Over the last two decades, location tax incentives programs serving as a motivating force have been progressively well known as activities to draw in and/or hold foreign direct investments (FDIs) in economically blighted areas. The study examined the impact of location tax incentives on the growth of the rural economy of Ghana from the period of 1994 to 2018. The data were sourced from Ghana Investment Promotion, UNCTAD, and the World Tax Database. Using ARDL Cointegration and Error Correction Models were estimated to examine the static and dynamic long-run effects as well as the short-run dynamics of the system and the speed of adjustment to the long-run equilibrium. However, FDI is skewed towards the Greater Accra region, Ashanti region, Central region, and Eastern and Western regions notwithstanding the location tax incentives the government has been given since the 1990s. The study shows that there is a positive and statistically significant effect of tax incentives on employment creation and rural development in the long run. It revealed that trade openness and market size have a significant effect on employment creation and rural development. It emerged that there is no correlation between location tax incentives and the regional distribution of FDI in Ghana. It has become a well-established fact that adequate tax holidays are beneficial to businesses and encourage them to make investment decisions. It is therefore recommended that a more extensive mindfulness crusade through workshops, courses, and advertisements is necessary to empower the investors about the accessible business opportunities. Few countries can remain competitive in today's globalized economy without foreign direct investment. With the potential benefits of technology transfer, expanding business, skill change, and development, it is no surprise that many governments provide location tax incentives . LocatioMost governments often use location tax incentives to collaborate with the private sector on development projects. Location tax advantages, in particular, are an important part of many governments' economic development strategies. They are used to achieve objectives related to economic growth and job creation, such as balancing economic activity across the country and focusing on high-value enterprises. In addition, the government uses location tax incentives to compete with other states and other countries for the commercial organizations that promise employment and more financial flow.Proponents argue that tax incentives are necessary to attract businesses and that the costs of these incentives are partially or totally offset by more tax revenues generated by increased economic activity. Opponents argue that location tax incentives are a waste of resources since they spend limited available funds on initiatives that would not have been done without the tax breaks. Several states have requested more detailed reports and evaluations, and the Government Accounting Standards Board has established new rules for monetary declarations that necessitate the inclusion of tax discount reports, a special sort of financial incentive , 4.The choice of international organizations' locations in other jurisdictions was investigated utilizing Dunning’s eclectic or Ownership, Location and Internationalization (OLI) theory . AccordiAccording to economic geography theories, different districts of a country are given different levels of transportation, other social and financial infrastructure, communication infrastructure, administrative organizations and business administration convenience, beachfront territories with ports open to global markets, labor markets, and an existing cluster of organizations. Localities that can profit from all or almost all their enhancements are considered affluent, while those that require them are considered less prosperous , 7. The The trend has been for people in rural areas that lack FDI and, therefore, job possibilities to migrate to more enticing areas in search of nonexistent jobs. Many governments have used location tax incentives to influence the geographic conveyance of FDI away from preferred locations to discourage people from relocating from remote regions to enticing regions where jobs are scarce. Most of the incentives for limiting are concessions that "reduce the tax burden of companies to encourage them to devote resources to specific activities, locations, or districts" of the host nation . OrdinarHistorically, investments in Ghana's economy have traditionally been concentrated in four distinct regions: Greater Accra, Ashanti, Central, and West, with metropolitan centers such as Tema, Accra, and Kumasi being the most popular , 10. It The government of Ghana, among other arrangements, makes extensive use of location tax incentives to ensure the geographical distribution of investment and, especially, FDI. Incentives under Law 478 of the Ghana Investment Promotion Center and Law 865 of 2013 are expressed as a tax rebate for investment opportunities for organizations as follows: manufacturing organizations in Accra and Tema benefit from a 25% corporate tax rebate, while organizations in the various provincial capitals benefit from an 18.75% corporate tax rebate.Corporations headquartered outside of provincial capitals are taxed at a rate of 12.5%. Furthermore, agro-processing companies in Accra and Tema received 20% of the total, while those in other local capitals  received 10%. Those in the North, East, and West receive 0%, while those outside of territorial capitals receive 0%. The motivating force structure was designed to assist manufacturing and agribusiness firms in locating themselves in underserved areas to adapt to economic development and improvement, reduce rural unemployment, and prevent rural–urban migration , 12.Over the last two decades, location tax incentive schemes that serve as motivational drives have been more well-known efforts to attract and/or retain businesses in economically depressed areas. According to McDonald , in BritGhana established location tax incentives in the form of a tax reduction for investment in 2000 under the Ghana Investment Promotion Center Act 478 (since substituted by Act 865 of 2013) to ensure the geographical distribution of investments, especially for FDI. Location tax incentives, in particular, are an important part of many countries' economic development plans. They help to achieve and expand economic activity across the country by focusing on perceived high-value firms to boost economic development and job creation.Despite the government's best efforts to change industrial taxes, there is still a lot of controversy concerning their efficiency across the world. Many proponents argue that industries spurred by incentives (or other changes in tax policy) would have been located in regions where incentives were not used , to the Despite the enormous popularity of tax incentive programs for community development, the available empirical evidence –18 on thEven with the immense popularity of tax incentives programs for community development, the available empirical evidence –18 on thGhana’s economy is based on agriculture. Between 1990 and 2018, agriculture's share of employment declined from 55 to 33%. The mix of value added has evolved away from agriculture investment toward services, with extractives playing a significant role. Figure 1.8b illustrates that the value-added share of 'Other Industry' has increased significantly over the last decade, owing mostly to the contribution of Mining and Quarrying, which includes oil and gas production; however, this has not been matched by an increase in the sector's employment share. As a result, the trends of employment and value-added shares by industry have diverged 29], thisi = 1, t = 1, 2…., T denotes time, Y = community development and Job creation, stochastic error term, A = other variables.where the index i at time t, which is defined as the dollar value of the development projects. Therefore, for this analysis, the study estimates the following long-run models:The model was modified to take into account the peculiarities of the country and the theories. Community development and job creation are the dependent variables that measure the inflow of development activities in the community ε is stochastic error term, and β0 is an intercept of the sector , βs are the coefficients of the variables .To test whether the appropriate tax incentive policy actually increases employment, we propose the second model.,t denotes time and To estimate the short-run model for this study, it is necessary to estimate the error correction model. Thus, the error correction model result demonstrates the speed of adjustment back to the long-run equilibrium after a disturbance . Thus, tror term . The coeCommunity development is a measure of a number of FDI projects  that can be seen as a way to deal with the country's improvement. Community development focuses on bringing people together within a geographical area. Several studies have found that tax incentives have a major impact on community development , 16–18.Employment creation is hard to assess because it is hard to quantify. Employment creation is measured by the expected employment created by FDI projects from 2001 to 2018. The famous brilliant egg of employment creation arrangements is the "net new occupation"—the activity that is created without uprooting some other economic activities. While it is simple to determine whether another activity has been created at the macroeconomic level by looking at total data from the Bureau of Labor Statistics, it is extremely difficult to determine whether (1) the occupations created did not only displace occupations in different areas or segments, and (2) if the occupations were created in response to a specific arrangement . This isTax Incentive is the explanatory variable with emphasis on tax incentives, taxes related to tax exemptions, and tax holidays from customs duties that are the most popular incentives in Ghana. Given the difficulty of measuring fiscal incentives, this study uses a fictitious variable to show the presence and absence of fiscal incentives in the sectors considered . It is aOther control variables that affect community development and the creation of employment are those that control the market size and the openness of the economy. Although many variables have been proposed in various kinds of literature as determinants of FDI, it is not possible to include them all. As a result, we chose a few based on previous studies specific to the country, the strength of the variable, and the availability of data.The market size is a proxy of GDP, which must be positively related to community development and job creation. The greater the market size, the greater the community development in terms of projects and the availability of jobs , 33.Trade openness measures the opening of the economy and its integration into the global economy. It is captured by the ratio of imports to exports in relation to GDP. A higher relationship represents more openness , 35. A pThe influence of tax incentives on community development and employment creation was studied using the maximum likelihood estimate (MLE) approach. The MLE approach is a method for estimating population parameters (such as mean and variance) from data that picks as estimates those parameter values that have the best chance of matching the observed data. The maximum likelihood estimation process may be used for a broad range of models, and it typically produces estimators with excellent asymptotic characteristics .The order of integration and time series characteristics of the data used in the Augmented Dickey–Fuller (ADF) and Phillip–Perron (PP) models were examined first. Second, the study uses the Autoregressive Distributed Lag (ARDL) technique to cointegration to examine the short-and long-run correlations between the variables . The ARDGhana's tax system has been in place since the 1990s, and it is updated on a regular basis in order to encourage foreign direct investment. The study looked at the degree of regional imbalance in the distribution of FDI projects using trend analysis. The analysis is done as follows:Figure Figure The study used trend analysis to examine the first objective of the study. Table This section of the study provides the descriptive statistics of the selected variables. The descriptive statistics include the mean, median, maximum, minimum, standard deviation, skewness, kurtosis, sum, and number of observations. Table Table Although the ARDL cointegration approach can be used independently of the order of integration, it is essential to verify the unit root test to determine if the variable are not integrated into an order higher than one with a specific one in order to extricate the results from spurious regression. This is on the grounds that the computed F-statistics gave by Pesaran et al.  won't beThe Augmented Dickey–Fuller (ADF) and Phillips and Perron (PP) tests were linked to all variables in the levels and first difference to formally build up their order of integration. The Schwarz–Bayesian Criterion (SBC) and the Akaike Information Criterion (AIC) were utilized to decide the ideal number of lags incorporated into the test. The study used the P value to settle on the unit root decision  that reached a comparable conclusion with critical values.In Table P value of the ADF statistic are not statistically significant. However, when these variables are differenced for the first time, they end up noticeably stationary. Therefore, the null hypothesis of the existence of unit root (non-stationary) at the significance levels of 1% are rejected.Table P values of both the ADF and the PP statistic are not significant at all the conventional levels of significance.From Tables The presence of long-run relationships is tested using the bounds test for cointegration. Cointegration test enabled the verification of existence of both long-run and short-run relationships among the variables used for the analysis. Pesaran and Shin  argued tThe implication is that whenever two or more variables are cointegrated, then theoretically, there exists an error correction mechanism. The error correction term is the lagged residual of the cointegration regression. It determines the speed of adjustment to long-run equilibrium. For this reason, a negative and significant coefficient of the error term is expected. According to Pesaran et al. , the lowTable The government encourages FDI in specific business development projects with tax relief on capital and gains if the government thinks the project is beneficial for Ghana. To promote rural development, the government offers tax incentives in the form of relief from stamp duty and full tax exemption from corporate income tax, dividend tax, and capital gains tax. This session presents the results and discussion of the long-run connection between community development and tax incentives.Since the results of the cointegration analysis demonstrates the presence of a long-run connection between dependent variable (community development) and the independent variables, the study continued to assess the long-run effect of the independent variables on community development utilizing the ARDL approach. The assessments of the selected ARDL demonstrate in light of the Schwarz–Bayesian Criterion-ARDL is displayed in Table Table Table Table This session presents the results and discussion of the short-run relationship between community development and tax incentives. The short run is defined as the period one year and below. The Error Correction Model (ECM) gives the methods for accommodating the short-run behavior of an economic variable with its long-run behavior. The presence of cointegration connections among the variables requires the estimation of ECM to comprehend the short-run dynamic behavior of the bank profitability model. The model uses the first difference of the variables (capture short-run changes). The analysis tests the null hypothesis of no short-run relationship between community development and tax incentives as against the alternative hypothesis of a short-run relationship between community development and tax incentives.The coefficient of the ECM, as shown in Table The F-statistic value shows that tax incentives, market size, and trade openness have a substantial impact on community development (as measured by FDI projects) across the research period. The R-squared (0.980565) estimation in the model shows that the independent variables in the study explain around 98.1% of changes in community development in the short run. The DW-statistics estimate of 2.167253 confirms that there is no serial correlation.Consistent to the results of the long run, the coefficient of the tax incentives is positive and statistically significant at 5% significant level. Hence, 1% expansion in tax incentives will lead to 66.3% increase in community development, compared to 50.3% over the long run. This shows that the tax incentives is efficient at a high percentage given its strategy of motivating investors to invests in areas that promote community development in the short run and long run. This contradicts to Abdulrahman and Olumide  findingsContrary to the long-run results, the coefficient of trade openness is positive and statistically significant at 5% significance level in the short run. In this way, a 1% expansion in trade openness has the capability of reduce community development by around 141.5%. The impact of trade openness on community development appears to be more extreme in the short run (141.5%) than over the long run (28.1%). This implies, utilizing trade openness to enhance community development is more viable over the short-term period than in the long run in developing countries. In the short term, integration with global commerce with sources of innovation is facilitated through trade, which boosts FDI gains. Trade openness encourages economies to grow output, resulting in higher returns to scale and economics of specialization . This isFinally, the coefficient of market size (GDP) is positive and statistically significant, which confirms to the positive relationship acquired over the long run. This implies, over the short run there is a positive connection between GDP and community development in both short and long term. The probability of firm exist increase as the market size increases resulting in an increase in investment projects which intend improve development. This finding concurs with discoveries of Kondo & Okubo The evaluated properties of a time series data, according to Hansen , may chaAlso, Table Finally, to check the stability of the coefficients of the model, the study employed the CUSUM and CUSUMSQ of recursive residuals stability tests as recommended by Pesaran and Pesaran . AccordiFrom Figs. This section analyses the effectiveness of tax incentives on employment creation. Under the Ghana Investment Promotion Center Act of 1994, the agriculture and manufacturing sectors that fundamentally used local raw materials or engaged in the production of agricultural equipment, building and construction, tourism and mining enjoy some incentives in terms of tax exemption from customs import duties on plants and machinery, reduced corporate income tax rates, and other incentives with the view of creating jobs. It noted that FDI activities ought to generate potential employment. The implication is that if such ventures are received in an area, more occupations are bound to be created in that region.The study compares the null hypothesis of no long-run relationship between job creation and tax incentives with the alternative hypothesis of a long-run relationship between job creation and tax incentives. The study continued to assess the long-run effect of the independent variables on employment creation using the ARDL approach after the results of the cointegration analysis revealed the presence of a long-run connection between the dependent variable (employment creation) and the independent variables. Table Table The coefficient of trade openness has a positive and statistical effect on employment creation. More importantly, all other things being equal, an increase in trade openness will result in 81.3% increase in job creation. This means that the greater the relationship, the more open the economy is and the greater the inflows of FDI and job creation are. This conforms to Amanuel's  findingsFinally, market size (measured as GDP) is negative and statistically significant to employment creation. The implication is that Job creation is aided by economic growth. Growth must also boost the productive capacity of sectors that have the ability to absorb significant amounts of labor (for jobs). Martins  concludeThe results and discussion of the short-term link between tax incentives and employment creation are presented in this session. The term "short run" refers to time periods of one year or less. The error correction term, according to Bahmani-Oskooee , is a moFrom Table The F-statistic value demonstrates that, at the total level, the tax incentives, trade openness and market size have significant effect on the employment creation (measured by the number of jobs created by FDI) over the study time frame. In the model, the estimation of the R-squared (0.809600) demonstrates that around 80.9% changes in employment creation in the short run are being explained by the independent variables in the study. The DW-statistics estimation of 2.251347 affirms that there is no issue of serial correlation.The coefficient of tax incentives is positive and statistically significant in the short run, which confirms to the positive relationship acquired over the long run. This implies, over the short run there is a positive link between tax incentives and employment creation. A conceivable clarification of this relationship shows that tax incentives attracts more FDI in the economy resulting in increase in job creation. Accordingly, government of Ghana needs to accomplish more to make an empowering domain for effective tax incentives management. This finding concurs with discoveries of Adurahman and Olumide .Contrary to the long-run results, the outcomes additionally uncover that in Ghana, trade openness negatively affects employment creation over the short run. This shows that an expansion in trade openness by 1% prompts a reduction in employment creation by 81.3% points. This negative relationship contradicts the study expectation. A conceivable clarification of this relationship shows that since imports overwhelm the trade in Ghana, and obviously most imports are consumer goods, this may tend to swarm out domestic productivity and employment generation. Policy-makers who devise trade policies are challenged by ascertaining their fiscal impacts. This negative relationship contradicts with the discoveries of Phillips and Goss  and KudaFinally, the coefficient of market size (GDP) is positive and statistically significant, which confirms to the positive relationship acquired over the long run. This implies, over the long run there is a positive connection between GDP and profitability yet a negative relationship exists between them in the short-run period. It showed that tax incentives have increased the rate of capital accumulation and improved efficiency in capital utilization in foreign investment which is essential for job creation in the communities where such projects exists especially which such projects are into manufacturing. Basnett and Sen  suggestsAccording to Hansen , the assAlso, Table Finally, to check the stability of the coefficients of the model, the study employed the CUSUM and CUSUMSQ of recursive residuals stability tests as recommended by Pesaran and Pesaran . AccordiFrom Figs. The government hoped that by establishing a location tax incentive, regions with low corporate taxation rates would attract more FDI. Correlation analysis was used in the study to determine the relationship between location tax incentives and FDIs.r = 0.126, P > 0.05). It reveals that there is no connection between location tax incentives and regional distribution of FDI in Ghana. This implies location tax incentives have not conveyed projects to the less endowed regions of Ghana. In quest for this vision, and as far back as 2004, location tax incentives in the structure decreased corporate tax for agro-preparing firms and firms that produce cocoa based items from cocoa waste, it was reported. The package included a 20% corporate tax for firms located in Accra and Tema, a 10% corporate tax for firms located in the other regional capitals, excluding Tamale, Wa, and Bolga, and no corporate tax for firms located in the Northern, Upper East, and Upper West regions. The general corporate tax rate was reduced to 25% in 2006.organizations that are situated in Accra and Tema pulled in at a similar pace of 25%, while firms that are situated in other regional capitals drew in 18.75%. Firms located outside of regional capitals earn 12.50%. Within the period, the regions have gotten a serious and generous measure of FDI, yet it is not yet realized whether the location tax incentive has had any impact on the local appropriation of FDI in the nation. The findings so far confirm the findings of ActionAid Ghana [The government of Ghana's approach to giving the location tax incentive was to impact the area of FDI away from the Gt. Accra regions to different regions, particularly, to the three northern regions of the Northern region, the Upper West Regions, and the Upper East Regions. The outcome demonstrates that Gt. Accra has a higher taxation rate, but it draws in more FDI than different regions that have a lower rate. Table id Ghana  and Van id Ghana  that locid Ghana  for Russid Ghana  suggest The Ghanaian government has devised tax regulations bestowing incentives on enterprises and individuals with the intention of conducting business in the nation in order to promote the Ghanaian economy. It has been shown that without adequate tax incentives, no corporation can effectively achieve the goals for which it was founded, particularly at the sustaining stage, given the astronomical cost of manufacturing in Ghana and the attendant challenges with infrastructure facilities. This investigation has gone to great lengths to show that tax incentives have significant effect on community development as well as job creation. It is no longer surprising that the government has acknowledged the significant role tax incentives play in job generation and rural economic growth.From the study, it been established that appropriate tax incentives are beneficial to companies and encourage them to make investment decisions. More importantly, location tax benefits operate as a motivator for investors by minimizing the impact of local manufacturing and increasing the overall impact of industrialization, which creates jobs and improves rural economic development.Trade openness and market size significantly affect community development and job creation in Ghana. These are nevertheless consistent with contemporary development and, in general, lead to realistic economic growth. Despite the location tax benefits provided by the government during the 1990s, the results show that FDI appropriation is biased towards Greater Accra, Ashanti, Central, Eastern, and Western regions. The study suggests that a more widespread mindfulness campaign, including workshops, courses, and advertisements, be launched to educate investors about available business opportunities, particularly since a significant number of people are wandering the streets due to a lack of employment. They may be able to encourage them to share their knowledge. The government should create tax incentives that emphasize the use of locally sourced goods such as raw materials, labor, and locally manufactured equipment and machinery. As a result, rural development and employment will improve.


Aims: There are several advantages to pooling survey data from individual studies over time or across different countries. Our aim is to share our experiences on harmonizing data from 13 Finnish health examination surveys covering the years 1972–2017 and to describe the challenges related to harmonizing different variable types using two questionnaire variables – blood pressure measurement and total cholesterol assessment – as examples. Methods: Data from Finnish national population-based health surveys were harmonized as part of the research project ‘Projections of the Burden of Disease and Disability in Finland – Health Policy Prospects’, including variables from questionnaires, objective health measurements and results from the laboratory analysis of biological samples. The process presented in the Maelstrom Research guidelines for data harmonization was followed with minor adjustments. Results: The harmonization of data from objective measurements and biomarkers was reasonably straightforward, but questionnaire items proved more challenging. Some questions and response options had changed during the covered time period. This concerned, for example, questionnaire items on the availability and use of medication and diet. Conclusions: The long time period – 45 years – made harmonization more complicated. The survey questions or response options had changed for some topics due to changes in society. However, common core variables for topics that were especially relevant for the project, such as lifestyle factors and certain diseases or conditions, could be harmonized with sufficient comparability. For future surveys, the use of standardized survey methods and the proper documentation of data collection are recommended to facilitate harmonization. Pooling survey data from individual studies has several advantages, such as enhancing the statistical power of the analyses, obtaining more generalizable results, allowing cross-country comparisons and the possibility to analyze changes over time –3. CommoRecently, the Maelstrom Research guidelines for retrospective data harmonization were published . The guiExamples of large projects that have utilized the Maelstrom guidelines in their harmonization process include the Canadian Partnership for Tomorrow project  and the www.thl.fi/poddy-hepo). Therefore, the harmonization process was reasonably comprehensive.In an ongoing Finnish research project, the ‘Projections of the Burden of Disease and Disability in Finland – Health Policy Prospects’ (PoDDy-HePo), data from 13 Finnish national population-based health examination surveys from the years 1972–2017 are used . AlthougWe aim to share our experiences on the harmonization process of data sets from 13 national population-based health examination surveys conducted in Finland between 1972 and 2017, and to describe challenges related to the harmonization of different variable types using four core variables as examples.The harmonization process is presented in relation to the Maelstrom Research guidelines .The research questions were defined by the study group as part of setting up the research project and when applying for external funding.The PoDDy-HePo project uses data from 13 health examination surveys carried out by the Finnish Institute for Health and Welfare  . These sAll surveys have followed the prevailing legislation and regulations at the time they were conducted. Written informed consent has been obtained from survey participants since 1997 but not from the participants of the early surveys that were conducted before the current legislation on medical research and the Helsinki Declaration. The participants in these early surveys were fully informed, they participated in the surveys voluntarily and the use of the data for medical and public health research was explained to them. Details on the ethical permissions of all surveys have been published previously .The extent of the surveys varied somewhat. The FINRISK Study focused mainly on cardiovascular risk factors, and the Health 2000 and 2011 surveys focused more broadly on health and functional ability. The FinHealth 2017 combined the protocols from the FINRISK Study and Health 2000 and 2011 surveys but had a more limited scope than the Health 2000 and 2011 surveys. The surveys have been collected over five decades, during which, working life, family composition, diet and medical care have changed dramatically in Finland, and thus, several questions have been modified accordingly.All surveys used questionnaires to collect data. Generally, the questionnaires were self-administered while personal interviews were carried out in part of the surveys. Basic anthropometric measurements and blood pressure measurements were performed during the health examination part of all surveys. Blood samples were drawn in all surveys, but other collected sample matrices varied between the surveys. Only biomarkers determined from blood were included in this harmonization process.Harmonization was performed only for variables relevant to the PoDDy-HePo project . We starto understand determinants of the health inequalities and their changes over time, and to assess the contribution of modifiable risk factors to these inequalities (www.thl.fi/poddy-hepo). We present examples of the harmonization of the following variables, which were essential in analyses related to this aim:As an extensive list of variables was selected in our harmonization process, we focus in this paper on the description of the harmonization of variables related to one of the original aims of the project – namely, - the fat type used in cooking;- a question on the use of cholesterol-lowering medication;- blood pressure measurement;- assessment of total cholesterol.To facilitate the harmonization process, we created a Google sheet platform in which we inserted information for those variables from all surveys that we aimed to harmonize. The individual surveys were organized in columns, whereas the variables were inserted in rows.The first column served as a title column with a general description of each variable. In the following columns, information available from each specific survey for this variable was filled in.Each survey took up three columns. The columns for variables based on survey questionnaires included the following information: (1) the exact wording of the original question, (2) the response categories  and (3) the variable name in the original data set .The content of columns for variables based on measurements and for biomarkers determined from biological samples was modified. For these variable types, the content of the columns was basically as follows: (1) description of the measurement or biomarker, (2) the values for categorical variable / the unit for continuous variables (e.g. mmol/l) and (3) the variable name in the original data set.Fully comparable variables across individual surveys were written on the same row. If there was a deviation in the formulation of the question/response options, measurements or biomarkers, information was inserted into a new row. This arrangement of variables helped the inspection of the variables and their differences during later phases of the project.Before the final selection of core variables to be used in the project, the study group discussed harmonization alternatives for the included variables, such as the number and content of the categories for different categorical variables. When there were doubts about the feasibility of the proposed categorization, the frequencies were checked and adjusted. Topic-specific experts were consulted, either in person or by email, to check the categorization of response options and the cut-offs of continuous variables regarding alcohol-related variables, for example. Based on these expert consultations and discussions among the study group in project meetings, the final selection of the harmonized core variables was decided on. Issues that were considered in the final selection were mostly related to possibilities to form comparable variables. For example, the time span that a specific question referred to varied between the surveys for some variables, which hindered comparability. No formal criteria for the final variables were used, but each variable was discussed separately.Finally, the harmonized variables for each survey were created using R following the coding instructions documented in the codebook, and one combined dataset including all surveys was formed. The harmonized variables were given common variable names.The Google sheet, including the documentation and codebook for variable harmonization, was made available for other in-house users of the same data sources.As some of the research questions took shape gradually during the project, the process was repeated later for other required variables.Generally, the prerequisites for harmonization of variables from more recent surveys were reasonable. However, the questions from the surveys conducted during the 1970s differed from more recent surveys.The questionnaires used in the individual surveys mainly included multiple-choice questions and only some open-ended questions. Harmonization of many of these questions was reasonably straightforward. For many questions, the wording of the question itself was identical across the surveys, but the response options varied. In most of these cases, it was generally feasible to form a harmonized variable by combining the response categories.vegetable oil or other mainly unsaturated fat; 0 = all other options , the number of categories was nine . InformaNew drugs over the five decades also resulted in changes in the survey questions. For example, the first commercial statin for lowering cholesterol levels was approved by the US Food and Drug Administration in 1987 . Thus, aMoreover, the treatment guidelines for some conditions have changed. Questions like, ‘Have you ever been diagnosed for high blood cholesterol level?’ are not directly comparable if the threshold for high cholesterol has changed. Our harmonized surveys cover 45 years, and the thresholds for elevated cholesterol and elevated blood pressure have changed. Therefore, we used measured cholesterol and blood pressure values together with information on the use of medication as the primary information sources for these conditions.The anthropometric and blood pressure measurements have been performed by trained study nurses in all included surveys. The measurement techniques followed standardized protocols, which usually remained unchanged between surveys, and there were only a few issues to consider in the harmonization process.EHES manual [Blood pressure has been measured with a sphygmomanometer in all surveys following the methods originally published by Rose and Blackburn in 1968 , and latS manual . The meaAll laboratory analyses have been performed at the same laboratory – that is, the laboratory of the Finnish Institute for Health and Welfare , except for the first FINRISK survey in 1972. The analytical methods have changed for some biomarkers. However, the laboratory of the Finnish Institute for Health and Welfare has taken part in the quality control programs of the WHO MONICA Quality Control Centre for Lipid Measurements in Prague between 1978 and 1997 and the Centers for Disease Control and Prevention, Atlanta, USA, since 2002 ,18.We described the harmonization process of 13 Finnish health examination surveys covering 45 years between 1972 and 2017, using four core variables as examples. Our harmonized variables included data collected by questionnaires, objectively measured data and biomarkers from laboratory analyses. Compared to research projects where data from several countries were collected and harmonized, our harmonization process was probably more straightforward. The same research institute has been responsible for data collection of all included surveys and has aimed to keep survey protocols as similar as possible. Nonetheless, the harmonization process took a considerable amount of work, consultations, meetings and discussions in the study group. It imitated the steps of the Maelstrom Research guidelines, where the harmonization process proceeds from the first step of defining the research question, objectives and protocol to the final step of disseminating and preserving the final harmonization products [One of the strengths in our harmonization process was that substantial consideration and effort had been put into the standard operating procedures of the surveys in the planning phase as well as in thorough training of the survey nurses. Core variables, such as measured blood pressure, did not need rigorous harmonization. Furthermore, the laboratory methods and their changes have been extensively reported previously and the systematic errors between the measurements have been assessed –19, whicBy contrast, some of the variables that were obtained from questionnaires were more challenging to harmonize. In many cases, when the wording of the question itself was identical across the surveys, it was possible to combine the response categories into common target categories. Revising the wording of a question or its response categories in new survey rounds may, however, lead to variables that are not feasible to harmonize. For continuous variables, this hindrance does not exist as the cut-off points may be set flexibly.Cross-country harmonization may be especially challenging if cultural differences are reflected in different questions or response options. This can be seen, for example, in diet-related questions, which commonly include foods that are common in the food culture of a country as well as locally available. This was seen in the BioSHaRE project, where data from six European countries were pooled. Dietary habit variables clearly showed lower harmonization potential than disease history and medication use, as examples . In our Overall, using standardized protocols such as those developed in the framework of the European Health Examination Survey (EHES) ,21 facilIt should be kept in mind that pre-harmonization (i.e. the use of standardized survey methods and protocols for data collection) is always easier than post-harmonization of already collected data. Obviously, the primary use of the collected data will guide the decisions on the data collection methods, especially when a new survey is a continuation of a series of earlier surveys. We often have to balance between two choices: (a) comparability with earlier surveys and thereby the possibility for trend analyses, or possibly even comparability with corresponding international surveys; and (b) the possibility to obtain accurate and relevant data using updated, nationally relevant, topical and/or validated survey questions and measurement protocols. Survey data collected for one purpose  are often also used for secondary purposes, such as research collaborations. In these cases, we usually must content ourselves with previously collected data and work on post-harmonization of the data. It is also essential to have proper documentation of the data collection available to support the harmonization process. Information about societal changes, development of the used treatments and treatment guidelines may affect the interpretation of the questions/measurements and should be used to guide the harmonization process.The harmonization of variables, which are based on objective measurements performed by trained study nurses in the health examination part of a survey as well as biomarkers measured from blood, were fairly straightforward to harmonize. The harmonization of questionnaire-based variables was more challenging. The surveys in the current harmonization process covered 45 years, and the questions or response options had changed for some topics, such as dietary habits. New questions on, for example, the use of medications had also been added. This provided an additional layer of complexity to the harmonization process. Common core variables for topics that were especially relevant for the project, such as lifestyle factors and certain diseases or conditions, could be harmonized with sufficient comparability.In general, pre-harmonization – that is, the use of standardized survey methods and protocols for data collection – is easier than post-harmonization of already collected data. Whenever possible, this is worth acknowledging in connection with future data collections. Proper documentation of the data collection also facilitates data harmonization in both pre- and post-harmonization processes.


Syria is a developing country that face enormous healthcare challenges that aggravated with the outbreak of COVID-19. In the study, we evaluate the perceived healthcare service quality based on hospital type, public and private, using five HEALTHQUAL dimensions. We find that service quality in Syrian private hospitals is perceived better that in public hospitals. However, neither type of hospitals scores exceptionally high in any of the examined HEALTHQUAL dimensions. On the contrary, both hospitals score extremely low in the Improvement dimension. We argue that crowdedness environment, medical staff availability and their low salaries, pricing policies as well as the health insurance system, are to blame for such low perceived quality. The Syrian healthcare system has a complex nature and has long been subject to changes amid political and economic conditions. Public hospitals were the backbone of the Syrian healthcare system pre-war and largely belong to the Ministry of Health, Ministry of Higher Education and Scientific Research and Ministry of Defense. The combined impact of wartime destruction, healthcare worker migration, poor working conditions, and severe budgetary shortfalls led to the deterioration of public hospitals' services and allowed private hospitals to increasingly compensated for poorly public services . Howeverth national conference of Al-Baath party officially announced the move to social market economy. Such move reduced the government intervention in economic activities and opened the door for private sector to participate in economic activities and healthcare is no exception. Expectedly, the government expenditure on health as percentage of GDP declined from 4.9 percent in 2005 to 3.4 percent in 2010 , in public and private hospitals, are thought to have resulted in a troubling number of deaths among patients and healthcare worker alike  is higher the mean of responses regarding the readiness of public hospitals (2.42 ± 0.952). Moreover, the difference in perceived readiness is in favor of private hospitals and is statistically significant with t-statistics of −6.485. This result can be explained by funding shortages due to war conditions that reduced the availability of necessary facilities and hygiene issues. In addition, personnel at public hospitals did not pay enough attention to hygiene issues due to the low self-awareness toward sterilization and personal hygiene guidelines 97 is hig, 50.Private hospitals have modernly designed buildings and attractive rooms, in addition of equipment and medical tools that surpass public hospitals. Private hospitals can easily adjust their prices to provide the necessary facilities and to cover the purchase of necessary hygiene equipment and to hire skilled staff. These results are attributed to several reasons, the most important of which is that private hospitals have modernly designed buildings and attractive rooms, in addition to medical equipment, tools and equipment that exceed public hospitals, whose buildings are old and neglected and in need of modification. Hospitals must provide a sophisticated and safe treatment environment for patients and staff that enhances a sense of comfort and safety.The results from the Safety dimension illustrate a mean of (3.29 ± 0.1.06) against the mean of responses in public sector (2.65 ± 1.108) and the difference is statistically significant at five percent level of significance. Syrian patients feel more comfortable and safer while treated at private hospitals compared to public hospitals possibly because they are less-crowded than public hospitals. Crowded environment stands as a major obstacle in improving the service quality in public hospitals. Another reason for these differences is related to the pricing policies where public hospitals treatment costs are free or symbolic and the income of medical staff at public hospitals is low and makes them careless in terms of diagnosis and follow up. Previous studies show that patients with high income receive better healthcare service , 51–53.The main purpose of improvement dimension is to measure whether the medical services meet the needs of patients and whether the patient feels satisfied during and after providing the services. Sharifi  called tIn terms of efficiency, private hospitals score higher than public hospitals in this dimension with an averages of (3.11 ± 1.016) and (2.74 ± 0.94), respectively. Moreover, this difference is statistically significant at five percent level of significance. However, this dimension has the lowest difference between public and private sector. This can be partially explained by the fact that public hospitals still attract expert medical staff who are highly experienced doctors. Those medical staff are still working in the public sector despite their low salaries either because they have contractual obligations or because they use their positions at public hospitals as tool to provide their private patients easy access to cheap public healthcare services.The results from the empathy dimension confirms previous dimension results. That is, private hospitals outperform public hospitals in terms of perceived empathy with averages of (3.36 ± 1.04) and (2.705 ± 1.02) for private and public hospitals, respectively. Again, the difference between averages is in favor of private hospitals and is statistically significant at the five percent level of significance. The overcrowded environment at public hospitals and shortages in medical staff do not permit medical staff spend enough time with patients and develop the sense of closeness and friendship. That is medical staff are forced, sometimes, to work beyond their knowledge and expertise to fill the shortage of services gap , and havIn order to investigate which of the examined variables affect the improvement dimension, we run the following linear regression for each type of hospitals separately,The results from estimating the above equation can be seen in When estimating the same equation on private hospitals, we also find that readiness is a significant determinant of improvement at one percent level of significance and efficiency is also significant and has the highest standardized coefficients with 0.349. This suggests that patients give more importance to efficiency than readiness as determinant factor of improvement. Empathy has also a positive and significant impact on improvement with a coefficient of 0.101. In addition, Safety has a positive and significant impact on improvement but only at 10 percent level of significance.To address the problem of endogeneity and as part of the robustness tests, we investigate if the variable Efficiency plays a mediator role in the relationship between the other three variables, Readiness, Safety, and Empathy, and Improvement. Thus, we construct a variable (RSE) as the average of these three variables and disentangle the direct and indirect effects of these variables on Improvement. The results from the public hospitals analysis in Syria is a developing country that face enormous challenges. Suffering from low resources, low service quality, shortage in protective equipment for the medical and nursing staff  due to war conditions. The outbreak of COVID-19 aggravated the already difficult situation and show the fragility of the healthcare system.In the study, we evaluate the perceived service quality based on hospital type, public and private, using five HEALTHQUAL dimensions. We find that service quality in private hospitals is perceived better that in public hospitals. However, neither type of hospitals scores exceptionally high in any of the examined HEALTHQUAL dimensions. We argue that crowdedness environment, medical staff availability and their salaries, pricing policies as well as the health insurance system, are to blame for such low perceived quality.The investigation of the impact of the examined four dimensions of HEALTHQUAL on improvement suggests that all these variables load significantly on improvement and contribute toward the perceived improvement of private hospitals' healthcare services. We also find that Efficiency plays a mediator role in the relationship between Improvement and Readiness, Safety, and Empathy. However, Efficiency fails to affect Improvement at Syrian public hospitals.The results of this study provide valuable insights to researchers, policymakers, managers, and patients. The novelty of this study lies in that it compares the quality of healthcare services between public and private hospitals in the special context of COVID-19 outbreak period and in a healthcare system that was on the edge of collapse due to war conditions. Policymakers and managers are increasingly interested in measuring and improving the service quality since healthcare service quality is one of the main factors that affect hospital choice. It is also of great importance for patients who select the hospital they visit on the basis of fellow recommendations. Hence, we present some practical implications for improving service quality for both private and public hospitals. Many of these prominent bottleneck inefficiencies of response to Pandemics challenge were also noted in an array of comparable health systems sharing some historical legacy with Syria's one in medical care provision and financing , 57.This study rings the alarm bell that patients are unsatisfied with healthcare services provided by public hospitals. Surprisingly, public hospitals failed at all HEALTHQUAL dimensions. Policymakers should address patients concerns regarding service quality at public hospitals. It is suggested that the almost free-of-charge policy applicable at public policy, with its negative consequences such as crowdedness, is the one to blame for the perceived low service quality. We recommend that policymakers consider introduce changes in pricing policies at public hospitals to allow reasonable fees. The fees collected should provide improvements in closing the gap between public and private hospitals' service quality levels. In addition, public hospital patients, who have longer waiting times than a pre-determined threshold, should be directed to private hospitals where their fees for hospital services should be covered by government. Following such suggestions, if the crowdedness of public hospitals decreases, it is believed that medical staff at public hospitals will provide more patient-centered care interventions, develop a consistent positive patient safety culture across the hospital. Furthermore, policymakers and managers of public hospitals should develop a performance evaluation system that encourage receiving feedbacks for patients. These may lead to an improvement in the service quality of public hospitals . In the Surprisingly and despite that private hospitals outperformed their public counterparts, private hospital performance at all dimensions as far below expectations. It is unexplained that private hospitals, while charging high fees for treatment, are not scoring quite high on all HEALTHQUAL dimensions. Private hospitals should pay more attention to HEALTHQUAL dimensions and particularly to improvement dimension by providing follow-up service to patients and provide patients with the best possible treatment.The health insurance system is one of the main causes of such low perceived healthcare quality. The refusal of insurance companies to cover COVID-19 treatment meant that those who are diagnosed with the disease do not receive full treatment and they are discharged before their full recovery and before they feel their health conditions are improved. The expected result is that they are dissatisfied with this service quality. Such findings indicate lack of adaptive capability by the health system affected with a large-scale epidemic which has been documented in other Mediterranean and Asian health systems .Finally, healthcare authorities should recognize that increase the awareness of public of COVID-19 and other pandemics is a priority that will have many advantages. On the one hand, it will reduce the transmission of disease and consequently the number of patients and deaths. On the other hand, such awareness will make hospitals care more about hygiene issues and consequently increase the perceived healthcare quality.There were a number of limitations in the study. First, the research is expected to have the majority of respondents from Damascus, the capital of Syria. We fear that our results may not reflect the service quality perceptions in hospitals from all around Syria. Even though the results confirmed the results of previous studies conducted in other countries, future research that includes country-specific hospitals or healthcare service quality models should also be conducted. Second, the study implemented an e-questionnaire, which definitely bias our sample toward young and internet users. In future research, it is advised to increase higher age representation through manual distribution of questionnaires to enable researchers to generalize their results. Third, other healthcare quality dimensions could be used in order to double check the results obtained from HEALTHQUAL measure.The raw data supporting the conclusions of this article will be made available by the authors, without undue reservation.LA designed the questionnaire and wrote the literature review. SM wrote the conclusion and limitations. MJ revised the draft and developed the discussion. All authors contributed to the article and approved the submitted version.The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.All claims expressed in this article are solely those of the authors and do not necessarily represent those of their affiliated organizations, or those of the publisher, the editors and the reviewers. Any product that may be evaluated in this article, or claim that may be made by its manufacturer, is not guaranteed or endorsed by the publisher.


The COVID-19 pandemic led to global lockdowns that severely curtailed economic activity. In this study, we set out to examine the social, economic, and environmental ramifications of the COVID-19 pandemic. This is a rare project that will have far-reaching consequences for the field. There are five sets of issues: short-term effects on oil and economic and agricultural policies, including regulations and COP26; long-term implications of monetary and fiscal intervention and investment in green agreements on future generations; prospects for further de-globalization and its effect on climate change and nature; and intergenerational environmental consequences, including debt and polling. In late 2019, Wuhan, the capital of the province of Hubei, was the first place COVID-19 erupted and spread to the entire world, causing widespread devastation. Many governments responded by imposing lock-downs of varying intensities and durations. There have been numerous geographical and even international curfews in the past; tales of globally scattered lock-downs following World War II Helm,  suggest The COVID-19 pandemic has exacerbated the world's affairs in various ways. For example, the rapid transmission of the virus across the globe has increased global economic uncertainty, which, in turn, has triggered financial and stock market volatility  discharges in numerous European industrial areas have dropped by almost half , the carbon content of fuels imported for consumption is a far more complicated story. For instance, UK carbon consumption is estimated to be 70% higher than carbon production .Even so, this expense of capital impact does not counterbalance the fall in vitality costs since it only applies to some innovations, not just low-carbon improvements. The effect would depend on what policymakers are doing, whether policymakers are changing the lower cost of spending financing into manageable and atomic vitality, and whether the significant oil expense is adjusted. What makes a difference is that ecological approaches regulate the money-related components and carbon taxes of national banks.Monetary aid enabled every global economy to respond to the 2007/08 recession. In the end, obligation rates in China, the United States, and the European Union increased proportion to GDP. The quantitative easing program of the European Central Bank, which committed to “take the necessary actions” to reduce loan cost spreads, supported a decline in financing costs for all EU member states to historically low levels , whereas the US Federal Reserve reported a $2.3 trillion assortment. Any such cost would have been incurred as a result of the programmed stabilizers compensating for greater labor costs and lower charge assortments. These indicators are connected to rising total requests and have a Keynesian basis. From a financial perspective, the questions are about the impacts of GDP spending, the uniqueness in effects between utilization and speculation, how the segment of the expenditure is spent, and specifically, the ability of governments to manage environmental change and different endeavors to improve ordinary capital. What is essential to the economy is not the financial improvement (even though it impacts spending as examined above), but its arrangement and how it ponders the accounting report. Monetary gain will increase demand for power, transportation, and agricultural items. They will, in turn, expand their interest in wood and things from rainforests. There will be a quest for these meat items (from Amazon). Hardwood production (from the world's rainforests), hydroelectricity generation (from the watersheds of the world's major rivers), and palm oil production would all increase as a result .Others argue that an open vehicle expenditure bundle is the key to being sought after with considerable interest and gently stunning the competition in light of the compositional influence of the money-related and financial improvements outlined above. A vital piece of this will be a cutting-edge environmental change pack, a green arrangement. Others called this another “Marshall Plan” green , particularly in the UK and the rural US. Regardless of the duration, the government's total spending is minimal, necessitating trade-offs and decisions. The final consideration is where the project funding will come from, given that the tax reductions will likely encourage currency speculation. Green agreement proponents dispute if this will be future finance and inevitable investment funds or QE to adjust purchase prices. Some think about an enormous scope QE plan and then compare it with a Keynesian case by proposing that the resultant lift in total interest would be spread over the economy and pay for itself. This last section does not address every issue with quantitative easing (QE) while arranging usage overspending on foundation shortages to enhance the creation and impact of the universe of rising market demand and use by expanding carbon emissions and natural weights. Blending feasible ventures with Keynesian interest control is one of the most quarrelsome parts of green agreement circumstances. The case for the green hypothesis should be presented for an autonomous reason concerning a log jam, not as a lift to total interest. . In the post-lockdown era, there would be other compelling requests for national spending plans, regardless of the financial justifications for green planning as a part of a massive open consumption program.In recent years, China's advancement and gigantic monetary development, estimated in regular terms of GDP, have directly and indirectly, exacerbated a major cause of ecological harm to the environment and biodiversity. China is the world's largest consumer of coal IEA, , dammingBy 2019, remote communication progress will have slowed even further due to the introduction of new media, making it possible to examine the impact of the outbreak in a counterfactual manner for the first time. Robots are a supplementary workforce that does not tire, require payment for benefits, or contract the coronavirus. Monetary advancement will decouple from the idea of situating yield near modest information costs instead of customer proximity, with mechanical technology and 3D printing allowing jobs. They should take some pressure off the notions. Moreover, there is a general inquiry into the last connection between globalization and the impacts of the atmosphere. Second, the investigation is whether contact with this pandemic would cause more de-globalization. Second, there is the fascinating issue of whether a fortified house for security purposes is also good for nature. The two eco-explicit qualities of the general relationship are delivery and aeronautics-related natural outflows . As has been noted, the famine has increased the apparent strength of country states over global establishments and their authority because of the hole in the factor input component . Given that the United States has yet to elect a new president to quorate the World Trade Organization's appeals body, its operations have been suspended. The growing approval of state aid has also fueled protectionist campaigns. These impacts should be sufficient to raise the trade bounce-back, hence the shipping and aviation post-lock-down markets. Thus, the cumulative environmental effects of production at various locations must consider the other technological and ecological impacts. An additional positive impact of the more global trade strategy on the climate is that it should encourage a move toward reducing environmental costs and, in particular, a shift in border pollution. The European Union has already suggested a plan before the pandemic , ecological reforms ensure that signature capital expended out of 21 current spending records is preserved. Changes include contingency funds toward credit obligations. Those ventures  would clarify the level of disparity. The scale of government spending and loans would likely lead to some accounting tricks, masking the figures. Although there would be constraints, taking spending off the balance sheet would not make them disappear. The traditional option was privatization, as the savings were associated with user fees. However, it is uncertain whether the government will increase its demand for electricity, water, transport, and even communications bills after the lockout to support these costs.Reports have been released that interaction with coronavirus can affect behavior and personal and political decisions. Many hope that it will lead to more concerted COP steps and a greater ability to tackle biodiversity depletion. Others have the opposite view, arguing that lower sales would lead to access to short-term ventures and growth in business. Economic decision theory is the logical starting point for understanding how the consequences of the virus could affect behavior. One of the longest litigations in economic theory is the presumption of exogenous preferences and their transformation into a rational orientation ordered by the choice axioms. Exogenous assumptions and innovations form the basis of the neoclassical principle of demand and supply and the general equilibrium derivation. The clarification of why inferring exogenous impulses is critical is to separate psychology from economics. Once accepted, the specification only changes with adjustments to the data. It is pointless to change the underlying condition since it will go out. All of this has implications for environmental policies and COVID-19. That investigation has certainly become significantly easier. Increased visibility and awareness have contributed to a more widespread belief that lockdowns are occurring due to the pandemic and its coverage in the daily news and on social media Shiller, . The adaThe fight against coronavirus's aftereffects will go on for a long time. It could end up being one blip in the long struggle between individuals and infections in the history of humanity, even though individuals largely disregarded the Spanish Flu during the 1920's and 1930's. Individuals are worried about diseases and may need to determine how best to respond to this pandemic. While there have been immediate ecological gains from reductions in emissions and consequent improvements in air quality, a portion of these is likely to be short-lived as and when things normalize and GDP recovers, backed by significantly associated capital and financial boosts. Although it is essential not to incorporate its longer-term impacts, the coronavirus offers necessary proof for examining the causes of contamination and, in particular, the effects of a wide-ranging abrupt stop investigation on a significant amount of financial movement, especially on transport. The fact that the epidemic has not been uncoupled from pollution and GDP is its single most crucial fact. It is hard to overstate this activity's importance for devising a strategy.We intended to mitigate environmental change and biodiversity loss. The rate of technological innovation over the next 30 years should be unsurpassed and accelerated by a fast-track initiative to convert capital stocks into global GDP growth of just 3 percent per year, another billion people, and a global temperature increase of only 1.5 degrees Celsius. To achieve mechanical success in critical biodiversity hotspots, especially the big rainforests, it will be necessary to account for and balance the typical degrading qualities. To create intergenerational inequality, macroeconomic strategies are likely to prioritize requests over investments, retain capital misestimation by quantitative easing (QE) and unfavorable actual loan payments, and promote wellbeing and associated transparent administration rather than conditions that will help the current generation—and especially the more experienced individuals—unnecessarily follow the needs of the future. It is difficult to discern the motivations behind assumptions. However, one stands out: the reduced assistance to globalization and the subsequent decreases in global carbon-scaled exchanges, as do the transport and avionics sectors and the related carbon-serious segments. For these potential points of interest, the pace of change from emerging developments that make driving and business-related travel targets less desirable should be applied, allowing for an even more carefully planned, competitive economy. While the total potential outcomes of the pandemic would not be ecologically sustainable, they do not deal with monetary disputes, environmental changes, and the unfortunate natural environment. The biological case aims to improve air quality, reduce marine emissions, and limit the loss of coal and peat, which is similar to the purpose behind transport zap. Coal and peat-eating misfortunes persist, as is the case with freight costs. This pandemic has essentially altered the points of interest, and bearing in mind that these alterations are insufficient to change our attitudes in the long run, they will help recalibrate the responses, and this is reinforced by the one significant advantage of coronavirus—an explosion of the logical realities of the realizations upon which we need to develop another approach to science.All authors listed have made a substantial, direct, and intellectual contribution to the work and approved it for publication.


In the light of recent emergencies in Europe and around the globe—including COVID-19 and the war in Ukraine—the spotlight has shifted towards the scarcity of Risk Communication and Community Engagement (RCCE) research applied to health emergencies. RCCE nurtures the sense of empowerment among communities since it ensures that individuals and communities are part of the solution creation, thus they take informed decisions to protect their health and in turn, contribute to emergency control. Therefore, RCCE can play an important role as core public health intervention across health emergency preparedness and response. However, its tremendous impact, is still underestimated and not widely common. This viewpoint showcases the RCCE measures applied to the Ukrainian emergency to ensure that Ukrainian refugees access health services in host countries, based on their needs and concerns. The essence of RCCE is working together with the community in order to co-design behavioural, social and public health solutions that are tailored to their needs and adapted to the evolution of the emergency and risk perceptions over time . ConsequTrust is a central factor to RCCE, as a trustworthy relationship between responders and communities is at the basis of public support to health emergencies’ response. In preparedness, RCCE strengthens the capacities and capabilities of countries to communicate risks to specific population groups based on their perceptions and concerns and by engaging trusted community actors . MoreoveIn the context of the war in Ukraine, the WHO Regional Office for Europe attributed a critical role to RCCE within the response plan in both Ukraine and surrounding countries. To roll out a strong RCCE response in refugee-receiving countries, the Communication Pillar of the Ukraine’s emergency Incident Management Support Team (IMST) prioritized strengthening RCCE capacities in the WHO country offices of the Czech Republic, Hungary, Poland, the Republic of Moldova, Romania, and Slovakia to ensure adequate support to respective countries .A RCCE rapid needs assessment was conducted across the countries in the initial weeks of the war, to understand the health needs, perceptions and concerns reported by Ukrainian refugees, along with capacity of each country to respond to these needs, while maintaining social cohesion. Interview guides were designed to interview civil society organizations (CSOs), governmental figures , key leaders, refugees, and host communities. These interview guides included the following themes: Scope of work ; coordination mechanism with other partners; Socio-demographics of the refugees; RCCE ; Communication channels . Finally, the last theme is related to the misconceptions/rumours the refugees receive as well as the perception of the host communities towards them. Fifteen focus groups discussions and 71 interviews were held with the different stakeholders with different surrounding European countries. This situational analysis led to objectives prioritization.The notes taken through the focus group discussions and in-depth interviews were analysed using a rapid analysis process to identify key themes and inform the development of interventions in a timely manner .The majority of the Ukrainian refugees were women (45%), men (12%) and children under 18 (43%). Although there were some discrepancies in the findings between different countries, in this report we highlighted some common challenges. The majority of persons arriving from Ukraine were Ukrainian citizens. As reported by CSOs and refugees the following health issues were prominent:Upper respiratory infections due to low temperature and long trips to arrive in the host countries.Exhaustion.Psychosomatic stress reactions .Gastro-intestinal conditions .Heart conditions .Chronic conditions .As for the access to healthcare system, all holders of the special long-term visa  could register and get health insurance free of charge in the host countries. Regardless, many Ukrainian refugees still preferred to rely on their Ukrainian physicians, whether online or in-person. Prescription medications and vaccinations were provided for free. However, many Ukrainians had the fear to change the medications they used to take in Ukraine to new ones in the host countries as once they went back, they’d have to change medicines again. As for the vaccination, if the child’s parents or other persons do not provide documentation of his/her vaccination, he or she will be treated as unvaccinated, and vaccination will be given to the child. However, many Ukrainian refugees are not ready to vaccinate their children. More hesitancy was noticed regarding COVID-19 vaccines uptakes related to concerns for side effects and toxicity of the vaccines. When it comes to psychosocial support, refugees especially children were open to it. But limited available number of licensed psychologists and psychotherapists posed a challenge to address this need. Some CSOs provided mental health support by integrating Ukrainian social workers as volunteers to support; However, more capacity building is needed to ensure the quality and sustainability of the services.All the ministries of health in the host countries posted health information on their governmental websites. The refugees were not always aware of these efforts; thus, accessing health information is a challenge for many. The information channels that generally Ukrainian refugees prefer to use were both online and offline, with a preference for the online channels for youth and offline channels for older people. Refugees show a high sense of gratitude towards the hosting system and population.As for the host communities’ perceptions, there was an initial overwhelming welcome and solidarity from the resident population. There is a very considerable number of Ukrainian refugees who have relatives and friends in the European countries who hosted them. Some cases of frustration towards refugees by the host communities have been already observed due to the perceived competition for resources .Based on the above findings, the goal across all the countries was to support Ministries of Health’s Risk Communication and Community Engagement efforts to encourage Ukrainian refugees to access health services, based on their needs and concerns. Four main objectives were identified:Objective 1: Strengthen trust between refugees, host population and health authorities.Objective 2: Support refugees to access health services.Objective 3: Promote healthy behaviours among refugees and host population.Objective 4: Strengthen community readiness and resilience.All the RCCE plans covering the health sector’s response to the refugees’ emergency are part of the overall inter-sectoral response plan 1. Drivers related to behaviour changes.Understanding both individual behavioural variables and the social and societal systems that underpin the behaviour is necessary to making health care available, acceptable, convenient, and appealing to individuals . Accordi792. Human interactions at the core of behavioural change.Understanding people’s perceptions; social and physical situations, and psychological requirements is essential for suitable and effective interventions . RCCE in3. Balanced approach to the needs of both resident and refugee populations.With the large influx of refugees, it is critical to act and communicate in a way that recognizes and addresses the needs of both residents and refugees. While the host community has been very open to welcoming refugees and caring for them, some negative sentiment is growing that refugees might take away resources from residents and hamper access to health and other services. Balanced interventions will contribute to social cohesion and will increase trust in the government and the Ministry of Health.A- Strengthening risk communications interventions:First, coordination with non-state actors is crucial. WHO worked on facilitating the communication between CSOs and MoH through launching the health sector working group that will include representatives from local actors, UN agencies, and MoH. WHO suggests that MoH should position itself as the active steer of the health response for refugees and as a caring actor of the needs of both hosting and refugee populations.Second, a community listening system should be established to build a regular channel of communication with both the host and the Ukrainian communities. A system for regular online updates  will also be established to keep the information flow between different partners. Solidarity and unity between state actors and non-state actors will lead to better health outcomes. The partnership between health authorities and CSOs allows community voices, context, culture and concerns to be heard at the governmental level.Third, behavioural and social insights research should be conducted to assess the perceptions of both the residents and the refugees regarding access to healthcare services, so action plans can be designed accordingly.Finally, a deployment strategy for health information produced by the government and other non-sate actors should be prioritized.B- Promoting healthy behaviours: through enhancing vaccination campaigns that target both the residents and the refugees noting that based on Geneva Centre of Humanitarian Studies, 167 articles were conducted from February 2022 till June 2022 tackling different health situations of those fleeing Ukraine or trapped in the country; however, none of them tackled the health promotion aspect of the RCCE pillar .C- Informing about the continuity of care: communicate transparently to refugees about the opportunities they have and what services country offers. Engage health workers, CSOs, and volunteers to support these communications to decrease burden of diseases at an early stage.D- Anticipating mental health needs through:Training a pool of social workers and engage health workers to detect signs of mental health impacts in refugees and colleagues.Building the capacity of all the social services employees to be able to detect and respond to mental health issues.Considering their constituencies and area of expertise, the CSOs present have the potential and skills to be engaged in co-development of community engagement activities, including health promotion campaigns and trainings for healthcare workers and community members. However, identifying funding opportunities to sustain CSOs work is essential, especially as CSOs are running out of funds.Some of the best practices are worth to be shared in these viewpoints. WHO was able to create a platform to link CSOs to policy makers, thus upgrading response coordination. In addition, engaging CSOs in messages testing, co-designing of interventions, monitoring and evaluation processes has been enhancing the participatory approach and leveraged the structures, systems and skills of local community organizations. RCCE interventions are only effective if they respond to the community needs and reflect its context and culture.Lessons learned from the response in Ukraine’s surrounding countries clearly highlight that community engagement is at the core of greater acceptance and uptake of health protective measures and of social cohesion. This is largely based on trust building between authorities and communities. Although RCCE is a specific pillar in emergency preparedness and response plans , it is a


Academics and practitioners have paid close attention to waste, energy, and resource management due to growing awareness of its effects on sustainable performance. This study aims to explore the status and challenges of efficient resource management in China, an under-researched area. Moreover, it proposes a theoretical framework to fill the academic and practical gap how efficient resource management practices can build sustainable performance. This study justifies the need to explore the need of efficient resource management practices in emerging economies like China. Empirical data derived using a cross-sectional survey of 265 employees from oil and gas firms in China were used to test the theoretical framework developed from mainstream literature. Empirical findings of this study highlight the role of efficient resource management practices such as CSR, process and equipment, human resource practices, product design, and manufacturing planning which have a positive and significant impact on sustainable performance. In addition, innovative culture plays a moderating role in enhancing firms' sustainable performance. The findings suggest that there is further scope to utilize the efficient resource management practices for encouraging innovative culture to build sustainable performance. This study creates a basis for future research of building sustainable organizational performance by integrating efficient resource management practices. This study also highlights gaps in the system and provides insights into policymakers and manufacturing sector employees on holistically building a sustainable organization. Due to environmental concerns, most of the organizations around the globe are expected to take responsibility for green environment or sustainable environment. According to different environmental expert the environment management is a priority for China because increasing industrialization will promote the growth of Chinese economy, but, at the same time, it demands more efficient resource management practices to achieve sustainable performance  that evaluated the relationships between management practices, innovative culture, and sustainable performance.Institutional theory is “an approach to understand organizations and management practices as the product of social rather than economic pressures. It has created a popular perspective within management theory because of its ability to explain organizational behaviors that defy economic rationality”  , suggesting that the variables were extremely trustworthy. Composite reliability has a range of 0–1 and is separated into three categories: “acceptable reliability (0.6),” “satisfactory reliability (0.6–0.7),” and “highly satisfactory reliability (0.6–0.7)”  must be greater than the highest relationship of the construct with the other latent variable to assess the discriminant validity of the construct using the Fornell and Larker Criterion”  considers as strong and sustainable performance value of R Square (0.177) considers as weak.The value of t et al.  recommenThis study analyzed the impact of efficient resource management on sustainable performance and moderating role of innovative culture. It produced some intriguing outcomes. Similar studies were carried out to assess the organizational approaches used in sports to get beneficial results. Moreover, according to demographic data, males are more likely than females to work for oil and gas companies in China. In previous studies, other factors use energy, waste, and resource management and some indirect effects through lean culture with sustainable performance (Habidin et al., This research was based on a number of theories about resource management links, such as innovative culture and sustainable performance. The 1st hypothesis evaluated the effect of component of energy, waste, and resource management as process and equipment positive impact on sustainable performance. To generate a regular and consistent flow within manufacturing processes, some techniques are required, such as process improvement, shorter setup times, ordering and maintenance, and the use of “error proof” process and equipment. The 2nd hypothesis evaluated the effect of component of energy, waste, and resource management as manufacturing planning and control positive impact on sustainable performance. There is a significant impact of manufacturing planning and control which manufacture and control pollutants. In the previous study, there is no significant effect with manufacturing planning and control with sustainable performance (Habidin et al., The 3rd hypothesis evaluated the effect of component of energy, waste, and resource management as human resource practices positive impact on sustainable performance. The human resource practices train and develop employees to improve sustainable performance. Human resource practices explained why this association exists, claiming that skilled personnel have a greater understanding of resources and can provide suitable solution, resulting in the reduced material waste. This conclusion contradicts the findings of Orji , who fouThe 5th hypothesis evaluated the effect of component of energy, waste, and resource management as corporate social responsibility positive impact on sustainable performance. The importance of corporate social responsibility in encouraging businesses to be concerned about environmental issues. The corporate social responsibility connection is one of the factors of the implementation and distribution of environmentally friendly manufacturing practices (Saad et al., This study analyzed the effect of efficient resource management on sustainable performance and the moderating role of innovative culture in oil and gas firms in China. The study revealed that processes and equipment, human resource practice, manufacturing planning and control, product design, and corporate social responsibility have a significant impact on sustainable performance in oil and gas firms in China. Furthermore, innovative culture partially moderates the relationship between management practices and sustainable performance. The findings of the study have a number of implications for manufacturing executives as well as practitioners. Considering the sustainability impacts that inspire manufacturing firms to employ resource management practices would assist practitioners in adjusting plans and practices to management practices among industries and, as a result, reduce energy and resource consumption and wastage. The research is a solid basis for making policies and building innovative culture in manufacturing industries, from both a theoretical and practical point of view.The purpose of this research was to produce theoretical and practical advancements in the realm of knowledge. Furthermore, this research provides policymakers, practitioners, and managers of manufacturing firms with relevant information in a variety of ways. The findings of the study have a number of implications for manufacturing executives as well as policymakers that modify this study to incorporate the waste, energy, and resource management practices that contribute to the firm's sustainable performance. The large positive benefits of waste, energy, and resource management relationships on company performance suggest that these resources should be linked to improve the firm's current sustainable performance. Managers should also focus on creating an innovative culture to improve the impact of human resource practices and corporate social responsibility on a firm's sustainable performance. From a research point of view, this study adds to “what is known about oil and gas manufacturing firms by showing how important it is to manage waste, energy, and resources to improve sustainable performance.” The study also contributes to the body of knowledge by looking at the impact of interactions between creative culture and waste, energy, and resource management on sustainable performance. As a result, managers and policymakers should develop a fair policy for implementing the understanding of innovative culture that motivates manufacturing firms to implement management practices. This will support practitioners in adjusting policies and initiatives to encourage waste, energy, and resource practices among businesses. Finally, the study established its own institutional theory into a particular framework. From an academic point of view, this research contributes to the current knowledge on resource manufacturing by identifying the importance of resource manufacturing techniques in improving a firm's long-term success. The research also adds to the body of knowledge by examining the effects of interactions between innovative culture and resource production techniques on long-term sustainability.Even though the study achieves its goals, there are some limitations that must be noted before extrapolating its results. This study was conducted among employees of oil and gas firms in China. So, generalizing study results to other sectors may be an issue. The study sample is limited to China, and the data were gathered from several oil and gas manufacturing companies. Future research can evaluate the study's conceptual framework in other countries, allowing the findings to be implemented more globally. Furthermore, future research should focus on a specific industry, as the relationship between waste energy, and resource management and sustainable performance may differ depending on the industry in which manufacturing businesses operate. Even though researchers may use a longitudinal study design in the future to figure out cause and effect more accurately, the data were collected using a cross-sectional method. As a result, longitudinal research is required to get a better understanding of how management practices impact on sustainable performance. More research is needed to test the idea in other nations, both advanced and developing.The original contributions presented in the study are included in the article/supplementary material, further inquiries can be directed to the corresponding author/s.The studies involving human participants were reviewed and approved by Jilin University, China. The patients/participants provided their written informed consent to participate in this study. The study was conducted in accordance with the Declaration of Helsinki.SZ and SX collected the data. YW conceived, designed the concept, and wrote the paper. The authors read and agreed to the published version of the manuscript.The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.All claims expressed in this article are solely those of the authors and do not necessarily represent those of their affiliated organizations, or those of the publisher, the editors and the reviewers. Any product that may be evaluated in this article, or claim that may be made by its manufacturer, is not guaranteed or endorsed by the publisher.


We present a case of ocular involvement in the context of a varicella zoster virus primary infection, in a 30-year-old man with type 1 diabetes. The ophthalmological examination revealed unilateral anterior uveitis resistant to topical treatment, which was complicated by association of vitritis and onset of retinal vasculitis diagnosed by angiography fluorescein. Herpetic eye involvement was confirmed by anterior chamber PCR for varicella- zoster virus. In addition, we started the treatment with oral valacyclovir 1 gram every 8 hours and 15 mg oral corticosteroid with very satisfactory results, without observing any side effects. Very few cases have been published on this topic, given the low prevalence of this ocular complication. Primary infection is more common in children and develops with feverish disease and chickenpox dermatitis. During primary infection, viral particles migrate along the nerve endings until they reach the sensitive ganglion, where the virus is stationed. Subsequently, and due to different factors, such as the patient’s immunity, diabetes .It is during the reactivation of VZV that herpetic ocular involvement usually occurs, with a small percentage of patients with ocular involvement during herpetic primary infection .Anterior uveitis and retinal involvement are more frequent during the reactivations of the disease .To date, there are very few published cases of retinal vasculitis due to primary infection of VZV, and even less with an association of anterior uveitis .Initial treatment for anterior uveitis during VZV primary infection usually involves topical corticosteroids and oral antivirals, as performed by Kuo YH and col. or Wong F et al. [The difference in our patient’s case is that he was a diabetic with anterior uveitis resistant to topical corticosteroid treatment.In a young diabetic patient with uveitis and vasculitis secondary to VZV, we decided to start valaciclovir 1 gram every 8 hours and low-dose corticosteroids, starting treatment with 15 mg. The reason for adding the oral corticosteroid, not described in these cases except for resistance to antiviral treatment, was the fast evolution, given the immunosuppressive state of the DM1 patient, as well as the lack of response of the anterior uveitis to topical treatment, trying to stop the inflammation of both the posterior pole and the anterior pole in a more radical way.After this treatment, we were able to verify the excellent result by stopping vasculitis and vitritis in less than a week, as well as stopping the previous uveitis that did not initially respond to topical treatment. We did not find any sequel to the use of oral corticosteroids in this patient.Antiviral treatment was maintained for 2 months, and oral corticosteroid treatment was maintained for two months in a slow descending pattern. Currently, the patient is with AV unit and free of ocular involvement.The results have been successful, so we consider that adding oral glucocorticoids to the usual antiviral treatment could help stop complications more effectively within clinical safety in these rare viral complications.Conflict of Interest statementThe author(s) declare no potential conflicts of interest with respect to the research, authorship and/ or publication of this article. Informed Consent and Human and Animal Rights statementThe patient(s) consented to the publication of this case and the use of the images. Authorization for the use of human subjectsEthical approval: The research related to human use complies with all the relevant national regulations, institutional policies, is in accordance with the tenets of the Helsinki Declaration, and has been approved by the review board of Hospital Universitari i Politecnic La Fe, Valencia, Spain.AcknowledgementsNone.Sources of FundingThe author(s) received no financial support for the research, authorship and/ or publication of this article.DisclosuresNone.