Hematopoietic stem cell transplant is a complicated intervention only offered in specialized centers. Access to transplants may vary based on the location of primary residence, income levels, age, and reported race or ethnicity. Using data from the Canadian Institute of Health (CIH) Discharge abstract database (DAD), all non-Quebec Canadians under the age of 65 with a diagnosis of AML between 2004 and 2015 were included in this study. Descriptive statistics were produced for the variables of interest: time period, age, sex, rurality, transplant status, proportion of visible minorities, proportion identifying as indigenous, and proportion of low-income families. Transplant rates were compared and reported using univariable and multivariable analysis. In multivariable analysis, time period, province of residence, gender, and age were significantly associated with the receipt of an allogeneic hematopoietic stem cell transplant. However, differences in transplant rates observed in indigenous patients, low-income families, and visible minorities were not found to be statistically significant. In non-Quebec Canada, transplant rates vary significantly with province of residence, with the highest rates recorded in Alberta. Contrary to findings previously reported in studies exploring access to transplant in the United States, a low-income level was not associated with lower rates of transplants. This might suggest that Canada’s universal health care insurance program is protective against socioeconomic barriers that impact access to health care services. Allogeneic hematopoietic stem cell transplant  is a potentially curative treatment for patients with blood cancers and disorders of the blood/immune system, but due to the complexity of the procedure, it is only offered in a limited number of medical centers. Many barriers that prevent patients from receiving an alloSCT might exist, including physical and social geographic barriers, such as a rural location of residence, geographical distance from a transplant specialized center, the level of income, and race/ethnicity amongst others. While the literature and data on access to stem cell transplants in Canada is limited, studies on access to solid organ transplants have been conducted in Canada. One study conducted by Mucsi et al.  showed tA literature review on access to hematopoietic cell transplantation in the United States conducted by Majhail et al.  identifiA more recent study on access to alloSCT using data from the Surveillance, Epidemiology and End Results (SEER) Program and the Center for International Blood and Marrow Transplant Research (CIBMTR) showed that higher levels of poverty were associated with lower rates of transplants . Pidala Previous studies done in Canada examining access to stem cell transplantation found that rural patients were somewhat less likely to receive an autologous hematopoietic cell transplant when compared to patients in urban areas; however, the difference identified was not statistically significant due to the small population size studied . Recent The Canadian Institute of Health Information (CIHI) Discharge Abstract Database (DAD) is a national record of all hospital admissions in all Canadian provinces other than Quebec. All acute care facilities or their respective regional health authorities in all provinces and territories except Quebec are required to report data, which capture administrative, clinical, and demographic information of hospital discharges, to the DAD. The rate of transplant was defined as the number of alloSCTs performed by geographic area divided by the population. In other words, the transplant rate is the percentage of patients diagnosed with AML who went on to subsequently receive an alloSCT during the study period.All Canadians under the age of 65 admitted to hospital in provinces other than Quebec with a diagnosis of AML between 2004 and 2015 were included in this study. Of the patients identified, we determined which of them were subsequently admitted for an alloSCT. The reason for including only patients under 65 is that many older patients who are diagnosed with AML are treated with chemotherapy regimens that do not always require hospitalization.The area of residence of the included patients at the time of admission with AML was identified using their forward sorting area (FSA) component of the postal code. The second character of the FSA was used to determine rurality; with “0” defined as rural, and other characters defined as urban. In addition, the socio-demographic attributes of their area of residence using data from the 2006 Canadian Census were considered. These attributes included whether they resided in a rural or urban setting and what percentage of the population belonged to a visible minority group or indigenous group. The proportion of individuals belonging to a low-income group after tax was also included as a variable of interest.Logistic regression was used to investigate potential associations between the variables of interest and the odds of receiving a transplant. To account for any difference in outcomes between the pediatric and adult population, sensitivity analyses were conducted separately for three different cohorts: (1) Full cohort , (2) Pediatric cohort (under 19 years old), and (3) Adult cohort (19 years old and above). Individuals from New Brunswick were excluded from the analyses due to a significant proportion of patient referrals to Quebec.Descriptive statistics were produced for the variables of interest . Time period refers to the year in which the transplant was performed and was included to account for shifts in clinical practice over time. Significant differences between these variables among individuals that did and did not receive transplant were determined using Chi-squared and Wilcoxon–Mann–Whitney tests where appropriate. A significance level of 0.05 was chosen as the cut-off for significance. SAS and STATAMP were used for statistical analysis.p-values of ≤0.2 indicating significance. All variables with p-values of ≤0.2 were further screened for autocorrelation using Cramer’s V, Pearson or Spearman correlation coefficients, and, where appropriate, point-biserial correlation and eta-squared. Pearson or Spearman coefficients greater than 0.80, Cramer′s V above 0.35, point-biserial correlations with p-values ≤ 0.05, and eta-squared > 0.26 were interpreted as indicative of potential autocorrelation.The variables of interest were screened for inclusion in a multivariable logistic regression model by testing univariable associations among all variables and the primary outcome of interest: receipt of transplant or not. Likelihood ratio testing was used to test these associations, with p-values ≤ 0.05 indicating significance. The relationship among continuous variables was modeled using restricted cubic splines. Akaike’s information criteria was used to select models with different numbers of knots. Model fit was evaluated using the Hosmer–Lemeshow goodness-of-fit test. Outlying covariate patterns and those with large leverage and influence (delta-beta) were evaluated visually with scatterplots. The multivariable model was constructed from the remaining variables using likelihood ratio testing with There were 6119 non-Quebec Canadians admitted to the hospital with a diagnosis of AML between 2004 and 2015. Overall, 1754 (28.7%) of those admitted with AML proceeded to receive an alloSCT. In multivariable analysis, time period, province of residence, gender, and age remained significantly associated with receipt of alloSCT. As the time period increased, the predicted probability of transplants increased up to 2013, after which the probability leveled off. Although living in a rural vs. an urban location of residence was not significantly associated with transplant rate, the province of residence had a significant association with the odds of receiving a transplant. In comparison to the province of Alberta, residents from other Canadian provinces had lower odds of receiving a transplant. The differences were statistically significant in all instances except for the three territories and in Prince Edward Island. In univariable analysis, the effect of sex appeared to be highly significant; however, after taking into account the effects of time period, age, and province, this significance slightly reduced. When compared to men, the odds of receiving a transplant in women were observed to be 1.12 times higher. As the age of the patient increased, there was a slight increase in the probability of receiving a transplant. This effect was observed up to the age of 30, after which the probability of receiving a transplant decreased. In the adult cohort, as age increased, the probability of receiving a transplant decreased slightly between the ages of 19 and 50 years old. After the age of 50, a dramatic decrease in the probability of receiving a transplant was observed. Within the same cohort of adult patients, as the year of admission for transplant increased, the probability of receiving a transplant also increased. This effect was most prominent between 2003 and 2010. In the pediatric cohort, as the age at admission increased, the probability of receiving a transplant also increased; however, this increase peaked at age 10, followed by a slow decrease in probability of receiving a transplant. Within the same cohort, an increase in the probability of receiving a transplant was observed to increase as the time period during which individuals were admitted for transplant increased. This relationship is seen from 2004 to 2010–2011, after which the probability reaches a plateau and then decreases. The rate of transplants was not found to be significantly different in indigenous patients compared to non-indigenous patients in the full and adult cohorts. Similarly, there was no significant difference in transplant rates among low-income families. Overall, adult sensitivity analysis results were identical to the main cohort; however, in the pediatric subgroup, age and time period were the only variables with significant difference between transplant and non-transplant recipients.Allogeneic hematopoietic stem cell transplant is considered the preferred type of post-remission therapy in patients with AML; for many, it is the only curative therapy ,13. ThisIn this study, we found that there were significant differences in the rates of alloSCT by province of residence, with residents of Alberta having the highest transplant rates. Higher transplant rates were also seen in British Columbia and Manitoba; with lower transplant rates seen in Saskatchewan, Ontario, Nova Scotia, and New Brunswick. The reasons for the regional variation observed amongst the provinces are unclear, but may include differences in practice patterns, availability of resources within each center, and provincial budgets set aside for health care. In one Canadian study examining geographical disparities in access to liver transplants, the evidence suggested that interprovincial disparities did exist and appeared to be related to factors that precede the transplant assessment process and not simply the distance of residence from the transplant center . RuralitThe association between time period and probability of transplant observed in all three cohorts shows an increasing number of transplant procedures being performed as the years progress. This increase is possibly due to an increasing number of resources and infrastructure to support the demand and need for alloSCT. Other possibilities previously highlighted in an article by Majhail et al.  include As highlighted in In the pediatric cohort, the probability of receiving a transplant increases as the age of admission increases, with a peak at age 10 followed by a slight decline. A similar finding was observed in the study done on access to allogeneic transplants in pediatric patients with ALL by Truong et al. .This increased risk of mortality observed within this age group has been reported in the literature, and studies in recent years have shown that adolescents and young adults diagnosed with malignancies often experience inferior health outcomes compared with younger and older cohorts for many reasons. In a review carried out by Trama et al. , a delayCompared to the general population, the difference in transplant rate observed among visible minorities was not statistically significant. This finding is different from trends seen in some studies conducted in the United States, where non-Caucasians were observed to have lower rates of stem cell transplants compared to Caucasians ,6. SimilThere are several strengths and weaknesses to our study. This is the first study in Canada to examine some of the variables that impact access to allogeneic stem cell transplants in adult patients with AML at the national level. While some of our findings are consistent with those seen in previous studies examining access to stem cell transplants, other findings show trends different to those previously reported in the literature, some of which can be accounted for by differences in the funding of the healthcare system. Although our study was limited to individuals under the age of 65 diagnosed with AML, an increasing number of individuals over the age of 65 diagnosed with AML are recipients of alloSCTs due to the availability of reduced-intensity conditioning regimens that are better tolerated in the older adult population. As a result, further research is needed to include patients in this age group to understand factors that impact their access to receiving transplants. Furthermore, additional research is needed to understand the reasons behind the regional variation in rates of transplants observed among the provinces in Canada.There are currently no Canadian guidelines outlining which patients with AML should receive an alloSCT, but there are several international guidelines publications that are widely used in Canada. We believe there is generally good consensus as to which patients with AML benefit from transplant, and that the finding that there is differential access to transplant is due to reasons other than interpretations of the medical literature.The availability of a donor is a prerequisite for alloSCT. It is possible that donor availability might be different in different demographic groups. However, in an era of large unrelated donor registries and increased use of alternate donors , most patients will have an available donor. Thus, the impact of differential donor availability will be small. In summary, we found that in patients diagnosed with AML, rates of transplants varied depending on province of residence, with Alberta having the highest rates in the country. We also found an association between the time period and probability of transplants in all three cohorts observed. Transplant rates also appeared to vary depending on the age group of the individuals. However, differences in transplant rates among visible minorities, indigenous populations, and low-income groups were not found to be statistically significant.


Background: In some countries, such as the Netherlands and Norway, point-of-care testing (POCT) is more widely implemented in general practice compared to countries such as England and Australia. To comprehend what is necessary to realize the benefits of POCT, regarding its integration in primary care, it would be beneficial to have an overview of the structure of healthcare operations and the transactions between stakeholders . The aim of this paper is to identify the current value networks in place applying to POCT implementation at general practices in England, Australia, Norway and the Netherlands and to compare these networks in terms of seven previously published factors that support the successful implementation, sustainability and scale-up of innovations.Methods: The value networks were described based on formal guidelines and standards published by the respective governments, organizational bodies and affiliates. The value network of each country was validated by at least two relevant stakeholders from the respective country. Results: The analysis revealed that the biggest challenge for countries with low POCT uptake was the lack of effective communication between the several organizations involved with POCT as well as the high workload for general practitioners (GPs) aiming to implement POCT. It is observed that countries with a single national authority responsible for POCT have a better uptake as they can govern the task of POCT roll-out and management and reduce the workload for GPs by assisting with set-up, quality control, training and support.Conclusion: Setting up a single national authority may be an effective step towards realizing the full benefits of POCT. Although it is possible for day-to-day operations to fall under the responsibility of the GP, this is only feasible if support and guidance are readily available to ensure that the workload associated with POCT is limited and as low as possible. Implications for policy makersCountries should have a dedicated leadership structure in place that governs the task of roll-out and management of healthcare technologies and continuously supports all involved and affected stakeholders. Currently, the implementation of point-of-care testing (POCT) is accompanied with higher workloads for clinicians, discouraging them from using innovative technologies. Countries should have a dedicated leadership structure or organization responsible for the quality improvement for laboratory services outside the laboratory and hospital. The ministry of health should work together with the appropriate (existing) professional organizations to establish such an organization. There should be improved support structures in place to ensure the responsibilities expected of primary care clinicians are reasonable and they should be provided with set-up assistance, quality control, training and support.  Implications for the public Innovative healthcare technologies can improve patient outcomes when successfully implemented. In some countries, healthcare technologies such as point-of-care testing (POCT) is widely implemented, while in others the uptake is quite slow and lagging. The findings from this research suggest that the biggest barrier to effective wide-scale implementation is a lack of communication between different stakeholders in the healthcare system and a high workload for clinicians aiming to implement POCT. Improved communication and a leadership structure dedicated to the roll-out and management of healthcare innovations such as POCT, could encourage its use by clinicians, and therefore positively contribute to the patient’s experience in the healthcare system.1 Accurate diagnostics can lead to clinical benefits for patients, but also economic benefits for the healthcare system.2 For many diseases, both clinicians and patients continue to expect rapid and simple diagnostic tests that can provide results within minutes.3 This has led to the development of innovative diagnostics, specifically, easy-to-use analyzers that can be performed at the point of care, more commonly known as point-of-care testing (POCT).1 Diagnostics is an integral part of primary healthcare, as it provides valuable insight to support medical decisions to improve patient outcomes and wellbeing.4 The tests often require only a small blood, urine, feces or sputum sample from a patient and can provide test results within a few minutes. This enables a real-time discussion of test results between the general practitioner (GP) and patient during the initial consultations and eliminates the need for a follow-up appointment or telephone discussion.5 Subsequently, the consultation process is more convenient for patients and has previously been associated with an increase in patient satisfaction.6 POCT has been proven to be cost-effective in areas with limited infrastructure and medical laboratories where it is typically used for easier and faster diagnosis of diseases and infections with high prevalence,7 including HIV,8 syphilis,9 and tuberculosis.10 The usefulness of POCT is not only limited to resource-poor settings. It has been shown to be cost-effectiveness in several first world countries for a range of health problems and functions, such as screening for cardiovascular disease,11 monitoring patients’ anticoagulant therapy,12 and diagnosing respiratory infections13 and influenza.14 While several studies have shown that POC tests can be cost-effective, ensure high-quality care and even show that outcomes may be better than if patients are monitored by laboratory tests,15 access to these tests in some countries is limited. A point-of-care (POC) test in primary care can be defined as an analytical test that is typically performed during or very close to the time of consultation by a healthcare professional near the point of care instead of a laboratory setting.16 Despite these improvements, the implementation of POCT is still predominantly reliant on the active organization and management of clinicians using the tests, including training and quality control.17 The implementation of POC tests in primary care varies significantly between countries. A survey published in 2014 looked at the usage of POC tests by primary care clinicians in five countries.1 They found that in Australia, for example, the only POC tests that are relatively widely implemented are urine pregnancy tests (68% of respondents), international normalized ratio (INR) tests (48% of respondents), and blood glucose tests (74% of respondents). In comparison, POC tests seem to be much more prevalent in the Netherlands with respondents reporting the use of urine pregnancy tests (94%), urine leucocytes or nitrite tests (96%), blood glucose tests (96%), haemoglobin tests (58%), C-reactive protein tests (48%) and quantitative β-human chorionic gonadotropin tests (22%). The United Kingdom also has high usage of certain tests such as urine pregnancy tests (80%), urine leucocytes or nitrite tests (90%), blood glucose tests (69%) and INR tests (43%). In Norway, 99% of all GPs use POC tests in their practice, with urine strips, blood glucose tests, C-reactive protein tests, haemoglobin tests, INR tests, hemoglobin A1C, urine pregnancy tests, urine albumin-creatinine ratio, streptococc, mononucleose tests and fecal occult blood tests being implemented by more than half of GPs.18 Over the past few years, enhanced manufacturing processes and new developments in microchip technology have led to the production of more robust and more accurate POC devices, compared to earlier generations.20 It has been shown that the use of COVID-19 POCT has positively affected healthcare providers through improved morale, and reduced worry associated with COVID-19 without disruption of workflow.21 The acceptance of COVID-19 POC tests by both healthcare providers and patients will, optimistically, improve the way that POCT is perceived, and contribute to growing adoption rates. The successful implementation of POC tests proven to be cost-effective demands transformation and integration of services across healthcare organizations. There is a need for a better understanding of how POCT fits into the care pathway and how stakeholders influence the implementation.22 Furthermore, implementing large-scale changes in a healthcare system successfully is a complicated task. The introduction of POC tests in general practice is not a single event but requires a series of interlinked processes involving several stakeholders with different responsibilities. To comprehend what is necessary to realize the benefits offered by POCT, it is key to understand if differences between health systems can explain different uptake levels. Therefore, it is necessary to have an overview of the actors in the POCT value network, that are involved in the core aspects and the structure of healthcare operations and the transactions between them. A value network can be defined as a network of interconnected and interdependent relationships and activities between actors that determines the way an organization creates and delivers value.23 It is merely the conceptualization of the complex relationships between different actors in the healthcare system. The slow adoption and uptake of certain POC tests have been attributed to several issues, mainly relating to costs and the high workload associated with the implementation. Furthermore, the negative perception of physicians  may also contribute to the slow adoption. The recent coronavirus disease 2019 (COVID-19) pandemic has emphasised the significance of rapid, reliable diagnostics and proves that POCT can potentially help reduce the burden on healthcare systems, especially those that are already overwhelmed. In this paper, we will use the concepts of value networks to analyse if they can be used to identify factors explaining why some countries have and others have not routinely adopted cost-effective POC tests. This paper maps the value networks in four countries  that can explain differences in uptake of POCT by GPs and compares these networks in terms of seven, previously published factors that support the successful implementation, sustainability and scale-up of innovations.23 For each country, a literature review is conducted to identify each of the respective country’s value network. An initial search of government websites was done for official reports and papers to gain an understanding of each country’s health system as a whole and to identify the stakeholders that play a role in the implementation of POCT. Standards, clinical guidelines, and implementation guides of diagnostics and POC tests within primary care were reviewed to identify the process(es) and requirements of POCT implementation at general practice. Only official documents from governments and organizations affiliated with the government were reviewed. Any journal publications referred to in these documents were included as well if relevant. The methodology applied to identify the value networks is based on a previously published theoretical framework for analyzing a healthcare system as a value network.24 Information flow refers simply to the movement of information between the different actors, and financial flow encompasses the flow of funds, both receivables  and payables . The value flow refers to the added value between two actors that would drive their Willlingnes to Pay; for example, a POCT can create added value for the GP by providing earlier information of the diagnosis. These flows do not reflect any downstream effects or impacts, such as societal costs or patient benefits. Since the focus of this paper is on primary care, specifically GPs, the presented value networks are from the perspective of the general practice. However, each primary care practice can consist of any number of GPs, and the constructed value network is applicable to either single or multiple GP practices. From the full set of information that was gathered during the literature review, the actors that are involved in the value network and the relationships between these actors (the way that actors are connected and communicates) were identified. A visual representation of the value network was developed to comprehend how the different actors connect. The relationships between actors were classified as information, value, and financial transactions or flows. If a country has public and private healthcare, the focus of the value network will be on the public system and the mechanism behind the implementation of POCT in the public system. Upon drafting the value networks, each value network was tested for consistency and exchangeability with the core investigators. The value network of each country was validated by the relevant investigators, namely JE and PF for Australia, CPP and HVM for England, SS and TBE for Norway and JTMD and JWLC for the Netherlands. Any uncertainties in the value networks that arose from a misapprehension of the official documents, guidelines, or standards were resolved during the validation process.25 A brief description of the seven factors is provided in 25 Based on these seven factors, key differences between the countries were identified and discussed. Upon validation, each of the value networks was summarized in terms of seven key factors that support the successful adoption, implementation, sustainability, spread, and scale-up of service innovations, as identified by Nolte. In all four countries, primary care is typically the first point of contact with the healthcare system and a patient has to be referred by a GP to receive specialist care. Therefore, GPs (as gatekeepers) play an essential part in containing costs. In all countries, if indicated, a consultation with the GP is followed by a sample being collected from the patient for the POC test, either by the GP or the practice assistant/nurse. The test result should be available within a few minutes and the results are discussed with the patient by either the practice assistant/nurse or the GP. GPs may also refer patients to secondary care based on the test results.26 In Australia, GPs are typically considered self-employed and part of a practice with an average of four GPs per practice.27 For specialist services, a patient can only receive an Medicare Benefits Scheme (MBS) benefit if referred by a GP. A description of the overall health system of Australia is provided in 28 The RACGP has stated that they believe POCT should be accessible by GPs and covered by MBS.29 The Australian College of Rural and Remote Medicine is the professional organisation for many rural GPs. The value network of Australia could potentially be slightly different from a rural perspective. Australia’s leading professional general practice organization is the Royal Australian College of General Practitioners (RACGP) and provides support to GPs through education, training and developing resources, guidelines and standards that GPs can use to deliver high-quality healthcare.29 This means that GPs have to follow accreditation measures that were developed for pathology laboratories, which requires each GP to apply to become an approved pathology practitioner and an approved pathology authority. It also requires GPs to register their practice as an accredited pathology laboratory according to Australian Standards administered by the National Association of Testing Authorities, which can be time-consuming and costly as it includes site visits and strenuous administration work. The majority of POCT currently implemented at GPs are conducted without accreditation through National Association of Testing Authorities certified system. This means that there is no governance of the quality for these tests, nor can it be charged to MBS.30 As of 2019, less than 20 GPs in Australia using POC tests in their practice have been accredited.30 There are no mandatory standards or guidelines for GPs to follow when using POCT, and practices are responsible for developing their own quality framework; however, the use of POC tests under these conditions is not covered by MBS. For a GP to be eligible for MBS rebates, the practice must be accredited against the standards for POCT. The standards for POCT  fall under the National Pathology Accreditation Advisory Council (NPAAC), which requires GPs to uphold the same standards as pathology laboratories.31 and the second by the RACGP.32 Both documents set out the requirements when implementing POCT at the GP, such as clinical governance, quality frameworks, training and safety, and waste disposal. Before implementation, practices are required to establish the clinical and diagnostic purpose of the POC tests they wish to implement, based on several reliable sources and provide evidence that the analytical performance of each test method has been evaluated. It is also required to prove that the POC tests will help in meeting the needs of patients in terms of local health infrastructure and other circumstances. The Australasian Association of Clinical Biochemists (AACB) recommends that any healthcare center wishing to implement POCT should set up a planning group consisting of all the staff that will be involved with the use of the POC tests, to share the planning responsibilities (before implementation) required by the standards and guidelines.30 This planning group will ideally also decide on which POC tests to purchase and be responsible for the procurement of the devices from the manufacturer. If no planning group is set up, the POCT supervisor (a designated member of the practice who is ultimately responsible for POCT) will be responsible. The guidelines and standards require that each practice has a POCT supervisor  that oversees the use and management of POCT in the practice, and that this person has a sufficient understanding of both POCT and the POCT standards.32 Currently, there are two sets of standards and guidelines for implementing POCT and ensuring appropriate use at the general practice; one is drafted by NPAAC31 The POCT supervisor must have completed appropriate POCT training and can delegate some of the responsibilities to another member of the practice, as long as that member has also received POCT training. The supervisor or delegate is also responsible for the quality assurance of POCT within the practice, and must regularly perform and review quality checks, investigate results and performance, and review trends in the quality check results. Although the practice should be accredited as a pathology laboratory, the clinicians in the practice using the POC tests  are considered non-laboratory trained personnel. Therefore, the POCT supervisors need to ensure that in addition to training, continuous support is provided to the users. Australia has introduced a regulation that requires POCT manufacturers to supply users with easy to understand instructions as well as specifications that ensures the devices are used correctly. It has been recommended by the AACB that POCT supervisors create active partnerships with manufacturers and other key stakeholders, including the AACB, to ensure continuous support, including additional training and assistance with maintenance and troubleshooting. A description of the overall health system of England is provided in  Since the GPs are contracted by the NHS, but are not employed by them, they need to follow specific guidelines and quality frameworks. The Medicine and Healthcare Products Regulatory Agency (MHRA) has guided the implementation and management of POCT devices along with a quality framework that should be followed to ensure that all requirements are met. One of the points raised by the MHRA is that a GP interested in adopting POCT within his practice should partake in close collaboration with a local hospital pathology laboratory. The pathology laboratory can give guidance on a diverse range of topics on the implementation and management of POCT. These may include the purchase of devices, quality control, and assessment, training, and safety provisions. For all issues regarding POCT, a close collaboration between the pathology laboratory and the GP using the test is of importance. In most cases, this should be formally defined through, for example, a service level agreement, specifying products, services, practical applications, and responsibilities from the relevant stakeholders. General practices are also strongly encouraged to assemble a POCT committee that represents all immediate stakeholders that will be influenced by the implementation, eg, clinicians, nurses, pharmacists, information technology (IT), finance. These committees should also have a POCT manager that keeps track of their responsibilities towards clinical governance as well as the medico-legal implications of inaccurate results. On top of all their other tasks, this is not a simple consideration. In many practices, the role of the POCT committee is embedded in the local hospital POCT committee with links to the general practice.33 The guidance set up by NICE considers both clinical and cost-effectiveness. Technology appraisals performed by NICE is supported by mandate, and NHS England is legally required to provide funding for all medicines and treatments recommended by the institute. The POCT committee should ensure that all guidelines set by the MHRA, NICE, and (if applicable) NHS trusts are adhered to and should also keep track of adherence. Manufacturers can submit the details of their POC test to NICE for consideration and should include sufficient data and analyses proving the accuracy and effectiveness of the device.34 The National Institute for Health and Care Excellence (NICE) is one of the many organizations working with the NHS. They provide the NHS with guidance on how to promote high-quality healthcare and how to prevent and treat illness. Furthermore, they also support healthcare providers and commissioners in improving health outcomes for people using the NHS, public health, and social care services.36 Approximately 95% of Norwegian physicians are registered members of the NMA, a professional association and a trade union for physicians. The NMA plays an active part in the development of the healthcare system.37 A description of the overall health system of Norway is provided in 35 Most GPs both in urban and rural settings make use of POCT. In 1992, the NMA, the Municipal Association of Local Authorities and the Ministry of Health and Care Services established The Norwegian Quality Improvement of Primary Care Laboratories (Noklus)38 to ensure that all POC tests are ordered, performed and interpreted correctly. In 2017, Noklus merged with the Norwegian Clinical Chemistry External Quality Assessment program to form the Norwegian Organization for Quality Improvement of Laboratory Examinations, which focuses on both primary and secondary care. Noklus is a non-profit organization (foundation) that aims to manage and improve the quality of the entire POCT process and covers the entire country. Noklus is also chairing the Scandinavian evaluation of laboratory equipment for POCT (SKUP), that was established in 1997 to improve the quality of POCT throughout Scandanavia. Suppliers and manufacturers of POC tests can pay to have SKUP evaluate their tests. Tests that fail to meet analytical or quality requirements are not recommended to be bought by GPs in Scandanavia.39 GPs are fairly widespread across the country, but specialist care is typically confined to urban areas.18 Noklus is managed by a team consisting of mainly biomedical laboratory scientists but also includes medical doctors, specialists in laboratory medicine, IT programmers, researchers and statisticians. Most of the biomedical scientists are trained as “laboratory advisors” and situated at 22 hospitals across Norway. These advisors supervise and guide the primary care laboratories in their region with regards to quality assurance and all laboratory matters. The advisors are involved with every step of the POCT process, including acquisition, implementation and management.18 Their responsibilities include giving individual advice on which POC tests are necessary, advising on maintenance programs, contributing to the protocols set up in terms of test usage, ensuring that quality control programs are followed and evaluated, providing support when problems might arise, and to arrange necessary training for GPs and assistants on the usage and quality control of POC tests. Each advisor has an overview of all POCT users in their region and a total register is maintained by the main office. The professional guidance of the laboratory advisors are done by the main office of Noklus who also runs the external quality assurance (EQA) system for all laboratory users in primary healthcare. Noklus constantly monitor and evaluate the users in terms of quality assurance, usage of tests and any problems that might arise. Noklus also advises the government and the NMA on which tests should be reimbursed, and the majority of tests recommended by Noklus for GPs are reimbursed by the government. Of Noklus’ 3300 participants, 1600 are GP offices. The remainining participants are nursing homes, home care units, oil platforms, prisons etc. Participation in Noklus is not compulsory, yet approximately 99% of all GPs participate willingly.40 Many GPs also employ nurses and practice assistants. A description of the overall health system of the Netherlands is provided in 41 A guideline directive for the usage of POCT in primary care in the Netherlands42 was developed by the Dutch Association for Clinical Chemistry and Laboratory Medicine together with the Dutch college of general practitioners and other organizations. The guidelines are based on international standards and guidelines and provide GPs with recommendations on how to ensure that POCT is used safely and responsibly in practice. The Dutch college of general practitioners is a scientific association for GPs in the Netherlands. They provide evidence-based guidelines for primary care and also provides education for GPs based on the guidelines.42 Since the guidelines recommend close collaboration between the practice and a laboratory, it is also recommended that all of the POCT usage data (including test results) are recorded in a health information system. This is to enable laboratories to easily assess and compare the quality and utilization of POCT at different GPs.42 The guidelines recommend that the practice should consult with a laboratory specialist to ensure that the POC test(s) under consideration is necessary to meet patient demands. Additionally, it is recommended that the practice works with a laboratory specialist throughout the entire implementation process. This includes maintenance of the devices, help with troubleshooting, setting up a quality assurance framework, and annual, or bi-annual verification from the laboratory of POCT performance in terms of diagnostic accuracy, utilization of the tests and whether treatment decisions based on test results are sensible.42 In order for a POC test kit (and certain devices) to be eligible for reimbursement, evidence must show that the POC test is effective. This is a statutory requirement in the Health Insurance Act; specifically, that the test has clinical utility. The National Health Care institute has to issue a positive report on the clinical utility of a test and the Minister of Public Health, Welfare and Sport has to convert that report into a positive decision to reimburse the test and test kits.43 For many POC tests the prerequisite of clinical utility has not yet been established in the Netherlands. The agreements between laboratories and GPs can vary between regions. For example, GPs can purchase POC tests from the manufacturer directly with guidance from laboratories. In most cases, laboratories purchase the POC tests and distribute them to GPs in their region. Reimbursements for the acquisition costs of a POC test or the setup costs of an information system are not available. However, GPs can be reimbursed for the cost price of test kits and for certain (very limited) test devices. The comparison of the four countries and how they support the successful implementation, sustainability and scale-up of POCT are provided in Table.44 This makes implementing a POC test in practice seem more complex than that of the Netherlands and Norway, and this complexity may limit the implementation of POC tests. Additional descriptions on the comparison of countries can be found in  A spider diagram comparing the extent to which each country’s value network addresses aspects related to each of the seven factors is shown in 45 Even though POCT has been proven to be a valuable tool in primary care, it does not necessarily incentivize GPs directly. Consequently, GPs might not be willing to take on an additional (high) workload or spend money to implement POCT in their practice. Therefore, support and guidance are necessary to encourage GPs to implement POCT in order to realize the benefits for patients and the health system. A dedicated leadership structure (such as Noklus) should be in place that actively supports the implementation and uptake of POCT. It seems likely that the organization and management of POCT would be more efficient if a separate team or organization, set up by the government, is responsible for all matters related to POCT. Each of the four countries, with their differences in health systems, has different principles when it comes to establishing a dedicated leadership structure or organization to facilitate implementation. As there are differences, it is not possible to define one generalizable approach, and thus, the ministry of health should work together with the appropriate (existing) professional organizations, such as medical associations and professional societies for GPs, laboratory professionals and healthcare providers, to set up a system of quality improvement for laboratory services outside the laboratory and hospital. Clear, well-defined guidelines and standards should be in place that are specific to POCT. In the countries where POCT falls under the umbrella of other guidelines (such as in-vitro diagnostics or pathology guidelines), GPs can be discouraged from following the required route to implementation as it is too complex and cumbersome. The benefits of POCT can be substantial. However, although POC tests share characteristics they can differ in terms of, for example, the turnaround times, user-friendliness and associated workload. Similarly, the prevalence and incidence of different diseases in different countries will affect how beneficial a test will be in a specific country. Therefore, the exact benefits will depend on the specific POC test and the context it is applied in. Generally, it can reduce unnecessary hospitalizations and referrals to secondary care, while patients benefit from shorter waiting times for results. It has also been shown to increase patient satisfaction. Such a POCT team should be involved throughout the implementation process, providing guidance to GPs on executing all aspects set out by the guidelines and standards. Furthermore, all stakeholders that would be affected by the implementation of POCT, including patients, manufacturers, and GPs, should be involved in setting up the standards and guidelines to improve commitment. One of the most significant barriers to POCT implementation for GPs is the high workload associated with setting up POCT in a practice. It is vital that GPs be part of setting up guidelines and standards to ensure enough support is provided and that the responsibilities expected of the GPs are reasonable. Dedicated and ongoing resources is a factor that is especially important for the implementation of POCT. Financial resources can improve the uptake of POCT if it allows GPs to adopt POCT within their practice without additional cost. In the case of Norway, the NMA in cooperation with Noklus negotiates reimbursements from the government for financial support, while in the Netherlands, GPs can make arrangements with laboratories. GPs could, potentially, also be offered a financial incentive to use POCT by returning the downstream cost savings realised in the healthcare system. Ongoing support for GPs is also a vital resource to reduce the workload and encourage implementation. Support during the initial implementation process is required to help GPs select a POCT repertoire that suits local needs. Ongoing monitoring and feedback are required to identify any opportunities for improvement within a practice. The guidelines and governing team should clearly provide GPs with instructions and support to set up a data collection system to collect and assess the performance of tests systematically. This will also simplify the process of quality assurance and evaluating the effectiveness of the POC tests in place at GPs.46 The value networks in these countries will, therefore, be very different than those in this paper, and will be hard to compare. Nonetheless, there are lessons that can be learned from the value networks presented in this paper and potentially from the value networks in LMICs. Future research should aim to identify the value networks in place in LMICs and investigate how comparable it is to those of high-income countries or what specific innovation and/or business models would apply. Although the value network of one country cannot simply be transferred to another country, the results remain important in understanding the critical factors behind the successful implementation of POCT. These value networks help to comprehend what the value is of using a POC test, where this value is delivered, and which stakeholders are driving the value generation. These aspects, together with the strengths and weaknesses observed in the value networks, will be helpful when it comes to strategic thinking and can be used as a starting block to set up rigorous implementation plans and roll-out plans. One limitation of this paper is that the results are not applicable to low- and middle-income countries (LMICs). This is mainly due to the fact that the implementation of POC tests in these countries are mostly governed by both the healthcare system and by the World Health Organization (WHO) and donors.47 However, efforts in developing POC tests and identifying cost-effective POC tests are wasted when their benefits are not realized. From the value networks identified in this paper, it is evident that differences exist in the organization of care between countries, which quite likely cause part of the observed differences in POCT adoption. The comparison of the value networks of different countries is useful in determining how countries can move forward in realizing the benefits of POCT, especially where adoption is low. It is observed that if a single national authority is responsible for POCT, the uptake of POCT may improve since they can govern the task of roll-out and management, and reduce the workload for GP’s by assisting with set-up, quality control, training and support. However, this might be predicated on the governance of a country. For example, allocating a single national POCT authority, while feasible, could work differently in a federation  regarding establishing and delivering a value network for POCT. Although it is possible for day-to-day operations to fall under the responsibility of the GP, this is only feasible if support and guidance are readily available to ensure that the workload associated with POCT is limited and as low as possible. Bringing about the necessary changes and integration can be complex and time-consuming, but it is nonetheless feasible, given the example of Norway. Future quantitative analysis could indicate the magnitude of opportunity loss caused by a lack of POCT adoption as incentive for initiating these necessary changes. It is expected that the global POC diagnostics market will reach $40.50 billion by 2022. An ethical approval was not necessary, since no human data was used. Only guidelines and reports that are openly published by the relevant governments and organizations were used. Authors declare that they have no competing interests. DL, HK, RK, and MJI provided input into the conception and study design. DL drafted the manuscript with input from HK, RK, and MJI. HK, RK, MJI, JDE, PF, CPP, HVM, TBE, SS, JWLC, and JTMD provided revisions to the manuscript.Supplementary file 1. Description of Factors.Click here for additional data file.Supplementary file 2. Additional Description and Comparison of Each Country’s Health System.Click here for additional data file.


Social media has become an indispensable aspect of young people’s digital interactions, as they use it mostly for entertainment and communication purposes. Consequently, it has the potential to have both positive and negative effects on them. Deterioration in mental health is one of the side effects stemming from social media overuse. This study investigates the relationship between social media and the increase in mental health problems in Saudi Arabia. The population considered for analysis includes young people from Saudi Arabia, with a sample size of 385. A closed-ended survey questionnaire was used to collect data on different social media features and criteria. Using the Analytical Hierarchical Process (AHP), the researcher analyzed data to compare the effect of different social media features on mental health. The social media features included in this paper are private chats and calls, group chats and calls, browsing posts, games, media sharing, adverts, likes/comments/followers, and pages. The researcher adopted entertainment, information, social interaction, privacy, esteem, and communication as the criteria in the AHP process. Among these criteria, the study found that entertainment was the most significant, while privacy was the least significant. Findings suggested that likes, comments, and followers were the biggest contributors to poor mental health . The least effective feature was ‘games’ . The researcher recommends that social media users be cautious when interacting with social media features, especially likes, comments, followers, media, and posts, because of their significant effect on mental health. Mental health is a crucial aspect of human wellbeing, yet it is often overlooked and stigmatized. According to the World Health Organization, the prevalence of mental health problems is increasing at a rate of 13% per year ,3. In adSaudi Arabia has a high level of social media usage, with 82.3% of the population (29.5 million people) using social media in 2022 . DepressThe aim of this study is to examine the impact of social media on mental health in Saudi Arabia and to identify which social media features have the greatest impact on increasing mental health issues. The study uses an Analytical Hierarchical Process (AHP) to analyze several social media features and determine their impacts on mental health. By understanding the specific features that contribute to mental health problems, individuals and policymakers can take steps to alleviate mental health issues and reduce the negative effects of social media. The results of this study will provide valuable insights into the impact of social media on mental health in Saudi Arabia and can inform the development of strategies to mitigate these effects.One of the primary features of social media is chatting. As a social network, chats are a powerful method of communication among social media users. They may take the form of group or private chats. According to , young pBrowsing posts and advertisements are equally part of social media. Social media posts often portray falsehoods by allowing one to elevate their good qualities and suppress their negative ones . Young pSharing media, playing games on digital social networks, and interacting on video conferencing channels may negatively impact an individual’s mental health. In some cases, ref.  found thAn individual’s following and the intensity with which people react to their posts can impact their mental health. For example, ref.  reports This section provides an explanation of the methodological processes that the researcher used in order to acquire data and analyze them. The research design of this study is described in The specific approach taken by the researcher is the Analytical Hierarchical Process (AHP). It is a decision-making model that uses paired comparisons to determine the most significant factors that affect a decision . In thisThis study considered Saudi Arabia as the unit of study, while the study population was Saudi youth aged between 18 and 35. The United Nations defines youth as persons between 18 and 24. However, the researcher sought a more accommodating criterion regarding respondent ages. The selection of young people as the target population was motivated by the fact that 98.43% of them are on social media . Gender-The researcher used social media platforms to reach a diverse and representative sample of young people in the country. The social media platforms used in communication with participants  included Facebook, Instagram, Twitter, and Snapchat. The researcher sent out a post including all the details about the research, and a link was included to direct the participants to the questionnaire page. The questionnaire was hosted on Google Forms to facilitate distribution, and it was left open for one month to allow respondents to respond at their convenience. The final questionnaire had a two-part structure, including demographic questions and three main questions with selective options for participants. The Analytical Hierarchical Process involves four primary steps, which areIdentifying decisions, options, and criteria;Conducting pairwise comparisons;Computing weights for the criteria;Calculating utility values.The decision is determining which social media features have the biggest effect on increasing mental health problems. The options were the eight social media features, namely private chats, group chats, browsing posts, adverts, media sharing, calls, likes and comments, and pages. The criteria for determining which features are the most influential were the importance of a feature to an individual, the time spent interacting with the feature, and the recency of interaction.Pairwise comparisons involve comparing two criteria simultaneously to build a square n × n matrix, where n is the number of criteria. The comparison is structured in such a way that the value entered in a cell represents the number of times one criterion is more important relative to the other. Because the two criteria being compared are the same, the relative value of each criterion is equal to one when they are compared to each other . The maxAfter populating the matrix, it is used to compute the importance weights. They signal to an analyst the extent to which each criterion will affect their ultimate decision. The researcher gave the biggest weight to the item with the most significant importance. The study computed the geometric mean of the criteria to ensure objectivity in the computation in the first step, as suggested by . In the Computing the utility is the final step in the analytical hierarchal process. It involves establishing the ‘utiles’ associated and multiplying them by their corresponding importance scores . The ‘utThis section analyzes the age, gender, and occupations of the study participants. The findings reveal that the most populous age group was that of members aged between 18 and 25, as they constituted 60.3% (232) of the study population. Male respondents accounted for 55.3% (213) of the sampled participants. The most dominant group by occupation was students, as they accounted for 41.8% (161) of the sampled participants. The researcher first examined which of the selected social media features were favored by the respondents. The findings suggested that likes, comments, and followers were the most relevant aspects of social media that the respondents liked, obtaining a mean score of 7.29/8.00. The least favorite feature was gaming, scoring a mean of 2.05/8.00. The researcher established the criteria comparison matrix using the responses to questions that asked participants to rank the factors influencing their sentiments on social media features. The ranking was based on the mean score obtained from the 385 responses regarding their criteria ranking. In this case, the highest ranked criteria by the respondents scored higher values in The computation of matrix values in iV: Geometric mean for criterion i;iX1: Pairwise importance of criterion i relative to criterion 1;iX2: Pairwise importance of criterion i relative to criterion 2;inX: Pairwise importance of criterion i relative to criterion n;n: Number of criteria.The first step involves the computation of the criteria’s geometric mean  to deteriW: Weights for criterion i.The second step involves finding the proportionate composition of the criteria values, which will count as their weights . The proThe researcher computed the feature utiles by first ranking their respective mean responses. The findings in iTU: Total Utility for criterion i;iW: Weights for criterion i;jUV = Utility Value for feature j;iMR: Mean Relevance for criterion i;i from 1 to 8, j from 1 to 6.This study computed the total utility as the product of the utiles (feature strengths), importance weights (criteria weights), and how favored the features were by the respondents (relevance). In The findings suggest that the feature with the most significant negative effect on mental health is ‘likes, comments, and followers.’ This feature scored a total utility of 56.24. On the other hand, the feature with the least significant negative effect on mental health is ‘social media games’. This study found the feature to have a total utility of 2.56. While the respondents had opined in In this study, the researcher found that social media has a significant negative impact on the mental health of Saudi Arabian youth. The feature that had the greatest impact was likes, comments, and followers, with a utility value of 56.24. This suggests that individuals who are seeking validation and social esteem through social media may be more prone to experiencing stress, depression, and anxiety. Browsing posts and media sharing were also identified as significant features that negatively impact mental health, with utility values of 45.03 and 25.40, respectively. These findings align with previous research that has identified the presence of influencers on social media as a potential source of stress and depression for regular users who may feel pressure to emulate these individuals . AdditioOn the other hand, this study found that social media games had the least impact on mental health, with a utility value of only 2.05. This finding differs from previous research that has identified games on social media as highly addictive and potentially harmful to mental health . HoweverOne potential implication of these findings is the need for greater education and awareness about the potential dangers of social media. This could involve educating people about the importance of finding validation from sources other than social media, as well as helping people to develop healthy habits when it comes to their social media use. This could involve setting limits on the amount of time spent on social media, being selective about the content that is consumed, and finding ways to disconnect from social media when necessary. Overall, these findings highlight the need for caution when using social media, particularly for youth in Saudi Arabia. While social media can be a useful tool for communication and connection, it is important to be mindful of the potential negative effects on mental health. It may be helpful for individuals to limit the attention they pay to certain features, such as likes, comments, and followers, and to engage in passive rather than active consumption of media. Further research is needed to understand the specific mechanisms by which social media impacts mental health and to identify effective interventions to mitigate negative effects.There are several potential limitations to this study that should be considered when interpreting the results. First, the sample size of 385 participants may not be representative of the larger population of Saudi Arabian youth. Additionally, the self-reported nature of the data may be subject to bias, as individuals may not accurately recall or report their social media habits. Finally, the cross-sectional design of the study means that it is not possible to establish cause-and-effect relationships between social media use and mental health. Another limitation of this study is that the definition of “youth” is not explicitly stated. It is possible that the experiences and activities of respondents aged 18 and those aged 35 may differ significantly. Additionally, the study did not explicitly consider the potential impact of gender on the relationship between social media use and mental health. Future research should aim to further explore these demographic variables in order to better understand the specific effects of social media on mental health among different populations. Such investigations should consider using larger and more diverse samples, as well as more robust research designs to further explore the relationship between social media and mental health.The purpose of this study was to examine the effects of social media on mental health among young people. Social media has become an integral part of modern society, with platforms such as Facebook, Twitter, and Instagram offering a range of features including messaging, media sharing, and gaming. However, there is growing concern that the use of social media may have negative effects on mental health, particularly among young people who are more likely to use these platforms extensively. The study aimed to identify the specific features of social media that have the greatest impact on mental health and to examine the underlying reasons for these effects. To achieve these objectives, the study used AHP to assess the relevance and importance of eight social media features to 385 respondents aged between 18 and 35. The findings showed that likes, comments, and followers were the most relevant features to respondents, while gaming was the least favorite feature. In terms of the criteria influencing the respondents’ sentiments, entertainment was the most important factor, while privacy was the least important. The study concludes that social media can have both positive and negative effects on mental health, depending on how it is used and the specific features that are engaged with. It is therefore important for young people to be aware of the potential risks and to use social media in a balanced and responsible manner.


As the proportion of the world's elderly population continues to increase, wearable devices can provide ideas for solving a series of problems caused by population aging. Therefore, it is of great significance for the development of intelligent elderly care and the improvement of the quality of elderly care services to explore the factors that influence the intention of elderly users to accept wearable devices.An improved unified theory of acceptance and use of technology (UTAUT) model is constructed from the perspective of elderly individuals, and new parameters are added, including four factors related to wearable devices, including performance expectancy, perceived cost, hedonic value and aesthetic appeal, and three factors related to elderly individuals, including personal physiological conditions, health anxiety and personal innovativeness in information technology. The data analysis was accomplished with the partial least square regression structural equation modeling.The findings of this study revealed that performance expectancy, perceived cost, hedonic value and aesthetic appeal all have significant impact on elderly users' intention to use wearable devices. Furthermore, personal innovativeness in information technology, personal physiological condition, and intention to use all have significant impact on elderly users' actual usage behavior of wearable devices. However, there is no obvious relationship between health anxiety and actual usage behavior.Elderly adults' attention to wearable devices plays an important role in the development of the wearable device-related industry chain, which provides management suggestions for stakeholders. As the populations of Europe, America, China, Japan, and other countries gradually age, it is very important to solve the problems related to medical care brought about by aging . HoweverAt present, many companies are investing heavily in research on wearable devices, indicating that wearable devices have value for health monitoring and information tracking and can be further used by hospitals and families to improve the health and self-care of patients. Bölen  held thaWearable devices integrate science, technology, aesthetics, and other elements, but user needs play a crucial role from the perspective of industry development. There are only a few studies on wearable technology for elderly users, but there are still some shortcomings. First, consumers  have low acceptance of wearable devices . Second,The objectives of this study are as follows: On the one hand, what factors influence the behavioral intention of elderly users to accept and use wearable devices? On the other hand, what theoretical framework is suitable for analyzing the intention of elderly users to accept these devices?Therefore, this study explores the intention of consumers to use wearable devices from a new perspective of elderly users and finds important factors that affect the use of wearable technology by elderly users. It can help elderly users manage their health, bring more possibilities for solving pension problems, and realize intelligent pension services. On the one hand, this study can help alleviate the burden of medical care brought about by population aging and the pressure on the social health care system and provide security for the elderly in society, especially the empty-nest elderly. On the other hand, wearable devices can quickly and conveniently collect user physiological data, which allows the health of the elderly in the postepidemic era to be effectively managed and effectively reduce the possibility of accidents among elderly individuals.Regarding the definition of wearable devices, there is currently no unifying statement in Academia, and this research use the form of a list to illustrate the definition of wearable devices proposed by different scholars, as shown in Research on wearable devices in the academic field tends to start from certain perspectives, such as sensor type, data extraction and classification methods, but there are relatively few studies on user preferences and behavioral intentions.For instance, Dehghani et al.  exploiteWith respect to the wearable devices, although some scholars have studied the influencing factors of user preferences and behavioral from the perspective of the theory of planned behavior, the unified theory of acceptance and use of technology, and innovation diffusion theory, existing studies are mostly concentrated on young users , 23. At The theory of reasoned action (TRA), the theory of planned behavior (TPB), the technology acceptance model (TAM), and other theories provide a theoretical basis to continuously enrich and develop research on users' intentions to use information technology. These theoretical models are often used to study individual adoption behaviors, information platform usage, and information service usage. They have strong applicability, but the influencing factors are too general and lack consideration of individual differences and contextual factors –27. The Based on the above model, Venkatesh et al.  proposedUTAUT, which has yielded rich research results and a wide range of applications, includes four core variables that affect intention to use and use behavior, namely, performance expectancy, effort expectancy, social influence and facilitating conditions. However, judging from the current research progress, the impact of these four core variables on users' intentions to use varies in degree across industries and scenarios . TherefoConsidering that the subjects studied in this article are elderly people, due to a minute difference caused by age, and according to the description of Bu et al. , factorsThis study theoretically intends to solve the following research questions according to the above study.What functions of wearable devices can encourage the elderly to adopt wearable devices?Do the physical health situations and psychological factors of the elderly affect the use of wearable devices?In the UTAUT model, performance expectancy is defined as “the degree to which an individual feels that using the system is helpful to his or her job” . PerformH1: PE has a significant positive impact on elderly users' intentions to use wearable devices.Economic issues have been identified as a major obstacle in the dissemination of information technology and services. Perceived cost is the tendency of users to compare the potential benefits and consumption costs of technologies and services . Based oH2: PC has a significant negative impact on elderly users' intentions to use wearable devices.Some studies on information systems and user experience suggest that the hedonic values users assign information systems and services can be viewed as a key motivation for their perceptions of systems and services. Yang and Lee  define HH3: HV has a significant positive impact on elderly users' intentions to use wearable devices.Aesthetic appeal is the level of feeling associated with style or fashion . PreviouH4: AA has a significant positive impact on elderly users' intentions to use wearable devices.Jain et al.  found evPersonal physiological conditions include hearing, vision, speech, and memory impairments, as well as a range of challenges to device use. Because of the decline in hearing, vision, speech and cognitive abilities associated with aging, elderly people have difficulty concentrating on complex problems with hardware and software devices. As an instrument to assist in monitoring physical health, wearable devices can provide significant information such as blood pressure, blood sugar, heartbeat, and temperature. Edelstein et al.  argued tH5: PPC has a significant positive impact on elderly users' intentions to use wearable devices.HA is individuals' concern or fear about their own illness or potential future health symptoms. Thatcher et al.  defined H6: HA has a significant positive impact on elderly users' intentions to use wearable devices.PIIT is the intention of individuals to try new information technology. Agarwal and Prasad  defined H7: PIIT has a significant positive impact on elderly users' intentions to use wearable devices.Many theories related to technology acceptance, such as TAM and UTAUT, verify the relationship between use intention and user behavior. Many scholars have also verified the relationship above. For example, Hanif and Lallie  used a mH8: Elderly users' intentions for wearable devices has a significant positive impact on their actual usage behavior for wearable devices.The applicability of the questionnaires included in this study was ensured, and they were carefully selected from published information. To ensure the feasibility of the questionnaire, a pretest was conducted in some elderly participants who wore wearable devices. Both statements were slightly modified based on the feedback received from the elderly individuals who had completed the pretest to improve their understanding of the variable data. The questionnaire contains three sections. The first section is the classification of the questions, which is used to filter out those users who have used or are familiar with wearable devices. The second section is demographic information, such as gender and living conditions. The third section is a rating scale question, using a 5-point Likert scale  to measure each variable in the study. The relevant measurement items are shown in The sample collection strategy of the study was divided into the following three stages.In the first stage, interviews were used to obtain qualitative data. The interviews were conducted in an elderly welfare center in Hangzhou, Zhejiang Province. The elderly welfare center provided opportunities for the elderly to continue learning and improve their quality of life. The respondents were all over 60 years old. The main questions of the interview focused on their current activity levels, health conditions, whether they had used wearable devices and their views on wearable devices. Considering that some elderly individuals may not know about wearable devices, we provided 40 Fitbits for the elderly participants.In the second stage (1 week after the first interview), the main task was to ask the elderly to fill in the survey questions to obtain their views on wearable devices. A total of 40 questionnaires from the elderly welfare center were used as predictive test samples to test the rationality of the questionnaire, and the questionnaire was finally modified and improved according to the feedback results of the pretest samples. After improving the details of the questionnaire distributed in the field survey, a formal questionnaire was obtained again. This approach can improve the efficiency and quality of the questionnaire when it is officially distributed, reduce unqualified questionnaires, and improve the practicality and scientificity of the questionnaire.In the third stage, expanded investigation, the survey scope was expanded from the elderly activity center in Hangzhou to other places. For example, in shopping malls, elderly gathering centers and other places.This paper used the following methods to reduce the impact of sampling error. First, in terms of sampling error, cross-checking was used by multiple members to reduce entry errors and ensure data accuracy, which control the errors caused by mistakes in registration. Second, this paper strictly abode by the principle of random. In the process of selecting data, the sample indicators with too high or low values were excluded which can reduce the systematic representative error. Third, to avoid the invalid answer caused by respondents which were unable or unwilling to cooperate, the questionnaires were designed to be more concise and clear, and the length of each items were controlled to reduce impatiently perfunctory answer. At the same time, each steps of the procedure were carefully arranged to prevent various loopholes and reduce the rejection rate of the respondents. Fourth, before distributing the questionnaire, survey members were carried out in centralized training for understand the questionnaire design as well as the skills of communicating with the respondents. For example, for some elderly people with poor hearing and presbyopia, survey members need to dictate each question on the questionnaire and explain the meaning of the questions and options in detail. When the elderly are unable to make a judgment, survey members will ask them carefully to help them make a judgment. Finally, all the survey members were organized with a strict standard. An intensive training was held for all the survey members before the questionnaire to ensure that they are familiar with all the questions on the questionnaire. Inductive words were prohibited in the process of survey. In addition, the workload assigned to each survey member was reasonable enough in order to avoid increasing measurement errors due to excessive survey intensity.α/2 is 1.96. The initial sample size was calculated when it reached the maximum value . The estimate of the sample n1 size can be taken:When determining the sample size, we weighed from time and the economical aspects. In order to make the survey results more scientific and representative, it is hoped that the maximum absolute error of the survey results lower than = 5%, and the significance level is 0.05, the confidence level Zn2:Furthermore, considering that the estimated response rate is 96%, the final sample size is A total of 400 questionnaires were sent out this time, and 388 valid questionnaires were collected. Among them, 31 respondents were replaced by the children of elderly individuals, so 357 effective questionnaires were actually collected.The Partial Least Squares (PLS) method, a statistical analysis technique based on the Structural Equation Modeling (SEM), was used to test and validate the proposed model and the relationships among the hypothesized constructs. Hair et al.  discusseResearch models were explored using confirmatory factor analysis and SEM methods. Guidelines from previous studies required Cronbach's α over 0.7, factor loadings over 0.7, and AVE over 0.5 , 53. If Discriminant validity was calculated according to Heterotrait-Monotrait Ratio (HTMT) by Henseler et al. . The disR2-value is applied to assess the model's explanatory power. The target is to have a high R2-value to explain the endogenous latent variance. R2-values range from 0 to 1. The higher the value, the better is the explanatory power of the model , HV , and AA —positively affect the intentions of elderly users, while PC negatively affects the intentions of elderly users .The path analysis results are summarized in t = 3.539, p = 0.013) and PPC  positively affect elderly users' actual behaviors when using wearable devices, but HA has little effect on actual behaviors.With respect to factors related to the characteristics of elderly individuals, PIIT  also shows a positive relationship with the actual behavior.In addition, IU (H8, β = 0.120, This paper constructed a model to study the factors of the behavioral intentions and actual behaviors of elderly users toward wearable devices. Research hypotheses based on the modified UTAUT model were proposed, and the relevant hypotheses were analyzed and tested by combining questionnaire data and SEM. The final results supported most of the hypotheses except for one. The specific analysis is as follows.This study found that PE has a significant positive effect on the intention of elderly people to use wearable devices, which is consistent with the results obtained in previous studies  and can This study found that PC has a significant negative effect on the intentions of elderly people to use wearable devices. This is despite many previous studies having identified the perceived cost of wearable devices as the most significant factor affecting the intention to accept . This maThis study found that HV has a significant positive effect on the intention of elderly adults to use wearable devices, which can be explained by previous work on the relationship between hedonic value and consumer postconsumer feelings . Our finThis study found that AA has a significant positive effect on the intentions of elderly adults to use wearable devices, and Yoon and Cho  stated tThis study found that PPC has a significant negative effect on the behavioral intentions of elderly adults to use wearable devices, because elderly adults who are in better health don't need it . TherefoThis study found that PIIT had a significant positive effect on the behavioral intentions of elderly adults to use wearable devices because elderly adults who possess a sense of innovation and self-directed learning toward new technologies generate a sense of pleasure when using wearable devices . This reThis study found that HA has a non-significant effect on the behavioral intentions of elderly adults to use wearable devices. Elderly users with health anxiety are willing to spend more time and effort finding all devices and tools that can assist in improving their health . TherefoElderly adults' attention to wearable devices plays an important role in the development of the wearable device-related industry chain, so this study helps expand the scope of research on wearable devices.In this study, we improved the original UTAUT model and constructed corresponding parameter variables from the perspective of wearable device function and elderly characteristics. Therefore, this study provides more value for enriching theories related to technology acceptance.Finally, the conclusions of this study provide more useful information for manufacturers and service providers in the corresponding industries.On the issue of sample selection, this paper mainly focuses on densely populated elderly activity centers but may ignore some elderly people who live at home for long periods or are located in remote areas due to poor health. Therefore, these groups should also be included in subsequent samples.In addition, there are many kinds of wearable devices, and they are constantly being updated; however, this article investigated only the use of the Fitbit smart bracelet by elderly individuals . The maiBased on the conclusions of the above analysis, future research should extend this study in the following ways. First, by developing a wearable device-centered elderly medical market, the imbalance between the supply and demand of elderly care services caused by the unfair distribution of medical resources can be alleviated . The speThe raw data supporting the conclusions of this article will be made available by the authors, without undue reservation.Ethical review and approval was not required for the study on human participants in accordance with the local legislation and institutional requirements. The patients/participants provided their written informed consent to participate in this study.JC designed the study and wrote the manuscript. TW amended the manuscript and participated in the improvement of conceptual model and data processing. ZF reviewed the literature, revised the manuscript, and discussed the uncertainties with JC to reach consensus. HW gave many valuable suggestions for this manuscript. All authors have read and approved the final version of the manuscript for submission.