Work-related stress is a global problem causing suffering and economic costs. In Sweden, employees in human service occupations are overrepresented among persons on sick leave due to mental health problems such as stress-related disorders. The psychosocial work environment is one contributing factor for this problem, making it urgent to identify effective methods to decrease stress at the workplace. The aim of the study is to evaluate a participatory intervention to improve the psychosocial work environment and mental health using an embedded mixed methods design. The study is a controlled trial with a parallel process evaluation exploring fidelity and participants’ reactions to the intervention activities, experiences of learning and changes in behaviours and work routines. We collected data through documentation, interviews and three waves of questionnaires. Our results show small changes in behaviours and work routines and no positive effects of the intervention on the psychosocial work environment nor health outcomes. One explanation is end-users’ perceived lack of involvement over the process causing the intervention to be seen as a burden. Another explanation is that the intervention activities were perceived targeting the wrong organisational level. A representative participation over both content and process can be an effective strategy to change psychosocial working conditions and mental health. Common mental disorders are the predominant cause of sick leave in Sweden today. During the last three decades, the share of psychiatric diagnoses in sick leave spells over two months increased from 13 to 45 percent among women and from 16 to 33 percent among men . In thisHuman service occupations within the health and social care industry typically stand out as risk occupations for sick leave ; in partThe reasons for the increase in mental illness are multifaceted, but psychosocial work factors have been found to contribute ,8. High Organisational interventions targeting stressors in the work environment rather than the individual stress response have been proposed ,14. HoweA participatory approach has been emphasized in the literature ,24,25 anOrganisational interventions are often considered challenging to evaluate. Therefore, it is suggested that elaborative evaluation frameworks are needed in order to uncover the so-called black box . One proThe overall aim of the current study is to evaluate a participatory intervention designed to improve the psychosocial working conditions and decrease symptoms of burnout among teachers and elderly care personnel. Three research questions are included.Can improvements over time be observed in the psychosocial work environment and health outcomes for the intervention group compared to the control group?Was the intervention implemented as intended (fidelity)?What were the participants’ (a) reactions to the intervention activities, (b) experiences of learning, and (c) changes in behaviours and work routines, related to the intervention (mediators)?We conducted a mixed methods study using an embedded design , wherebyn = 60; control n = 44) (n = 82 at baseline) and two nursing home units were invited and accepted to be controls (n = 121 at baseline). The intervention and the process evaluation (interviews) include all management levels within the two administrations. The selection for the effectiveness evaluation, however, includes only frontline workers and first-line managers since the aim of the intervention was to improve psychosocial work environment and quality of sleep, and decrease symptoms of burnout in these groups. The activity within the management groups and amongst politicians are seen as means to reach the goal of an improved work environment for frontline workers and first-line managers.The intervention took place in a middle-sized municipality in Sweden from 2016 to 2018. The administrations of early childhood and childhood education and the social services were enrolled. Additionally, the municipality management team and the political boards of each administration were involved. The control groups were matched with workplaces with similar type of work. Within the early childhood and childhood education administration, the elementary school department was chosen to generate both intervention and control groups. The two enrolled schools both represent pre-school to sixth grade. All occupations within the schools were included (intervention:  n = 44) . Within The selection of participants for the interviews was purposefully stratified . The proThe intervention named “Me, myself, the team and the mission” was designed to promote mental health by enabling a dialogue on workplace challenges associated with stress as identified and prioritized by frontline employees. The job demands–resources theory (JD–R theory)  and the The implementation of the intervention focused, in line with research, on engagement from senior  and lineTo evaluate changes in outcomes over time, data were collected using questionnaires at baseline, after 18 and 24 months. Pencil-and-paper surveys were administered in September 2016 (baseline), in February 2017 (follow-up 1) and again in September 2018 (post-intervention). The surveys were distributed by the project manager in the municipality during work meetings. All employees were expected to attend the session, but participation was voluntary. Individuals who were absent on the given time for data collection were given approximately two weeks to fill out the questionnaire. Individual participants were not traceable; however, they were linked to their closest manager, meaning that all analyses are performed using aggregated data.To evaluate whether the intervention components were delivered according to plan (fidelity) we studied number of intervention activities conducted as planned and proportions attending these activities (dose received). Fidelity was examined using documentation from the project management who kept careful notes of planned and completed activities with completed attendance lists.Sequential semi-structured individual interviews collected data on reactions, learning and changes in behaviours and in work routines, see The open-ended interview guide was informed by the Nielsen and Randall framework  for evalThe primary outcome measure is symptoms of burnout, which was determined with the Shirom Melamed Burnout Measurement (SMBM) , a 14-itInformation on psychosocial work environment was collected through 9 scales from the General Nordic Questionnaire (QPSNordic) . For inft-tests for continuous variables and Pearson’s chi-square test for categorical variables.Differences in background variables, work environment and mental health at baseline between control and intervention groups were tested using independent t-tests for continuous variables. However, all outcome data is ordinal, which suggests that the median and inter quartile range should be reported and non-parametric tests be applied. However, normative data [t-tests to ensure the trustworthiness of our results. In order to test if homogeneity of variances existed between the intervention and control groups we performed Levene’s test.Since the individuals were not traceable, we applied weights and adjusted the analysis for background variables and baseline measures, respectively . Differences in work environment and mental health at 18 and 24 months between control and intervention groups were tested using independent ive data ,40 and pive data ,42 report-test for partially overlapping samples in order to handle partially different study population at each time point caused by employee turnover and drop-out [Changes of outcome variables over time was calculated using drop-out ,44,45. Wdrop-out . See SupBefore starting the analysis, we categorised the imported files in NVivo in order to organise informants by administration to enable identification of different perspectives from these two groups. The two administrations differ in several aspects, for example regarding educational level, which could mean that the intervention was perceived differently within the two administrations. The same was done to identify if the informant was a manager or a frontline worker. Dividing managers and frontline workers occurred because of their different roles in the intervention project. As the frontline workers were the main end-users of the intervention, the aim of the intervention was to improve their work environment. Hence, we compared and contrasted findings from two administrations and two stakeholder groups across time.The analysis of interview data was organized in two stages. Through both stages, we were guided by Braun and Clarke’s thematic analysis , which iAfter categorising data into the three dimensions of the Kirkpatrick model , we searNo differences were found in any of the administrations between the intervention and control groups regarding baseline characteristics such as age, gender and job tenure . HoweverRegardless of which time points being compared, for both administrations no significant within-group differences over time after adjusting for background variables and the risk of mass significance were found. No data shown.t-tests (Data not shown).Regardless of administration, our findings show no significant improvements in the intervention groups compared with the control groups for any of the outcomes, see Most of the planned activities targeting frontline workers and first-line managers were delivered according to plan with a high participation rate. However, there is a discrepancy between the management levels, where the senior management and the political level have a lower fidelity compared to the middle and line managers. Due to time constraints and high turnover rates among the senior management, they cancelled most of the planned activities. For a detailed description see The thematic analysis of the individual interviews led to the development of nine themes with two sub-themes, see Within the home care services managers agreed that the management development had contributed to clarification of goals and roles for the team. Further, frontline workers described increased learning about work routines and where and how decisions are made from participating in the horizontal dialogues. Another encouraging result for this group is the positive reporting of the impact of work groups. This intervention component contributed to both positive emotions and actual changes in behaviours and work routines. Within this activity, the participants perceived a meaningful participation in contrast to the other intervention components.One theme not depicted in The results showed, contrary to our expectations, no improvements in psychosocial working conditions or mental health. Instead, the intervention group within elderly care reported a development in an unfavourable direction regarding the psychosocial work environment when compared to the control group. Our results showed that the intervention activities basically were implemented as intended among frontline workers, first-line and middle managers. Low fidelity among these groups can most likely not explain the lack of improvements in outcomes. However, among senior management teams and the political boards, fidelity was low. Furthermore, the intervention led to few changes in learning, behaviours and work routines, which was a prerequisite for improvements in work environment and mental health.It is often assumed that organisational interventions, although they have no effect, at least do not cause harm . HoweverThe studied intervention fulfilled several of the factors identified as important in order to improve psychosocial working conditions and mental health. It had a primary organisational focus, a theoretical starting point regarding theory of health, and a participatory approach. Despite this, it was unsuccessful in bringing about the intended effects. We propose three types of explanations: (1) The design and method of the evaluation did not capture the desired changes (2) Program theory failure (3) Insufficient implementation strategies. These are discussed in more detail below.As randomization was not possible, both confounding and selection bias may have affected the reported results. At baseline, the intervention group within elderly care reported less favourable working conditions in five of the nine items, compared to the control groups. It is possible that the intervention group were on a trajectory towards more negative working conditions when the intervention started, a trajectory that the intervention activities were not able to stop. Poorer baseline levels in the intervention group could, on the other hand, be associated with room for improvements, making a positive development more likely . In the The core feature of the program theory was the participatory approach. The stakeholders were involved mainly in developing the content of the intervention. The interviews revealed that the participants perceived the aim of the intervention as meaningful; however, they had less confidence in the form in which it was delivered. The intervention design allowed participation in the development of the content of the intervention, but not over the process. The design, planning and implementation (process) of the intervention was primarily decided by the consultants and HR-representatives resulting in, it seems, a bad organisational fit . Thus, oFurther, it seems that the choice of including all frontline workers instead of using representatives (directedness) was unfortunate. The process evaluation revealed that when representatives were used  the participants reported both positive reactions and actual changes in behaviours and work routines. The analysis also shows that the component  where full participation was applied did not lead to any reported changes in behaviours or work routines, nor was it appreciated (reactions). To the contrary, participants felt that the intervention was very time consuming in relation to what came out of it, which led to frustration and disappointment. Gupta et al.  found siThe basic question here is whether the intervention activities were carried out as intended (fidelity). Fidelity was high among frontline workers and first-line managers. However, the intervention was not carried out as intended among the senior management teams and the political boards, suggesting that the anticipated support and engagement from them lacked. Another implementation strategy had the aim of enabling everyone to participate by placing the meetings on work hours with summoned substitutes. As most of the intervention components were delivered according to plan, this strategy fulfilled its function. However, it was also associated with high costs for, it seems, little effect.Similar to Aust and colleagues , the intA strength in the study is the mixed methods design, allowing triangulation of data from the different methods. Without the process evaluation data in this study we would not have been able to understand the results of the controlled trial. Additionally, the longitudinal design with multiple measurements in the controlled trial and the qualitative design (3 phases of interviews) including a large number of informants (interviews) strengthens the study. The controlled trial evaluates the intervention program in total while the qualitative component allows for evaluation of the different intervention components. This gives an opportunity to disentangle the mechanisms of change within the intervention program. One limitation of this study is the lack of identification numbers of the participants, which did not allow to link individuals over time. This means that we cannot investigate within subject changes over time and we cannot control for the possible attrition bias . HoweverOne further limitation is the selection process of the two interventions groups, allowing possible confounding factors due to differences between intervention and control groups resulting from selection bias . ParticiThe participants hoped for structural changes such as more time to spend with the care recipients and more personnel. Thus, they perceived that the intervention was targeting the wrong organisational level. This implies that researchers and practitioners, before implementing an intervention, need to thoroughly explore the context  and alloTo consider the risk of unintended negative effects of an occupational health intervention, continuously monitoring of these effects are suggested. This is in line with previous research suggesting a dynamic evaluation model for occupational health interventions where results are examined and fed back to the organisation during the trial . If a neThe studied participatory intervention with the aim of improving the psychosocial work environment and mental health failed to bring about the expected changes. We also found some negative trends regarding the psychosocial work environment for the home care unit. We have two suggestions to why. First, even though the program theory was based on a high level of participation the participants influence on the process was perceived as low and frustration over how the intervention was delivered was expressed. This failure contributed to that the intervention was seen as a burden and rendered a bad organisational fit. These consequences contributed to the lack of changes in psychosocial working conditions and mental health. Secondly, our results indicate a lack of fundamental organisational capability in the sense that basic prerequisites such as human and technical resources were insufficient in some respects. Hence, the intervention activities were perceived targeting the wrong organisational level.Finally, we recommend that the design of future interventions utilize representative participation over both content and process, which may be an effective program theory to change psychosocial working conditions and mental health. This should also be a focus for future studies.


Artisanal small-scale gold mining (ASGM) in the Amazon results in the dumping of tons of mercury into the environment annually. Despite consensus on the impacts of mercury on human health, there are still unknowns regarding: (i) the extent to which mercury from ASGM can be dispersed in the environment until it becomes toxic to humans; and (ii) the economic value of losses caused by contamination becomes evident. The main objective of this study is to propose a methodology to evaluate the impacts of ASGM on human health in different contexts in the Brazilian Amazon. We connect several points in the literature based on hypotheses regarding mercury dispersion in water, its transformation into methylmercury, and absorption by fish and humans. This methodology can be used as a tool to estimate the extent of environmental damage caused by artisanal gold mining, the severity of damage to the health of individuals contaminated by mercury and, consequently, can contribute to the application of fines to environmental violators. The consequences of contamination are evaluated by dose-response functions relating to mercury concentrations in hair and the development of the following health outcomes: (i) mild mental retardation, (ii) acute myocardial infarction, and (iii) hypertension. From disability-adjusted life years and statistical life value, we found that the economic losses range from 100,000 to 400,000 USD per kilogram of gold extracted. A case study of the Yanomami indigenous land shows that the impacts of mercury from illegal gold mining in 2020 totaled 69 million USD, which could be used by local authorities to compensate the Yanomami people. The Minamata disaster in Japan, in which thousands of people were seriously impacted by mercury dumped by various industries, culminated in the Minamata Convention in 2013. As a result, mercury’s use has been restricted [Mercury is a heavy metal widely distributed across the planet and is therefore classified as a global pollutant ,4. This Despite its damage to human health, mercury is still widely used in legal and illegal gold mining in Brazil, an activity that has been growing every year due to the high gold price and lack of inspections . The sitWhile the repression of illegal activities can imply the imposition of fines related to damages, there are still important methodological bottlenecks to establish responsibilities, and no standardized approach to evaluate damages. Methodological bottlenecks depend on several factors. Firstly, it is necessary to differentiate between natural mercury  and additional mercury from human activities  ,25,26,270). The fraction of metallic mercury that is not recovered during the extraction process contaminates the atmosphere and rivers in the Amazon region. Once released into aquatic systems, a part of metallic mercury is oxidized and can be methylated by the action of microorganisms or abiotic factors. This process gives rise to the most dangerous mercury species, methylmercury (MeHg). Methylmercury is biomagnified along the aquatic food chain, contaminating fish and other organisms used for food such as turtles, crabs, shrimp and alligators. Furthermore, much of the toxicity of methylmercury is due to its high neurotoxic potential and its ability to overcome the blood-brain and placentary barriers.The mercurial form used in the gold ore extraction process is metallic mercury, also known as elemental mercury  the potential area of mercury dispersal in the water, as well as the estimation of the maximum affected population, given the average level of contamination and fish consumption; (ii) the definition of dose-response functions for different health outcomes and population groups; and (iii) the valuation of health impacts of mercury in monetary terms. Therefore, we seek to link a chain of events, concepts, and value estimates from the literature through a series of hypotheses, which allow us to relate the use of mercury in small-scale gold mines to health outcomes and their negative economic values.Considering all of the gaps mentioned, the main objective of this study was to develop a precise methodology to estimate the health damage caused exclusively by the mercury used in ASGM . For estimation calculations, the amount of gold that is extracted in a given location and the amount of mercury used and discarded during the process were considered. The study provides value estimates that can support social impact assessment, define fines for illegal gold miners, and provide parameters for the evaluation of public policies related to inspection and prevention of this activity. The methodology construction contributes to the incorporation of impacts on human health by decision makers and expands the discussion on the effects of illegal mining activities in a strategic area such as the Amazon for economic development. This study is the first to estimate the average impacts that a gold mine can generate on human health due to the use of mercury and its ingestion from fish consumption.This section, based on an extensive literature review, establishes the hypotheses to make the connections between average mercury use, its dispersion in the environment, potential absorption by humans, and its effects on human health. The study area is the Brazilian Amazon, which concentrates 93% of all small-scale mining in Brazil . Gold miWe establish links between several factors, using average values from the literature, in a chain which can be divided into two major goals: how mercury used in gold mining is dispersed in water until it reaches humans, and the quantification of the impact on human health from mercury ingestion.To complete the logical line presented in The study begins with the presentation of the relationship between the use of mercury from gold mines and the effects of increasing methylmercury concentration in the hair of the affected population. Then, the study assesses which adverse effects on human health are considered when there is an increase in the level of methylmercury in the hair.We aim to relate the use of mercury by gold mining with the increased mercury concentration in the hair of the affected population. We divided into two main specific objectives. The first is to explain how the mercury used in gold mining is dispersed in water until it reaches humans. The second is to describe how mercury from gold mining and human mercury intake affects the population.The following variables have the objective of explaining which variables are important in defining how the mercury used in gold mining is dispersed in the water until it reaches humans. For this, the next three described variables are the proportion of mercury used for each kilogram of mined gold, the proportion of mercury released in water and soil and emitted into the atmosphere, and the proportion of mercury that transforms into methylmercury (methylation). The last section presents a summary of these variables.Mercury is used in the amalgamation process, which, when combined with gold, forms a metallic alloy called amalgam. The literature shows that the proportion of mercury used in the extraction process can vary in both Brazil and worldwide due to different factors (such as different yields for gold extraction). This proportion can vary considerably from 1.3–8.0 g of mercury for each g of gold extracted ,87,88,89The mercury used in gold mining is dispersed in both soils and rivers, as well as in the atmosphere. This study analyzes only the release of mercury in aquatic environments, since the objective is to understand the effects of methylmercury on human health from ingesting contaminated fish. Therefore, we sought to review the literature that indicates the proportion of mercury released in soil and water. This proportion can vary from 12–35%, with the lowest proportion (12%) being a conservative scenario ,19,20,88When mercury is dumped into an aquatic environment, part of it is transformed into an organic mercury compound called methylmercury, which is about 30 times more toxic than inorganic mercury  and is iGiven the knowledge of the amount of mercury released into water, another process widely discussed in the literature is the proportion of mercury that transforms into methylmercury (MeHg).The literature shows that the methylation process occurs in different contexts in the Amazon, with conditions such as low pH and high levels of dissolved organic carbon favoring mercury oxidation and methylation . SeveralThe formula below demonstrates the results found from X = mercury used by mining, is released into aquatic environments and undergoes methylationA = gold amount extracted by mining (kilos)B = proportion of mercury used for extraction of each kilogram of gold (%)C = proportion of mercury released in the water (%)D = methylation rate (%)After estimating the amount of mercury that is dispersed in the environment and potentially consumed by humans, we estimated how this amount will be consumed: (i) by individuals who eat contaminated fish daily; and (ii) by the number of individuals that may absorb this amount of mercury across their lives. Therefore, we need to understand how many people may be exposed (up to an average contamination level) by a consuming a given additional amount of mercury throughout their lifetime.The average long-term contamination level of one individual is estimated based on the daily contaminated fish consumption, which gives us the total amount of mercury that will lead one individual to the negative health outcomes considered. Based on this individual total consumption, we can estimate how many individuals could be impacted at the same contamination level within a given impact area.Methylmercury is a chemical substance that is absorbed by the trophic chain in aquatic environments . ThroughAs an organic form of Hg, MeHg has extremely neurotoxic effects and is readily accumulated in biota due to its lipophilic and protein-binding properties ,103. A sTo use recommended values at a global level, this study chose the Codex Alimentarius , jointlyThe Amazon region is historically known for eating fish, whether in riverside and indigenous populations or large urban centers. Riverside dwellers, for example, eat more fish, with an average consumption of 189 to 243 g of fish per day ,112,113.To calculate the average daily mercury intake per person, we described the average weight of an individual in each population profile as 70 kg for urban people , 65 kg fChronic ingestion of mercury-contaminated fish by the Amazon population increases health risks.The formula below represents how average daily intake is calculated:I = average mercury daily intake (μg/kg bw (Bw = body weight)/day)P = proportion of urban, indigenous, and riverside populations in the municipality affected by gold mining. Therefore, a balance between these factors is necessary.Cm = average fish consumption per day (g/day) for population typeCont = average contamination in fish (µg/g fish)  for type of populationThe average daily intake is related to contextual factors of the location that is being affected by gold mining, such as the proportion of indigenous, riverside, and urban populations.Several studies have demonstrated the instability and complexity of methylation and demethylation ,95,96,97Based on this hypothesis, it is possible to quantify the mercury consumption for an average individual over 50 years using the following formula:Z = average mercury intake per person over 50 years (g/50 years per person)T = time Y = average mercury daily intake per person (g/day per person)  and average mercury daily intake (μg/kg bw/day)Therefore, it is assumed that the daily mercury intake by each social group in the region  will chronically occur over 50 years. In other words, individuals with an average daily intake of 0.76 g/kg/day will have a total intake of 0.9 g over 50 years, resulting in an average increase in mercury contamination of 5.0 µg/g µg/g (hair). Such information is essential to understand how methylmercury released by gold mining will be distributed among fish consumers in the region.Knowledge regarding mercury release by gold mining and subsequent impacts on fish and daily mercury intake by humans, when associated with the time variable, requires a hypotheses on the proportion of methylmercury that will be absorbed during this period. We hypothesize that all bioavailable methylmercury from gold mining will be consumed by humans, that is, will be consumed between 0.22% and 4.5% of the total mercury used by ASGM. This hypothesis does not imply that all methylmercury will be instantly absorbed by humans, but rather chronically absorbed over 50 years by humans at the top of the trophic chain. This type of hypothesis is needed due to the literature gap on tracing mercury molecules from ASGM until human absorption.Methylercury will accumulate in the hairs of people who consume of fish contaminated by mercury. This clear relationship between contaminated fish consumption and methylmercury accumulation in hair was demonstrated by the Poulin and Gibbs . AccordiF = hair methylmercury concentration (in ug/g)I = average mercury daily intake (μg/kg bw/day)Knowledge about the amount of mercury released by gold mining, methylated in the aquatic environment , and disPop = population affected by mercury contamination from gold miningZ = average mercury intake per personX = estimated amount of methylmercury from mining that reaches the top of the trophic chain.Socioeconomic characterization of the affected population is considered, where groups with higher fish consumption are expected to have higher contamination values. The average daily intake of mercury through fish consumption is differentiated by the riverside population, which has a higher fish consumption, and urban population, having a lower fish consumption and a lower chance of being exposed.Additionally, we considered the population density as a limiting factor of the total number of people that may be exposed within a given radius. Mercury distribution in river and tributaries is influenced by the distance from gold mines . TherefoPiratinga) [Several studies present the average distance that metallic mercury can travel in rivers, ranging from 4 to 100 km ,129,130,ratinga) ,135,136)The effects of this release are limited to the number of people within a 100 km radius. A highly contaminated region with a low population density means that few humans will be affected, although it continues to have a significant impact on the region’s fauna. Likewise, urban areas close to the center of contamination have a high population density, potentially causing damage to human health of more individuals.The formula below demonstrates these results found from F = hair methylmercury concentration (in ug/g)I = average mercury daily intake (μg/kg bw/day)P = proportion of urban, indigenous, and riverside populations in the municipality affected by gold mining. Therefore, a balance between these factors is necessary.Cm = average fish consumption per day (g/day) for population typeCont = average contamination in fish (µg/g fish)  for type of populationAll of the logical links described above can be summarized as follows. It is possible to relate mercury use by gold mining and its respective loss in the environment until it reaches the human body and affects the population:Pop = population affected by mercury contamination from gold miningX = mercury used by mining, is released into aquatic environments and undergoes methylation  (depends on the absorption of methylated mercury (100%).A = gold amount extracted by mining (kilos)B = proportion of mercury used for extraction of each kilogram of gold (%)C = proportion of mercury released in the water (%)D = methylation rate (%)I = average mercury daily intake (μg/kg bw/day)P = proportion of urban, indigenous, and riverside populations in the municipality affected by gold mining. Therefore, a balance between these factors is necessary.Cm = average fish consumption per day (g/day) for population typeCont = average contamination in fish (µg/g fish)  for type of populationT = time variable (MeHg in the environment) = 50 years (multiplied by mercury intake per person).The health economics literature quantifies the impact on health using the disability adjusted life years (DALY) index to compare the impact of different health problems. The DALY index weighs health measures of mortality and morbidity in one equivalent measurement unit: time (years), considering the severity, magnitude, and duration of the problem . DiffereTo calculate the DALY, it is necessary to know the following variables: discount rate, age, weight, disability weight, disease duration, and incidence rate which can be seen in the next sections.The next section relates mercury release in gold mining to IQ loss in children and mild mental retardation due to maternal ingestion of contaminated fish, a health outcome that leads to loss of productivity and income from the birth of the infected child to death . AxelradGiven the total affected population, as described in To calculate the DALY related to IQ loss in children, we highlighted the variables based on a literature review on the subject. One of these parameters is a discount rate which can be defined with the objective of assigning less importance relative to years lost in the future than to years of life lost in the present, given that a human being, in general, has short-term rather than long-term preferences ,139. We chose to use the 3% discount rate as it is applied in health economics studies , in enviThe monetary measurement of DALY has been widely discussed in several studies, such as Kenkel  and HammThe association between contaminated fish consumption and cardiovascular diseases considers that mercury in fish muscle, when absorbed by the human gastrointestinal tract, interferes with lipid peroxidation and can cause atherosclerosis. This condition can lead to increased blood pressure  and acutThis section presents the parameters used to describe the relationship between mercury concentration in hair due to the use of mercury in gold mining and two cardiovascular diseases: acute myocardial infarction and arterial hypertension.For acute myocardial infarction, Salonen et al.  found thCalculating Acute Myocardial Infarction Burden Disease Attributable to Mercury Ingestion from Gold MiningThe disease burden methodology in the gold mining context in the Amazon was adapted from a study by Salonen et al. . We firsTo estimate the “Number of Infarction Cases Attributable to Mercury Exposure (≥2.0 µg/g Hg)” it is necessary to multiply the total number of infarcts in the sample and the attributable fraction.Ip = people infarcted due to mercury levels > 2.0 µg/gAfi = attributable fraction .Values for the probability of risk accumulated over the years are based on Zaletel-Kragelj and Bozikov , who estThe estimation of the number of infarction cases associated with mercury over the years for the male population over 40 years old and the accumulated infarction risk associated with mercury over time is multiplied.Cri = cumulative risk of mercury-associated myocardial infarction = 1.61%Hm = male population over 40 in the region who will be hospitalized in 27 years for mercury ingestionMp = male population over 40 years in region2.Variables for Calculating the DALY and Monetary Impact of Mercury-Associated Acute Myocardial Infarction from Gold MinesThe DALY for mercury-associated acute myocardial infarction was based on the following parameters: 3% discount rate, 100% weight for age, disability weight for acute myocardial infarction of 0.439 , disabilThe resulting value is given in years lived with disability for the extraction of gold per kg. For example, 10 kg of gold can generate, on average, the impact of 8.5 years lived with disability or 174,000 USD at 20,600 USD for each DALY .High blood pressure has long been recognized as a major risk factor for cardiovascular diseases. A recent analysis suggests that the burden of high blood pressure has increased over the past three decades ,159. In Methodology for Calculating the Hypertension Burden Disease Attributable to Mercury Ingestion from Gold MiningThe hypertension disease burden methodology in the context of gold mining in the Amazon fundamentally involves adaptation to the study by Hu et al. , with thAlthough Hu et al.  presenteBased on this understanding, we estimated the risk of arterial hypertension occurrence  to be 0.To estimate the “Number of Hypertension Cases Attributable to Mercury Exposure (≥2.0 µg/g Hg)” we multiplied the total number of hypertension cases in the sample by the attributable fraction.Hp = number of hypertension cases attributable to mercury exposure (≥2.0 µg/g Hg)Afh = attributable fraction (hypertension)Th = total number of hypertension casesUnlike the myocardial infarction outcome, the literature does not indicate a greater or lesser hypertension risk depending on gender ; that is, the population over 20 years should only be evaluated as that is the year in which hypertension begins to be observed . Figure To attribute the fraction of this outcome to fish intake, it is necessary to use the attributable fraction calculated as 26% of the risk associated with mercury. Using the methodology of Zaletel-Kragelj and Bozikov , the cumBased on the knowledge of the temporality of the outcome, it is feasible to estimate the number of cases of hypertension associated with mercury over the years. For this, the population over 20 years in the region that will be hospitalized over 52 years of exposure and the accumulated risk of hypertension associated with mercury over time is multiplied.Crh = cumulative risk of mercury-associated hypertensionHp = population over 20 years in the region who will be hospitalized in 52 years for mercury ingestionPp = population over 20 years in region2.Variables for Calculating DALY and Monetary Impact of High Blood Pressure Associated with Mercury from Gold MiningTo calculate the DALY related to arterial hypertension, we considered the following parameters: discount rate of 3%; 100% weight for age; disability weight of 0.246 ; year onThe methodology presented above consists of the first estimate of the relationship between the use of mercury by gold mining and the negative effects on human health. Defining the amount of mercury used per kilogram of gold mined , the proGiven the knowledge of the amount of mercury released by gold mining, the present study demonstrated that the population context is essential to define the impacts on human health. Therefore, it is assumed that the daily mercury intake depends on social group affected in the region  As an example of a population with indigenous and riverine population, an average daily intake of 1.2 μg/kg bw/day corresponds to an average concentration in hair of 12 µg/g, which corroborates other studies. Bastos et al. , identifLikewise, the study demonstrated that the context of the affected population is not restricted to these population characteristics, it is also important to consider population density and the distance of the population to the gold mining. This is explained due to the fact that areas with low population density and far from gold mining will have a limited effect on the health of the population, while regions with high population density and close to a radius of less than 100 km has a higher probability of consumption the methylmercury released by the ASGM.The By defining the characteristics that influence the level of contamination and the number of people affected, the study made use of existing studies that addressed the relationship between exposure to mercury and impacts on human health ,10,47. IMeanwhile, for cardiovascular outcomes , an area located mainly in the Brazilian Amazon in the states of Roraima and Amazonas. YIL is the largest indigenous land in Brazil, with an area of 96,000 kmThe variables used to present the results are described in the following Despite the variability of each parameter shown in 2 were degraded by illegal ASGM [In 2020, 5 kmgal ASGM , which, gal ASGM , would uThe methodology developed in this paper is the first of its kind to assess the impact on human health caused by mercury used in gold mining. To achieve this methodology, it was necessary to understand the complexity of the mercury cycle and the ASGM processes. First, using this methodology, we presented evidence against the argument that the source of the impacting mercury is deforestation, which releases natural mercury present in the forest ,24,25,26Given that we consider only the additional mercury released from ASGM, another complexity arises from the difficulty in attributing responsibility to specific mines. Such complexity can be explained by the ability of mercury to remain bioavailable for long periods , bringinGiven the whole context of mercury and the ASGM, this article proposes an innovative methodology that proposes a linear relationship based on the amount of mercury used by ASGM and its adverse effects on human health. For this, an extensive literature review was performed that tracks the average mercury use of ASGM ,74,87,88After the study related the use of mercury in gold mining and the average increase in mercury concentration in the population, we explored the literature relating gold extracted and negative effects on human health ,73,74. KWe must reinforce that before the development of this methodology, the Brazilian institutions responsible for setting fines for illegal ASGM did not measure the impact on human health from the use of mercury in the mines. This methodological gap is filled with the tool developed in this article, and based on this, institutions such as the Federal Police and Federal Public Prosecution in Brazil have instruments to prosecute illegal gold mining damages in order to stop the advance of this activity in the Amazon.Nevertheless, this article recognizes the limitations of the relationship between mercury use in gold mining and its impacts on human health. Given the lack of studies that assess the factors that influence the response time between changes in deposition and changes in methylmercury concentrations in fish, in this study we needed to assume the temporal effect of mercury release and fish bioaccumulation over 50 years. In addition, the Amazon region is complex and diverse. The model presented is simplified and does not consider local differences, such as river color and water flow, that could impact the local mercury cycle. Such characteristics need to be further studied.We did not find any study in Brazil that relates mercury concentration to myocardial infarction. The study by Salonen et al. , carriedThe limitations presented throughout the article can be overcome with new studies of biophysical mercury dispersion until it reaches humans and possible impacts to human health from increased mercury intake by humans. Long-term monitoring studies that collect mercury concentrations in water, sediments, and fish are needed, particularly in the Amazon. These efforts can lead to long-term data records that can be compared to predictions. Likewise, additional studies should be carried out to assess fish consumption rates in pregnant women, women of childbearing age, and men.Finally, the methodology presented in this article does not address all impacts on human health since only the outcomes related to the release of mercury in the aquatic environment are measured, not considering the impacts of air exposure due to the inhalation of mercury in the atmosphere  ,172,173.This article is the first scientific work whose objective was to propose a methodology to quantify the average economic health impact of the extraction of gold by ASGM in Brazil (using the DALY indicator) and convert them into monetary losses (using the VSL indicator).2 illegally deforested for ASGM in 2020 would result in severe damages to human health. Based on this, we estimate that around 32 kg of mercury were spilled into rivers, affecting up to 44,000 people. We estimated that 307 people will develop hypertension problems from this activity, 85 people will develop acute myocardial infarction, and 4 children would have born with mild mental retardation. These effects are related only to the presence of small-scale gold mining in 2020, which demonstrates the significant and growing impact with the expansion of this activity in Brazil in recent years. The economic health impact of these health outcomes could reach up to 69 million USD for the 2020 spills alone.The application of this methodology to estimate the impacts of mining in Yanomami territory revealed that the 5 kmThe standardization of mercury impacts assessment is essential for supporting the containment of illegal gold mining activities in the Brazilian Amazon. The developed methodology contributes to the work of control agencies such as the Brazilian Public Prosecutors Office and the Federal Police, who are already using this methodology to estimate fines in the estimation of compensation, showing reliability on the part of these institutions in the scientific results presented. In addition, it contributes to the speed of judicialization in the fight against this illegal activity, and it may support policymakers to plan investments in command-and-control that can prevent the expansion of illegal ASGM.


Bangladesh has adopted a structured approach to train general nurses as vision technicians, in order to address the shortage of trained eye care professionals in rural areas.In Bangladesh, eye care services are provided by the government, private hospitals, and local and international non-governmental organisations. However, access and coverage are still inadequate, as most ophthalmologists are located in urban areas, whereas 63 per cent of the country's population resides in rural areas. The current cataract surgical rate is 1,950 while the rate needed to address the backlog as well as new (incident) cases is estimated at 6,000. The Cataract Surgical Rate (CSR) is defined as the number of cataract operations done per million population per year.Bangladesh requires a robust, scalable, and innovative solution to meet the need for cataract surgery and other eye services in the country. The health ministry therefore adopted a model developed by the Aravind Eye Care System. Under the model, trained ophthalmic personnel at the institute's telemedicine enabled vision centres (VCs) will offer eye care services at the primary level.The government decided to integrate primary eye care in the portfolio of primary health care services by setting up community vision centres. After making the necessary budgetary allocation, the government appointed a senior team consisting of the Director: National Institute of Ophthalmology, senior ophthalmologists, and heads of teaching hospitals in Bangladesh, to visit Aravind Eye Hospital in India. The team studied Aravind's Vision Centre model in detail and developed a strategic road map for implementing a similar model in Bangladesh.The team decided to set up the first 20 community vision centres around a government tertiary eye hospital which would provide teleconsultation services, provide surgery, advanced investigations, and treatment to patients referred by the community vision centres. The team also decided that the community vision centers should be established in Upazila health complexes. Upazila refers to the third administrative level in Bangladesh and each of these covers a population of 100,000 - 200,000 people. The plan is to have a vision centre in each of the 500 Upazilas eventually.Bangladesh has sufficient general nurses trained, available, and are working in various Government health care facilities. Hence, the team decided to select and train general nurses as vision technicians to work at the vision centres. The selection criteria, although strict, was designed to maximise staff retention. Nurses had to:live near the Upazila health complexbe willing to learn new skills and switch to a career in ophthalmologybe aged between 25 and 40 years.The nurses who were selected had to undergo two months of intense training at the National Institute for Ophthalmology in Bangladesh. This covered:basic eye careanatomy and functions of the eyehandling of basic ophthalmic equipmentvisual acuity measurementsubjective refractionidentification of common eye conditions.After training the nurses were assessed for their knowledge and skills. This was followed by a 45-day intense training programme at Aravind Eye Hospital, the mentoring institute and its vision centres. This program provided hands-on training in the following areas:These included visual acuity measurement, subjective refraction, retinoscopy, slit lamp examination, tonometry, identifying common eye conditions, fundus photography, ocular pharmacology, and treatment options for different eye conditions.This focused on the use of electronic medical records, and teleconsultation between patients and ophthalmologists at the base hospital.Counselling to enhance compliance with treatment.Managing supplies, equipment maintenance and generate reports.The mentoring team at Aravind assessed nurses' new skills. On their return to Bangladesh, the newly qualified vision technicians then returned to the National Institute of Ophthalmology to continue learning and practising their skills until the first vision centres were launched.A team from Aravind Eye Hospitals, comprising the programme manager, vision technicians and an IT expert, worked closely with the team in Bangladesh, to set up the first 12 community vision centres. This helped to iron out first issues and ensured the smooth functioning of the community vision centres.To build a cohesive working relationship between the vision technicians and the ophthalmologists at the tertiary hospital, both groups were invited to attend a workshop at the tertiary eye hospital, where the speakers emphasised the importance of the community vision centres and the vital role they play in extending effective eye care services to the rural population of Bangladesh.Carrying out comprehensive eye examination supported by teleconsultation with ophthalmologists.The vision technicians offer the services like dispensing spectacles and medicines as per e-prescription from ophthalmologists.Those requiring cataract surgery or advanced care are referred to the hospital.Currently, there are 50 community vision centres in Bangladesh. Twenty are linked to a tertiary eye hospital , and 15 each are linked to two medical colleges . Sister Sathiraha Bhodendranath is a general nurse who underwent intensive training to become a vision technician at one of Bangladesh's 50 community vision centres.“I was working as a staff nurse in Upazila health complex in Lohagara, Khulna when I applied to train as a vision technician. I have always wanted to help people to regain their eyesight, so I was very motivated! The fact that vision technicians do not work night shifts was also very attractive.The interviews were very competitive, so I was delighted to be one of the first group of 20 nurses selected to attend the initial training at the National Institute for Ophthalmology (NIO).The shift from general nursing to ophthalmology was very challenging in the beginning. The two months of training at NIO boosted my confidence, and subsequent practical training at Aravind, with the continuous feedback they offered, really helped me to master the required skills.I now see 20 to 25 patients per day, on my own; it is very satisfying work! The number of outpatients that come to us is increasing steadily, and the positive feedback from our patients is a motivating factor. The highlight of my career as a vision technician was when I demonstrated the vision centre model at the Digital Bangladesh Mela in 2020 with my colleague Mrs Smirti. We won an award at this Mela. I am working now as a vision technician in the community vision centre at Lohagara.”


Electric power frameworks become intensely loaded because of the expanded power demand, and as a result, the power system faces great power losses and fault currents. The integration of Distribution Generation (DG) units plays a key role in minimizing the load pressure on a power system. DGs are transmitted with a high fault current, which surpasses the evaluations of circuit breakers. This paper presents various DG units’ optimal placement with Fault Current Limiters (FCLs) in different phases. The Improved Coyote Optimize Algorithm (ICOA) and Electrical Transient Analyzer Program (ETAP) are assessed for the proposed technique in terms of normal and faulty working status. Similarly, to enhance the efficiency of a distribution system, a fuzzy-based multi-objective mechanism is applied. The proposed method is employed on an IEEE 21-bus and 28-bus distribution system. The simulation analysis proved that the power losses and fault levels are reduced at an acceptable level. There has been an increase in power demand in the last decade, which means electric grids are heavily loaded ,2,3. ThiIn order to resolve the proper allocation problem of DGs and reduce power losses and fault current levels, a number of research works have been done so far. In , the autHowever, the presented research models contain several technical and economical issues. Hence, to minimize the power losses and fault current in an installed power distribution system, a new procedure is needed. Thus, this paper studies the optimum placement of DGs and FCLs in a single-phase.The remaining part of this paper is organized as follows. The analytical model is discussed in The major purpose of this work is to reduce the power losses of the power system and can be defined ,16 as methodology is presented. Hence, the behavior of the coyote is adopted by the fitness function Here, mth constraint in terms of ith solution for gth solution. The solution of the best Here, g. The decision from middle solution is further elaborated asFor the purpose of updating the social condition for the coyote in each group, updated solutions exist in COA around old solutions for two distances in terms of i is related to old and new conditions, which correspond to old and new solutions, respectively. The ith coyote.In order to select the performance procedure, each coyote From Equations (18) and (19), it is observed that ICOA produces two generations in every iteration. The produced solutions in the first generation in all groups are newly upgraded and the second generation includes only one upgraded solution for each group. Thus, these newly generated solutions in an iteration are measured asThe Coyote Optimize Algorithm (COA) has been broadly applied for streamlining issues in a wide range of fields. In , the autCase 1:DGs working at a unity power factor and related to Type 3.Case 2:The power factor is kept constant for DGs, related to Type 1.Case 3:Controllable power factor technique is used for DGs.IEEE-28 bus systems are designed to analyze the optimum location of DGs and FCLs using ICOA. The flow chart for analyzing optimum allocation for DGs and FCLs is presented in In Case 1, where DGs are working with the unity power factor, the ICOA is employed, and the outcomes are presented in The proposed model was designed in ETAP, as shown in The analysis of load flow needs input data, which consists of nominal values, the impedance of generators, lines and DGs, and other values, and these are shown in ICOA Technique for Allocation of DGs: The planned ICOA is chosen for finding the simultaneous site and sizing of DGUs in a single-stage method. The gained outcomes are compared to the bi-stage method. In The performance of the proposed model is also analyzed using graphical analysis, where The results of power losses as a function of light, shoulder and peak loads are investigated in The employed ICOA is tested at different runs for case 1 and class 1, as declared in The simulation analysis among bus voltage and numbers is evaluated in The balance of electricity demands and power losses with proper allocation of DGs are highlighted issues in installed power systems. Therefore, to enhance the voltage profile and to measure better placement of DGs in the distribution system, the ICOA algorithm is analyzed in this paper for an IEEE 28-bus system. The major constraints and their solutions are also addressed analytically, which concludes that by compensating the power and voltage constraints, a stable distribution network cannot be designed. The proposed ICOA technique for allocating and sizing DGs is explored in different steps to show how fitness functions are defined as solutions to the generated issues. In addition, the results of the proposed model are declared in tabular and graphical forms, using different cases and classes. It was found that, when compared, the proposed ICOA outperforms the other optimizers. The optimization placement of DG units is proposed, correlated with FCLs in single-phase as compared to multi-phase. To reduce power losses and fault current levels, an improved coyote algorithm (ICOA) methodology is used. The simulation results present that the ICOA mechanism helps in choosing the best position for DGs and FCLs in the distribution network. Using the ICOA procedure, the proposed setup is able to achieve acceptable outcomes and minimize power losses and faulty current levels. It is found that a huge amount of power losses are reduced by increasing the voltage profile. Hence, the issues of optimum placement of DGUs in distribution networks and decreasing economical and technical issues may be improved by considering the proposed ICOA model.


Objective: The present study focused on examining fear of the coronavirus disease 2019 (COVID-19) is correlated with depression and explored the potential role of resilience and social support on the association between fear of the COVID-19 (FoC) and depression among Chinese outbound students studying online in China amid the COVID-19 pandemic period.Methods: A total of 476 Chinese outbound students from different universities worldwide, currently studying via online mode in China, completed an online survey including measures on FoC, resilience, social support, and depression.Results: (1) Fear of the COVID-19 was positively correlated with depression and negatively correlated with resilience and social support. Both resilience and social support were negatively correlated with depression. Social support showed a positive correlation with resilience. (2) The effect of FoC on depression mainly occurred through two paths: the mediating effect of resilience and the moderating effect of resilience. However, the moderating effect of social support on the association between FoC and depression was not sustained in this study.Conclusion: This study indicated the mediating and moderating effects of resilience on the association between FoC and depression among Chinese outbound students studying online in China during the COVID-19 pandemic period. The current findings confirmed that resilience has significant implications in preventing negative mental states under the COVID-19 context among this particular group. Due to the rapid spread of the coronavirus disease 2019 (COVID-19) pandemic, governments worldwide have imposed travel restrictions and most higher education institutions have switched to online learning . Howevervia online mode  is a negative emotion or a negative response toward any danger or health threats such as harm to oneself physically, any discrimination, or isolation related to the COVID-19 . Depressesources . Howeveresources  and resiesources , this stPrevious research has shown that there is a significant positive correlation between fear of FoC and depression . KaparouHypothesis 1 (H1): FoC will be positively correlated with depression.The ability of a person to recover from the traumatic events is referred to as resilience, also called the capacity to learn to live in times of fear and uncertainty and the ability to adjust to the difficult and problematic experiences in life . Past stHowever, the role of resilience in the association between FoC and depression is not clear. Previous research has shown that resilience plays a mediating role in the relationship between FoC and negative mental states such as stress , anxietyHypothesis 2 (H2): Whether low levels of resilience will mediate the association between FoC and depression . Additionally, changing 2R = 0.007 statistically due to interactions, F = 5.885, p < 0.05, which means that the moderation explained the 45.96% of the variance in the resilience of the model. Therefore, resilience has a positive significance on the relationship between FoC and depression. The results illustrated the interaction by depicting the regression line of the relationship between FoC and depression at high, medium, and low  resilience scale scores. The graph showed that resilience played a role in narrowing the positive correlation between FoC and depression mentioned in the research literature. The highest levels of depression were found in the individuals who reported low levels of FoC and low resilience  = 58.8261, p = 0.956] (After controlling for sex, age, and education level, the moderating effect of social support on the association between FoC and depression was analyzed. Contradictory to H4, the result showed that the moderating role of social support is insignificant. Being a predictor of FoC on depression, social support does not act as a moderator for the relationship  .. Thus, This study examined the mediating effect of resilience as well as the moderating effects of resilience and social support on the relationship between FoC and depression among the COSs studying online amid the COVID-19 pandemic period. The correlational analyses revealed that FoC had a positive relationship with depression, which was consistent with the previous studies that higher FoC is positively correlated with increased depression . The resThis study also contributes to the theory by revealing the mechanism through which FoC influences the depression of the COSs studying online in China. Although previous research revealed that FoC is associated with depression, the underlying mechanism was not enough clear. Previous research indicated that mindfulness could help to counter the negative effects of FoC on depression, thus reducing depression . This stThe findings of this study also showed that resilience moderated the relationship between FoC and depression, which is consistent with prior research showing that resilience has a negative and substantial impact on depression . IndividThe present finding also contributes to the buffering effect in the buffering model of social support . The modFear of the COVID-19 has a tremendous mental health impact all over the world; therefore, related mental illness prevention is critical during this difficult time . While eSince FoC is a reaction to the worldwide spread of the COVID-19 , this stFirst, this study extends existing FoC and depression literature among the international student group by showing that FoC has a significant positive effect on the depression of the COS. A positive association between FoC and depression was found, which is consistent with previous studies showing that FoC can be a trigger to depression in the domestic contexts . Second,Some limitations that exist in this study need to be acknowledged. First, a previous study revealed that there are regional differences in FoC . HoweverThis study demonstrated the mediating effect and the moderating effect of resilience on the relationship between FoC and depression among the COSs studying online in China during the COVID-19 pandemic period. However, the moderating effect of social support on the association between FoC and depression was not sustained in this study. The findings provided empirical evidence to confirm not only a positive relationship between FoC and depression but also suggest that it is mediated as well as moderated by resilience. Thus, providing more research evidence to attention in resilience training from institutions in higher education because of their significant role in the mental health of the international students.The datasets generated for this study are available on request to the corresponding author.The studies involving human participants were reviewed and approved by the Research Ethics Sub-Committee of the College of Liberal Arts and Social Sciences in the City University of Hong Kong. The patients/participants provided their written informed consent to participate in this study.YC designed the research and completed the manuscript writing. YC, YL, and ZL collected and analyzed the data. YZ and TZ reviewed and edited the manuscript. All authors contributed to the article and approved the submitted version.The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.All claims expressed in this article are solely those of the authors and do not necessarily represent those of their affiliated organizations, or those of the publisher, the editors and the reviewers. Any product that may be evaluated in this article, or claim that may be made by its manufacturer, is not guaranteed or endorsed by the publisher.


Perceived stress, Internet addiction and procrastination are common issues among college students. Based on the Compensatory Internet Use (CIU) model and emotion regulation theory, this study aims to explore two possible mechanisms for the connection between perceived stress and Internet addiction: mediating effect of procrastination and moderating effect of flow experience on the Internet. Cross-sectional design and questionnaire survey were used in this study. Data were collected from 446 college students who voluntarily completed self-reporting of perceived stress, internet addiction, procrastination and flow. Potential relationship structure and moderation model between variables was calculated during the process. The results revealed that there were significant associations among perceived stress, Internet addiction, procrastination and flow. The results also showed that procrastination plays a mediating role between perceptual stress and Internet addiction, flow plays a moderating role between them. The results emphasized the importance of the intention behind college students’ overuse of the Internet. These results also provided a perspective of finding the possible causes of Internet addiction in college students, that is, individuals use the Internet to avoid stress and procrastinate, and the mobile experience on the Internet also affects the process. In today’s world, the Internet closely relates to our life. By March 2020, the world’s Internet penetration rate has reached 58.7%. Approximately 1167% higher than the rate over the past 20 years . EspeciaInternet addiction is a new form that relies on devices connected to the Internet. This addiction has many negative effects . It is cInfluenced by society, family and school, contemporary college students are faced with various pressures in many aspects, which are often overlooked and lead to a certain degree of negative emotional state. There is a significant positive correlation between stressful life events and Internet addiction . CollegeThe motivation to use the internet as a coping strategy is an important factor in the development and maintenance of internet addiction. As mentioned in Flow is a state closely related to inner psychological motivation, and is the overall feeling that an individual feels when he is fully engaged in action. People in this state are usually reluctant to be disturbed, able to forget time and fatigue, and accompanied by a high degree of excitement and fullness . When anThe relationship between the Internet and perceived stress is also related to its use as a tool for procrastination. Procrastination is defined as delaying a behavior until subjective discomfort is experienced . It is aThe purpose of this study is to explore whether there is a relationship between perceived stress and Internet addiction, and hypothesize that procrastination plays a mediating role and flow plays a moderating role in this relationship.In this study, data were collected from 460 college students. All participants gave informed consent. The questionnaires lacking basic information and incorrectly filled out were eliminated, and finally 446 valid questionnaires were obtained, including 163 male students (36.5%) and 283 female students (63.5%). The sample of college students ranged from grade 1 to grade 4. Freshmen accounted for 25.3%, sophomores accounted for 25.8%, juniors accounted for 31.6%, and seniors accounted for 17.3%.PSS is a self-assessment scale for measuring perceived stress. So far, the scale includes three versions of PSS-14, PSS-10, and PSS-4. As scholars from various countries pay more attention to direct stress and individual mental health, PSS was introduced into more than 20 countries including France, Germany, and China after cross-cultural debugging. Professor Yang Tingzhong et al. first Chineseized PSS-14 and introduced it to China in 2003 . The CroThe Internet Addiction Test (IAT) was developed by Young, a scholar of the University of Pittsburgh, in 1995, based on the DSM-IV standard and based on the diagnosis of pathological gambling addiction. Whether Internet addiction and the degree of Internet addiction. The scale consists of 20 items and uses a 5-point scoring method. These items involve compulsive Internet surfing and Internet addiction withdrawal, Internet addiction tolerance, interpersonal health, time management, etc. The total score is 100 points, the higher the score, the more serious the degree of Internet addiction. Kronbach’s Alpha is 0.904, which is a broad measurement tool for Internet addiction. It has been translated into multiple languages and its psychometric properties have been tested in different samples around the world. Therefore, it has good reliability.In order to directly measure the frequency of procrastination in using the Internet, a project was used (do you often use the Internet to postpone tasks that you feel unpleasant?). Likert scale is used to divide the project into 1 (ever) to 5 (often). This project focused on the core aspect of procrastination, that is, voluntarily choosing the delayed task to compete with another task , which iA scale in the  network SPSS 24.0 is used for descriptive statistics and correlation analysis, and the process program prepared by Hayes is used to test the mediating and moderating effect.In this study, the questionnaire survey method is used to collect data. In the process of data statistics, Harman single factor test is used to estimate the influence of common method deviation. Exploratory factor analysis is carried out on all the questions of the four variables. Eight factors with characteristic roots greater than 1 are extracted from the results, and the maximum factor variance interpretation rate is 25.31%, which is less than the 40% limit proposed by Podsakoff et al., so there is no serious common method deviation in this study.As is shown in the t = 10.49, p < 0.01), and the direct predictive effect of perceived stress on Internet addiction was still significant  after the mediating variables were added. Perceived stress has a significant positive predictive effect on procrastination , and procrastination has a significant positive predictive effect on Internet addiction . In addition, the upper and lower limits of the 95% confidence interval of perceived stress on Internet addiction and procrastination mediation effect do not contain 0  compiled by ontain 0 , which it = 7.695, p < 0.01), and it is still significant when flow variables are included . Flow has a significant positive predictive effect on Internet addiction , and the interaction term of perceived stress and flow is of great importance in predicting Internet addiction . This suggests that flow has a significant moderating effect on the relationship between perceived Stress and Internet addiction.The model1 in process is used to test the moderating effect of flow between perceived stress and Internet addiction. Gender and grade are included in the control variable. As shown in A simple slope test was performed to explain more clearly the interaction between the perceived stress and the flow. The effect analysis diagram found that perceived stress has a significant positive predictive effect on Internet addiction, regardless of low and high flow. While, the positive predictive effect of high flow is more obvious .This study links perceived stress and procrastination with internet addiction, which has certain theoretical significance. Exploring the mediating role of procrastination between perceived stress and Internet addiction is helpful to study the reasons that affect college students’ Internet addiction, and it also provides a new analysis perspective for college students’ procrastination behavior. Procrastination is a deliberate and unnecessary act of delay, which can be manifested in trivial matters of daily life, but serious or frequent procrastination often leads to serious consequences. College students are prone to procrastination and Internet addiction. When people feel stressed, they may develop bad emotions and take negative responses, which tends to be procrastination. College students, as a large group exposed to the Internet, can easily use the Internet as a tool for procrastination. Therefore, this negative coping style of negative emotions will lead to the consequences of negative behavior, that is, Internet addiction. The problems that college students may have in the process of using the Internet have aroused widespread concern. This study points out that perceived stress urges individuals to use procrastination to escape bad emotions, which in turn leads to college students’ Internet addiction.Based on the emotional regulation theory and the structural view of emotional regulation, Kim’s experimental results show that individuals have the ability to perform certain emotional behaviors in an appropriate way and avoid the ability to perform certain emotional behaviors in an inappropriate way . This stIn addition, this study has certain practical significance. The mediating and moderating model constructed in this study have certain enlightenment to guide college students to make rational use of the Internet and reduce the occurrence of Internet addiction caused by individual stress. First of all, college students should be encouraged to timely detect stress levels, reduce negative responses to negative emotions, and actively seek help in the face of bad emotions; secondly, college students should use the Internet moderately and regard the Internet as a tool to assist social contact and study, instead of a tool to procrastinate, so as to reduce the negative impact of Internet addiction; finally, cognitive intervention can be carried out to reduce the time and frequency of network use of individuals who are easy to have flow experience on the Internet.There are also some shortcomings in this study, which need to be improved in the future research. First of all, in order to avoid the influence of other irrelevant factors, a project may be needed to more directly and clearly measure the level of flow in network usage. This study uses a cross-sectional design to investigate the relationship between procrastination and Internet addiction, but this may affect the direction of measurement. There may be a two-way effect between procrastination and Internet addiction, that is, Internet addiction will also aggravate procrastination, which needs to be explored by longitudinal studies and hierarchical linear modeling in the future.Based on the compensatory network use model and emotion regulation theory, this study constructs two models with procrastination as the mediating variable and flow on the Internet as the moderating variable, which clarifies how procrastination affects college students’ procrastination behavior (the mediating effect of procrastination), and explains under which conditions perceived stress has a more significant effect on Internet addiction (the moderating effect of heart flow). The results are consistent with the hypothesis. The perceived stress of college students is significantly related to Internet addiction, in which procrastination plays a mediating role in it, and the flow on the Internet plays a moderating role. The results of this study combined with the actual situation of college life, link perceived stress with procrastination and flow, and explore reasons behind Internet addiction among college students. This research has positive significance for expanding the study of the relationship between perceived stress and Internet addiction and constructing a theoretical model of Internet addiction.The raw data supporting the conclusions of this article will be made available by the authors, without undue reservation.The studies involving human participants were reviewed and approved by the Institutional Review Board, Normal College, Qingdao University. The participants provided their written informed consent to participate in this study. The patients/participants provided their written informed consent to participate in this study.ZG: propose research ideas and design research schemes. LW: responsible for conducting experiments. ZG and LW: responsible for collecting, cleaning, and analyzing data and responsible for manuscript drafting. HW: responsible for final revision. All authors contributed to the article and approved the submitted version.The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.


Health care delivery is undergoing a rapid change from traditional processes toward the use of digital health interventions and personalized medicine. This movement has been accelerated by the COVID-19 crisis as a response to the need to guarantee access to health care services while reducing the risk of contagion. Digital health scale-up is now also vital to achieve population-wide impact: it will only accomplish sustainable effects if and when deployed into regular health care delivery services. The question of how sustainable digital health scale-up can be successfully achieved has, however, not yet been sufficiently resolved. This paper identifies and discusses enablers and barriers for scaling up digital health innovations. The results discussed in this paper were gathered by scientists and representatives of public bodies as well as patient organizations at an international workshop on scaling up digital health innovations. Results are explored in the context of prior research and implications for future work in achieving large-scale implementations that will benefit the population as a whole. Health care delivery is undergoing a rapid change from traditional processes toward the use of digital health services -3, that Barriers and enablers for scaling up digital health innovations were identified and discussed in the context of a conference workshop. The workshop participants, who are also coauthors of this paper, were both junior (n=8) and senior scientists (n=2) and representatives from nongovernmental organizations (n=2) and a home care provider (n=1). The participants came from diverse countries with backgrounds in public health, implementation science, information systems research, and computer science. Many of the participants had several years of experience with the design and implementation of digital health services. All participants came together at the “1st International Workshop on Best Practices for Scaling-Up Digital Innovations in Health care–Scale-IT-up!” The workshop was held at the BIOSTEC conference in Valletta, Malta, on February 25, 2020 and spanned 3 sessions, with 5 papers presented by some of the workshop’s participants . Two keyThe discussion during the last session of the workshop followed a structured approach. To this end, 2 topic leaders—one each for the topics of barriers and enablers—were determined. The remaining participants were then split into 2 groups. Both groups undertook a 2-round group process, with discussions on barriers and enablers.In the first round, the groups identified either enablers or barriers for scaling up digital health innovations depending on their initial topic assignment. This identification was carried out according to the brainwriting technique , with eaIn the second round, the other group was informed about the results of the first round and could extend and revise these findings. Finally, all participants were given the final results, which were discussed and consolidated until a group consensus between all 13 participants was reached. Owing to our clustering, some items could have been mentioned multiple times and therefore carried more weight than others. However, no weights were added after identifying and discussing the findings. Afterwards, the raw results of each topic were digitized and categorized, and duplicates were removed. Finally, the results were aggregated and aligned with the existing work of DeLone and McLean  regardinIn total, 36 enablers and 33 barriers were identified in the workshop session. To align these enablers and barriers with prior research, they were grouped in categories classified by DeLone and McLean  as enablOverarching aspects that are influenced by all stakeholders involved on all levels are leadership, culture, interdisciplinary cocreation, innovation characteristics, and methodology. Although missing leadership in projects is an exemplary barrier hindering the scale-up of digital health innovations, dialogue between all stakeholders involved can be supportive. Further, a culture in favor of digital health innovations needs to exist, as it otherwise hinders the scale-up process when not existent. If interdisciplinary cocreation is missing, this can be a barrier, while collaboration between stakeholders or stakeholder engagement are exemplary enablers: indeed, the importance of the “quadruple helix”  and engaBarriers rather than enablers were identified on the macro level, referring to legislation, regulation or finance guidelines, and the respective stakeholders. The characteristics of regulation, funding, reimbursement, and planning are currently mainly hindering a successful scale-up of digital health innovations. Liability issues or the generally missing innovation-friendliness in the health care system together with missing funding or reimbursement can be named as examples. Further, the experts shared their experience that the aim of most research is not a successful implementation. All barriers and enablers on the macro level are presented in The meso level, for example, the community around individual end users, on the contrary, seems to enable the scale-up of digital health innovations rather than hinder it. Even though using different infrastructure systems as regional infrastructure can be a barrier, culture and social support can help in raising awareness and building capacity and trust. All barriers and enablers on the meso level are presented in On the micro level, the level of individual end users, the recommendation of digital health innovations by physicians  can enable their scale-up. Other individual characteristics of the end users, for example, lacking motivation or trust, their individual resources, or negative associations are rather hindering. The latter two mainly refer to the physicians/professionals as end users as they could be affected by additional work or see digital health innovations as a threat, negatively influencing their scale-up. All barriers and enablers on the micro level are presented in Technical aspects, particularly aspects regarding the innovation itself, form the largest group of enablers and barriers named by the experts. The categories related are information quality, usability, integration, interoperability, the business model, standards, and the innovation process itself. Although information quality  is seen as an enabler, usability is only seen as a barrier if not well-thought-out . Integration and interoperability aspects can hinder the innovation if not sufficiently considered but can also support actively the innovation’s success. Providing incentives or added value and having the business model in mind already at an early stage are important aspects for successfully scaling up digital health interventions. If, on the contrary, no suitable business model or no sufficient value propositions exist, it can easily turn into a hindering factor. Standards are a category, which only supports the scale-up of digital health innovations if appropriately followed. Using existing infrastructure and aligning to existing standards can be an advantage of each digital health innovation. Flexibility and modularization in the innovation process can support the innovation’s success too, while the pressure of change and the risk of innovations are hindering in some cases. All barriers and enablers related to technical aspects or regarding innovation itself are presented in Workshop outcomes were used to compile a classified list of enablers and barriers. The workshop’s aim was to match existing theoretical insights on enablers and barriers of digital health innovations with the practical experiences that the workshop participants brought to the activity. Participants offered insights from both research-based  and real-life perspectives. After the workshop, the resulting brainstorming (brainwriting) results were classified into categories to reach a single consolidated list of enablers and barriers. The results represent the collective perspective of the group members who participated in the working session. The viewpoint represented is that of a set of people who have actively participated in different forms of research on the development and implementation of digital health interventions.The categories of enablers and barriers have shown that the successful scale-up of digital health innovations is influenced by actors and aspects on different levels . Actors in each of these levels are perceived to influence the success of digital health innovations. These different levels are in line with the focus areas that were identified by Labrique et al  criticalPrior work of some of the participants in the workshop  covers dLeadership was referred to as both enabler and barrier (when considering the lack of it). It is an essential trigger for digital innovation and adoption . In lineFurther, commonly mentioned in the workshop, at different levels, are the regulatory and trust issues that hamper adoption at a large scale. Indeed, policymakers and health care management need to be part of innovation processes, understand the needs for change, and provide guidelines that increase trust to take decisions on scaling up . BusinesIt needs to be elaborated further if the discrepancy between the findings of our workshop and prior literature shows different perspectives in the perception of enablers and barriers for digital health innovations between research and practice. Moreover, future research should corroborate our findings with larger groups of experts to see how they hold or vary per medical subindustry. We suggest that the development of digital health apps for smartphones may be different from the development of hospital information systems. The findings reported are mainly limited by the size of the expert group involved in the workshop. It could have been too small or not representative enough since the group was composed mainly of researchers. Nevertheless, the experts involved combined extensive experience in  health care.The workshop took place at the very onset of the pandemic breakout; days after it occurred, Malta restricted travel in and out of the island. As so, the reported viewpoint did not consider all the digital transformation that happened in the last year owing to the need for fast response to health care needs. Many identified barriers for adoption and scale-up were suddenly put aside owing to the urgent need to provide remote and safe care and monitoring. Leadership, regulatory issues, and reimbursement are categories of those barriers, which were also identified in To summarize the findings and discussions from the workshop, 5 conclusions for the scale-up of digital health innovations can be highlighted. First, digital health services can help to drive data quality, outreach to communities, and manage disease transmission/progression. Second, to reach these aims, a general cultural shift is needed when aiming to have digital services as viable instruments in health care along with classic pharmaceutical, surgical, or other therapeutic measures. Third, technological developments and interoperability appear to be enablers supporting digital health services rather than acting as hindrances. This latter finding is rather surprising since lack of interoperability has often been named as a barrier in prior work ,54. Inde