finally, the interaction between trust and demand uncertainty was added to the model 3, this leads to model 4. The model 4 fits the data well (R2 = 0.351). However, it is found that the coefficient of the interaction term is not significant. Therefore, the uncertainty of demand does not moderate the relationship between trust and repeated purchase intention of agricultural materials, thus Hypothesis 6 is not supported. The three-step test of hierarchical moderating regression method is adopted to examine the moderation effect. The detailed approach is as follows. Firstly, the impact of trust on the intention of repeated purchase is tested. It can be seen from model 2 that trust has a significant positive impact on the repeated purchase intention. Secondly, the influence of trust and demand uncertainty on the repeated purchase intention is examined. The model 3 fits the data well . Finally, the interaction term of trust and competition intensity is added to the model 3, this leads to model 5. The fit of model 5 is also good (R2 = 0.358). The coefficient of the interaction term is significant . Therefore, the moderation of the intensity of competition is verified, and the Hypothesis 7 is supported.The same method is used to examine the moderation effect of competition intensity. Firstly, model 2 has verified the significant positive impact of trust on repeated purchase intentions. Secondly, the impact of trust and competition intensity on repeated purchase intentions is examined. As shown by model 3, both have significant effects  and examined again. The results are completely consistent with the models 4 and 5, indicating the results for the test of the moderation effect of dynamic environment are stable and reliable. Therefore, Hypothesis 6 is not supported, and Hypothesis 7 is supported.In order to more intuitively reveal whether demand uncertainty and competitive intensity have a moderation effect on the relationship between trust and repeated purchase intentions, an interaction diagram of the two variables is shown in In order to verify that there is no random trend or determined trend in the empirical results, 300 questionnaires were selected by the EXCEL random sampling method from 578 questionnaires for robustness test, and the hierarchical regression analysis was performed again. The results are shown in 2 vary from 0.007 to 0.056, and the values of adjusted R2 vary between 0.005 and 0.053. Thus, the variance is relatively small and negligible. Therefore, it can be concluded that there is no big difference in the model fitting between 578 questionnaires and 300 questionnaires.The R values of the six models vary between 0.008 and 0.046, the values of Rp < 0.01) and the regression results of 300 questionnaires  indicate the relationship is significant and positive, with subtle differences in β values.Regarding Hypothesis 1, in which the impact of personal relations on trust is to be examined. Both of the regression results of 578 questionnaires in model 1  and the regression results of 300 questionnaires  indicate the same effect, i.e., instrumentality is significantly but negatively associated with trust, only that the result for 300 questionnaires were slightly more significant.Hypothesis 2 proposes the impact of instrumentality on trust. Again, the regression results of 578 questionnaires in model 1  and the regression results of 300 questionnaires  indicate the same result, i.e., there is a significant positive relation between personal relations and repetitive purchase intentions, only with subtle differences in β values.Hypothesis 3 proposes that the impact of personal relations on repeated purchase intentions. The regression results of 578 questionnaires in model 2  and the regression results of 300 questionnaires  show the same effect, i.e., instrumentality significantly and negatively associated with repeated purchase intentions, with subtle differences in beta values.Hypothesis 4 proposes the impact of instrumentality on repeated purchase intentions. Both of the regression results of 578 questionnaires in model 2  and the regression results of 300 questionnaires  shows the same effect that trust is significantly and positively correlated with repeated purchase intentions, with only subtle differences in beta values.Hypothesis 5 proposes the impact of trust on repeated purchase intentions. Again, the regression results of 578 questionnaires in model 2  and the regression results of 300 questionnaires  indicate a significant negative moderation effect of competition intensity, except that the significance level of the 578 questionnaires was slightly higher.Hypothesis 7 proposes the moderation effect of competition intensity on the relationship between trust and repeated purchase intentions. Both of the regression results of 578 questionnaires in model 5   and Lin Furthermore, demand uncertainty does not have a moderation effect on the relationship between trust and repeat purchase intentions. The reason may be that, due to the relatively fixed planting area, the annual demand for agricultural materials of farmers is basically stable. In addition, farmers have always chosen agricultural materials based on past experience. Therefore, the choice of agricultural brands has not changed much. In this situation, relying on trust to increase farmers’ intention to repeat purchases is more significant than increasing the product variety or adjusting the inventory by agricultural retailers. The intensity of competition moderates the relationship between trust and repeated purchase intentions, which indicates the convenience of transforming agricultural retailers brought about by the intensity of competition negatively affect the role played by trust in the intention of repeated purchases.Finally, the interaction between guanxi, trust, competition intensity, and repeat purchase intention in the agricultural material market has important implications for food system. Global food security and sustainability is subject to food productivity and the way that food is produced. The application of circularity economy and reuse of food waste to improve the sustainability and security of food supply is gaining a ground in recent years ,40. ThisEven when some agricultural retailers are not keen to sell materials that are produced from food waste or by new technologies, given that circular economy is increasingly applied to food systems ,40, inteIt is also worth noting that the unique characteristics of Chinese agricultural material market may be changing. The education of the new generation of farmers is improved significantly in recent years. The young generation are better educated and increasingly appear to be more reliant on science and technology to make growing and purchasing decisions. They are more interested in understanding market demands and customer preferences, and more capable of responding to the government’s concern of food security and long-term strategy in developing industrial agriculture ,42. GiveThis study makes several important theoretical contributions. Firstly, it extends the theory of relationship marketing by showing that the impact of guanxi on the trust varies crossing different contexts. The empirical examination of this study proves that instrumentality has a negative impact on trust in the context of agricultural material marketing in China, while the extant research shows the contrary in the B2B marketing. Secondly, this study enriches scholarly understanding of the impact of guanxi on repeated purchase intentions by showing that the former may have a different effect on the latter in different marketing contexts. Previous studies have confirmed the positive role played by guanxi in repetitive purchase intentions ,9,11,38,Thirdly, this study extends scholarly understanding of the effect of guanxi on repeated purchase intentions by showing that this effect may be transferred through trust, i.e., trust can be an influencing mechanism between the two. The integration of the three variables—i.e., guanxi, trust, and repeated purchase intentions—in the conceptual model shows that the interaction between them in a special context, such as Chinese agricultural material marketing, could effectively explain the repeated purchase decisions of buyers. In a special context of Chinese rural area, where Chinese traditional culture plays an important role in the social life, relationship marketing practice may well be different from that is in other contexts.Finally, this study enriches the scholarly understanding of repeated purchase intentions by showing that the effects of some important antecedents, such as guanxi and trust, could be influenced by environmental conditions, such as competition intensity in the marketplace. Different from the previous literature of agricultural marketing, in which the external marketing and consumers’ own characteristics are the focus of discussion, this study examines the relationship between trust and repeated purchase intentions based on the dynamic environment. The research results show that the more intense the competition between agricultural retailers is, the less the role of trust can play, and the dynamic environment will affect the effect of trust on repeated purchase intentions. The results of this study have important implication for practice. Firstly, it shows that the role of personal relations played in agricultural materials market is significant. This suggests that agricultural retailers should properly manage guanxi with farmers, paying particular attention to the establishment and maintenance of personal relations with them, and weaken farmers’ instrumental choices, thus increasing their repeated purchase intentions.Secondly, trust plays a key role in the purchase of agricultural materials. This suggests that agricultural retailers should emphasize cultivating farmers’ trust in themselves. Agricultural retailers ought to take actions such as improving the quality of agricultural materials, keeping promises to farmers, providing satisfactory after-sales services, and upgrading their professional skills. So that trust can be built and repeated purchase intentions can be obtained subsequently. Finally, the highly competitive environment has a negative impact on the economic interests of agricultural retailers. This suggests that agricultural retailers should aware the competition intensity in their industries and adopt appropriate marketing strategies. In the case of high competition, agricultural retailers ought to take extra efforts, such as offering preferential prices, credit sales services and door-to-door delivery to maintain customers. Therefore, farmers received more ‘real’ benefits, and perceive the deals as ‘big bargains’. On the contrary, if the competition in the market is relatively weak, agricultural retailers should pay more attention to cultivating farmers’ trust to maintain customers and achieve more sales.Although the study has important contributions to the literature, it is not without limitations. Firstly, the agricultural materials, the purchase of agricultural materials and the rural social network in Chinese rural area compose a special context of this study. Therefore, caution is advised when applying the results of this research to other contexts.Secondly, this study focuses on the two dimensions of guanxi—i.e., personal relations and instrumentality—other dimensions such as human feelings and face have not been considered. Therefore, more elements of guanxi should be explored in the future, thus a deeper and more comprehensive understanding of the effect of guanxi on repeated purchase intentions could be achieved.Thirdly, the data collected only from four provinces of the eastern, central, and western regions of China, but did not reach a wider region, thus the generalization of the research results needs further investigation. In addition, this paper uses only horizontal data but not longitude data, it is more conducive to discover the change of data along time span. Therefore, longitudinal research design can be considered in the future to verify the causal relationship in the conceptual model.Finally, as discussed above, the Chinese agricultural material market is changing, especially the education of young generation of farmers is improved significantly in recent years, combined with new technology, and the development of industrial agriculture, and the long-term strategy of government in food security, the interaction between guanxi, trust, and repeated purchase intention in Chinese agricultural material market is very likely to change. Thus, a dynamic perspective must be applied to understand the conclusions of this study. At the same time, it will be interesting to conduct a research in a few years time to find out if and to what extent the expected change would happen. This study explores the influencing factors of repeated purchase intentions of farmers in the agricultural resource market in China. In particular, it examines the impact of guanxi and trust on repeated purchase intention, and the moderating effect of dynamic environment on the relationship between trust and repeated purchase intentions. A data set of 578 samples was used and hierarchical regression analysis was conducted to examine the conceptual models. The results generally support the hypotheses that based on the conceptual model. The results show that guanxi between farmers and agricultural retailers has a positive effect on trust between them and on repeated purchase intentions of farmers. While instrumentality has a negative effect on trust between them and on repeated purchase intentions of farmers. The trust between farmers and agricultural retailers promotes farmers’ repeated purchase intentions. The intensity of competition negatively moderates the positive relation between trust and repeated purchases. Demand uncertainty does not moderate the positive effect of trust on repeated purchases. The results and discussion shed light on the agricultural food system sustainability from a dynamic environment embedded business relationship perspective. They also suggest that conclusions drawn by previous research that based on B2B and e-commerce market may not be applicable to Chinese agricultural material market, where customers’ background and their interaction with suppliers are of unique characteristics.


Owing to the fact that firefighters have unique health risks, access to firefighter-specific internet-based health information is a potential mechanism for achieving better health and work outcomes.The objective of our study was to identify the amount and nature of health information resources available on Canadian firefighter-specific websites and the extent to which resources are consistent across websites as a surrogate indicator of diffusion of information.A search of health resources on firefighter websites (union and employer) for all Canadian provinces, major cities and a subset of smaller cities, and the International Association of Fire Fighters (IAFF) website was conducted on Google (July 2017). Content was identified and classified based on the type of resource, health focus, and location. The quantity and nature of the resources were summarized using descriptive statistics.Among all (N=313) websites reviewed, 41 websites had health information with a cumulative total of 128 resources that addressed firefighter mental , physical , and work health . The highest density of information was found on international and national websites (13 resources per website) and the least on local websites (1 resource per 7 websites). Three provinces  hosted 81% (65/80) of the provincial, territorial and local resources. General mental health , posttraumatic stress disorder , and suicide  were the most prevalent topics within the mental health resources, whereas half  of all physical health resources were on cancer. No resources from Northern Canada were found. Musculoskeletal health was not mentioned in any of the resources identified. There was minimal cross-linking of resources across sites (only 4 resources were duplicated across sites), and there was no clear indication of how the content was vetted or evaluated for quality.There was wide variation in the amount and type of information available on different firefighter websites with limited diffusion of information across jurisdictions. Quality evaluation and coordination of resources should be considered to enhance firefighters’ access to quality health information to meet their specific needs. Mental health and cancer information aligned with high rates of these health problems in firefighters, whereas the lack of information on musculoskeletal health was discordant with their high rate of work injury claims for these problems. Firefighting involves complex and uncontrollable situations during fire suppression, rescues, and medical calls. These risks carry many inherent risks to mental and physical health . NotableMSK injuries and cumulative disorders (MSKD) are not usually deadly; however, they present a predominant barrier to healthy work role participation. MSKD are the most common injuries and causes of firefighter work loss claims ,6,12 witA recent systematic review conducted by Jones looked at the relationship between duty-related trauma exposure and increased risk for mental health problems in first responders. The team found the accumulation of repeated traumatic exposures from calls to be a key risk factor for posttraumatic stress disorder (PTSD), depression, suicide, alcohol use, and sleep disturbances . FirefigAnother major area of health concerns for firefighters is cancer, with a meta-analysis demonstrating increased risk of multiple cancers , includiResearch from the Pew Internet Project conducted in 2013 discovered that 72% of internet users in the United States went online for health information . Most fiDespite extensive research being conducted on the effects of occupational hazards on the physical and mental health of firefighters, very little attention has been paid to studying the access firefighters have to health information and how this information contributes to injury prevention and treatment. Web-based interventions for stress and anxiety management for the general population have been developed and evaluated ,23. HoweBecause we know that firefighters have unique information needs and are most likely to trust information coming from firefighter-specific websites, it would be helpful to understand their current access as a foundation for planning future improvements. The purpose of this study was to identify and characterize health information resources available on Canadian firefighter websites. A secondary purpose was to determine the extent to which the resources were concordant across sites as an indicator of diffusion of information across fire services.The population of Canada is 35,151,728, according to the 2016 Canada Census . Canada This structured search explored the nature and extent of available resources pertaining to the physical and mental health of firefighters by searching fire department and firefighter union websites across Canada. Relevant websites were defined as any webpages on department or union websites that contained information on the prevention, treatment, or any course of action targeting physical and mental health injuries.Google was used as the sole search engine for searches to explore resources on published fire department and firefighter union websites because this is the search engine most likely to be used by firefighters. A 3-layered search strategy  was implemented to garner the widest scope possible while maintaining depth. In addition, because Canada is a subdivision that falls under the umbrella of the parent organization, the International Association of Fire Fighters (IAFF), the IAFF website was also included. For the national and provincial or territorial level searches, the following 3 types of unions or associations were explored: fire chiefs, professional firefighters, and volunteer firefighters. All searches were performed in July 2017.The international and national search involved the IAFF, the Canadian Volunteer Fire Services Association, and the Canadian Association of Fire Chiefs websites. Once the association website was found, a detailed search of each page and any links on the website was conducted to identify any health-related information resources. Although many websites had information in a limited number of hierarchical levels, the IAFF website was more layered and required more extensive exploration of multiple levels to access all of the information on the website. A similar search occurred on the provincial and territorial level. Here we used Google to find the fire chiefs, professional firefighters, and volunteer firefighters association websites for the 10 provinces and 3 territories in Canada and then conducted a detailed search of each page of the website.The initial search strategy and data extraction were developed using Ontario websites because Ontario is the largest province and has the largest proportion of the country’s population. Thus, we expected that Ontario would have the greatest number of websites. We searched for each of the 444 municipalities in Ontario, as determined by the Association of Municipalities Ontario . Upon fuFor the international and national level search, the following search terms were used: IAFF, IAFF Canada, Canadian Association of Fire Chiefs, and Canadian Volunteer Firefighters Association. For the provincial and territorial level search, the following search terms were used: province or territory fire chiefs association, province or territory professional firefighters association, and province or territory volunteer firefighters association. For the local level search, once the municipalities to be included were chosen see , the folOfficial websites in English or French affiliated with a fire department or firefighter association were included. Resources were included if the firefighter website provided a link to the resource. Additional unlinked resources on the secondary website were not counted or classified. Websites under construction or inaccessible at the time of the search and social media accounts of the fire department or association were not included. This study also excluded links on firefighter websites that led to the homepages of other firefighter associations to avoid double-counting.The team developed the initial data extraction sheet and revised it based on piloting. The coding was established to classify what health problem the resource addressed, focusing on the two domains of health . Because some resources were generically related to work health that could cross both physical and mental health domains, this category was added. Iterative consultation with team members was used to check consistency and subgrouping of codes. Data from the IAFF website were coded separately because it is a unique international body that has a specified mandate for firefighter health and safety. The format of the resources was classified into, for example, checklists, apps, and forums. A supplementary table see  for toolGiven the large numbers of resources and codes, the data were further synthesized to characterize the major types of information available. A descriptive numerical summary (frequency distributions or percentages) was used to describe the overall number of websites included, type of websites found, types of resources, topics or focus of the resource, and location of the website publication. Summary tables were used to describe the health information resources based on type, format, and content area. The differences in the total numbers or percentages are due to rounding.Overall, we found large variability in the type of health information available and the density of the information on different websites. None of the websites mentioned a process for quality appraisal or relevance vetting by firefighters to determine which type of information was posted.It was found that despite the relatively large number of associations and departments having websites (N=313), only 41 of the 313 websites (13.1%) contained health information resources relating to firefighters’ mental, physical, and work health. From these 41 websites, 128 resources were found with almost half  focused on mental health, a third  focused on physical health, and the rest  focused on work health, as seen in The international and national, provincial, and local firefighter websites each contained approximately one-third of the resources found. The IAFF, national fire chief, and firefighter websites accounted for more than half  of all the resources found on physical health. The provincial and territorial and local firefighter websites focused on mental health; approximately half of all resources found on these websites addressed topics such as PTSD, critical incident stress, and suicide, as seen in The resources identified in this study were predominantly found on firefighter websites from Central Canada (Québec and Ontario) and the West Coast (British Columbia). Of the total number (n=80) of resources found on the provincial and territorial and municipal level, 65 were found in these 3 provinces; of these, 42 resources were from Ontario and Québec  and 23 from British Columbia (West Coast). In all the regions in Canada, mental health was the most common focus on firefighter health resources. No resources of any kind were found from the firefighter websites from the Canadian Territories in the North , although fire department and association websites were identified, as seen in Resources on mental health (n=59) varied in format, most commonly existing as information sheets 13/59, 22%), information packets with multiple pages , and manuals . Articles, videos, and links to website home pages were less common, each contributing 10% (6/59) to the total number of resources identified. Many  of the mental health resources were general in topic, and there was a relatively even split between more specific topics addressed, as seen in /59, 22%,A common format for physical health resources (n=43) was links to webpages , whereas a large portion of work health resources (n=26) were forms , often relating to the administrative processes involved in work injury and return-to-work . Predominant topics addressed in physical health resources (n=43) were cancer  and health hazards . Work health resources (n=26) were most commonly on safety  and protocols .The density of resources was highest on international and national level websites with 40 health information resources found on 3 websites (approximately 13.3 resources per website). Provincial websites averaged around 2 resources and websites with 49 resources found on 24 websites.Conversely, across 282 local websites, only an additional 39 health information resources were located (1 resource per 7 websites), indicating a much smaller density of information on these websites. Most of the 128 resources found were unique. Only 4 duplicate resources were found, which were mainly web links to other organizations providing relevant information .In addition to cataloging information resources, we classified resources as tools if they were structured to implement or execute specific actions or serve as a platform for engagement . Only a small number of tools specific to firefighters were identified. The tools (n=12) found on local websites mostly focused on physical health  with the most common format being a members’ forum . Overall, the most common types of tools were generic or focused on work health.Work tools included operational resources that firefighters needed to implement workplace health and safety. The tool resources were provided in a variety of formats from forums to checklists and information packets. The majority  of national and provincial tools (n=7) were formatted as references, as seen in The IAFF website was a major source of health information specific to firefighters. In addition to health information, it provided information about in-person training courses and programs on firefighter health and safety. Provincial and local websites frequently linked to IAFF health and safety resources, as seen in The British Columbia (BC) Professional Fire Fighters’ website  was espeIn general, health information resources were most often on union, rather than employer, websites. This was particularly apparent at the local level, where almost all resources found were on firefighter association websites and very few on the municipal fire department websites.This study suggests that the process by which health information is provided to firefighters through their websites is highly variable and informal in terms of a process for vetting or sharing of information. This high variability might indicate that champions for a cause, expertise in different areas, experiences within the local environment, and other factors may influence what health resources are posted on websites. The one common link for health information is IAFF, which contains the most firefighter-specific health information and resources. However, the uniqueness of information with limited crossovers between different websites indicates that there is little diffusion of information across contexts.The density of information and provincial differences indicates that resources may be a substantial issue in determining what is shared because smaller organizations and poorer provinces had the fewest health resources. Owing to the fact that the duplication of health resource development would be a poor utilization of public dollars, greater sharing of health resources across websites or a single repository of information might facilitate effective dissemination of firefighter health information resources. Because the majority of firefighters in Canada are volunteer firefighters, with few resources and little time for face-to-face knowledge sharing, sharing of internet resources would also enhance equity in access to information. Web-based information can be shared easily across contexts, including those without the resources to create their own websites.Given the high rate of injuries and illnesses that firefighters incur, optimizing their access and use of health information are important. Firefighter-specific websites exist for many functions beyond sharing health information. This is reflected by the fact that only 13.1% (41/313) contained any health information. Many websites, particularly city department websites, were intended for public education, providing information on the fire department, fire prevention, and outreach programs in the community. Because these are all important aspects of the fire service mandate, it is important to recognize the important competing demands that exist in terms of website development and maintenance. The development, vetting, interpretation, and application of firefighter-specific health information requires substantial resources. Labor union and association websites were more likely to provide resources that are focused directly on firefighters, which is consistent with their mandate in comparison to the fire service that has a primary mandate for public safety.The types of resources located reflect program development and priorities in different localities. The variation in content across different cities or provinces partially reflects the difference in program development in those jurisdictions. If those programs diffused into other jurisdictions, we would have expected to find commonly shared resources on different websites. The lack of redundant information across websites indicates limited diffusion and the need for greater dissemination of information.The fact that almost half  of all resources we found had a mental health focus was consistent with firefighters’ need for support to deal with higher rates of exposures to traumatic events . Their dWeb-based discussion forums or resources may be particularly valuable in the fire service because a community of practice or virtual support group could be established, where people share common experiences or access contextually relevant information. The advantage of using the internet for sharing mental health experiences is that people can choose to remain anonymous. A study on university students with mental health issues found that about one-third of them used the internet to deal with their mental health problems. The single most common reason cited for valuing Web-based mental health resources was that it provided anonymity .Similarly, our study found that physical health resources often addressed the cancer risks due to exposure to carcinogens. Some of the few linked websites that appeared recurrently were the home pages of mesothelioma information and cancer support organizations. Mesothelioma is a rare, aggressive form of cancer that develops in the lining of the lungs, abdomen, or heart; it has no known cure and has a very poor prognosis. Firefighters are particularly at risk because exposure to asbestos is the major risk factor. A study by Daniels conducted in 2013 found a two-fold increase in malignant mesothelioma mortality and incidence in firefighters compared with that found in the general US population . Given tThe lack of resources on MSK health stands in stark contrast to the fact that MSK injuries are among the most common injuries incurred by firefighters ,14. FurtSome aspects of health that were notably absent included sleep and nutrition which are potentially important to both physical and mental health. This is a notable absence because shift work potentially impacts both of these health behaviors.This study provides an indirect insight into the knowledge translation processes that are currently taking place with respect to health information for firefighters. Effective dissemination would be reflected in concordance or as duplicate information across websites. However, we found only four duplicates across the websites from which we extracted information. This lack of overlap is a proxy for limited dissemination. Although firefighters might be motivated to go to the IAFF website for information, recognizing it as an umbrella organization, it is unlikely that they would go to multiple websites for information. A generalized and central firefighter-specific website that features structured information sharing processes might improve dissemination of information.Another observation was the lack of transparent processes for how information was included on websites. Both the scientific quality and the relevance of the information should be important considerations. Although these might have been considered, it was unclear to what extent this was true. Therefore, the quality of the information that is being provided to firefighters is uncertain. Of course, some resources did contain references. However, this was variable. Firefighter-specific health information is dependent on firefighter-specific health research. Generally, research that focuses on single occupations presents challenges for researchers and may not have the capacity that disease-specific health research does. This suggest that health researchers who focus on firefighter-specific topics have a heightened obligation to ensure that they engage in knowledge translation to optimize the dissemination and implementation of their work.Regionally, Ontario was the province with the most resources available on both the provincial and local levels. This is likely because Ontario has the greatest number of firefighters in Canada with over 11,000 professional firefighters as members of the Ontario Professional Fire Fighters Association . AnotherThis paper provided a snapshot of the Web-based health information resources from a large number of websites that may be accessed by firefighters across multiple contexts and provinces in Canada. We used a structured process to extract available resources and classify them. Although this information provides insights into the health resources available, focus, knowledge translation outcomes and gaps in the field, the nature of the work also has substantial limitations that must be considered when interpreting the results.First, we searched only Web-based information; we recognize that this represents a fraction of the health information available to firefighters. Firefighters engage in substantial training, conferences, and other learning opportunities that likely provide additional information. Second, some of the websites had password-protected areas which we were unable to access and these areas may have contained additional resources. Third, we did not evaluate the quality of the resources.A further limitation is that we analyzed websites and content separately, not accounting for the interdependence between the two. Further, we could not ascertain from reading websites what processes for development and vetting of resources might actually be present across different organizations. We also do not know whether firefighters are not disseminating the information or just not posting the available information on their websites. There is a possibility that firefighters shared information on social media accounts which were not included in this study.In Ontario, only the single districts, regions, and major cities were searched, and in other provinces, the 20 most populous cities’ websites were searched; therefore, there is a chance that some resources from smaller cities or towns were missed. Although possible, this is unlikely because very little health information was found on websites for the smaller cities . In many of the smaller provinces, such as Prince Edward Island, New Brunswick, and Nova Scotia, there were fewer than 20 cities that existed within the entire province. Thus, all cities were included. This provided a comprehensive overview of the resources available to firefighters on fire department and association websites. Another limitation is the possibility of misclassification because a majority of the coding was conducted by a single person. To limit misclassification, the ongoing coding was examined regularly with another investigator and random rechecks of the classification were performed. Nevertheless, in classifying information, it is inevitable that the complexity of the information is lost and classifications are oversimplification of the information that was provided. An additional limitation arises from the fact that we only searched firefighter-specific websites and important information specific to firefighters could have been contained on other websites. We did this because we heard from firefighters that they tended to go to their local websites or provincial or IAFF for information. However, there are examples where substantial contributions to public safety health that would be relevant to firefighters would be contained elsewhere, for example, the Canadian Institute for Public Safety Research and Treatment recently published mental health resources (Web-based self-screening tools and research papers) for first responders . The VanThe key recommendations arising from this study are the need for better coordination and sharing of health information resources specific to firefighters. Greater linkage between firefighter-specific health research and health information resources for firefighters is needed. We suggest that formal processes for evaluating what health information is shared with firefighters, widespread dissemination of lay summaries of firefighter-specific research, collaboration between researchers and firefighters, and sharing of information on formal evaluation of existing health programs would all be important contributions to effective knowledge translation. An emerging awareness of the important challenges facing firefighters with respect to firefighter health and programs was evident for mental health, whereas substantial gaps in MSK health resources were also evident. Given that some associations had few information resources, the need for greater sharing to decrease health inequities across regions is clear. Knowledge repositories and inventories that document firefighter-specific health information and those that are broadly shared might leverage existing knowledge for greater health impacts. Future research should focus on developing and evaluating the effectiveness of firefighter-specific health information resources and tools and knowledge translation plans should include widespread dissemination through firefighter websites.