Patients with diabetes mellitus are exposed to important complications. Currently little evidence exist on the guidelines that these patients, at some risk of foot ulceration, should follow for physical exercise.To reach a consensus among multidisciplinary and international experts on physical activity/exercise recommendations for patients with diabetes, according to foot ulcer risk.Using a three-round Delphi method, a panel composed of 28 multidisciplinary experts in the management of diabetic foot assessed 109 recommendations on physical activity/exercise for patients with diabetes mellitus, according to their risk of foot ulcer. Consensus was assumed when 80% of responses matched the same category (agreement/disagreement).Twenty-nine experts participated in the first and second rounds of consultation, and twenty-eight did so in the third, reaching final agreement on 86 of the 109 recommendations considered (78.9%). The study, thus, generated a consensus set of recommendations concerning different aspects of diabetic footcare before, during, and after exercise .This Delphi study generated recommendations based on the consensus of international experts on physical activity and exercise by patient with diabetes at risk of ulceration. Recommendations considered the state of the foot and the patient's history and status before physical activity and included information on intensity, duration, frequency, and progressions of physical activity/exercise, and the use of custom-made plantar orthoses, shoe prescription, and the convenience of returning to physical activity after an ulceration. According to the International Diabetes Federation (IDF), in 2019, 135.6 million people aged 65 years or more had diabetes, equivalent to 19.3% of the total population with diabetes worldwide. Moreover, if present trends continue, the number of people aged 65 years or over with diabetes will rise to 195.2 million by 2030 and 276.2 million by 2045.,,People with diabetes mellitus (DM) are at increased risk of developing serious health problems that could lead to a poorer quality of life and increase healthcare costs.Diabetes induces characteristic pathological changes in the feet, such as infection, diabetic foot ulcer, and neuroarthropathy, broadly termed diabetic foot syndrome.,Physical activity is defined as any movement that increases energy use, as distinct from exercise, which is a planned and structured physical activity. Physical activity improves blood glucose control in type 2 DM, reduces cardiovascular risk, contributes to weight loss, and enhances well-being.Although physical activity and exercise are recommended for people with DM,Patients with diabetes with impaired protective sensitivity and restricted pain response are vulnerable to trauma and extrinsic forces from ill-fitting footwear. Motor neuropathy causes muscle weakness and an intrinsic muscle imbalance that can lead to deformities such as hammer or claw toes, which in turn create elevated plantar pressure due to instability of the metatarsophalangeal joint. For this reason, performing physical activity or exercise without medical supervision can create a risk for persons with DM.In clinical practice, uncertainty remains about the best type and intensity of exercise for these patients, especially those at high risk of developing a foot ulceration or re-ulceration. Accordingly, the aim of this study was to reach a consensus among multidisciplinary and international experts on recommendations for physical activity/exercise by people with DM, according to their risk of foot ulcers.This observational, cross-sectional, descriptive study was conducted using a three-round Delphi technique,Four experts working in Spain in the field of diabetic foot  were recruited to the scientific committee. These experts, selected out of convenience from the research group's professional network, conducted the critical review of the first version of the Delphi survey created by the research team, reviewed the selection criteria for the expert panel, and identified other experts to participate in the study.An expert panel was formed to elicit the opinions of international, multidisciplinary experts working in various fields related to the management of diabetic foot , through an online Delphi survey to be completed individually and anonymously.,There are no firm recommendations regarding the optimal size of a Delphi panel in heterogeneous samples. In recent Delphi studies, some panels have included as many as 60 members,,The research group developed an adapted version of the Delphi survey based on a literature review of guidelines related to physical activity and diabetesA letter of invitation, following the script proposed by Jon Landeta,The Delphi process consisted of three rounds. After performing the pilot study, which proceeded without suggestions being offered, the first round commenced on 12 June 2021. The panelists were given eight weeks to complete the survey, during which time three reminders were sent, if necessary, to maximize the response rate. After the first round, the researcher responsible for maintaining the participants’ confidentiality downloaded the data into an Excel sheet, which was then analyzed by the entire team. The second and third rounds began on 19 September and 23 October 2021, respectively, inviting responses from the experts who had participated in the previous rounds. In this case the panelists were given two weeks to respond to each round, which included only the items that had not previously produced a consensus, and to provide, if they wished, explanatory comments in the free-form text fields. The final list of recommendations was based on the items for which a consensus was reached.The panelists’ specialties and countries were characterized by absolute and relative frequencies. Their responses to each survey item were analyzed in terms of the percentage of response categories obtained, as is the case in most of the studies cited in the CREDES guide.In the first round, 29 experts (48.3% response rate) responded to the Delphi survey. By specialties, 10 of these participants were experts in physical activity, sports sciences, or physical therapy, 10 were podiatrists and 9 were endocrinologists, family physicians, or vascular surgeons . Most weIn no case did disagreement among the panelists reach 80%, and so none of the items were directly eliminated. The results of the first round are provided in n = 29)  . A consen = 28). The initial deadline was extended, and four reminders were sent to maximize the number of participants. Once the responses were recorded, the final analysis for round 3 was performed  . The 23 The experts’ consensus recommendations for patients with diabetic foot are summarized as follows. Before starting any physical activity, all patients should undergo a prior check-up of both feet, and those classified as risk 2 or 3 should repeat this check-up during and after the activity. In addition, every patient should receive a prior assessment of their general condition and of any keratotic lesions or excessive dryness in different areas of the foot.When neuropathy and/or PAD are observed, the socks worn should have no seams, rubber, or elastic, and the choice of footwear should be guided by a professional. Aerobic exercise is recommended, with strength and flexibility training adapted to each type of foot at risk, such as the inclusion of rehabilitation exercises for patients with motor neuropathy or the practice of aquatic exercise rather than walking, thus avoiding pressure on the foot, for those at high risk of ulceration. Orthopedic treatment is recommended for patients at risk 3, while those at risk 2 or 3 should receive a check-up 15 days after starting physical exercise and monthly at the location where the exercise takes place.These recommendations are consistent with those of the American Diabetes Association,Shortly after the completion of this study, the American College of Sports Medicine published new recommendations, with clarifications regarding the types of exercise appropriate for patients with peripheral neuropathy, among other aspects also addressed in our study. These guidelines are consistent with the conclusions drawn from our study.The IWGDF,Several publications detail the key footwear aspects to consider.,A question that remains to be clarified is that of the appropriateness of exercise by patients with an open ulcer. To date, no guidelines have specifically addressed when and how patients should return to physical activity after an ulceration, although some studies have made observations in this regard. For example, Lyu et al.,Pending new studies that address this topic, in the presence of PAD, our study offers expert recommendations on mobilizing the foot when there is ulceration. Another current issue is when and how to start or resume exercise after a recent ulceration. Our panelists agreed that patients should gradually ease into their exercise program, a view that is consistent with the results of other studies, suggesting that a well-controlled activity regimen that includes walking, maintaining balance, and strengthening the legs can positively influence the patient's health and function.The recommendations for which we failed to reach consensus reflected a similar lack of agreement in the scientific literature, relating to aspects such as the correct way to cut nails, the best type of socks for patients with neuropathy and PAD, and the use of smart watches or mobile apps to monitor blood oxygen (due to the absence of available devices with sufficiently reliable measurements). Given the dearth of quality studies or evidence on clinical efficacy, the panelists also failed to reach a consensus on recommendations for exercise in patients with IWGDF risk 2 or 3, the use of static pedals, the best type of surface on which to practice physical activity, or the use of a definitive offloading orthosis within 15 days of ulceration.Some of these recommendations for which no consensus was reached, such as the type of sock or the correct cut for nails, are specific to the field of podiatry, while others  correspond more to the field of sports medicine. Nevertheless, in our Delphi study, the relevant specialties were well distributed among the panelists. The lack of consensus regarding the more specific items might be due to the neutral position adopted by the experts who lacked specialist knowledge in these areas, a factor that may have introduced some bias into the study. To counter this possibility, we believe that recommendations on specific aspects of the foot or on types and repetitions of exercises should be agreed upon by a panel composed of experts within a single discipline.The limitations to our research are those inherent to this type of qualitative study, such as the constraints of a close-ended survey, although free text space was provided for each item for panelists to freely comment. Another limitation, is the convenience nature of the sampling procedure used and the voluntary participation of the experts. Either or both of these factors may have introduced a selection bias. The low response rate in the initial selection of experts may be due to the difficulty getting in touch with the experts, because contact information was retrieved from their scientific publications, which in some cases may have been outdated. Consequently if the invitation was never received, this too would have constituted a selection bias. Another limitation is the fact that patients were not included in the panel or consulted as part of the study. However, we intend to conduct a follow-up study in which the recommendations obtained will be shared and managed by a group of people with diabetes, to better adapt the recommendations and the vocabulary to their needs.Among the study's main strengths, to our knowledge this is the first set of expert recommendations to be proposed that address, in a clear and structured way, how patients should exercise, in accordance with their individual foot risk. Another strong point of this study is the high response rate obtained in each of the three rounds of the survey process . The Delphi methodology in itself represents another important strength, as its participatory nature favors the acceptability of the recommendations among multidisciplinary practitioners and their implementation in a range of clinical settings. On the other hand, these exercise recommendations have been formulated solely with the consensus of clinical experts; our research design method is not intended to be a replacement for robust, high-quality clinical trials, but rather a clinical guide to determining the patient's status and a starting point to consider important aspects for the individual patient. Further studies are needed to evaluate the ease of implementation of the recommendations, the degree of patient adherence, the long-term benefits, and the safety and efficacy of different types of physical exercise for this population.This Delphi study generated recommendations based on the consensus of international experts for physical activity and exercise by patient with diabetes at risk of ulceration. These recommendations take into account the state of the foot and the patient's history and status before physical activity. They include guidance such as when and how the foot should be examined, an initial consideration of the patient's general condition, the type of sock to be worn by those with PAD, neuropathy, and foot deformities, considering also the risk of foot ulcers (IWGDF risk 0–3), the type of exercise to be performed , and recommendations for during and after physical activity/exercise, such as the use of custom-made plantar orthoses and shoe prescription, and the considerations for returning to physical activity after an ulceration.The authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper.


Donkeys are resilient species and exhibit functional adaptation in a wide range of climatic conditions. However, in comparison to other livestock species, their inclusion in agricultural or livestock health and nutrition policy, education, and research sectors is negligible. The focus of the current review is on the value of donkeys across a range of sectors, including agriculture, construction, industry, and tourism. The study emphasizes the importance of donkey welfare, as well as the vital function that donkeys serve in sustaining the livelihoods of some of the most underprivileged communities all around the world. In poor and oppressed communities all around the world, donkeys can help to empower women and give them a way to work and make a living.Despite the substantial contribution donkeys make to the livelihood of the world’s poorest populations, the existence of donkeys has received little notice worldwide. This article reviews the value of donkeys in a variety of sectors, including agriculture, construction industry, and mining, as well as their role in empowering women and achieving sustainable development goals. However, donkeys and mules are not given enough credit or attention in terms of developing strategies regarding their role in reducing poverty. There is a dearth of information and statistics on their impact across industries, the factors contributing to the donkey population dropping, the socioeconomic status of the dependent communities, and related animal and human welfare issues. Donkeys and mules are non-ruminant members of the Equidae family found in a range of ecological zones, including semi-arid, temperate, and highlands, across the globe. Mules are the offspring of a male donkey (Jack) and a female horse (mare), while hinnies are the offspring of a female donkey (Jenny) and a male horse . Throughout this manuscript, the word mule is applied to refer to both mules and hinnies. The domestication of donkeys dates back to over 7000 years ago ,2,3 whenDeveloping countries are home to 96% of donkeys and 60% of horses globally ,9. In ruDespite the important role played by donkeys in the socio-economic fabric of rural and peri-urban areas, not much importance has been accorded to their existence in most parts of the world . The welAccording to the study by , the accAlthough the estimated population of donkeys in developing countries has risen for the last four decades, their population has decreased significantly in India. According to the 20th livestock census, the donkey population has declined from 0.32 million in 2012 to 0.12 million in 2019—a decline of 61.23% . Over a A rapid decline in local donkey populations is also being observed in some  African countries. The decline in African donkey populations is thought to be related to the increased export of donkey hides to supply the expanding demand for traditional Chinese medicine, ‘ejiao‘. According to , the incThe domestication of the African wild ass revolutionized ancient transit methods, as well as the organization of early cities and pastoral cultures in Africa and Asia. Donkeys are uncommon in the archaeological record, and evidence for early phases of animal domestication is difficult to detect; therefore, genetic research implies an African origin for the donkey. However, pinpointing the period and location of domestication has been difficult because donkeys are uncommon in the archaeological record . AccordiThere is a powerful contention that it was pastoralist cattle herders in northeastern Africa who originally enlisted local jack asses to work in their herds in the fifth millennium BC, for shipping their camp belongings, and to fetch water from far-off water sources . The conAccording to ancient literature, donkey milk was used by Hippocrates, the father of modern medicine, who used it to treat liver problems and infectious diseases. In particular, donkey milk is regarded as a good source of nutrition for treating conditions such as psoriasis and dry skin that are related to the skin; joint pains, asthma, stomach ulcer, sore throat, liver problems, infectious diseases, fever, edema, poisoning, and wounds ,20,21,22Donkeys are considered an important source of draught animal power in arid and semi-arid regions, as they can tolerate drought conditions more successfully than oxen, and they can tolerate infrequent access to water . Many reDonkey draught power has had a significant impact on highland communities, decreasing their drudgery. A study by  reportedDifferent communities within the population own donkeys in India. A recent study by , points Affordability is a key factor influencing the choice of working equids made by the potential owner or trader. Donkeys are a more economical option compared to mules and horses which are expensive to purchase and maintain; in India, the price of a donkey may vary between USD 70 and 175 on average compared to the price of horses and mules, which ranges between USD 600 and 1000 on average (Source: FGD with the equid owner in Maharashtra by the first author). The price of an equid is based on its health, age, and body condition; for example, equids in poor body condition fetch a lower price. Other factors which may influence the purchase price are the competency of the buyers in equid selection, beliefs and perceptions, requirements of working capacity, maintenance capability, and owners’ preferences . Most ofIn rural and peri-urban areas, working animals—particularly equids—could be the primary source of income and livelihood, sustaining the family units of hundreds of millions of impoverished people. Each equid supports up to 20 persons to fulfill their daily survival needs . The parTo mobilize and enable active support from a variety of sources, such as government or private extension workers, veterinarians, community-based animal health workers, and field staff from community organizations, collective action is important for the poorest communities that raise draught animals. Through participatory action research, development actors (NGOs/extension agents) and farmers who rear draught animals can learn more about equine welfare and find suitable solutions. On a related note, there is an exemplary case study on equid welfare in Uttar Pradesh, a northern state in India where horse owners worked collectively to identify the cause of persistent wither lesions in their equines. While the risk analysis observations were facilitated by the equine welfare organization, the horse owners solved the issue as a group and arrived at a local solution that was effectively implemented. It is equally important to provide a similar case in examples of the knowledge of policymakers to highlight the importance of donkey welfare as a contribution to strengthening the livelihood of their owners. This will facilitate the devising of policies that aim to achieve the improved welfare of working animals in the longer term .The Sustainable Development Goals (SDGs) are set by the United Nations (UN) and designed to create a more sustainable future for humanity. According to a recent report by the charity Brooke, donkeys play an important role through direct and indirect support in income-generating activities in a variety of sectors such as agriculture, transport, tourism, and the construction industry; they play a vital role in poverty alleviation, as described in SDG1 . A studyStrong evidence of working equids’ importance in assisting and supporting the resilience of communities in Low- and Middle-Income Countries (LMICs) will be necessary to persuade policymakers to recognize them (and provide the budgets to support them) in difficult and complex emergencies, especially given the emergence of climate-related crises. Researchers and practitioners will have to provide proof of working equid contributions in these at-risk areas, which is currently lacking but is essential to improving working equids’ standing in international policy and humanitarian agendas. This evidence might be concealed; for instance, if there are other, more important tasks to attend to when coping with a crisis. As a result, records documenting the contributions of working equids might be lost or forgotten .With the increase in events of high temperatures and growing seasonality that affect rainfall patterns, leading to frequent floods or cyclones, the contribution of animal-powered transport technology should be both acknowledged and valued. Donkeys are drought tolerant and can traverse and transport over long distances . Animal It is a common practice to use donkeys, mules, and horses in the construction industry in the South Asian region. They are known to play an especially important role in brick production industries in India, Pakistan, Nepal, and Afghanistan ,31. TheiIn a survey conducted by The Brooke on the brick kiln industry in 10 districts of the state of Uttar Pradesh in 2013, of the total annual income earned by equid-owning families, 80% was generated from brick transportation by the animals. During the brick kiln season, 23.5% of equid owners depended entirely upon the services of their animals as their only source of income .Donkeys in particular can play a key role in the empowerment of women in developing countries by generating income and influencing social status ,40, thouAccording to the research by , the decLoss of genetic diversity can have substantial consequences when animals have evolved and adapted to geographical locations through centuries of natural selection; if these animals face changes in their environment, they are less able to adapt, thrive, and evolve in response . Since gThe traction energy of equids, which are frequently seen in rural, isolated parts of developing countries, is most effectively used by poor communities. These landscapes and the weather they are linked with can be difficult, requiring draught animals to work tirelessly for lengthy periods of time. Further, these animals may suffer from a lack of appropriate nutrition due to limited access to clean drinking water and feed due to the financial hardship of their owners and their lack of land ownership. This situation is particularly challenging during dry seasons. Donkeys with poor Body Condition Scores (BCS) are prone to dehydration when they are working in harsh conditions . Poor BCA study conducted by  to perfoAccording to the study conducted by , policymIn a recent policy development work, global standards for the welfare of working equids have been adopted by the World Organization for Animal Health (OIE). The first of its kind includes guidelines on the living and working conditions of the donkeys, mules, or horses, used for or retired from traction, transport, and generation of income. These standards offer a basis for the formulation of policies and regulatory instruments to promote equid welfare in various sectors, including the construction industry. It is required of the OIE members of all countries to take requisite actions to implement these standards .As part of the animal welfare indicator (AWIN) project of the European Union, the AWIN welfare assessment protocol for donkeys has been developed with the purpose of disseminating information about their welfare indicators. The protocol is based on four welfare quality principles, namely good feeding, good housing, appropriate behavior, and good health .Numerous difficulties must be overcome to measure animal well-being, but one promising strategy is to combine existing knowledge into fresh frameworks that can provide uniform methods for doing so in a range of situations. The welfare of equids can be measured using a variety of measures; however, these tools are frequently created for specific circumstances. There is no “one size fits all,” and therefore the resulting datasets are typically incomparable, which makes it difficult for the various organizations attempting to improve equine welfare around the world to share information and work together. To address this, The Donkey Sanctuary (TDS) team created the Equid Assessment, Research and Scoping (EARS) tool, which combines already validated welfare assessment techniques with new welfare indicators to deliver a larger and more comprehensive set of welfare indicators than those that are already available . This reSeveral initiatives have emerged that promote sustainable donkey production to harness emerging markets and promote donkey conservation. There has been an increase in the demand for some donkey products. For example, donkey milk is sold at a premium price in some cities due to its alleged therapeutic and extra nutritional benefits. The application of donkey milk is especially being researched for consumption by infants . Some ofThe composition of donkey milk is found to be closer to that of human breast milk regarding its lactose content and protein constitution . It alsoAn increase in the consumption demand for donkey meat and milk has been observed in developing countries. This is being viewed as an incentive towards investing for improvement in donkey husbandry and production . Brazil It is evident from the literature that working equines contribute much to the sustainable development goals by supporting the livelihood of the poorest families worldwide. They are considered sources of employment in various sectors, including agriculture, construction, tourism, and the mining sector. However, their contribution to enhancing the livelihood of the poor and welfare issues, especially in the case of the donkeys and mules, is underacknowledged and neglected in policies and development programs due to the lack of information and data to support their contribution. Efforts by various animal welfare organizations to improve the welfare of working equines have not achieved significant positive changes. When the health and welfare of working equines are not addressed in policies, it leads to poor welfare of equines, which subsequently has a negative impact on the income of communities dependent on them. This will lead to a trap of poor welfare of animals as well as humans.There is a need for one welfare approach where the welfare of animals and humans are considered interlinked to each other, so a change in human welfare will bring positive change in animal welfare and improved animal welfare will increase productivity and household income. There are no data or information available at the national level to highlight the welfare issues of the donkey and mule population and their dependents to include them at the policy level. There is a need for detailed mapping of the donkey and mule populations in developing countries, the socio-economic status of communities who own them, their usage pattern, and the welfare issues of both humans and animals for a better understanding of sustainable intervention planning. There is a need for research and evidence to prove that improved human welfare increases the animal welfare condition and vice versa. Further study is needed to explore the emerging market for donkey milk, human nutrition, and its implications for the poorest communities.


The sustainability of fitness centers depends on two factors: member recruitment and retention, which is why these factors have received attention in recent decades. Temporal trends in fitness center membership purchase channels from 2016 to 2022 and motivation for exercise in 2022 in the Slovenian general population were investigated. The sample included 3419 participants, including 3131 participants  and 288 participants  for the first and second objectives, respectively. Data were assessed using a web-based recruitment questionnaire and the EMI-2 motivation questionnaire. Traditional advertising strategies such as radio and flyers are the least effective (only 0.9% of memberships in 2022), while more sophisticated advertising strategies such as the internet and social media are becoming increasingly important in the advertising world (26.6% of memberships in 2022). On the other hand, word of mouth is the most influential method, attracting 51.3% of new members. Females, older members, and Eastern Slovenians were more motivated to exercise by health and esthetic motives, and males and younger members by challenge and competition. Fitness center management should focus on providing the best possible quality of service, tailoring it to the age, gender, and motivation of customers. Nowadays, people invest a lot of time and resources in a healthy lifestyle, which is reflected in the growth of the fitness industry. With an estimated annual revenue of $87 billion in 2018, it is one of the world’s fastest-expanding industries . In NorwTo attract new customers, it is important to know what factors influence customers’ purchase intention and what motivates potential customers to exercise. Previous studies have investigated the factors influencing customers’ intention to purchase fitness center membership ,11,12,13As a second pillar of fitness center sustainability, member retention can be observed through member motivation, a very important psychological factor for participation in regular exercise. The goals of exercise and physical activity range from improving physical fitness and health to enhancing talents and skills . A studyFor these reasons, we designed a study with two objectives: (1) to investigate the temporal trends of fitness center membership purchase channels from 2016 to 2022 and (2) to investigate the motivation for exercise in 2022 in the Slovenian general population. We cannot hypothesize on the first objective of the study due to inconclusive results in the literature and a variety of variables that have been examined. However, regarding motivation for exercise, we hypothesize that social recognition and competition are more important for male and younger participants, while weight management and appearance are more important for female and older participants.This is the first study of its kind in Slovenia, where people generally maintain a healthy lifestyle and children are among the most active in the world ,26. The The total sample included 3419 participants, members of the 4P Fitness Center in Ljubljana (Western Slovenia) and Novo Mesto (Eastern Slovenia). The sample consisted of two subsamples: the first subsample of 3131 participants  was involved in assessing reasons and advertising channels for new membership each year from 2016 to 2022 (on average 447 participants per year), while the second subsample of 288 participants (age 29.39 ± 10.43 years) reported on the motivation for exercise in 2022. Participants were later classified by gender , by age: youth ≤ 24 years (n = 134) and adults > 24 years (n = 154), and by geographic location: Eastern Slovenia (n = 53) and Western Slovenia (n = 235).Temporal trends in membership purchase channels from 2016 to 2022 were assessed using a web-based questionnaire that included five questions about advertising channels and reasons for joining the fitness center see . The Exewww.1ka.si). This study was conducted in accordance with the Declaration of Helsinki. All participants provided written informed consent before participating in the study, and the Ethics Committee of the University of Ljubljana granted ethical approval for data collection (No. 2021-19).Reasons and advertising channels for joining were assessed in 2016, 2017, 2018, 2019, 2020, 2021, and 2022. Motivation to participate in exercise was assessed in 2022. Participants first signed an informed consent form and then completed questionnaires through an online platform called  as independent variables. Due to the ordinal and nominal nature of the data, the nonparametric Mann–Whitney U test was used in this study. Alpha was adjusted with a Bonferroni correction. All statistical tests were analyzed using the Statistical Package for the Social Science software . The alpha level was set at 0.05.The association between genders and age groups for the advertising strategies used is shown in All correlation coefficients for all advertising strategies were positive and significant except for radio and flyers, which were negative and not significant. The same nature of the relationship was found for the age group factor. In addition, the correlation coefficient for internet and social media was not significant for the age group.The scales, sample items, and Cronbach’s Alpha for EMI-2 are shown in All Cronbach’s Alpha coefficients were high, indicating high reliability of the items used (0.711 ≤ a ≤ 0.908). The differences between female and male participants in mean ranking scores on exercise motivation are shown in Mean ranking scores on exercise motivation and the differences between participants with different demographics are shown in Additional analyses were performed on participants regarding their marital status and type of training. The results showed that single participants were more motivated to exercise because of their affiliation, while for married/in relationship participants, revitalization, ill-health avoidance, positive health, and appearance were considered more important factors for exercise. Regarding the type of training, there were differences in three scales: ill-health avoidance, positive health, and weight management. Ill-health avoidance and positive health were the most important motivating factors for group training participants, while weight management was the most important for personal training participants.We designed the present study to investigate membership recruitment and retention by examining temporal trends of membership purchase channels in fitness center from 2016 to 2022 and leisure-time motivation for exercise in 2022 in the Slovenian general population.As mentioned earlier, the sustainability of fitness centers is based on two factors: membership recruitment and retention. To investigate membership recruitment, we examined the temporal trends of membership purchase channels from 2016 to 2022, as shown in The most surprising and potentially important finding was that becoming a new member through a friend (or word of mouth) as a reason for joining increased from 19.6% of members in 2016 to 51.3% of members in 2022. Previous studies show that word of mouth is one of the most influential communication channels in the market . This isThere were also other reasons for joining—16.3% of members in 2016 and 4.7% in 2022. It should be further investigated what these other reasons could be, but given the decreasing trend and the very low percentage in 2022, perhaps not too much importance should be given to this investigation. From the obtained results, we can conclude that, in order to attract new members, fitness center owners and management should not invest in “old-fashioned” traditional advertising methods such as radio and flyers, but instead should direct their advertising strategies towards more modern strategies such as the internet and social media, and above all, spend time and energy on providing the best possible service to their customers.Regarding member retention, we examined customers’ leisure-time motivation for exercise in 2022 using the EMI-2 questionnaire. In our previous study . Our firThe Mann–Whitney U test showed that five motivational scales were of different importance to females and males. Social recognition and competition were more important for males, which is in line with previous studies ,43,44,45Similar to the different age groups, there were significant differences between members from Eastern and Western Slovenia for six motivational scales . Stress This is the first study to investigate both factors important to fitness center sustainability: membership recruitment in terms of purchase channels and leisure-time motivation for exercise in the general Slovenian population. An additional value is the insight into the data from the temporal trends of fitness center membership recruitment. This provided us with data to compare and predict future outcomes, providing us with deeper insight into the direction of future advertising and working strategies. One of the limitations of this study is that motivation to exercise was assessed only in 2022. A temporal trend in motivation would be desirable to provide a comprehensive overview of motivational factors throughout the observation period. This would also help fitness center management to predict the future motivational factors of their future customers so that they could benefit from such an analysis and provide the best possible service in the future. Furthermore, future studies should be conducted in a wider geographical area. In addition, the different sample size in Eastern and Western Slovenia could potentially bias the results, somewhat limiting their interpretation. Finally, due to the nominal and ordinal nature of the data, an analysis that would reflect the interaction effects of multiple independent variables on the individual dependent variables and allow for more in-depth statistical analysis was not possible.We believe that the results of the present study are of great theoretical and, above all, practical importance. They provide insight into the temporal trends of membership purchase channels and member motivation, which may help fitness center owners and management design their promotional and operational strategies to maintain the sustainability of their fitness centers in terms of membership recruitment and retention.It has been shown that traditional advertising strategies such as radio and flyers are the least effective, but on the other hand, more sophisticated advertising strategies such as the internet and social media are becoming increasingly important in the advertising world. However, the results of the present study show that word of mouth is the most influential method for attracting new members, which indicates that fitness center management should focus their energy on providing the best possible quality of service. In terms of motivation to exercise, our study showed that females, older members, and members from Eastern Slovenia were more likely to be driven to exercise by health and esthetic motives. In comparison, males and younger members were motivated by challenge and competition. This is an indication that targeting customers of different gender, age, and demographic characteristics should be tailored to their needs in order to maintain or exceed past operational and financial performance.Considering the implications of our research for fitness centers’ operations, we advise fitness managers to invest more in newer marketing solutions such as digital marketing and social media. In addition, service quality and satisfaction with the fitness center are very important, as the trend in our study clearly shows that word of mouth and e-promotion are becoming the most important ways to attract customers. Our results also show that gym managers should consider that different customers have different motivations to exercise, and if we want them to stay active, we need to communicate with them differently. In this way, they would increase customers’ repurchase intention and generate more revenue. This is extremely important in the fast-growing and very competitive health and fitness industry.


The provision of integrated care (IC) across alcohol and other drug (AOD) and mental health (MH) services represents the best practice, yet the consistent delivery of IC in routine practice rarely occurs. Our hypothesis is that there is no practical or feasible systems-change approach to guide staff, researchers, or consumers through the complex transition that is required for the sustained uptake of IC across diverse clinical settings. To address this gap, we combined clinical and consumer expertise with the best available research evidence to develop a framework to drive the uptake of IC. The goal was to develop a process that is both standardised by the best available evidence and can be tailored to the specific characteristics of different health services. The result is the framework for Sustained Uptake of Service Innovation (SUSI), which comprises six core components that are applied in a specified sequence and a range of flexible activities that staff can use to deliver the core components according to their circumstances and preferences. The SUSI is evidence-based and practical, and further testing is currently underway to ensure it is feasible to implement in different AOD and MH services. Integrated care (IC) is widely recognised as a best-practice service delivery approach for people who have multiple healthcare needs ,13,14,15There are two possible reasons for the lack of sustained uptake of IC into routine practice. First, service providers may be reluctant to commit their scarce resources and training opportunities to IC because the empirical evidence supporting its effectiveness is still emerging , and theSecond, it may be that the uptake of IC is not being guided by the application of a feasible, acceptable, and relevant framework for implementing change. Existing IC models exist, such as the Dual Diagnosis Clinician Shared Care Model , which dWhile organisational change models, such as Lewin’s 3-Stage Model  and KottOne approach to increasing the uptake of system-wide IC that shows promise across a range of healthcare services is the adaptation of evidence-based practice (EBP). This method involves the development of clinical care that is grounded in the best available research evidence whilst at the same time incorporating clinical and consumer expertise ,37. The Consequently, this study aimed to utilise the opportunity of implementing IC into routine clinical practice in MH and AOD services to articulate a co-designed, pragmatic framework for the Sustained Uptake of Service Innovations (SUSI): the SUSI framework.The development of the SUSI framework was informed by two key principles. First, the principle of evidence-based practice, which is defined as the combination of current best evidence with clinical and consumer expertise ,37. Current best evidence was determined by identifying the existing key principles of organisational change ,31,32,33Clinical and consumer expertise was determined in a Participatory Action Research (PAR) study conducted by the authors CF, AS, JA, JL, and RC, which identified the key issues for managers and clinicians in moving from the independent delivery of AOD and MH services to IC .The second principle involved establishing a framework that can be tailored to different services and aligned with the adaptation of EBP at a service level. The authors previously developed treatment models comprising core components that are standardised by the best available research evidence and operationalised by activities that are identified by services and tailored to their own circumstances ,42,43,44A research advisory group was formed during the PAR study  to proviThe SUSI framework was developed in alignment with the procedure for adapting EBP for groups into a framework ,38,39. TMapping the key change transition processes that were identified in the PAR study  into the key elements of successful organisational change models ,31,32,33Grouping those core components into sequential phases to reflect both the learning from the PAR study’s real-time change transition and the steps that are widely used to implement existing organisational change models. The SUSI framework was then circulated for feedback amongst clinical and research experts through ten iterations. Feedback was requested regarding whether the core components were sufficient and easy to understand and whether the sequence for implementation was pragmatic and feasible. The responses were provided by email and at monthly meetings, reviewed by the Research Advisory Group, and the final analysis was conducted by two reviewers (CF and AS). The comments were analysed deductively using the key principles identified in the research evidence ,41,42,43The data appraised in Step 3 of the EBP procedure were triangulated  by:MappiCore component 1. Secure Commitment and Active Participation.The six core components are described as follows:Service managers and clinical leads. Clinicians are unlikely to engage in collaboration and practice change if their line supervisor is not actively supportive of the process. Clinical leads and service managers can ensure effective service planning and delivery, and they are well-positioned to lead and/or support innovations with staff and consumers. Participation at this level establishes IC as a priority and demonstrates to the staff that their involvement is valued and taken seriously. Involvement is also required from executive (or senior) managers, however, to ensure the clinical managers’ role expectations are met and their decisions are supported, for example, by allocating time for staff to take part in co-designed activities. If securing commitment and participation from clinical/service managers is successful, the process of securing a commitment from senior managers can then be taken appropriately and optimised for success.Senior (Executive) managers. Sustainable change requires a commitment to system-level change. For example, allocating designated leaders to drive the shift to IC increased the services’ capacity to maintain momentum in the change process whilst also allowing time to develop sustainability mechanisms, such as strategically identified Performance Indicators. Without input from the executive level about how to create and support designated leaders on the frontline, however, known barriers  are likely to prevent a successful change transition. This step acknowledges and draws upon expertise from the executive level, creates opportunities for access to other initiatives and resources, and ensures the proposed innovation aligns with the health services’ priorities and limitations.Clinicians and frontline staff. This step establishes staff confidence and interest in delivering IC and works to secure active participation from clinicians to drive the co-design and co-implementation process. Once participation is established, the implementation can draw on the clinical expertise that already exists within the workforce to improve staff confidence and capability. This step enables the development of practices that staff are more likely to adopt.Clients of the participating health service . Consumer participation is key to designing care that meets the needs of the people most likely to seek that care. Navigating complex systems can be difficult, but involvement from consumers from the design phase onward can help services to identify those difficulties as well as strategies to reduce their occurrence or impact. This step enables the development of practices that are acceptable and relevant to consumers and are, therefore, more likely to be used.Core component 2. Describe the Current State of Play.This component is a critical first step. The goal is to identify relevant stakeholders and form an alliance by establishing commitment and active participation at multiple organisational levels. Successful engagement at different levels helps to ensure the feasible implementation of a substantial change to clinical service delivery. In addition to collaboration with non-government and community organisations, for example, a change in government-funded health service requires involvement from:This second step helps to ensure that the proposed change is targeted appropriately and that the progress and impact can be monitored. For IC, for example, this includes determining the size of the problem  and the levels of motivation toward providing IC  and the strategic priorities of the organisation (does this innovation target a known area of need and/or respond to an established performance indicator), and conducting an assessment of the service capability and staff confidence and attitudes towards delivering IC. Core component 3. Formalise Collaboration and Build Relationships.In this critical step, teams decide how and where they will co-design practices, e.g., for inclusion in the tailored model of care. Priority is placed on developing the collaborative partnership, which means allowing sufficient time to build genuine professional relationships between staff and between staff and consumers and encouraging a shared goal to emerge rather than be imposed. Consistent with the iterative, experiential learning approach of PAR, this component may overlap with core components 4 (co-design of the model) and 5 . Core component 4. Co-design the Innovation.This step involves reviewing the existing practices and designing, trialling, and adapting new practices, e.g., for inclusion in a new model of care. Encouraging staff to play an active role in determining how new practices are structured, communicated to clients, and implemented facilitated meaningful contributions to the development of clinical procedures. Creating opportunities for clinicians to devise their own activities and methods fosters a sense of ownership over new procedures and a shared responsibility for ensuring uptake. In the specific context of IC, in which the SUSI was developed, the co-designed model of care is presented elsewhere and provides a detailed example of how core component 4 might be actioned . This coCore component 5. Develop Training & Clinical Support (for delivering new procedures).Ensuring that new practices are acceptable and feasible for clinicians to implement is critical to the uptake of the practices. This applies not only to those clinicians who actively participated in the co-design process but also to those within the participating services who did not play an active role. Increasing confidence and interest in delivering IC and in collaborating with other teams is key to improving staff satisfaction and shifting historical perceptions about the divide within or between services. Ensuring the appropriate clinical supervision for staff, both during and beyond the practice change, helps to foster staff satisfaction and sustainability. This component may overlap with core component 3 (relationships) and core component 4 (co-design). Core component 6. Monitor and Sustain the Innovation.This step helps services operationalise the ‘refreezing’ or ‘sustaining momentum’ phase of change models. The goal is to embed sustainability mechanisms and monitor uptake of the innovation, and to build confidence among staff to deliver new procedures. Essential to this phase are (a) sustaining connections between staff; (b) maintaining a visible, collaborative presence; (c) embedding routine evaluation; and (d) choosing evaluation methods to monitor both process and outcome levels through key performance indicators . A critical aim of this step is to transition short-term implementation and evaluation tasks into strategically identified embedded roles to support the sustained uptake of IC beyond the implementation phase.This paper presents the SUSI framework for guiding the process of implementing the sustained uptake of health service innovations using the example of moving from the independent delivery of AOD and MH services to IC. The SUSI comprises six core components, and these components need to be operationalised by individual services through a range of flexible activities. A clear pathway is established for actioning the core components in a sequence recommended to optimise the efficiency with which the service innovations are implemented: identifying the need to engage clinical managers first and then senior managers, clinicians, and consumers; taking the time to develop relationships between teams and allow a shared goal to emerge; co-designing an innovation ; developing training and clinical supports to support uptake of the innovation, and monitoring sustainability whilst building staff confidence to deliver new procedures. Although organisational change models exist ,31,32,33The core components of SUSI are standardised across any setting and are, therefore, comparable, and measurable, but their implementation needs to be co-designed by service provider experts to their own specific circumstances. In the study case of IC, for example, core component 1  was operationalised through identifying a manager as an advocate, presenting at existing meetings to secure support, seeking candidature in the Health Education Training Institute’s Rural Research Capacity Building Program, and holding regular collaborative meetings. Core component 6 (monitoring and sustaining the innovation) was operationalised by identifying the performance measures and mechanisms already in place for the routine monitoring of the outcomes. A key focus in the design of the SUSI framework was to ensure that it could be applied to a range of different health services and tailored to the specific characteristics of those services, which includes the use of established and meaningful measures. While the primary feature of the SUSI framework is its clear focus on being pragmatic, its key limitation is that it has not yet demonstrated its effectiveness in achieving timely service improvements in a range of different settings. Consequently, it clearly needs to be tested in prospective and well-controlled evaluation studies. Nevertheless, the SUSI framework is likely to be effective because its construction was based on the established principles of evidence-based practice ,37,38,39The SUSI framework was developed to respond to the complexity of integrating service innovations into the real-world delivery of health and human services. It complements existing organisational change models by providing a more pragmatic, step-by-step guide for the implementation of service delivery innovations in real-time. It also recognises and responds to the emerging idea that the translation of research evidence into practice is much more complex than rolling out evidence in clinical settings in a linear way. Rather, feasible implementation requires the tailoring of that evidence to fit specific services and settings without compromising the effectiveness of the innovation. A framework for the sustained uptake of service innovations is more likely to facilitate the embedding of research evidence efficiently and effectively into clinical practice if it is driven by frontline staff with leadership from consumers, and permission and support from middle and senior managers. The SUSI is underpinned by this leadership from those who are most affected by changes to healthcare services, that is, the people who receive health services, and those who deliver health services. Moreover, the SUSI explicitly addresses the need to tailor the best available research evidence to the routine delivery of services.


Bioretention cells, or rain gardens, can effectively reduce many contaminants in polluted stormwater through phytoremediation and bioremediation. The vegetated soil structure develops bacterial communities both within the soil and around the vegetation roots that play a significant role in the bioremediative process. Prediction of a bioretention cell’s performance and efficacy is essential to the design process, operation, and maintenance throughout the design life of the cell. One of the key hurdles to these important issues and, therefore, to appropriate designs, is the lack of effective and inexpensive devices for monitoring and quantitatively assessing this bioremediative process in the field. This research reviews the available technologies for biomass monitoring and assesses their potential for quantifying bioremediative processes in rain gardens. The methods are discussed based on accuracy and calibration requirements, potential for use in situ, in real-time, and for characterizing biofilm formation in media that undergoes large fluctuations in nutrient supply. The methods discussed are microscopical, piezoelectric, fiber-optic, thermometric, and electrochemical. Microscopical methods are precluded from field use but would be essential to the calibration and verification of any field-based sensor. Piezoelectric, fiber-optic, thermometric, and some of the electrochemical-based methods reviewed come with limitations by way of support mechanisms or insufficient detection limits. The impedance-based electrochemical method shows the most promise for applications in rain gardens, and it is supported by microscopical methods for calibration and validation. Stormwater is the excessive amount of rainfall or melted snow that does not sink into the ground and flows over the landscape surface to eventually find its way to a receiving water body. Impervious surfaces, which are prevalent in urban areas, generate large amounts of stormwater because they are compact surfaces with low permeability (such as roads and parking lots) and do not allow the rainfall to penetrate the subsurface . StormwaWater quality is a significant component of stormwater management. Stormwater management involves flood prevention and increasing the quality of stormwater runoff before it discharges into receiving waters. Modern stormwater management includes Sustainable Urban Designs (SUDs) and Low-Impact Development (LID), which integrates land-use planning and engineering design to manage storm water runoff . GeneralBioretention cells are a popular form of LID, particularly for its stormwater quality treatment capacity. Also termed biofilters, they are effectively biological media filters that improve water quality by temporarily storing large stormwater volumes ,5. StormIn general, bioretention cells can be used for a wide range of applications, from high infiltration to pretreatment of urban runoff . The bioThe process of bioremediation in bioretention cells that uses specific types of plants for contaminant removal is called phytoremediation. This can be further classified into where the removal is conducted—either through, or at the roots, or further up the plant matrix. Scientists have identified more than 400 plant species with the potential for direct soil and water bioremediation . However3−) or nitrite (NO2−) is converted to nitric oxide (NO), nitrous oxide (N2O), or nitrogen gas. More than 50 genera of bacteria have been identified as being capable of denitrification, but in general, the bacteria have one (or both) of two types of nitrate reductase, Nar and Nap [Nitrosomonas use ammonia nitrogen (NH3) by converting it to nitrite in the nitrifying process. The genus Nitrobactor then converts the nitrite to nitrate in the two-stage process called nitrification [Among various species of microorganisms, certain types are capable of forming aggregates of bacterial cells, called biofilms. The key initiation mechanism for the formation of biofilms on surfaces such as plant roots is chemotaxis, which allows single planktonic bacterial cells to form functional glue-like biofilms . Biofilm and Nap . Nitrifyfication . Nitrifyfication . Numeroufication . Howeverfication .Biofilm can be formed as result of the aggregation of millions or single species of organic/inorganic compounds that can range from decomposing materials to microorganisms ,26. AccoStormwater, unlike wastewater, is intermittent, with low concentrations of contaminants as compared to wastewater. The contaminants are nutrients for the rhizobacteria, which can undergo drastic fluctuations between rain events. The health, growth, and extent of the vegetation are certainly functions of the retention capacity of the soil and its organic content. These are most often predetermined by local conditions  but are designed to promote healthy growth in the local environment. Bioretention cell function in cold weather is continually being researched , but rhiDepending on the physical, chemical, and biological conditions of the environment of interest, methods of studying biofilm differ from one another in the sense that the monitoring method used in one environment or application may not be as useful when utilized in a different application . DespiteAll biofilm monitoring methods function on the basis of a response signal acquired from the biofilm. These signals are a result of energy transfer, light scattering, heat transfer, acoustic waves, electrical fields or electrical currents, and mechanical signals. The process of monitoring involves transmittance of input signals, modification of the input signals by the biofilm and its host environment, and detection of the output signals by the sensor. The biofilm leaves a characteristic footprint in the modified signal  . Funari Conventional methods of studying biofilms involve the enumeration and morphological observation of the microorganisms using microscopic techniques such as light and epifluorescence microscopy, as well as confocal laser scanning microscopy (CLSM) and scanning electron microscopy (SEM). Light microscopy and epifluorescence techniques are suitable for biofilms with a thickness of less than 3–4 µm because the multilayered biofilm structures scatter the light emitted at the sample and disrupt direct observation. The dye 4′,6-diamidino-2-phenylindole (DAPI) is one of the few staining dyes that has been used widely by researchers for biofilm studies. DAPI binds to the double-stranded regions in the DNA of the cells and makes the visualization of dead and live adherent cells possible. Grohmann and Vaishampayan  reportedPseudomonas fluorescens isolated from the natural soil environment to find an estimation of the biofilm’s chemical composition, using light microscopy together with CLSM, TEM, and SEM. In a creative method to monitor biofilm in situ by using an optical microscope, de Carvalho et al. [x-y plane and the number of cells in the z-direction. They tried to investigate the biofilm 3D structure with brightfield transmitted and fluorescence light with an optical microscope. While unable to create 3D images, brightfield light transmittance is also the principle behind determining biomass concentration in spectroscopy methods.Transmission electron microscopy (TEM) and scanning electron microscopy (SEM) are the two subcategories of electron microscopy (EM), both of which have been used by researchers recently for the three-dimensional analysis of biofilm structures. Electron microscopy functions based on the emission of a focused beam of electrons on the surface of the specimens and producing images based on the interactions of the electrons with specimen atoms. Rajeb et al.  employedo et al.  developeEnvironmental scanning electron microscopy (ESEM) is the modified version of SEM that eliminates the occurrence of mass loss and shrinkage owing to sample preparation procedures required for classical SEM . ESEM beMicrobial monitoring using piezoelectric systems are based on the effect arising from bacterial mass formation on the surface of electrodes. It involves transmitting an alternating current (AC) to the sample through metal electrodes formed on glass  substrates to induce the oscillation of the electrodes . The for5 cells/cm2 up to 1010 cells/cm2. Fischer et al. [3 cells/cm2.Fiber-optics are an optical-based sensor in which the differences in the turbidity, light scattering, light absorption, reflectance, refractive index, fluorescence, bioluminescence, and surface resonance resulting from the corresponding interaction between the biofilm and the light source, are sensed by the fiber-optic ,49 see . Turbidir et al.  designedr et al. . The resIn the field of biosensing, thermometric transducers measure the amount of heat induced by bacteria presence with a thermistor that is sensitive to heat  see Fig. Like piThe metabolism of bacteria occurs through a series of biochemical reactions such as converting large molecules into smaller ones and releasing the energy, as well as utilizing organic and inorganic compounds for their maintenance and growth . AccordiAmperometric biosensors function based on the electric current generated by the oxidation–reduction reaction of species in contact with the surface of the working electrodes, while keeping the reference electrode at a fixed potential . AmperomImpedimetric biosensing has gained significant interest in fields related to studying biological species in general and bacterial biofilm specifically. This has led to the advent of the field of impedance microbiology (IM), which is simply the application of impedance spectroscopy on microbiological species. This method involves measuring the impedimetric features of bacterial samples as a measure of their growth and availability in the system. Electrical impedance is the resistance of the circuit against the flow of current when a certain voltage is applied. Impedance, however, is not only the resistance of a resistor in the circuit but also the resistance from any capacitance and inductance features available in the system, if there are any. This stems from the fact that, in certain conditions, other than resistors, capacitors and inductors can display resistance against the flow of the current. Therefore, resistance, capacitance, and inductance could create impedance that includes at least one, and up to all of these, three features at the same time. If the voltage applied is through a direct current (DC), an inductor of the system behaves like a normal wire and does not display any inductive resistance, and a capacitor in the system acts like an open circuit, such that the resistance is infinite. However, when the voltage applied to the circuit is through an alternating current, any resistor, capacitor, and inductor available in the system will display some measurable impedance.Living cells are composed of a closed, insulating membrane that is filled with liquid plasma and shows dielectric properties . Such a Vibrio natriegens and P. aeruginosa. Davis et al. [There have been numerous research works based on the idea of impedance microbiology. From food safety monitoring  to points et al.  studied s et al.  also proAn ideal biofilm-monitoring system for a rain garden in the field would be a system that can function non-destructively, continuously, and without impacting the microbial community. It should have fast, accurate online feedback acquisition. Researchers have been developing systems to achieve bacterial biofilm monitoring that fall into several categories, including microscopical , piezoelMicroscopy is the traditional method used for monitoring biofilm , and it Microscopical methods could be used in combination with each other to fill the gaps and constraints of one another. ESEM, for example, can be used jointly with the CLSM-FISH method to provide an estimation of the volume containing the total cell counts (determined by CLSM-FISH) per substratum . However5 cells·cm−2 for Pseudomonas cepacian bacteria with this method. In addition, the environmental pressure and temperature that the crystal was exposed to affected the oscillation frequency. This indicates the need to use QCM in temperature- and pressure-controlled environments or to use techniques to compensate for such effects. This effectively eliminates their use in the application of interest in this work. Other types of piezoelectric sensors have been developed to detect different kinds of vibrations, but there is no evidence of their employment in the realm of biofilm monitoring [These devices provide the means for real-time and non-destructive biomass monitoring. The main downside of this technique, however, is the necessity of biofilm adhesion onto the surface of the electrodes. This is a limitation of use, especially for bacteria in aqueous media—where existing unattached bacteria in the sample are of interest. This could also apply to biofilms that are loosely attached . The fornitoring .3 cells/cm2, which is also low. However, to date, there is no report of the successful use of fiber-optic sensing in the subsurface and soil environments. Moreover, the geologic environments are genuinely opaque media that contain abiotic and grain-like substances that could potentially disrupt the process of illumination and detection in such sensors. Other disadvantages include the fact that optical fibers are not suitable for the monitoring of thicker biofilms [The main benefits of using fiber-optic sensors are the low power consumption and low cost. Another advantage is the fact that LEDs are able to stop and start illumination in a few milliseconds, thus empowering the system to emit reproducible light intensities. Ming et al.  designedbiofilms . This suIn general, a disadvantage of thermometric sensors for use in the field is the additional instrumentation required for the sole purpose of keeping the environmental temperatures optimal for biofilm formation. This optimal temperature is not necessarily constant but less dynamic than natural changes to allow for the biofilm formation heat effect to reach a sensible signal-to-noise-ratio. According to Janknecht and Melo , this tePotentiometric methods that are based on the measurement of the potential differences between a working electrode and a reference electrode separated by a membrane suffer from the same weaknesses as those of amperometric systems when it comes to measuring biofilms. In addition, potentiometry requires a very stable and accurate reference electrode that is genuinely a challenge to maintain . TherefoAccording to the literature review, impedance-based methods are the most promising electrochemical methods for monitoring biofilms. Frequency-domain-induced polarization, also known as complex conductivity or impedance spectroscopy, has the potential to be a suitable monitoring method for geologic media. A major advantage of impedance spectroscopy is the minimal sample preparation. This means that continuous monitoring is possible without having to physically exploit samples and interrupt the host environment . Recent The ideal monitoring system of biofilm in situ in rain gardens (bioretention cells) should include the following functional requirements: operation in real-time, non-invasive, non-destructive, online, quantitative, portable, autonomous, sufficiently long testing uptime and signal acquisition, large substrate surfaces, and affordable tracking. Despite vast efforts and the advances in the field of biosensor development, to the authors’ knowledge, there is still no sensor that is commercially available and can be used at an industrial scale and for field use in rain gardens to determine biomass activity leading to bioremediation. This review paper examined the possible methods for measuring biofilm characteristics as an indicator for bioremediation in rain gardens. Microscopical methods form the traditional method for the direct and accurate measurement of biomass, but they lack the portability and quick analysis required in the field. Thermal and piezoelectric sensors typically require the formation of biofilm layers in the order of tens of micrometers to show a response. These are not options for the early detection of bacterial biofilms that is highly crucial in many different applications . In the To reach the objective of developing a portable, low-cost, effective tool for biofilm characterization in a rain garden, lab-scale implementation and testing is certainly required during development. There are a few commercially available systems that are compatible with lab-scale use, but a lack of guidance for verification methods, sensitivity, and detection thresholds suggests the need for further implementation and development of a well-calibrated field-scale biosensing system. Moreover, a system is required for researchers to be able to study the effect of environmental conditions on the growth and metabolism of different biofilm-forming microorganisms to better engineer the bioretention cells. In addition, field use without lab-scale and pilot-scale verification could bring serious uncertainties in the device.Impedance biosensing is recommended as the main method behind developing a sensor for use in monitoring environmental biofilm in rain gardens, but with microscopic and optical density methods used for verification and calibration of the sensor. Furthermore, rather than trying to execute the impedance experimentation on the biofilm around plant roots in uncontrolled environments, bacterial samples in known growth media can be used to help calibrate the device. The parameters that can be measured using such a system would have to characterize the relationship between the electrical capacitance/resistance and biofilm growth.


In 2016 and 2018, the Peruvian Ministry of Economy and Finance (MoEF) significantly reformulated taxes on tobacco products, alcohol and sugar-sweetened beverages (SSBs). During these processes, different actors advanced arguments supporting or opposing the taxes. This study examines Peru’s political and socioeconomic factors, the role of other actors and framing strategies, shaping health taxes introduction.We conducted qualitative analysis by collecting information from three sources, such as: (1) media material (n=343 documents), (2) government documents (n=34) and (3) semistructured interviews (n=11). That data allowed us to identify and characterise the actors involved in implementing health taxes in Peru. We combined the data from these sources, synthesised our findings and conducted a stakeholder analysis.Key actors supporting taxes were the MoEF and civil society organisations, while trade associations and the alcohol, SSBs and tobacco industries opposed them using economic, trade-related arguments and criticised the policy process. The supporting group used arguments related to the economy and health to legitimate its narrative. The framing strategies employed by these stakeholders shaped and determined the outcome of the policy process.Peruvian stakeholders against health taxes demonstrated a strong capacity to convey their messages to the media and high-level policy-makers. Despite these efforts, attempts to interfere with health taxes were unsuccessful in 2016 and 2018 and failed to overcome state institutions, particularly the MoEF. Strong institutions and individual decision-makers in Peru also contributed to the successful implementation of health taxes in Peru in 2016 and 2018. There is extensive literature worldwide on the political processes that affect the implementation of public health policies, particularly health taxes. Areas such as the effectiveness of implementation, the stakeholders’ participation and industry interference have been more widely addressed by studies.In the case of Peru, the implementation of health taxes has been more focused on tobacco than other damaging products Nevertheless, since sugar-sweetened beverages tax adjustments in 2018 more literature regarding these products has started to be produced.This is the first time that health taxes in Peru have been analysed using a political lens, which comprehends the sociopolitical factors that led to the implementation of health taxes policies.This study used a framing analysis to understand the arguments of both stakeholders in favour and against health taxes and identify the main stakeholders stating these positions, which had not been studied before in Peru.This study offers important insights which can demonstrate and illuminate how political processes affect the implementation of public policies in countries such as Peru.The results from our study, which focused on the successful adoption of health taxes, may inform other countries currently discussing similar public policies.Gathering public health and economic-related evidence about the impact of health taxes is an excellent way to confront narratives and arguments against these taxes.There is a strong evidence that consuming products such as alcohol, sugar-sweetened beverages (SSBs) and tobacco contribute to the increase in non-communicable diseases (NCDs).As of 2021, 21 countries in the Region of the Americas have taxes on SSBs,There is still a limited understanding of the factors that lead to adopting these health taxes: the political strategies adopted by supporters and opponents of the taxes and the discourse and arguments they put forth.We used qualitative methods, including a review of scientific studies; an analysis of media material from 2016 to 2018; a review of documents from the Peruvian government; and 11 semistructured interviews. The study was undertaken between February 2022 and July 2022. Data were in Spanish and English.To investigate the framing of health taxes in Peru, we conducted a systematic analysis of media coverage, building on similar studies.To supplement these data, we also conducted a manual search of news and other documents, guided by recommendations from key informants with expertise in health taxes in Peru (see Systematic search strategy).We searched documents discussing the selective consumption tax, where at least one of the products under the Peruvian health taxes—alcohol, tobacco or SSBs—was discussed . Details10.1136/bmjgh-2023-012024.supp1Supplementary dataAfter removing duplicates, all documents were reviewed by at least two researchers from a group of three: two researchers (MAZ and SP-L) and one research assistant. This was an iterative reflective process where non-agreements were always discussed among the team. Documents were included if they mentioned health regarding any of the three products to be analysed. They were excluded if they referred to health taxes on other commodities  or were merely a translation of other material already included. We reviewed media documents from 1999 to the time of data collection and identified two key periods as the most relevant for our study, with a drastic increase in the production of news on health taxes: in 2016 with more news discussing tobacco and in 2018, with information more focused on SSBs. We further analysed documents from these years only (292 documents).Trome’ (not available on Factiva), and the economic newspaper ‘Gestión’, only covering May 2018, when health taxes were widely discussed. From this search, we found 51 articles.We searched for news articles through the National Library’s depository, including the most-read newspaper, ‘We also accessed other documents identified by key informants (see below). We accessed 34 documents from the MoEF through the ‘Transparency and Access to Public Information Law—No 28706’.The process of inclusion/exclusion of documents was a first step to extract some initial relevant data: media source, date of publication, language, title, type of news , stakeholders mentioned, and its stance on health taxation see . That prThe media analysis and document review allowed us to identify key stakeholders involved in the discussion of 2016 and 2018 around health taxes. We contacted them and used the snowball sampling methodThe interview guide was developed see  by two rAll interviews were transcribed verbatim by researcher MAZ and a professional transcriber, who also worked under the ethics consent rules of our study.First, for the stakeholders analysis,Here, we describe the context for the Peruvian health taxes in more detail, based on the above analysis conducted. We then present the arguments of those in favour and those against health taxes before introducing our findings from our stakeholder analysis. We refer to Neither patients nor the public were involved in any stage of the realisation of this research.Prior to the 1990s, Peru was subject to government protectionism and interventions on prices. There were also restrictions on imports and a growing external debt, among other measures that resulted in a hyperinflation and a recession.The political contexts allowed the health taxes adjustments in 2016 and 2018. In 2016, the adjustments to health taxes came at the end of the then government in place (which lasted from 2011 to 2016). However, in 2018, changes came at the start of a new government after the resignation of the former President of the Republic. MoEF officials interviewed for our study considered these periods windows of opportunity for tax adjustments .In May 2016, the MoEF raised cigarette taxes by 157%, the most significant increase in Peru’s history of health taxes.In May 2018, several taxes were adjusted, including beverages with more than 20% in alcohol concentration, where taxes were raised from 25% to 40%, and cigarettes taxes which were increased by 50%. SSBs containing more than 6 g/100 mL of sugar were subjected to a 25% taxThe President of the Republic and the Minister of Economy both supported these taxes, and their opinions were often highlighted in the media, which placed the issue of health taxes on the public agenda. In the following months of May 2018, a dispute occurred between the President and the MoEF related to a strike threat from the transporter’s union due to increased health taxes on gas. The President soon gave signs that he might not be so supportive of taxes, for political reasons. In this context, the Minister of Economy lose political support, which led him resigning from his position.Despite the country’s political instability and institutional crisis in recent years, which has led to six changes of Presidents between 2016 and 2022, the MoEF is considered a stable government institution, with its officials in charge of taxation, most of which took office in 2014 and remained in their positions in the institution at least until the period of data collection for this study.In the following section, we present the arguments in favour and those opposing health taxes, as identified through our analysis. The following There was a broad range of arguments supporting health taxes. Those considered most relevant were health-related arguments, economic-related arguments and arguments that international organisations and the experiences of other countries stated.Some common arguments for advocating for health taxes were related to the potential health benefits that would happen if the taxes were introduced. These arguments were, in most cases, advanced by the MoEF as one of the main actors advocating for health taxes. The MoH also expressed its support for taxes and used similar arguments related to health, but less frequently than the MoEF.We identified three main health arguments, such as: (1) health taxes would reduce the consumption of harmful commodities; (2) health taxes would compensate for the negative externalities caused by harmful commodities and (3) harmful commodities impact negatively on public health.The argument (1) that health taxes would reduce the consumption of harmful commodities was used in 2016 to refer to the consumption of tobacco products, specifically in children and teenagers, an argument supported by Pan American Health Organization (PAHO/WHO) and the World Bank.About the argument of the (2) negative externalities, the MoEF pointed out the negative consequences of consuming harmful products using evidence from abroad.And more or less in the year 2005–2006, this concept began to appear, it is already mentioned that selective consumption taxes  are applied on goods and services that cause negative externalities, so the concept of negative externalities begins to appear in the guidelines .However, in our review of the media, we found evidence for the concept to be used publicly just in 2016 and more widely in 2018, when the discussion of health taxes was on the public agenda.One argument widely used by those advocating for health taxes was referred to (3) the negative impacts of harmful commodities on public health, especially mentioning diseases, such as cancers in the case of tobacco smoking in double and obesity, in the context of the consumption of SSBs. These arguments were, in some cases, supported by epidemiological data about the incidence of diseases. The direct and indirect costs of diseases such as cancer, obesity or diabetes for the government were also mentioned,Those advocating for health taxes used arguments related to the economy, noting the double dividend on the economy and population health if the taxes were implemented.Government officials, journalists/columnists, public opinion leaders and, in fewer cases, civil society organisations used these arguments. Something particular about these arguments was that they were commonly used by high-ranking government members, such as the President of the Republic and the Ministry of Economy, as noted earlier. Using an economic argument from these authorities may have attracted media attention. It could have responded to the arguments from the industries and trade associations against health taxes, which also used economic arguments—which we will discuss further in the present manuscript.Two leading economic arguments were identified supporting health taxes: (1) health taxes would be a source of revenue for the government and (2) health taxes would not have a negative economic impact. In the first argument, the MoEF publicly stated the need to ‘make cash’.The Minister of Economy, David Tuesta, defended the recent increase in the Selective Consumption Tax (ISC) rates for some products and acknowledged that this decision was based, in part, on the actions required to ‘make cash’ in addition to correcting negative externalities. Still, every time government representatives, even the President, used these arguments in favour of health taxes, they also mentioned health-related statements, which might be considered a validation strategy.The framing of health taxes as a source of revenue had its critics, especially industry-related stakeholders and public opinion leaders, against health taxes. For them, the real purpose of the taxes was generating income,In their second argument, current and former government officials pointed out that the economic impacts of the taxes would be ‘minimal’The third group of arguments used to advocate for health taxes was arguments showing the support from international organisations to legitimate its importance. First, opinions and statements from international organisations were highlighted, such as those of the WHO, including the WHO FCTC, as a leading treaty, primarily when tobacco taxes increased in 2016, and those of the World Bank.For those opposing health taxes in Peru, there were three more frequently used arguments: those related to the economy, those related to illegal sales and other arguments related to the process of health taxes adoption and implementation.Most of the arguments against health taxes had an economic background behind them, used mainly by industry-related actors. The most common concerns were that health taxes would impact prices and sales, decreasing employment and investments and negatively impacting market competition.Industry representatives and business associations stated that the weakest parts of the value chain and the sectors with lower incomes would be the most affected after taxes implementation.Another group of arguments widely mentioned by opposing stakeholders focused on the detrimental consequences on the trade of these products, either by showing that adverse outcomes have occurred after their implementation or by anticipating what would happen in the future.The leading trade associations stated that increasing health taxes would increase informality and illegal activities such as smuggling and production of adulterated products.Every time we have a modification, they come up with studies, with information, which in reality are not very reliable but which they can afford to finance and have public exposure of these reports .The beer and tobacco industries highlighted the risk that tax evasion would occur after smuggling increased, the amount the government would lose in revenues. They emphasised the gap that would open up between formal and informal sales and called for more state control over smuggling.Associations’ representatives and public opinion leaders who criticised the health taxes adjustments stated that the alleged lack of concern from the government about smuggling demonstrated that they ‘do not know the reality of the country’Similarly, opponents of health taxes argued that products would be adulterated. Trade association representatives and public opinion leaders said that these products would even put people’s health at risk,The third set of arguments against health taxes was questioning the process of their adoption and implementation. Industry representatives claimed that there was a lack of dialogue and little discussion with the industries; and criticised the alleged volatility or unpredictability of the measure. The industries also sought to emphasise that they were willing to talk to the government but had not been heard and considered that the taxes adjustments were ‘arbitrarily decided’.Trade associations also referred to the lack of ‘transparency and planification’ of the policy. They argued that the ‘rapid increase’ of taxes was ‘surprising’ and that they did not have a reasonable time frame to implement it.The above messages reflected the concerns and interests of different stakeholders. The stakeholder analysis  helped iExcept for Peru’s major beer company, it was rare that companies themselves came out in the discussion on health taxes. The tobacco industry played a minor role publicly; its low profile in Peru may be due to higher public scrutiny than other sectors.In turn, a leading actor in the political discussion championing health taxes was the MoEF. Key informants belonging to civil society, international organisations, academia and the government referred to the MoEF as an institution whose stability and institutionalism was crucial for advancing the adoption and adjustments to health taxes, especially from officials in charge of taxation, who combined both the arguments of economic efficiency with public health purposes .So there was a debate in Congress and if you listen to the representative of the Ministry of Economy, you would think that she is a person who represents health, I would say that she has presented better than any representative of the Ministry of Health. .On the other hand, actors opposing health taxes criticised the MoEF, saying it was a ‘biased’, ‘ideological’ institution  that didInternational organisations such as the WHO, the PAHO (PAHO/Office of the WHO of the Americas), the World Bank, the IMF and the OECD were also essential stakeholders that made public statements  advocatiOther stakeholders in favour of the health taxes were civil society organisations such as the National Anti-Tobacco Commission, and the Centre for Information and Education for Drug Abuse Prevention, academic think tanks such as the Development Analysis Group, the Institute of Peruvian Studies, and independent academics and public health advocators. These institutions and individuals provided evidence and expert opinions.On the other hand, the MoH did not have a leading role in the health taxes discussion but was instead consulted to provide health data for establishing health taxes. Interviewees from the MoEF and MoH considered the latter to be a fragmented institution, understaffed, with limited staff continuity, and, therefore, a weak capacity to plan long-term public policies. This role was, in some cases, questioned in the media, as these policies related to health did not come from the MoEF .The Health Commission of Congress was another institution where health taxes and public health policies faced significant opposition. According to some of our interviewees, attempts to introduce new public policies were stopped due to industry lobbying. Obstructionist strategies and actions such as delaying or not scheduling legislation related to regulating harmful commodities were reported practices. A remarkable event occurred in 2016More recently, in 2021, there were attempts in Congress from different political parties to pass lawsThe independence of the MoEF from the Congress to adjust taxes is unique to Peru, compared with other countries in the region.The use of trade association to represent companies in the alcohol, SSBs and tobacco industries was also noted in other studies.Similarly, the industries also employed other groups to legitimise their arguments and try to influence agenda-setting.Economic considerations were identified as central arguments, both in favour and against health taxes. When actors supporting health taxes, especially those from the government, gave economic arguments, they were primarily accompanied by health-related statements. This framing may be considered a validation strategy legitimising health taxes and increasing public support for them, as has been pointed out in specific cases, such as taxes on SSBs in other countries.Applying a systematic media search process allowed us to analyse a longer time frame before focusing on more precise moments. Also, deductive scope during systematic media analysis allowed us to explore a broader range of given arguments. Therefore, we believe in having captured all relevant statements from stakeholders.Some limitations should be noted. First, we only included three products in our analysis, and other arguments may have been used in Peru products such as fuels. We had difficulties accessing more interviewees from sectors of government involved with health taxation. We also had more information from industry-related sources in the case of SSBs, which may have biased our overall findings for this sector.As in several contexts where the implementation of taxes encounters strong obstacles, mainly from industry and its allies, stakeholders also demonstrated a strong capacity to convey their messages to the media and high levels of decision-making. Although attempts to interfere with health taxes policies were unsuccessful in 2016 and 2018 and failed to overcome state institutions that implemented health taxes and received support from other civil society actors.Institutional factors and political context contributed to the successful implementation of health taxes in both years. We found that the committed participation and stability of government actors, particularly that of the MoEF, despite a chaotic last few years and continuous changes in the Republic’s Presidency, were fundamental for the adoption of health taxation. However, this reality does not exempt itself from an inherent fragility in volatile political contexts such as Peru. The sustainability and progress of such public health measures require empowered state institutions with sufficient strength and independence to stand up to the industry’s influence. For that purpose, it is necessary to encourage the production of local evidence from different framings, not only health related, to accompany policy-makers’ decisions to confront the narratives and arguments against health taxes.