The innovative teaching behaviors of college teacher are of positive significance for promoting the construction of educational informatization in China and realizing the high-quality development of higher education. Based on the theory of social cognition and theory of behavioral change, the paper explores the influential mechanism and its boundary conditions of college teachers’ information literacy on their innovative teaching behaviors during the new era of educational informatization. Through the investigation of 280 college teachers, it is found that: (1) information literacy and its dimensions of information knowledge and information capability have a significant positive effect on innovative teaching behavior; (2) Creative self-efficacy plays a mediating role between information literacy (information knowledge and information capability) and innovative teaching behavior; (3) College innovation climate significantly moderates the positive relationship between information literacy (information awareness and information knowledge) and creative self-efficacy; (4) College innovation climate significantly moderates the mediating effect of creative self-efficacy between information literacy (information awareness and information knowledge) and innovative teaching behavior. Therefore, colleges and universities should focus on enhancing teachers’ information literacy level and their creative self-efficacy, creating an excellent atmosphere for innovation, and encouraging college teachers to actively carry out their innovative teaching practice in the new stage of educational informatization. Since Chinese Education Ministry put forward the Ten-Year Development Plan of Education Informatization in 2012, China’s education informatization construction has taken a new step after ten years of layout and development. At the new stage of comprehensive development of educational informatization, the deep integration of new information technology and course teaching by college teachers to carry out teaching innovation is not only beneficial to colleges and universities for further improving the quality and effectiveness of course teaching [Scholars have explained the causes of teachers’ innovative teaching behavior at the individual level such as proactive personality , technolAccording to social cognitive theory, human activities are determined by the interaction of three factors: individual behavior, individual cognition and other individual characteristics, and the external environment in which individuals live , so collBesides individual factors, environmental factors such as college innovation climate are also important factors affecting teaching innovation ,15. ThisTherefore, this study takes creative self-efficacy as the mediator and college innovation climate as the moderator to explore the mechanism and boundary conditions of college teachers’ information literacy on their innovative teaching behavior under the conditions of informatization, so as to achieve three research objectives: (1) examining the effects of information literacy and its dimensions on college teachers’ innovative teaching behavior under the condition of informatization; (2) clarifying the mechanism of college teachers’ information literacy affecting innovative teaching behavior, that is, investigating the mediating role of creative self-efficacy between information literacy and innovative teaching behavior; (3) exploring the moderating role of college innovation climate on information literacy and creative self-efficacy, and thus examining the moderated mediating effect of college innovation climate on the above intermediary mechanism.Information literacy of college teachers is a comprehensive quality of college teachers to use information and information technology purposefully and reasonably , which sUnder the background of the rapid development of information technology, teachers should not only pay attention to the upcoming information technology related to teaching and the resulting constantly updated information knowledge, but also integrate these technologies and knowledge deeply into their own teaching process. Therefore, the study draws on the views of Chinese scholars and refines innovative teaching behavior as a teaching practice in which teachers constantly adopt new teaching concepts, update teaching content, and apply new teaching methods and means to improve teaching effect with the goal of better growth and development of students in the teaching process . InnovatAs for the effect of college teachers’ information literacy on innovative teaching behavior, behavioral change theory proposes that information and knowledge are the basis and key factors for individual behavioral decision-making . TherefoIn terms of specific dimensions, college teachers with high information awareness can effectively solve the negative impact brought by technology pressure , have a H1: College teachers’ information literacy has a positive effect on their innovative teaching behavior;H1a-1c: College teachers’ information awareness, information knowledge and information capability have a positive effect on their innovative teaching behavior.Creative self-efficacy refers to the belief in one’s own capability to perform an innovative task effectively and attain certain desired goals . AccordiSpecifically, information awareness can help college teachers judge whether the strategies and methods of information collection are appropriate and whether the information found can meet the needs of teaching innovation. Information knowledge can help identify the new technologies that can be used in teaching innovation, while information capability can help integrate new information, new technology into teaching process required for teaching innovation effectively. All these qualities can significantly increase the successful experience and self-confidence of college teachers in carrying out teaching innovation, and then stimulate them to carry out more teaching innovation. In this regard, Chinese scholars also found that the sense of creative self-efficacy plays a partial mediating role between the teaching innovation ability and college teachers’ innovative teaching behavior . In sum,H2: College teachers’ creative self-efficacy plays a mediating role between their information literacy and innovative teaching behavior;H2a-2c: College teachers’ creative self-efficacy plays a mediating role between their information awareness, information knowledge, information capability and innovative teaching behavior.Innovation climate in colleges and universities is the perception of college teachers on the innovation environment of their school, such as sufficiency of teaching resources, encouragement from leaders and administrative support level . As mentWhen the innovation climate is strong in colleges and universities, the support and encouragement from teaching teams or leaders and the relaxed climate created by them will make teachers with weak information awareness still have confidence to carry out innovative teaching activities. A perfect further education and training mechanism can effectively reduce the difficulty of college teachers lacking information knowledge to carry out teaching innovation. Adequate support for teaching innovation, such as continuous support of teaching resources and administrative personnel, can enhance the confidence of teachers with weak information capability to achieve the expected innovation results . TherefoH3: College innovation climate can be a moderator that weakens the positive relationship between teachers’ information literacy and their creative self-efficacy;H3a-3c: College innovation climate can be a moderator that weakens the positive relationship between teachers’ information awareness, information knowledge, information capability and their creative self-efficacy.Implementing teaching innovation with information technology is actually a kind of teaching activity to explore the unknown, of which the behavior results have certain uncertainties and external dependence. Therefore, the innovative teaching behavior of college teachers will not only be affected by their personal factors, but also vary due to different external environments. Some scholars have proposed that the innovation climate in colleges and universities is the premise and guarantee for teachers’ innovative teaching behaviors, and plays a positive role in the possibility and quality of teachers’ innovative teaching activities . This poAs mentioned above, when colleges and universities have a good innovation climate, even if teachers’ information awareness, information knowledge and information capability are not high, that is, the overall level of information literacy is not high, the high creative self-efficacy brought about by high-level innovation support will still stimulate their deeper participation in creative teaching activities. That means, high innovation climate will weaken the mediating effect of creative self-efficacy between information literacy (and its dimensions) and innovative teaching behavior. On the contrary, when the innovation climate in colleges and universities is poor, teachers perceive that the external environment is not conducive to teaching innovation, and they can only build up the confidence to carry out teaching innovation through their information awareness, information knowledge and capability, that is, relying on their own information literacy to bring about innovative teaching behavior. That means, low innovation climate will strengthen the mediating effect of creative self-efficacy between information literacy (and its dimensions) and innovative teaching behavior. In sum, the study proposes the following hypothesis:H4: College innovation climate can moderate the mediating effect of teachers’ creative self-efficacy between their information literacy and innovative teaching behavior;H4a-4c: College innovation climate can moderate the mediating effect of teachers’ creative self-efficacy between their information awareness, information knowledge, information capability and innovative teaching behavior.The conceptual model constructed in this study is shown in https://www.wjx.cn/vm/tUUmRZW.aspx#).The researcher conducted a retrospective questionnaire survey on full-time college teachers to empirically examine the mechanism of information literacy of college teachers on their innovative teaching behavior in the context of informatization. According to the research purpose, research context and previous research results, the formal questionnaire of the study was formed. The whole formal questionnaire included four parts: the basic information of teachers, the measurement of information literacy level, some aspects of teaching innovation, college innovation climate and future prospects, with a total of 48 questions. There were 8 questions in basic information part, including gender, age, education, professional title, teaching school, etc.; the measurement of teachers’ information literacy level had 19 items; and the third and fourth part included 10 and 11 items respectively. After the content of the questionnaire was determined, the researcher produced an electronic questionnaire on the well-known online survey platform “Questionnaire Star” in China  has a doctor’s degree and 171 (61.07%) has a master’s degree. There were 89 people (31.78%) with associate professor title and above, and 144 people (51.43%) with lecturer title. There are 113 people (40.36%) from the first batch of ordinary undergraduate group (including 985 and 211), and 142 people (50.71%) from the second batch of ordinary undergraduate Group See .All the research tools used in this study were from domestic and foreign maturity scales, and a strict “translation-back translation” process was adopted. Two professors engaged in pedagogical research were invited to review the final translation, and a formal questionnaire was formed after a small range of modifications. Except for the 7-point Likert scale used for creative self-efficacy, the other measuring tools used 5-point scale.Information literacy. The study referred to Chinese scholar Wang to divide college teachers’ information literacy into three dimensions: information awareness, information knowledge and information capability . For theInnovative teaching behavior. Scott and Bruce’s innovative teaching behavior scale was adopted to measure the innovative teaching behavior tendency of college teachers . The scaCreative self-efficacy. The Chinese version of creative self-efficacy scale was adopted to measure the sense of college teachers’ creative teaching self-efficacy , which wCollege innovation climate. The study adopted the organizational innovation climate Scale adapted by Yu to measure the teaching innovation climate in colleges and universities . The scaControl variables. Referring to previous studies, this study takes the gender, age, education and school type as control variables.Statistical software SPSS22.0 and AMOS23.0 were used to test the reliability and validity of all measuring tools, common method variance and the fit of the model. Then, the researcher used SPSS22.0 to calculate the Pearson correlation coefficient to examine the relationship between all the studied variables. After that, AMOS23.0 was used to examine the direct effect of information literacy (and its dimensions) on innovative teaching behavior and the mediating effect of creative self-efficacy. For the test of mediating effect, the number of repeated samplings was set to 5000 and the confidence interval was 95%. To examine the moderation effect of college innovation climate between information literacy (and its dimensions) and creative self-efficacy, the researcher run a series of linear regressions by SPSS22.0 to predict the effects of information literacy (and three dimensions), college innovation climate and their interaction on creative self-efficacy sequentially. Finally, model 7 of Process V3.4 macro program in SPSS22.0 was selected to test the moderated mediation effect of college innovation climate.We conducted the Harman’s single factor test to check the common method bias due to the self-reported items. Exploratory factor analysis was performed for 37 items of all variables. The results showed that 6 factors had eigenvalues greater than 1, explaining 67.59% of the variation. The variance explained by the first factor is 38.91%, which is lower than 40% of the total explained amount, indicating that the common method bias in the study is acceptable.Due to the large number of variable items, the scales of three dimensions of information literacy and college innovation climate are packaged respectively before confirmatory factor analysis. The packaged scale of information literacy and college innovation climate contains 10 and 4 items respectively. Then it is analyzed together with creative self-efficacy and innovative teaching behavior. The results of confirmatory factor analysis are shown in 1. Main effect. As shown in 2. Mediation effect. The test results of the mediation effect show see  that the3. Moderation effect. In order to avoid the multicollinearity problem, the variables involved were first decentralized before the hierarchical regression analysis was used to test the moderating effect of college innovation climate. The results of hierarchical regression are shown in As for the specific dimension, the interaction of information awareness and college innovation climate significantly negatively affect creative self-efficacy , and the interaction of information knowledge and college innovation climate also significantly negatively affect creative self-efficacy . It shows that the college innovation climate has a significant moderating effect on the relationship between teachers’ information awareness, information knowledge and creative self-efficacy, so H3a and H3b are supported. However, the interaction between information capability and college innovation climate has no significant negative effect on creative self-efficacy , indicating that the moderating effect of college innovation climate on the relationship between information capability and innovation self-efficacy is not significant, that is, H3c is not supported.So as to have a more intuitive understanding of the moderating effect of college innovation climate between teachers’ information literacy, its dimensions and creative self-efficacy, this study further divided college innovation climate into high and low groups according to the principle of one standard deviation below and one standard deviation above the mean, and drew the moderating effect diagram. As shown in Similarly, according to Figs The study also used Model 7 of the Process V3.4 macro program to examine the mediating effect of creative self-efficacy between information literacy (and its dimensions) and innovative teaching behavior under different levels of college innovation climate. The results show see  that wheAs for the three dimensions of information literacy, when the college innovation climate is low and high, the indirect effects of information awareness and information knowledge on innovative teaching behavior through creative self-efficacy are also significant ; The moderated mediation index are -0.10 and -0.07 respectively, none of the 95% confidence intervals contain 0, which means that H4a and H4b are supported. The result of Process V3.4 macro program also shows that the indirect effect difference of information capability on innovative teaching behavior through innovation self-efficacy is -0.04 when the college innovation climate is low and high, and 95% confidence interval  contains 0; Besides, the 95% confidence interval  of the moderated mediation index also contains 0, indicating that H4c is not supported.The study found the significant positive impact of college teachers’ information literacy on their innovative teaching behavior, which was highly consistent with that of former scholars ,9. This The research also verified the mediating role of creative self-efficacy between college teachers’ information literacy (information knowledge and information capability) and their innovative teaching behavior. This shows that while the higher the level of information literacy (information knowledge and capability) of college teachers, the stronger their ability to understand and apply new technologies to carry out teaching innovation, thus the more confident they are to overcome the difficulties and challenges encountered in the process of teaching innovation and achieve the expected teaching innovation effect, and the stronger their motivation and tendency to carry out teaching innovation . TherefoAs for the moderation effect, it was found that innovation climate in colleges and universities significantly moderated the positive relationship between information literacy (information awareness and information knowledge) and creative self-efficacy, and then moderated the mediating effect of creative self-efficacy between information literacy (information awareness and information knowledge) and innovative teaching behavior. In other words, under the condition of low innovation climate, the effect of information literacy (information knowledge) on innovative teaching behavior through teacher’ creative self-efficacy is stronger; Vice versa. It is worth noting that information awareness itself cannot affect innovative teaching behavior through creative self-efficacy. However, in the context of poor college innovation climate, teachers with strong information awareness have stronger sense of creative self-efficacy and tend to carry out more innovative teaching activities. This further illustrates the key significance of college innovation climate to their innovative teaching psychology and behavior in the information age. So, colleges and universities should create a good innovation climate, with strong support and rewards to significantly enhance teachers’ positive initiative to carry out teaching innovation. In this regard, colleges and universities should increase investment, gradually improve the information and intelligent construction of teaching equipment, and provide hardware support for teachers to carry out teaching innovation; At the same time, it is also necessary to introduce and improve a set of mechanisms to support teaching innovation, including teaching innovation awards, re-education training, and teachers’ teaching and academic assessment to create an innovative climate that advocates reform and permits errors, encourage teachers to innovate boldly and practice actively, with expectation to build and form a number of first-class undergraduate majors at the world level.This research aimed to explore the mechanism and boundary conditions of college teachers’ information literacy and its dimensions affecting their innovative teaching behavior based on the theory of social cognition and theory of behavioral change. To achieve the first goal of the study, the research verified the effect of college teachers’ information literacy on their innovative teaching behavior firstly, and further examined how do the three dimensions of information literacy affect innovative teaching behavior. 280 valid data showed that college teachers’ information literacy and its dimensions of information knowledge and information capability had a significant positive effect on their innovative teaching behavior, the influence of information awareness on innovative teaching behavior is not significant. Moreover, there are differences in the impact of the three dimensions of information literacy on innovative teaching behavior. Among the three dimensions, the influence of information capability on innovative teaching behavior is the greatest.Next, the study was also interested in the action mechanism of college teachers’ information literacy (and its dimensions) on their innovative teaching behavior, so the researcher examined the mediating role of creative self-efficacy. It was found that creative self-efficacy played a significant mediating role between information literacy (and its information knowledge and information capability dimensions) and innovative teaching behavior, but there was no evidence in the study for supporting the mediating effect of creative self-efficacy between information awareness and innovative teaching behavior.The third purpose of the study was to investigate the moderating effect and the moderated mediating effect of college innovation climate to explore the boundary conditions of the action mechanism. The results showed that college innovation climate significantly moderated the positive relationship between information literacy (information awareness and information knowledge) and creative self-efficacy, and significantly moderated the mediating effect of creative self-efficacy between information literacy (information awareness and information knowledge) and innovative teaching behavior. However, the study found no supports for the moderating effect of college innovation climate on the relationship between information capability and creative self-efficacy, neither for the moderating effect on the mediating role of creative self-efficacy between information capability and innovative teaching behavior.On the whole, the possible novelties and theoretical contributions of the study are as follows: Firstly, on the basis of verifying the influence of information literacy on teaching innovation, the study further examined the effect of its three dimensions on innovative teaching behavior, and obtained some new viewpoints, including different dimensions of information literacy had different impacts on teaching innovation; among three dimension, information capability had the most powerful impact on innovative teaching behavior, which can strongly explain the causes of college teachers’ teaching innovation under the background of informatization, and can further enrich the existing research on the factors influencing innovative teaching behavior. Second, As mentioned above, there is no research on the mechanism of information literacy affecting innovative teaching behavior. The study examined the mediating role of creative self-efficacy between information literacy (its dimensions) and innovative teaching behavior, which not only revealed the “black box” in which college teachers’ information literacy affects teaching innovation, but also positively responded to some scholars’ call for strengthening the exploration of the mechanism of innovative teaching behavior influenced by various influential factors . FinallyThere are still some research limitations. The sample data collected in the study is mainly concentrated in some universities from central areas, which brings some limitations in regional selection and sample number. Future research can cover universities in eastern and western regions, collect more representative sample data, track the influence of college teachers’ information literacy in different regions on their innovative teaching behavior, and improve the universality of the research conclusions. Besides, this study only uses the questionnaire method to explore the influence of college teachers’ information literacy on their innovative teaching behavior, in which the research method is relatively simple, and the research conclusions may also be biased. Future studies can be combined with semi-structured in-depth interviews to further explore the influential factors and mechanisms of college teachers’ innovative behavior in information-based teaching, and expand the research conclusions of this research.S1 Dataset(SAV)Click here for additional data file.


Bone cement augmentation surgery includes percutaneous vertebroplasty (PVP) and percutaneous kyphoplasty (PKP). In this study, we aimed to investigate the risk of sandwich vertebral fractures in the treatment of osteoporotic vertebral compression fractures via PVP and PKP.N = 30) underwent PVP treatment and group B (N = 31) underwent PKP treatment. The surgical time, fluoroscopy frequency, visual analog scale (VAS) score, amount of bone cement, the leakage rate of bone cement in intervertebral space, Cobb angle, and the incidence of fractures in both groups of sandwich vertebral were recorded after 1 year of follow-up.We performed a retrospective analytical study and included 61 patients with osteoporotic vertebral compression fractures who underwent PVP and PKP at the Spinal Surgery Department of The Second Hospital of Liaocheng Affiliated with Shandong First Medical University from January 2019 to January 2022. These patients were divided into the following two groups by simple random sampling: group A (P > 0.05). However, a statistically significant difference was found in terms of the amount of bone cement, the leakage rate of bone cement intervertebral space, Cobb angle, and the incidence of vertebral body fractures in both groups (P < 0.05). The amount of bone cement, the leakage rate of bone cement in intervertebral space, Cobb angle, and sandwich vertebral fractures were higher in Group A than in Group B.No statistically significant difference was found in terms of surgical time, fluoroscopy frequency, and VAS score between the two groups (When PVP and PKP were performed to treat osteoporotic vertebral compression fractures, the sandwich vertebral exhibited a risk of fracture. PVP exhibited a greater relative risk than PKP, which may be due to the relatively larger amount of bone cement, higher rate of bone cement leakage in the intervertebral space, and larger Cobb angle. Osteoporosis is a common disease in elderly patients, which can lead to increased bone fragility and risk of fractures , 2. EpidOsteoporotic vertebral compression fractures can lead to chronic low back pain, kyphosis, and posture restriction, which can seriously affect the quality of life and physical and mental health of patients . For ostN = 30) received PVP treatment and group B (N = 31) received PKP treatment. PVP was performed through bilateral pedicle puncture, whereas PKP was performed through unilateral pedicle puncture. After surgery, both groups were treated with anti-osteoporosis drugs.We performed a retrospective analytical study by including 61 patients with osteoporotic vertebral compression fractures who underwent PVP and PKP treatment at the Spinal Surgery Department of The Second Hospital of Liaocheng Affiliated with Shandong First Medical University from January 2019 to January 2022. These patients were divided into the following two groups by simple random sampling: group A . Conversely, the comparison of the amount of bone cement and Cobb angle between the two groups , with Group A being greater than Group B (Table P < 0.05). The comparison between the two groups was statistically significant. The leakage rate of bone cement intervertebral space and the incidence rate of vertebral fractures in group A were both higher than those in group B . The surgical time, fluoroscopy frequency, and postoperative VAS score of the two groups showed no statistically significant difference (P > 0.05). Conversely, the amount of bone cement, Cobb angle, the leakage rate of the intervertebral space, and the fracture rate of the sandwich vertebral body showed statistically significant differences between the two groups (P < 0.05).In this study, patients were divided into Groups A and B. Patients in Group A were treated with PVP, whereas those in Group B were treated with PKP to explore the risk of PVP and PKP for osteoporotic vertebral compression fractures on the occurrence of interbody fractures. The general characteristics of patients in the two groups, including age, gender, height, and weight, were statistically analyzed and the results showed no statistically significant difference in the general characteristics of the two groups (During PVP surgery, we performed a bilateral pedicle puncture. The amount of bone cement in the vertebral body was higher than that observed during PKP. The vertebral bodies at both ends of the interbody were filled with more bone cement. Researchers found that when bone cement was injected into vertebral bodies with compression fractures, the stress of adjacent vertebral bodies increased significantly, causing adjacent vertebral fractures , 18.The diffusion area of bone cement in the vertebral body observed during PVP was larger than that observed during PKP; owing to the higher amount of bone cement in PVP, bone cement can be easily distributed to the upper and lower endplates of the vertebral body during PVP. Studies have confirmed that the strength and hardness of bone cement distributed in the upper and lower endplates are greater than those of undistributed bone cement in the vertebral body , 20. TheDrug therapy for osteoporosis is particularly important after vertebroplasty for osteoporotic vertebral fractures; however, we did not study the effect of antiosteoporosis drug therapy on sandwich vertebral fractures. Furthermore, the number of cases in both groups was relatively small and the follow-up time was also short. Therefore, studies with expanded sample sizes and a long-term follow-up should be performed to verify the present findings.When PVP and PKP are used to treat osteoporotic vertebral compression fractures, the sandwich vertebral body possess a risk of fracture. PVP leads to a greater relative risk than PKP, which may be related to the relatively larger amount of bone cement, the higher rate of bone cement leakage in the intervertebral space, and the larger Cobb angle.


Our final sample included 21 articles/reports, including 14 mixed methods and seven qualitative-only projects. Articles spanned all U.S. states. Articles had similar research questions to understand school meals and/or general food access during COVID-19, with an emphasis on long-term policy implications. Hybrid deductive/inductive analytic coding was used to analyze data, utilizing domains from the Getting to Equity Framework (GTE). GTE considers multi-level factors that influence nutrition behavior while centering more equitable pathways to improve nutrition security and reduce adverse health. Findings were sorted into two categories: operational challenges during the pandemic and solutions to address inequities in school meal distribution during and after the pandemic, particularly during school closures such as summers or future emergencies. Key challenges related to supply chain issues, safety, and balancing families’ needs with limited staff capacity. Programs addressed equity by (a) reducing deterrents through federally issued waivers and increased communications which allowed the serving of meals by programs to families who previously did not have access, (b) building community capacity through collaborations and partnerships which allowed for increased distribution, and (c) preparing and distributing healthy options unless barriers in supply chain superseded the effort. This review highlights the importance of emergency school meal programs and provides insights into addressing challenges and promoting equity in future out-of-school times. These insights could be applied to policy and practice change to optimize program budgets, increase reach equitably, and improve access to nutritious meals among populations at highest risk for nutrition insecurity.The emergency school meals program provided free meals to children in the United States (US) during COVID-19-related school closures. This scoping review aims to synthesize the existing qualitative empirical evidence published between March 2020 and January 2023 on the operations and utilization of emergency school meal programs during the pandemic. Qualitative, US-based peer-reviewed literature was collected from three sources: (1) parent review of all federal nutrition assistance programs; (2) systematic search of four databases; and (3) manual search of grey literature. Identified scientific articles and grey literature reports ( Children living in low-income households, those living in rural areas, and those identifying with racial and/or ethnic minority groups are among the most likely groups to experience inequitable access to nutritious food and associated adverse health outcomes such as food and nutrition insecurity. Food and nutrition insecurity  ,2,3,4,5 Federally funded school meal programs—including the US Department of Agriculture (USDA)’s National School Lunch Program (NSLP), School Breakfast Program (SBP), and Summer Food Service Program (SFSP)—can serve as health equity-focused policy solutions to advance food security by providing a source of year-round nutritious and consistent meals for all children. Roughly 30 million children and adolescents currently participate in school meal programs, including approximately 20 million low-income students who receive meals for free or at a reduced price . HoweverWhen COVID-19 forced broad school closures in March 2020, USDA implemented nationwide waivers that allowed the continuation by school districts of providing meals to all children while mitigating virus spread . The waiDuring the period that the waivers were in effect (primarily 2020–2022), researchers across the US collected empirical implementation data, which is primarily qualitative, to examine how waiver operations worked across a variety of policy, cultural, and geographical contexts. The goal of this scoping review was (1) to describe the scope of existing qualitative literature on emergency school meal programs, including operations, utilization, and challenges to meal distribution; and (2) to evaluate the degree to which emergency school meal programs addressed challenges and optimized reach to all children using the Getting to Equity (GTE) framework. GTE, first published in 2018  and applWe conducted a scoping review of qualitative literature in the United States (US) that sought to characterize the implementation of school meal program operations across the country under the COVID-19 waivers. Scoping review methods were selected given the limited understanding of the evidence . We folln = 74). We replicated the search on 7 January 2023 and identified 93 additional articles.We included peer-reviewed articles and grey literature in this review. For peer-reviewed articles, we leveraged the search strategy of a separate scoping review  referre. The parFor grey literature reports, we conducted two Google searches  using search terms most relevant to the objectives of this review and different combinations of the terms “school meals”/“waiver”/“covid”. The searches yielded sources such as newspaper articles; blogs; federal and state websites; reports; and other informational websites. We followed recommendations of our Health Sciences Librarian and reviewed the first 100 hits for both dates. For the grey literature search, 164 of the 200 hits were excluded upon title review because they were informational websites or informational links to social media webpages. In the abstract and full text review, we included US-based qualitative or mixed methods papers that described barriers/facilitators of serving school meals and excluded grey literature if they were quantitative only, commentaries, or newspapers/magazines.We used Covidence, a web-based collaboration software platform that streamlines the production of systematic and other literature reviews , to extrn = 184) and removed irrelevant or ineligible articles (n = 141). Next, three members of the research team performed full-text screening (n = 41). During the full text screening, we reviewed reference lists and similar article lists within the search engines to ensure an exhaustive search. From this, we identified two additional articles. We included any peer-reviewed articles and grey literature reports in English that examined or explored the operations of school meal programs during the COVID-19 pandemic and described waiver implementation, reach and utilization, challenges, social and structural barriers, best practices, and gaps in practices. We included primary research studies with qualitative-only research design as well as mixed methods studies that reported relevant qualitative findings. We excluded articles published in languages other than English, quantitative research studies, review articles, press releases/news articles, and commentaries. We excluded one paper (a textbook chapter) because we could not access the full text.Two members of the research team performed title and abstract screening of all peer-reviewed and grey literature  Describe the operations, reach, and utilization of the emergency meals programs; (2) Describe utilization and perceived impact of USDA waivers on the emergency meals program. Each paper was summarized by two team members to ensure thoroughness and consistency . Then, oFor our second objective, we performed a hybrid deductive/inductive thematic analysis of the included studies . We broan = 14, 67%) or solely qualitative . School meals were the primary focus of 10 (48%) articles, while 11 (58%) integrated school meals as a secondary focus . The studies collectively spanned all US states and Washington DC and five US territories. California, Ohio, and New York were part of multiple studies. The communities served included urban alone , rural alone , urban, suburban, and rural together , urban and rural together , and locations that were not specifically named . Participants of interviews and focus groups were emergency food task force members, school food service directors, school superintendents, parents, community partner organization representatives, vendors, Latino immigrants from agricultural communities, and state agency directors. Additionally, nine (43%) articles explicitly listed the race/ethnicity of communities served or included analyses in which races/ethnicities were of interest. The data collection protocols  were similar across studies and typically inquired about the COVID-19 pandemic, policy, school meals, and general food access. Only two studies (10%) included a Health Behavior Theory—namely the Social Ecological Model [Of the 21 records included in the synthesis, 16 (84%) were original peer-reviewed articles and 3 (16%) were other types of records . Methodsal Model ,30—and fal Model ,32, Conse n = 7, %. Schoolal Model . Out of Next, we describe themes constructed across studies that highlight challenges encountered by school meal programs during the COVID-19 pandemic; these challenges were organized using the four quadrants of the GTE framework to better understand equitable solutions: (a) Reduce deterrents, (b) Build on community capacity, (c) Improve social and economic resources and (d) Increase healthy options .Almost all (81%) articles highlighted implementation challenges faced by food service directors serving emergency school meals. Some of these challenges aligned with those described in prior research on summer meal programs, but were amplified by the pandemic: limited awareness of/dissatisfaction with the program, inconvenient times for families, lack of transportation, stigma, and limited options for religious conventions or dietary needs ,46,49,53Other operational challenges included staff burnout, staff illness, limited volunteer capacity, and staff feeling underappreciated ,46,47,50Despite facing innumerable challenges throughout the course of the pandemic, food service directors found innovative tactics to continue meal distribution. While most studies did not explicitly describe utilizing specific tactics with the purpose of increasing equity, we conceptualize the ways in which their approaches addressed social and structural barriers and promoted equitable meal distribution using GTE domains.As described above, we used definitions of GTE domains created by McLoughlin et al. (2020) . ReducinThe USDA waivers were the biggest tool food service directors used to address barriers to accessing free meals. For example, 15 (74%) studies described the USDA waivers as a mechanism to increase access to meals in ways that had not previously been possible. The area eligibility, non-congregate meals, meal service time flexibility, and parent/guardian pick up waivers were the most referenced . These wConsistent communication was another approach used to reduce deterrents to participation. Approximately one third (36%) of studies intentionally described increased communications with families through a variety of modalities including social media, printed fliers and signs, announcements from teachers through the virtual classroom, emails from food service directors and school administrators , reminder texts, information on school and district websites, robocalls and phone banking, press releases, and hosting promotional events ,46,49,52Finally, although this was not a common approach, food service directors in one study described participating in stigma training as an approach to creating belonging and supporting people participating in school meals . The FSDBuilding community capacity refers to partnerships and collective efforts of school meal programs with other organizations and networks . A totalPartnerships also expanded the reach of school meals by increasing the number of funding sources and fundraising opportunities, addressing gaps in distribution plans, and mitigating supply chain issues ,39,42,50In other cases, school meals programs worked with community-based organizations and government offices to cross-promote their programs, which was “mutually beneficial” for all parties because they were able to increase participation at all partner events . In one The increasing healthy options domain refers to the mechanisms by which emergency school meal programs distributed food, how they promoted nutritious foods , and how they promoted overall safe access to foods . ProvidiImproving social and economic resources beyond meeting immediate food and nutrition needs is an important domain of the GTE framework. This domain refers to the ways in which school meals programs provide resources to families to help offset other costs, which in turn mitigates the effects of economic and food insecurity. In a study including parents, many participants felt that the meals independently and in combination with P-EBT increased their sense of financial security by reducing their grocery budget . Food seAnother important way that school meal programs can provide social and economic resources is through upstream solutions that work toward removing challenges for school meal staff ,46,51,53In this scoping review, we described the landscape of qualitative literature on emergency school meal programs and identified major implementation challenges impacting participation in programs . Additioreducing deterrents domain. Conversely, the improving social and economic resources domain had the least supporting data. Although the school meal programs inherently improve social and economic resources by allowing families reallocation of funds toward non-food needs , the studies published during the pandemic focused mainly on reporting food service director perceptions of barriers and facilitators to serve meals . Additional studies focused on family perceptions of COVID-19 relief programs, including school meal flexibilities and waivers, which may have revealed more about social and economic resources. Other pre-pandemic studies have highlighted these benefits [The GTE framework proved to be a useful tool for evaluating how emergency school meal programs utilized equitable approaches to adapt to challenges. We found that data were most robust in the benefits ,57,58.Overall, the authors of only one article in this review explicitly utilized a health equity framework as part of their methodology . The autOur synthesis of the literature on school meal program operations under the waivers enables recommendations to improve meal distribution during out-of-school times, particularly in the summer. Specifically, the waivers allowed programs a quick pivot and adaptation in creative ways to provide more meals for families who previously faced barriers to access. Looking forward, it is important to continue to build on local efforts to provide equitable access. This includes considering the structural barriers that hinder programs from providing access to the most vulnerable populations. Racism and other forms of systemic discrimination are built into the structure of our society . It has To start, federal and state policy changes to expand area eligibility  and maintain non-congregate meals  are needed. Policy changes that expand eligibility and maintain non-congregate meals seem especially realistic since—despite the challenges—emergency school meal programs through waivers and flexibilities demonstrated a tremendous value on the investment by making a pathway for increased food security as evidenced in this scoping review.This review suggests that the USDA waivers played a significant role in increasing meal access and serving children who were previously unable to access out-of-school meals, and could improve participation during future school closures and summers. For example, the SFSP’s reach is limited by area eligibility requirements, which currently restrict the program to areas where at least 50% of children are eligible for free or reduced price school meals . RelaxinAdditionally, we found that supply chain issues caused a major disruption to the continuation of school meal programs. Increased support for Farm to Summer programs may help mitigate supply chain issues by creating/improving communication between food sources  and summer meal providers, as well as simplifying the process of receiving food by simplifying the process and shortening the travel distance between food source and distribution sites. Research has also shown numerous positive effects of serving local foods and providing food education through child nutrition programs, including increased participation and engagement in meal programs, consumption of healthier options, and support of local economies ,70.Finally, there is a need to strengthen technical assistance from state and federal agencies to school food service directors during periods of school closure such as summer to support clear, timely, tailored, and culturally responsive communication strategies. Future research should evaluate both the effectiveness and implementation of policies and communication strategies at the federal, state, and local levels, including the experiences of recipients of summer meals.Future research could simulate how and to what extent COVID-19 relief efforts, coupled with equitable living wages, enabled school food service professionals and other low-wage earners to meet the costs of daily living standards and achieve food security ,71. Our The strengths of this review are in the robustness of the study design and data analysis, which enabled a comprehensive representation of the existing qualitative evidence on emergency school meal programs during the COVID-19 pandemic. This review followed the PRISMA guidelines, ensuring a rigorous and systematic approach to study selection and data extraction processes. To enhance the accuracy of the results, all data extraction was cross-checked by verifying and confirming the extracted data against the original included studies, ensuring that the key themes and information were accurately represented. This approach reduced the likelihood of errors or misinterpretations during the synthesis of the qualitative data.This scoping review has some limitations. First, while qualitative data allows for a rich exploration of the challenges, experiences, and perspectives of stakeholders involved in the implementation of school meal programs and provides real-time insights during the rapidly evolving COVID-19 pandemic, it is possible that including quantitative studies could help support  contradict our findings. As quantitative studies looking back at this period proliferate, future reviews of the full body of literature are needed. Second, we did not conduct a quality assessment of included studies. The purpose of this review was to map the evidence in a broad and comprehensive manner as opposed to assessing the risk of bias and/or evaluation of the strength of evidence. Many of the included studies were rapidly conducted during the COVID-19 pandemic with the intent to disseminate best practices for meal distribution and to inform ever-evolving policies; as a result, there may have been a methodological trade-off and/or time and/or resource limitations. We aimed for comprehensiveness over quality assessment and thus included both peer-reviewed and grey literature. This approach helped us to include a broad range of evidence. Finally, it is important to note that only three studies in this review offer the perspectives of children, families, or caregivers . As the recipients and key beneficiaries of school meal programs, children and families are a key voice in informing practical, actionable policy recommendations that better align program operations with their needs. Engaging families, particularly those most at risk for food and nutrition insecurity, in research is aligned with the virtues of reciprocity and community-based practice ,32,73. AThe scoping review provides valuable insights into the operations and utilization of emergency school meal programs during the COVID-19 pandemic. Our findings highlight the immense challenges faced by school food service directors, such as ever-evolving policy changes, competing needs and priorities of families, and overhauled staffing and operational protocols. Findings also highlight the innovative approaches that the directors used to maintain program operations and to provide meals to families who may have previously faced barriers to participation during out-of-school time. Application of the GTE framework revealed that studies of emergency school meal programs reported on equity considerations to varying degrees. Future research should intentionally incorporate health equity frameworks into data collection and analysis, evaluate how emergency school meal programs impact non-food-related social and structural barriers to economic and food security, and assess how policies (such as the recission of the USDA waivers in 2022) affect program operations and implementation. For example, as more states adopt policies to make meals universally free, researchers should monitor policy adoption and implementation to ensure that the meals are more accessible to the hardest-to-reach children. By addressing challenges and implementing equitable solutions, school meal programs have the potential to close the health gaps between those more and less affected by structural and social barriers while improving the health of the population overall.


With rapid industrialization and urbanization in China, inadequate preservation of traditional architecture coupled with natural deterioration have led to the fragmentation of architectural landscapes. Drawing from ecological fragmentation research in landscape ecology, we consider the cultural landscape as our research object, viewing buildings as landscape patches, and determine a system for measuring architectural landscape fragmentation in traditional villages. The study shows the degree of landscape fragmentation can reveal the characteristics of traditional villages and the process of regional modernization. The results are as follows: (1) From the perspective of landscape diversity, the study area was rich in landscape types in all dimensions, and the relative evenness index was high, signifying evident or severe fragmentation. (2) The index of landscape heterogeneity in the dimensions of building quality, height, and landscape appearance is low in the study area, with mild levels of landscape fragmentation caused by heterogeneity in the aforementioned dimensions. (3) Mild fragmentation suggests the integrity and homogeneity of architectural landscape types, reflecting a lagging level of economic development, whereas high fragmentation signifies rapid economic development, leading to a substantial deterioration in the integrity and homogeneity of architectural landscape types. Therefore, efforts to preserve and develop traditional villages should not solely aim for low fragmentation as it could potentially constrain sustainable development. As the cradle of Chinese farming civilization, traditional villages hold immense historical, cultural, aesthetic, and economic values enjoying high esteem and protection from the government4. The traditional village landscape is a unique symbol reflecting regional and cultural landscape differences. Traditional Chinese architectural landscapes, shaped by inhabitants with unique geographic and environmental mindsets, incorporate factors such as the natural environment, economic conditions, customs, and ethical values of their long-standing lifestyles. They bear distinct regional identities and offer an unparalleled sense of place. They are considered ideal and natural heritage transmitters and express China’s national characteristics and rich history of traditional culture, seated at the heart of a village’s cultural landscape. Generally, traditional Chinese architecture refers to architecture from the pre-Qin dynasty to the mid-nineteenth century and represents an independently formed architectural system.Traditional Chinese villages exemplify the successful active adaptation to, and effective use of, the environment, including environmental protection5. Therefore, it is crucial to address the fragmentation of traditional village architectural landscapes into ‘patches’ or ‘islands’7. Ensuring the organic transmission and integration of landscape genes is essential for the ongoing renewal of architectural landscapes.However, rapid industrialization and urbanization have undermined the preservation and development of traditional villages. Environmental impacts, the trend towards replacing older buildings, informal construction, infrastructure-related construction, and commercial expansion have all threatened traditional villages, resulting in the fracturing and fragmentation of traditional village architectural landscapes. This scenario poses a significant threat to the protection, transmission, and effective utilization of unique Chinese, vernacular, and cultural genes8. Landscape indices are typically used in quantitative studies to describe landscape patterns and their changes. Recent research has mostly analyzed landscape fragmentation within the scope of landscape ecology, focusing on topics such as land use analysis and construction, vegetation cover changes, landscape patterns12, ecosystem sensitivity evaluations, ecosystem service value analysis, and ecological security network pattern construction16. The studies also include the impact of climate change on landscape fragmentation, species evolution19, regional human landscape characteristics, and their conservation25. An observable trend has emerged where the analysis has shifted from natural to human landscape ecosystems26.Landscape fragmentation refers to the gradual changes wherein previously coherent landscape elements become discontinuous or transform into patchy mosaics due to disturbances caused by anthropogenic effects28. Traditional architecture, such as that found in typical rural villages, represents a cultural landscape under threat of fragmentation, a situation exacerbated by urbanization and the rapid development of rural tourism.A cultural landscape is a complex blend of natural and human factors that embodies the characteristics of a certain region, continually evolving due to human activitiesThis study aimed to clarify the implications of architectural landscape fragmentation and measure its degree. It questions whether fragmentation was caused by heterogeneous landscapes and if the fragmented architectural landscape is entirely detrimental to the protection, development, and historical value of villages.26.Most studies initiate their research by classifying the fragmentation of architectural landscapes based on land type and then analysing their land fragmentation characteristics and spatial heterogeneity features in terms of their morphology. Traditional villages often have rigorous protection mechanisms, and the architecture of their land typically does not undergo significant morphological changes during development. This tendency often leads to overlooking vital aspects. Considering a single building as a landscape patch and studying its fragmentation characteristics in terms of architectural quality, style, age, height, and other intrinsic functions have not been thoroughly covered in the literatureGiven this background, and borrowing from the theory of landscape ecology, this study constructed an index system and evaluation criteria for architectural landscape fragmentation from the perspectives of landscape diversity and heterogeneity. Traditional villages in Western Hunan were taken as examples, and the fragmentation characteristics of their architectural landscapes were analyzed to provide a reference for traditional villages to define continuous, homogeneous, diversified, and moderately fragmented architectural landscapes.30. This transition can be classified into four spatial processes, namely perforation, fragmentation, shrinkage, and disappearance. The analysis of natural landscape fragmentation typically involves three aspects: the division of landscape elements into patches, the heterogeneity of landscape elements, and the spatial interrelationships among landscape elements31.Landscape ecology views fragmentation as a transformation process wherein landscapes, owing to disturbances from natural or human factors, transition from simple, homogeneous, and coherent wholes to complex, heterogeneous, and discontinuous patchworks or mosaicsArchitecture is the space created for human habitation and use that, composed of building materials such as clay, brick, tile, stone, and wood. Vitruvius, the ancient Roman architect, proposed three criteria for architecture in his classic work, ‘The Ten Books of Architecture’: firmitas (sturdiness), utilitas (utility), and venustas (aesthetics). Traditional Chinese architecture predominately consists of wood-frame buildings, while traditional Western and modern architecture are largely characterized by masonry and reinforced concrete, respectively.In traditional Chinese villages, architectural landscapes are primarily composed of buildings. However, due to rapid socio-economic development and urbanization, some traditional buildings have been demolished or disappeared, leading to the emergence of heterogeneous architectural landscapes with varied structures and styles, which increases the fragmentation of architectural landscapes.Three types of landscape fragmentation can be observed in traditional village architecture: (1) self-loss fragmentation, which arises from natural deterioration, such as the collapse of old buildings, resulting in the fragmentation of the overall landscape; (2) foreign-loss fragmentation, which occurs through the replacement of old structures with new ones. When the new style is clashes with the original aesthetic, it leads to fragmentation of the local landscape; and (3) external-loss fragmentation, which emerges from the visual and stylistic incongruity between traditional village buildings and surrounding modern structures, leading to the fragmentation of the peripheral landscape.If we consider each building as a separate patch and disregard the space between them, the properties of the individual building patches  determine the fragmentation of the building landscape. Single buildings do not result in shape fragmentation, which only occurs in relation to the building landscape types and patterns. Therefore, the fragmentation of architectural landscapes can be studied without analyzing the fragmentation of patches and patch shapes, focusing on two aspects: landscape type fragmentation and landscape space interrelationship fragmentation.From the perspective of landscape diversity and heterogeneity, landscape fragmentation manifests either through the impact of climatic conditions or human activities, such as urbanization, leading to fragmentation characterized by a decrease in the quality of certain buildings. This fragmentation also appears through challenges faced by traditional buildings attempting to accommodate modern living requirements, for example, in terms of function, including aspects such as functionality, comfort, safety, lighting, and ventilation. This results in alterations to building styles, number of stories, and structures. The fragmentation of building functions often sees residential purposes replaced and commercial buildings added to cater to the evolving needs of rural tourism. Typically, the more varied the landscape type, the higher the degree of fragmentation. For instance, if all buildings are one-story tall, the landscape is homogenous and coherent, with no fragmentation. In contrast, if buildings display a range of landscape types, such as one-, two-, and three-story buildings, the emerging heterogeneity amplifies the complexity and unpredictability of the architectural landscape, thus inducing fragmentation.32. External loss fragmentation represents the wider pattern of foreign loss fragmentation. In essence, the more noticeable the external loss fragmentation, the stronger the islanding features of the traditional landscape. When heterogeneous landscapes are scattered, the degree of fragmentation is low if landscape types are few (as in point-like scattered distribution) and high if many landscape types exist (as in block-like scattered distribution)  and abundance (Shannon–Wiener diversity index)i)i is the number of landscape types and Σni signifies the sum of all landscape types39.(1) Plaque multiplicity (Pmax symbolizes the maximum possible uniformity under the given landscape type. ‘D’ is more sensitive to the homogeneity of landscape types40.(2) Relative homogeneity index (E)max is the maximum possible richness. An increase in the type of architectural landscape signifies a rise in the complexity of the architectural community; that is, the larger the ‘H’ value, the greater the information content of the architectural landscape and the greater the fragmentation41. When only one landscape type was present, the ‘H’ value was zero, indicating no fragmentation. When two or more landscape types were present in equal numbers, the ‘H’ value achieved its maximum.(3) Relative abundance index (R)i is the probability of occurrence of a particular landscape type ‘I’.In Eq. , ‘m’ is (4) Landscape heterogeneity index (F)42. The calculation is shown below.y denotes the sum of the number of patches of heterogeneous landscape types, and ΣSz symbolizes the sum of the number of patches of traditional landscape types43.The heterogeneity index for a traditional village architectural landscape type (F) encapsulates the ratio of the heterogeneous landscape index to the traditional landscape index within an area. When ‘F’ is 0, no heterogeneous landscape or heterogeneous landscape fragmentation is present; when ‘F’ is 1, the quantity of heterogeneous and traditional landscape patches are equal, indicating conspicuous landscape fragmentation. A higher heterogeneity index for traditional village architectural landscape types signifies a stronger impact of modernization on the traditional architectural landscape, leading a higher degree of fragmentationThe fragmentation of traditional village architectural landscapes was assessed based on landscape diversity and heterogeneity. Landscape diversity was measured using the relative evenness (E) and relative richness (R) indices. The value ranges of both ‘E’ and ‘R’ were 0, 1], corresponding to the degree of landscape fragmentation. The value ranges were classified into four levels: 0 = no fragmentation; . The value range of ‘F’ is [0, + ∞) corresponding to the degree of landscape fragmentation, and is split into four levels: 0 = no fragmentation;  = severe fragmentation  of the People’s Republic of China (PRC) in 2013, the architectural value and characteristics of traditional villages are typically analysed in terms of architectural landscape, architectural age, structure, quality, number of stories, roof style, and architectural functions. Architectural quality can signal the level of ‘self-damaging fragmentation’ of the architectural landscape; architectural style (roof) and structure can denote the level of ‘heterogeneous fragmentation,’ in both external and internal styles; architectural age can reveal the level of ‘heterogeneous fragmentation’ over time; and the number of stories can suggest the level of ‘heterogeneous fragmentation’. The fragmentation of the architectural landscape is characterized by the degree of variation and deterioration of architectural landscape types, combinations, and attributes over space or time. To quantify the degree of fragmentation of architectural landscape types, the existence of traditional and heterogeneous landscapes must be discerned and analysed. For instance, in architectural landscapes, cultural heritage protection units (FM1), historical architecture (FM2), and traditional landscape architecture (FM3) constitute types of traditional village architectural landscapes, while new architecture with incongruent landscapes (FM4) type is considered heterogeneous as it contrasts with the aforementioned traditional landscape types. Based on this, the traditional village architectural landscape was classified into seven major categories and 30 subcategories , ranking first in Hunan Province and fourth nationally, forming a ‘colony’ of traditional villages. Given the mountainous terrain and abundant timber, wooden houses dominate the residential architecture.Located in the northwestern region of Hunan, Xiangxi Tujia and Miao Autonomous Prefecture are the only autonomous prefectures of ethnic minorities in the province, encompassing one county-level city and seven counties45, resulting in a ‘self-destructive’ landscape fragmentation. Concurrently, urban development brings about changes in lifestyle and values, making traditional buildings inadequate to meet the population’s demands for functionality and comfort. As a result, traditional architecture is gradually replaced by modern buildings, leading to a heterogeneous landscape in terms of style, height, structure, and other features. This shift triggers localized heterogeneous landscape fragmentation. A comprehensive assessment of the degree of fragmentation of different architectural landscape types will facilitate more effective management and restoration of local cultural heritage. To explore the fragmentation characteristics across different batches of architectural landscape types, this study selected 14 traditional Chinese villages in Western Hunan as case studies 3) to derRegarding the uniformity of the landscape types, a higher relative uniformity index implies a greater inclination for an equivalent number of landscapes types. Based on the relative evenness index of the architectural landscape of the first batch of villages Table , Fig. 4,More specifically, (1) three categories of architectural quality landscapes exist: good, medium, and poor. Approximately 57.1% of the relative uniformity indices for traditional village architectural quality landscapes fell within the  Generally, there are four types of architectural landscapes: cultural preservation units, historic buildings, traditional buildings (including new style-coordinated buildings), and new style-uncoordinated buildings. The ratio of severe and evident architectural landscape fragmentation in the 14 villages resembled that for architectural quality landscape, demonstrating general consistency across the villages. For instance, the villages of Lao Dong and Yan Paixi exhibited evident fragmentation of the architectural landscape and landscape quality, whereas Lao Siyan, Shou Badong, Xiao Xi, La Hao, and Hang Sha showed severe fragmentation  Traditional villages feature four categories of architectural chronological landscapes: the Qing dynasty, the Republican period, the 1950s to the 1970s, the 1980s, and post-1980s. About 71.4% of the village building chronological landscapes were within the range  There are three types of building height landscapes: one story, two stories, three stories, and more than three stories. The village of Lao Siyan was predominantly composed of one-story building landscapes, accounting for 93%, whereas two- and three-story buildings were less common, resulting in low fragmentation in the building height landscape. In the villages of Lao Dong, Xiao Xi, and another 50% of other villages, all three types of building heights represented a certain proportion of landscape complexity, with fragmentation being severe. In 42.9% of villages, such as Ban Li, there are primarily one- and two-story buildings and a few with over three stories, exhibiting evident fragmentation  there were three landscape types: good, medium, and poor architectural quality in all 14 traditional villages. Approximately 85.7% of these villages showed a relative richness index for architectural quality landscape in the  there was a ‘self-damaging’ fragmentation of architectural landscape quality, with 92.9% of villages in the  As the most visually apparent dimension of ‘heterogeneous landscape fragmentation,’ architectural style exhibited three fragmentation states; however, the heterogeneity index for each village did not differ significantly in the mild fragmentation state. The architectural style heterogeneity index for 85.7% of the villages was in the  Building height is the vertical intuitive dimension of ‘heterogeneous landscape fragmentation,’ with fewer heterogeneous landscapes of three or more stories and no or light fragmentation. For instance, Lao Siyan, Shou Badong, and Shu Jiatang consisted of one- and two-story buildings with no heterogeneous landscape impact. The remaining villages displayed slight fragmentation, with a low heterogeneity index Fig. b.(4) The architectural age landscape represents ‘heterogeneous landscape fragmentation’ in the time dimension. The 14 traditional villages exhibited three stages: light, evident, and severe fragmentation. However, the heterogeneity index for each village varied significantly. Yan Paixi and Shou Badong were mildly fragmented with heterogeneity indices of 0.2222 and 0.4483, respectively, whereas Lao Siyan was fragmented with a heterogeneity index of 0.5435. Most villages exhibited a high heterogeneity index for architectural age and severe fragmentation, with the highest heterogeneity observed in Ban Li, reaching 81, followed by Zhong Huang at 15.1176  traits while undergoing certain cultural ‘mutations’ to adapt to new environments. However, their overarching genetic traits remain consistent, with exceptions occurring only in rare instances of ‘mutations. This ensures the preservation of their regional individuality and ‘local’ cultural heritage47. Therefore, one should not blindly aim for a low fragmentation level when aiming to protect and develop traditional villages, as this could hinder sustainable development. From an architectural landscape perspective, the layout of new buildings should consider the need to minimize fragmentation of architectural style and building height landscapes to meet new demands. For those buildings contributing to heterogeneous landscape fragmentation, landscape components should be altered by repairing deteriorating buildings and modifying modern architectural styles to ensure the conservation and sustainable development of traditional culture.Landscape heterogeneity and fragmentation are objective phenomena that are pervasive in cultural landscapes and represent contradictions that inevitably occur during rural modernization and developmentThis study adopts diversity and heterogeneity estimation methods from landscape ecology theory to quantify the fragmentation of traditional architectural landscape types. The results obtained are objective, scientifically sound, and adaptable. However, the validity of these measurements hinges on data reliability; hence, it is vital to scientifically discern each dimension of the architectural landscape type (three-level index) when quantifying the degree of architectural landscape fragmentation. Future studies should investigate the following aspects: (1) methods and systems to quantify architectural landscape fragmentation; (2) the evolution of architectural landscape fragmentation in traditional villages across different periods, to further understand the trend of architectural landscape fragmentation in different dimensions and thus support scientific governance and restoration; (3) the underlying causes and mechanisms of architectural landscape fragmentation in traditional villages; and (4) landscape fragmentation in general, which is the process by which landscapes transition from a homogeneous and cohesive state to a discontinuous and patchy mosaic. Studying the fragmentation of architectural landscape types can reveal heterogeneous landscape fragmentation, but an analysis of the spatial pattern fragmentation of architectural landscapes can expose varying spatial fragmentation patterns triggered by landscape diversity or heterogeneity. These distinct patterns signify an inclination towards village development to a certain extent. Therefore, it is crucial for future research to explore the spatial pattern fragmentation of architectural landscapes.Architectural landscape fragmentation, which involves the alteration and decay of architectural landscape types, combinations, and properties across space or time, falls into two categories: ‘self-damaging fragmentation’ and ‘heterogeneous fragmentation’. The fragmentation of architectural landscape types was assessed from two perspectives (landscape diversity and heterogeneity) and across seven dimensions . The measure of landscape fragmentation from the diversity perspective indicates whether fragmentation exists in each dimension of the landscape type within traditional village architectural landscapes. Measures of landscape fragmentation based on the heterogeneity perspective indicate whether fragmentation occurs in each dimension of the landscape type due to heterogeneous landscapes in traditional village architecture.From the viewpoint of landscape diversity, the first batch of villages showed a rich variety of landscape types across all architectural dimensions and high relative evenness indices, exhibiting either evident or severe fragmentation. However, there were fewer villages with the same architectural landscape undergoing the same stage of fragmentation across different dimensions, with the majority of villages experiencing the same stage of fragmentation across two or three dimensions. Given the unique nature of architectural landscapes, the fragmentation resulting from a variety of landscape types is not entirely negative. For example, a uniform building height does not necessarily lead to an appealing skyline, whereas an appropriate variety in building height can enhance the vertical visual experience. Another example can be seen in the varying periods of architectural landscapes in traditional villages, which signifies that villages are not static; rather, but have undergone growth and expansion.From the perspective of landscape heterogeneity, 14 villages had low heterogeneity indices for architectural quality, height, and style. Even though there was a diverse range of architectural landscapes across the aforementioned three dimensions, the number of heterogeneous landscapes  was low. Landscape fragmentation caused by heterogeneous landscapes was minimal, and 85.7% of the village architectural landscapes showed low fragmentation across all three dimensions. The heterogeneity index for architectural age landscapes was high, the number of heterogeneous landscapes (buildings from the 1950s or later) was high, the degree of landscape fragmentation due to heterogeneous landscapes in the time dimension was high, and buildings from the PRC era or earlier had severely deteriorated or collapsed, requiring urgent protection and renovation. Generally, landscape fragmentation does not contribute to the preservation and protection of traditional landscape, except for considerations related to building age.


To explore the response and management experiences of nurses and nurse aides in dementia special care units when caring for residents with sundown syndrome based on the person-centered care model.Focus group interviews were conducted among nurses and nurse aides from four dementia special care units that have been accredited by the Ministry of Health and Welfare in Taiwan. Content analysis was used for data analysis.The 29 nurses and nurse aides were recruited to participate in the study. Analysis of interview content revealed six themes, identifying the intra-individual, inter-individual, and organizational dimensions. The central topic was commitment. Under the umbrella of commitment, six themes including self-preparation, non-suppression, diversion, pacification, continuity of meeting, and collaboration, which had 18 subthemes, emerged as responsive care practices for person-centered care when supporting residents with sundown syndrome.The findings provide responsive care practices based on person-centered care for people living with dementia who develop sundown syndrome. The study can inform practices for quality of care for dementia in long-term care institutions and contribute to the development of materials for nursing training and education.The online version contains supplementary material available at 10.1186/s12912-023-01598-x. It is estimated that at least 57 million people living with dementia (PLWD) in 2019, and this number is expected to triple by 2050 . GeneralThe person-centered care (PCC) model for PLWD has been advocated for several years; it is widely attributed to Kitwood’s framework grounded in personhood and involves aspects of basic psychological needs , addressing malignant social psychology, and positive person work  –8. PCC eIn Taiwan, various services including home care, community care, and institutional care are part of efforts to address dementia care needs as stipulated by the long-term care policy (2.0). Dementia special care units (DSCUs) have gradually expanded in special accommodation institutions that primarily care for ambulatory residents with moderate-to-severe dementia. Nurses and nurse aides collaborate closely in providing care in DSCUs. PLWD receive their care from nurse aides who are responsible for caregiving tasks and directly addressing the care needs of PLWD. Nurses not only assist with nursing care but also play a supervisory role. However, nurses or nurse aides may be prone to conflict and could experience burnout, as they relentlessly provide care from morning to evening and must deal with the chaos resulting from SS. For example, PLWD who experience SS face particular challenges with regard to their daily routines   and mediThere is an urgent need to support cooperation between nurses and nurse aides when implementing the PCC model for PLWD to address conflicts, particularly when dealing with the challenging behaviors exhibited by PLWD during handover, when they are fatigued and under high stress after a day’s work. Therefore, this study aimed to increase the understanding of the response and management experiences of DSCU frontline nurses and nurse aides when their residents develop SS based on the PCC model.Nurses and nurse aides were recruited from the participating DSCUs in the Greater Taipei Area that have been accredited by the Ministry of Health and Welfare. The inclusion criteria were as follows: (1) having experience caring for SS, (2) aged 20 years and above, (3) no sex restriction, and (4) willingness to participate in the study.The research team explained the study purpose and processes to the DSCU chairs. After receiving their approval for the study, the recruitment advertisement describing the study and the main topic Table  discusseFour focus group interviews were conducted in the participating DSCUs , with 5−8 participants per group . For theEach focus group interview (lasting approximately 1–1.5 h) was arranged by a contact person in each participating unit; each interview started with an opening introduction and the completion of a general personal information form. The moderator of the focus group interviews was the first author, who has extensive knowledge and expertise on matters related to PLWD and their caregivers and a decade of teaching experience in dementia care. To ensure the moderator’s neutral and catalytic role in the interviews, an immediate review and transcription of the interviews were conducted after each focus group.During the interviews, the moderator asked open-ended questions from the interview guide and ensured that the participants had equal opportunities to share their perspectives. First, the participants spoke about the SS symptoms they have witnessed in their care experience and then shared their perspectives of and strategies for person-centered dementia care in different scenarios. Moreover, the moderator encouraged all contributions to the discussion, and the similarities and differences between various perspectives were compiled. Collaboration among participants with varied perspectives facilitated greater interaction within the focus group. Furthermore, a discussion was held based on the participants’ statements, and “restatement” was employed to ensure accurate understanding of participants’ responses.Each focus group interview was recorded and transcribed to obtain a description of the care experience. Content analysis was used. The first step was to review the interview content repeatedly and develop a coding framework. The research members independently reviewed the same set of interview transcripts and highlighted any key points of interest as initial ideas, which were then shared and discussed in a team meeting to reach a consensus. The second and third authors continuously performed data comparisons and compared the data using the same codes. The first author made a decision in case of any inconsistencies. Thereafter, they reconfirmed whether data with the same code contain the same concepts and whether the data were appropriate . SubsequNext, the dependability, credibility, and transferability of qualitative studies were conducted. We periodically reviewed the data analysis context, process, and results to reconfirm that the data were reliable and avoided excessive personal bias (Dependability). Subsequently, some interviewees were randomly selected to rectify facts or transcription errors (Credibility). This study had a specific context and we placed restrictions on the inference of study results to ensure the rigor of the study (Transferability). Finally, we summarized the interview data analysis results to compile the study results and interpret the content.This study was approved by the Research Ethics Committee of National Taiwan University (201907ES030). The researcher explicitly explained the purpose and procedures of the study to all the participants, and their signed informed consent was obtained to confirm that they fully understood and consented to participate in the study.Of the 29 participants, eight (27.6%) were nurses and 21 were nurse aides (72.4%). There were 27 women (93.1%) who participated in this study. The mean age was 51.6 years (SD = 9.29), and the mean level of work experience was 9.07 years (SD = 5.39). Among the participants, the four focus groups included two nurses and three nurse aides in Unit A (age range: 53–61 years), two nurses and six nurse aides in Unit B (age range: 42–60 years), two nurses and six nurse aides in Unit C (age range: 24–64 years), and two nurses and six nurse aides in Unit D (age range: 26–63 years).Analysis of interview content revealed that common challenges and scenarios in the residents with SS include: (1) Wandering: wandering or continuous walking; (2) Seeking escape: walking toward elevators and wanting to go out; (3) Continuous clamoring to return home/look for family members; (4) Repetitive speech or behavior: asking the same question repeatedly or rummaging; (5) Hallucinations: Visual and auditory hallucinations; (6) Delusion: delusion of theft, persecutory delusion; (7) Sleep problems: circadian rhythm disruption; (8) Inappropriate sexual needs; (9) Emotional problems: anxiety, shouting; (10) Aggressive behavior: cursing, physical violence (toward objects or people); (11) Eating disorders: binge eating, refusal to eat, eating wrong foods; (12) Bathing: refusing guidance to bathe; and (13) Toileting problems: frequent toileting, urination outside of the toilet.Through qualitative content analysis, the central topic was commitment while six themes and 18 subthemes emerged as responsive care practices, identifying the intra-individual, inter-individual, and organizational dimensions . Instead of attempting to pacify residents, the residents’ attention was redirected toward more positive activities that could distract them from the source of their agitation.This theme reflects the third type of optimally effective approach in the inter-individual dimension. It illustrates three subthemes: a safe environment, going through the flow, and cold treatment.A safe environment could help nurses and nurse aides take steps to minimize disruptions to their routines if the residents had SS. Going with the flow outlined creative approaches instead of telling residents that it was not possible to leave. However, it is important to ensure the safety of residents and monitor their behavior. Cold treatment sometimes works. As nurses and nurse aides faced situations in which residents showed aggressive or other behaviors without any reason, taking residents away from the scene and changing the environment, if necessary, ensured that their behavior did not escalate or cause any injury.This theme reflects the importance of teamwork and is planned in the organizational dimension. It illustrates three subthemes: between colleagues, support from residents, and support from non-clinical coworkers.Between colleagues highlighted the importance of seeking help from colleagues, especially when managing agitated behaviors in older residents with SS. Support from residents was an important experience shared by nurses and nurse aides who emphasized the effectiveness of identifying the leader and using peer-to-peer interactions to pacify residents with SS. Support from non-clinical coworkers outlined the importance of team cooperation. Engaging in nonclinical roles in a care team has several advantages. Some nurses and nurse aides sought assistance from other staff members such as security guards and administrative staff.This theme reflected the importance of planning and communication in caring for PLWD with SS. It illustrates two subthemes: medication adjustment and enhancing safety precautions.Medication adjustment was pointed out. Some nurses and nurse aides focused more on managing residents’ behaviors through medication rather than addressing underlying issues or providing non-pharmacological interventions. Enhancing safety precautions outlined concerns about ensuring the safety of residents, particularly by preventing falls. The focus was on balancing the need to ensure the safety of the residents with the desire to avoid the use of restraints as much as possible.This exploratory qualitative study examined PCC-related responsive care practices and management experiences in DSCUs when residents develop SS. In the case of the units recruited for this study, there are more nurse aides than nurses. According to the regulations of the Taiwanese Establishment Standards of Senior Citizens’ Welfare Institutions, one nurse must be appointed for every 20 residents in each DSCU. During the daytime, one nurse aide must be assigned for every three residents, and during the nighttime, one nurse aide must be assigned for every 15 residents. Nurses and nurse aides are well positioned in the DSCUs and nurse aides may be in the majority. Nurses and nurse aides described special SS scenarios requiring significant care, including wandering, seeking exits, continuously clamoring to go home/search for family members, and repetitive speech or behavior. Generally, patients showed various symptoms , 18 and Given the challenges of caring for PLWD with SS, we found that the PCC model conducted with different practices that align with the respective residents’ unmet needs may improve the quality of life of PLWD and decrease the behavioral and psychological symptoms of dementia , 23. At At the inter-individual level, some practices to support PLWD with SS aligned with the 12 types of positive interactions identified by Kitwood , 8, inteWe found that diversion and non-suppression are required in PCC practice for PLWD with SS. However, this does not entail reaffirming the authority of the nurses and nurse aides; rather, it is about satisfying the needs of PLWD through specific approaches. These strategies alleviate physical and mental discomfort in PLWD, thereby lessening physical and mental exhaustion in nurses and nurse aides. Practice recommendations for PCC demonstrate that respect should be accorded to residents, and equal respect should be felt in interpersonal relationships . ResidenThe organizational-level provision of PCC requires a top-down and bottom-up approach. While nurses and nurse aides are skilled in the delivery of PCC among PLWD, the entire organization must also be supportive, which would be beneficial to the quality of life of PLWD . CollaboIn the Western PCC framework, “love” is the core value , but peoThere are some limitations to this study. First, data were not collected through nursing records or case analyses because experienced institutional nurses and nurse aides can provide good SS-related care information. As SS is similar to other neuropsychiatric symptoms, there is an increasing consensus on the use of non-drug methods as the first-line treatment, and drug treatment is restricted to PLWD who do not respond to non-drug methods .This study adds to the literature by describing the PCC-based care experiences of DSCU nurses and nurse aides supporting PLWD with SS. It sheds light on the management methods that can be adopted when problematic SS behaviors occur in PLWD, provided reference for nurses and for developing professional training materials. It can contribute to an improved quality of care provided by nurses and nurse aides who take care of older adults with dementia and SS.Below is the link to the electronic supplementary material.Supplementary Material 1