Poor Research Articles

Building responsible and sustainable supply chain frameworks: limits of international investment law and the CSR initiatives taken by the EU and China

ABSTRACT Supply chains play a pivotal role in global economic relations, fostering growth, employment, and poverty alleviation. Multinational enterprises (MNEs) are central actors in these chains, bearing responsibilities towards workers and the environment. Corporate Social Responsibility (CSR) standards guide MNEs in assessing the societal and environmental impacts of their activities, though these standards remain largely voluntary. Recent investment treaty practice shows a trend to incorporate CSR provisions in international investment agreements (IIAs), but such clauses fail to impose direct human rights, labour and environmental obligations on investors. Amidst this landscape, the EU and China, major players in global trade and investment, have established diverging legal and policy frameworks to build responsible and sustainable supply chains. Considering these developments, the objectives of this article are twofold. First, the article explores the integration of CSR in international investment law. Second, it evaluates the different CSR initiatives taken by the EU and China that frame their foreign direct investments. Focusing on EU–China FDI relations, the article delineates implications for global supply chain governance offering insights into the evolving landscape of CSR frameworks, and the plagued path in adopting mandatory corporate responsibility standards.

Cost effectiveness analysis of a fixed dose combination pill for primary prevention of cardiovascular disease from an individual participant data meta-analysis

Cardiovascular disease (CVD) continues to impart a large burden on the global population, especially in lower income countries where affordability limits the use of cardiovascular medicines. A fixed dose combination strategy of at least 2 blood pressure lowering medications and a statin with aspirin in a single pill has been shown to reduce the risk of incident CVD by 38% in primary prevention in a recent meta-analysis. We report the in-trial (median follow-up: 5 years) cost-effectiveness of a fixed dose combination (FDC) pill in different income groups based on data from that meta-analysis. Countries were categorized using World Bank economic groups: Lower Middle Income Countries (LMIC), Upper Middle Income Countries (UMIC) and High Income Countries (HIC). Country specific costs were obtained for hospitalized events, procedures, and non-study medications (2020 USD). FDC price was based on the cheapest equivalent substitute (CES) for each component. For the CES-FDC pill versus control the difference in cost was $346 (95% CI: $294-$398) per participant in Lower Middle Income Countries, $838 (95% CI: $781-$895) in Upper Middle Income Countries and $42 (95% CI:-$155 to $239) (cost-neutral) in High Income Countries. During the study period the CES-FDC pill was associated with incremental gain in quality-adjusted life years of 0.06 (95% CI: 0.04-0.08) resulting in an incremental cost-effectiveness ratio (ICER) of $5767 (95% CI: 5735-$5799), $13,937 (95% CI: $13,893-$14,041) and $700 (95% CI: $662-$738) respectively. In subgroups analyses, the highest 10 years CVD risk subgroup had ICERs of $2033, $7322 and-$6000/QALY. A FDC pill produced at CES costs is cost-neutral in HIC. Governments of LMI and UMI countries should assess these results based on the ICER threshold accepted in their own country and own specific health care priorities but should consider prioritizing this strategy for patients with high 10 years CVD risk as a first step. Population Health Research Institute.

Unveiling the influence of reproductive health on poverty: a cross-sectional study in Magwi County, South Sudan

Objective: To understand the relationship between household poverty and reproductive health characteristics in Magwi County, South Sudan. Background: Household poverty is a significant issue in many countries, including South Sudan. Poverty has been identified as a major obstacle to international development, affecting various aspects of development goals such as food security and health. Despite interventions by organizations like the World Bank, poverty rates in beneficiary countries like South Sudan have not seen significant reductions, suggesting the presence of predictors of poverty from behavioral, structural, and political origins. Methods: The study was conducted using an analytical cross-sectional survey design. The study targeted female and male spouses in households and employed a multistage sampling approach to select participants. Result: The results of the study revealed that the level of household poverty in Magwi County was 42%. The prevalence of household poverty was found to be influenced by reproductive health characteristics. The use of short-acting contraception by women was associated with a higher prevalence of poverty, whereas women who had ever aborted a pregnancy had a lower prevalence of poverty. Unintended pregnancy and inconsistent condom use by men were also associated with higher poverty rates, whereas men with only one sexual partner had lower poverty rates. Conclusion: This study provides valuable insights into the relationship between household reproductive health characteristics and poverty in Magwi County, South Sudan. It emphasizes the need for comprehensive approaches that address both behavioral and structural factors to effectively reduce poverty and improve development outcomes.

Drivers of hospital nurse practitioner turnover: A national sample survey analysis

BackgroundHospital nurse practitioner (NP) turnover is costly and complex. PurposeProvide a pre-COVID-19 pandemic baseline of hospital NP turnover. MethodsA secondary analysis of NSSRN18 data on 6,558 (67,863 weighted) NPs employed in hospitals on 12/31/2017. We describe rates of turnover, intention to leave, and reasons for leaving or staying. Using multivariate logistic regression, we examine the association between individual and organizational characteristics and turnover. Survey weights and jackknife standard errors were applied to analyses. DiscussionApproximately 10% of NPs left their job the following year, and 53% of NPs that remained considered leaving at some point. The top reasons cited for leaving or staying were largely organizational factors. Regression analysis revealed not practicing to one’s fullest scope, lower income, lack team-based care, and non-white race were associated with an increased likelihood to leave. ConclusionWe find several modifiable factors associated with hospital NP turnover that can be used to tailor recruitment and retention strategies.

Determinants of Income Composition Inequality

A rich literature examines the determinants of income inequality. Less is known about the distribution of income composition, or the extent to which different socio-economic groups hold different sources of income. This article explores the drivers of income composition inequality (ICI). Contrary to recent studies, which show that the composition of government has ceased to shape redistribution and income inequality dynamics, this article posits that left-wing parties are associated with lower income composition inequality. We test this expectation with data from thirty European countries between 2003 and 2017. Our results suggest that the polarization between capital and labor income holders declines under left-wing governments. We establish that this is mainly because left-wing parties seek to broaden access to capital income.

The Cointegration Between Energy Subsidy and Energy Accessibility in Eastern Africa Countries

Despite the significant potential, the energy industry in East Africa remains largely underdeveloped, with minimal modern energy access, low per capita consumption, and heavy reliance on biomass energy, which makes up over 90% of the region’s energy consumption. Less than 1% of rural areas have access to electricity. Introduction of subsidies on energy influences energy accessibility. The study found it clear that subsidies slightly improved energy accessibility in Eastern African countries in the long run. This can be explained by the fact that energy subsidies often result in lower prices for energy consumers. This makes energy more affordable for households, particularly those with lower incomes. Lower energy prices reduce the financial burden of meeting energy needs, making it easier for individuals and families to access essential energy services such as electricity, heating, and cooking. Lower energy prices due to subsidies can lead to increased energy consumption. It is therefore the responsibility of each member state to encourage the adoption of renewable energy sources by providing subsidies and incentives for renewable energy technologies such as solar panels, wind turbines, and energy-efficient appliances. Subsidizing renewable energy reduces reliance on fossil fuels, mitigates environmental impacts, and promotes sustainable energy practices.

Carboxymethyl chitosan-methacrylic acid gelatin hydrogel for wound healing and vascular regeneration

At present, wound dressings in clinical applications are primarily used for superficial skin wounds. However, these dressings have significant limitations, including poor biocompatibility and limited ability to promote wound healing. To address the issue, this study used aldehyde polyethylene glycol as the cross-linking agent to design a carboxymethyl chitosan-methacrylic acid gelatin hydrogel with enhanced biocompatibility, which can promote wound healing and angiogenesis. The CSDG hydrogel exhibits acid sensitivity, with a swelling ratio of up to 300%. Additionally, it exhibited excellent resistance to external stress, withstanding pressures of up to 160 kPa and self-deformation of 80%. Compared to commercially available chitosan wound gels, the CSDG hydrogel demonstrates excellent biocompatibility, antibacterial properties, and hemostatic ability. Both in vitro and in vivo results showed that the CSDG hydrogel accelerated blood vessel regeneration by upregulating the expression of CD31, IL-6, FGF, and VEGF, thereby promoting rapid healing of wounds. In conclusion, this study successfully prepared the CSDG hydrogel wound dressings, providing a new approach and method for the development of hydrogel dressings based on natural macromolecules.

To renovate or build with wood? Results from Finnish citizen survey data

Finland shows strong support for reducing its climate footprint originating from the built environment as part of the national carbon neutrality goal by 2035. Two prime examples are increasing wood use in construction and favoring building renovation to alleviate emissions from the use of virgin construction materials. However, the open question remains whether citizens also support these decarbonization pathways. By using national-level data from a randomly sampled citizen survey in Finland (n = 1448), we model citizen preferences to these two decarbonization pathways. The results suggest that a preference to renovate rather than to build anew is shown by respondents of the female gender; over 55 years of age; with a lower household equivalent income; and possessing housing property investment. Wood material is positively favored by respondents with higher age; a lower household equivalent income; living in smaller population centers in the countryside; and owning forestland. Interestingly, the effect of climate agency was negative in both models. This can be interpreted in the wood material case as reflecting conflicting views of negative environmental effects from forest harvesting to produce renewable building materials. In the renovation model case, we argue that the climatic impact of renovations remain weakly understood by citizens in Finland, given that the media and national regulations emphasize operational emissions. These results benefit both policy makers and municipal-level decision making in understanding of acceptability of wood material use and building retrofits among the general public.

Exploring Activity Interests of Older People with Low-Income

ABSTRACT Older people living on low incomes may experience inequitable access to activities they find interesting because they may live in homes with even fewer resources and may not be able to afford to participate in the activities they enjoy. The aim of this study was to explore the interests of older people living on low incomes living in residential homes. We used a cross-sectional analytic study design and the Interest Checklist to investigate the activity interests of 82 older people with low incomes in 9 residential homes in Cape Town, South Africa. Findings revealed 27 activities they were most interested in, within five categories: musical, everyday, social, free time, and religious or cultural activities. There were few statistically significant differences between men and women, or between residents with different levels of independence. Understanding the interests of older people with low incomes is a first step toward creating opportunities for participation, and growing well-developed individual interests.

Factors Associated with Head and Neck Cancer Postoperative Radiotherapy Delays: A Systematic Review and Meta-analysis.

Initiating postoperative radiotherapy (PORT) within 6 weeks of surgery for head and neck squamous cell carcinoma (HNSCC) is included in the National Comprehensive Cancer Network Clincal Practice Guidelines and is a Commission on Cancer quality metric. Factors associated with delays in starting PORT have not been systematically described nor synthesized. PubMed, Scopus, and CINAHL. We included studies describing demographic characteristics, clinical factors, or social determinants of health associated with PORT delay (>6 weeks) in patients with HNSCC treated in the United States after 2003. Meta-analysis of odds ratios (ORs) was performed on nonoverlapping datasets. Of 716 unique abstracts reviewed, 21 studies were included in the systematic review and 15 in the meta-analysis. Study sample size ranged from 19 to 60,776 patients. In the meta-analysis, factors associated with PORT delay included black race (OR, 1.46, 95% confidence interval [CI]: 1.28-1.67), Hispanic ethnicity (OR, 1.37, 95% CI, 1.17-1.60), Medicaid or no health insurance (OR, 2.01, 95% CI, 1.90-2.13), lower income (OR, 1.38, 95% CI, 1.20-1.59), postoperative admission >7 days (OR, 2.92, 95% CI, 2.31-3.67), and 30-day hospital readmission (OR, 1.37, 95% CI, 1.29-1.47). Patients at greatest risk for a delay in initiating guideline-adherent PORT include those who are from minoritized communities, of lower socioeconomic status, and experience postoperative challenges. These findings provide the foundational evidence needed to deliver targeted interventions to enhance equity and quality in HNSCC care delivery.

Artificial intelligence utilization in the healthcare setting: perceptions of the public in the UAE

ABSTRACT Understanding the use of AI in healthcare is essential for the successful implementation of AI-driven healthcare solutions. The aim of this study was to evaluate public perception of AI utilization in healthcare settings. A validated questionnaire assessed general perceptions towards AI utilization, the use of AI by physician , and the use of AI by pharmacists . The study included 770 participants. The median perception score indicated an unfavorable attitude. Participants who had lower education level and those with no employment had a significantly lower perception scores than their counterpart. Participants who reported low income and those who visited the pharmacy five to ten times on average had a higher perception than their counterparts did. The reported negative perception necessitates the implementation of education campaigns to improve AI literacy and dispel any misconceptions and concerns, particularly among individuals with low education, high income, unemployment, and frequent pharmacy visits.

Impact of neighborhood disadvantage on posttrauma outcomes after sexual assault.

In the United States, 8,000,000 people seek emergency care for traumatic injury annually. Motor vehicle collisions (MVCs) and sexual assault are two common sources of trauma, with evidence that reduced neighborhood-level socioeconomic characteristics increase posttraumatic pain and stress after an MVC. We evaluated whether neighborhood disadvantage was also associated with physical and mental posttrauma outcomes after sexual assault in a sample of adult women (N = 656) who presented for emergency care at facilities in the United States following sexual assault and were followed for 1 year. Neighborhood characteristics were assessed via the Area Deprivation Index, and self-reported pain, anxiety, depression, and posttraumatic stress disorder (PTSD) symptoms were collected at 6 weeks posttrauma. Adjusted log-binomial regression models examined the association between each clinical outcome and neighborhood disadvantage. Women in more disadvantaged neighborhoods were more likely to be non-White and have lower annual incomes. At 6 weeks posttrauma, the prevalence of clinically significant pain, anxiety, and depressive symptoms more than doubled from baseline (41.7% vs.18.8%,62.4% vs.23.9%, and 55.2% vs.22.7%, respectively); 40.7% of women also reported PTSD symptoms. Black, Hispanic, and lower-income participants were more likely to report pre- and postassault pain, anxiety, and depression. After adjusting for race, ethnicity, and income, no significant association existed between neighborhood disadvantage and any outcome, ps =.197 -.859. Although neighborhood disadvantage was not associated with posttrauma outcomes, these findings highlight the need for continued research in diverse populations at high risk of adverse physical and mental health symptoms following sexual assault.

Gender-transformative school-based sexual health intervention: study protocol for a randomized controlled trial

BackgroundThere is general agreement that sexuality is a central aspect of human development; it is key in sexual health and reproductive education during adolescence. However, in spite of the existing interventions on this topic and the evidence generated, the inclusion of a gender focus in sexuality is relatively recent and there is little evidence available, thus structured and corroborated interventions with a gender-transforming perspective in sexuality are required.MethodsWe will use a mixed method experimental design with a parallel cluster-randomized trial (GRTs) that will evaluate the effectiveness of a comprehensive gender-transformative intervention of sexual education (ENFOCATE -Focus-on-), which will be complemented with qualitative studies to understand the implementation process. The participants will be 609 10th and 11th-grade students. The randomization will be by grade, and the data will be collected at three moments (pre-intervention, post-intervention, and a 3-month follow-up).DiscussionComprehensive, gender-focused, and culturally pertinent interventions in sexuality are needed for adolescents of countries with high, middle, and low incomes. These produce better results in terms of sexual health, and including a gender-transformative focus contributes to equity in health. Focus-on is unique since it uses a comprehensive gender-transformative intervention in sexual education that will allow putting into practice a program based both on international evidence and that which arises from the object population. It also uses a culturally-sensitive focus, since it is designed based on the characteristics of the object population; it will allow adapting some activities to the needs of the context in which it is developed.Trial registrationThe study was prospectively registered on June 6, 2023, at ClinicalTrials.gov ID: NCT05896540. Protocol version number 1.0. May 22, 2023.

Usability of the Japanese Late-Stage Elderly Questionnaire for screening major depression.

Older adults with major depression are at risk of frailty and long-term care needs. Consequently, screening for major depression is imperative to prevent such risks. In Japan, the Late-Stage Elderly Questionnaire was developed to evaluate older adults' holistic health, including mental well-being. It comprises one specific question to gauge life satisfaction, but the effectiveness of this question to screen for major depression remains unclear. Therefore, we aimed to assess the usability of this question to screen for major depression. This retrospective cohort study used a large, commercially available claims database in Japan. Participants were older adults aged ≥75 years who completed the Late-Stage Elderly Questionnaire and were classified with and without new major depression within 1 year. We evaluated the questionnaire's ability to screen for major depression using C-statistics, developing three models to assess the cut-off value based on responses to the life satisfaction question ('Satisfied', 'Somewhat satisfied', 'Somewhat unsatisfied', or 'Unsatisfied'), estimating the sensitivity and specificity of each model. Among 11 117 older adults, 77 newly experienced major depression within 1 year. The C-statistic for screening major depression was 0.587. The model setting the cut-off between 'Somewhat unsatisfied' and 'Unsatisfied' the demonstrated lowest sensitivity and highest specificity, while the model setting the cut-off between 'Satisfied' and 'Somewhat satisfied' demonstrated highest sensitivity and lowest specificity. Our results suggest that due to its poor screening ability and high rate of false negatives, the question assessing life satisfaction in the Late-Stage Elderly Questionnaire may not be useful for screening major depression in older adults and may require modification.

Income mobility and crime: a hierarchical cluster analysis on principal components for 27 OECD countries

PurposeThe aim of this paper is to investigate the linkages between intergenerational income mobility and crime for 27 OECD countries, considering different types of crime, family ties, enforcement, in terms of punishment rate and perceived quality of the legal system, redistributive outcomes and government expenditure.Design/methodology/approachUsing the Global Database of Intergenerational Mobility (GDIM), the empirical analysis is conducted by coupling the principal components analysis with the hierarchical clustering. The variance tests verify the robustness of the clusters.FindingsIncome mobility is higher in those countries where there is high public investment devoted to education and high perception of rule of law to buffer the adverse effects of crime on income mobility. The redistributive policies must be oriented to better the wealth distribution and not only income equality opportunity to decrease crime and to increase income mobility. A plausible existence of “hidden” income mobility emerges from the linkages between income mobility and frauds.Social implicationsMore redistributive policies for education, income and wealth equality should be applied in those countries with low income mobility and high violent crime rates; higher punishment rates should be applied to reduce the rates of thefts and frauds in high income mobility countries.Originality/valueThe main contribution is the identification of what type of crime leads to downward income mobility, as well as the role of perceived quality of the legal system, government and family ties in the association between income mobility and crime, suggesting also the potential existence of “hidden” income mobility.Peer reviewThe peer review history for this article is available at: https://publons.com/publon/10.1108/IJSE-07-2023-0520

Maternal pre-pregnancy body mass index and related factors: A cross-sectional analysis from the Japan Environment and Children's Study.

Socioeconomic status and smoking are reportedly associated with underweight and obesity; however, their associations among pregnant women are unknown. This study aimed to investigate whether socioeconomic factors, namely educational attainment, household income, marital status, and employment status, were associated with pre-pregnancy body mass index (BMI) categories, including severe-moderate underweight (BMI ≤ 16.9 kg/m2), mild underweight (BMI, 17.0-18.4 kg/m2), overweight (BMI, 25.0-29.9 kg/m2), and obese (BMI ≥ 30.0 kg/m2) among Japanese pregnant women using data from the Japan Environment and Children's Study (JECS). In total, pregnant women were included 96,751. Age- and parity-adjusted multivariable multinomial logistic regression analyses assessed socioeconomic factors and smoking associations with falling within abnormal BMI categories (normal BMI as the reference group). Lower education and lower household were associated with overweight and obesity, and, especially, lowest education and household income had relatively higher point estimate relative ratios (RRs) of 3.97 and 2.84, respectively. Regarding the risks for underweight, however, only junior high school education had a significantly higher RR for severely to moderately underweight. Regarding occupational status, homemakers or the unemployed had a higher RR for severe-moderate underweight, overweight, and obesity. Unmarried, divorced, or bereaved women had significantly higher RRs for mildly underweight status. Quitting smoking early in pregnancy/still smoking had higher RRs for all four not having normal BMI outcomes; however, quitting smoking before pregnancy had a higher RR only for obese individuals. Lower educational attainment and smoking are essential intervention targets for obesity and severe-moderate underweight prevention in younger women. Lower household income is also a necessary target for obesity.

Investigation of geographic disparities of diabetes-related hospitalizations in Florida using flexible spatial scan statistics: An ecological study.

Hospitalizations due to diabetes complications are potentially preventable with effective management of the condition in the outpatient setting. Diabetes-related hospitalization (DRH) rates can provide valuable information about access, utilization, and efficacy of healthcare services. However, little is known about the local geographic distribution of DRH rates in Florida. Therefore, the objectives of this study were to investigate the geographic distribution of DRH rates at the ZIP code tabulation area (ZCTA) level in Florida, identify significant local clusters of high hospitalization rates, and describe characteristics of ZCTAs within the observed spatial clusters. Hospital discharge data from 2016 to 2019 were obtained from the Florida Agency for Health Care Administration through a Data Use Agreement with the Florida Department of Health. Raw and spatial empirical Bayes smoothed DRH rates were computed at the ZCTA level. High-rate DRH clusters were identified using Tango's flexible spatial scan statistic. Choropleth maps were used to display smoothed DRH rates and significant high-rate spatial clusters. Demographic, socioeconomic, and healthcare-related characteristics of cluster and non-cluster ZCTAs were compared using the Wilcoxon rank sum test for continuous variables and Chi-square test for categorical variables. There was a total of 554,133 diabetes-related hospitalizations during the study period. The statewide DRH rate was 8.5 per 1,000 person-years, but smoothed rates at the ZCTA level ranged from 0 to 101.9. A total of 24 significant high-rate spatial clusters were identified. High-rate clusters had a higher percentage of rural ZCTAs (60.9%) than non-cluster ZCTAs (41.8%). The median percent of non-Hispanic Black residents was significantly (p < 0.0001) higher in cluster ZCTAs than in non-cluster ZCTAs. Populations of cluster ZCTAs also had significantly (p < 0.0001) lower median income and educational attainment, and higher levels of unemployment and poverty compared to the rest of the state. In addition, median percent of the population with health insurance coverage and number of primary care physicians per capita were significantly (p < 0.0001) lower in cluster ZCTAs than in non-cluster ZCTAs. This study identified geographic disparities of DRH rates at the ZCTA level in Florida. The identification of high-rate DRH clusters provides useful information to guide resource allocation such that communities with the highest burdens are prioritized to reduce the observed disparities. Future research will investigate determinants of hospitalization rates to inform public health planning, resource allocation and interventions.

Is the Workload Indicators of Staffing Needs (WISN) method rigorous enough to tell us how many nurses we need in a general hospital?

ABSTRACT This study aimed to evaluate the practical use of the Workload Indicators of Staffing Needs (WISN) method in a general hospital in Iran. This method was used to determine the staffing needs of nurses in various hospital units, and the study examined the gap between the theoretical calculations and the actual use of the data in the hospital. Data was collected through a mixed-method approach including observations, interviews, and document analysis. The results showed that the WISN method indicated a surplus of nursing staff and no work pressure on nurses. However, the method did not account for the complexity of nurses managing multiple tasks simultaneously, and the low bed occupancy and low hospital revenue raised concerns about the excess of nurses obtained by the WISN method. The study suggests that decision-making on staff arrangements should not be solely based on WISN's numbers, and modalities of nursing care should also be considered. While the WISN method is important in determining nurse workload, it must be used with other factors to ensure the standard of patient care is not compromised. This study contributes to the understanding of the practical use of the WISN method in the context of Iran's healthcare system.

Spatial inequality in the accessibility of healthcare services in the Philippines

Ensuring equitable access to healthcare is important for universal health coverage (UHC). Using the enhanced two-step floating catchment area (E2SFCA) method, we found disparities in the spatial accessibility of outpatient and inpatient healthcare facilities in the Philippines, particularly in the central and southern regions of the country. Municipalities with a higher proportion of older people had better spatial accessibility to outpatient care, while municipalities with a higher density of older people had better accessibility to inpatient care. Municipalities with high poverty rates had better accessibility to outpatient care but poorer accessibility to inpatient care. Addressing these disparities is essential for achieving UHC in the Philippines.

Geographies and determinants of rent burden: A regional economic analysis of the U.S. metropolitan landscape

Rental housing affordability, a growing topic in interdisciplinary scholarship, remains relatively peripheral to geography and regional science. This article focuses on geographies of rent burden and factors affecting it at the metropolitan level in the conterminous U.S. By conducting cartographic and regression analyses, we examine relationships between rent burden and numerous related aspects derived from scholarly work. Besides offering a new measurement of rent burden, we put a special emphasis on regional economic specializations as potential predictors of rent burden’s intensity. The relationship between these two have not been studied in existing scholarship. Our results indicate that the most consistent determinants of more intense rent burden in numerous models include higher housing values and poverty rates, substantial shares of racial/ethnic minorities, and family structure represented by lower percent married. Regarding economic specializations, we find that manufacturing is a strong predictor of lower rent burden in most models, with its effect demonstrating an opposite direction—higher rent burden occurs in metropolises not specializing in manufacturing. Simultaneously, metropolises with substantial concentrations of employment in (i) education and medicine and (ii) arts, entertainment, and recreation exhibit higher rent burden and most of these metropolises are mid- and small-sized.