A bionic robotic hand can perform many movements similar to a human hand. However, there is still a significant gap in manipulation between robot and human hands. It is necessary to understand the finger kinematics and motion patterns of human hands to improve the performance of robotic hands. This study aimed to comprehensively investigate normal hand motion patterns by evaluating the kinematics of hand grip and release in healthy individuals. The data corresponding to rapid grip and release were collected from the dominant hands of 22 healthy people by sensory glove. The kinematics of 14 finger joints were analyzed, including the dynamic range of motion (ROM), peak velocity, joint sequence and finger sequence. The results show that the proximal interphalangeal (PIP) joint had a larger dynamic ROM than metacarpophalangeal (MCP) and distal interphalangeal (DIP) joints. Additionally, the PIP joint had the highest peak velocity, both in flexion and extension. For joint sequence, the PIP joint moved prior to the DIP or MCP joints during flexion, while extension started in DIP or MCP joints, followed by the PIP joint. Regarding the finger sequence, the thumb started to move before the four fingers, and stopped moving after the fingers during both grip and release. This study explored the normal motion patterns in hand grip and release, which provided a kinematic reference for the design of robotic hands and thus contributes to its development. The hand is a crucial component of the human body, and it can handle numerous precise and complex tasks. The versatility of the hand benefits from its sophisticated anatomical features, as it comprises many bones and is driven by numerous muscles . AdditioHand gripping or grasping is a basic movement that involves flexion and extension of multiple joints. Up to now, the studies on human hand grip mainly focus on the range of motion (ROM), including active, passive and functional ROMs ,13,14,15The purpose of this study was to determine the finger kinematics during hand grip and release, in order to figure out normal hand motion patterns. Specifically, dynamic ROM and peak velocity of the finger joints were measured. Additionally, the joint sequence and finger sequence during flexion and extension were investigated.Twenty-two individuals with no hand abnormalities participated in the study . All participants were right-hand dominant. Before the experiment, all participants had understood the experimental content and provided the written informed consent.Hand motion was detected by an elastic sensory glove with 15 sensors . SpecifiDuring data collection, the participants sat on a chair and placed the right forearm on an armrest, while keeping the palm faced down. They were asked to use the right hand to perform a grip and release motion as quickly as possible, while trying to ensure the fingers at maximum flexion when the hand is closed and at maximum extension when the hand is open. Rapid finger motion can avoid artificial motion patterns, thus reflecting natural patterns. Specifically, the participants were required to complete 10 cycles of motions within 5 s. Normal people are believed to perform more than 20 cycles in 10 s .The maximum and minimum angular values of finger joints in each cycle were calculated, as well as the peak velocity of joints during the flexion and extension phases.On the other hand, the time normalization of data was required for the analysis of motion coordination, because the actual duration of motion varied basically from cycle to cycle. As shown in Note that in this study, the initiation and completion points did not always correspond exactly to the start and end of joint motion. For the feature points of finger, the earliest initiation point of two or three joints was considered to be the initiation point of the finger, and the last completion point of any joint was considered to correspond to the completion point of the finger. The determination of feature points of fingers is also shown in For the kinematic variables related to angle and velocity, the mean value for each participant over 10 cycles was calculated, and then the mean and standard deviation (SD) of all participants were calculated. Additionally, for the same type of joints from different fingers, the one-way analysis of variance (ANOVA) was used to determine any significant differences among the fingers.T-test was performed to compare the locations of motion feature points between the joints within each finger. Similarly, the time differences for the feature points between different fingers were evaluated via the paired t-tests.In addition, average values of the locations of the feature points for all participants were calculated to determine the joint sequence and finger sequence. The paired p-value = 0.001; index finger and ring finger: p-value = 0.002; index finger and little finger: p-value = 0.023). However, there was no significant difference in DIP ROM amongst the middle finger, ring finger and little finger.The dynamic ROM for the 14 finger joints during hand grip and release motion are shown in According to The averaged time relationships amongst the feature points of finger joints at different phases during hand grip and release are shown in The averaged time relationship on finger feature points amongst five fingers at different phases during hand grip and release are shown in Hand grip and release are holistic movements that involve all five fingers. It is clear that the joints of a same kind shared similar dynamic ROM. The comparison among the dynamic ROM of DIP, PIP and MCP joints shows that the PIP joint has the largest dynamic ROM. Additionally, it is found that the DIP ROM of the index finger was smaller than the other three long fingers during rapid grip and release. A previous study based on static measurement has reported no significant differences on active DIP ROM amongst four long fingers . When thANOVA indicated no significant differences in peak flexion velocity or peak extension velocity among all four fingers, demonstrating the consistency of finger motion for holistic movements. For long fingers, the peak velocity was largest at PIP joint, followed by MCP and DIP joints, regardless of whether it was during flexion or extension. Similarly, the PIP joint had a higher peak velocity than MCP joint in fast index finger flexion  and in rThe analysis of joint sequences and finger sequences during hand grip and release motion revealed much information of finger motion patterns, which reflect the functionality of the hand. The results showed that, although the joint sequences were not absolutely identical among all fingers, they shared some commonalities. On the other hand, previous studies have implied that the finger joint sequence would change during the motion process ,34. HoweIt is known that the fingers are controlled by several muscles, and most of these muscles act over the phalanges through the tendons, which are inserted into the bones . As for The joint sequence of the thumb is different from that of the long fingers. The MCP-IP sequence occurred most frequently in the thumb flexion in this study, which was also observed during the cylinder grip  and duriIn characterizing the finger sequence during hand gripping and release, there appears to be a time gap in the motion between the thumb and four long fingers. As the participants were asked to place their thumb outside of the fist during fist clenching, it was expected that the thumb would be the last appendage to stop moving at the end of hand gripping. Similarly, the participants had to move their thumb firstly to unlock the remaining fingers at the beginning of hand release. In long fingers, the motion was highly synchronized due to their similar biological structures. This finger sequence supports to some extent the view that the thumb is the most independent finger . TherefoUndoubtedly, grasping is one of key issues in the study of robotic hands. In order to enable robotic hands to achieve effective grasping, it is recommended to establish a database of human grasps and develop the models on grasps . LearninFinger kinematics during human hand grip and release was investigated in this study. Segmental findings on motion patterns showed good correspondence with the literature. Furthermore, more kinematic features were involved in this study, as the dynamic ROM, joint sequence and finger sequence were described. This study presented hand motion features from healthy people, which can serve as the basic information for designing bionic robotic hands. For example, an exoskeleton that aims to enhance hand function of healthy people needs to have the same motion pattern as healthy human hand. Meanwhile, the findings in this study can be used as a baseline for investigating the motion patterns of people with hand injuries and disabilities, and support the design of hand rehabilitation robots. Overall, analysis of the kinematic variables helps to reveal the nature of the finger movement, and is of great reference value for the development of the robotic hand. Bionic robotic hands with normal motion patterns are believed to have the functionality closer to human hands.


The recognition of the importance of effective communication in the healthcare system has been growing. Given that communication courses must be adjusted to the specificity of a particular culture, language, and other contextual issues, many countries and communities sharing a common language have proposed their recommendations for a communication curriculum for undergraduate medical education. To date, no recommendations have been developed for either any Central and Eastern Europe countries or for regions where Slavic languages are spoken. Their specificity of post-communist transformation should be acknowledged. This study aims to review communication curriculums and offer recommendations for medical communication training for undergraduate medical students in Poland.The recommendations were developed through an iterative consultation process with lecturers, faculty members of medical schools, and education coordinators. PubMed and Google Scholar databases were searched to identify full text English and Polish language articles on communication curriculum for undergraduate medical education. Additionally, the new Regulation of the Polish Minister of Science and Higher Education, defining educational standards for undergraduate medical education was analysed in search of learning outcomes that could be applied in communication skills teaching. The authors extracted the most relevant communication skill competencies, as determined by the process participants, discussed current challenges, including those of the COVID-19 pandemic era, and indicated best practices.A review was conducted, and a set of recommendations was developed pertaining to the scope and methodology of teaching communication skills. The study included: (1) definition, (2) education content, (3) learning outcomes, (4) the recommended teaching methods. The recommendations are in concord with the graduate profile, as well as the current structure of medical studies. The authors listed and discussed the basic communication competencies expected of medical graduates, as well as medical communication course content viewed from different perspectives, including clinical, psychological, sociological, legal, and linguistic.Detailed recommendations aimed at integrating best practices into a comprehensive communication curriculum may promote successful teaching, learning, and assessment of medical communication. The communication skills of healthcare workers are part of basic clinical skills . CommuniWith the increasing recognition of the importance of medical communication, its teaching has been incorporated into the core curriculum of undergraduate medical education. Medical faculties worldwide started to introduce appropriate courses to their curricula at the end of the 20th century. One of the first experiences came from the University of Lagos in 1984 . More reThe need for standardized teaching practices lead to several countries developing their own consensus statements. One of the first consensuses on the teaching and assessment of communication skills in medical schools came from Canada in 1992  and 1993Attempts have been made to offer international recommendations or consensuses based on the languages spoken, such as the Latin American, Portuguese and Spanish consensus on a core communication curriculum for undergraduate medical education  and the Unlike the countries of Western Europe and North America , in PolaSome medical educators believe that communication skills are constant across different cultures and languages. Also, UK communication skills curricula suggested that they can be implemented worldwide. However, other researchers question this assumption; Mirza argued that such skills cannot plausibly be considered universal . She sugAlso, the context of local language significantly impacts medical communication, which was reflected in the attempts to write consensus based not on the language spoken. Therefore, it became vital to prepare recommendations that were specific to the system of undergraduate medical education in Poland, including present day challenges.Over the last years, Poland has undergone vast political and economic changes beginning with the postwar period, through the time of communism, political transformation, to capitalism and inclusion in the European Union. These political changes were accompanied by fluctuations in living standards and social inequalities .Social transformations in the countries of North America and Western Europe have been spread over the years after World War II until today. The same direction of social processes in Poland  appeared only after 1989 and brought dynamic (revolutionary) changes in Polish society (towards civil society).It brought social differentiation and a revolution in attitudes. The transformation in 1989 affected many aspects of the functioning of Poles .Studies focusing on transformations in post-socialist countries have usually dealt with major economic and political shifts, particularly regarding democratization, civil participation, and the transition from formerly planned economies into market economies , 26. SocOn the other hand, attitudes of Poles have also changed - those towards health itself  and – consequently - patients’ expectations in health care –29. All The aim of the study was to review medical communication curriculum.research and present recommendations for communication skills training for undergraduate medical students in Poland acknowledging their global and local context.Therefore, the aim was to prepare a curriculum including parts present in most published consensus that are global in nature, but also parts that take into account cultural differences and local language. The latters requires the teaching and learning to be targeted to central and eastern European countries. They need to be a reason for the unique parts of a medical communication curriculum.The recommendations for the undergraduate medical communication curriculum were developed through an iterative consultation process with 8 teachers, members of medical faculties, and the education coordinators representing the five Polish medical schools , all of whom are members of the Polish Society of Medical Communication.For the study, a narrative literature review was performed using Web of Science, Google Scholar and PubMed/MEDLINE databases. The review followed previous guidelines on the development of a narrative review outlined by Dixon-Woods et al.  and PeteThe narrative discussion was aligned with individual articles and interpretations of relevant articles by organizing it into sections: (1) definition, (2) education content, (3) learning outcomes, (4) the recommended teaching methods.The inclusion criteria were full text articles published in English and Polish between January 2001 up to December 2022 concerning communication curriculum for undergraduate medical education.One author selected papers which fulfilled the inclusion criteria and extracted data for the outcomes using a standardized data extraction form. Papers not describing learning outcomes concerning communication skills were excluded. Another author rechecked the extracted data. Out of 6381 papers chosen by the search strategy including Medical Subject Headings terms and keywords, 168 were included after reading the titles. Then, a total of 73 were included after reading the abstract. Eventually, after reading the full texts 28 articles were included to the final analyses based on the quality of the studies.The review process was used to list learning outcomes concerning communication skills . The autThe new Regulation of the Minister of Science and Higher Education on educational standards for undergraduate medical education  also undTo develop the communication curriculum recommendations for undergraduate medical education in Poland and to achieve a consensus, a systematic academic approach and the Delphi technique were used. The process of the curriculum development was split in 6 phases within the process: (1) development of a list of learning outcomes concerning communication skills on the basis of literature, existing consensus statements, frameworks and guidelines, (2) in person expert meeting to discuss: (a) general communication competencies, (b) education content based on various aspects of communication, (c) educational content concerning medical consultations, (d) the recommended teaching methods, (3) development of a first draft of recommendations, (4) online meetings and electronic discussion process to revise the first draft; (5) second Delphi round to test the revised draft and make suggestions for improvement (6) a final Delphi round for the recommendations.The objectives and learning outcomes needed to be most comprehensive in inclusion and detailed. They were defined according to Bloom’s taxonomy using a skills-based approach. Ambiguous aspects among experts were reworded and new aspects incorporated.The study includes: (1) definition of medical communication, (2) education content, (3) learning outcomes, (4) the recommended teaching methods.Medical communication is an interaction between healthcare professionals  and patients (and their relatives) , as wellMedical communication has also become a research discipline, which has been developing dynamically (including in Poland) for over a dozen years, as evidenced by the growing number of studies and publications. Research and medical education need to go hand in hand for best practices to be gradually institutionalized .Communication competencies are necessary to make medical communication effective. Those competencies comprise knowledge (appropriate background), skills , and attThe process of medical communication remains strictly linked with general communication competencies. Those competencies used at different stages of the consultation contain:communication skills required to build a relationship with the patient.verbal and non-verbal communication in the relationship between the doctor and the patient.communication skills in telemedicine.active and careful listening - methods to improve communication.empathy and cognitive empathy  and their importance in medical communication.overcoming communication barriers.assertiveness in communication.With the proper training every graduate should be able to:recognize the patient’s perspective , effectively connect it with the biomedical perspective during the information gathering stage, and provide information in an understandable manner;easily interact with the patient and his relatives using various channels and forms of communication, during both the diagnostic stage and throughout the therapeutic process;build a trusted relationship with the patient based on the mutual understanding of the role and course of action ;make medical decisions together with the patient while respecting their autonomy;serve as the patient’s advisor and guide throughout the diagnostic and therapeutic processes;skillfully and consciously shape a relationship with the patient, even during periods of increased stress and emotional tension;behave in a mature and empathetic way; knowledge and skills allow him to flexibly interact with various patients (and in different situations);have comprehensive medical knowledge, extended with elements other fields (including psychology and sociology), he gives patients multidimensional help in the context of therapy as well as prevention and strengthening health or improving functioning, including environmental interventions;demonstrate the ability to absorb new knowledge and skills and adjusting them to changing working conditions and requirements;care about the personal well-being , because the students know that the smooth functioning of them as doctors and the whole team they are a part of depends on it;communicate efficiently with members of the medical team and manages conflict situations.A proposed content list to be included as a part of the communication curriculum in medicine and dentistry may ensure consistency and a high and similar level of education.The listed issues relate to general problems  and detailed (related to specific situations in doctor’s work). All the topics listed are directly related to the practice of medicine.Although general interpersonal communication competencies remain a basis for medical communication, various aspects of communication should be considered, such as: psychological, sociological, legal, ethical, and linguistic.Medical consultation may be considered as a core situation in medicine. Figure Education content should include communication in specific situations:Communication in terminal care - conversation about the end of life, values important to the patient.Communication in pediatrics - communication with patients of different ages - infants, preschool children, early school children, teenagers. Communication in the triad - doctor - patient - patient caregiver.Communication in geriatrics - conversations with elderly patients, people with dementia, with cognitive disorders or degenerative diseases e.g. Alzheimer disease. Communication in the doctor-patient-companion triad.Communication in psychiatry - communication in the situation of exacerbation of mental illness, communication with patients with mental disorders, respect for the rights of patients with mental disorders.Communication in caring for people with disabilities - taking into account the special needs of patients with disabilities, especially intellectual disabilities, Deaf, visually impaired and blind patients.Issues related to motivating patients are presented as a separate module in teaching communication in medicine for several reasons –55. FirsThe recommended teaching methods are grouped into types as presented in Table The learning outcomes of these proposals provide guidance to the universal introduction, support, and development of a communication curricula as a part of undergraduate medical studies in Poland.The following set of recommendations is the first of its kind in Central and Eastern Europe. Country and language-orientated list of content, learning outcomes and teaching methods may inspire experts from other countries in this region and encourage them to prepare recommendations on the development of communication skills in medicine that correspond to Slavic countries’ linguistic and cultural contexts.The reference for the definition of communication in medicine is the one formulated by Jan Doroszewski in 2007 . Its basThe importance of communication in clinical practice has also been recognized in Poland –58, as aThis history of teaching communication in healthcare in Poland justifies the need for a recommendation . ContempThe perception of communication should be interdisciplinary. Communication as a field of study and competence draws from various sciences. Integrating this knowledge and skills together is essential. As a result, this leads to the acquisition of competencies that the graduate can use in clinical practice. Therefore, the first part of the educational content Fig.  is relatPsychological, sociological, legal, ethical, and linguistic aspects of communication have been detailed Fig. .The basic skills associated with the consultation stages are based on the Calgary Cambridge model , 64, whiTeaching methods should be selected according to the aims and means of instruction. Using practical methods is highly recommended.Multiple studies confirm that the manner in which a physician communicates with his or her patient directly impacts patient satisfaction , 66 and The process of educating doctors depends on the medical culture  and evolThe practice of medicine requires current and future doctors to develop new clinical skills, demonstrate broadly defined competencies (including communication skills), and emotional maturity. One thing does not change: medicine must maintain its primary goal of providing support to others in need, and to help facilitate their return to good health in life-threatening situations.Being a doctor is not only about providing medical services. It is most importantly having – the privilege of building a special relationship with another person based on trust, respect, and an openness that no machine can replace.A model utilized to train doctors should meet various requirements and expectations . When deMedical universities should follow modern standards of instruction with a view toward the future practice of medicine.The development of highly competent communication skills should be initiated as early as possible, and optimally should be made a permanent part of the curriculum throughout all the years of a student’s medical studies. During undergraduate medical education, the student should initially develop knowledge and appropriate attitudes. They will transpose into simple skills, and over time into more complex ones.The introduction of communication skills training should also be integrated as an educational tool into inpatient and outpatient settings, as well as in medical simulation centers. The curriculum should be structured in such a way as to enable students to acquire practical communication skills that are essential in the practice of medicine. For the best education of practical communication skills, the number of students included in the study groups should not exceed the number of students in the clinical training groups. In Polish medical universities, this means six-person student groups.Some studies suggest that communication skills can diminish during the four years of medical school . Which mThe medical communication curriculum and classes should be designed, coordinated, and implemented  by an internal unit responsible for the enhancement of communication competencies at a given university. Entrusting these tasks to a unit specialized in medical communication ensures that the consistency of the content taught in various classes will be maintained. Moreover, the appropriate preparation of those teaching communication subjects, and the employment of the appropriate didactic methods will ensure proper outcomes. The team responsible for teaching communication should employ specialists in medical communication who have certificates confirming their qualifications in this field. Communication teachers should be well prepared, both in terms of theoretical knowledge about communication, the necessary knowledge of medical practice and didactic competence. It is necessary to create training opportunities in this area. These factors should guarantee a high quality of education.However, appropriate care should also cover teachers’ needs and prevention of their burnout. Medical faculty stress/burnout links directly to a willingness to implement medical school curriculum change . OccupatAssessment of practical skills is crucial in the learning process and should be an integral part of the curriculum. Formative assessment and summative assessment  are recoBoth classic oral examinations  and some written forms of examinations  can assess communication skills . HoweverWhile the aforementioned components, referring to specific skills, can be assessed using well-consulted checklists, components associated with attitudinal aspects, such as empathetic approach, are better evaluated using a global rating scale.One of the key elements enhancing OSCE standardization is the use of simulated patients (SP). SP is a person who is trained to present standardized scenarios, which ensures that all students are tested on the same clinical encounter . This reAnother very frequently used standardized clinical skills exam is the mini-CEX. Unlike the OSCE, the mini-CEX  is an exam from the workplace-based assessment (WBA) group and is conducted in a real environment in a hospital or outpatient clinic. The mini-CEX is a brief, focused assessment that can be completed within 10–15 min and is intended to be repeated multiple times over a learner’s training period to track their progress and provide ongoing feedback. Clinical communication is not only communication between the patient and HCP , but also communication within the team so methods from Multiple-Source Feedback are recommended. Multiple-Source Feedback (MSF), also known as 360-degree feedback, is a formal questionnaire-based method of evaluating the performance of medical trainees that involves soliciting feedback from a variety of sources, including colleagues, patients, supervisors, and self-assessment.Summarizing there is no single, best assessment method that can provide all the data required for assessment anything so complex as communication. It is important to note that assessing communication skills should be an ongoing process, with multiple opportunities for students (HCP) to practice and receive feedback throughout their medical education (work).As underlined in the background – the main argument for building Polish recommendations is a differentiation of the society due to the history of Poland and its modern transformation. Doctors meeting the patient will meet people of highly different expectations toward healthcare professionals, highly different health competencies, socio-economical status and preferable models of care  . It makeSpecific for post-communist countries, ambivalent attitude towards authority means that on one hand one has to obey authority, and on the other, there is no trust in authority doing any good. In this regard, the basic ambivalence towards any kind of authority relates to the typical authoritarian figure, a doctor, then this ambivalence would come into play in physician-patient relationship. Trust towards doctors’ authority levels in western countries for some age groups tends to exceed 70% , 32, 35 Instilled ambivalence towards authority plays also a crucial role in a way students are willing to accept feedback from seniors, who are authority. And this is why they seem unable and not willing to give feedback to each other. Preliminary data reveals problems students have with receiving or giving feedback. Reports from teachers say that students at the least indication of the slightest criticism in a feedback, become resistant, do not accept it, and instead of analyzing what has just been said, fight back using counter arguments, which brings the whole idea of feedback to the point of failure. Teachers should pay special attention to this point. It is also why there is a particular need for a good student-teacher relationship and friendly learning environment, as well as for teachers who care for themselves and are not burned out - to be attentive and convincing.By comparing previous medical models/frameworks of communication curriculum –42, 63, Unlike educational content concerning medical consultations, which remains rather similar worldwide, education content describing medical communication and its significance in healthcare is characteristics for Polish and non-Western. In the local context – as described in our study – new definition and scope, goals, importance in medical practice, impact on patient’s safety and health literacy Fig.  should bPolish school of medical communication share their own breaking bad news protocol (EMPATHY protocol)   incomplete understanding  of separateness and interdisciplinary foundations of medical communication, (2) misidentification of communication with persuasive (or even manipulative) techniques, and (3) perception of communication competencies separately from clinical practice.In order to optimize undergraduate communication skills teaching in practice, Junnod Perron cited the special need to: (1) modify the climate and structure of the working environment so that training and teaching of good communication skills in clinical practice become valued, supported, and rewarded; (2) extend communication skills training to all fields of medicine; (3) regularly provide structured training and adapt it to trainees’ needs .There is a need for developing a communication skills training program as the communication skills of many students turned out to be inadequate .However, the quality of delivering the course should be high. Researchers in India found a high prevalence of unfavorable attitudes toward communication skills classes based on a poor quality of the subject .The passage of time and the added experience gained by teachers may promote change. Students’ attitudes toward learning clinical communication skills at the end of medical school have greatly improved over twelve years in two Norwegian medical schools from 2003 to 2015 .Of course, competent communication includes an essential range of skills, and in order to maintain these skills beyond the undergraduate stage, continuing education will be needed .Training in communication skills requires approaches which are different from the instruction related to other clinical subjects. It is also a challenge to ensure that students not only absorb the nuances of communication and interpersonal skills but adhere to them throughout their careers . Due to The content of the recommendations and their method of building the student’s attitude is also applicable in the special situation of remote communication with patients. This communication requires the doctor to be aware and important of its individual elements. Therefore, the importance of teaching this competence will increase in the future.Based on the experience of Polish and foreign medical universities, detailed recommendations for the organization and training of communication competencies on medical courses are offered to integrate views on teaching, learning, and assessment of clinical communication. It should be extended to and adapted to other medical faculties in the long term and adjusted to their specific needs and conditions.It is hoped that this paper may be of assistance to those involved in the planning, development, application, and evaluation of medical communication curricula, especially new ones emerging in Central and Eastern Europe. Although designed for undergraduate education, the consensus statement provides a starting point for further professional development.Changes in the practice of medicine should lead rapidly to adjustments in the curricula content.The responsible and wise implementation of the teaching of medical communication at Polish universities is of great importance to the future of the healthcare system, the performance and efficiency of doctors and medical teams, and in the level of the quality of care that patients receive.The necessary curriculum and organizational changes should be evolutionary, not revolutionary. It is essential that training in effective communication be coherent to the rest of the medical curriculum. Gradual integration of new techniques into the existing teaching model promises best chances of success. What is desired is also an approach change of the faculty members, who need to share the belief about the importance of medical communication teaching.


Investigation of the association between physical frailty and cognitive performance through spatial navigation is important to enable the identification of individuals with cognitive impairment and physical comorbidity.To analyze the association between spatial navigation and frailty in frail and pre-frail institutionalized older adults.Forty older people of both sexes, aged 60 years or over, residing in four Brazilian Long-Term Care Facilities (LTCFs) participated in this study. The following tests were applied: Mini-Mental State Examination (MMSE), 2.44m Timed Up and Go, Floor Maze Test (FMT), and Fried's frailty criteria. For data analysis, the Mann-Whitney and independent t-tests were used to compare the groups (frail x pre-frail), principal component analysis was used to explore the main variables related to the data variance, and binary logistic regression to estimate associations.There was a significant difference in performance in the FMT immediate maze time (IMT) (p=0.02) and in the delayed maze time (DMT) (p=0.009) between the pre-frail and frail older adults. An association between FMT DMT performance and frailty was found, showing that older people with shorter times on the DMT (better performance) had approximately four times the chance of not being frail .Frailty is associated with impaired spatial navigation ability in institutionalized older adults, regardless of gait speed performance. Frail individuals are those who require the most care, which makes frailty an important marker for managing elderly health conditions.The frailty syndrome is an age-related condition that is characterized by a decrease in physiological reserves and compromised responses to chronic stress, impairing the body's capacity to cope with adverse health outcomes propose the most accepted conceptual model of frailty. The “Frailty Phenotype” described by Fried et al. establishes that exhaustion, dynapenia, reduced gait speed, involuntary weight loss, and low levels of physical activity are substantial criteria for determining frailty. The frail state reduces the individual's independence and increases the chances of institutionalization, hospitalization, and/or early death.According to the scientific community, Fried et al.. The association between frailty and oxidative stress helps to understand the increased risk of frail older people to present AD.Currently, gait speed, which is a criterion for determining frailty, stands out among these markers and its use is recommended as there is an association between slow gait and the onset of Alzheimer's disease (AD) and future dementia. A 12-year cohort study found that frailty, after adjusting for age, sex and education, is associated with a high risk of developing MCI, so that each one-unit increase in frailty was associated with a 63% increase in the risk of developing MCI .Studies report that the severity of the frail state is associated with an accelerated global cognitive decline and predicts mild cognitive impairment (MCI), which is characterized by the integration of complex cognitive processes, such as visual perception, learning, memory, and executive functions. The hippocampus, parahippocampal gyrus, prefrontal, parietal and entorhinal cortex are the main brain regions triggered by spatial navigation ability and are sensitive to normal aging.Among the cognitive domains affected in institutionalized older adults is the spatial navigation ability. Among the reasons for choosing this instrument are its ease of application, low cost, and reliability of results. Verghese et al., in a longitudinal study, used the FMT to assess spatial navigation and found that the 10-second increment in FMT execution time is related to 25% increase in the risk of cognitive decline and 53% increase in the risk of motoric cognitive impairment, being a state of prodromal dementia. Some investigations have identified possible hyperintensities in the cerebral microvasculature arising from frailty in important regions for spatial navigation, such as the hippocampus. This finding strengthens the original definition of cognitive frailty as a condition of poor cognitive performance related to physical conditions in the absence of apparent neurodegenerative diseases.The Floor Maze Test is an instrument for measuring spatial navigation ability, executive functions, and memory, which has been applied to institutionalized older adults for cognitive screening. To date, we have not identified studies that have spatial navigation and its interaction with frailty. In this context, the present study aimed to analyze the association between spatial navigation and frailty in pre-frail and frail institutionalized older adults.Investigating the association between frailty and cognitive performance through spatial navigation is important to enable the early identification of individuals with physical comorbidity and cognitive impairment simultaneously. From this perspective, the verification of a single test capable of discriminating pre-frail and frail older adults, and at risk of cognitive decline, becomes relevant for screening for prodromal dementia, which would facilitate the implementation of more specific interventions to prevent and/or minimize the development of dementia as well as adverse events arising from the frail conditionThis cross-sectional study was performed in the Brazilian cities of Rio de Janeiro and Montes Claros. The data is part of two research projects, which can be accessed at the Brazilian Registry of Clinical Trials (http://www.ensaiosclinicos.gov.br), protocols RBR-6rytw2 and RBR-8dv3kg. Both projects were approved by the Research Ethics Committees of Universidade Federal Fluminense  and Universidade Estadual de Montes Claros . All participants or their legal guardians signed an informed consent form.A finite population of 200 older people living in four Brazilian Long-Term Care Facilities (LTCFs) was included, three of these located in the city of Rio Janeiro (RJ) and one in Montes Claros (MG). The sample calculation, considering the significance level of 5%, the proportion of 50% of individuals per group, and the confidence interval of 95%, was performed using the Australian Bureau of Statistics website , which identified that the sample should be composed of 132 individuals. Participants were recruited according to the following inclusion criteria:Being a resident of a long-stay institution for older adults;Having preserved communication skills;Having medical consent to perform physical exertion;Not having neurological impairment or neurodegenerative diseases, based on the diagnosis made by the physician.The following exclusion criteria were applied:Having severe cardiovascular impairment;Suffering from acute musculoskeletal injury andDelirium.; in addition, some older adults were unable to complete the assessments, which forced us to use convenience sampling, since the number of participants was below that was estimated in the sample calculation.Only 40 older people of both sexes, aged over 60 years, were considered eligible to participate in this study. The reduction in the number of participants was due to the high prevalence of cognitive impairment, dementia, and physical disability in LTCFsIn the morning, the older adults underwent the cognitive test  and, in the afternoon, on a different day from the cognitive test, they performed the frailty tests. The Floor Maze Test (FMT) was applied in the afternoon. The main aspects observed were: older adults’ willingness to perform activities, meal times, and free time to answer questionnaires and perform physical tests.. It consists of 11 items with a 30-point score and was used to track the cognitive level through memory and short-term retrieval, temporal and spatial orientation, language and visuospatial skills, calculus, and praxis. Different reference values were used for different levels of education: ≤ 13 points (illiterate), ≤18 points (from one to seven years of schooling), and ≥26 points (>eight years of schooling). There was no exclusion of participants based on the stratification of the MMSE.The MMSE was used to assess global cognition. The evaluation consisted of two moments, with a 10-minute interval between the end of the first and the beginning of the second. The time spent between the end of instruction and discovery of the correct route (planning time — PT) and the time spent traveling from the entrance to the exit of the maze (immediate maze time — IMT) were recorded. After the end of the course, the individuals were taken to a room, without visual contact with the maze, where they remained for 10 minutes. Then they were positioned at the entrance of the maze and instructed to follow the path that leads to the exit (delayed maze time — DMT) without prior planning. The amount of time used to perform the IMT and DMT is inversely related to the spatial navigation capacity; in this sense, the longer the time used by the IMT and DMT participant, the worse the spatial navigation ability. In this study, PT was not used, as there was no guarantee that the older adults really planned the route.Spatial navigation was assessed using the FMT which considers five objectively measurable components: unintentional weight loss, self-reported exhaustion, low level of physical activity, slow gait , and grip strength (hydraulic hand dynamometer SH5001 SAEHAN®). The older adults were classified as pre-frail (one or two components) and frail (three or more components). No robust older individuals were identified.The frailty syndrome was evaluated using the Frailty Phenotype proposed by Fried et al.,.The 2.44 m Up and Go test was selected to assess gait through agility and dynamic balance. Test execution time is timed from the sound signal emitted by the evaluator to the moment when the subject sits on the chair. After a familiarization test, three tests were applied and the shortest time was countedDescriptive statistics were used and the data are presented as mean and standard deviation , median, minimum and maximum . The Shapiro-Wilk test was used to test normality in the distribution of data regarding age, Timed Up and Go, FMT (IMT and DMT), and MMSE. After this analysis, the Mann-Whitney test was chosen to verify differences in age, agility, and dynamic balance, and time of IMT and DMT between groups. The independent t-test was used to compare the mean values of global cognition. Principal component analysis (PCA) was used to explore the variance and possible associations between variables  within the sample. The results of this analysis included the combination of the two main generated components, which explained 72% of the variability present in the data. The variables that presented the highest values in the two main components were used in a binary logistic regression model, in order to test the association of these variables with frailty, using odds ratio estimates. The Backward Stepwise method was used and the pre-frail stage was considered as a reference category. Omnibus, R² Cox and Snell, and R² Nagelkerke tests were used to test the coefficient of each model. p-values ≤0.05 were considered as indicators of statistical significance in all analyses, which were performed using Statistical Package for the Social Sciences (SPSS) version 21.0 and Jamovi (version 1.6).The PCA based on the correlation matrix was used to standardize the data through the Z-score and prevent the variables with a larger numerical scale (IMT and DMT) from gaining greater importance over the other dependent variables. The analysis revealed that the combination of the two main components explained a total of 72.2% of the data variance, with the first component contributing 47.61% and the second 24.63% in the model. The variables that most contributed to the first component were IMT and DMT, and, to the second, age and gait speed.2=0.313, df=1, p=0.576). The variable explained 22–29.5% of the frailty (Cox and Snell R2=0.220 and Nagelkerke R2=0.295). The older adults who showed the lowest performance times in the DMT (best performance) had four times the chance of belonging to the pre-frail group. The regression model before considering the independent variables showed 54.3% of correct prediction. After including the DMT variable, the predictive power of the model increased to 65.7%. Sensitivity and specificity were 52.6 and 81.3%, respectively.This study showed that execution time in the DMT can be associated with the frailty stages. Older adults who presented shorter execution times in the DMT (better performance) have more preserved spatial navigation abilities and are more likely to belong to the pre-frail group., there was no difference in the distribution of age between the groups, as well as no association with frailty in this study. The sample size may be a possible explanation for this divergence. Regarding space navigation, Sanders et al. reported that the performance of individuals in both IMT and DMT was not associated with age, which leads us to believe that frailty can be an influencing factor that does not depend on age in spatial navigation ability.Although frailty is an age-dependent clinical condition demonstrated that the association between frailty and cognitive performance can be found from 75 years onwards  and its chance is 15 times greater from 85 years old . In our study, the screening of global cognition between groups showed a significant difference, which may be a confounding factor to be considered; however, this difference was also found in studies that compared global cognition and cognitive performance between pre-frail and frail older adults. Alves et al. showed that global cognition and short-term memory are different between pre-frail and frail older adults (p<0.01), with global cognition explaining 14–19% of the frailty model.A previous studyAlthough global cognition was different between groups, in the PCA analysis this variable did not show sufficient value to compose the binary logistic regression model, showing the direct association of frailty with spatial navigation.. Tangen et al. verified that individuals with subjective cognitive impairment, MCI, and AD had worse performance in the FMT, according to the severity of the impairment. Zanco et al. showed that older people with AD have significant deficits in spatial navigation and that IMT and DMT are related to the impairment of global cognitive status. Our results showed that time spent to go through the maze in both IMT and DMT was different between groups. Frail older adults took longer to exit the maze, which corroborates previous studies, as these individuals also had lower levels of global cognition.Some studies report an association between spatial navigation, global cognition, and cognitive impairment and is one of the components for the assessment of frailty; in addition, worse performance on DMT is associated with an increased risk of developing motoric cognitive impairment. Our data reinforce this sensitivity, as frail individuals have worse gait performance, and a better performance in DMT was associated with the pre-frail stage. Time on IMT and age were considered protective for the pre-frail stage in our analysis, which is intuitive, as better IMT performance and younger age are associated with more preserved cognition and lower risk of motoric cognitive impairment and frailty. Such information provides us with guidance that should be explored in further studies that investigate the association between spatial navigation and frailty through the FMT.It is important to emphasize that only DMT was associated with the stages of frailty in the binary logistic regression analysis. A possible explanation is the fact that gait speed is only associated with DMT, there was no difference between groups or association with frailty. The choice of the Up and Go test as a gait speed evaluation parameter was determined by the similarity of its execution with the FMT since both tests require a response to an initial sound command and a change of direction during the trajectory.Although questions related to gait are considered important in understanding frailty, cognition, and risk of dementia. To date, the mechanisms and pathophysiology underlying the increased risk of dementia in frail older people are not completely clear. However, frailty and dementia are complex and heterogeneous conditions that share risk factors in their development and may present a pathophysiological convergence concerning the brain.A close interdependent relationship between frailty and cognition is also described in the literature, postulating that the impairment of one component can interfere with the other, a cycle of deleterious events that reduce functional capacity and quality of life, which may increase the risk of dementia and evolution to death using magnetic resonance identified that the presence of frailty verified through Fried's criteria is related to signatures in the brain regions that are fundamental for spatial navigation, such as a reduction in the volume of the hippocampus, middle frontal gyrus, right inferior parietal lobe and middle occipital gyrus, which may explain the poorer performance of frail older people in the ability of spatial navigation found in our study.The study by Chen et al.. Our results demonstrate that the FMT, in addition to being a predictor of MCI, motor deficit, and a predictor of prodromal dementia, is a practical test, of easy clinical application and low cost, that can be used to differentiate from pre-frail and frail older adults through spatial navigation. It facilitates the diagnosis of cognitive decline and frailty, which are two important conditions related to the health of institutionalized older adults.Both spatial navigation and frailty seem to be dementia predictorsOur study has some important limitations; the first is sample size. It was not possible to reach the number of individuals predicted in the sample size calculation. Another limitation is the absence of robust older people in the sample. With a larger sample and the presence of robust older adults, it would be possible to further explore the data, to establish the magnitude of the influence of independent variables on dependent ones and the degree of accuracy in differentiating pre-frail and frail older adults. Although our study has limitations, the results of our analysis point to an interesting path that should be investigated in longitudinal studies with larger samples in order to identify individuals with simultaneous cognitive and physical impairment at an early stage.Frailty is associated with impaired spatial navigation ability in institutionalized older people regardless of age and gait speed. Institutionalized pre-frail older people perform better on the FMT when compared to their frail peers. The early identification of frailty and cognitive impairment has a substantial impact on the quality of life of older adults, as it allows the use of multicomponent methods and treatments, such as increased exercise and cognitive training, in order to reverse the frail state, improve the cognitive performance and delay and/or prevent the onset of dementia. In addition, early identification of dementia and frailty is extremely important. Using one test to identify both conditions reduces the number of tests used to evaluate older adults, reduces costs, and facilitates the adoption of health policies for this target population. It is important to prioritize multi-component strategies that integrate financial investments and quality of life, focusing on frail older adults and actions aimed at them.


The advancement of the mobile app market is reshaping healthcare, emphasizing the imperative for quality and efficacy in health applications. This methodology has been devised to assess mobile health applications, aiming to assist healthcare professionals in selecting apps for e-healthcare consumers. Key facets of this approach are:•A stringent selection process within mobile app stores•A standardized assessment using the Mobile App Rating Scale to achieve consistent and replicable evaluations, systematically organizing app evaluations•A comprehensive framework guiding healthcare practitioners in determining which apps to integrate into clinical practice and which to excludeCentral to this method is the emphasis on distinguishing apps that enhance clinical practice from those that fall short in important areas such as the effectiveness of proposed health features, data accuracy, adherence to clinical guidelines, data security, and user privacy. With heightened attention to usability and accessibility, the methodology also addresses the common risks inherent in mHealth implementation, ensuring that selected apps not only meet technical criteria but also align with the broader healthcare ecosystem's needs and challenges.  Specifications tableThe technological advancement of recent decades has had a profound impact on multiple sectors of daily and professional life, and healthcare is no exception The presence of these platforms has made the publication and distribution of applications a simpler and more accessible process for developers, leading to an exponential increase in the number of available applications A critical aspect of this proliferation of healthcare apps concerns their quality and effectiveness. Not all applications undergo rigorous quality control or scientific evaluation before being made available to the public The objective of this research methods is to develop a standardized quality assessment system for healthcare applications. This method is designed to be used by teams of healthcare professionals or research groups, rather than by single individuals, in order to ensure a thorough and objective analysis. The application of the method by a team allows for a more balanced evaluation, minimizing potential biases that could emerge if the method were applied by a single professional. The method covers various key aspects: the effectiveness of the proposed healthcare features, the accuracy of the information provided, compliance with clinical guidelines, data security and privacy, and finally the usability and accessibility of the user interface.Furthermore, this method is designed to be flexible and able to adapt to the new challenges and changes characterizing the rapid and constant evolution of the application market. This work represents a significant step forward in ensuring that the potential offered by mobile technology is best exploited to improve patient health and wellbeing, while minimizing associated risks.In a preliminary phase, a thorough analysis of relevant documents and clinical practice guidelines released by recognized health organizations and foundations should be carried out. This initial step is crucial to gain an adequate understanding of current best practices and official recommendations in the study area. This information can also aid in defining the inclusion and exclusion criteria for the apps to be evaluated. Subsequently, a comprehensive and systematic search of mobile applications will be conducted by two academic researchers to ensure objectivity and reduce the risk of bias. The main databases for this search should be Google Play Store and Apple Store, given their predominance in the mobile application market. The use of two researchers will allow for a comparison and contrast of results, thus enhancing the reliability of the selection process.As the use of abbreviations and logical operators is not possible in the app store databases, each relevant keyword for the study area should be entered individually. This method will increase the likelihood of identifying all pertinent applications. In addition to the systematic search, a manual search using Google or other search engines should be conducted. This additional step can help to identify any application that might have been missed during the systematic search.When planning a comprehensive assessment of mobile applications for health purposes, the research will be conducted by two independent academic researchers. The decision to involve two reviewers not only adds to the robustness of the methodology by reducing the potential for bias, but also contributes to the overall reliability of the assessment, given that different reviewers might perceive and interpret the same app features differently. The search process itself needs to be thorough and meticulously conducted. It would involve the identification of the apps, a preliminary evaluation based on the app store descriptions, and the subsequent download of the chosen applications for a more detailed screening.Establishing clear inclusion criteria from the outset would be crucial. Some potential criteria might include: (1) the language in which the application is offered, taking into account the linguistic and cultural context of the target population for the study, (2) the demographic or population that the application is designed to serve, ensuring a match with the intended study group, (3) the specific health condition addressed by the application, ensuring direct relevance to the subject of study, (4) the presence of personalized healthcare programs within the application, indicative of the level of user-centered approach of the app, (5) the cost factor, favoring free applications or those offering a trial period of at least 14 days, to ensure equitable accessibility and usability for a diverse range of users, and (6) the privacy policy, selecting the apps that guarantee data protection and respect for user privacy.In the same vein, well-defined exclusion criteria should also be set. For instance, one might exclude mobile health apps focusing on health conditions that are outside the research scope, to ensure that the selected apps are all pertinent and related directly to the research interest. Furthermore, apps created specifically for professional healthcare providers could also be excluded as they may introduce a level of complexity not intended for the general public, and could therefore skew the study results.Several tools are available for assessing the quality of health mobile apps. In 2023, Jacob et all. conducted a comprehensive review of eHealth tools, resulting in the categorization of 36 unique criteria into 13 clusters •comprising a toolkit that encompasses fundamental dimensions, such as information accuracy and reliability, usability, accessibility, data security, regulatory compliance, interactivity, and engagement;•demonstrating reliability, objectivity, and impartiality through subsequent validation studies;•featuring ease and expediency of use;•utilizing quality assessment criteria derived from a systematic analysis and synthesis of pertinent literature.In this context, we believe that the ideal scale should possess key attributes to ensure a precise and valuable assessment of applications, namely:In the landscape of assessing the quality of mHealth apps several evaluation tools have emerged. These include Enlight Our perspective underscores the suitability of the MARS scale for a methodical and standardized evaluation of the selected mobile apps. Originally developed by a team of researchers in Australia, the MARS provides a comprehensive multidimensional measure for the classification and assessment of mobile health apps, making it an invaluable tool in this context (Supplementary File).The MARS scale consists of 19 items divided into four broad sections, each assessing a different aspect of the app's quality. The “Engagement” section, for example, evaluates the app's ability to capture and sustain user interest over time. This is an essential feature of any app as sustained engagement contributes significantly to the app's efficacy. In this section, factors such as the entertainment value, the degree of customization allowed by the app, and the extent of interactivity are considered.Next, the “Functionality” section focuses on the app's performance and user-friendliness. It examines the ease of use, the navigation structure, and the gestural design of the app. These are all critical factors that can directly affect the user's experience and ultimately influence the app's effectiveness.The “Aesthetics” section appraises the visual aspects of the app. It takes into consideration the graphic designs, overall esthetic appeal, color schemes, and the style consistency. Although seemingly trivial, these factors can significantly impact the user's perception of the app and their willingness to use it regularly. Lastly, the “Information” section assesses the app's content in terms of its credibility, relevance, and quality. This section is particularly crucial for health-related apps, as the reliability of the information provided can directly impact the health outcomes of the users. It scrutinizes various elements such as the accuracy of app descriptions, goals, quality and quantity of information provided, visual information, credibility of the sources of information, and evidence base. In addition to these four main sections, MARS includes a “Subjective Quality” section, giving an overall user impression and a “Specificity” section that assesses the app's potential to change the user's knowledge, attitudes, and intentions to change behavior.The MARS scale is available in various languages including, but not limited to, Spanish (MARS-S) The MARS scale distinguishes itself from other assessment instruments by its rigorous foundation in a systematic analysis and synthesis of pertinent literature. Unlike several other scales, the MARS scale doesn't arbitrarily select criteria but ensures their relevance through a thorough literature-based approach Furthermore, the MARS scale offers practical advantages. Its user-friendliness and efficiency stand out, as it requires only a brief 15-minute preparation by professionals. This is a marked contrast to more intricate and time-consuming matrices like that of Khoja et al. The Health Information Management Systems Society (HIMSS) guidelines, while valuable for assessing app usability in terms of efficiency, effectiveness, and user satisfaction, neglect the criteria for evaluating the quality of the information. This omission is critical, as inaccuracies or inadequacies in healthcare information within mHealth apps can jeopardize user safety. In contrast, the MARS scale comprehensively addresses information quality as one of its fundamental criteria.Regarding Enlight By utilizing this standardized scale, researchers can ensure a comprehensive, consistent, and objective evaluation of each app. This would allow for a deep understanding of the app's quality and efficacy from multiple perspectives, which would be instrumental in identifying the most appropriate and effective health apps for recommendation or further research.To conduct a meaningful assessment of mobile applications, it will be necessary to ensure that evaluators are well-trained and capable of conducting an in-depth analysis. This will likely require the assembly of a diverse team of healthcare professionals to act as evaluators, in line with the scope and target of the apps and the health condition being studied. The composition of the team can vary but it is important to ensure a variety of perspectives and skills. For example, in a previous study Team members should undergo thorough training to familiarize themselves with the specific tool being used for the evaluation, in this case, the MARS scale. If the MARS scale is not available in the native language of the evaluators, training could be conducted via an e-learning course, with training videos and materials in English. However, this is contingent on both the evaluators and the ultimate end-users (patients) having a competent level of understanding of English. It's crucial that all evaluators understand the MARS scale, its sections, and the nuances of its scoring system to ensure a uniform evaluation across different applications. For effective training, evaluators should engage in practical exercises where they test and assess pre-selected apps. The length of testing could vary, but at least 15 min of usage per app should be considered to allow for adequate exploration of its features. As substantiation of this, even in the study conducted by Martinon et all., in order to assess the quality of nutritional mobile applications available in the French market, evaluators downloaded and subjected each application to a minimum testing duration of 15 min Once training is complete, the assessment process can commence. The length of this process will depend on the number of apps to be evaluated, but sufficient time should be allocated for an in-depth analysis. During this process, each evaluator should independently use each assigned application for an appropriate duration  and then immediately evaluate it using the MARS scale questionnaire. This approach aims to reduce recall bias and ensure that evaluators' impressions of the apps are precise and accurate.The use of the web-based MARS scale questionnaire would facilitate real-time recording of evaluators' responses, which can be easily collected for subsequent analysis. This procedure ensures a uniform and systematic evaluation process, which is critical to generate reliable and robust data on the quality of the apps under consideration.In The selected mobile applications should be organized according to the specific objectives of the investigation; then the findings and comprehensive conclusions should be summarized for each individual objective. These should be reported, as for example in a literature review, both as a narrative summary and as statistical results, in well-structured tables These tables should provide a comprehensive and transparent summary of the study's findings. For instance, they could include the name of the mobile application, the overall MARS score, as well as the score for each MARS subcategory. This would offer a detailed insight into the strengths and weaknesses of each app, enabling a more direct comparison amongst them. Furthermore, these tables could provide additional details about each app, such as the target population, the health condition addressed, and any other notable features, thereby enriching the depth of information available to the end user.The presentation of results as a narrative synthesis and in tables facilitates clear communication of complex data. It provides an efficient way to share and interpret the study's findings while also allowing for a more detailed examination of the data where necessary.U test could be applied. The Mann-Whitney U test is a non-parametric test, which signifies that it does not rely on any assumptions about the distribution of the data. It is commonly deployed in cases where the data are not normally distributed or where the sample sizes are small. Two-tailed p-values less than 0.05 should be deemed as statistically significant.The data collected should be anonymously input into a specialized database and analyzed using an appropriate statistical software package. The specific software chosen should be capable of conducting a wide range of analyses, from descriptive to inferential statistics, and should be well equipped to handle large datasets efficiently. Descriptive statistics, such as the median, the interquartile range (IQR), and frequencies, should be employed to summarize the data. The apps should be evaluated using the MARS questionnaire. For the analysis of ordinal variables, the Mann-Whitney The choice of the statistical test should be guided by the nature of the data, the research question at hand, and the distribution of the data. Emphasis should be placed on ensuring that any statistical analysis adheres to the principles of transparency and rigor, guaranteeing that the results are both reliable and robust. Utilizing these methods will bolster the integrity of the findings and provide more valuable insights from the collected data.In A possible limitation of this methodology lies in suggesting a strategy for assessing health apps based solely on a limited number of criteria arbitrarily evaluated as important and encompassed within the MARS scale. A future development could involve the validation of an indicator system for assessing the appropriateness of a quality evaluation scale for health apps.This method has established a methodology for the assessment of health applications available on the Apple App Store and the Google Play Store with the objective of aiding teams of healthcare professionals or research groups in the selection of apps to be employed for e healthcare consumers use. Particularly, through its proper application, this method can assist healthcare practitioners in discerning which apps to incorporate to bolster clinical practice and which to discard due to their unsuitability concerning the effectiveness of proposed healthcare features, accuracy of information provision, adherence to clinical guidelines, data security, privacy, usability, and accessibility. Indeed, these aspects represent common risks within the realm of mHealth implementation in healthcare.10.2196/mhealth.3422.English Version of the Mobile App Rating Scale (MARS) available at: doi:MS: Conceptualization, Methodology, Writing Original Draft, Review & Editing, Investigation, Visualization; DA: Conceptualization, Methodology, Writing Original Draft, Review & Editing, Investigation, Visualization; LG: Methodology, Writing Original Draft, Statistical Analysis, Review & Editing, Visualization, Coordinator; DG: Methodology, Writing Original Draft, Review & Editing, Visualization, Coordinator.MS & DA provided an equal contribution as first author in drafting the manuscript; LG & DG provided an equal contribution to the coordination of the research group. All authors read and approved the final manuscript.The authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper.


Tourism is one of the most important promoters of sustainable development in many nations and regions around the globe. Tourism expansion has been a significant contributor to social and economic growth, particularly in developing economies. It is, however, vulnerable to all kinds of health crises and natural disasters, no matter how small they are. The primary purpose of this study is to acquire an empirical understanding of the effects of health crises and disasters on international tourism. The SYS-GMM was used to examine the impact of health calamities and crises, carbon footprints from transportation, and green finance on the tourism of 51 countries between 2007 and 2020. The results showed that health crises and natural disasters have a big effect on international tourism. Alternatively, the presence of eco-friendly and secure transportation at tourist destinations has a positive effect on the tourism industry. The results also showed that environmental expenditures have positive short- and long-term effects on international tourism. Furthermore, the sensitivity of travelers to health crises and natural disasters varies over the short and long term. The study also showed that compared to normal times, international tourism dropped by more than 67% during COVID-19. Consequently, this research assists us in comprehending, predicting, and preventing the potential adverse effects of COVID-19 and other similar economic, health disasters and crises that could occur in the future and harm the tourism industry. The tourism industry has evolved rapidly over the last three decades in several countries around the globe, and it has been widely recognized as a key driver of economic growth and development, especially in emerging markets and developing countries. Tourism is also one of the most important sectors owing to its large contribution to global employment ,2 but diEven though the tourism industry has become more resilient to various crises, it is still the sector most affected by the COVID-19 pandemic. The current health crisis confronting this industry is not only distinct from previous ones, but it may also have significant long-term implications for tourism as a socioeconomic activity and industry. The most important things about this pandemic are its global and huge size, as well as its many and interconnected effects, which challenge current values and systems and cause a global economic slowdown and depression ,9. The CThe COVID-19 will have different impacts on the tourism industry of various countries due to its uneven economic impacts and depending on the strictness of public health and social measures  . Global Crises may bring about change, but the tourist industry has not yet undergone a profound transformation . Crisis-Green financing is recognized as one of the pathways to foster sustainable economic growth and achieve several of the current United Nations’ sustainable development goals. Environmental quality is prioritized more in green finance than in traditional finance, which places less emphasis on ecological conservation and efficient resource use. Green finance targets to attain sustainable development by incorporating financial activities with ecological protection. Green finance is a cutting-edge financial concept that combines ecological protection with financial benefits . A very Therefore, the following research questions have been formulated: i) To what extent does a health disaster or crisis impact tourism at a destination? ii) To what extent does the quality of health services contribute to the revitalization of the tourism industry? iii) To what extent does green finance affect the tourism industry? To what extent do air quality and transportation carbon footprints affect global tourism? Based on the aforementioned research inquiries, it is possible to construct research hypotheses; for instance, the anticipated health disaster or crisis is projected to have an adverse impact on the international tourism industry. The quality of health services and implementation of green finance are anticipated to have a positive impact on the revitalization of global tourism. The adverse impacts of suboptimal air quality and inadequate transport infrastructure significantly undermine the global tourism industry.So, the main goal of this study is to look at the effects of current and past health crises, as well as green financing, on the global tourism industry. This will help professionals and academics better understand and value both the touristic effects and transformative opportunities of health crises and green financing, as well as filling in gaps in the literature. The first objective of this research was to analyze the effects of health disasters and crises on international tourism. The second objective of the study was to explore the effect of green financing on the world tourism industry. Another key objective of this study was to examine the impact of transportation carbon footprints and safe transportation system on the tourism inflows.This study is the first to examine the impacts of health disasters and crises, air quality, and green financing on the global tourism industry. It would contribute significantly to decision-making on sustainable tourism during the ongoing health crisis, as well as how transitioning to a green economy can affect international tourism.This research is an important addition to the growing body of scientific literature. It will help us understand, predict, and prevent the possible negative effects of the COVID-19 crisis and other similar economic and health crises that could happen again in the future and hurt the tourism industry. Furthermore, this research will improve our understanding of how to support, encourage, shape, or even lead the tourism industry during health crises and disasters.The term "disaster" refers to an occurrence characterized by a sudden, unpredictable, or significant manifestation of unfortunate circumstances . Carter Attractions are considered essential components of tourism ; diverseThe occurrence of sudden insecurity has a notable influence on the demand for tourism  as it isThe preservation and maintenance of the environment, encompassing both natural and man-made elements, play a crucial role in the development and sustainability of tourism. Nevertheless, the interplay between tourism and the environment is multi-faceted. This encompasses a multitude of activities that have the potential to have detrimental effects on the environment. Numerous consequences are associated with the development of essential infrastructure, such as transportation networks and aviation hubs, as well as the establishment of tourism services encompassing resorts, hotels, dining establishments, retail outlets, golf courses, and marinas. Air quality plays a significant role in tourists’ decisions . The numPotential tourists exhibit a keen interest in places to visit that possess both aesthetic appeal and cleanliness, while also providing services of exceptional quality. Nevertheless, an environment lacking the characteristics of a high-quality environment not only fails to attract visitors, but also fails to provide an enjoyable environment for the residents of the area . AccordiIn summary, attractions play a significant role in the advancement of tourism. However, relying solely on attractions as a prerequisite for the glory of a tourist destination is insufficient. This is due to the fact that the absence of safety measures, low air quality, poor infrastructure, and dirty environment can hinder the growth and sustainability of tourism, as emphasized by the statement "no safety, no tourism" .The empirical analysis of the current study is based on a time-series dataset for both developing and developed countries. Due to a lack of required data, the number of countries considered has been reduced to 51 in this study. The variables of the study comprise tourism, health crises, transport infrastructure, healthy system quality, environment, and green finance-related factors that affected the tourism industry over the period of 2007–2020. The current study incorporates data from a variety of sources, such as the World Development Indicators (WDI), the International Monetary Fund (IMF), and the World Health Organization (WHO).A country’s tourism can be measured using a variety of measures, including the amount of money spent on leisure travel, business travel, travel and tourism that directly contributes to GDP, and the number of tourists who cross its borders. The current study considered international tourism receipts (US dollars) to capture the tourism.A crisis denotes "occurrences that are more tightly related to the company’s surroundings," but a disaster, on the other hand, is the outcome of an external action that may have an immediate impact . TherefoTourist road injuries and deaths are a major concern for tourist authorities and policymakers working to increase tourism in their respective countries. A tourist with a bad experience will share their negative story with an average of 11 people. Wilks et al.  describeHealth spending per person is affected by a wide range of social and economic factors, as well as the organizational structure of a country’s health system . As a reAir quality is also a very important part of tourism, since the main reason people travel is to get away from their everyday lives and find a place where they can relax and release stress . So the As a measure of green finance, this study considers a touristic country’s environmental expenditure for reducing the types of pollution  and investment for ecological conservation (protection of biodiversity and landscape).This study has used two control variables (per capita income and population), as these variables are likely to affect the size of the response to government economic and tourism policies. The per capita income significantly differs among countries, which affects the development of tourism policies . FurtherThis research used the system generalized method of moments (SYS-GMM) model to analyze the effect of health disasters and crisis, transport infrastructure quality, air quality, the health system, and green finance on international tourism. This model was preferred for the present data set because it can address many hidden problems in the panel data such as endogeneity, correlation, heteroskedasticity, and autocorrelation ,62. The Moreover, in cases where the number of time periods is limited and the time series exhibits persistence, it is expected that the GMM estimators will exhibit poor performance after applying the first difference technique . The inaThe GMM approach proposed by Arellano and Bover  and BlunIn our GMM estimation, we used Arellano and Bover’s 67) specification tests to determine how well the instruments worked as an empirical inquiry [ specificEven though both types of GMM models, such as difference GMM and system GMM, have gained popularity among research scholars, Levine et al.  describeThe extended version of the GMM estimator, also known as the System-GMM estimator developed by Blundell and Bond 65), is considered acceptable and has been employed in this study because of its evident advantages over other methods used to estimate standard linear dynamic panel data models [, is consit (dependent variable) describes the tourism receipts, which describe the revenue received from tourist inflows in a country; yit-1 represents its lagged value. The zit is the vector of control variables; the xit describes the vector of explanatory variables; and the uit is the error term; it includes the "random error term" and the unobserved country-specific effect or fixed effect. A necessary condition of SYS-GMM is that the error term should not have second-order serial correlation; otherwise, the standard error for instrument estimates grows without bound [yut bound . Therefout bound  were empThe main objective of this study is to analyze the effects of health crises, transport infrastructure quality, and green finance on international tourism. Descriptive statistics for the different variables for the 51 countries are presented in Regarding the units of the variables before converting them into log form, the tourism receipts and health expenditure variables were measured in US dollars, and the carbon footprints were measured as a percentage of total fuel combustion. Mortality from road injuries and health crises was expressed in terms of the number of deaths; the air quality parameter was measured in micrograms per cubic meter, and green finance was measured in the form of local currency that was converted first into US$ before taking their log form.The results presented in The theoretical literature has suggested positive and negative correlations between the determinants and tourism in this study. The aggregate linear correlation between variables that occurred during per capita income and population changes over time provides useful intuitions. The first aggregate correlational linear relationship between deaths due to health crises and tourism describes significant negative results. This negative relationship between health crises and tourism is shown in The green finance improves the tourism of the countries, which can be described by the results available in The short run and long run coefficients estimated by using SYS-GMM are given in The results also showed that the quality of the transportation infrastructure  negatively influenced tourism. The transportation carbon footprints also have an inelastic short-run effect on tourism. In the short run, a 1% increase in the CO2 emissions from transportation will reduce tourism by 0.32%. In the long run, a 1% increase in CO2 emissions from transportation will decrease international tourism by 1.51%. In the long run, the relationship between emissions from transportation and tourism is elastic. A 1% increase in mortalities due to road injuries will reduce international tourism by 0.18% in the short run, while it has no significant relationship with tourism in the long run. However, mortality due to road injuries and tourism has an inelastic relationship in the short run.The model results for air quality show that a 1% increase in PM 2.5 causes a 0.22% decrease in international tourism, indicating an inelastic relationship between air quality and tourism in the short run. On the other hand, a 1% increase in PM 2.5 will decrease international tourism by 1.04%. This demonstrates that air quality and tourism have a greater long-term impact than a short-term one.Green financing has a significant short- and long-term impact on international tourism. In the short run, a 1% increase in green finance will cause 0.10% increase in tourism. In the long run, the effect of green finance on tourism is larger than in the short run because a 1% increase in green finance will increase tourism by 0.46%.The We looked at the impact of various additional control variables on the findings during the robustness check. We used the log of urban population as a percentage of total population, and the log of population density because these variables have a significant correlation with tourism . Table 4Tourism is an important sector for world economic growth and requires special attention and different policies during various health disasters and crises for sustainable tourism. The panel of 51 countries in this study is subjected to the six different repressors in this study . The lagged variable for tourism in the current study is positive and significant. More international tourism in a year contributes positively to the development of tourist places, which attract more tourists the following year. The increase in revenue at the tourist sites induced the development activities to proceed at a high pace. This means that tourism contributes to sustainable tourism and development. These results are in line with Gao et al. .Health disasters and crises are also one of the most important factors that affect the international tourism inflow. Health disasters and crises both result in high death rates, influencing tourists’ perceptions and behaviors toward the touring country. The world has become a global village, and people are inextricably linked to one another. News of various disasters and crises reaches every part of the world quickly, both via social and mainstream media, ultimately influencing the decisions of foreign tourists. The media fuels such factors by creating a bad image of the destination , which sEcofriendly and safe transportation is a basic necessity and a prerequisite for sustainable tourism in any country . Better The current study found both short- and long-term negative impacts of poor air quality on international tourism. The results related to air quality corroborate with Zhou et al.  who alsoGreen finance includes the financial activities that have been conducted to ensure a better environmental outcome. The findings of green finance on tourism are consistent with previous research from Ip et al. , Zhang , and XiuTourism is one of the main sectors that contribute significantly to sustainable economic development, but the tourism industry in any country is influenced by a number of factors. The significant negative impact of health crises and disasters implies that a 1% increase in deaths will reduce tourism by 0.07% in the short term and 0.02% in the long term. The 1% increase in CO2 emissions from transportation reduces tourism by 0.32% in the short run, while it has a significant impact in the long run by reducing tourism by 1.51%. Mortalities due to road injuries decrease tourism by 0.185 in the short run and 0.86% in the long run. The air quality impact was elastic in the long run, with a coefficient value equal to 1.04%, and inelastic in the short run, with a coefficient value of 0.22%. The significant positive impact of green finance implies that tourism will increase by 0.10% in the short run and by 0.46% in the long run due to a 1% increase in environmental protection expenditure. The model results depicted that health disaster and crises, the quality of health systems, transportation carbon footprints, and mortality from road accidents, air quality, and green finance all significantly affect international tourism. This demonstrates that the presence of a well-managed health system, an environmentally friendly and safe transportation system, better air quality, and more green finance in terms of pollution reduction investment increase international tourism in the destination country. To accomplish this, financial institutions should accelerate their policies to provide cheaper green loans in order to improve investment in reducing environmental pollution. Further, green finance experts and financial authorities view the involvement of environmental protection departments in the development and enforcement of regulations at various tourist destinations as essential. Governments must ensure harmonious coordination between monetary and fiscal policies. To enhance the ecological conditions of tourist destinations and attract visitors, it is imperative to strategically adjust the financial allocations and government expenditures related to controlling environmental pollution. This approach aims to achieve mutually beneficial outcomes for both the environment and the tourism industry.The main limitation of this study was the availability of data for all countries. The limited availability of data for the countries reduced the number of countries to 51 in this study. Moreover, the study does not take into account the demographic differences among countries for data analysis, which might have affected the results of the study. There are some other variables that may affect sustainable tourism during the pandemic, such as digitalization, but these could not be considered due to the unavailability of authentic data for the studied countries. Despite these limitations, this study provides insightful findings for policymakers aimed at sustainable tourism worldwide.S1 File(RAR)Click here for additional data file.