The Islamic Republic of Pakistan has been a mere victim of climate change in recent years. The country needs emergency measures at every level to mitigate environmental dilapidation. The role of enterprises in the country’s environmental efforts is critical. In this regard, the hotel sector is known for its outsized carbon footprint. Knowing this, the current study aims to improve a hotel enterprise’s environmental performance (ENP) as an outcome of corporate social responsibility (CSR). The study also considers the mediating role of pro-environmental behavior (PEB) of employees and the moderating role of altruistic values (ALT). A hypothesized model was developed, which was validated by employing the structural equation modeling technique. The empirical results confirmed that CSR, directly and indirectly (through PEB), positively induces the ENP of a hotel enterprise. Whereas the conditional indirect role of ALT was also found significant. The study offers different implications for theory and practice, among which one important takeaway for the hotel sector is to realize the importance of employees to spur ENP of a hotel enterprise through their eco-friendly behavior. At the same time, the current work also advances the theory by highlighting the moderating role of ALT between the indirect relationship of CSR and ENP. Perhaps, environmental protection is one of the top priority agenda items for every sector. Concern to preserve the environment is not new, however, the recent environmental issues like global warming, climate change, pollution, etc., have urged every stakeholder to partake in activities to preserve the environment . Almost A recent review of the literature pertinent to environmental studies unveils that most of the mainstream literature on PEB presents two perspectives—the consumer perspective  and the Additionally, the available literature largely considered PEB as an outcome construct. For instance, the studies of Given that the manufacturing industries directly impact the environment through their industrial practices, most of the environmental studies have focused on the manufacturing industries . HoweverPakistan, which is a developing economy, Where, pollution from different sectors, including the industrial sector, has been identified as a significant contribution toward such alarming environmental conditions. Country’s hotel sector has no exception, as it was also identified as a sector for its outsized carbon footprint. Waste creation, energy consumption, water, and food wastage are some of the major environmental issues associated with this sector in the country. This is why the current study has focused on this sector of the country to test the proposed relationships.The current study intends to fill the knowledge gaps in three areas. First, the study attempts to fill the knowledge gap in the field of behavioral studies and environmental management literature from the perspective of CSR, employee behavior (PEB), and altruistic values under a unified model. To this end, the prior literature did not explore the potential of such constructs from an environmental perspective. Though, the role of altruistic values to guide the behavior of employees was discussed , the potSecond, the consideration of the hotel sector also serves as an important contributor to advance the available literature, as a plethora of previous environmental studies were conducted in a manufacturing context , howeverThe remainder of the current work is composed of four parts. The next part deals with the theory and related literature to develop the hypotheses and research framework. Similarly, the methodology part discusses the sample, data collection procedure, and instrumentation. The last two parts are dedicated to results and discussion, respectively. The results part deals with the statistical analysis and outcomes whereas, the discussion part discusses the study results in the light of previous findings. This part also discusses the theoretical and practical implications of the current study.The theoretical framework of the current research is rooted in the social identity theory developed by In the current context, a CSR inclined firm is expected to generate a value congruence between employees and a firm. This congruence of values led the employees to develop a strong bond with a socially responsible firm. All this process eventually constitutes a situation where employees are motivated to identify themselves with a responsible firm strongly. Altogether, the noble CSR engagement of a firm can significantly influence the behavior of employees positively due to the value congruence, which ultimately fosters the firm’s environmental performance. Moreover, the altruistic values of employees are also in congruence with the crux of CSR as both concepts  focus on the value of caring for others. Therefore, the current theoretical perspective finds social identity theory as a grounding theory to formulate different hypotheses.Corporations are assumed to operate without producing any negative environmental impact. Moreover, contemporary corporations are also required to assume their social responsibly while conducting different business operations . In the Hypothesis 1 (H1):Corporate social responsibility activities of a firm can positively induce its environmental performance.To address different environmental challenges, firms consider different approaches. Among such approaches, promoting sustainable behavior among the employees has received mounting importance in recent literature . AdditioHypothesis 2 (H2):Corporate social responsibility positively influences the pro-environmental behavior of employees.The seminal work of In the same vein, the positive association between the citizenship behavior of employees and the environmental performance of a firm has also been proposed by different scholars . RelatinWhen looked at from the perspective of the current study, it is quite possible to propose a mediating link of PEB between CSR and the environmental performance of a firm. Given that the firm’s CSR orientation helps employees build a strong identification with the firm, and by referring to social identity theory, employees put every effort to induce the overall performance of their firm, including the environmental performance. The above discussion clearly indicates that PEB directly influences the environmental performance of a firm and can also spur the relationship of CSR and environmental performance through its potential mediating role. Hence the following hypotheses may be proposed.Hypothesis 3 (H3):Pro-environmental behavior of employees positively influences the environmental performance of a firm.Hypothesis 4 (H4):Pro-environmental behavior of employees mediates the relationship between corporate social responsibility and a firm’s environmental performance.Values are central to shaping individual behavior. As per the definition of Hypothesis 5 (H5):The presence of altruistic values moderates the mediated relationship between CSR, PEB, and environmental performance, such that the relationship is stronger in the presence of altruistic values.The targeted industry was the hotel sector of Pakistan which has been active in the country since its independence back in 1947. Given the country’s improved law and order situation during recent years, the hotel sector has witnessed considerable growth. From an economic perspective, the sector contributes 7% of the total GDP of Pakistan. Moreover, the sector is considered a labor-intensive industry, as currently employs almost 3.85 million people . DespiteOf more importance, the above two cities are also known globally for a poor air quality index and environmental conditions. Especially, Lahore joins the list of the top five most polluted cities in the world . SimilarA self-administered questionnaire (paper–pencil technique) was employed as a data-collecting instrument. Before finalizing such an instrument, the questionnaire items were assessed by experts in the field. Only after receiving valuable feedback from the experts, the final version of the questionnaire was provided to the survey respondents . The queThe current study constructs were operationalized by adapting different reliable and valid sources. Acknowledging the importance of pre-established scales from the perspective of reliability and validity , the autThe issue of common method variance (CMV) has been regarded as a potential threat to contaminate a dataset. Especially, this potential threat becomes critical in cases where data collection for all constructs is made from a single source. More specifically, different researchers reported this issue as a contributing factor toward a false internal consistency . The manConsidering the importance of the above potential issue of CMV, and given that the data for the current study were collected from a single source, the authors opted to detect if the current study data encounters the issue of CMV.A general approach toward detecting the CMV is to perform a single-factor test proposed by Given that the approach of single factor test is a very old technique, though still, it finds its place in different studies, the author decided to perform an advanced level test to detect CMV. In this respect, different authors have argued in favor of common latent factor test (CLT). To employ this technique, AMOS software was considered. In this regard, the authors developed a measurement model, which was then allowed to be influenced by a CLT. This common factor was assumed to directly influence each item of a construct. The constrained value of this common factor was fixed to ‘1.’ However, in line with the Harman single factor test findings, the CLT approach also indicated that the common factor is not explaining the sheer amount of total variance (50%). Thus these results cross-validated the findings of the single factor test in the early stage. Therefore, the CMV was not considered a potential threat to the dataset of the current study.The evidence against the presence of any CMV in the current dataset encouraged the authors to proceed with the further stages of data analysis. Hence the authors evaluated the constructs of the study by performing different statistical tests. For instance, the factor loading of each item was assessed to validate if each item’s loading is appropriate with respect to its corresponding construct. The common norm in this respect is to detect any item with a factor loading ideally less than 0.7 and to identify if there is a case of cross-loading with any item. These results are given in r = 0.38), which provided initial support to H1 of the current study, implying that CSR and ENP move in the same direction with the changes in values. Meanwhile, the authors also performed another important validity test which was to check the discriminant validity of the study’s constructs. For this purpose, the square root value of AVE for each construct was first evaluated . These results statistically confirmed the theoretical statements given in hypotheses H1, H2, and H3.The current study employed the structural equation modeling technique (SEM) in AMOS software to test the hypothesized relationships. Indeed, SEM is an advanced-level data analysis technique that contemporary scholars largely prefer due to its ability to deal with complex models (as in the current study). Moreover, SEM can analyze the complex relationships (models with mediating and moderating constructs) simultaneously. This is one of the reasons why contemporary scholars are greatly inclined to use this data analysis technique . Moving Secondly, the structural model was developed to record the mediating effect of ALT between CSR and ENP . In thisThe statistical findings of the current survey revealed the potential importance of CSR perceptions of hotel employees to foster the environmental performance of a hotel enterprise. The participation of a socially responsible hotel in different activities for the larger interest of society and the environment inculcates positive feelings among the employees. In return, the employees also participate in different environmental conservation activities, which induces the overall performance of a hotel enterprise from an environmental perspective. The CSR perspective of an enterprise to improve its environmental footprint is of utmost importance. Given that under the philosophy of CSR, a hotel enterprise continues its caring for others approach, and hence it puts every effort to preserve the natural resources, for instance, energy and water consumption, improving operations to generate waste to the minimum and facilitating the added support to the environment. Moreover, this CSR perspective also assumes to adopt eco-friendly activities, which exceeds the required state laws and considers a responsibility for any external negative effect on the part of an enterprise. At the same time, it has been reported that the environmental perspective of CSR deals with a series of actions taken by an enterprise to reduce its carbon footprint and thus to induce the overall environmental performance of an enterprise. These insights of the current analysis are also supported in the prior literature on environmental studies . SpecifiThe current work also documents the role of employees in improving the environmental performance of a hotel enterprise as an outcome of CSR and PEB. In this vein, the CSR commitment of a hotel enterprise is well taken by its employees who are encouraged to support the environmental initiatives of their enterprise by performing different environmental improvement activities. Communicating the CSR concern of a hotel enterprise with the workforce is generally assumed to be helpful in improving the eco-friendly behavior of employees. A socially responsible hotel enterprise gives a clear message to its workforce that it has a concern for ‘caring of others. When employees see such a caring attitude, they are expected to regard this attitude positively. These results of the current work are also endorsed by different researchers who acknowledged the important role of CSR perception of employees in shaping environmental behavior . In thisvia CSR and PEB. Given that the role of values in shaping human behavior is critical, the moderating role of altruistic values provides additional support to the employees for their engagement in different environment-related behaviors. Because the focus of altruistic values is ‘caring for others and the CSR approach of an enterprise stresses the same, therefore a congruence of values between employees and the enterprise occurs . The “Karighar” program by Serena is one example of this CSR perspective. However, this is the time for this sector to realize the potential role of CSR to reduce its outsized environmental footprint. The management needs to realize that the CSR perception of employees can significantly improve the environmental performance of a hotel enterprise. The approach of Monal hotel can be considered by its counterparts, as the hotel has significantly reduced its food wastage by constantly communicating its CSR role and highlighting the importance of food wastage. Importantly, such efforts were helpful to Monal for reducing its food wastage not only on the part of consumers but also on the part of employees. Therefore, the current study suggests the hotel sector closely aligns their CSR strategy from the environment perspective and the current philanthropic orientation. Because considering the philanthropic CSR efforts will be as good as “feeding the titanic with a teaspoon.”Similarly, the current study’s findings also highlight the role of altruistic values for environmental improvement. In this regard, the hotel management is suggested to consider this factor during their recruitment and selection process. Moreover, for the current employees, the management needs to organize different seminars and workshops where employees can learn about environmental values to get themselves engaged in different environment-related causes at the workplace. Lastly, the negative environmental impacts of the hotel enterprises must be mitigated if these enterprises desire to be sustained in the future. In this respect, hotel management is required to improve their environmental footprint through different sustainability initiatives at an organizational level  and through a better environmental behavior of its employees for which a well-planned CSR strategy is a way forward for this sector.Though the current work has made different important theoretical and practical implications, still it faces different limitations. However, such limitations also open new avenues for future researchers. In this vein, the first limitation lies with the geographic orientation of the current study, as this study only included two large cities (Lahore and Karachi). Therefore, it is desirable for future researchers to consider more cities so that a better and larger aspect may be realized. Secondly, the study only records the perceptual measures of CSR and environmental performance. Though such perceptual measures are helpful in a plethora of studies, using an objective measure of such constructs in the upcoming studies may generate more realistic outcomes. Similarly, the current study’s findings may remain limited in its scope because a cross-sectional survey design was employed, limiting the causality of association among different constructs. In this regard, a better approach for future studies may be to incorporate a longitudinal data design. Lastly, given that CSR is context and culturally specific, the current survey findings may remain similar for the like cultures . However, due care is necessary in different cultures before interpreting the current survey results.Given that the concern for the environment has become the main topic of debate of the present time, all sectors are realizing the importance of sustainability. In this respect, rethinking sustainable practices in the hotel sector is becoming a matter of prime importance, as this sector is globally known for its outsized carbon footprint.For promoting sustainability, the current study contributes by highlighting the importance of CSR to improve the environmental performance of a hotel through its employees. As this sector in the country constitutes a multi-million workforce, improving eco-friendly behavior among employees in this sector is of utmost importance to induce environmental performance. In this regard, organizational factors (CSR) and personal values  are at heart to influence an employee’s behavior.Based on the data collection from the employees of hotel industry, the important takeaway of the current research is that CSR activities of an enterprise create a value congruence between employees and the enterprise, which creates a strong bond on the part of employees to show extra commitment to a socially responsible enterprise, which then provides extra support to a hotel for enhanced environmental performance. Therefore, to have a sustainable future in this sector, undoubtedly, CSR is a way forward for hotel enterprises operating in Pakistan. Hotel industry needs to develop appropriate measures for promoting sustainable and eco-friendly practices. Hotels should introduce different CSR activities to promote pro-environmental behavior among employees and consumers.The study results are insightful to analyze the adoption of sustainable practices in the hotel industry. However, there are some limitations associated with the current study. The data collected for the study were from the hotel industry and incorporated CSR, PEB, ALT, EVP, and introduced the mediating role of PEB. However, future studies might consider other mediating variables. Further, the study model can be applied to other sector for validation. One of the main limitations of the study is taking sample of study from two cities of the country, therefore, the generalizability is questionable. However, further studies might consider more cities to improve generalizibility.The raw data supporting the conclusions of this article will be made available by the authors, without undue reservation.BA: writing original draft. HX: reviewing and editing, and project sponsorship. MZ-U-D: literature review and data collection. MZ: data collection, project funding, reviewing, and comments. NA: data curation and data analysis. MG: proofread and editing and revision and editing.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.


The purpose of this study is to examine the relationships between organizational commitment and turnover intention, and to test the mediating effect of perceived insider status, and moderating effect of gender on that relationship.Data were collected using a questionnaire survey method from 820 temporary employees of government agencies working in China. The data obtained were analyzed according to the moderated mediation.As a result of the analysis, it was determined that perceived insider status has a partial mediation effect on the relationship between organizational commitment and turnover intention. Also, the results supported the moderated mediation and showed that the indirect effect of organizational commitment and turnover intention through perceived insider status was weaker for males than females. Then, the theoretical and practical implications of the findings are discussed. With the continuous development of the economy and society, the government has taken on more and more responsibilities in economic construction, social management, people’s livelihood, and public services, which has placed higher demands on the ability and efficiency of government departments to perform their duties . Under tTemporary employees in the local government refer to workers temporarily hired by the government through public finance to assist government departments and agencies in public management activities or administrative affairs, and these workers are not government workers with a formal establishment . We needWe review the existing studies on temporary organizations or temporary employees. Some studies try to explain the growth of temporary work in China from the perspective of institutional and organizational characteristics . Some stThe purpose of this paper is to combine social identity, social exchange, and role conflict theories into a model explaining the turnover intentions of temporary employees in the local government from an individual level. Therefore, this study tries to investigate the relationship between organizational commitment and turnover intention, as well as the mediating role of perceived insider status and the moderating role of gender, to reduce the detrimental effects of turnover intentions from temporary employees, promote their motivation, and provide informative policy recommendations for improving the management of government temporary staff.Organizational commitment is linked with a strong desire amongst employees to remain within their organizations, the identification and reliance of employees on organizational goals, values, etc., as well as their internal driving force to stay in the organization and an important manifestation of their loyalty to the organization . Three dFollowing social identity theory, temporary employees usually perceive high job insecurity, which concerns the perception of an involuntary and undesired change in the continuity of the work situation . PreviouHypothesis 1: The organizational commitment of government temporary employees negatively correlates with their turnover intention.Perceived Insider Status was first proposed by Stamper and Masterson, is defined as the extent to which an individual employee perceives him or herself as an insider within a particular organization, describing employees’ cognition of their identity status in the organization, feeling accepted and recognized by the organization, and truly becoming the “internal people “of the organization . An impoHypothesis 2: The organizational commitment of government temporary employees positively correlates with their perceived insider status.Perceived insider status can be affected by personal and organizational factors, which in turn can affect employee behavior in the organization. Relevant studies have investigated the role of perceived insider status as a predictor of attitudinal and behavioral work outcomes, especially in the relationship between individuals and organizations . Once neHypothesis 3: Perceived insider status may affect turnover intention negatively.Combining the three hypotheses above, it is easy to find that the impact of organizational commitment on the turnover intention of government temporary employees may partially affect the identity of insiders. Studies have shown that after the needs of employees in the organization are met, they will have a sense of attachment to the organization, so their willingness to continue to maintain membership in the organization will be stronger, and the generation of turnover behavior will be reduced . The higHypothesis 4: Perceived insider status may mediate the relationship between organizational commitment and turnover intention.Turnover intention is a complicated manifestation, which is a comprehensive performance of job dissatisfaction, leaving thoughts, looking for other jobs, and the possibility of finding other jobs . In addiCombining gender role stereotypes and role conflict theory, men feel a strong sense of insider identity and have a lower turnover intention when they have a high sense of organizational commitment, which is inseparable from gender roles. Society’s perception of women is that family attributes are stronger than work attributes. In addition, women take on more responsibility for caring for the family and raising children than men . StudiesHypothesis 5: Gender plays a moderating role between perceived insider status and turnover intention.The theoretical framework of this study can be summarized as follows see .In this study, questionnaires were distributed to temporary employees of government agencies in Henan Province through Questionnaire Star , and a total of 840 questionnaires were recovered with 820 valid questionnaires obtained, and the effective recovery rate was about 97.62%. Among them, as shown in In this study, measuring scale items were adopted from the existing literature and adapted into the Chinese context with the help of bilingual researchers and m-government experts. Before conducting the survey, we pilot-tested 50 citizens to make sure of the logical consistency, wording, meaning, and appropriateness of the instruments. All items were measured using a 5-point Likert scale ranging from “strongly disagree = 1” to “strongly agree = 5.”Organizational Commitment. Three-Factor Organizational Commitment Scale compiled by Perceived Insider Status. The 6-item scale developed by Turnover Intention. The 4-item scale compiled by In this study, SPSS statistical software was used to analyze the data. A descriptive analysis was performed to examine the characteristics of the samples. A correlation analysis was performed to examine the correlations between each variable, and an effective method was used to examine causal relationships and moderating effects in studies focused on our topic.p < 0.05, the results indicate that there is a correlation between variables, suitable for factor analysis, and the questionnaire has better structural validity. Collecting data by the self-report method may lead to common method bias. Therefore, this study first used Harman’s single-factor test to verify common method variance. It was found that there were 4 factors with eigenvalues >1 in the unrotated case, and the largest factor varies nicely explained the degree of accuracy was 38.79% (<40%), so there is no serious common method variance in this study.The Cronbach’s alpha of each variable was measured to test the reliability of the variables, all of the Cronbach’s alpha values are above 0.70, indicating high instrument reliability. The KMO values of the organizational commitment scale perceived insider status scale, and turnover intention scale is all >0.7, In addition, to ensure the validity of the regression analysis results, Collinear Diagnostics was used to test the multicollinearity problem between independent variables, and measure the tolerance and variance inflation factor (VIF) indicators. Tolerance and variance inflation factor are reciprocal to each other, the smaller the VIF, the weaker the multicollinearity, if the VIF is ≥10, it indicates that there is a very serious multicollinearity between the independent variables, it is generally believed that VIF should not be >5. In the regression analysis of this study, the VIF of the independent variables was <5, indicating that there was no multicollinearity between the variables and that the questionnaire validity was good.According to H1; B = −0.80, p < 0.01) but also indirectly through perceived insider status; organizational commitment had a positive effect on perceived insider status ; perceived insider status significantly and negatively predicted turnover intention . Based on the Bootstrap method using 5,000 bootstrap sample indicate that perceived insider status mediated significantly and partially between organizational commitment and turnover intention .Results in B = −0.26, p < 0.05). To further explain the moderating effect of gender, a simple slope test was performed for both male and female groups. Hypothesis 6 predicted that gender will play a moderating role between perceived insider status and turnover intention. The moderating effect is tested using the Model 14 of the SPSS macro program PROCESS. The results in Firstly, the results show that organizational commitment of government temporary employees is significantly negatively correlated with turnover intention. Sustained commitment refers to an awareness of sunk costs and a willingness to stay in an organization as individuals increase their commitment to the organization. The data of this study shows that more than 50% of the government temporary employees have worked in the unit for 1–3 years. Most of the temporary employees’ wages are only higher than the local minimum wage and are half of the formal civil servants . Due to Secondly, the perceived insider status of government temporary employees has a partial mediating effect. That is to say, the organizational commitment of government temporary employees can not only directly affect the turnover intention, but also affect the turnover intention through the intermediary role of perceived insider status. Government temporary employees’ perception of their insider identity will directly affect their turnover intention. When government temporary employees have a strong sense of belonging to the organization, they will take the initiative to regard themselves as the owners of the unit, and are more willing to stay in the organization .Thirdly, gender plays a moderating role between perceived insider status and turnover intention. When the staff is male, the perceived insider status has a significant negative predictive effect on their turnover intention; while when the temporary recruit is female, the perceived insider status hurts their turnover intention. Enhance the predictive effect. Therefore, it shows that under the same level of perceived insider status, different genders have different negative effects on turnover intention, that is, under the same insider identification result, women are more likely to have turnover intention. The reason for this result may be that the social cognition and role positioning of different genders are different, and men and women act according to the behavioral standards given by society, thus forming different behavioral patterns of the sexes, which are also manifested in psychological cognition. Influenced by traditional Chinese gender concepts, women tend to identify more with family roles, while men are more identified with work roles .In general, this research tried to enrich the understanding of underlying mechanisms between organizational commitment and turnover intention among temporary employees in local governments in China. This paper investigated the relationships between organizational commitment and turnover intention and tested the mediating effect of perceived insider status, and moderating effect of gender on that relationship using a questionnaire survey method from 820 temporary employees of government agencies working in China. As a result of the analysis, it was determined that perceived insider status has a partial mediation effect on the relationship between organizational commitment and turnover intention. Also, the results supported the moderated mediation and showed that the indirect effect of organizational commitment and turnover intention through perceived insider status was weaker for males than females. Moreover, some suggestions for governments to decrease the turnover of their employees may be as follows.For managers and organizations, this study suggests some practical implications. First, research findings revealed that turnover intention and organizational commitment are directly affected by organizational commitment. Managers can increase emotional commitment by taking into account temporary employees’ emotional needs, creating a positive, relaxed, and pleasant organizational atmosphere and environment. At the same time, a career management system in line with the actual situation of government temporary employees might be considered, to help temporary employees break the promotion “ceiling” and enhance their continued commitment. In addition, a variety of training activities are carried out to improve work skills, relieve work pressure, adjust work mentality, and improve the sense of normative commitment of temporary employees.Second, research findings demonstrate that perceived insider status negatively predicts the turnover intention of government temporary employees and mediates the relationship between organizational commitment and turnover intention of government temporary employees. Therefore, government managers can positively contribute to the decrease of turnover intention, increasing perceived insider status by enhancing the sense of team support, giving respect and trust, and helping government temporary employees truly participate in organizational decision-making.In addition, this study also highlighted the indirect effect of organizational commitment on turnover intention through perceived insider status is strong when the gender is female. Therefore, managers may pay more attention to the characteristics and needs of different genders, like flexible working hours, and family support plans. Also, some support may be helpful to get closer to employees to understand the psychological demands and expectations of employees of different genders and integrate the pursuit and development of temporary employees.In summary, the results of this study verify the hypothesis and have a certain value for systematically understanding the relationship between organizational commitment and turnover intention of government temporary employees, but there are still some deficiencies, and follow-up research can be improved in the following aspects: The first limitation of this study is the selection of research samples, which are affected by objective factors such as time and geographical factors. Therefore, future research should fully consider regional differences to improve the representativeness of the sample. Furthermore, the turnover intention is expressed as the psychological tendency of employees to leave their current work, which reflects the two-way interaction between temporary employees and the organization. However, because the behavior process of the organization is more complicated to measure, the research on turnover intention is only from the perspective of temporary employees. In the future, the research should be further enriched and developed from the perspective of both temporary staff and the government.The raw data supporting the conclusions of this article will be made available by the authors, without undue reservation.DX conceived of the presented idea. JS developed the theory and performed the computations. YZ verified the analytical methods. CZ supervised the findings of this work. All authors contributed to the article and approved the submitted version.This work was supported by the China Postdoctoral Science Foundation (no. 2022M712858), National Social Science Fund of China (no. 22BZZ066), and Education Department of Henan Province (nos. 2023-YYZD-24 and 2021-CXTD-07).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.


Palliative sedation involves the intentional lowering of consciousness at the end of life. It can be initiated to relieve a patient’s burden caused by refractory symptoms at the end of life. The impact of palliative sedation needs to be clinically monitored to adjust the proper dose and regimen of sedative medication to ensure that patients are at ease and comfortable at the end of their lives. Although there is consensus among health care professionals and within guidelines that efficacy of palliative sedation needs to be closely monitored, there is no agreement about how, when, and by whom, this monitoring should be performed. The aim of this study is to evaluate the effects of palliative sedation by measuring the discomfort levels and sedation/agitation levels of the patients at regular timepoints. In addition, the clinical trajectories of those patients receiving palliative sedation will be monitored and recorded.The study is an international prospective non-experimental observational multicentre study. Patients are recruited from in-patient palliative care settings in Belgium, Germany, Italy, Spain and the Netherlands. Adult patients with advanced cancer are monitored by using proxy observations of discomfort (DS-DAT) and depth of sedation/agitation levels (RASS-PAL) during palliative sedation. After the palliative sedation period, the care for the specific participant case is evaluated by one of the attending health care professionals and one relative via a questionnaire.This study will be the first international prospective multicenter study evaluating the clinical practice of palliative sedation including observations of discomfort levels and levels of sedation. It will provide valuable information about the practice of palliative sedation in European countries in terminally ill cancer patients. Results from this study will facilitate the formulation of recommendations for clinical practice on how to improve monitoring and comfort in patients receiving palliative sedation.Clinicaltrials.gov since January 22, 2021, registration number: NCT04719702.This study is registered at  An increase in cancer incidence together with a longer survival time for patients with advanced cancer is observed. Increasing treatment possibilities are available but are accompanied with progressively more morbidity. Therefore, the number of patients in need for end-of-life care is likely to increase . PatientMost guidelines recommend that the level of palliative sedation should be proportional to the intended clinical effect of symptom relief . PreviouMoreover, major differences between study protocols and characteristics occur, for instance in patient characteristics, definition of palliative sedation, and its indication to start. Consequently, reported outcomes and associated treatment goals differ between these studies which prevent the generalization of outcomes and decisions about the effective use of palliative sedation in clinical practice .To understand the observed clinical outcomes of palliative sedation in patients with cancer suffering from refractory symptoms, it is important to relate these to the reasons to start palliative sedation, the prescribed drugs and dosages and the specific clinical context where they are measured. Moreover, differences across various palliative care settings and European countries in both clinical and ethical aspects should be included in the interpretation of the results . So far,To study the clinical practice and outcomes of palliative sedation from different perspectives, we conducted a prospective multicenter non-experimental observational study in cancer patients from palliative care settings, in five European countries.To evaluate the effects of palliative sedation on advanced cancer patient’s comfort levels in hospices, palliative care units and hospital wards in five European countries.To evaluate the effects of palliative sedation on patient’s sedation levels in hospices, palliative care units and hospital wards in five European countries.To describe the current clinical practice of palliative sedation in hospices, palliative care units and hospital wards in five European countries.To describe the evaluations of the relatives and health care professionals with the palliative sedation given in the patient cases.In this clinical observational study, participants with advanced and untreatable cancer will be followed prospectively after informed consent given prior to the start of the decision-making process for end-of-life care until death. Before and during the palliative sedation in a patient, prospective measures and clinical observations will be performed to evaluate the sedation process. After the patients’ death, one of the attending health care professionals and one of the relatives will receive a questionnaire to evaluate the palliative sedation and care in the specific patient case.This prospective study will be conducted in five European countries: Belgium; Germany; Italy; Spain and the Netherlands. Participants are recruited from in-patient palliative care settings: hospital wards; palliative care units and hospices. In each country, we are aiming to recruit 30 participants receiving palliative sedation.In the study by van Deijck and colleagues  a mean dBecause the present study will aim to include a wider range of settings and with more variability in forms of palliative sedation, therefore the effects may be smaller. Estimating a smaller effect size of 2.4 points on the DS-DAT, using an alpha of 0.05 and 0.80 power in a two-sided, paired t-test, with a standard deviation of 6.2, and correcting for clustering due to the multiple international centre settings (using an ICC of 0.05 and pre-assumed design effect of 1.2) we will need to include 110 sedated patients. To anticipate at missing data and dropout rate during the study we aim to include 150 sedated patients in total.All adult patients with a diagnosis of advanced cancer and a limited life expectancy, as assessed by the attending health care professionals, are eligible for inclusion. Additionally, intractable distress caused by one or more symptoms during the hospitalization needs to be present or expected, according to the health care team. Lastly, patients need to be able to give informed consent  one of the health care professionals (physician or nurse) involved in the initiation of palliative sedation; 2) one of the relatives, who takes care of, and supports, the patient for most of the time. This relative may not necessarily be a family member.All consecutively admitted patients in the participating settings will be screened for eligibility by a health care professional from the local participating setting. Eligible patients and their relative(s) will be informed by the responsible health care team about this study as soon as possible after admission. This team defines in each particular case what is the best timing to ask for informed consent.Screening and recruitment for the study started May 2021, and will be in progress for 24 months.Potential participants receive the information letter via one of the responsible health care professionals in the participating setting. When a potential participant has had sufficient time to consider and indicate that he/she would like to know more about participating, the local researcher is notified. One of the local researchers will visit the patient to explain the study, answer questions and discuss participation. Preferably, the informed consent procedure is performed by one of the local researchers independent of the patient’s care team. In addition, at each clinical centre, there is a local principal investigator that serves as a primary contact point for the study or to perform the informed consent procedure. Informed consent is requested for obtaining data about the patient’s treatment trajectory following admission.The main outcome of this study is the proxy measurement of change in discomfort levels of patients before and during the period they receive palliative sedation.As a secondary outcome, proxy measurement of agitation/sedation levels will be measured at the same time points as the discomfort levels, to evaluate a correlation in the course of both measurements.Other outcomes in this study are clinical aspects in the process of decision-making about palliative sedation; administered type, doses of sedative medication and adverse effects as reported in the patients notes and in the case report forms. Besides, one of the health care professionals completes a questionnaire regarding the overall evaluation of palliative sedation in the specific patient case. Lastly, one of the relatives is asked to rate how satisfied he/she was with the care for the patient during the palliative sedation period.Data collection is planned to use a two-stage approach See Fig. . When inOnly those patients in which the process for palliative sedation is initiated will advance to phase 2 of the study. In this phase, extra questionnaires and measurements are completed by the health care professionals at the bedside, regarding the decision-making process of palliative sedation, baseline discomfort levels, the use of medication and other clinical aspects of palliative sedation.To gather data about the study parameters we predominantly use data that is normally collected in clinical practice at the participating settings. This data is gathered from the available patient data management system (PDMS), and directly registered into the electronic case report form. Required study data regarding baseline measurements and all palliative sedation measurements, not regularly registered in the PDMS, are collected by study questionnaires or measured by additional scales.Assessment of variables is planned at different time points during the trajectories of the study participants, and contains more measurements for the participants who start with palliative sedation See Fig. .Fig. 2StThe Edmonton Symptom Assessment System (ESAS) is an assessment scale designed to assess the symptom burden of the patient. It contains 9 items, scored on a visual analogue scale . As baseThe Eastern Cooperative Oncology Group (ECOG) Performance Status is a scale that uses standard criteria to measure the impact of the disease on patient’s daily living abilities. The scale describes a patient’s level of functioning in terms of their ability to care for themself, conduct daily activities, and physical ability . The ECOThe Discomfort Scale-Dementia of Alzheimer Type (DS-DAT) is a validated instrument to assess discomfort in patients with severe dementia by observing patients’ behavior over 5 minutes of observation. Participating health care teams were trained online and at bedside how to use the DS-DAT tool. The tool covers nine categories: noisy breathing, negative vocalizations, content facial expression, sad facial expression, frightened facial expression, frown, relaxed body language, tense body language, and fidgeting. Items are scored by indicating behaviors that are present/absent with a resulting range of scores of 0 to 3 per item and a total score from 0 to 27. Higher scores represent higher amount of discomfort .In our study the DS-DAT is measured 8 hours or less before the start of palliative sedation, within 6 hours after the start, and then twice daily during the period palliative sedation is provided by one of the attending health care professionals.The Richmond Agitation Distress Scale-modified version for Palliative care (RASS-PAL) is an observational instrument assessing levels of sedation and agitation that requires no patient input with scores ranging from + 4 (overtly combative patient) to − 5  .The depth of sedation as assessed with the RASS-PAL will be measured at the same time points as the discomfort measurements.The presence of the following clinical signs and/or symptoms will be registered in the daily monitoring forms: breathing difficulties ; respiratory secretions; (drug induced) delirium; paradoxical reaction/agitation; patients regaining consciousness; and other clinical observations.The attending health care professionals will be asked about their evaluation of the palliative sedation period for the specific patient. Daily rating of the effectiveness of palliative sedation at patient’s comfort level will be scored on a Likert Scale ranging from excellent to very poor.1 week after the participants death, a questionnaire will be sent to one of the health care professionals, with three questions 1) about their personal rating of agreement to start palliative sedation in this patient, scored on a Likert scale ranging from 1 strongly disagree to 5 strongly agree, 2) the overall effect of the palliative sedation at the comfort levels, and 3) the quality of dying in the particular patient’s case, both scored on a 5-points Likert scale ranging from 1 very poor to 5 excellent.Two different methods will be used to evaluate the experiences of the relatives with the palliative sedation. First, a daily reporting by the attending health care professionals in the case report forms of expressed concerns and/or complaints of relatives during the palliative sedation period.Furthermore, at least 1 month after the participant’s death, a structured questionnaire will be sent to one of the relatives. This family satisfaction with care questionnaire (FAMCARE-2) contains 17 items about the care received, which are scored on a Likert scale between 1 very unsatisfied to 5 very satisfied .Changes in type-, dose- and route of administered sedative(s) and other medication during the palliative sedation period will be recorded daily on monitoring forms from the start of palliative sedation until the time of death.This medication list contains information about: 1) Changes in dosages of sedative medication which is recorded in numbers and units (mg or mg/hr.); 2) Changes in the sort of sedative medication used for palliative sedation which are recorded with the medication name; 3) Changes in the route of administration of sedative medication. All changes will be recorded with the accompanying date and time.During the decision-making process about palliative sedation, the involved health care professionals will complete questionnaires regarding aspects related to this process. The questionnaires contain questions regarding the initiation and timing of the decision-making and the involvement of various stakeholders  in different stages of the process.Statistical analysis will be performed using SPSS, version 25  and R software, version 3.6.0 .Missing data will be explored, reason for missing data will be reported and, when missing at random, they will be imputed with multiple regression imputation .We will use a multilevel approach for analysis of changes in the repeated measures of discomfort and levels of sedation during palliative sedation. We will use these measurements as dependent variables and time and baseline measurements as independent variables. Secondary analyses will include possible confounding or effect modifying factors such as age, gender, country and setting.Descriptive analysis will be performed, using proportions for categorical variables and mean with standard deviations for continuous variables, or median with interquartile range for data with skewed distribution.Differences between settings will be tested through a Chi-square test for categorical variables (Fischer’s exact test in case of cell frequencies < 5), Kruskal-Wallis test for ordinal variables, and ANOVA for continuous variables.The association between variables such as age, gender, country, setting, primary diagnosis, performance status and amount of symptom burden, with dosages of medication, levels of discomfort and length of sedation as continuous dependent variables, will be analysed in multivariable analyses.www.palliativesedation.eu).Dissemination of our findings will be presented at relevant conferences, meetings and through peer-reviewed journals, and is expected at the end of 2023. Within the EU funded project Palliative Sedation other dissemination plans are foreseen, such as an online education programme. More information about all dissemination activities can be found at the project website (This study will explore the clinical practice of palliative sedation at the end of life in different palliative care settings in five European countries, and will study similarities and differences in indication, practice and specific outcomes of palliative sedation in patients with advanced cancer suffering from refractory symptoms.The PALSED study is the first international multicenter study in which the palliative sedation trajectories of advanced cancer patients are observed in a standardized manner and with the main focus on the levels of discomfort in relation to the levels of sedation. Use of the same measurements in an international and multicenter context across different in-patient palliative care settings will provide valid results and may increase generalizability. Because participants can be included in the study earlier on during their palliative trajectory, in most participants the process of palliative sedation can be followed, from decision-making until the patients’ death and even afterwards by the involvement of relatives.The use of observational measurement scales by experienced palliative care specialists, makes their evaluation more standardized and interpretable. In all settings and countries, the same questionnaires and clinical items will be observed and evaluated in a clear standardized manner. Since the main goal of palliative sedation is patient comfort, we presume that the level of symptom relief, and not unconsciousness as such, is used to guide titration of medication. Therefore, change in perceived discomfort levels could be an appropriate measurement for effectiveness, possible in combination with depth of sedation. When achievement of adequate sedation can be monitored in a patient by levels of discomfort this might result in a more tailored and proportional approach of the palliative sedation in the specific patient.During preparatory meetings it became apparent that there were differences between countries and settings in the way information about palliative sedation was given. Differences in wording, timing and recipients of the given information. To stay as close as possible to daily practice, differences in the patient information sheets between the countries are respected in this study as are differences in timing of the informed consents.Patients with rapid deterioration where the decision to start palliative sedation is very sudden may be missed for inclusion, since the time for informed consent procedures is limited and they need to give informed consent themselves. When these patients are included, missing data can be expected for measurements when the clinical situation requires a rapid response and time for study measurements are limited.The absence of a validated scale for measuring comfort in patients with palliative sedation is a limitation, but discomfort in non-communicative patients at the end of life has been studied before. In patients receiving continuous palliative sedation, van Deijck and colleagues used discomfort as the primary outcome  which waIn an earlier version of the protocol, we had envisioned that independent observers would complete the measurements of discomfort levels . However


Management strategies for pregnancies with abnormal adherence/invasion of the placenta  vary between centers. Expectant management (EM), defined as leaving the placenta in situ after the delivery of the baby, until its complete decomposition and elimination, has become a potential option for PAS disorders in selected cases, in which the risk of Caesarean hysterectomy is very high. However, expectant management has its own risks and complications. The aim of this study was to describe the rates of subsequent hysterectomy (HT) in patients that underwent EM for the treatment of PAS disorders. We reviewed the literature on the subject and found 12 studies reporting cases of HT after initial intended EM. The studies included 1918 pregnant women diagnosed with PAS, of whom 518 (27.1%) underwent EM. Out of these, 121 (33.2%) required subsequent HT in the 12 months following delivery. The rates of HT after initial EM were very different between the studies, ranging from 0 to 85.7%, reflecting the different characteristics of the patients and different institutional management protocols. Prospective multicenter studies, in which the inclusion criteria and management strategies would be uniform, are needed to better understand the role EM might play in the treatment of PAS disorders. In 1937, Irving and Hertig were the first to publish a cohort study including 20 cases of placenta accreta and a review on the previous 86 cases reported in the literature at that time .The incidence of PAS disorders in the general population of pregnant women is estimated at 1.7/10,000 pregnancies ,6 and haUltrasound is an excellent tool for the prenatal diagnosis of PAS  and, altThere are three important stages in the care of pregnant women at increased risk of PAS: the recognition of the risk factors, establishing an accurate prenatal diagnosis, and referral to a tertiary center with expertise for follow-up and delivery . The diaThe aim of our study was to review the recent literature published on the method of EM in treating PAS and to describe the risk of subsequent hysterectomy when this approach is used. We also aimed to underline the possible advantages and disadvantages of the different modalities employed in the treatment of PAS.We undertook an analysis of the reviews and single/multicenter studies that report maternal outcomes, and specifically, the rate of subsequent HT, when EM is used for the treatment of PAS disorders. PubMed was searched for studies published from the beginning of records in relation to treatment of PAS disorders. We then selected those dealing with expectant management and that were published in the last 15 years. We searched for the terms “expectant”, “expectative”, or “conservative” and “placenta accreta”, “percreta”, and “increta”. The search retrieved 468 entries. We selected the studies and literature reviews that included more than three reported cases.We found 12 studies that met our search criteria, published between 2010 and 2022, that included cases of PAS managed expectantly. Of the twelve studies , nine haWe found large variations in the reported rates of subsequent HT between the studies in the centers where EM was used for the treatment of PAS. Most studies were retrospective, inherently presenting specific biases. Patients with different severities of PAS were included: in some of the studies, there were differences in the severity of PAS based on the prenatal diagnosis , while many of the studies did not report a PAS grade. In some of the studies , there wThere is a lack of consensus regarding the optimal strategy for the management of PAS disorders , with a The treatment options for PAS and their advantages and disadvantages are presented in Our study aimed to review the outcomes of EM for PAS, especially in relation to the need for subsequent hysterectomy. Overall, in the studies included in our paper, 33.2% of women with PAS disorders who underwent EM required HT. The rate of success of EM observed in our study (67.8%) is similar to the figures published recently in a review by Sentilhes et al. [The overall need for HT in those who underwent initial expectant management was 37.5% in the reviews included. Again, the rates of reported HT were different between the studies. The reviews reported the complications that can arise during EM as hemorrhage, infection, fistulas and sepsis, coagulopathy, and even maternal death. There is a lack of consensus on how expectant management for treating PAS is defined in the literature, who should benefit from this approach, and how follow-ups should be arranged. The primary and secondary outcomes reported by different studies are very heterogenous . Our paper reflects these large differences between studies. Another issue regarding the expectant management of PAS disorders is the lack of histological confirmation of the diagnosis. When a hysterectomy is performed for PAS, specimens can be examined fresh by a senior pathologist, together with the lead obstetrician, to establish the existence of an abnormal adhesion, complete or focal. Biopsies are taken from the most suspicious areas. Correct diagnosis and reporting allow a better correlation with the US aspects and a possible reassessment of future management . CurrentOur study has certain limitations that we acknowledge. We did not have the required data to undertake a systematic review related to the subject; thus, there may have been subjectivity bias. We included studies published in the English and French languages, potentially missing reports from different settings in low- or middle-income countries. Nevertheless, our study could be of benefit to doctors counseling women with PAS regarding options for management and their associated risk. It is surprising that the results of the EM were so scattered and so different between the centers. Future prospective multicenter studies are required to better understand the role of expectant management in the treatment of PAS. These studies should be controlled and include centers with similar management protocols. The most convincing results would be achieved through a randomized controlled trial, in which EM could be compared with other strategies, if feasible. Regarding counseling, a more pragmatic and approach, focused on providing patients with information, would be for centers treating PAS disorders to audit their own data and to offer counseling based on these data.Although Caesarean hysterectomy is recommended by most authorities as the gold standard, the expectant management of PAS disorders is increasingly used with the goals of avoiding severe maternal morbidity, or even mortality, associated with surgery, as well as preserving fertility. There is a growing body of evidence showing that expectant management, in selected and carefully monitored cases, could be successful. In our study, approximately 1 in 3 women required a HT after expectant management. When complications occur during follow-up for EM, they can potentially be treated with fewer risks, by multidisciplinary teams, in dedicated centers. There are limited data on expectant management in placenta percreta. The application of expectant management in PAS disorders has the disadvantage of the lack of histopathological diagnosis.We acknowledge that PAS disorders are iatrogenic pathologies and, despite encouraging success, expectant management is still a debated subject. A safer reduction in the rate of primary Caesarean delivery would reduce the incidence of and risks associated with PAS disorders. Pregnant women, especially in countries with a high rate of CSs, doctors, and society at large, should be aware of the potential complications associated with CS.


This allowed an assessment to be made of their level of health literacy (HL) using the 10-point HBSC research tool. The aim of the study was to investigate the relationship between HL and risk behaviours (RB). A standardised index of RB in the last 30 days was considered as an outcome measure. This index was significantly higher in the group with low HL (0.318 ± 1.269) in comparison with the group with high HL (−0.083 ± 0.962). In a multivariate linear regression model, the strongest predictors of RB were gender, academic performance and level of regional deprivation, but the association with HL remained significant. This significant association persisted in general schools and in girls but disappeared in vocational schools and in boys. It was also shown that in rural areas, good academic performance has a less significant impact on RB if the HL level is low. The analyses led to the conclusion that when examining the relationship between HL and RB in older adolescents, it is advisable to take into account gender, the educational track and neighbourhood characteristics.In the last Health Behaviour in School-Aged Children (HBSC) survey conducted in Poland in 2018, a group of 17-year-old adolescents ( In view of the increasing inequalities in health that apply to all demographic and social groups, including young people , it is aAccording to a broad systematic review by Broder et al., in which 12 definitions and 21 models of HL have been analysed, HL in children and young people is described as comprising variable sets of key dimensions, appearing as related abilities, skills and knowledge that enable a person to approach health information competently and effectively and to derive health-promoting decisions and actions. As a result of this research, the authors claimed that children and young people are expected to develop skills today that influence their health (outcomes) and well-being over their life course and reduce health expenditures. Broder et al. concluded that young people are at a crucial stage of development, characterised by many physical, emotional and cognitive changes . That isThe association between low HL and unhealthy behaviours mentioned by Broder et al.  is especIf we consider inequalities in health, the neighbourhood must be taken into account. The environment—the neighbourhood or place of residence ,12, schoThe strong positive correlation between HL and both family affluence and the social and structural aspects of the environment in which school-aged children grow up was confirmed by the authors of this article in previous studies  that covIn the light of these data, it is reasonable to analyse the school environment more precisely by taking into consideration the type of school that a young person attends. In the literature, there are studies presenting the differences in HL levels between adolescents in general schools and those in vocational schools. Danish research has shown that young people from vocational schools come from less privileged backgrounds and that low HL is associated with unhealthy behaviours in this population . FurtherThis paper extends previous studies based on data from the Health Behaviour in School-Aged Children (HBSC) network, which deal with the RB syndrome , the levHBSC is a 30-year-old network of researchers from 50 countries in Europe and from Canada who organise a questionnaire study on the health behaviours of 200,000 adolescents aged 11, 13, and 15 every four years, based on the same international protocol.In 2020, a national report was issued in Poland  comparinThe results of the systematic review by Fleary et al. suggest that there is a meaningful relationship between health literacy and adolescent health behaviours. To fully understand the role of health literacy in health-related decision-making among adolescents, future research should use comprehensive definitions and measures of health literacy and integrate theoretical frameworks for health behaviour and adolescent development in the study design. Somewhat in response to this conclusion, it seems that this paper, which takes the RB syndrome as the main outcome, fills a knowledge gap and provides a basis for identifying directions for further research. The authors of the aforementioned research believed that developing validated and objective measures of health literacy that assess all of its aspects  and integrating developmental theory in research design is critical for determining the relationship between adolescent health literacy and health behaviours, as well as identifying areas for intervention. Intervening in health literacy may likely improve health behaviours in adolescents, as it provides the tools for converting knowledge into behaviour and empowers adolescents in health-related decision-making now and throughout their lives .The authors of this paper follow this scope and would like this research to be in line with Fleary’s conclusion. The authors claim that the level of health literacy in children of secondary school age has an impact on their health-related behaviours—in this case, the RB—and that the strength of this relationship depends on their educational track and the neighbourhood in which they live.Is there a significant correlation between a high level of HL in boys and girls attending secondary schools and a reduction in their RB?Does the relationship between HL and RB remain significant after controlling for school factors related to educational track and academic performance?To what extent do factors related to neighbourhood deprivation and level of urbanisation change the strength and direction of the relationship under examination?To confirm this, the following research questions were asked:The Polish education system has undergone several changes during the past 25 years. From 1999 to 2019, adolescents who finished primary school (aged 13–16) attended lower-secondary schools, called gymnasiums, followed by upper-secondary schools. The gymnasiums have been gradually phased out, and, currently, education is divided into two instead of three tiers (primary vs. post-primary). Primary school education lasts 8 years, and after graduating, adolescents typically continue it at a secondary school, which takes 3 or 5 years to finish. After graduating from general secondary school or technical secondary school and passing the final leaving exam, called ‘Matura’, one can pursue higher education at university level. In secondary school, Polish youth can choose a general or vocational track. Vocational education is mainly provided by technical secondary schools, as the alternative sectorial vocational schools exist at the first and second stages, where pupils receive work experience and qualifications through apprenticeships.p < 0.001). Data were drawn from 84 school classes and 55 schools located in 51 provinces (16 voivodships), whereas the number of respondents ranged from 12 to 59 per school. The HBSC 2017/2018 sampling design included stratification according to the local deprivation index. This means that schools from regions with different levels of economic development were reached. The deprivation index is a composite indicator that measures a region’s level of development based on external data. It has been defined as a combination of subindices for population income, employment, living conditions, education and access to goods and services [Data included in this study come from 2018/2019, when upper-secondary schools were still present in the Polish educational system during the transition period, and the youth who took part in this survey were still attending this ‘old’ tier of schooling, having had completed a gymnasium 1–2 years before. The study included 1663 secondary school students who were included in the Polish study outside the international protocol for the latest round of HBSC surveys conducted in 2017/2018. These students completed the same questionnaire as the group of 15-year-olds routinely participating in HBSC surveys according to the international protocol. The structure of the extended study was identical and followed the same protocol . A totalservices . The proThe survey was conducted on school premises, using a traditional paper questionnaire. The questionnaire for the study and its organisation, including the procedure for obtaining the consent of parents of under-age students, received a positive opinion from the local bioethics committee operating at the Institute of Mother and Child in Warsaw (17/2017 on 30 March 2017).The main dependent variable is the Risk Behaviour Index (RBI), which was constructed from questions about RB in the past 30 days. For the purpose of this study, the following were considered: smoking traditional cigarettes, smoking e-cigarettes, drinking alcohol, getting drunk and using marijuana. The authors of the present study called them risk behaviours to stay in line with the main HBSC research protocol and the name of the tool used to measure these unhealthy activities. This approach has been applied by Bulgarian researchers before . For theThe first group of factors concerned personal competencies that may influence RB. The scale of HL  was taken into account; this was created on the basis of the Finnish prototype and was included in the HBSC 2017/18 research protocol following validation studies that were also conducted in Poland . The insSubjective assessment of academic achievement was also included in the group of personal competencies. Students were asked to rate their academic achievement against other students in the class on a visual scale, adopting the graphic image of a ladder according to McArthur’s concept . There wThe second group of factors included sociodemographic variables. Family wealth was examined with the revised Family Affluence Scale (FAS III), which is a tool used to measure the material status of the families of students surveyed in HBSC studies . FAS IIIIn the group of sociodemographic factors, the following were also considered: gender , type of school , deprivation index quintile and place of living .The characteristics of the sample, together with the mean standardised RB indices, can be found in A psychometric analysis was performed of the scales used, testing their homogeneity with the PCA method and their reliability with Cronbach’s coefficient. The differences between the indices in groups distinguished by socioeconomic characteristics and personal competencies were compared using the nonparametric Mann–Whitney test (two groups) or the Kruskal–Wallis test (more than two groups). The chi-square test for categorised variables and Spearman’s rho coefficient for continuous variables were used to examine the relationship between the variables under study. In the multivariate analysis of the determinants of the variability of the RBI, a classical linear regression, as well as a general linear model (GLM), were used. Diagnostics of the linear regression model included R-squared coefficient of determination, F test of ANOVA and variance inflation factor (VIF) analysis. A series of two-way and three-way interactions were tested in order to determine the best GLM model. The presentation of the GLM results is provided in the In the study group of 1663 second-year secondary school students, the percentage of traditional cigarette smokers was slightly higher than that of electronic cigarette smokers (32.5% vs. 28.7%). The difference to the disadvantage of boys was statistically significant only in the second case. There were more boys than girls who smoked both types of cigarettes, but the difference was more significant for e-cigarettes. Three-quarters of the respondents had drunk alcohol at least once in the previous month, and every fourth respondent had gotten drunk at least once during that time. Gender-dependent differences to the disadvantage of boys were found only with respect to the frequency of alcohol abuse. Almost every fifth boy and every tenth girl had had contact with marijuana in the previous month .p < 0.001) as well as with improvements in school performance. The RB were found to be significantly more frequent among boys and in areas with higher levels of deprivation. The association between place of residence and family wealth was on the verge of statistical significance, with a tendency towards worse results in cities and in wealthier families.The sociodemographic determinants of HL levels were also demonstrated . The corThe correlation coefficient between HL and RBI was equal to −0.091 across the entire study group, and the strength of the relationship was weaker in vocational schools than in general secondary schools. Gender appeared to be a moderating factor in this relationship. In both types of schools, a significant negative correlation was found only for girls and was at the same level (rho = −0.126) in both cases. No significant relationship was shown for boys in either type of school. The stronger correlation in general secondary schools may, therefore, be due to the higher representation of girls among these students .p = 0.144). However, school type moderates the strength of the relationships under examination, as was confirmed by the two models estimated for students attending general (GE) and vocational (VT) schools. Notable differences were related to the association of the RBI with HLSAC and with environmental variables. In general schools, the impact of the level of deprivation in the region was not significant. In vocational schools, the association with place of residence was not significant, whereas deprivation was one of the most important determinants of RBI variability. The association with HLSAC became apparent only in GE schools , while it was insignificant in VT schools .School performance, gender, deprivation, FAS, HLSAC and place of residence were introduced to the final model as significant predictors of RBI variability. Only school type was found to be insignificant (p = 0.015) than in boys . In boys, only a negative relationship with academic achievement (p = 0.004) was evident, meaning that good school performance protects against smoking, alcohol drinking and cannabis use. In girls, similar to the previously discussed model for the total sample, all the analysed factors proved significant. In addition to high HL, less frequent participation in risk behaviours co-occurred with: living in a rural area, higher neighbourhood affluence and better school performance. Only the relationship with family affluence as measured with the FAS scale was positive, which means that the girls from more affluent families were more prone to RB.The respective gender-specific models also differed considerably . School Additionally, a series of multivariate GLM models were estimated to find independent predictors of variation in the RBI and to examine the interaction between those predictors. This time, we looked for significant interactions with academic achievement, which has proven to be the most significant predictor in previous analyses (with the highest beta). The results are presented in All the models confirmed a significant relationship between RB and health literacy as well as with several educational and neighbourhood factors. However, they all explained the variation in the RBI analysed to a small extent, which peaked at around 9% for girls. Collinearity was not detected in the VIF analysis. In the model estimated for the total sample , the maxThe article presents data on 1663 students from the sophomore year of upper-secondary schools in Poland, according to the education system that was in place in Poland in the school year 2017/2018. These students were surveyed according to the HBSC study protocol, which was being carried out simultaneously, although the international protocol covered only the lower grades and lower tiers of education. The focus of the study was the exacerbation of RB associated with substance abuse, as well as HL levels. The issues examined included the relationship between HL and RB adjusted for a range of social factors, academic success and the social determinants of RB and HL.A standardised index of four RB  was used as the main outcome measure. Previous publications from HBSC studies confirmed the validity of combining RB into a single factor together with sexual behaviour. To date, however, the use of e-cigarettes has not been included in the composite indices .The results of this study confirm the authors’ hypothesis that there is a significant association between the high level of health literacy in children of secondary school age and their less frequent RB. Furthermore, this relationship depends on the demographic and socioeconomic circumstances in which the secondary school students are growing up.The following discussion refers to the research questions and also explores gender differences more in-depth.In order to discuss the answer to the first research question, an analysis of the prevalence of RB among the youth needs to be performed. In the present study, the boys performed worse, but this was mainly influenced by the large differences in the answers for getting drunk (37.9% vs. 32.3%) and marijuana use (19.2% vs. 11.3%). As far as the remaining analysed behaviours are concerned such as smoking traditional cigarettes (33.5% vs. 31.3%) or drinking alcohol (74.4% vs. 72.8%), the girls had higher scores. This is quite surprising, as we are accustomed to finding that it is men, not women, who are more prone to engaging in RB. This negative trend has also been observed among young adults to the disadvantage of women . These fThere is a different situation regarding the issue of smoking electronic cigarettes and gender distribution in this relationship. The results are unfavourable for the boys examined in the present study while being in line with the research of Patanavanich et al. . These aWe turn next to aspects that exacerbate RB among adolescents. The aim of the study was to analyse the relationship between RB and HL as a possible factor that could inhibit such behaviours. This is in line with previous international studies ,48,49.To answer the second research question, the authors of this paper analysed several determinants of HL in adolescence. The level of HL of the youths in the study depended on environmental factors and demographic determinants. It was proved that the level of HL depends on gender—the girls scored higher on HL, but only in the average category (71.1 vs. 75.7), whereas at the high level of HL, the boys scored better (17.8 vs. 16.2). The HL level was higher among young people from more affluent backgrounds and those with better school achievements. This is in line with previous international studies on this subject. The authors of an Indonesian study led by Prihanto  achievedAs regards school and school performance, this study confirms that there is an association between better grades and less frequent RB. It could be concluded that students who pay more attention to education are less likely to undertake risk behaviours. Such a conclusion could be logical, but it should also be stressed that this relationship may be inverse—children who engage in risk behaviours more frequently have worse grades at school. What can be said with confidence when it comes to discussing the results of this research is that there is a significant correlation between those two factors, and further analyses to understand the causes of this association need to be undertaken.Furthermore, the analyses strongly emphasise academic achievement as an important factor with the potential to modify the relationship between HL and RB. Lithuanian studies have also revealed higher HL levels among students with better grades. These findings are consistent with the outcomes of previous research, indicating that academic achievement is a predictive variable for HL in young people ,52. AcadHowever, in the 17-year-old group, the type of school has been confirmed as a factor differentiating HL levels, with students attending general secondary schools performing better. This might indicate that there are not only age-related changes but also sociocultural factors. Students aged 13–15 attended secondary schools, which was the compulsory secondary tier of education in Poland at the time, and represented a complete cross-section of the society. According to the same research conducted in 2018 , the perMany authors emphasise that social inequality analyses need to take into consideration a complex set of correlations. An independent study was conducted on 2223 students from Polish secondary schools using the Health Literacy Survey Questionnaire tool, which consists of 47 items (HLS-EU-Q16) and investigates approximately 10 social factors. A multipoint analysis confirmed only the connection with the parent’s level of education, the self-assessed economic situation and the city size. Interestingly, differences between the individual school types were not confirmed, even in the univariate analysis. However, the research was conducted only on a regional scale and included 20 schools . Our resNumerous studies indicate that the educational system is a factor in deepening social inequality. According to research conducted in Austria, Belgium, Germany and the Netherlands, students attending vocational schools are more likely to engage in RB . LongituThis paper also focuses on the neighbourhood as one of the main factors that affect adolescent health behaviour. In an attempt to find the proper answer to the third research question, we could conclude that the place of residence does matter. The findings from this study confirm that students from less privileged backgrounds engage in RB more often than their colleagues from more affluent neighbourhoods. These results are in line with previous analyses showing that the environment in which young people are raised and grow up has an impact on their behaviour. A negative correlation between poor living circumstances and RBI was observed in the case of young people from backgrounds with the highest levels of deprivation and those from the least affluent families.Simple analyses indicate a significant correlation between intensified RB and the regional deprivation index, a weaker tendency for higher RB in cities as compared with rural areas and a lack of correlation with family affluence level according to the FAS scale. The correlation between these factors and HL levels was stronger. Higher HL levels were observed in cities and in students from wealthier families. According to Aljassim’s and Ostini’s systematic review, differences in HL between residents of cities and those of rural areas may become less pronounced when other social status metrics are taken into consideration . TheoretOur research also indicates a highly statistically significant correlation between HL levels and regional deprivation, but the observed linear relationship was not as strong as in the case of the RBI.The findings allow us to evaluate the manner in which HL changes by the end of the second decade of a person’s life. Furthermore, we can talk about the systematic increase in HL that can be observed between the 13th and the 17th year of life.The limitations of this study should also be noted. Its cross-sectional nature does not allow us to establish a causal relationship between the propensity for RB and its potential correlates, including HL level. The models presented explain the variation in the RBI only to a small extent. However, creating a more complete model was not our intention. We aimed to explore the association between HLSAC and RB in a robust way after adjusting the analyses for several sociodemographic factors. Whereas almost all the variables were derived from self-reported data, information on neighbourhood wealth was obtained from an independent source. The added value of the analyses is their relevance to publications from HBSC surveys based on data for younger students collected at the same time and according to the same procedure. It was, therefore, possible to assess whether HLSAC is a good alternative to other survey tools for older adolescents  and to cWith reference to the research questions posed at the beginning, it can be stated that a higher level of health literacy plays a protective role against RB undertaken by young people, and it could be a means of inhibiting selected RB. The association between health literacy and RB is much stronger for girls than it is for boys at about the age of 17 and remains significant after controlling for other educational and social factors. For both the overall sample and the subgroups distinguished by gender, good academic achievement is the strongest predictor of RB. Adolescents from general and vocational schools show similar levels for the RB analysed. School type can only be considered a factor that modifies the determinants of RB. Compared with general schools, the neighbourhood characteristics in vocational schools are more significant as predictors of RB. The place of residence makes little difference in the frequency of engaging in RB. However, in young people from rural areas, the protective effect of good academic achievements is reduced if those achievements are not accompanied by a high level of health literacy. It is important to take the social and economic determinants into consideration when planning intervention programmes dedicated to young people, especially considering the aspects of the neighbourhood in which they are growing up.


A high-precision location is becoming a necessity in the future Industry 4.0 applications that will come up in the near future. However, the construction sector remains particularly obsolete in the adoption of Industry 4.0 applications. In this work, we study the accuracy and penetration capacity of two technologies that are expected to deal with future high-precision location services, such as ultra-wide band (UWB) and WiFi fine time measurement (FTM). For this, a measurement campaign has been performed in a construction environment, where UWB and WiFi-FTM setups have been deployed. The performance of UWB and WiFi-FTM have been compared with a prior set of indoors measurements. UWB seems to provide better ranging estimation in LOS conditions but it seems cancelled by reinforcement concrete for propagation and WiFi is able to take advantage of holes in the structure to provide location services. Moreover, the impact of fusion of location technologies has been assessed to measure the potential improvements in the construction scenario. In recent decades, a new industrial revolution has emerged thanks to the introduction of Information and Communication Technologies (ICTs) in industrial processes , giving In Industry 4.0, advances in the fields of robotics, AI, and Machine Learning (ML) come together to conform production to new customer demands, such as an increased customization, optimal machinery efficiency, and reduced costs . Thus, tTechnological progress in recent years has focused its efforts, among other objectives, on the location of users. The Global Navigation Satellite System (GNSS) has established itself as the reference location system for outdoor navigation . HoweverThis paper evaluates and compares the performance of ultra-wide band (UWB), WiFi fine time measurement (FTM) and fusion of technologies in a construction scenario with an indoor scenario from a previous work . This evThe rest of this paper is organized as follows: This section provides an overview of the two location technologies that are most commonly used indoors, and may therefore be used in construction scenarios.UWB provides high distance measurement accuracy based on the Round Trip Time (RTT) protocol, even in environments with difficult propagation characteristics . This teThe IEEE 802.11mc standard includes precise fine time measurement (FTM) for distance estimation to the router by time stamping using the RTT protocol ,18. ThisAlthough fingerprinting claims to provide high accuracy with low infrastructure deployment, it has some drawbacks that make it unfeasible for the construction case. First, it requires complex training that makes it impractical to cover the entire infrastructure. Secondly, the periodicity of this training becomes very frequent due to constant changes in the environment. Thus, the trilateration method seeks to find the final position of the user through the intersection between geometric shapes, such as circles or hyperbolas defined by the distance between the target and the different RPs ,21,22.Although the received power may not follow a specific propagation model, if the environment does not change drastically, it tends to remain static over time.A is the Euclidean distance matrix of the computed position  iterative method finds the optimal solution to this problem as follows:In trilateration, it is usually assumed that the distance measurement information comes from a single technology. However, in  a schemeW matrix. The system stores the error of each RP iteratively with a temporal window and weights the sources according to their standard deviation. Supposing that The classical Least-Square algorithm is highly influenced by outliers. However, the Maximum Likelihood Estimator (MLE) estimator evaluates signal accuracies to enhance the location service. MLE obtains the parameter ribution . In thison fθ(x) . So, theL as seen below:The MLE estimates the best candidate that optimally maximizes N time epochs which may improve over-determined location systems.Assuming that observations follow a Gaussian distribution ,25,26, tIn this section, an experimental setup for evaluating UWB, WiFi-FTM, and fusion in a real construction scenario is described. To show the performance of the different technologies with real data, a setup of UWB anchors and a WiFi FTM APs has been deployed. In this work, two experiments have been performed to evaluate the ranging and location accuracy in the same floor of UWB, WiFi and fusion, and to evaluate the penetration capacity and accuracy of UWB and WiFi in different floors (one above and below from where the deployment is set-up). The first experiment takes place in the basement floor X, respectively. The yellow dots represent the ground truth of the path there and back where the measurements are taken. In this experiment, all the measurements were taken in LOS conditions and for UWB4 and UWB6 in partially NLOS conditions. Two path there and back measurement recollections were performed to have a sufficient dataset, over 150 samples that were collected statically during each 30s measurement. UWB anchors are set at different heights  and connected via Bluetooth Low Energy (BLE) to the smartphone which reads the UWB data. The developed application relays the captured data via WiFi to a server where it is stored and processed. The database is a Flask server with a MySQL database that is configured on a Windows 10 laptop. Samples have been collected in an offline phase to check the accuracy of the positioning results with a sampling rate of 0.3 Hz.The UWB devices—anchors (reference points) and tag (location target)—are based on Decawave DWM1001 devices which compute the range estimation via RTT protocol . The UWBThis section describes the results obtained in each experiment to demonstrate the performance of the different technologies for positioning accuracy and penetration capacity.In addition, As can be observed, UWB seems to perform better than WiFi for ranging accuracy and, therefore, in location estimation. In general terms, the geometry of the deployment and features of the environment  are key factors that may change the performance of a location system. Indoor scenario ranging outperforms compared to the construction site, and the fusion algorithm enhances both UWB and WiFi performance in both scenarios. Despite having all UWB anchors and WiFi APs located in areas with good propagation conditions, the 90% percentile of the positioning error is above a meter in all construction cases due to multipath effects, geometry distribution, which leads to dilute the final precision, that affects both UWB and WiFi FTM although, for WiFi, it can be seen that the effects are slightly smaller. Despite having worse ranging performance in WiFi, the final solution is similar to the UWB final results. As it can be seen, more ranging information in fusion improves the geometry of the system and overdetermines the LS algorithm, which results in a better performance. In this case, the fusion algorithm benefits from the data of estimated ranges to RPs obtained from multiple technologies , when UWB only captures normally 4 ranging data and WiFi a maximum of 3 ranging data. The full potential of fusion is realized in cases where the scenario is such that RPs of a single technology do not offer full coverage. In other words, in scenarios where points where less than 3 RPs of a single technology are visible. In these cases, fusion may complement the missing RPs with a different technology. Nevertheless, in the setup of this experiment, our objective was not to demonstrate this opportunistic nature of fusion.In this second experiment, we measured the location provided by the RPs one floor above and below the scenario. The first observation was that no signal was received from UWB. In other words, to have location in a floor, the UWB anchors must be installed in the same floor. As it can be observed, the error estimation reasonably increments compared with performance of the WiFi ranging information in LOS conditions from the first experiment in This paper presents the results of a measurement campaign of UWB and WiFi FTM in a construction scenario for location purposes. The goal of the experiments is to compare the accuracy, coverage, and penetration capability of UWB and WiFi technologies and the fusion of technologies in this type of dynamic scenarios. UWB has demonstrated to provide better ranging accuracy, however, WiFi has demonstrated robustness against blocks in the scenarios with better propagation performance and penetration capabilities. The measurements show the elements of the construction site affect in UWB and WiFi ranging estimation compared with an indoor scenario. Moreover, it can be observed that fusion can improve the accuracy of location in all scenarios.Penetration measurements show that reinforcement concrete completely cancels UWB propagation and WiFi is able to benefit from holes in the structure to achieve location. However, in cases where no holes are present, WiFi performs with difficulties for positioning, but still manages to report ranges.