This study explored the important factors affecting drunk car/motorbike drivers’ willingness to use and pay for alcohol interlocks. Data were obtained through a survey upon choice-based sampling conducted in central Taiwan. Questionnaires were distributed to the participants of drunk driving and road safety education courses from 17 August to 26 October 2020. All drunk drivers whose driver’s licenses are revoked for drunk driving are mandated to participate in this course. Prior to the survey, the researchers explained the questionnaires, instructed the participants to complete the questionnaires, and then collected all the questionnaires. The socioeconomic characteristics of drunk drivers, awareness of alcohol interlocks and drunk driving, drinking patterns and health self-assessment before and after drunk driving ban enforcement, and changes in the number of trips were investigated. This study applied the double-hurdle model for data analysis to estimate the variables affecting drunk car/motorbike drivers. Results indicate that the respondents who were classified by the Alcohol Use Disorders Identification Test as high-risk drinkers before and after drunk driving ban enforcement were more willing to use alcohol interlocks and to pay higher prices. Additionally, the respondents with declined health self-assessments were also more willing to use alcohol interlocks and pay higher prices. This study suggests offering subsidies for alcohol interlocks to families with financial difficulties, in order to increase the alcohol interlock installation rate. Moreover, since the current duration of license suspension and withdrawal is considerably long, drunk drivers avoid using and installing alcohol interlocks by reducing the number of trips. In other words, the willingness to install alcohol interlocks may be increased by reducing the duration of license suspension and withdrawal. According to the statistics of the National Police Agency, among A1  class traffic accidents in Taiwan in the past 10 years, the top three causes for accidents caused by drivers’ negligence are related to drunk driving. While the proportion of drunk driving accidents has declined in recent years, drunk driving continues to be a serious issue. As the main cause of road traffic accidents globally . The unconditional expectation can be broken down into two parts, the conditional expectation of E, which is the expected value of iy for the values of the explanatory variables, x, the conditional of iy > 0, and the probability of a positive value of iy for the values of the explanatory variables, x, P[iy > 0 |x].To assess the impact of the repressors on the dependent variable, marginal effects can be calculated using the maximum likelihood results, as obtained from the double hurdle model. A total of three different marginal effects can be calculated based on three different definitions of the expected value of dependent variable The decomposition of the unconditional expectation into the probability of participation and the conditional expectation is based on the work by  in theirIn the double-hurdle model, the probability of participation and the level of expenditures conditional on participation are ,32:(6)P[given by ,32:(8)∂PThe marginal effect for the unconditional level of expenditures can be derived by applying the product rule of differentiation to Equation (2):The model can be modified to allow for heteroscedasticity by specifying the variance of the errors as a function of a set of continuous variables ,31 as foThis section provides statistics on the differences between the participants with willingness and the participants with no willingness in the two groups. The analysis focused on social-economic characteristics, awareness of the alcohol interlock and drunk driving, drinking patterns and self-health assessment characteristics, changes in the number of trips of the participants, and their willingness to use and pay for the assumed alcohol interlock scheme. The employed statistical analysis techniques include one-way and two-way exploratory analyses, EFA and AUDIT.As shown in The questionnaire of this study was developed based on , which dSPSS software was applied for Principal Component Analysis (PCA) for EFA on the data collected from the 838 respondents. The rotation method was Oblimin with Kaiser Normalization (KMO) with indices from 0 to 1; when the indices were 0.6 and above, they were considered as being appropriate to perform factorial analysis ,33,34.p < 0.001). The result indicates that the relationship among the variables was strong, and the data were suitable to conduct EFA [In this study, the KMO was 0.82 suggesting that the samples are adequate for performing factor analysis, and Bartlett’s Test of Sphericity was significant , which indicates small differences in acceptable prices and vehicle price has an insignificant effect on drunk drivers’ willingness to pay for an alcohol interlock.In the future, drunk drivers may be forced to install an alcohol interlock for one year if he/she wants to reapply for his/her driver’s license upon the end of suspension or revocation of driver’s license. The alcohol interlock price list approved by the government is provided for reference. More than half of drunk drivers are willing to buy or rent an alcohol interlock, and This study applied a double-hurdle model as the theoretical basis model to discuss drunk drivers’ willingness to use and pay for alcohol interlocks. The following section uses drunk car drivers and drunk motorbike drivers as an example for demonstration purposes.Model calibration was executed based on the respondents with their car driver’s licenses being revoked for drunk driving. Significant variables for model calibration and calibration results are listed in According to the double-hurdle marginal probability results of the drunk car drivers listed in Model calibration was executed based on respondents with their motorbike drivers’ licenses being revoked for drunk driving. Significant variables for model calibration and calibration results are listed in According to the double-hurdle marginal probability results of drunk motorbike drivers listed in The scores given by drunk drivers on the attitude towards alcohol interlocks were counted and used to generate variables by the Least Square Regression method. According to the calibration results, variables were significant in both vehicle groups of car and motorbike. This demonstrates that their personal attitude towards alcohol interlocks affects their willingness to use and pay for alcohol interlocks. According to AUDIT, high-risk drinkers will not change their willingness to use alcohol interlocks due to different vehicles, which demonstrates that when the risk level of drinking increases, drunk drivers have a stronger preference for alcohol interlocks . The heaWhile more than 60% of drunk drivers were willing to install alcohol interlocks in exchange for the right to drive, their willingness to pay was far less than the product prices approved by the government, which explains the reason for the ineffective implementation of alcohol interlocks in Taiwan. High-risk drinkers may develop long-term risky alcohol consumption behaviors ,37, and According to the calibration results, when the risk level of drinking increases, respondents would have a stronger preference for mandatory alcohol interlocks, which might be because high-risk drinkers believe that they would be more compliant by installing alcohol interlocks. On the other hand, they would not curb their alcohol consumption modes . FactorsIn view of the fact that risky alcohol consumption modes are often signs of drunk driving , high-riFamilies with economic hardship, such as families that raise several children or have a low family income, should be granted subsidies to encourage the installation of alcohol interlocks. In 2006, the US required all drunk drivers to install alcohol interlocks, granted subsidies to low-income individuals, and required that alcohol interlock usage be monitored .The research results indicated that changes in the number of daily trips affected the demands for the right to drive, thus, drunk drivers would reduce the number of trips to avoid the cost of installing alcohol interlocks. Therefore, if the period of suspended or revoked driver’s licenses is shortened, drivers may be more willing to install alcohol interlocks .Suggestions are proposed based on the research results to provide a reference for future studies and policy revision.


The COVID-19 pandemic has uncovered the ways in which disabled people are made more vulnerable due to structural inequalities. These vulnerabilities are the result of the interaction between individual and structural factors that shape how risk is experienced by disabled people. In Australia, these vulnerabilities are influenced by the way disability services and care for disabled people are delivered through a consumer-directed approach. We analysed the policies and documentation made by the Australian Government and state and territory governments during the pandemic to explore whether these were disability-inclusive. We aimed to unpack how these policies shaped disabled people as vulnerable citizens.Guided by documentary research, we used framework analysis to examine the policies of the Australian Government and state and territory governments. We analysed legislation that was given royal assent by the federal, state and territory governments, and documents  published by the federal government and the state of Victoria  between February 2020 to August of 2020.We found that most of the resources were not aimed at disabled people, but at carers and workers within disability services. In addition, most policies formulated by the Australian Government were related to the expansion of welfare services and the creation of economic stimulus schemes. However, while the stimulus included unemployed people, the expansion of benefits explicitly excluded disabled people who were not employed. Most of the legislation and documents offered accessibility options, though most of these options were only available in English. Disability oriented agencies offered more extensive accessibility options.The findings indicate a large number of documents addressing the needs of disabled people. However, disability-inclusiveness appeared to be inconsistent and not fully considered, leaving disabled people exposed to greater risk of COVID-19. Neoliberal policies in the health and welfare sector in Australia have led to an individualisation of the responsibility to remain healthy and a reliance on people as independent consumers. Governments need to take a clear stance towards the emergence of such a discourse that actively disvalues disabled people.The online version contains supplementary material available at 10.1186/s12939-021-01506-2. Disabled people are disproportionately affected by the COVID-19 pandemic; existing inequalities have exacerbated, and new ones have emerged . DisableInsights into the ‘structural vulnerability’ of people with disability can be found in governmental half- and non-existent measures of disability inclusion. Many of these pre-date COVID-19, and reflect historical and contemporary ableist assumptions –7. For eData from other countries has provided empirical insights into the specific effects of policy, including lockdowns or movement restrictions, on the experiences of people with disability. Epstein et al.  found thAcross the world, governments, communities and collectives have designed varying strategies to support disability inclusion in formal responses to the pandemic. Examining disability inclusion and COVID-19 in four South American countries, Sakellariou et al.  found thIn this article, we focus on Australia, a country which has successfully suppressed COVID infections, to unpack the place of COVID-related policies in shaping disabled people as vulnerable citizens and thus reinforcing ideas of deficiency and personal responsibility. These constructions act in opposition to key elements of the CRPD, to which Australia is signatory, as we outline below. Our analysis is informed by the ‘Health in All Policies’ (HiAP) approach, which calls for a collaborative and multisector public policy orientation within government to simultaneously consider the health implications of their initiatives, decisions and settings, with the goal of improving health for the whole population , 17. As Australia recorded its first case of COVID-19 in January 2020 . Rapid i1The strategies that were implemented to contain COVID-19 risk had specific implications for disabled people, many of which had not been considered in the rapid and decisive response to contain the pandemic. A ‘Statement of Concern,’ issued by the Royal Commission into Violence, Abuse, Neglect and Exploitation of People with Disability 2 on MarcThe very nature of the NDIS has exposed disabled people to increased risk, revealing the failures of an understanding of people as autonomous consumers: the combination of a large number of carers moving between different homes with no centralised form of organisation has two implications. First, they can act to spread infection and second, it is difficult to issue directives and policies that can reach such an expansive and disparate work body. Within our methodological framework (outlined below), this aligns directly with the theme of ‘protection of people living in residential settings’ but also has implications for questions of ‘reasonable accommodations’.Furthermore, being based on a gig economy structure, NDIS offers no incentives to carers to stay at home if they have suspected COVID as they only get paid for services they render . HoweverThese factors together reimpose vulnerability onto disabled people. In attempting to address the policy and structural contributions to the experiences of increased insecurity, anxiety and precarity experienced by disabled people as a result of government and community responses to the pandemic, the Royal Commission into Violence, Abuse, Neglect and Exploitation of People with Disability  publisheThe aim of the study was to investigate how the Australian government’s response to the COVID-19 pandemic addressed the needs, particular risks, and vulnerabilities of disabled people. The study design was guided by documentary research . We usedlegislation (Acts and Statutory Rules) passed by states and the Australian Governments. The second category we designated as other documents, which included a variety of documents composed of publications, media releases, guidelines, and webpages published online by both state and federal governments.The documents collected are divided into two major categories: the first category of documents is We looked at all the legislation that was given royal assent during the time period and that had any mention of COVID-19 . We undertook a search strategy by searching in the Federal Register of Legislation which is a government website that contains the full text of the Commonwealth’s legislation. In addition, we also searched each Australian state government’s website that provided the full text of the state’s legislation including Bills considered by Parliament, Acts of Parliament, and statutory rules. We searched for legislation with the keywords COVID, COVID-19, and coronavirus with Boolean operators when available in the respective site.This category included press releases, reports, fact sheets, websites/webpages, presentations, and other types of publications. This was deemed to be necessary because the Acts of parliament as well as state regulations passed were broad in scope, and in the case of the state of Victoria, allowed for emergency powers to the Premier and the state government. This resulted in policy documents and guidelines being produced through press releases and governmental websites that delineated the mitigation strategies of the state government without having to pass legislation for every action taken. This also meant that updates to guidelines and policies were made rather quickly, and new directives were announced and implemented during the course of the pandemic.We also noticed that while we analysed documents that were obtained from government sources, there were other resources from organisations and non-governmental bodies that were not analysed. In contrast to the legislation analysed which encompassed Australian States and Territories, as well as the Australian Government, we focused the other documents section on those produced by the Australian Government and the Victoria State Government. We focused on the state of Victoria because of its unique situation: at the time of the collection of the documents and legislation, Victoria was undergoing a second outbreak of cases that at its height saw 687 new daily cases on August 4th 2020 as recorded by the State of Victoria Department of Health and Human Services (DHHS) . Victoriother documents category, we searched several government websites that provided information regarding the COVID-19 pandemic. In this case, most of the documents were sourced from the websites of the Australian Government: Department of Health (DOH), Department of Education, Skills and Employment (DESE), the National Disability Insurance Scheme (NDIS) and the Department of Social Services (DSS). Some other documents were also sourced from the state of Victoria’s Department of Health and Human Services (DHHS); because of the great number of cases in the state and the second wave of cases as well as ensuing lockdown measures that occurred between July and October of 2020. We selected documents that spoke directly to measures, guidelines, and indications to be followed by the general public during the pandemic.For the We used framework analysis to examine the included sources. The steps we followed included:Familiarisation: In this step, we familiarised ourselves with relevant literature and performed a cursory read of the dataset.Identifying a thematic framework: We developed a framework based on guidelines for disability inclusion published by the International Labour Organisation [nisation , the Uninisation , and thenisation . Table 2Indexing: We used the thematic framework across the two data categories, legislation and other documents. At this stage, we examined the data for information that was relevant to the thematic framework, and we made necessary adjustments to the framework, to ensure it was relevant and reflected the data. First, we broadened the focus of the analysis to include other meaningful data (what we classified as “other documents”). This other data was communicating government policy that would have otherwise been captured by looking solely at legislation - mainly because of the decision making residing in cabinet members with powers granted by declared state of emergencies. Second, as shown in Table harting: This phase focused on data extraction. We kept a spreadsheet that included the name of each data document and brief notes on each theme found in it.CMapping: Here, we examined the findings for emerging patterns that illustrated the disability inclusiveness of the policy landscape. As such, the legislation and documentation were classified as being inclusive of people with disabilities to the extent of its comparison with the thematic framework.We found that most of the resources were not aimed at disabled people. The documents were written for the general, non-disabled, population. In order to find information about guidelines and practices specific to disabled people, it was necessary to visit specific websites and government agencies.Table Table Of the total of 83 pieces of legislation that were analysed, 30 were specifically aimed at addressing issues that arose because of the COVID-19 pandemic. The rest can be considered amendments or minor changes to existing Acts to account for the changes that have happened because of the pandemic. All but one of the thirteen Acts passed by the Australian government were economic stimulus related; the remaining Act was related to privacy and contact information regarding the government’s mobile contact tracing application.Out of the 114 documents classified as other documents, 54 were aimed at disabled people, their carers, and other support workers. Out of these 54 documents, 33 were written with language suggesting they were aimed at disabled people, including 7 web videos from the DSS with Australian Sign Language versions of documents and information. The remaining 21 documents were aimed at carers or people who work with disabled people. Most of these documents – 29 – were published by Australian Government agencies, while the rest were published by the DHHS, on behalf of the Victorian Government.The remaining 60 documents that were not aimed at disabled people provided information and guidance to the general public. Because of the broad scope of these documents, disability or disabled people were rarely explicitly mentioned. The exception to this last point was the guidance for using masks in public spaces, which explicitly mentioned having a disability as a reason to be exempt from wearing a mask in public.Finally, we noted that only five of the documents were either prepared or informed by advisory groups/bodies including ad-hoc committees and organisations such as the Council for Intellectual Disability and the Victorian Disability Advisory Council. Though, these resources were obtained from government body websites, they included contact details for organisations associated or affiliated with disabled people. One of the documents from the DOH, mentioned principles of governance and consultation with disabled people and relevant stakeholders as part of their Management and Operational Plan for People with Disabilities.vulnerable person. As such, the legislation analysed was not specific to disabled people but could apply to a disabled person. The legislation analysed addressed issues pertaining: care agreements and arrangements as well as flexibility in not being able to fully meet these arrangements given the pandemic without risk of penalty; alternative arrangements to avoid in-person attendance by people affected by family violence; expanded the definition of vulnerable person to include disabled people under the Public Health Emergency act of the Australian Capital Territory; information to carers of disabled people regarding contact tracing efforts; and including the COVID-19 pandemic in situations where impaired decision making falls under the rights, expectations, and responsibilities of those who have power of attorney. Five of these policies were formulated by the Australian Capital Territory, and one by the Australian Government.Only six pieces of legislation addressed people with multiple exclusions, yet the framing was around what the legislation called a Overall, we found that there were limited considerations made. Forty-one of the documents analysed fell under the purview of the theme, but only 17 of these were specifically aimed at disabled people, their carers, or support workers. One of these documents from the state of Victoria highlighted a boost in funding for advocacy and additional support for children and students, people under guardianship, disabled people in the forensic disability and youth.Nine of the documents focused on translation and interpreting services that were available to speakers of languages other than English and Culturally and Linguistically Diverse (CALD) communities. The documents also addressed the mental health needs of young people and those in aged care given necessary isolation due to COVID-19 exposure or illness by providing resources and guidelines. Some of these publications provided contact details or redirected the reader to organisations associated or affiliated with Aboriginal and Torres Strait Islander peoples, people in aged care, international students, remote communities, trauma, family violence, and specialist schools.We found that all but one state’s legislation (Tasmania) could be exported and read in PDF format. Three of the states offered a Microsoft Word document export format (.docx), South Australia offered files in rich text format (.rtf), and only one state, Tasmania, offered an option to change the size of the font on its legislation webpage.other documents, almost all were accessible in a PDF format. Of the available PDFs, the majority were offered in easy read or easy English format. Those that were not, were in a webpage format or available as a downloadable Word document. Only 37 of the total 114 of the documents did not have any type of accessibility option. Of the webpages that offered accessibility features, 41 of them had a listen option. It is important to note, however, that this option was only available in English. The web pages lacked translation features and only 25 of the documents had easy read versions. All information and documents were available in standard Australian English.From the resources analysed under Resources with the more accessible information were the ones targeted to disabled people. However, these had to be sought out from specific agencies. As an example, the DSS offered Australian Sign Language friendly COVID-19 resources in the form of web videos. The DSS web pages also featured visual aids such as icons .Only one Act from the Australian Government addressed access to healthcare of disabled people. While the Act was allocating funding to specific services provided by the NDIS, it was not adding any further funding to the scheme because of the COVID pandemic. Twenty-four of the other documents addressed access to healthcare. These resources provided guidelines and information  aimed at healthcare professionals and support workers in the areas of mental health and disability. Limited information and resources were directly addressed to disabled people. We found that much of the disability-focused information on healthcare was available via the NDIS webpage. Some of the key focus areas of these resources were the availability of telehealth, telemedicine, personal protective equipment, and payment schemes for support workers.There were some measures announced to support the purchase of assistive technology for eligible beneficiaries of the NDIS. This assistive technology was for the use of telehealth as well as the purchase of low-cost disability-related health consumables for those that rely on face-to-face contact with support workers. These are examples of the very few specific accommodations made available for disabled people to have access to healthcare. It must be noted that personal protective equipment (PPE) access was limited to registered NDIS providers.One important MedicareNone of the legislation analysed addressed access to education for disabled people. Resources under other documents provided basic information on operation of schools and contact details for organisations associated or affiliated with disabled people. Only 7 documents provided limited information that was made available for students with disabilities via the DESE’s website, such as particular schools remaining open in certain locationsOnly two Acts addressed financial support during the pandemic. However, the legislation briefly addressed: the payments or options for leave (as well as long service leave) for employees who work in care facilities; and the extension and renewal of professional registrations. In addition to this, there were several budgetary bills that specified a variety of economic stimulus and benefits packages to several industries and people under current financial support programs. The onset of the pandemic saw the introduction of a coronavirus supplement of AUS$550 per fortnight for people in eligible support income payments until September 2021; then the payment was reduced to AUS$250 until December 2020 . The panOnly 8 documents addressed financial support regarding disabled people. However, we found that most of the information regarding financial support was largely available for (and aimed at) carers of disabled people. This included access and/ or changes to carers’ payments in relation to the JobSeeker and JobKeeper programs. The Victorian government committed additional funding ensuring accessibility and appropriate linkages with health and disability supports at each coronavirus assessment centre.Only two legislative documents addressed the needs of people living in residential settings, and one of them was not specific to disabled people. South Australia passed regulations that specified several accommodations that housed and supported disabled people, mental health inpatients, and aged care would fall under their protected person definition. In contrast, the Act from the Australian Capital Territory addressed the changes needed to hold meetings without the in-person attendance of the residents. Twenty-three documents addressed the theme of people living in residential settings. Resources under other documents indicated the key measures taken to protect people living in residential settings were aimed at organisational levels. The Department of Health provided specific guidelines and recommendations in place for organisations providing residential care and their employees. Fact sheets and guidelines for supported residential service proprietors and their staff provided guidelines for the appropriate accommodations that had to be made in relation to COVID-19 and the people in residential care. There were some general recommendations such as information that directed people to existing schemes and support programs. On the other hand, there was tailored and specific information that directed the use of face masks, guidelines for the isolation of individuals suspected or suffering from COVID-19, information on priority testing, among other recommendations. Although disabled people were recognised in some of these documents as a group at greater risk of contagion, only a minority of the documents were aimed at this population.Of the legislation analysed, only two Acts directly addressed reasonable accommodations towards disabled people. The two Acts passed by the Australian Capital Territory addressed voting participation by disabled people in the upcoming territory’s election through electronic means or by phone. The other change pertained to updating decision making regarding medical treatment by a trustee or guardian under the territory’s Mental Health Act. An additional eight legislative documents did not directly address disabled people, but their scope did affect this population. Four of these legislation documents waived in-person requirements of various issues and were substituted by alternative methods; two pertained to rent relief and breaches of contracts during the pandemic; one expanded the definition of an ‘ill’ person to a more comprehensive definition; and one was related to police dealing with a person from a protected category and intentional transmission of the COVID-19 virus.Thirty-one resources under other documents addressed the issue of reasonable accommodations for disabled people. In particular, the resources highlighted some key accommodations made for disabled people including targeted information with the use of inclusive language and communications, details regarding the expansion of resources available to disabled people, and guidelines and communications aimed at support workers and other healthcare providers.Out of the 31 resources analysed, 17 were targeted at disabled people, support workers, and carers. One of the key messages of the documents was the state of Victoria’s guidelines which exempted disabled people from the mandated use of facemasks outside of their homes. The messages from the DHHS analysed under this theme included the use of images of a diverse range of people that included disabled people. The documents outlined some guidelines for practitioners and support workers that work with people classified as high-risk of infection, which included disabled people. Further, almost every publication from various agencies provides contact information for disability support services.The findings indicate a large number of legislation, policies, and other documents outlining the response to COVID-19, at the state and Australian Government levels. However, despite this seemingly comprehensive response, the needs of disabled people were not fully addressed. Furthermore, the structure of the Australian political system means that there are disparities across the different states, with each implementing its own policies in areas such as education, delivery of health care services, among others.The findings revealed the existence of a few direct and several indirect measures. Direct measures were those that were drawn with specific reference to disabled people, while indirect measures were those that also affected disabled people, along with other groups of the population. Disability-inclusiveness appeared to be inconsistent and not fully considered, leaving disabled people exposed to greater risk of COVID-19, with the exception of South Australia that ensured that disabled people living in residential settings were included in their definition of a protected person. A failure of governments to fully protect disabled people against reduced access to or exclusion from healthcare, employment, and social care, and the lack of explicit measures taken to address instances of medical rationing, will inevitably lead to exacerbating existing inequities, further disadvantaging disabled people .Neoliberal policies in the health and welfare sector in Australia  and elseubiquitous disablism [capable of these “essential measures” in the first place” [The intersections of isablism  with a dt place” . As Andrt place” . This ist place”  which arThis article adds to a growing body of evidence showing how disabled people experience structural vulnerabilities, which are exacerbated during the COVID-19 pandemic. Governments need to take a clear stance towards the emergence of such a discourse that actively disvalues disabled people. If one thing has become clearly evident, is that the idea of an “autonomous individual body”  is a ficAdditional file 1. Legislation analysed.Additional file 2. Other documents analysed.


The surface quality expressed by Rz and Ra roughness parameters is examined depending on the sample material and the machining technology. The next part deals with the use of neural networks in the evaluation of measured data. In the last part, the measured data were statistically evaluated. Based on the conclusions of this analysis, the possibilities of using neural networks to determine the material of a given sample while knowing the roughness parameters were evaluated. The main goal of the presented paper is to demonstrate a solution capable of finding characteristic roughness values for heterogeneous surfaces. These surfaces are common in scientific as well as technical practice, and measuring their quality is challenging. This difficulty lies mainly in the fact that it is not possible to express their quality by a single statistical parameter. Thus, this paper’s main aim is to demonstrate solutions using the cluster analysis methods and the hidden layer, solving the problem of discriminant and dividing the heterogeneous surface into individual zones that have characteristic parameters.This work deals with investigative methods used for evaluation of the surface quality of selected metallic materials’ cutting plane that was created by CO The surface quality of the solid material determines and expresses both the grade of the workpiece and the product. Wood and stone products already require a certain level of surface quality for further use. Requirements on it are intensified with the development of metallurgy, especially in the production of cutting tools for daily use, e.g., knives, swords, sickles, scythes, and tools. However, in the production of these types of tools, the evaluation of the surface by sight or touch has been sufficient .Machining methods have also been evolving, ranging from downright primitive to the traditional methods used to date, along with methods for classifying surface quality determination ,2. The rThe methods of surface quality evaluation prescribed by the standards and the repeatability of the production process have led to the idea that it is possible to determine the type of material to be machined under the conditions of repeatability of the measured roughness parameters. The subject of this work was to verify this idea ,4.The need for standardization of parts, products, and processes in industrial production is almost as old as industrial production itself. However, as globalization increases, the importance of interchangeability and substitutability within the supplier–customer chain increases. Setting up rules for assessing different products or production processes is the main goal of the International Organization for Standardization. Standardization in surface quality assessment is mainly dealt with in ISO 4287 and ISO 4288 , which were the measured values of these roughness parameters on all samples machined in the same way. Then, these triplets were inserted at the input of the appropriate neural network, which performed its recognition of the type of material and laser machining technology. The neural network was debugged in the environment of Statistica 14.0 software, specifically in the neural network part.In order to use this neural network without software Statistica 14.0, C ++ source code was generated using the scales, and the neural networks were further tested with a free Dev C ++ development environment. Based on this theoretical estimate, the neural network would look as suggested in 2 laser sample evaluation neural network showed a lower probability of a correct decision due to a lower level of learning. Hence, a higher error formula value was lying on the error plane.Both neural networks recognized the material correctly, even though the COBased on measurements of individual heterogeneous surfaces of sample materials defined in This was used to teach the creation of a three-input neural network and with one hidden layer. The optimum number has been optimized by the number 6, which comes from As shown in 2 laser, the situation is more complicated. The probability of recognition may decrease to 50% for measured unknown samples, which is extreme. In general, samples cut by fiber laser technology have a much higher probability of correct recognition than samples cut by CO2 laser, which is mainly due to the different typology of cutting [In the case of a CO cutting ,10.The main idea of this work was to show the use of the measured values of roughness parameters to determine the sample material using artificial intelligence elements. First, Rz, Ra, and Rmr parameter values were acquired for each sample using the Talysurf CLI500 3D scanner. The measured data were first analyzed by Minitab version 18. It was verified whether the data contained outliers or whether gross measurement errors influenced them in several steps. After that, the sets of values of Rz and Ra’s parameters were analyzed for a statistically significant influence on the material or technology used. In all cases, the influence of the material and the machining technology applied was found to be statistically significant. In the next step, data were sorted by similarity criteria using cluster analysis. Since the two sets of data always shown high similarity, it turned out that using only the parameters Rz and Ra in combination with standard statistical analysis procedures was not sufficient to determine the sample material. Therefore, for each laser type, Statistica 14.0 generated a perceptron neural network with one hidden layer, which evaluated the measured values of the parameters as mentioned above together with the values of the parameter Rmr, which was used as an additional criterion in the determination of the sample. Then, these networks were tested on a test dataset, and in all cases, the material was correctly recognized by the network. 2 laser sample network. The highest reliability was recorded for fiber laser-treated steel 1.0043 and the lowest was recorded for CO2 laser-treated steel 1.0043.In general, the fiber laser sample network showed higher reliability than the COWhen comparing the results contained in this article, it can be stated that the evaluation of heterogeneous surfaces of samples based on the parameters of ISO 4287 and ISO 25178 standards cannot be done well without using discriminatory statistical methods. However, even today’s commonly used cluster analysis in this assessment may fail or give distorted and inexact results if clustering is based on Pearson coefficients, as described in the article and the relevant tables.Unambiguously, the best but not the most uncomplicated method seems to be the use of artificial intelligence elements, namely the classical three-input neural network, with one hidden layer containing six neurons, performing its solution to the discriminatory problem in cutting technology and sample material having a heterogeneous surface.In the case of high-quality sorted data containing triples of amplitude and hybrid parameters, the so-called learning of the found neural network, as described in the article, can be realized according to the triplets describing the character of heterogeneous surfaces in arbitrary sections. As shown from the results table, a well-learned neural network, one with minimized error function, can indicate a low probability of discriminant in various cutting technologies and complicated heterogeneous surfaces.Then, it depends on whether it is possible to create separate networks for individual technologies, which is understandably more likely to be discriminatory, but at the expense of significantly complicating the solution or a universal network, as demonstrated in this article.


The COVID-19 pandemic has wreaked havoc in the world from last year, and any further insults like Zika virus will surely bring the apocalypse unto us. In July 2021, Zika began spreading in India, mainly in the state of Kerala. Zika infection resembles closely COVID-19 and other arboviral infections, which might lead to delayed and misdiagnosis, further leading to underreporting of cases. Some of the feared complications of Zika include Guillain–Barré syndrome and congenital Zika syndrome leading to microcephaly. Thus, Zika virus disease (ZVD) has significant public health and social impacts. Since the trifecta of infectious diseases  are all conducive to the spread of Zika in India, there is a huge risk that ZVD might become endemic in India, which is especially dangerous in the backdrop of this pandemic. This has to be stopped at all costs: the main aspects of which are public health measures, vector control and early diagnosis, especially in case of pregnant women. The diversion of healthcare resources for this pandemic has albeit made this difficult, but we must do our bit if we have to overcome this situation. Dear Editor,The world today is grappling to control the SARS-CoV-2 pandemic. The situation is even dreadful in India due to the lack of public health awareness among the population combined with an overburdened healthcare system . There hSince the inception of the COVID-19 pandemic, the index case of the Zika virus disease (ZVD) was reported in Kerala on July 8, 2021, with the tally rising to 65 on August 03, 2021 , 8. ZIKVCurrently, the actual numbers might be even higher than the official data because of lack of testing facilities, asymptomatic cases and coinfection with diseases with similar presentation as mentioned below. The possible birth of a superimposed epidemic due to ZVD is to be anticipated and this would wreak havoc on the already exhausted health system. The clinical course of Zika in itself is responsible for many public health repercussions . Zika inZIKV disease is in itself a self-resolving infection. Rare complications include Guillain–Barré syndrome, neuropathy and myelitis , 14. GuiAnother devastating effect is if a woman is infected during pregnancy, it may result in congenital Zika syndrome, including microcephaly and other congenital malformations; other complications during pregnancy including preterm birth and miscarriage . This inIndia is at a higher risk of the quick spread of Zika infection as numerous parallels exist between India and the countries most affected by the disease with respect to climate, distribution of mosquito species, and the prevalence of other arboviruses such as chikungunya and dengue; with a population that does not possess herd immunity to ZIKV . The lacWith the pandemic exposing the faltering health system, we cannot afford another outbreak in the country. Hence, creating awareness among the public about ZVD, vector control and preventing the disease are the best and the most cost-efficient options available. Long-term effects that affect the newborns will lead to a population that needs more medical and economic support adding on to the existing economic burden of the nation.The aspect of mitigating Zika infections that is in practice in India is limited to mitigating the vector, and as such, there are a number of other avenues which can be explored to decrease the Zika risk significantly. These include actions at the topmost level, such as legislation to actions involving the lowermost rungs of the healthcare system, such as accredited social health activists (ASHA) workers, who can play a key role in disseminating valuable information to the most vulnerable population groups.A proper protocol can be developed by the government for diagnosis, treatment and most importantly preventive actions; allocating appropriate funds for each aspect. Awareness about the disease among pregnant mothers should be prioritized and asked to take necessary precautions against being infected with ZIKV to prevent congenital deformities and other complications during pregnancy . This caNecessary precautions like minimizing bare skin exposure, mosquito proofing houses by installing screens on doors and windows, preventing the stagnation of water around the house, using protective nets around the bed and use of EPA-approved insect repellents in the areas affected by ZIKV are to be advised .If a pregnant lady is diagnosed with ZVD, the mother should be advised to get an ultrasound scan to rule out abnormalities in the fetus. Two vaccines are in development in Phase II under Bharat Biotech for ZVD ; howeverFurthermore, identification of cases is through RT-PCR test of the blood samples of the infected . In IndiTo prevent the virus from entering the endemic population of viruses in the country, we must be vigilant in detecting the cases as early as possible, especially at this crucial time where more breeding sites for the Aedes spp. are made available due to the monsoon season . HoweverThus, the situation is currently like a tightrope walk: the balance depends on adequate public health measures along with cooperation from the public. Each individual will have to do his/her part and maintain vigil to overcome the situation.


Leadership theories predominantly focus on the top-down managerial influence on employees. Recent theoretical developments, however, have accentuated the call for scholarly attention on holistic models comprising both leadership and followership. In the present study, the author developed a theoretical framework of upward influence and leadership construction by drawing on resource dependence theory. Specifically, the author proposed a novel outlook illuminating upward influence in hierarchical relationships whereby employees, as the hosts of tacit resources, inculcate interdependent relationships with their managers. Considering the dependence of employees and managers on each other for tangible and intangible resources, relationships with a (a) power imbalance and (b) joint or embedded dependence emerge. The author further explained the role of leadership construction in power-imbalanced and embedded relationships and elaborated on organizational and team structural boundary conditions. By revitalizing upward influence, the proposed theoretical framework offered new insights into leadership and followership literature, with the potential to change the conversation from a foundational thesis assuming the managerial capacity to lead and bestow resources on their subordinates to a two-way resource-dependence perspective, which has been scarcely considered in contemporary management research. Leadership is predominantly conceived as a top-down influence process that attracts profound scholarly attention in management research  that is necessary for an individual to perform a job; other characteristics referred to personality traits or other attributes that affected the ability of individuals to perform a specific job. For instance, in the classic conceptualization of human capital, Becker and Gerhart  in proportion to the need of A for resources that B can provide and (2) in inverse proportion to the availability of alternative actors capable of providing the same resources for A. Conversely, actor B is dependent upon actor A (1) in proportion to the need B has for resources that A can provide and (2) in inverse proportion to the availability of alternative actors capable of providing the same resources for B. Translating this to manager–employee relationship, the interdependence of a manager and an employee will be affected by both (a) the dependence of the manager on an employee and (b) the dependence of the employee on the manager. An employee is dependent on the manager (1) in proportion to the need of the employee for resources that the manager can provide and (2) inversely with the availability of alternative managers capable of providing the same (or better) resources for the employee.sum of dependencies of actors on each other, and dependence asymmetry, or the difference in dependencies of actors on each other. Casciaro and Piskorski  and a project manager in a software development team can create a power imbalance in favor of the technical expert employee. A chief architect is an expert in software design responsible for design choices, standards, coding, tools, and platforms. A project manager, on the other hand, is responsible for the successful execution of a project within the given time and approves the budget-fulfilling requirements of stakeholders. In most organizations, career paths for an architect and a manager delineate in two parallel career ladders. Although a software architect may formally report to the project manager, as a subject matter expert, they possess tacit knowledge and information. Thus, the chief architect who is considered valuable and difficult to replace with generic alternate choices holds considerable power and dependency to influence the manager. In his classic work, Crozier  explaineUpward leadership is constructed in such dependence relationships when an employee claims to be the leader and a manager grants leadership, nodding in acceptance of the informal leadership of the employee. Extant research suggests that, when the leaders lack the expertise to lead, the employees use upward influence by means of legitimization and direct pressure on the leaders  the attempt of the employee to claim leadership is granted by the manager and (b) the attempt of the manager to claim leadership is denied by the employee.via consultation with charismatic and inspirational leaders  attempt of the manager to claim leadership is granted by the employee, and (b) attempt of the employee to claim leadership is denied by the manager.Active joint/mutual dependence relationships form when both the employee and the manager possess critical resources needed by the other. Unlike the hierarchical leadership seen in power-imbalanced relationships, a participative and shared leadership is likely evolved between the employee and the manager in embedded relationships. Gulati and Sytch  argue thconsultation, which refers to the seeking of joint participation in planning a strategy, activity, or change for which the assistance of the other is desired. Second, they participate in exchange, which refers to the offering of an exchange of favors with a target that indicates a willingness to reciprocate at a later time and a promise to share the benefits if the target helps. Last, the parties form a coalition, which refers to the seeking of aid from others to persuade a target to do something or using the support of others as a reason for the target to agree. Accordingly, the author posits,Ansari and Kapoor  highlighProposition 5: When a manager and an employee have a dependence relationship with an active joint/mutual dependence, (a) the attempt of an employee to claim leadership is granted by the manager and (b) the attempt of a manager to claim leadership is granted by the employee.Passive joint dependence relationships are formed when neither an employee nor a manager possesses the critical resources needed by the other. A passive joint/mutual dependent relationship is likely to stay dormant unless external organizational forces build an “interpretive context” that increases the salience of dependence between the manager and the employee. Accordingly, the author posits that neither employee nor the manager claims leader identity from the other,Proposition 6: When a manager and an employee have a dependence relationship with a passive joint/mutual dependence, neither (a) the employee attempts to claim leadership nor (b) the manager.Social influence and leadership construction are affected by situational contingencies such as team and organizational structures  × 2 (organic vs. mechanistic organizations) matrix in Proposition 9: In organic organizations, the manager–employee relationship will be embedded–jointly dependent in uniform teams and asymmetric in specialist teams, such that the positive relationship between the firm-specific human capital resources of an employee and their influence on a manager will be strongest in specialist teams as compared with uniform teams.On the other hand, a mechanistic organizational structure creates an internal environment, which restricts the influence of an employee on managers due to the power of the manager over the human capital resources of the employee because of bureaucratic rules of authority and conformity Weber, . In suchProposition 10: In mechanistic organizations, the manager–employee relationship will be embedded–jointly dependent on specialist teams and asymmetric in uniform teams, such that the positive relationship between the firm-specific human capital resources of an employee and their influence on a manager will be weakest in uniform teams as compared with specialist teams.The theoretical framework explained upward influence and leadership construction processes from a resource-dependence lens by considering employees as active sources of leadership. The framework elaborated on the personal and interpersonal attributes of upward influence whereby employees create dependence and thus influence the managers. On this basis, in the interpersonal context, employees act to claim leadership identity, which meets either the acceptance or refusal of the managers contingent on the team and organizational boundary conditions. In particular, the framework discussed upward influence in specialist vs. uniform teams and mechanistic vs. organic organizations. Whereas, specialist teams facilitate opportunities to claim leader identity so that employees can influence higher authorities through dependence on the tacit HCR, uniform teams provide more alternatives for managers, consequently reducing dependence on the employees and, in turn, restricting the opportunities of employees to claim leadership from higher authorities. Lastly, the framework illustrated the moderating effect of mechanistic vs. organic organizational structures. In mechanistic organizations, the hierarchical structure is stable and well-defined, giving rise to the traditional top-down leadership. However, in organic organizations, lateral and relational relationships flourish, providing employees the openness to influence higher authorities. Overall, as proposed in the theoretical framework, two kinds of dependence relationships, power-imbalanced and embedded, emerge. Upward leadership influence is co-created by employees and managers in power-imbalanced and embedded relationships through the claims of employees of the leader identity.The proposed theoretical framework contributed to the literature in several important ways. First, the extant leadership literature abounds in leadership theories focusing on “leading” Zaccaro, . The treSecond, resource dependence theories explain interdependence relationships between manager –employee dyads, especially in investigating the influence that rises from the bottom-up. Scholars in sociology and social psychology were among the first to theorize asymmetric and join dependence in interpersonal relationships  as a function of interrelational resource dependence. Two meaningful messages evolved from the proposed framework. First, the co-construction of leadership employs active participation from both leaders and followers from a resource-dependence barometer to forecast upward influence. The scholarship of resource dependence in a leader–follower dyad empowers followers-centric notions to determine the perspective when leadership influence reverses the flow cascading up through the hierarchy. Organizations should be mindful of the social influence dynamics in the dyads by paying caution to how they may assume traditional viewpoints of leadership, which could be polarized toward the employees in certain work contexts, teams, or organizations. Second, managers should change their fixed mindsets to foster the leadership capabilities of followers by leveraging a work environment that is conducive to follower-centric leadership through positive interactions and the reduced use of denial when the followers attempt to claim the leader identity. More importantly, both leaders and followers must thoughtfully devise stability and congeniality in the dyadic relationship by paying attention to the nuances of resource dependence. In this regard, organizations should encourage norms and practices that their managers and employees can use to work together toward a mutual understanding and openness to recognize the bidirectionality, both upward and downward, of dependence, social influence, and leadership.The operationalization of firm-specific and generic human resources capital is of prime significance to empirically test upward influence and leadership construction in the proposed theoretical framework. The author suggests a few direct and indirect ways to operationalize this key construct. In a direct method, the researchers can collect useful information from job descriptions, open- and/or closed-ended questionnaires, and interviews with employees or other raters, for instance, supervisors. In an indirect method, the supervisory ratings of a person–job fit for an employee or the self-ratings of a person–organization fit can provide proxies for people to hold firm-specific human resources capital. Theories that have dominated a set of person–environment fit research in organizational psychology include the theory of work adjustment (TWA)  and organizational (mechanistic vs. organic) boundaries were discussed, enabling novel avenues for future research to study the upward influence processes in organizations based on the interplay of dependence, power, resources, and social influence.The author confirms being the sole contributor of this work and has approved it for publication.The author declares 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 aim of the study was to assess adherence to hand washing by healthcare workers (HCWs) and its variations over time in hospital wards. We wanted to check whether the pandemic had changed the behavior of HCWs. The study was conducted between 1 January 2015, and 31 December 2020. The HCWs were observed to assess their compliance with the Five Moments for Hand Hygiene. We described the percentage of adherence to World Health Organization (WHO) guidelines stratified per year, per specialty areas, per different types of HCWs. We also observed the use of gloves. Descriptive data were reported as frequencies and percentages. We observed 13,494 hand hygiene opportunities. The majority of observations concerned nurses who were confirmed as the category most frequently involved with patients. Hospital’s global adherence to WHO guidelines did not change in the last six years. During the pandemic, the rate of adherence to the procedure increased significantly only in Intensive Care Unit (ICU). In 2020, the use of gloves increased in pre-patient contact. The hand-washing permanent monitoring confirmed that it is very difficult to obtain the respect of correct hand hygiene in all opportunities, despite the ongoing pandemic and the fear of contagion. Hands are the main vehicle of infection in healthcare. The increasingly frequent use of digital devices multiplied the opportunities for contact between hands and the environment. The repeated pressures of the fingertips, sometimes covered with gloves and sometimes not, on cell phone or on workstation keyboards, PCs, monitors, or buttons of electro-medical equipment makes these objects become vehicles of infections ,2 RecentEven though the World Health Organization (WHO) and Centers for Disease control the guidelines and recommendations for appropriate hand hygiene (HH) practices since 2002 ,5, the cNumerous studies tested the knowledge, attitudes, and HH compliance among healthcare workers (HCWs), through questionnaires or by direct observation of the HCWs behavior ,8,9,10. Despite extensive data that were published on hand washing and on the usefulness of this procedure in preventing the transmission of infectious agents within the hospital, the topic is not discussed as such to be an indicator of the behavior of health workers towards patient. Some authors evaluated the evidence on behavior change interventions and policies directed at healthcare professionals working in primary healthcare centers. Education, training, and enablement in the context of collaborative team-based approaches are effective for changing the practice of primary health care professionals ,13. The The interventions are commonly divided into three main categories—persuasive; action and monitoring; and educational or informative . Audit aIn this work, we described what was observed over a period of 6 years and verified the different approaches to the same hand-washing hospital procedure. In particular, we wanted to verify if the percentage of adherence to hand washing was influenced by the COVID 19 pandemic, in 2020.Recent studies published in the literature report that the vulnerability to mental health illnesses increased in the general population ,19,20,21We reported observations of a routine practice among health professionals to verify whether the fear of acquiring the infection, nervousness, anxiety, social distancing, or other psychological aspects, unknowingly led to the adoption of proper behavior, consequently improving the level of adherence to the hand washing procedure.Assuming that external elements can affect healthcare workers’ adherence to hand washing, their presence or absence was recorded, during the observations in the wards. We checked whether the compliance of the procedure was linked to scientific knowledge or whether other factors acted in increasing or reducing the percentage of adherence to hand hygiene, in addition to permanent monitoring of hand washing.This study was conducted between 1 January 2015 and 31 December 2020, in a reference teaching hospital of 400 beds located in Catania, Sicily, Italy. Observation of the HCWs for the hand washing practice was conducted during one of their contacts with the patients in the different wards, by members of the infection control team. The HCWs were observed during working shifts to assess their compliance with “Five Moments for Hand Hygiene” extracted from the WHO Guidelines on Hand Hygiene in Healthcare [The observers were infection-control nurses who had done a training course according to the rules of the WHO. They were inside the room looking at the behavior of HCWs, while they were taking care of the patients. WHO form checklist was used to collect data obtained by direct visual observation on compliance with HH guidelines and proper glove or gown use, on at least 200 opportunities per ward, every six months.For this study, we grouped members of the healthcare team that provided direct medical care to patients, according to their main mission, and labelled them as follows.NU–Professional nurses. The people in this group provide direct, hands-on patient care, often directed by a doctor, but also initiating care based on their own clinical judgment and observation at the patient’s bedside. They monitor patient progress and response to treatment. They deliver primary, clinical, bedside care to patients in hospitals, including nursing assessments, medication administration, and delivery of blood products. They provide care for all types of patients, supervised by a head nurse.PHY-Attending Physician or Specialty doctors. They are medical doctors who graduated from an accredited medical school, with extra expertise in one type of medicine or another. Attending Physicians are doctors who are responsible for supervising and teaching, and training interns, residents, and medical students. They are ultimately responsible for all aspects of patient care.R-Resident Physician or Medical Student. Resident Physician is a physician who participates in a postgraduate medical education and training program in a specialized area of medicine. He acts as both a student and a health care provider and works in concert with other members of the health care team to provide direct medical care to patients. He is supervised by attending physicians or Specialty doctors.Others-Support Staff. In this category, we grouped healthcare assistant or auxiliary nurses. They have a lower level of training than a professional nurse, typically providing basic patient care. Auxiliary nurses require no academic qualifications. The role of an auxiliary nurse is to assist qualified nursing practitioners in administering care to patients. They are required to assist patients for personal care, for food, and personal hygiene.Each year the observations were made in a limited number of wards, which were randomly selected at the beginning of the year. The list of potential wards always included the departments of general medicine, surgery, and intensive care. Surveys of other departments, such as pediatric departments, were carried out annually but did not form a part of this work.The personnel knew that they were observed, but they did not know exactly when. Everyone was made aware of the results of the observations carried out. A letter from the Hospital’s Infection Control Team was addressed to the Medical Director and the Head Nurse at the beginning of the year, informing them that they would be part of the control program.-HCWs training and field training, in small groups, were carried out in various departments with simulators.-Observations were carried out in wards for two months, twice a year, and the results were reported to the Medical Director and Head Nurse to share the recorded data with their staff-Fixed hydro alcoholic gel dispensers were installed in the main transit points of various departments.-Posters were affixed to remember how to correctly perform hand hygiene, as ordered by the WHO.-Informative brochures with the correct instructions for hand hygiene were edited for staff and visitors, annually renewed, and distributed on the celebration day on 5 May.The following interventions were carried out to increase adherence to HH, as a part of the Hand Washing Observation audit and feedback program (HWOP):The study consisted of two phases—in the first phase, the observations made in a single unit were reported and then grouped into four clinical areas.We also recorded, once for each session of observation, the presence or absence of favoring factors concerning adherence to HH in a special note field. We assigned one point when the factor was present and zero when the factor was absent.The primary endpoint is the overall percentage of adherence to WHO guidelines and recommendations for appropriate HH practices over a six-year period by HCWs. We described the percentage of adherence to WHO guidelines stratified per year, per specialty area, and for different types of HCWs. We wanted to check whether the use of gloves in pre-contact maneuvers with the patient showed changes, by comparing the data observed in 2019 and those observed in 2020, because of COVID 19.t test comparisons were performed among group means.Descriptive data were reported as frequencies and percentages. One-way analysis of variance along with orthogonal p values of less than 0.05 were accepted as significant. Trend analysis along years using linear correlation was conducted among operators working in different setting units.We observed 13,494 hand hygiene opportunities in total.The hospital’s global hand hygiene compliance per year is described in The percentage of overall hospital compliance with hand washing increased sharply in 2016, when the systematic intervention actions described in the methods began. The percentage grew further in recent years, increasing overall by 20% in 6 years. However, it is not possible to evaluate the weight of each single intervention in a reasonable manner.Hand washing with soap and water is preferred to hand rubbing with an alcohol-based formula. Alcohol-based hand rubs rather than soap and water are preferred by physicians and residents.The hospital’s global percentage of adherence to the procedure did not change in 2020.In 2019, 1652 pre-contact opportunities were observed and in these, the use of gloves was recorded in 68% of cases. In 2020, with 1188 pre-contact opportunities, gloves were used in 74% cases. The overall percentage of use of gloves, during patient care, increased slightly. It was noted that in 2020, the use of gloves, previously reserved only for aseptic maneuvers, increased in pre-patient contact, going from 66 (2019) to 73 (2020). On the contrary, during aseptic maneuvers, the use of gloves reduced (from 89% to 82%), while the use of a gel hydro-alcohol increased.Adherence to HH by year and by professional category is described in p < 0.05) to the procedure, except in 2018. The percentage of adherence remained stable throughout the years under observation. The majority of observations concern nurses who are confirmed as the category most frequently involved with patients. Nurses recorded higher adherence . Compliance showed variations over the years in all professional categories observed.Intensive care—Nurses in the ICU always showed higher compliance, in comparison with the other professional figures observed. Anesthetists sometimes reported insufficient rates.The environmental and organizational factors, mostly influencing the aspects of the procedure are indicated in As we can see in The hospital annually offers several editions of a training course with videos, questionnaires, and tests, with a simulator. New workers or those serving in high-care-intensive wards are especially welcome to participate. In 2019, the members of the Hospital Infection Control Committee changed and it was not possible to organize these courses, consequently, these were postponed until the following year. Unfortunately, due to the pandemic in 2020, the hospital was able to organize only a few courses, in the first 2 months only.The medicine area showed a steady increase over the years, starting from 3 up to 8 positive factors listed, until 2019.r = 0.6; surgical area r = 0.3; intensive care area r = 0.23. For the relatively small number of observations only in the medical area, a weak positive correlation was found, even if it did not reach a significant level. No correlation was observed in the other data sets.A correlation was sought between the score obtained by the areas and HH compliance for the different years observed—medical area The recent COVID-19 pandemic focused on proper HH practices , as a procedure of proven efficacy in the prophylaxis of the transmission of infectious diseases. Great importance was recently placed on the use of facial masks in hospitals, and of course, on hand washing .A contaminated environment is one of the major risk factors for healthcare-associated infections, but some factors can definitely affect their incidence. It is widely documented that HCW’s hand decontamination practices, reduces the rates of hospital-acquired infections ,28,29.The Hospital Infection Control Committee drafted an internal evidence-based guideline for HCWs in 2002 and interventions were carried out in a Hand Washing Observation Program (HWOP) that started in 2015. Permanent monitoring of hand washing makes it possible to identify possible improvements in different health situations . We collAdherence of HCWs, to recommended hand hygiene procedures, grew over the years, but is still insufficient, as compared to the lower limit suggested by the WHO (70%).Despite these interventions and the adoption of a hospital procedure, we observed numerous differences among the operators of different departments.The nurses are the healthcare personnel with the closest and most frequent contact with the patient. The rate of adherence of nurses is usually higher than the overall average percentage recorded in the wards, in any year under observation. It is likely that the nurses are educated and undergo adequate training for the described practice. In 2020, however, nurses worsened their performance due to understaffing, patient overflow, and reorganization in the wards.The physicians who have more frequent contacts with patients are surgeons. The physicians hardly follow training courses in this area considering it not within their competence.We observed that their own models influence the behavior of health professionals, confirming the benefit of leadership in HH improvement strategies .In the general medical area, the procedure recorded the worst compliance, but it grew over time. The increase in adherence to the WHO protocol in the Medicine Unit probably might be due to parallel positive increase in favoring elements, as shown in To explain these differences in behavior, we evaluated the critical elements regarding the organization of the department reported in the forms of the operator’s observation.The presence among the nursing staff of a nurse as a member of the hospital’s infection control team was fundamental. Only deep awareness and training allow reaching the highest levels of adherence. For residents, adequate training on the subject is recommended. In fact, no specific subject is provided in the entire course of their studies on Medicine and Surgery.To promote correct behavior, it can be proposed to entrust “adherence to the respect of hand hygiene” as a performance objective of all HCWs. It can also be suggested to do a practice run, because it is often found that HCW does not have a clear awareness of the 5 moments recommended by the WHO. They use the procedure more for defensive purposes than for preventive ones.To achieve adequate levels of adherence, collaboration of the Hospital’s Pharmacy is essential for supplying the correct hydro alcoholic solutions and devices. The allocation of the hydro alcoholic gel dispenser in any room where patients were visited seemed to be more useful than the sink placed at the entrance of the hospital room.A separate note should be written for discussing the use of gloves; this is being monitored since 2017. Healthcare personnel’s use gloves for defense against contagion rather than for prophylaxis towards the patient ,33. The The use of environmental decontamination procedures or disinfection of instruments might reduce the microbial load in the environment, but are never a substitute for hand hygiene, which remains the main vehicle of pathogens in hospitals ,37,38,39Respect for correct behaviors in the hospital is not only a problem of technical knowledge of the procedures, but also personal education, psychological factors, and above all, organizational factors play an important role . A high New motivations in staff and patient involvement in hand hygiene should also be tested ,45,46.We can consider that the risk of contagion, through the hands of the healthcare staff, is effectively kept under control, since half of the observations concern nurses, and they carried out positive actions in about 70% of the cases observed.Our work showed that the pandemic did not change the habits of health personnel regarding hand washing when approaching the patient. Despite the presence of guidelines, strong recommendations and the fear of COVID-19, unlike what could have been hypothesized, global adherence to correct hand hygiene procedures remained unchanged. In case of overcrowding of departments, it is not possible to guarantee correct hand washing. Health personnel practically reached maximum adherence to the procedure even before the pandemic. Only in ICUs, supported extensively by personnel and safety devices, a significant increase of the correct behavior was found, confirming that only major organizational changes could lead to an increase in the level of compliance.Neither the percentage of washing with water nor the friction with gel changed. Health workers’ preference for hand washing rather than hydro alcoholic friction was also confirmed in 2020.Limitations and strengths of the study. Observations were conducted in a single medium-sized hospital for a period of six consecutive years.The constant monitoring over the years by the same observers reduced possible bias in the collection and analysis of data. These data would be used to evaluate the comparison with those that would be subsequently processed.The comparison between the observations made in the years preceding the pandemic and the surveys carried out in 2020 did not show an overall increase in compliance with the procedure, despite fear of contagion.Probably the overcrowding of the departments or under sizing of the staff did not make it possible to improve the performance of HCWs and therefore provide optimal care. Only in intensive care units, which are widely supported by personnel and safety devices, there was a significant increase in correct behavior.Despite the health management involvement in the reduction of the transmissible charge by any means ,47, everFear of contagion led to an increase in the use of gloves in pre-patient contact manoeuvres.Despite what might be expected, adherence to the procedure did not increase. The medical staff probably already did the maximum.More research on the psychological influence of COVID 19 on HCWs is needed.


Venous access devices (VADs) play an important role in different clinical contexts. In pediatric subjects, VAD placement is more complicated than in adults due to children’s poor cooperativity and reduced vascular access. Adherence to guidelines for the placement of VADs could prevent the occurrence of complications, but data in the literature are general and not exhaustive, especially with regard to the pediatric population. The objective of this study was to assess adherence to guidelines for the placement of VADs in a pediatric setting. A retrospective observational study was conducted in the general ward of a pediatric hospital in the northern region of Italy. Data related to consecutive admissions in the period from 1 January to 31 December 2019 were collected according to the availability of clinical documentation. A cohort of 251 subjects was considered, yielding a total of 367 VADs. Device permanence in situ and the effective administration of intravenous therapy were associated with an increased risk of complications, while adherence to guidelines was an important protective factor. Adherence to guidelines for the placement of VADs is an independent and positive predictive factor for the prevention of complications due to the presence of a vascular device. Vascular access devices (VADs) are among the most discussed topics in healthcare services because of their important role across all disciplines in children and adults in both inpatient and outpatient settings. The positioning of vascular devices, in various forms, represents the most common invasive procedure performed in secondary care , such asIn particular, children require vascular access for many indications, including hydration, infusion of parenteral nutrition, administration of medications, and obtaining blood samples for laboratory analysis . HoweverRisks associated with intravenous devices can vary depending on which device is selected. Even after choosing the lowest-risk device, such as peripheral VADs, patients can suffer from multiple attempts at insertion and re-sites, all of which can be avoided if critical thinking is applied early in selecting the most appropriate device for treatment . FurtherPeripheral intravenous cannula is the most commonly used device in hospitalized patients . The corThe characteristics of infusion therapy, such as low pH and high osmolarity, are recognized as risk factors for peripheral vein infusion-related phlebitis .Spina et al. proposed, in the Italian context, high- and intermediate-risk drug lists produced by the Infusion Nursing Society (INS) Task Force on cytotoxic substances that can cause tissue damage ; the comIn a recent review, an evidence-based index of low-risk noncytotoxic vesicant medications and solutions was developed, expanding the previous list cited in a second list, reported in Central venous catheters are used to deliver intravenous medications, are essential for diagnostic and therapeutic interventions and are indicated in patients with limited or difficult peripheral access, including those requiring frequent blood collection . SeveralVADs are identified as the most common device associated with hospital admission for adverse medical events in pediatrics, both peripheral and central ; the mosAdherence to guidelines for the placement of VADs could prevent complications, premature device failure, vessel damage and venous depletion, but to the best of our knowledge, there is an important lack of information about this topic, especially in the pediatric context.The objective of this study is to evaluate the association between adherence to current guidelines for VAD placement and the development of complications in hospitalized children.This observational retrospective study was conducted in the Friuli—Venezia Giulia Region, northeastern Italy. Data were collected from consecutive medical charts (according to the availability list provided by the structure) of subjects hospitalized in the general pediatric ward of Burlo Garofalo Pediatric Hospital in Trieste.Data were collected anonymously on an electronic case report form by means of the web software REDCap (Research Electronic Data Capture) in collaboration with the Unit of Biostatistics, Epidemiology and Public Health, Department of Cardio-Thoracic-Vascular Science and Public Health of Padua University.The study did not involve direct patient contact. Informed consensus through the GE.CO. system (in use in the region considered) for the use of clinical data for purposes of clinical research had to be obtained before conducting the present study, which was required and considered valid.The inclusion criteria were age between 29 days and 16 years at the time of last admission, admission to the selected care unit between 1 January 2019 and 31 December 2019, and the presence of signed informed consent to the treatment of data for scientific reasons through the GE.CO. system given by legal guardians of the subjects. Patients were excluded from the study in case of absence of one of the inclusion criteria, subjects in replacement renal therapy and arterial devices and/or arterial blood sampling.The variables collected can be divided into three groups: demographics and anthropometric characteristics ; disease and therapy characteristics ; and VAD characteristics . Data on all types of intravenous (IV) therapy, including those according to lists of injectable substances recognized as dangerous for peripheral veins, were also collected. These drugs are presented in The criteria used for defining adherence to clinical guidelines were (i) drug infusion in central VADs for drugs associated with endothelium damage ; (ii) inA basic descriptive data analysis is reported using the median (I–III quartile) for continuous variables and the percentages (absolute numbers) for categorical variables, as appropriate. Unadjusted differences were tested using Wilcoxon or chi-square tests without continuity corrections whenever appropriate, depending on the variable analyzed.D and R2 on a set of bootstrapped  resamples. The analysis was performed using the RMS libraries [The effects of relevant confounders on complications were considered by estimating a multivariable longitudinal linear model. Variables were selected from a pool of significant variables by univariable analysis (at least 0.25) using the Akaike information criterion in a forward fashion and a threshold for significance of 0.10 . Nonlineibraries  and the ibraries .The study sample included 251 subjects, yielding a total of 367 admission events observed (from 1 to a maximum of 5 events per subject). Among all admissions, 270 VADs were explored (flowchart reported in p < 0.001), duration of intravenous therapies (p < 0.001), presence of venous access (p < 0.001), and complications (p = 0.005). In eight occurrences, it was not possible to evaluate adherence to guidelines because no data concerning VAD were retrieved.A significant difference between the two groups (nonadherent vs. adherent to guidelines) was observed in length of stay (p < 0.001), infusion of intravenous therapies (p < 0.001), and adherence to guidelines (p = 0.003).In A multivariable model was implemented to estimate the association between the presence of complications and guideline adherence, VAD dwelling days, and administration of intravenous therapy .p < 0.0001), while for the other two factors, a positive association was observed . The effect of VAD dwelling days was still significantly nonlinear (p = 0.0014).A significant negative association was observed between the presence of complications and adherence to guidelines  were performed in accordance with the hospital’s institutional policy following practical guidelines on this topic .In this study, nonadherent cases seem to be associated with a prolonged length of stay, which can increase several risks related to the hospital setting, costs for the healthcare system, and the psychological suffering of children ,21. Howemidline in case of nondamaging substances, is required [The first aspect used to define nonadherent cases was represented by therapies prolonged over 6 days. In the observed institute, no protocols or procedures were found that regulate in detail the replacement of vascular access; in addition, it should be considered that some devices may have been removed and repositioned, but these actions might not have been documented. Although the gold standard is represented by the less invasive procedure, in this case, a central VAD, or alternatively, required ,29. AdvaHowever, data from this study revealed that peripheral devices were often inappropriately present. Furthermore, more infusions of drugs belonging to list B have been shown to be administered in the nonadherence group than in the adherence group. Similarly, a significantly higher number of complications  occurred in the nonadherence group. However, other factors, such as the disease severity and the activity level of the patient, should be considered in the evaluation of complications. No differences were observed in VAD dwelling days with respect to adherence patterns.Intravenous therapy is recognized as an important variable related to the occurrence of complications: obviously, the infusion of substances through all devices, especially through peripheral devices, can increase adverse phenomena, such as phlebitis . The resObserving the results of the multivariable model, adherence can be considered a strong and independent factor correlated with the occurrence of complications in the pediatric population. This association was already reported by Tiwari, who found a strong link between the inappropriate use of devices and adverse device-related outcomes . FurtherSimilarly, the dwelling catheter’s time has been demonstrated to be a predictor of complications in a nonlinear relationship, with maximum occurrences on the third day; the subsequent slope is likely linked with the few observations after that time point, mainly observed in peripheral VADs. Guidelines suggest the prompt removal of VADs when not necessary, as longer catheterization is associated with the development of complications . Lastly,This is the first study investigating the relationship between adherence to guidelines for VAD positioning and the development of complications in pediatrics. Furthermore, this is the first study that sought to explore these issues in the Italian setting, and therefore, the results can act as a starting point for future research regarding the use of VADs and the development of specific training projects aimed at healthcare personnel.This study also has several limitations. First, subjects and related hospitalization records were not randomized. However, analysis was performed to account for potential confounding factors using a multivariable model, and the selection procedure, although not randomized, was entirely based on a consecutive list of patients. Second, data were collected from a single general care unit of a pediatric hospital . Therefore, these results cannot be generalized to other care units or to a national level. Finally, it seems important to point out that no information could be retrieved regarding the characteristics of the vascular access of patients or about the number of attempts for success in the positioning of peripheral VAD. These outcomes were reported as factors that may influence the requirement of a venous line, suggesting the use of advanced techniques, such as ultrasound, to obtain it . FurtherThis study revealed that adherence to VAD placement guidelines, which represents the gold standard in quality of care, should be recognized as an independent and predictive factor for the occurrence of complications in hospitalized pediatric subjects.Therefore, it is important that healthcare personnel, particularly nurses who are responsible for drug administration, constantly monitor aspects related to the patient’s vascular access and the actual need for a specific type of vascular access. The right and early choice of the appropriate device based on all of these factors can lead to a decreased number of complications and, therefore, to a better quality of life for hospitalized children.