In addition to established bibliometric parameters, advanced analyses using market driver and scientific infrastructure values were carried out to provide deep insight into incentives, necessities, and barriers to international research.Unlike most other commodities, rare earth elements (REEs) are part of a wide range of applications needed for daily life all over the world. These applications range from cell phones to electric vehicles to wind turbines. They are often declared as part of “green technology” and, therefore, often called “green elements”. However, their production and use are not only useful but also risky to the environment and human health, as many studies have shown. Consequently, the range of global research efforts is broad and highly variable, and therefore difficult to capture and assess. Hence, this study aims to assess the global parameters of global research on REE in the context of environment and health (REEThe focus of REE research is in line with national aspirations, especially from the major global players, China and the USA. Whereas globally, regional research interests are related to market interests, as evidenced by the inclusion of drivers such as electric vehicles, wind turbines, and permanent magnets. The topics receiving the most attention are related to gadolinium used for magnetic resonance imaging and the use of ceria nanoparticles. Since both are used for medical purposes, the medical research areas are equally profiled and mainly addressed in high-income countries. Nevertheless, environmental issues are increasingly in focus.There is still a need for research that is independent and open-ended. For this, market-independent technologies, substitutes and recycling of REEs need to be addressed scientifically. The results of this study are relevant for all stakeholders, from individual scientists to planners to funders, to improve future research strategies in line with these research mandates. Entire daily lives are impacted by rare earth elements (REEs) as they are found in every car, computer, cell phone, television, and energy-efficient fluorescent light bulb, naming just the most common applications . This exInternational Union of Pure and Applied Chemistry (IUPAC), they form a homogenous group of 17 chemical elements forms the REEs, which show a coherent behavior [According to the behavior . In addibehavior . REEs arbehavior . Therefobehavior . HoweverREEs are highly reactive because they are very easily oxidized. Therefore, they are used as reducing agents for difficult to reduce metals . The excThe difficult separation of the elements remains a challenge to this day. Additionally, the eminently increasing use in technical devices raises concerns about the sustainability of REEs, which has stimulated numerous studies on the subject . This diThe increasing use of REEs for industrial applications implicates a corresponding increase in health and environmental impacts. As anthropogenic compounds, they enter soils and waters through disposal, discharges from mining operations, wastewater, and atmospheric emissions. Further dispersal in the environment occurs through wind blowing, runoff, leaching, or irrigation, releasing, for example, radioactivity or other chemical byproducts , 9. Its Adverse health effects on aquatic and terrestrial organisms have been already reported –14. Howeeh), as intended in the present study, is useful and important. Scientists can benefit from it to identify, plan, and expand current and future projects. Policymakers and funders can benefit by being able to support scientific efforts more specifically. Thus, the goal is to present the scientific basis on REEs in terms of their impact on the environment and human health by assessing general and advanced features of the research output. That will provide information on the drivers and barriers to the research conducted, as well as the incentives and requirements for future research, and identify and assess key player of global research on REEeh.Therefore, an analysis of the scientific landscape of REEs related to environmental and human health  could be retrieved from WoS.For the overall publication output on REEn = 6833). Only a few articles were published in other languages, e.g., Chinese (n = 32), German (n = 17), and Spanish (n = 16), to name those that contributed more than 15 articles.The majority of articles were written in English , the adverse effects of gadolinium as a contrast agent in magnetic resonance imaging, and accumulation processes in soil, plants, and water  increased similarly since the 1990s, reaching two major peaks in 2008  and 2015 . Afterward, a steep decline could be observed. The average annual citation rate (cr) emphasizes the year with high citation numbers and small publication volumes, leading to the peaks of 1978, 1987, and 1990  articles, measured by the ratio Articles / , shows the above-average growth of articles on REEeh , could be assigned to at least one country of origin. Of these, China and the USA are by far the most publishing countries at REEeh, with more than 1500 articles each . Germany follows in third place by a wide margin with n = 478. Ranks 4 and 5 were occupied by India (n = 444) and Japan (n = 345). Of note is Iran’s ranking of 11th with n = 225 and Russia’s ranking of 15th with n = 153 articles on REEeh  but had the 4th highest citation rate of countries with at least 30 articles on REEeh. Austria ranked first in citation rate (cr = 58.25), followed by Denmark (cr = 46.80), and Switzerland (cr = 42.94). The UK (cr = 42.62) is followed by the USA in 5th place (cr = 40.62) . This was followed by Germany , the UK c = 14,532), and France  , the US-American share among the top 10 countries decreased to 16.47%, while China’s share increased to 28.27% , only a few countries participated in REE27% Fig. . The pareh research. The USA, as the core country, has generated the most collaborations. They collaborated primarily with China (n = 133) and the UK (n = 74). However, joint work with Germany (n = 46) and Canada (n = 39) is also notable. In addition, the partnerships between China and Australia (n = 41) and Saudi Arabian and Indian researchers (n = 36) are worth mentioning , the most publishing European countries , and Japan (17.21%), the most frequently assigned area was Radiology, Nuclear Medicine & Medical Imaging. In India and China, this field landed in the last places of the top 10 research areas. Environmental sciences & Ecology was most represented in Canada (23.11%), followed by France (18.79%). However, this field also ranked second in Chinese REEeh research (19.59%). In Western countries and Japan, Cardiovascular System & Cardiology was the second most covered research area, while in China, India, and France, this area is rarely covered and falls to the last place of the top 10. The WoS category Materials Science was assigned most frequently in South Korean articles on REEeh and ranked second in China and India , the ranking was topped by Iran, followed by Portugal, Pakistan, Ukraine, and Romania. When calculating RRES , Switzerland ranked first, followed by Romania, Italy, Portugal, and Iran  .To determine the correlation between the number of articles on REEan) Fig.  were caleh are summarized in Table The institutions that mainly work on REEeh, a total of 6941 original articles indexed in WoS could be identified. They can be grouped according to the occurrence of keywords in some main topic areas, which are headed by the term “toxicity”. The first article on REEeh published in 1950 by Cochran et al. addressed the acute toxicity of some REEs and found that the general toxicity observed in rats was consistent with the similarity of the elements [For the publication output on REEelements . This stelements .eh. In 2008 and 2015, both years with major citation peaks, particularly high-cited articles were published, including the top-cited studies of Xia et al. on cerium oxide toxicity [The next study with a substantial number of citations (c = 420) was published in 1990. It examined the influence of thermodynamics on the toxicity of gadolinium complexes to increase their inherent safety . This putoxicity . This alIn the 1950s, the nuclear arms race gave impetus to REE production and research. The opening of mines in Russia, South Africa, and California (USA) in the early 1950s was caused by the rising value of REEs. The contrast-enhancing effects of gadolinium were discovered in the 1980s , which leh has been extremely high, leading to a citation peak in 2015 with two high-profile articles, Kanda et al. [After this year of high interest in the scientific community in 2008, the number of annual citations declined from 2009 to 2012, representing an apparent interim low point analogous to the declining depletion of REEs. At the same time, the number of publications continued to increase at a high level. In 2008, the share of Chinese articles was rather low compared to the years before or the steady increase after. This rise led China to overtake the USA in terms of the number of publications in 2013. Thus, it is to assume that the trend during this period is not due to an actual drop in citations, but more to the extremely high response in 2008, which was mainly due to the high proportion of US-American and German articles. Accordingly, China’s share of articles assigned to the subject area “Radiology, Nuclear Medicine & Medical Imaging” is small, while US-American and German research is primarily focused on this area. The trend, except for 2008, seems to be coherent. Since 2012, the growth of publications on REEa et al.  and McDoa et al. . Both arThe subsequent decline in citation numbers is due to the methodological phenomenon of the so-called cited half-life (CHL). This concept describes the estimated time it takes for a publication to reach 50% of its citations. For biomedical research, this period is assumed to be 7-8 years corresponding to the CHL . The citeh research is not surprising, as both countries have been competing for key positions in research performance in recent years [eh research in these countries. They focus on the health effects of gadolinium as a contrast agent.The high share held by Chinese and US-American REEnt years . The maint years . Russiannt years . BesidesIn comparison, China and India focus more on chemical and material topics. In China and Canada, environmental issues also receive high attention. For this, China, with the most production facilities, is clearly in the best position to study the hazardous effects of unregulated production. The results of these studies led to a rethink by Chinese authorities and the introduction of regulations and restrictions. So, China has shut down some small-scale mines and thinks about gentle mining procedures and the prevention of illegal mining through the Chinese consolidation strategy  to reduceh was only just above the analysis threshold of 30 articles. Grobner is a physician and specialist in internal medicine but not a high-profile scientist, having achieved only an h-index of 6 so far. Nevertheless, he set a milestone with his scientific observations in REEeh research.Regarding the ranking in terms of the citation rate, Austria is leading. With 1261 citations alone, the article by Thomas Grobner on the health risk of gadolinium  was respn = 44), which ranked second in terms of citation rate, also achieved this rank with research on the health effects of gadolinium, e.g., during pregnancy and lactation [Denmark , formerly Indian Rare Earth Limited [Among REE mining countries, also India is in the top 5 of the publication ranking. It is also leading when the national economic interest concerning the stock of electric vehicles is included in the comparison. India has a long tradition of REE mining, as the government established  Limited , back inLooking at other countries that mine REE and are ranked in the top 15 of the publication ranking, Brazil, has a long tradition of mining, as does Russia. The former USSR had long mined REEs with its mines in Kyrgyzstan . Scientieh research. In Madagascar and Burundi, mining only started in 2017 and 2018, respectively [eh research can be explained.Other mining countries, Myanmar, Madagascar, Vietnam, and Burundi play rather minor roles in REEIn addition to the influence of the countries’ mining status, the strong relationship between publication output and proxy values for market drivers  was demonstrated by significantly high correlation values.eh. It also ranks at the top when including interest in wind energy as measured by the number of national wind turbines. The Iranian government announced in early 2020 that it intends to industrialize the production of REEs [Iranian Society of Economic Geology [eh in Iran.In addition to these ratings, Iran tops the ranking when national research expenditures (GERD) are included in the evaluation of countries’ research performance in REE of REEs  – an eff Geology . Notably Geology , especia Geology . This deThus, the major publishing countries in absolute terms, the USA and China, fell behind when economic characteristics or the number of researchers per country were taken into account. As nations with the highest science funding and the highest number of researchers worldwide, this drop is not surprising when the ratio to publication output is calculated.eh. For example, studies have been conducted in the Tagus Estuary Nature Reserve, one of the most important wetlands in Europe, or in other water bodies to determine REE contamination as an indicator of anthropogenic activities. Another Portuguese research focus was the accumulation of REEs in the environment. It was investigated where the REEs come from, whether from near inactive chemical complexes, effluents from wastewater treatment, or lithogenic sources, as in a coastal lagoon near Aveiro. The University of Aveiro was the institution where most Portuguese research on REEeh has been conducted [Instead, Portugal ranked second in the GERD rankings after Iran. Environmental research is at the heart of Portuguese studies on REEonducted –48.eh publication is Pakistan. It ranks third in regard to the inclusion of GERD and first in the inclusion of the trade value of permanent magnets. Even after REE deposits were discovered in Pakistan, the government did not initially promote mining. The reason given was the lack of financial resources and technical expertise for exploitation, although the reserves were highly estimated. A shift in thinking in this regard began in 2010 and coincided with the start of REE research in Pakistan. But it was not until 2021 that Pakistani publications reached double digits for the first time, at a time when the government finally decided to exploit its REE reserves [Another country worth mentioning in terms of REEreserves .eh depend on economic factors on the one hand and interests and accessibility to data from mining sites on the other hand. The exploitation of REEs is still in the hands of a few countries, first and foremost China. Therefore, obtaining data is difficult for independent and open-ended research is difficult, which is necessary for research on the environmental and health risks of REE use and production. In addition, an independent and secure supply of REE must be maintained. Substitutes or reduction possibilities must be sought for the REEs applied, like those currently available are generally even less effective. New separation technologies for energy-saving processes must be sought. There is also a need for research in the area of recycling REE-containing equipment, as only a very small proportion is reused to date. All of these mandatory tasks represent an enormous challenge for future research that can only be met with networked expertise and resources on a global scale.Taking all these historical and regional aspects into account, it is clear that the research efforts on REENew Quality and Quantity Indices in Science (NewQIS) platform, which is an established methodology for assessing scientific performance under a variety of basic [This analysis is based on the methodological and technical principles developed by the of basic  and advaof basic . It combof basic .The metadata underlying the bibliometric analyses was taken from the Web of Science (WoS) Core Collection, one of the most representative and qualitative sources of bibliometric research.The data collection took place on 04-08-2022 and included all years from 1900 onwards.Title: “rare earth element*” OR “rare earth metal*” OR “tech metal*” OR “high-tech metal*” OR “cerium” OR “dysprosium” OR “erbium” OR “europium” OR “gadolinium” OR “holmium” OR “lanthanum” OR “lutetium” OR “neodymium” OR “praseodymium” OR “samarium” OR “terbium” OR “thulium” OR “ytterbium” OR “yttrium” OR “scandium” OR “lanthanid*” OR “lanthanoid*”.The search strategy included, first, a title search with the various denominations for REE and all elements declared as REE. Only the radioactive promethium was excluded from the search because it does not form stable isotopes and cannot be extracted from geological material because it occurs only in “infinitesimal” concentrations , 53.Titl2)Topic: “Risk*” OR “contamination*” OR “hazard*” OR “*toxicolog*” OR “*toxicit*” OR “adverse effect*” OR “negative effect*” OR “negative health effect*” OR “*toxic effect*” OR “ecological” OR “pollution*” OR “contaminant*” OR “pollutant*” OR “bioaccumulat*” OR “bio-accumulat*” OR “bioavailab*” OR “bio-availab*” OR “threat*” OR “ecology” OR “environmental impact*” OR “oxidative stress” OR “fibrosis” OR “fibrotic” OR “male sterility” OR “pneumoconiosis” OR “neurological disorder*” OR “anti-testicular effect*”Second, a combination of relevant terms describing human and environmental health effects of REEs was searched as a topic search in the title, abstract, and keywords. These terms were combined with the title search.Entries were filtered for original articles and then manually checked for representativeness. Subsequently, the term “price” had to be excluded from the search because it returned not thematically related entries. All metadata were transferred in a structured manner to an MS-Access database, which served as the basis for all analyses performed. Afterward, some data had to be manually standardized, such as the variations in the designation of affiliation, to unify them and thus make them suitable for further analysis.eh research worldwide. Relative parameters such as the characteristics of the scientific infrastructure and the main drivers of rare earth exploration were additionally used for an enhanced assessment. For this purpose, the number of researchers and the gross expenditure on research and development (GERD) [The analyses included absolute parameters such as annual publication parameters, the number of publications, the number of citations, the citation rate per country, and research institutions to identify the major players in REEt (GERD)  were uset (GERD) , the natt (GERD) , and thet (GERD)  were incThe main research areas were identified and analyzed for clustering using the VOSviewer application  and visuTo visualize the geographic results, DEMPs were applied to the national publication patterns. Using this algorithm, the world map is distorted according to the particular evaluation parameter by increasing the size of countries with high values and decreasing the size of countries with respective low values.Statistically, the relationship between national characteristics and the number of publications was calculated using linear regression and correlation analysis (Spearman).The results presented have to be considered in context to the limitations and strength of the methods applied. WoS has been recommended for bibliometric analyses in numerous studies and has proven its worth by not only providing citation information but also ensuring database quality through strict listing requirements , 60. HenThe search strategy also has some limitations. It must be taken into account that, in principle, not all existing publications can be found and integrated into the analyses. However, the strategy can be optimized to find the majority of related entries and the minimum of unrelated entries. To ensure the representativeness of the database generated in this way, the metadata found were additionally checked manually and on a random basis.


Scientific ideas on the human population tend to be rooted in a “slow demography” paradigm, which emphasizes an inertial, predictable, self‐contained view of population dynamics, mostly dependent on fertility and mortality. Yet, demography can also move fast. At the country level, it is crucial to empirically assess how fast demography moves by taking migratory movements into account, in addition to fertility and mortality. We discuss these ideas and present new estimates of the speed of population change, that is, country‐level population turnover rates, as well as the share of turnover due to migration, for all countries in the world with available data between 1990 and 2020. Population turnover is inversely related to population size and development, and migratory movements tend to become important factors in shaping demography for both small and highly developed countries. Longitudinally, we analyze annual turnover data for Italy and Germany, documenting the changing speed of population change over time and its determinants. Accepting the “fast and slow” demography perspective has several implications for science and policy, which we discuss. How do we make sense of human population change? Ideally, we start from a reliable snapshot of the present, based on solid data on the recent past and adequate knowledge about the more distant past. This information is used to understand the direction of population change and to feed future scenarios. Population data are organized in temporal scales that are considered to be appropriate according to the current scientific consensus: what temporal scale is appropriate might vary, also, within a subject. In meteorology, for instance, data are timed over decades and years or centuries, as well as over hours and minutes depending on the specific purpose of research and/or analysis. For instance, in weather forecasting, aggregating precipitation data at the hourly level implies higher information loss, as compared to the aggregation of air temperature data , including countries with relatively large populations. Furthermore, we document the changing speed of population change over time for two cases: Italy and Germany. We conclude that demography is both “fast and slow.” We discuss the implications of this emerging perspective, in terms of scientific and data challenges for population, as well as its interrelations with other dimensions of global and local change, including policy issues.In current scientific discourse, the inertial and slow nature of demography is epitomized by two paradigmatic and interrelated global‐level megatrends: the demographic transition and population aging. The demographic transition from high mortality and fertility to low mortality and fertility is the main lens through which we can generally make sense of population change Vallin . While dEssay, already juxtaposed the problems of fast population growth with the virtues of slow population growth , with a posttransitional “slow” world with low demographic turnover . Population turnover rates relate the total amount of flows (in and out) to the population of reference. While traditionally used in ecology , starting from its constituent components. For a given country j, within a specific time frame , and given estimates for the number of births Bj, the number of deaths Dj, and average population size (or person‐years lived) Pj, the  birth rate and the  death rate are respectively:First of all, let us introduce the simple, formal definition of a Ij and Ej, the  immigration rate and the  emigration rate are, respectively:Given the number of immigrants and emigrants, The PTR is then defined as:migration share of turnover (MST), which can be computed using either rates or absolute numbers, and is—by definition—between 0 and 100 percent:A fundamental indicator to characterize the nature of population change is the For a given population, in a specific period of time, the PTR summarizes the speed of population change using the basic flow rates of population dynamics. A major challenge in estimating country‐level PTRs is related to data quality and availability: while birth and death rates are widely available over time and space, reliably estimating data on immigration and emigration flows at the country level is difficult , while total flows from a country provide the number of emigrants Ej. For our main results, we select Abel–Cohen estimates based on the “demographic account pseudo Bayesian closed” method, which provides the largest correlation coefficient with “ground truth” validation sets for outmigration rates (0.44), and the second‐largest correlation coefficient for immigration rates (0.82). As a robustness check , we also produce estimates based on the “demographic account minimization closed” approach by Abel–Cohen. The latter approach provides the highest correlation with immigration rates in their validation exercise (0.84), but a substantially lower correlation with outmigration rates (0.30).At the global level, thanks to new bilateral migration flow estimates provided by Abel and Cohen , combineFederal Statistical Office, data between 1990 and 2020) and Italy  .At the national level, some statistical offices produce estimates of population flows that include immigration and emigration, also on an annual basis. For our case studies, we use official estimates provided by the national statistical institutes of Germany emergence of “fast” demography after the demographic transition, we need to give up the paradigmatic idea that population change tends to be self‐contained, inertial, and therefore exogenous to other factors. We must thus focus on factors that can influence population turnover in the short run: when the rate of change is fast, demography can also move fast.Fast population change might happen for several factors. First, the economy. Since Malthus first noted this connection, economic developments, including sudden recessions and crises, or booms, have affected key components of population change. Recent evidence confirms this link, for example, for fertility  for about two decades. The subsequent decline in emigration, linked with the significant fertility decline that eventually turned Italy into a “lowest‐low fertility” forerunner  on population turnover. In contrast, family policies and migration policies have been rather passive, one could say The case of another posttransitional, wealthy, and relatively large‐population country, epitomizes the impact of sudden political and policy changes on demography. Germany, with more than 83 million inhabitants in 2020, is the most populated country among the top 10 in terms of the HDI . During the period subsequent to German reunification (1990 onward), East Germany was significantly impacted by the fall of fertility and outmigration  population size and levels of development when analyzing countries at the global level and to political and economic factors for Italy and Germany. The role of migration in shaping the speed of population change has so far not received adequate attention, perhaps for the (endogenous) lack of systematic data on immigration and emigration flows, but also for the longer‐term perspective usually adopted in the “replacement migration” debate.In general, we can conclude that the currently prevalent “slow demography” perspective is misleading when applied as a general approach to the study of population change. This is especially true when one focuses on the country level (or below). Taking a “fast demography” perspective that complements the “slow” one is therefore crucial for the years ahead. This has important implications for science and policy—some of which are of a more speculative nature—which we now address.With regard to population science, the implications of a “fast and slow demography” perspective are multiple. First, demographic data collection needs to fully take the speed of population change into account, collecting more up‐to‐date and frequent information on stocks and flows at higher frequencies, as opposed to relying on more traditional snapshots such as population censuses, or surveys, spaced 10 years apart. We have new opportunities thanks to the digital revolution: more frequent information on population and enhanced methods for “nowcasting” the present using register data as well as digital footprints  has hidden the relevance of migratory flows for demography Rogers . While tThird, the practice of making long‐term population forecasts, which relies on the “slow demography” inertial idea, might mislead users, especially at the national level. While the acknowledgment of uncertainty can be made explicit in probabilistic population forecasts  needs to become more integrated with the factors interacting with demographic behavior. Second, institutions, both at the supranational and the country level, need to be aware that demography can change fast. Policymakers and experts advising them should acknowledge the uncertainty surrounding long‐term demographic scenarios, and the impact that they could have on population change, including in the short run. As an example of political uses of demographic scenarios, in the runup to the Brexit referendum (November 2015), the British Prime Minister David Cameron wrote a letter to the President of the European Commission Donald Tusk. The letter used long‐term population forecasts as a political argument (“we are forecast to become the most populous country in the EU by 2050”), but also referred to failures in shorter‐term forecasting regarding (“… the current very high level of population flows from within the European Union into the United Kingdom. These have been unplanned and are much higher than forecast”). Third, when designing population policies, as in the Italian and German cases, more emphasis needs to be devoted to migratory movements, also tackling population aging from a replacement migration perspective. Fast demography is less inertial than slow demography, and it matters.Figure A1. Country‐level annual Population Turnover Rates PTR (per 1000) (a), and Migration Share of Turnover MST (%) (b). 5‐year periods between 1990 and 2020Figure A2. Country‐level annual Population Turnover Rates PTR (per 1000) for 1990‐95 (a) and 2015‐20 (b), and Migration Share of Turnover MST (%) for 1990‐95 (c) and 2015‐20 (d), by country size. Loess smoothing and 95% confidence bandsFigure A3. Country‐level annual Population Turnover Rates PTR (per 1000) for 1990‐95 (a) and 2010‐15 (b), and Migration Share of Turnover MST (%) for 1990‐95 (c) and 2010‐15 (d), by Human Development Index , and education Figure A4. Country‐level annual PTR (per 1000) for 1990‐95 (a) and 2010‐15 (b), and MST 1990‐95 (c) and 2010‐15 (d), by Gross National Income (log) per capitaFigure A5. Country‐level annual PTR (per 1000) for 1990‐95 (a) and 2010‐15 (b), and MST 1990‐95 (c) and 2010‐15 (d), by expected years of schoolingFigure A6. Country‐level annual PTR (per 1000) for 1990‐95 (a) and 2010‐15 (b), and MST 1990‐95 (c) and 2010‐15 (d), by mean years of schooling. Loess smoothing and 95% confidence bandsClick here for additional data file.


Literature suggested that COVID-19 patients experienced hospitalization as a physically and psychologically stressful event, with the risk to develop post-traumatic stress symptoms. The study aimed to understand psychological experiences of COVID-19 survivors with severe complications during and after ICU hospitalization, and any relevant health consequences. From October 2020 to January 2021, a qualitative study was conducted in Italy via semi-structured interviews by phone or video call addressed to COVID-19 survivors, randomly enrolled among people who released their stories publicly on newspapers, television, or social media. Fifteen individuals (three women and twelve men with average age of 56.4 years) were interviewed. Four main themes emerged: (i) emotion of fear; (ii) isolation and loneliness; (iii) unawareness about the gravity of the situation as a protective factor; (iv) “Long COVID” as consequences of the disease on physical and psychological health. During hospitalization, 66.7% of participants had mild or moderate values of anxiety and depression. After discharge, 86.7% moved to normal values. The results suggest that long-COVID is an important problem to manage to improve patients’ quality of life. It is essential to guarantee a holistic take in charge starting before the discharge and continuing care after discharge in the community where they live. Coronavirus disease COVID-19) is caused by the SARS-CoV-2 virus, and it determines mild or moderate respiratory illness in most infected people 9 is caus,4. The lSince the beginning of the pandemic, the scientific evidence related to the psychological consequences has mainly focused on objectively measurable aspects related to the clinical sphere, such as panic disorder, anxiety, depression, and post-traumatic stress disorder, neglecting the subjective experiences and emotions which may affect the psychological well-being and quality of life of patients who survived severe complications of the disease in the ICU ,27,28.To the best of our knowledge, in Italy there are no qualitative studies exploring the feelings and the experiences of ICU survivors with severe complications from COVID-19. Indeed, these patients experienced suddenly severe clinical complications of a disease still unknown, at the time of the study. For this reason, the present study aims to understand the individual experiences  of survivors and to obtain relevant information about psychological experience during the ICU stay and any post-hospitalization consequences to be managed in order to encourage patient and family-centered models of care and to ensure organized, safe, and evidence-based action for future pandemics, thus minimizing negative feelings and contributing to the humanization of care.From October 2020 to January 2021, a qualitative study was conducted in Italy through the administration of a semi-structured interview to ICU survivors after severe complications due to SARS-CoV-2 virus infection . The research was carried out using Colaizzi’s phenomenological method , which fThe study participants were randomly identified in relation to their hospitalization experience that they had reported to journalists, on television, on social media. The recruitment of the sample, took place through searches from online newspapers, television, public pages of social networks in which the participants gave interviews or wrote their experiences about the hospitalization and the illness. When contact numbers or emails were not immediately available, secondary information  emerged from the news was used to deepen web searching and track down people’s phone numbers or email addresses to get in touch with them. A list of 30 potential participants was developed and people were approached by phone or by email to participate in the study. The inclusion criteria were: (1) to have been hospitalized in an ICU for severe conditions due to COVID-19; (2) to have spontaneously told their own experience to journalists, on television, on social media; (3) to freely consent to participating in the study.A semi-structured interview guide was developed by consulting and by adapting instruments from available scientific literature on the topic ,15,20 anAt the end of the interview, the Patient Health Questionnaire (PHQ-4)  was admiA total of 19 out of 30 persons answered the call for the research. Among them, four individuals refused to participate in the study. The final sample included 15 participants. After presentation of the purpose of the research, individual appointments were agreed with the participants and the methods for performing interviews  were proposed based on the participants’ preference. The researchers were available to answer to any doubts or clarifications about the project and methods.Interviews were audio-recorded and had an average duration of 30–40 min. They were always conducted by the same member of the research group. During the interviews, the researcher took written notes to keep track of the key points to be used for data analysis. The interviewer had a Master’s Degree in Nursing Sciences with experience in qualitative interviewing, and they worked within the COVID-19 department for assisting patients with SARS-CoV-2 infection. It was never necessary to interrupt any interview for clinical or other reasons. Participant recruitment and interviews concluded when all data were collected and no new information arrived .Participants were informed about the study aims and with prior informed verbal consent, they voluntarily chose to take part in the study and agreed to tape-record their narratives. Anonymous identification code (ID) with sequential number was used for each participant to preserve anonymity. This research complies with the Helsinki and the General Data Protection Regulation (EU) 2016/679 (GDPR). Participants were informed that anonymity would be guaranteed in compliance with the Italian Data Protection Law (Decree No. 196/2003) and their right to withdraw from the study at any time without adverse consequences was clarified.All interviews were verbatim transcribed by the interviewer. Slang expressions, variations in voice tone, and silences were reported in the transcripts to emphasize the experiences collected. In a first phase, all members of the research team (the authors of this paper) conducted the transcription analysis separately. Each researcher made a careful reading of each transcript and once they acquired a general sense of the data, each one extracted significant statements and main concepts emerged from the narratives. Any textual notes were written to describe any relevant concern to be discussed with the research group. At the end of this process, each researcher produced a list of some main themes. In a second phase, all the researchers met together and triangulated data by comparing and discussing the results and retracing all the previous steps. After this final discussion, the researchers identified the final main themes.To strengthen rigor and to minimize potential method bias, the researchers’ reflexivity with respect to their orientations and values was fostered to make them aware that personal and professional background could influence different stages of the research. However, the team was multidisciplinary with adequate expertise to perform the study and manage potential biases. To promote self-reflexivity, field notes with reflections by the interviewer were also discussed and commented with the team during the data analysis, and audits were performed among the team members during the phases of the study.Quantitative data from PHQ-4 were analyzed in the form of frequencies (n) and percentages, and by analyzing questionnaire scores based on Kroenke et al.’s indications .A total of 15 individuals residing in Italy, aged from 38 to 75 years (average age: 56.4 years) represented the study sample. Men (80%) represented most of the study sample. Among them, six aged <50 years, with three women ranged between 63 and 75 years old. Among men, four worked as freelancers, six as employees, and two were retired. Among women, two were housewives and one was retired. Six participants came from Lombardy, a Northern Italy region that recorded the highest percentage of infection cases and hospitalization for severe complications in the first phase of the pandemic. The other nine participants came from regions of Central and Southern Italy, and Islands. Twelve of fifteen (80%) were hospitalized in ICU at the start of the pandemic and three participants were admitted by October 2020. Eleven individuals (73.3%) underwent endotracheal intubation and five of them were also tracheotomized (33.3%) with consequent prolongation of the hospitalization in almost all the cases . ClinicaThe analysis of the interviews identified four main themes related to the participant’s experience about ICU hospitalization and the post-discharge period: (i) emotion of fear (split in two sub-themes); (ii) isolation and loneliness; (iii) unawareness about the gravity of the situation as a protective factor; (iv) “Long COVID”: consequences of the disease on health .The emotion mostly reported by participants was the fear related to not being able to overcome the disease and the fear of dying. This emotion was also related to the breathing difficulty that was a complication of the disease, thoughts about not being able to see their loved ones again, and the fear of getting sick again. The theme, given the different facets, was split into two sub-themes: fear for one’s own life and fear about getting sick again (and about the risk of contagion for one’s own family).For the participants, the fear for one’s own life meant concern for losing their usual life and for not being able to return to their loved ones.ID7: “the greatest fear was when I got into the ambulance and I thought to my daughter who greeted me from the window saying “Hi dad, I love you”. It was the worst moment, the fear for not coming back home”.ID9: “the fear for dying, and the fear for not being able to come back my house even for one day… I remember this fear as a daily fear”.The fear for one’s own life was already real at the time of hospitalization. The participants expressed concern for not being able to overcome the situation with an explicit fear of dying.ID6: “the first day [of hospitalization] I thought I was going to die. I remembered my whole life and I thought «ok that’s what happened, I am 57 years old and I have already done many things in my life”.ID15: “fear for failing, I also saw two people die next to me, so the fear of ending up the same was strong”.ID11: “let’s face it, I saw as a coffin and someone waiting for me”.The fear of dying emerged even in moments of high emotional tension such as the need for endotracheal intubation was communicated and during the ICU stay, as told by some interviewees:ID14: “I remember the fear given by the breathing difficulty, fear and panic… and in the end, they [doctors] intubated me (…). After waking up it seemed that the worst was over, but for me, it was not really like this, I always continued to have anxiety and fear to die”.ID4: “I was very scared, I immediately asked which possibilities I had [with endotracheal intubation]. I was really very afraid, and the greatest fear was to not being able to come back home to my loved ones, afraid to die and not waking up”.ID15: “the head physician informed me that I needed to be intubated. I would say that I felt terror, I didn’t know what I was getting into (…)”.Other forms of fear that emerged by participants’ stories were the fear of having infected their loved ones  and the risk of their loved ones getting infected :ID4: “one of the biggest fears that never left me was the fear of having transmitted the infection to someone at home”.ID 11 “(…) Now that the numbers [of infections] are always growing I do not deny that it makes me worry, especially for my grandchildren and the people around me … and this fear I’m only having right now”.As emerged from the words of two interviewees, together with the fear of contagion of one’s own family, the fear of getting sick again and still being sick was experienced after hospital discharge:ID8: “(…) to date I am also afraid to infect me again, just afraid of taking it back and reliving everything I have already been through”.ID13 “(…) When you see such things the fear is still there, since I was discharged I have never had a great social life (…)”.The interviews experienced the feeling of fear in a close connection with that of loneliness due to the impossibility of seeing loved ones, as told by some interviewees:ID3: (…) well, what could I say … that I was alone, that yes, I suffered loneliness”.ID7: “I feared loneliness a lot and when a person is alone s/he knows s/he can’t do much, at that moment I raised my hands and said to myself «I know it’s done»”.ID11: “loneliness seemed an insurmountable thing, thinking about it today I don’t know how I could do it (…). The loneliness was always there, but luckily it was dampened by those wonderful characters [the health care workers] who surrounded me”.The participants said that the fear of being alone was accentuated by the isolation experienced in the hospital and by the consequent inability to be close to loved ones.ID6: “There were a few moments where I felt anxious. For example, the lack of contact with people, we were many [hospitalized patients] but perhaps the isolation [from loved ones] made us feel even more alone”.ID12: “Another thing that I experienced really badly was that we were alone because there were single rooms, it happened that there was not always someone inside, I always asked the nurses what time it was and when it was evening I couldn’t wait to asking for something to sleep, so I could spend some time without thinking I was alone”.ID13: “I was afraid of being alone, of loneliness… just the fear for not being accompanied, for dying and not having anyone close to, none of the loved one I shared my life with”.Loneliness was also described as a source of stress and anxiety. Being alone, the need to respect physical distances, and strict mandatory care rules for the prevention of the infection led patients to living isolation in a much more stressful way, regardless of the worry for their health condition, as revealed by three interviewees:ID4: “(…) the greatest stress was loneliness, being alone when there were no nurses. It was very stressful to me being alone… we had no one close to”.ID11: “I was alone, I had no company. I had no one, loneliness was the real stress. I wished someone who could stay with me longer, but I understood that it was not possible, I suffered from not having someone to chat with, I missed people, the contact, chatting…”.ID12: “I remember as if it were yesterday, a day when I burst into tears [with a doctor] (…), but I immediately I said «doctor, it’s not the cure that making me a nervous wreck, because I feel that it [the cure] is going well, but I react like this because I am alone, the fact of not having company makes me very sad”.Fear is contrasted with an unawareness of the gravity of the experienced situation. The lack of a concrete perception of the severity of the clinical condition emerged for some circumstances of ICU hospitalization. However, it represented an important aspect that was defined by the interviewees as a positive element.ID5: “(…) I couldn’t quantify how long I was wide-awake after the coma, perhaps this lack of perception, somehow, saved me”.ID13: “(…) I don’t remember much of those days in ICU, maybe on the one hand it went better this way… I didn’t realize the gravity of the situation… I would have died of fear (…). On the other hand, I thank a bit the drugs and my freaking out that kept my thoughts away from reality.ID11: “It seems like as I didn’t have an inkling of what happened to me. I had an inkling that something wasn’t right, but it was as if I had my ears plugged towards what was happening”.Unawareness of the situation contributed to reducing the perception of the dramatic situation, which countered negative emotions, preventing them from taking over, as emerged from the words of some interviewees.ID1: “I didn’t know what was going on (…), I didn’t think I was going to die (…), I was never afraid of dying”.ID7: “(…) there were some days, like those after the coma, where I had no conscience, and maybe that helped me to don’t let me go to bad emotions and feelings”.ID6: “Everything was so fast and maybe I didn’t become aware of the gravity of what was happening to me. I don’t think I was afraid at that moment [before endotracheal intubation]”.The interviewees reported feeling good at the time of the interview, but they listed a number of health problems still present after discharge. Consequences included both a mental dimension and a physical component .Regarding physical problems, they involve a variety of organs and systems, but the most common consequence included bone, lower limbs, and muscles problems, as evidenced by the words of three interviewees.ID5: “today I am certainly fine compared to before, but I have problems with my ankles, toes, fingers, and mainly at the bone level (…)”.ID9: “COVID has left me with pathologies, mainly to my bones and muscles (…)”.ID11: “(…) I can’t close my hands (…). I can no longer handle the big toe of my right foot; I cannot drive for a year. I have mobility problems, I’ve ruined my hips, when someone sees me walking s/he understands, it’s really hard walking for me”.In addition, among the problems about the physical level, the participants also reported breathing problems and fatigue:ID7: “I’m fine now, but COVID has left me with respiratory problems, dyspnea and I feel pressure on my chest (…)”ID5: “fatigue is always latent and I’m realizing that I no longer have the strength of before (…), I struggle to sing, I’ve never recovered my diaphragmatic breathing”.ID15: “(…) if I go up the stairs I am a bit out of breath, or maybe when I have to manage bad days, when I feel profound tiredness”.Again, the interviewees said they have numbness of some parts of the body and difficulty in moving:ID6: “I have a deficit in the external popliteal sciatic nerve to both feet, a nerve injury and the left thigh still looks like it is under anesthesia”.ID9: “(…) a circulation problem has arisen in the lower limbs (…). I have a sense of paresis in my feet and legs, my limbs are always cold and I feel electric discharges, as if needles”.ID14: “(…) neurological problems in the lower limbs, I feel as if they are passing inside the shocks, it seems to feel the electric current”.In relation to the mental dimension, the interviewees reported problems related to anxiety and memory, as emerged from the words of two interviewees:ID14: “What I am left is definitely anxiety (…)”.ID13: “I have problems (…) with my head. Besides anxiety I have many memory lapses, holes, and difficulties in remembering some things that happened a few hours before”.From the stories that emerged, participants also benefited from psychological or pharmacological support to deal with mental health problems:ID12: “I’m fine now but mostly on a psychological level I have problems. I always take the sleeping pill and also the psyche pills”.ID15: “I am not as I was before the hospitalization, but thanks to psychotherapy I am learning to look back as well as forward (…)”.Results from the PHQ show that during hospitalization, 10 of 15 participants (66.7%) had mild or moderate depression and anxiety symptoms. After discharge, 13 of 15 participants (86.7%) moved to normal values of patient health. Nobody presented severe symptoms in both hospitalization and after discharge .n = 8) of participants had anxiety and depression mild values referred to hospitalization and moved to normal values after discharge, one participant (6.7%) moved from moderate to mild values and 40% (n = 6) of participants remained unvaried on normal or mild values of anxiety and depression.This study investigated the experiences and the emotions of COVID-19 survivors who were hospitalized in ICU. Previous studies explored the emotions of patients hospitalized for SARS-CoV-2 infection ,15,32, bAn interesting aspect that emerged from the interviewees’ stories was their unawareness of the gravity of the experienced situation, which is opposed to the negative feelings experienced by survivors. In effect, many interviewees reported the lack of a concrete perception of criticality of their clinical condition during hospitalization, an aspect defined by themselves as a positive element. Unawareness would therefore represent a protective factor that attenuates the perception of the drama of the lived experience, thus preventing negative emotions from taking over.However, some interviewees who did not remember anything about the lived experience said that they would have liked to remember to allow them a better awareness of what happened. This aspect is in line with the results of Mongodi et al.  in whichThe most important contribution of this study is the relevance about the long-COVID problem. This aspect emerged from the interviews, and it is unique to COVID-19 for all hospitalized patients. It refers to post-discharge complications and the long-term effects of the disease. The interviewees reported negative consequences affecting different body districts and the psychic sphere. Although they reported an improvement in their health condition if compared to the hospitalization period, the participants reported that they still had fatigue, dyspnea, wheezing, depression, insomnia, and memory impairment in some cases. The World Health Organization considered these symptoms as common after the illness, and they usually had an impact on quality of life . FurtherRegarding quantitative results from the PHQ, the majority of participants had mild or moderate values of anxiety and depression referred to the hospitalization period and then changed to normal values after discharge. Nobody presented severe mental health symptoms in both hospitalization and after discharge. These results suggest that feelings of anxiety and depression seems to be more related to the experience of uncertainty and isolation due to hospitalization, and once patients return to their personal life routine, these feelings lessen despite long COVID effects. However, although 13 out of 15 participants refer a reduction in mental health-related disorders after discharge, recent findings emphasize that long-COVID symptoms negatively impact quality of life , thus hiThis research had limitations that should be considered for future studies. Due to random sampling, the female gender was poorly represented. However, this aspect was in line with what emerged from the general Italian population hospitalized in the ICU for COVID-19. Indeed, the male gender had a higher risk of transfer to the ICU  for the Based on the study results, future research may focus on long-COVID by investigating people’s real care needs and how professionals can support them to better cope in the post-COVID phase, thus improving quality of life. In addition, it may be interesting for future studies to compare the perception of survivors’ PHQ before getting COVID with perceived PHQ during and after hospitalization.The results indicated that most of the study participants admitted to the ICU for the SARS-CoV-2 virus infection mainly experienced feelings such as fear, loneliness, and anxiety during hospitalization, and they had physical and psychological consequences after discharge from the hospital (long-COVID). Based upon the recent Italian law 77/2020 that defines a nurse role as important to manage COVID-19 patients in the community, it is crucial to identify patients at risk for long-COVID and guarantee a holistic take in charge starting before the discharge and continuing care after discharge in the community where they live.


Suicide is an intriguing act of the human being. The reasons behind the violation of an instinct for survival is far from being understood. Besides, the emergence of assisted dying is raising even more questions about the concept of rational suicide, defined as a well-thought-out decision to die by whom is mentally competent.Understand the concept of rational suicide, in parallel with suicide, by exploring the views on this debate over the years and elucidating the relationship with mental disorders, mental capacity and patient’s rights.Literature review performed on PubMed and Google Scholar databases, using the keywords “rational suicide”, “assisted death”, “suicide”, “phenomenology”, “mental capacity” and “responsibility for life”.The theological condemnations of suicide – as sin or crime – were put aside with psychiatric development in the last century. Durkheim was the first important precursor of the contemporary view - suicide is a form of mental illness (psychosis or depression) not compatible with rational deliberation. With the increasingly open debate on assisted dying, this vision is being tested by cases of terminally ill patients subjected to experiences that many wouldn’t choose to tolerate. Moral right to self-determination and needless suffering are examples of arguments in favor of rational suicide.The need for an open discussion about rational suicide is raising, specifically in relation to psychiatric disorders, mainly to resolve the conflict between the duty of care of psychiatrists and the autonomy of patients.No significant relationships.


The goal of this paper is to determine whether a company’s performance on environmental, social, and governance (ESG) indicators influences customer choice, and if so, which ones are the most important, as well as whether the COVID-19 pandemic had an effect on changing this hierarchy. Additionally, it intends to investigate the influence of regional and demographic factors on its formation. To achieve this goal, primary data were gathered in Greece via a questionnaire survey. According to the findings, a company’s performance on ESGs influences consumer choice, with an emphasis on environmental and social indicators. It was also demonstrated that a company’s social indicator performance is relevant to both urban and suburban customers. Customers in urban areas place a higher value on a company’s performance in governance indicators than those in suburban areas, who place a higher value on a company’s performance in environmental indicators. Finally, no significant COVID-19 effect was evidenced on the findings, although the emphasis on “social indicators” was further reinforced, probably due to the increase in social awareness of citizens during the pandemic. The efforts of modern businesses to maintain momentum in a volatile operating environment are particularly difficult. This is based on the needs of all stakeholders, including employees, local communities, customers, and non-governmental organizations (NGOs). The preceding requirements allude to the need for a responsible and transparent business operation, while also acknowledging the need for the firm to grow and be profitable. Businesses are increasingly attempting to adapt to the application of societal, employee, customer, and environmental protection practices. It is critical for company executives to understand how corporate social responsibility (CSR) actions can be incorporated into their development strategy, risk management, and corporate culture, particularly in the context of sustainable development, which is the new challenge for modern businesses. The UN’s Sustainable Development Goals (SDGs) are a global call to action and initiatives for businesses through their ESG activities. Effective adoption of ESG indicators in conjunction with the implementation of the SDGs is expected to result in benefits for both business and society.The purpose of this study is to look into the impact of company performance on ESG indicators on customer satisfaction and the formation of consumer preferences in Greece, as well as the impact of geographical factors . It also looks into the role of demographic factors in the development of these preferences, as well as whether the COVID-19 pandemic had an impact on them. To accomplish this, this study is structured as follows: first, a theoretical foundation is presented for the concepts of sustainable development, SDGs, and ESGs. Following that is a review of the literature. The research approach is then described, and the key findings are presented. Finally, the main conclusions are summarized and suggestions for practical application are put forward accompanied by recommendations for further research.According to Boufounou and Argyrou , the firThe United Nations Member States, acknowledging the crucial role of sustainability, have adopted in 2015 the 2030 Agenda for Sustainable Development. This agenda revolves around 17 Sustainable Development Goals (SDGs), which represents a global and pressing call for action. Figure Environmental. These criteria refer to whether the business activity includes actions to protect and manage the natural environment, such as pollutant and greenhouse gas emissions, energy consumption, use of renewable energy sources, climate change mitigation, resource management, and waste management.Social. They investigate societal, human rights, and labor relations issues in the communities where a company’s operations are located, such as gender equality, equal employment opportunities, pay, employee education and training, community benefits, supplier evaluation, health and safety issues, and data security and privacy issues.Governance. They examine factors and issues related to management practices, decision-making processes, business ethics, and corporate governance structure, such as executive compensation, corruption, bribery, accountability, and ethics.Moreover, the UN developed the concept of ESG  while working with the financial sector. The main argument was that ESG could shield organizations from financial risks resulting from ESG-related issues as employment disputes, human rights issues, low governance quality, and climate change. More specifically, ESG is comprised of the following 3 factors:The UN started the initiative to incorporate ESG factors into capital markets in 2004. In 2005, the UN released the Compact study, which fundamentally altered the way that people make financial and investment decisions. The Compact study found that incorporating environmental, social, and corporate governance factors into capital markets not only makes good business sense but also ensures sustainable development and yields more favorable outcomes for society as a whole . Recent The Greek Sustainability Code is a practical tool for businesses and organizations that want to promote sustainable development to increase transparency and self-commitment. The Greek Sustainability Code, which is directly linked to the European Sustainability Code, is a structured reference framework that consists of four pillars  and a total of 20 criteria and presents the level of integration of the principles of Sustainable Development & Corporate Responsibility of organizations at the national level. Based on international reporting standards , and which meets both the requirements of the European Directive on the disclosure of non-financial information and the needs of measuring the economic, environmental, and social performance of organizations, which aim at upgrading both their image and reputation, continuous improvement, enhancing their competitiveness, positive evaluation by investors and therefore raising capital, joining international “Responsible Supplier Networks,” and strengthening their export activity. To date, 45 Greek companies (the majority of them large) have published reports based on the guide, with the first of them dating back to 2017.Participating in the United Nations’ Sustainable Stock Exchanges (SSE) initiative in 2019, ATHEX published the relevant ESG Reporting Guide, the implementation of which is not mandatory. The guide proposes specific key performance indicators (KPIs) for each ESG pillar. The KPIs are divided for each pillar into general, advanced and sectoral .Furthermore, the new “ATHEX ESG” index began trading on ATHEX in August 2021, and it monitors the stock market performance of ATHEX-listed companies that adopt and publish their performance based on ESG criteria. The current composition of the “ATHEX ESG” index is based on the performance of 35 publicly traded companies, and an annual review is planned.Finally, in order to align with Agenda 2030, Greek banks are now incorporating ESG criteria into the process of assessing the creditworthiness/lending capacity of companies, but also, in the near future, of private individuals in terms of mortgage loans based on the energy efficiency of the property. However, there is still insufficient published data in Greece to study these findings. They also create Sustainable Development Management Units at the highest administrative level to measure, capture, and coordinate the impact of their operations on ESGs.According to Boufounou and Argyrou , the impExtant literature has documented the positive impact of ESG practices on firm-level operating and financial performance  and on sHowever, in this study, we focus on the Greek market and assess whether a company’s performance on environmental, social, and governance (ESG) indicators influences customer choice. Moreover, we explore which are the most important and whether the COVID-19 pandemic had an effect on changing this hierarchy, thus extending and complementing the extant literature.Corporate social responsibility (CSR) has been a top priority for businesses around the world for the last 15 years, as it is regarded as an essential component of the new business model. CSR is defined in the context of evaluating a company’s performance as the company’s acceptance of a commitment to achieve a balance between profits, social welfare, and customer satisfaction .According to Green and Peloza , a commoPositive feedback and information (word of mouth) about a firm’s products or services circulated to consumers’ personal communication networks, as well as consumers’ repurchase intention , are manifestations of their satisfaction . One of A key feature of consumers in the last decade is their growing concern about social, environmental, and ethical issues. The aforementioned growing concern of consumers is considered the main reason for the development and placing on the market of products and services that are characterized as green, ethical, or socially responsible . From thThe aforementioned studies lay down a theoretical framework that highlights how investors’ decision-making is influenced to switch to firms with high performance on ESG indicators and with CSR profiles, aiming for a high financial return directly dependent on customer satisfaction. However, although the majority of research is focused on the relation between ESG indicators and economic performance of companies, there is a lack of research on the topic of investigation of the effects of ESGs on customer satisfaction.Table Companies’ environmental performance has a positive impact on their economic performance. This research hypothesis was based on research papers that found that companies that engaged in environmentally responsible business practices improved their financial performance demonstrated that disclosing greenhouse gas emissions from corporate activities resulted in poor financial performance for these companies –28. The Firms’ social performance has a positive effect on their financial performance. The studies on which this research hypothesis is based link social corporate performance to economic performance through issues related to human resource management , as well as through activities characterized by social responsibility .Companies’ performance on corporate governance indicators has a positive impact on their financial performance. The functions and structure of the board of directors, the remuneration policy, the company’s vision and strategy, and the rights granted to shareholders are all part of a company’s corporate governance structure. Furthermore, companies voluntarily display certain corporate governance elements and information in order to increase transparency . The perMonda and Giorgino  discoverIn particular, Cek and Eyupoglu  studied The findings of Cek and Eyupoglu , based oIn the same vein, Ionescu et al.  investigIt is clear from the above overview that CSR and ESG indicators have a positive impact on the financial performance of companies. However, the COVID-19 pandemic has forced companies to rethink how CSR programs are able to contribute to corporate performance, both in terms of profit growth and customer retention and satisfaction, while Basdekis et al.  pointed Environmental indicators had an impact on the long-term value generation and financial performance of companies before the pandemic event, while during it only on financial performance.The social indicators had no effect on customer satisfaction, long-term value generation, and financial performance before the pandemic, while during it they had a significant effect on customer satisfaction and long-term value generation.Corporate governance indicators had a significant effect only on financial performance before the pandemic, and during the pandemic on customer satisfaction and long-term value generation.Up to now, this topic remains under-researched in the relevant literature, with only exception of the paper of Mitra and Anas . The aimThe review of the literature in the “Literature Review” section reveals a research gap associated with the lack of current research on the topic of ESG indicators and their association to customer preferences, as well as the additional confounding effects of the COVID-19 pandemic on this relation. Moreover, the literature research identified the absence of potential influence of regional and demographic factors on the aforementioned relationship.RQ1: Which ESG indicators, and to what extent, influence the consumer’s choice to purchase products/services from companies operating in Greece that implement policies regarding these indicators?RQ2: To what extent has the COVID-19 pandemic influenced consumers’ perception regarding the impact of ESG indicators on their choice to purchase products/services from companies operating in Greece that implement policies regarding these indicators?RQ3: Are there any differences between the place of residence and other demographic characteristics of the survey participants regarding their choice to purchase products/services from companies operating in Greece that implement policies regarding ESG indicators?RQ4: Which ESG indicators are related to and how can they predict customer satisfaction, regarding companies operating in Greece that implement policies regarding ESG indicators?Hence, the present study focuses on examining whether ESG information affects consumer choices and more specifically to examine the following research questions:The above research questions are the corresponding frameworks utilized for their investigation which are visualized in the following diagram Fig. .Fig. 2Th5 closed-ended questions to collect demographic data 5 rating scale questions framing the variable “environmental indicators”9 rating scale questions surrounding the variable “social indicators”4 rating scale questions framing the variable “corporate governance indicators”4 rating scale questions framing the variable “customer satisfaction”3 rating scale questions to explore the impact of the COVID19 pandemic on the responses of the survey participantsTo accomplish this goal, primary data were collected through random sampling from a Greek population sample of 282 consumers in order to investigate their views and attitudes toward their consumer behavior in general, as well as their current views on ESGs. This is accomplished by developing a relevant questionnaire consisting of 30 questions as follows:“urban areas” “suburban areas” (composed of the responses of 126 consumers in suburban areas (outside the Attica region)Grant Thornton  studied In addition, as far the “greenwashing phenomenon” is concerned, Grant Thornton  evidenceThe sub-questions framing the ESG indicators were formulated on the basis of ATHEX (2019) . The subU and Kruskal–Wallis X2 non-parametric tests were utilized for examining differences in Indicators based on various demographic characteristics. Correlations in the sample were tested using the Spearman’s rho coefficient due to the type of the collected data. Finally, reliability of the sample is tested through the use of the Cronbach’s alpha and inferential analysis for examining the impact of indicators on customer satisfaction was performed through regression modeling.Suitable statistical analysis techniques were utilized for analyzing the obtained data and responding to the research questions of the paper. Specifically, descriptive statistics is deployed in order to summarize indicators and variables collected through questionnaire. In addition, statistical inference techniques such as the Mann–Whitney The basic characteristics of the sample are described in Table With regard to the first research question, the main results of the survey in terms of descriptive statistics are presented below , broken down into urban and suburban areas.A summary of the environmental indicators is presented in Table Respectively, a summary of social indicators is presented in Table Governance indicators are presented in Table A summary of “customer satisfaction” variables is presented in Table It is clear that ESG indicators have a moderate to high influence on consumers’ decisions to purchase products/services from a company operating in Greece that implements ESG policies. Surprisingly, the average values for environmental and social indicators are the highest in both samples of the current survey.Regarding the second research question, Table U test for gender and employment status differences Mann–Whitney Kruskal–Wallis test, for age, monthly income, and educational level differences (as these are classifiable variables)In order to study the third research question and to determine whether the variables depend on the demographic characteristics of the sample, the following statistical analysis was carried out:0 assumes independence and the alternative of Η1 assumes their dependence. The hypotheses are tested at the 5% level of significance.For conducting the tests, we consider that the null hypothesis ΗAs can be seen in Table 0 hypothesis is accepted for the variables “environmental indicators” and “corporate governance indicators” as p-value (sig.) > 0.05. That is, the above mentioned variables are not dependent on the gender of the sample.The Η1 is accepted for the variables “social indicators” and “customer satisfaction,” as p-value < 0.05; i.e., the aforementioned variables are dependent on the gender of the sample, with females, scoring higher on the individual factors surrounding these variables.Hypothesis ΗFor the urban sample, it can be seen that:0 is accepted for the variables “social indicators,” “corporate governance indicators,” and “customer satisfaction” as p-value > 0.05. That is, the aforementioned variables are not dependent on the gender of the sample.Hypothesis Η1 is accepted for the variable “environmental indicators” as p-value < 0.05; i.e., this variable depends on the gender of the sample, with males scoring higher on the individual factors surrounding this variable.Hypothesis ΗFor the suburban sample, it follows that:As can be seen in Table 0 is accepted for the variable “environmental indicators” as p-value > 0.05. This means that the above variable does not depend on the employment status of the sample.Hypothesis Η1 is accepted for the variables “social indicators,” “corporate governance indicators,” and “customer satisfaction,” as p-value < 0.05 (dependence of these variables on employment status). More specifically, it is observed that the survey participants who are employees score higher on the individual factors surrounding the aforementioned variables, compared to non-employees.Hypothesis Ηa) for the urban sample, it appears that:0 is accepted for all variables of the research model as p-value > 0.05. That is, the above variables do not depend on the employment status of the sample.Hypothesis Ηb) for the suburban sample, it can be seen that:As can be seen in Table 0 is accepted for all variables in the research model as p-value > 0.05. That is, the above variables do not depend on the age of the urban sample.Hypothesis Ηa) for the urban sample, it can be seen that:1 is accepted for all variables in the research model, as p-value < 0.05 . It is observed that the younger respondents of the suburban sample scored higher on the factors surrounding the variables of the research model .Hypothesis Ηb) for the suburban sample, it follows that:0 hypothesis is accepted for all variables in the research model as p-value > 0.05. That is, the above variables do not depend on the monthly income of both samples.By the inspection of Table 1 is accepted for all variables in the research model, as p-value < 0.05 . It is observed that as the educational level of the two samples increases, the mean value of the variables under study also increases.As can be seen in Table p-value < 0.001). That is, as the levels of “corporate governance indicators” increase, the levels of customer satisfaction will increase.Strong positive correlation between “customer satisfaction” and “corporate governance indicators,” at a statistical significance level of 0.01 . That is, as the levels of “social indicators” increase, so will the levels of customer satisfaction.Strong positive correlation between “customer satisfaction” and “social indicators,” at a statistical significance level of 0.01 . That is, as the levels of “environmental indicators” increase, so will the levels of customer satisfaction.Strong positive correlation between “customer satisfaction” and “environmental indicators,” at a statistical significance level of 0.01 . That is, as the levels of “social indicators” increase, the levels of “corporate governance indicators” will also increase.Strong positive correlation between “corporate governance indicators” and “social indicators,” at a statistical significance level of 0.01 . That is, as the levels of the “environmental indicators” increase, so will the levels of the “corporate governance indicators.”Strong positive correlation between “corporate governance indicators” and “environmental indicators,” at a statistical significance level of 0.01 . That is, as the levels of the “environmental indicators” increase, so will the levels of the “social indicators.”Strong positive correlation between “social indicators” and “environmental indicators,” at a statistical significance level of 0.01 . That is, as the levels of “corporate governance indicators” increase, the levels of customer satisfaction will also increase.Positive correlation between “customer satisfaction” and “corporate governance indicators,” at a statistical significance level of 0.01 . That is, as the levels of “social indicators” increase, the levels of customer satisfaction will also increase.Positive correlation between “customer satisfaction” and “social indicators,” at a statistical significance level of 0.01 . That is, as the levels of “environmental indicators” increase, so will the levels of customer satisfaction.Positive correlation between “customer satisfaction” and “environmental indicators”, at a statistical significance level of 0.01 . That is, as the levels of “social indicators” increase, the levels of “corporate governance indicators” will also increase.Positive correlation between “corporate governance indicators” and “social indicators,” at a statistical significance level of 0.01 . That is, as the levels of the “environmental indicators” increase, so will the levels of the “corporate governance indicators.”Positive correlation between “corporate governance indicators” and “environmental indicators,” at a statistical significance level of 0.01 . That is, as the levels of the “environmental indicators” increase, so will the levels of the “social indicators.”Strong positive correlation between “social indicators” and “environmental indicators,” at a statistical significance level of 0.01 . First, a reliability analysis was performed using Cronbach’s alpha and the internal consistency method. The Cronbach’s alpha index is greater than the allowable limits set for all variables, as shown in Table p-value and can predict the dependent variable are as follows:Tables p-value < 0.001), which change in the same direction as the dependent variable (Beta =  + 0.482 > 0)“Social indicators” , which vary in the same direction as the dependent variable (Beta =  + 0.328 > 0)“Corporate governance indicators” , which change in the same direction as the dependent variable (Beta =  + 0.305 > 0)“Environmental indicators” , which vary in the same direction as the dependent variable (Beta =  + 0.296 > 0)“Social indicators”  with good performance on key ESG indicators that contribute to long-term value generation [neration .Enhancing corporate reputation and stakeholder engagement. Disclosing non-financial information and improving a company’s ESG performance demonstrates its commitment to transparency best practices, alignment with sustainable development goals, and long-term value creation [creation . The afocreation .As pointed in ATHEX (2019) , effectiThis study found that ESG indicators, with a focus on environmental and social indicators, have a moderate to high influence on consumers’ decisions to choose products/services based on the policies implemented regarding these indicators, regardless of their region of residence (urban and suburban area). The pandemic does not appear to have changed their minds significantly, though it should be noted that it had a greater impact on social indicators, which is consistent with Mitra and Anas’ findings . This reSocial indicators seem to have a greater influence on the choices of the urban sample, while for the suburban sample, the environmental indicators play a more important role. Governance indicators for both samples had no significant effect on their choices, with the urban sample rating them higher than the sample residing outside. The high scores given to the environmental indicators by the suburban sample may be due to the fact that the economic development of these local communities is directly linked to the environment  and therefore the policies for its protection, implemented by the companies, are an important criterion for their choice of purchase for this sample. These results may provide indications and suggestions to both urban and suburban companies in order to improve their resilience by taking into consideration these findings relating to the customer choices and preferences as these are found to be affected by the three ESG indicators.Women in the sample who live in cities performed better on the “social indicators.” This finding could be explained by the fact that women face more injustice/discrimination in terms of professional rehabilitation as well as prejudices about women’s roles in society.Employees in the sample who lived in urban areas performed better on “social indicators” and “corporate governance indicators.”This result may be based on the fact that citizen employees perceive to a greater extent (insider experience) that the financial performance of a company depends to a significant extent on activities related to society, human rights, labor relations, and business ethics.The younger respondents of the suburban sample rated higher the factors framing all variables of the research model. Younger age respondents who do not reside in a large urban center may be more concerned to a higher degree about the social, environmental, and ethical problems of business activities, the non-solution of which is the source of the need for these individuals to move to large urban centers.Higher educated individuals in both samples scored higher on all ESG indicators. It is possible that the education and information style (as it fits the higher educated profile) of these individuals may reinforce perceptions linking a company’s financial performance to ESG indicators.The following results were obtained from the test of dependence of the sample’s demographic data on the variables of the research model:Furthermore, no significant COVID-19 effect was evidenced on the findings, although the emphasis on “social indicators” was further reinforced during the pandemic, probably due to the increase in social awareness of citizens.Finally, a positive correlation was found between the dependent variable “customer satisfaction” (customer retention and spreading positive word of mouth feedback ) and theExamining an even larger sample from all regions of the country in order to assess any regional differences between themStudying the existence of any differences in the importance of ESG for the choice of consumption/buying products/services of different sectors of economic activityTo be repeated after a few years in order to identify and comment on changes linked to c To make the findings more widely applicable, the current work could be expanded by the following: