Nowadays, water resource security is becoming increasingly prominent, and this problem is a primary bottleneck restricting China’s future sustainable development. It is difficult to come to a unified conclusion on water resources security, and applications of highly feasible evaluation methods are lacking in practice. In this paper, a novel evaluation methodology is proposed for regional water resources security evaluation. First, water security is divided into two aspects: water quantity security and water quality security. The disposal rate of harmless household garbage, the excellent water resources proportion, and the functional water body loss proportion are creatively considered as indicators of water quality security in the evaluation system. In addition, a Technique for Order Preference by Similarity to Ideal Solution (TOPSIS) method is used to evaluate the water security levels in different regions. For distinguishing the importance of different indicators, a Best–Worst Method (BWM) is employed to calculate the indicator weights, as triangular fuzzy linguistic sets can more flexibly describe the preferences of decision makers (DMs) regarding the indicators; therefore, it is embedded in BWM to determine indicator weights. Moreover, the fuzzy BWM-TOPSIS method is applied to evaluate the water security levels of six regions in North China, a comparison analysis with the equal weight TOPSIS method as well as the fuzzy BWM-AHP method, and a sensitivity analysis for indicator weights are presented to illustrate the effectiveness of this proposed method. Finally, some suggestions based on the evaluation results are given for effective and rational utilization of water resources in North China. Since the beginning of the 21st century, water resource security issues have increasingly restricted development all over the world .According to the 2018 World Water Development Report released by the United Nations at the 8th World Water Forum in Brasilia in 2018, due to population growth, economic development, and changes in consumption patterns, the global demand for water resources is increasing by 1% per year, and this speed will be greatly accelerated in the future. There are currently 3.6 billion people living in water-deficient areas (for at least one month in a year), and that number could grow to between 4.8 billion and 5.7 billion by 2050. Although it seems that there is more water for agricultural irrigation than for industrial production, it is undeniable that with the growth of developing countries and emerging economies, this situation will not last long, and industrial water use will increase gradually. Under this trend, there may not be enough water for industrial production in the future. In a word, water demand has a very wide public coverage and will keep sustained growth. Therefore, the situation of water shortage will become more and more serious. According to Liu and Yang [In addition, with the development of society, water quality has gradually become an important factor affecting water resources. According to the data released by the World Water Week in Stockholm, 26–31 August 2012, 60% of the world’s ecosystem services are deteriorating . AccordiIt is estimated that nearly 80% of the world’s people are at risk of water security or water-related biodiversity . Water sAt the same time, the evaluation methods of water security are also constantly applied and developed. For example, Ou et al.  combinedIn addition, there is another class of methods available, i.e., decision making, which can be defined as identifying and selecting alternatives from a set of alternatives based on the decision makers’ (DMs) preferences. Xu et al.  used a nTo sum up, this paper focuses on combining fuzzy BWM and TOPSIS methods to form a hybrid fuzzy BWM-TOPSIS method for the evaluation of regional water resources security. In the proposed method, the BWM method considering triangular fuzzy linguistic sets is used to get the indicators’ weights in the evaluation system, based on which the TOPSIS method is employed to rank the water resources security measures of the regions .The general framework of regional water security evaluation is as follows: firstly, the key problem statement is introduced in Water quantity security means meeting the reasonable human demand for water resources. Water quality security implies meeting the reasonable requirements of human beings and the ecological environment.If regional water resources security only considers the amount of water, it will pose a major threat to the ecological and social environment where people live. This results in the loss of high-quality water resources that can be used, although there are sufficient water resources, and this cannot meet the requirements of human beings and the ecological environment for water quality. If we only consider the quality of water, people will have high-quality water resources that can be used, but reasonable demand for water quantity cannot be met, and people will still be in a state of water scarcity. Therefore, in the water security evaluation system, both water quantity security and water quality security should be taken into account, which is the main idea of this paper. In this paper, the indicators of water quantity security includes water resources per capita, average annual rainfall, water resources modulus, exploitation and utilization level of surface water, exploitation and utilization level of groundwater, water consumption per 10,000 yuan GDP, water consumption per 10,000 yuan industrial output value, and daily domestic water consumption per capita, which are the main key factors that reflect water quantity security ,35. The With the increase of the initial exploitation and utilization of surface and groundwater resources, the pollution level in water resources is deepened. Among them, effluent discharge of 10,000 yuan output value, the main pollutants discharged into water , excellent water resources proportion, and functional water body loss proportion can reflect the polluted situation of water in a certain region. In order to solve this pollution situation and realize sustainable development, it is necessary to conduct harmless treatment of domestic garbage and sewage. At the same time, these purified water resources can be reused for daily life and industrial production so as to reduce the exploitation of all kinds of water resources. Therefore, it can coordinate the relationship between the reused water resources and the initial exploitation of water resources and better protect the water ecological environment. From this, we can see that water quality security and water quantity security are inseparable in water resources. Only when water quantity security and water quality security are both considered comprehensively can long-term, sustainable development of the water resources system be realized see .As mentioned above, three indicators  are rarely considered in the previous studies. The reasons why they are included in the evaluation indicator system in this paper are listed below.Household garbage refers to the discarded leftovers, paper, plastic, glass, batteries, and fluorescent tubes in daily life. Some of the wastes contain toxic or harmful substances that are difficult to deal with, especially white pollution  because of its difficult degradation. This pollution can be seen out in the open along roads or ditches in urban and rural areas, which will not only affect the surrounding environment but will also be washed into rivers or lakes during rainfall. It will seriously affect the safety of people’s living and production of water in downstream areas . TherefoExcellent water resources proportion refers to the proportion of water bodies with a water quality grade of I-III , which generally refers to headwater, centralized domestic water, surface water source protection area, fishery water area, etc. It can directly reflect the quality of water, which is of great significance to judge the security of water quality and should be considered.Functional water body loss proportion refers to the proportion of water with water quality level lower than class V  . The polThis section introduces the evaluation methodology including the general framework, the evaluation indicators, and the fuzzy BWM-TOPSIS method.The principle of integrity. A complete water security evaluation indicator system is put forward according to the regional characteristics with full consideration of all factors about water quantity security and water quality security.A combination of qualitative and quantitative aspects. The water security evaluation indicator system should try to select quantifiable indicators, and the important indicators that are difficult to quantify can adopt qualitative expression.The principle of comparability. In order to make the evaluation results comparable in different regions, the concepts and calculation method of indicators should be standardized.The principle of operability. The indicators about regional water resources security should be concise and clear in concept, and the data should be of good accessibility and avoid being too cumbersome, which can fully show the actual degree of regional water resources security and is conducive to its improvement.The principle of mutual exclusion. It should be ensured that there is no concept or content of coincidence among indicators in the evaluation system, and there is no intersection between water quantity and water quality subsystems.The water resources security indicator system includes two primary subsystems, namely, water quantity security  and ammonia nitrogen. COD is an important indicator of organic pollution of a water body, while ammonia nitrogen reflects nonorganic pollutants of a water body. The less COD and ammonia nitrogen, the healthier the water. Let As mentioned above, the treatment rate of harmless municipal solid waste should be considered in the water quality subsystem. Assume that the total discharge amount of urban household garbage is expressed as The wastewater produced by human life is an indispensable part of wastewater treatment and an important part in measuring the security of water quality. Therefore, the municipal sewage treatment rate   is used m indicators   the indicator values. Suppose that j in region i, the normalized value of Step 2. Use the fuzzy BWM method to calculate the weight Step 4. JStep 5. Calculate the Euclidean distance between the evaluated region  i and the positive ideal solution . The information on the annual average rainfall in 2017 was acquired from the statistical yearbook of each region. The urban domestic sewage treatment rate came from the data of 2017 shown in the 2018 China Environmental Statistical Yearbook. The water resources proportion and functional water body loss proportion were obtained by consulting the 2017 Ecological Environment Bulletin of each region. Through data collection, the values of the indicators in six regions  are shown in Assume that After collecting the data of each indicator, the decision matrix of Equation  is liste4≤L6 see . It can Previous studies lacked consideration of using a triangle fuzzy linguistic set to express the importance comparisons between water resource security indicators; they preferred the importance of indicators with equal weight. However, it is worth mentioning that different indicators should have different degrees of importance in the evaluation system, for some indicators have more significant impacts on water resources security. Therefore, the triangle fuzzy linguistic set is integrated in BWM here for generating different indicator weights for the TOPSIS method. A comparison of results of the proposed fuzzy BWM-TOPSIS method and the traditional equal-weight TOPSIS is shown in The Analytical Hierarchy Process (AHP) is one of the most widely adopted MCDM techniques as TOPSIS ; therefoThe sensitivity analysis of the final ranking of the scheme to the weights assigned to different indicators is conducted here so as to verify the effectiveness of the indicators’ weights calculated by the fuzzy BWM method. Fourteen groups of experiments were carried out. For the first experiment, based on the original indicator weights, the weight of indicator quations –26), an, anC11 iIt can be seen from According to the collected indicator data and the final ranking results, some key problems of water resources are highlighted in North China.First, from the perspective of water quantity security, the distribution of water resources among regions is uneven. Relatively speaking, the economic development of the region is highly dependent on the water resources of the region, the more developed a region is, the higher its population will be, and the less its corresponding per capita share will be, which will further aggravate regional water resource disparities. As shown in Second, from the aspect of water quality security, water resources are seriously polluted from a general view. As seen in Integrating the above analysis, suggestions are put forward to promote the overall development of North China and make effective and reasonable use of water resources.(1) Put forward the strategic plan of water use. The local government should optimize industrial structures, promote the adoption of innovative water-saving technology, and develop clean energy and other measures so as to improve water use and reduce water resources consumption and sewage discharge . At the (2) Crack down on factories and enterprises with severe water pollution, and slowly raise the standards for industrial waste water discharge. Water pollution is still an inevitable obstacle to the progress and development of modern society. Nearly 1/5 of water in rivers in North China cannot be used, and the unit area of pollutants discharged into the water is an important cause of water pollution; therefore, as China’s heavy industry base, the local governments in North China need to more strictly control industrial wastewater, and people should also play a role in supervising the local governments and enterprises.(3) Focus on the development of seawater desalination technology to reduce the development and utilization of inland surface water and groundwater. With the increase in population and rapid development of the economy, the demand for water resources is constantly intensifying. In the process of urbanization, excessive exploitation of groundwater reduces the recycling of groundwater and intensifies damage to groundwater. Desalination technology could efficiently settle the shortage problem of water resources in North China (near the sea).(4) Publicize the importance of water conservation, promote the installation of water-saving equipment in rural areas, and form good habits of recycling and water conservation, especially in the rural areas of villages and towns. At present, the awareness of water resources protection is still weak, and the water-saving facilities in a household are not complete. It should be noted that the potential for continuous development of water resources in the region is limited, while the potential for water conservation  is very large, so it is of significant importance to publicize water-saving ideas to the people. In addition, we can promote water-saving behaviors and mobilize people’s enthusiasm for water saving by appropriately raising water prices in different regions.For the provinces and cities in North China, the following suggestions are put forward.(1) Based on the evaluation results, Henan Province is closest to the optimal solution and farthest from the worst solution  among the six regions. Compared with the other five regions, Henan Province is rich in water resources, and its water quantity security and quality security are both at relatively better levels. However, its water consumption per 10,000 yuan GDP is highest among six regions see ; therefo(2) The water resources security level in Shanxi Province ranks second, but as a large coal mining province, it should be noted that the garbage and sewage treatment rates in the province still need to be improved, for its two indicators  have relatively worse performances among the six regions. Some centralized sewage or garbage treatment plants can be built on the original grounds to improve the treatment rate of pollution so as to prevent the re-pollution of industrial wastewater. In addition, it can also be seen from the seventh experiment for sensitivity analysis in (3) Shandong Province, ranking third among the six regions of North China, has a relatively poor performance in both functional water body loss proportion and the pollutants discharged into water per unit area (COD and ammonia nitrogen), which are the main reasons for it ranking lower than Shanxi Province. Therefore, it is imperative to strictly control the re-pollution of water bodies and the discharge amount of pollutants to strengthen its performance on water resources security.(4) Hebei Province, oriented towards heavy industry and ranking relatively in the middle in the whole region, should try to change its industrial structure to light industry gradually. At present, the wastewater and residue produced by heavy industry is relatively high, as the effluent discharge per 10,000 yuan GDP of Hebei Province is larger than that of Shandong Province and Henan Province, so more strict examination and purification measures should be taken in order to control pollution and improve its water quality security level. In addition, exploitation and utilization levels of surface water and groundwater are relatively high, especially for groundwater, which should be controlled to avoid damage to the ecological environment caused by over exploitation and to narrow the gap with the top two regions.(5) Beijing City, as a region with wide concerns, had the penultimate comprehensive score. Some indicators were close to the worst line in North China, such as daily domestic water consumption per capita, the effluent discharge per 10,000 yuan GDP, proportion of excellent water resources and functional water body loss proportion, and exploitation and utilization level of surface water. Therefore, the local government not only needs to strengthen the protection of rivers, which can promote to control the water pollution and protect water resources environment, but also control surface water exploitation in the meantime. Moreover, it should be noted that the daily domestic water consumption per capita in Beijing City is much higher than that in other regions, which does not match the per capita water resources in Beijing City. Therefore, it may be necessary to raise the water price to encourage people’s daily water saving. All in all, it can be seen from the above analysis that Beijing City did not perform well in water quantity and quality security subsystems. The local government should take active and forceful measures to build a better city image in water resources security.(6) Tianjin City, always ranking last among the six regions, had the lowest per capita water resources and over developed surface water resources with high load (216% surface water exploitation and utilization degree). Therefore, the local government should limit local water resources exploitation. It can alleviate the shortage of water resources by purchasing water resources intensive products. While depending on the South-to-North Water Diversion Project for water supply, it should also rely on government propaganda to promote water-saving awareness among the people. In addition, the lower water resources security level in Tianjin City is not only reflected in the amount of water, water quality security is also under serious condition. Since 40% of the river water in Tianjin City has lost its function, it is necessary to formulate a comprehensive prevention and control plan for water pollution, adhere to the principle of comprehensive control, and cooperate with the economic growth mode transformation, so as to improve the efficiency of pollution control. With consideration of its very poor performance in water resources security, Tianjing City cannot change its situation at the bottom of the ranking without attaching great importance on the aforementioned water quantity and water quality measures.The main claim of this paper is that regional water resource security is closely related to people’s lives and health, so ensuring regional water resources security level can improve people’s life quality. Based on the above consideration, this paper proposes a novel methodology for regional water resources security evaluation. Firstly, this paper divides regional water resources security system into water quantity and quality security subsystems involving social, economic, ecological, and environmental factors, based on which a regional water resources security indicator system is established. It is worth mentioning that the three key factors of the water quality security subsystem  are highlighted and analyzed. Secondly, a fuzzy BWM-TOPSIS method is proposed to rank the regional water resources security of the regions . In this method, triangular fuzzy linguistic set, which can more accurately express evaluator judgements on the importance degrees of indicators, is introduced in the BWM method to generate a fuzzy BWM method, through which the indicator weights can be obtained. Based on the generated indicator weights, the TOPSIS method is utilized to rank the regions  through the formula of Euclidian distance between each region and the optimal/worst solution. Finally, the regional water resources security evaluation indicator system and the integrated fuzzy BWM-TOPSIS method are applied to conduct a case study on six regions in North China. A comparison analysis with equal-weight TOPSIS method and a sensitivity analysis on indicator weights are conducted to verify the practicality and efficiency of the proposed method. Furthermore, some managerial suggestions on improving the water resources security levels in the whole region and different provinces and cities of North China are given.The multi-criteria decision-making method proposed in this paper is not only suitable for regional water resources security evaluation, but it could also be applicable to other evaluation problems. The future research direction could focus on studying and employing more complicated fuzzy linguistic environments  in the evaluation methodology. In addition, we will keep track of the latest available data of the water resources security evaluation system to analyze variation trends and also further the research.


The sustained work ability of microentrepreneurs has a significant impact on regional labor markets and society in general, because microenterprises form a significant portion of all enterprises in the EU and in Finland. In such enterprises, with 1–9 employees and whose annual turnover and/or annual balance sheet total does not exceed two million euros . Heavy wA few studies have been published on the factors associated with work ability among microentrepreneurs , 10. CroOne reason for poor results from intervention studies might be that behavior change interventions often lack a solid theoretical background , 17, altSDT is a theory of human motivation and personality , which sPrevious systematic reviews of health behavior change as in our interventions have highlighted the effectiveness of some behavior change techniques over others. These include goal-setting , 24, 25,When aiming to utilize the evidence of effective behavior change techniques provided by previous systematic reviews, two points should be taken into account. First, systematic reviews , 25, 32 Persuasive technology is increasingly used for promoting behavior change. It has been used in mobile applications for assisting people with issues such as weight management, sleep problems, and depression –37. HoweThis paper describes the protocol of a randomized controlled trial, because publication of study protocols increases research quality and transparency . The oveThe design is a randomized controlled trial comparing one intervention arm (Recovery! application intervention) with a waiting list control group among microentrepreneurs in Finland. The waiting list control group will receive the Recovery! app six months from the commencement of the trial and will use it for eight weeks.Eligible participants are Finnish-speaking microentrepreneurs (those with enterprises of 1–9 employees) whose companies are in Finland. The target group excludes the employees of these enterprises. Included participants must work full-time as entrepreneurs, understand Finnish, and have an Android phone. Entrepreneurs who are also employed in another organization, or who are on sick leave or off work for another reason, will be excluded.The intervention consists of a mobile application for microentrepreneurs. The application aims to promote health and work-related behavior changes and to enhance recovery from work and work ability during working hours and free time.The intervention group will receive the mobile application after baseline survey and will be asked to use it for at least eight weeks, but may continue longer. In the mobile app users select relevant modules (key components), goals for themselves, and subsequently select exercises to complete with guidance from the app. The users can also use additional support tools, such as a meal planner or step counter, and use tracking tools such as self-assessment of stress levels. These modules and tools will be described in closer detail in the forthcoming paper related to process evaluation. During the trial period the control group receives no intervention. However, the waitlist control group will receive the same mobile application at six months, and will be followed for two months.The intervention program to promote work ability and recovery from work among microentrepreneurs will be delivered and implemented via a smartphone application), that is, it is designed directly as mobile application using compiled language , rather The key contents Fig.  and compThe behavior change techniques used in the application have been selected according to the evidence of their effectiveness. The selection of techniques also reflects the aims to 1) include various different techniques, as the diversity of techniques has capability to increase the effectiveness of an intervention , 50, andAnother background theory for developing the intervention is trans-theoretical model (TTM) of change . The oriThe basis for the design of the mobile information system application is the Persuasive Systems Design (PSD) model , which sIn the present application, analysis of the persuasion context identified a need for goal-setting at the core of the application, and as such, goal- and task-setting are present in all parts of the application. Moreover, common features throughout the application modules include various features from the primary task support category, such as self-monitoring and virtual rehearsal, aiming for direct task-related support for the system users. All modules also include the computer-human dialogue features of praise as positive feedback, and provide suggestions for the user (tips and hints). In addition, modules are used that aim to promote immediate compliance with good health activities  through reminders. As social support, the application uses the features of social comparison. Attention will also be paid to making the users feel that the information system application is credible.The application is developed and programmed specifically for this intervention. The user will choose the module(s) freely as per the SDT, although one will be suggested by the system based on questions at the beginning of usage and another module will be suggested later on . The contents of the application are divided into seven modules, which include total of 51 tasks, 11 videos e.g. mindfulness exercise, and seven self-monitoring tools e.g. pedometer. The user will receive information and tips about improving personal health and will choose tasks or will use self-monitoring tool of one’s own liking that will help with achieving the target behavior for example via self-reflection.The primary outcome is the change from baseline in current Perceived Work Ability (PWA) in six months and secondary outcome the change from baselin in the Need for Recovery (NFR) scale in 6 months. The participants will evaluate their current PWA on a scale of 0 to 10, ten indicating lifetime best work ability. The question used for this is the first item of the Work Ability Index –57.The NFR comprises 11 items . Items iAs background information, we will collect information on the entrepreneur  and enterprise .The primary outcome is perceived work ability (PWA). Barene et al.  found a Based on our previous experiences of recruiting entrepreneurs for developmental projects, we estimate that less than 1% of those invited will be willing and able to participate. Thus, in order to get enough participants, we invite markedly more.There are two main bases for specifying the target difference: a difference considered to be ‘important’ , and a ‘realistic difference’ based upon current evidence .The main recruitment route is an email invitation to microentrepreneurs. The source for email addresses is a Finnish commercial enterprise data register, called Bisnode. We use the Bisnode register because the register provides access to contacts with email addresses. It contains the contact information of over 468,000 organizations (0–9 employees) in continental Finland (data checked on 20-04-2017). After the exclusion of public and third sector organizations, housing cooperatives, and property companies and microenterprises without email address, the final total register base is 74,971 companies. The microentrepreneurs whose email-addresses are available will be sent an invitation letter via email. We expect 740 registrations for the study through this channel.A media campaign was run from November 2017 to January 2018 in order to obtain a sufficient participation rate. The media campaign enabled those who were interested in participating in the study to register for the study on the FIOH website .The aims of the media campaign were to make entrepreneurs aware of the topic of recovery from work, create willingness to change their habits toward better work ability, and finally to register for the study. The campaign included participating in events relevant for entrepreneurs, distributing printed handouts and flyers, a nationwide radio campaign (two weeks), press releases, articles and advertisements in newspapers, videos and posters on social media, targeted social media advertising, and blog texts. Both the researchers’ and research groups’ own social media outlets and the interest groups’ outlets were utilized to distribute the contents.We used SDT principles (such as autonomy and relatedness) and different behavior change methods in designing the media campaign . For insThe two groups (self-registered and invited) will be randomized and analyzed separately because possible differences in the level of motivation might cause selection bias in the results. The entrepreneurs will be sent basic information about the study and a web-based questionnaire. When they return the completed questionnaire, they will be enrolled on a list. The order of the enrolment list is the basis for randomization into intervention or control groups.A statistician did randomization using a table of random numbers (in batches of ten) and used SPSS for random sampling and allocation ). The paAfter randomization, the team responsible for the survey data management will upload the name, gender and email addresses of the intervention group through a secure channel to the team responsible for the application. Name is needed for personalization of the mobile app for the user, for a simple example it says hello ‘name’. Gender is used for gender specific feedback information in the app. Email is used for informing the intervention group that they belong to the intervention group and will be invited to download the application from the Google Play store. The email message will contain a personal account name, password and instructions for downloading and installing the application. In any technical issues, the IG can contact the application-specific helpdesk through email. At the same time, the project coordinator will send the CG an email message informing them that they belong to the wait list control group, which means that they do not miss out on anything but only receive the same intervention later. Whilst waiting they will be requested to fill in the follow-up surveys. Both survey data management and application teams will delete all identity information of study subjects right after the data collection has ended. All researchers will receive unidentified data to be used in data analyses. Only principal investigator of the consortium has access to identification data.The pilot version of the application was distributed via a registered domain (website) to the pilot users, which involved them checking and altering their smartphone settings accordingly, as well as manually downloading and installing the application. We chose the Google Play store as the distribution platform during the intervention on the basis of feedback from the pilot users, in order to improve the ease of downloading and installing the application. This may require a few minor changes to the application to ensure that it could be published (and distributed to the users) via the Google Play store.We will collect data via self-administered web-based questionnaires, the application and interviews Fig. .Fig. 2PThe self-administered web-based questionnaires at baseline and after two and six months from the beginning of the intervention will include questions measuring primary and secondary outcomes and other variables, and background information and questions whose responses will be used in evaluating the receipt and acceptability of the intervention and the users’ evaluations. Two reminders will be sent. Web-based surveys are used to promote data quality. Two months from the beginning of the intervention we will collect the experiences of and information on the use of the mobile information system application. The number of questions will be kept as minimal as possible in questionnaires, and the motivation will be enhanced in the invitation letter to obtain maximal participation rate.The application will collect log-data for process evaluation purposes during the eight-week intervention. These data will be utilized to evaluate the usage of the application, for example through login and logout times, the activities completed, time spent on studying each content area as well as answering questions related to it. Only prespecified log data will be collected and stored on a secure server site.n = 20–30 in both groups) will be interviewed after the usage period (two months) of the intervention. The participants will be asked to give written or taped informed consent according to the declaration of Helsinki. The first group will be interviewed about the user experience and usage of the mobile application according to themes such as persuasion, credibility and behavior change. The themes and questions have been tested by interviewing two pilot users. On the basis of lessons learned from the pilot, mainly the difficulty in recruiting interviewees, we included the option of confirming potential interest in interviews and of filling in more detailed contact information (phone number) to the baseline survey. The second group will be interviewed about themes related to experiences of work as an entrepreneur, the history and future hopes of the enterprise, professional identity, taking care of one’s well-being, recovery from work and work ability, lifestyle habits and the meaning of health, the effects of entrepreneurship on work ability and work recovery, the effects of work ability on being an entrepreneur and on business or work performance and productivity, the support needed for taking care of one’s own work ability, occupational health services, experiences of the use of the mobile application for promoting work recovery and work ability, and effects on lifestyle habits. The themes and questions will be tested in five interviews.Two randomly selected groups (adjusted for gender and route of enrolment for the study) of microentrepreneurs . The analyses will be performed using SPSS , an alpha level of 0.05 being accepted as significant. Analyses will be controlled for covariates such as gender, age, education and group (self-registered or invited).The qualitative data from interviews will be transcribed and anonymized, and analyzed by content analysis . At leasIn order to examine the mechanism of change, we will conduct process evaluation. We will describe and analyze the recruitment process more carefully in separate process evaluation  papers. Context For example, how the context of microentrepreneurship in Finland influenced the planning and development stages of the intervention, and how the context was taken into consideration.Reach For example, how many of the contacted microentrepreneurs participated; how many of participants dropped out or were engaged in the study; who were they (subgroups?); what were the key reasons for engaging or not engaging in the intervention?Dose For example, how and to what extent did the participants use the application and perform other intervention tasks (e.g. achieve changes in their lifestyles); what kind of actions did they perform; did contextual factors “outside the application” have an influence on the dose; did the subgroups differ in their interaction with the intervention/use of the application?Fidelity For example, to what extent was the intervention delivered as intended and what factors influenced this? Description of the intervention (e.g. logic model), including its underlying theory and mechanisms of impact will be evaluated for understanding the extent to which the intervention and application were consistent with the underlying theory; whether participants followed the guidelines and suggestions; whether the application worked as intended.Implementation For example, to what extent were the intervention and application implemented and received; to what extent were the different materials/activities/contents of application used/utilized; what kind of practical barriers did participants face during the process in terms of application and lifestyle change?Recruitment For example, how was recruitment carried out in practice; what kind of participants engaged in the intervention; did they represent the target group in general; were some groups of entrepreneurs overrepresented/underrepresented; what were the barriers to recruiting participants?Participants’ experiences of the intervention process and application  will be collected and analyzed, for example, how easy/difficult was it to follow intervention procedures and to use the application; what kind of experience was it; what were the key strengths and weaknesses of the intervention in general and of the application in particular; how could the intervention/application be developed; did the subgroups differ in regards to how they experienced the intervention?The evaluation will focus on the following components –72:ContThe data collection methods for answering the above-mentioned questions will be web analytics, quantitative measures/scales integrated into pre-, post- and follow-up questionnaires and one-to-one interviews. We will use participant interviews and the results of short web-based questionnaires to evaluate the reception and acceptability of the intervention and the evaluations and interpretations of the causal mechanism of change.This study aims to evaluate whether an occupational health promotion intervention using a mobile application is an effective way of reaching and promoting work ability and recovery from work among microentrepreneurs. Promoting the recovery from work and work ability of microentrepreneurs requires understanding the target group and the context in which they operate. They work long hours, have challenging timetables and difficulties in combining family and work. Lack of time is often suggested as the reason for not taking care of one’s health and work ability. Thus, a native mobile application may be suitable in this context.Microentrepreneurs are an under-researched population in terms of recovery from work and work ability , 42, 73,Web-based and mobile applications usually share similar features, although they have different implementations when compared to each other. Most important difference is that native mobile applications can function without an internet connection, unlike web-based apps . As regaAs far as we know this study is a starting point of a new research line. While earlier research on this topic in this target group (microentrepreneurs) does not exist, process evaluation might even be the most valuable research aim in order to improve the feasibility of the forthcoming studies in this topic among this target group. Process evaluation of the intervention will provide deeper knowledge on the factors related to the context, reach and recruitment and fidelity and dose, which all are important factors related to the feasibility and effectiveness of the intervention study among microentrepreneurs. Because the microentrepreneurs include very heterogenous group of entrepreneurs, the context is essential, and it might be difficult to develop a feasible and suitable intervention, although it is done by cocreation. Fidelity and dose might be very different among microentrepreneurs compared to those among wage earners. Heterogeneity of the target group may hamper the reach and recruitment, and thus to invite microentrepreneurs largely, not only some specific subgroup of them might also be a limitation of the study.Further, we do not know if our hypothesis related to the main components of the intervention are suitable and good for microentrepreneurs, because of the lack and research gap of earlier research. We will use mixed methods to collect data, we will have a good possibility to learn more about this target group and about the most important issues related to the promotion of work ability by the means we will use in this intervention study. This gap of intervention studies among microentrepreneurs is surprising, because microentrepreneurs are important from the societal point of view: microenterprises cover about 93% of all companies in European Union, and thus are very important for the economy and employment of EU , 2, 8. MThere can be factors, that can confound the effects of the intervention, such as economic situation or smartphone’s operational environment (we chose Android) and its technical problems and misfunctioning. Further, we try to take into account seasonal issues, e.g. holidays, but it can be that microentrepreneurs have their holidays in different season that wage earners usually have, or have no or shorter holidays.This innovative approach, if successful, may provide a means through which to deliver a low-cost work ability promotion program that has the potential to reach large groups, particularly among microentrepreneurs, which form the vast majority of all enterprises and do not usually have occupational health services. A novel aspect of this project is the development of a new kind of mobile application, based on strict science, and specially designed for microentrepreneurs.


The World Health Organization (WHO) declared the outbreak of the Coronavirus disease-2019 (COVID-19) infection a pandemic on 11 March 2020. As of the end of October 2020, there were 50 million cases of infection and over one million deaths recorded worldwide, over 45,000 of which occurred in Italy. In Italy, the demand for intensive care over the course of this pandemic crisis has been exceptionally high, resulting in a severe imbalance between the demand for and availability of the necessary resources. This paper focuses on elements of preventive medicine and medical treatments in emergency and non-emergency situations which, based on the international scientific literature, may prove to be useful to physicians on a behavioral level and avert professional liability problems. In order to achieve this objective, we have performed a search on MEDLINE to find published articles related to the risks associated with the pandemic that contain useful suggestions and strategies for mitigating risks and protecting the safety of the population. The results have been collocated in line with these specific study areas. The World Health Organization (WHO) declared the outbreak of the Coronavirus disease-2019 (COVID-19) infection a pandemic on 11 March 2020. The infection can cause severe respiratory insufficiency, sometimes requiring hospitalization in an intensive care unit (ICU) in order to provide invasive ventilatory support ,4,5,6,7.Despite efforts on hospital and national levels to raise the quality and efficacy of healthcare, the demand for intensive care over the course of this pandemic crisis has been exceptionally high, resulting in a severe imbalance between the demand for and availability of the necessary resources. This situation has raised unprecedented dilemmas and situations , which tFurthermore, to stem the spread and severity of the pandemic, national and European authorities issued numerous emergency provisions of a logistical and economic nature to suspend production activities and movement, including a general lockdown on economic and social activities that lasted until the beginning of May 2020 . ThereafAs of the end of October 2020, there were 50 million cases of infection and over one million deaths recorded worldwide, over 45,000 of which occurred in Italy ,13.The epidemiological situation in Italy seems to be relatively under control, despite the slight and continual increase in cases of infection.New and significant challenges have emerged due to the need to coexist with the virus until a sufficient population immunity threshold has been reached, primarily through vaccination. This paper focuses on elements of preventive medicine and medical treatments in emergency and non-emergency situations which, based on the international scientific literature, may prove to be useful to physicians on a behavioral level and avert professional liability problems. Furthermore, as part of this literature review, we have analyzed articles that contain recommendations of strategies and conduct to mitigate pandemic-related risks and to protect the population.We searched for all articles written in English in the literature available on MEDLINE in the last year until 31 October 2020 using the following search terms: “medical liability SARS-CoV-2,” “medical liability COVID-19,” “medical liability pandemic,” “malpractice SARS-CoV-2,” “malpractice COVID-19,” “medico-legal litigation SARS-CoV-2,” “medico-legal litigation COVID-19,” “liability claims SARS-CoV-2,” and “liability claims COVID-19.” The objective of this review is to concentrate on articles and documents that contain useful information on prevention techniques for containing dissemination and contamination within the broader program of clinical risk management. We included only articles available in the literature that contain information concerning pandemic-related situations of risk and that recommend the implementation of specific activities designed to mitigate these risks and facilitate the proper operation of strategic sectors to protect the population. Articles that contained merely clinical or microbiological indications regarding the nature and characteristics of the virus were excluded. All sources were evaluated independently by two of the authors to determine their relevance to the present study and then selected for inclusion by all the authors.Using the above search strings, MEDLINE produced 53 results that the authors considered relevant to the study in that they contain useful information for the prevention of adverse events despite the persistence of the pandemic. Details of the documents analyzed and excluded are displayed in PRISM format in (a)Lack of or reduced ability to care for and treat infected patients due to the insufficiency of available resources, which has contributed to causing harm or patient death.(b)Harm to or death of patients not infected by COVID-19 but affected by ingravescent diseases  indirectly caused by the pandemic, the reduction of available healthcare resources, or the cessation of medical activities pertaining to non-pandemic-related infirmities preventing access to adequate, timely care.(c)Patient infection within hospitals or residential facilities used as shelters due to failure to observe prevention recommendations and protocols.(d)Infection and consequent harm to or death of employees in ill-prepared companies, or more likely, hospitals and residential care homes that lack adequate safety equipment.(e)Harm to or death of patients infected with COVID-19 and treated with experimental or off-label drugs.In the course of a pandemic, reaching a high level of care safety ,15 may pBefore analyzing each of the hypothetical profiles listed above, it is worth remembering that from a general point of view the Italian legal system, even without specific liability exemption laws, contains certain important institutions that relate to this situation. Regardless of the specific liability profile envisaged, the fact that there is no scientific evidence available regarding the nature, transmissibility, and treatment for the SARS-CoV-2 infection necessitates careful consideration. At the time this document was drafted and even less so towards the beginning of the epidemic, there were no guidelines or recommendation documents based on solid evidence that could provide reasoned and specific direction to guide medical decisions. In effect, with no covering laws, this meant extreme difficulty in delineating either proper or censurable conduct with scientific certainty.The second aspect of interest concerns the effect a substantial lack of hospital resources has on the decisions made by individual operators, liability for which in no way attributable to the operator personally but to institutional decision-makers. This is a particularly significant factor in criminal proceedings where liability is necessarily attributed to a specific person.If performing the service requires the solution to particularly difficult technical problems, the service provider is not liable for damages in the absence of malicious misconduct or gross negligence.” According to some authors, this provision could serve as an initial shield against possible attacks, especially if brought for speculative purposes. Furthermore, the provision set forth in Article 9 of Law No. 24/2017 on recourse states: “In order to quantify damages, with the exception of the provisions set forth in Law No. 20, 14 January 1994, Art. 1 (1b) and Art. 52 (2) of the consolidated act referred to in Royal Decree No. 1214, 12 July 1934, particularly difficult situations, including those of an organizational nature, that affect public health or social care facilities in which healthcare professionals operate must be taken into account (…).” Although said provision refers to recourse claims, it is clear that it also implies that certain organizational difficulties may enable the quantum of compensation to be regulated. The epidemic that has developed in Italy can without doubt be classified as a medical, scientific, and organizational situation of exceptional difficulty.The profile of liability described in point (a), where an individual operator is unable to administer life-saving treatment due to insufficient resources ,28, reprIn light of these provisions, although an ad hoc law to limit professional medical liability may not seem necessary, high-level legal assessment and medico-legal abilities , compliaHowever, there is still the issue of liability for the decisions of those who have caused the national situation of general unpreparedness and the constant reduction of social and public healthcare services by failing to implement policies that foresee both developing and unanticipated exigencies and situations. Such shortsightedness, the reasons and associated liability for which shall be analyzed, has not only led to a failure to safeguard human dignity, given in many cases it is impossible to allocate adequate treatment resources to some patients, but also, no less dramatically, to healthcare professionals being obliged to implement decisions they would never have wanted to implement.Though this situation has defined the initial stages of the pandemic, it cannot be allowed to become the norm in future crisis stages. For that reason, regional and national initiatives must be activated to increase available therapeutic resources in preparation for a further rise in demand. Such an increase may require action on three levels: (1) intensive care, (2) internal medicine, and (3) community care.As regards the first level, national institutions have made significant contributions in the past few months. Prior to the pandemic (2017), there were 5090 intensive care spaces available in Italy  , whereasTreatment during the pandemic has required not only intensive care unit admission but also considerable assistance from entire medical and surgical departments, which have been transformed into reception areas for infected patients. This influx of patients has had two basic effects: (1) interruption of surgical care and treatment of other diseases that do not require urgent intervention, and (2) filling departments with infected patients ,42,43,44With respect to point (b), in order to prevent this legal scenario, home medical care services for patients infected with COVID-19 who do not need hospital or intensive care will have to be enhanced. This approach has been incentivized through the extensive hiring of healthcare personnel for community care, especially nurses, who can provide support to sick people and their families in isolation at their homes or in designated facilities to prevent the spread of infection and enable full physical recovery. It will also prevent hospital congestion and facilitate the normal practice of non-pandemic-related medical and surgical services . This leAs regards point (1), accurate assessments of patient conditions are essential so as to decide whether to hospitalize or whether home care would be sufficient. This assessment should be carried out by trained medical personnel and subjected to periodic reviews by means of remote monitoring systems so that if the situation were to deteriorate, the patient could be hospitalized in time and, if necessary, admitted to intensive care ,50. TherIn relation to point (2), plans and strategies to manage severe crisis situations must be formulated on an institutional level, even when resources are available, making full use of all the options that scientific innovation presents. As a result, in times of greater difficulty, all available technical solutions can be utilized to ensure the continuity of essential medical-surgical activities and to develop not only logistical and economic but also scientific responses to crises. An example of the type of proactivity needed to ensure such continuity during emergency situations would be the proper management of blood resources. Maintaining adequate supplies of safe blood in order to guarantee the execution of necessary surgical procedures or other medical activities can prove to be particularly difficult in emergency situations, especially epidemics. In the first few months of the pandemic, many countries , includiPBM is a multidisciplinary, multimodal approach adopted to limit or eliminate the need for allogenic blood transfusions through evidence-based management of anemia, blood loss reduction, and optimization of blood salvage strategies . This apThe implementation of PBM presents both a challenge and a particularly profitable opportunity in Italy and other countries with an older average population. In the years ahead, these countries will find themselves unable to satisfy the transfusion demand, as the population will not be in a position to donate blood due to old age despite their potential need to receive it. In that sense, the pandemic may accelerate the instituting of processes to safeguard public health in addition to presenting a remarkable opportunity for economic saving .With regard to point (c), in recent months there has been significant media attention, particularly because of the high number of deaths in residential care homes for the elderly due to, according to critics, superficial management of admissions and preventative activities to create a safe environment for the frail that occupy it . It is iWhile the level of unpreparedness during the initial stages of the pandemic may have been justifiable, the current situation necessitates that there be no further procrastination in the implementation of strategies to improve care by means of early diagnosis of signs and symptoms, the use of standard diagnostic criteria, the adoption of adequate preventive measures, and the institution of monitoring and control systems. Such measures will simultaneously increase the probability of optimizing results and ensure the safety of patients and the well-being of workers ,73. FurtFrom a medico-legal standpoint, each facility needs to prepare internal protocol documents with clear behavioral indications for all operators, including a precise plan of action to guarantee safe crisis management. The objective of such documents, registered and shared with all facility personnel, is to ensure that all those concerned act responsibly and to provide an effective, documented defense in the event of litigation ,75,76,77Scenario (d) highlights the need to ensure the safety of employees, especially healthcare employees, as they are deemed at greater risk of infection. On 24 March 2020, an agreement between the Italian government and representatives for companies and employees was proposed and subsequently adopted on 24 April 2020 . The maiThe Italian government supports the implementation of these recommendations as they promote the safety and protection of workers, forming the basis for the safety activities that companies must adopt, including for the purposes of preventing litigation. Healthcare personnel must be included among the category of workers who, being in constant contact with infected patients, are at greater risk of infection. This factor was particularly highlighted during the initial weeks of the epidemic due to the severe shortage of PPE. This brings to mind the high number  of physiFinally, as far as liability in the event of harm or death caused by the use of experimental or off-label drugs is concerned, Italian law permits and delimits their usage (Law No. 94/98). Despite the fact that the use of off-label drugs may expose a patient to potential risks, in the specific context of the pandemic—considering the scarce knowledge of the virus’ mechanism of action and target organs—physicians must show greater prudence in resorting to such drugs. Evaluations of proper conduct shall take into account the specifics of the case, the severity of the patient’s clinical manifestations, the nature of the drug, known contraindications, verified side effects, and the dosage administered.Since the beginning of the year, Italy has experienced a lockdown that is even more dangerous from a social viewpoint—that of the justice system. Particularly, the justice system has been paralyzed and come to a standstill with the exception of cases of extreme urgency and gravity. This has caused a series of problems with regard to maintaining the country’s social and economic system. The motive for the lockdown is the fear of potential infection in courtrooms and of court employees. However, as things stand, the justice system must be reactivated as soon as possible in order to prevent further delays in the country’s economic activities. To do so safely, courts can take advantage of all the available technological and organizational resources at their disposal, e.g., videoconferencing systems, certified electronic signatures, and remote access to judicial archives . In so dEqually important, to provide an adequate response to major emergencies, particularly to epidemics of mostly unknown infectious agents, it is essential to seek the input of all scientific disciplines, especially that of legal medicine. In this regard, it is useful to reiterate the value of autopsies from a legal and, more importantly, scientific and clinical point of view in identifying causes of death and in contributing to the reconstruction of physiopathological pathways that lead to death. This approach may provide determining scientific information to find possible therapeutic options that would otherwise have been impossible to obtain ,83,84,85Ultimately, Italy must adopt a proactive mentality towards these and other crises if it is to be prepared and scientifically equipped to handle future major emergencies.The COVID-19 pandemic has highlighted several pitfalls in the National Health Service in Italy and, more generally, in Western countries that have had to handle and find extemporaneous solutions to this unforeseen event . As a result, the health services have been faced with ethical dilemmas such as deciding who to treat considering the shortage of resources and inability to ensure all patients receive the necessary intensive care treatment ,90,91,92Initially, public opinion was in favor of instituting a legal shield to protect physicians, but the provision encountered numerous obstacles, abroad as well as in Italy, and to date has not been approved. Clarification is necessary since it is proper to safeguard healthcare professionals who have been forced to serve in dramatic conditions  but also to recognize organizational and medical flaws that have de facto exacerbated the situation.The current pandemic has led to profound changes in the lives of individuals and healthcare professionals, brought to light weaknesses in the more developed health services, and called into question many healthcare policy decisions that have been made in recent decades. There are obvious limits to this study as many articles have been published in recent months and, therefore, offering a complete and up-to-date review of the literature presents a challenge. Although not all areas of pandemic-related risks can be mentioned, this article has analyzed and explored strategies for mitigating risks associated with the dissemination of the infection in various key sectors in the administration of public services for immediate application. In addition, it has highlighted programs that may aid the National Health Service such as PBM, particularly important in Western countries with an aged population. Some countries have already implemented praiseworthy organizational strategies: for example, Australia has put in place an extensive PBM program, such that has facilitated a 60% reduction in the use of red blood cells ,93. ThesIn addition to all the issues discussed in this article, the future will present other issues in connection with the development of a vaccine. It seems that at least one vaccine will be available from January 2021 and nationwide distribution will soon commence. This may create further problems in that the probability of procuring sufficient doses for the entire population is remote, meaning difficult decisions will need to be made in terms of who to prioritize. Moreover, additional vaccines may become available in the coming months, resulting in a diversified vaccination campaign due to the particular characteristics of each product in terms of efficacy and protection time. The health authorities will need to weigh these elements carefully, providing full decisional transparency. The public should also be apprised of these decisions by means of an information campaign in order to maximize voluntary participation in the vaccination drive.


Digital health care is becoming increasingly important, but it has the risk of further increasing the digital divide, as not all individuals have the opportunity, skills, and knowledge to fully benefit from potential advantages. In particular, elderly people have less experience with the internet, and hence, they are in danger of being excluded. Knowledge on the influences of the adoption of internet-based health and care services by elderly people will help to develop and promote strategies for decreasing the digital divide.This study examined if and how elderly people are using digital services to access health and social care. Moreover, it examined what personal characteristics are associated with using these services and if there are country differences.Data for this study were obtained from the Special Eurobarometer 460 (SB 460), which collected data on Europeans’ handling of and attitudes toward digital technologies, robots, and artificial intelligence, including data on the use of internet-based health and social care services, among 27,901 EU citizens aged 15 years or older. Multilevel logistic regression models were adopted to analyze the association of using the internet for health and social care services with several individual and country-level variables.At the individual level, young age, high education, high social class, and living in an urban area were positively associated with a high probability of using internet-based health and social services. At the country level, the proportion of elderly people who participated in any training activity within the last month was positively associated with the proportion of elderly people using these services.The probability of using internet-based health and social services and their accompanying advantages strongly depend on the socioeconomic background. Training and educational programs might be helpful to mitigate these differences. Health care systems in Europe and beyond are currently under pressure. Considering financial, demographic, and epidemiological developments, there is a need for new approaches to deliver health care equally and cost effectively and with the best medical outcomes . There aDespite the potentials of digital health care, there are risks that lead to several challenges. In particular, the promise that all individuals will benefit equally needs to be questioned, as digital health requires not only infrastructure to use the internet, but also skills to operate digital technology ,4. Both,When investigating influences on internet use for health and care services among elderly people, the following three aspects need to be considered: (1) factors influencing internet use in general; (2) factors influencing internet use for health-related purposes; and 3) factors influencing the capability to understand and process information, so-called eHealth literacy  factors .With regard to the first aspect, several studies reported that internet use declines with increasing age in Western societies ,10. EuroWe were interested in exploring eHealth use in terms of using the internet to access health and social care services among those who were already on the internet. Considering the use of the internet for health purposes, previous research has revealed multiple influences on the use of new digital technologies to access health care by elderly people. There are, however, multiple overlapping factors. As for internet use in general, sociodemographic characteristics, such as gender , age, education, and household income, are associated with using the internet for health and social care services -25. At tIt is important to determine if and how elderly people use the internet to access health care; what personal characteristics are associated with using eHealth; and whether there are country differences in access to eHealth, and if so, how can these be explained. To obtain this information, this study analyzed data from a Special Eurobarometer , using mThis study contributes to the field in several ways. First, the inclusion of individual as well as country level determinants of the probability of using digital health care services provides a more holistic picture of the potential of digitalization for health care among elderly people. The findings shed light on relevant disparities in the use of digital health care services among elderly people at the individual and country levels. The second contribution is the data used in the study, which were derived from a recent survey conducted in 2017. As digital technologies are changing quickly and new possibilities for digital health care provision are being developed constantly, regular monitoring of how elderly people use this approach is necessary. The third contribution is the comparative perspective. The inclusion of several countries in the analysis allows the identification of factors that foster and hinder the use of eHealth, which can be transformed into policy recommendations.Attitudes toward the impact of digitization and automation, which collected data on Europeans’ handling of and attitudes toward digital technologies, robots, and artificial intelligence, including questions on the use of internet-based health care in the year 2017. The SB 460 is part of the Eurobarometer program that includes several public opinion surveys among the citizens of the European Union on a variety of topics. For the SB 460, the TNS Political & Social network performed face-to-face interviews for 27,901 EU citizens aged 15 years or older. The interviews took place at the home of the interviewees and in their native language. Sampling was performed with a multistage random probability approach [The analysis in this study was conducted with data derived from the Special Eurobarometer 460 (SB 460) approach . For theMultilevel logistic regression models were used to analyze the association of using the internet for health care services with several individual and country-level variables. Multilevel regression is an adequate tool of analysis when the data have a hierarchical structure with units at the lower level nested in those at the higher level ; in thisIn the last 12 months, how often have you used, if ever, health and care services provided over the internet without having to go to the hospital or doctor's surgery ? The respondents could answer this question with any one of the following four predefined statements: once, twice, thrice or more, and never. Missing data were negligible . As over 83.87% (5787/6900) of the respondents reported never using internet-based health care services, the other three categories  were summarized into one category. This resulted in the dichotomous variable “use of digital health care services,” with values of yes and no.The variable for the use of digital health care services was based on the following question: At the individual level, age, gender, education, social class, marital status, employment status, and urbanization degree were correlated with the use of digital health care services. Education was measured according to age on completion of education and was divided into the following three categories: younger than 15 years, 15 to 20 years, and older than 20 years. Social class was divided into the following three categories: high, medium, and low. Marital status was dichotomized into having a partner and not having a partner. Additionally, employment status was dichotomized into being employed and not being employed. Information regarding urbanization degree had the following three categories: rural area, towns and suburbs, and cities.At the country level, we included five variables. The proportion of elderly people (aged 65 years or older) who had participated in educational or training activities within the last 4 weeks was used as a measurement for common life-long learning among elderly people. The gross domestic product per person was used to measure the economic development of the countries. To measure the spending for old age, we included the share of the national budget that was used for elderly people. The proportion of people older than 64 years to people younger than 65 years was used to measure how far demographic ageing in a country has progressed. Finally, the subdimension connectivity of the Digital Economy and Society Index was used to measure a country’s access to the internet. Data for all five indicators were derived from Eurostat, the statistical office of the European Union .On comparing users and nonusers of eHealth , users wP<.001). The results also showed significant positive associations between education  and social class  on one hand and use of eHealth on the other. Employment status, marital status, and household size were not associated with eHealth use. Population density was associated positively with eHealth use . At the country level, only the proportion of elderly people who participated in educational activities was significantly associated with eHealth use .The results from the multivariate analysis are presented in This study explored the determinants of internet-based use of health and care services among elderly Europeans, using data from the SB 460 and the multilevel regression technique. Our study focused on elderly people who were already using the internet and who went on the internet to use health and care services. We found that a large proportion of elderly people in Scandinavia and Estonia use the internet for health and care services and very few people in Malta, Cyprus, and Germany use the internet for these services. One explanation is the difference in broadband and mobile internet availability between these countries. Scandinavia and Estonia have a high number of households with internet access, whereas Malta, Cyprus, and Germany lag behind in terms of broadband availability . ConsequBy analyzing the factors at the micro level, which seem to have an influence on the use of internet-based health and social care services among elderly people, we could confirm the results of previous research. In line with previous results, we found that users who are better educated and from a higher class are more likely to use these services . We alsoIn addition to scientific implications, political and societal implications can be drawn. The results underline several issues accompanying the spread of digital technology in general, but particularly in health care. Although internet-based health and care services have main advantages to support elderly people, policy makers and other stakeholders should also acknowledge that most elderly people do not use these services. Additionally, the probability to use these services does correlate with socioeconomic status and place of living. In particular, people with a low socioeconomic status and those living in rural areas seem to be at risk of being excluded from chances to use eHealth, although, in particular, the latter group could benefit from remote health services. This has the risk of increasing social inequality. Technology can cause or intensify social inequality and ultimately lead to social exclusion. Against this background, the capability of using modern technology itself can be seen as a dimension of social inequality . PreviouOur study has several limitations. First, it included a specific database. The Special Eurobarometer only includes one item that asks about eHealth . Hence, we could not draw any conclusions on the different facets of eHealth and could not provide detailed information on patterns of use. Second, we only investigated people who were using the internet and did not cover those not using the internet. We were mainly interested in exploring the personal characteristics of those using internet-based health and care services and macro factors potentially influencing the use. This leaves room for a more detailed analysis including those not using the internet. Although we could confirm most of the results of previous studies and add new aspects to the discussion on the use of digital health by elderly people, there were several limitations. Third, the data used for the analysis were cross-sectional data; hence, no causal links could be made between the different variables. Fourth, the analysis was limited to European countries; however, demographic ageing and digitalization are global trends.Despite these limitations, this study contributes to the field in three ways. First, the inclusion of individual- and country-level determinants of the probability of using digital health care services provides a more holistic picture of the potential of digitalization for health care among elderly people. The findings shed light on the relevant disparities in the use of digital health care services among elderly people at the individual and country levels. Second, the data used in this study were derived from the most recent survey conducted in 2017. As digital technologies are changing at a fast pace and new possibilities for digital health care provision are being developed constantly, regular monitoring of how elderly people use these services is necessary. Third, there was a comparative perspective. The inclusion of several countries in the analysis allowed the identification of factors that foster and hinder the use of eHealth, which can be transformed into policy recommendations.


In the wake of COVID-19, there is an urgent need for a diverse public health work force to address problems presented or exacerbated by the global pandemic. Educational programs that create our work force both train and shape the makeup of access through graduate applications. The Graduate Record Exam has a number of standing issues, with additional barriers created by the pandemic. We trace the GRE waiver movement over several years, focusing on the gradual adoption in CEPH accredited programs and the rapid expansion of temporary waivers as a response to testing access. Going forward, we need to consider gaps in waivers during the pandemic and how this data can be used to shape our future use of the GRE. As we move forward in the profession of public health, many of the problems presented or exacerbated by the COVID-19 global pandemic may require new solutions and a diversity of thought and approaches to problem solving. The future of our public health workforce is shaped by decisions from our educational programs that decide who can access public health training and who designs the trainings. It is important that we consider how components of our graduate school applications currently shape our workforce and the possible barriers we create by the inclusion of testing metrics, such as the Graduate Record Exam (GRE). As the pandemic has unfolded, I have been active in collecting and sharing data on issues with the use of the GRE in public health admissions and I believe now is the time to re-think its problematic role in our public health workforce.Over the last decade, issues with how the GRE increases barriers to graduate education have been more widely discussed. The GRE may not predict academic success, with correlation between GRE and academic success appearing to be weak at best . Boston The inequalities in testing have been increased during the COVID-19 pandemic. In March 2020 as lockdowns began and testing centers closed, ETS rolled out a solution to testing access: the GRE at Home. This version allowed testing to continue online, but came with a number of hurdles . The reqRecently, the practice of waiving the GRE in graduate applications has spread. In 2016, the American Astronomical Society recommended the elimination of the GRE due to the test's poor predictions of success, correlations with gender, race, and socioeconomic status, and financial burden . In NoveAs COVID-19 started to spread in the United States and lockdowns were initiated, public health programs began to consider the possibility of temporarily waiving the GRE in light of barriers to the GRE at Home. By the beginning of April, Rutgers allowed temporary waivers for Fall 2020 . By the The coverage of GRE waivers in public health programs is not equal, with very few programs allowing a blanket waiver to all graduate degrees. Among top 50 public health programs ranked by US World News, only 15 have a waiver for all degrees (permanent or temporary) as of September 20, 2020. Inclusion of a waiver also varies by concentration, with some programs including permanent waivers for specific degrees or concentrations, and temporary or no waivers for others. Seventy percentage of degrees in CEPH accredited programs currently offer at least a temporary GRE waiver, but that percent drops as low as 59% for admissions to biostatistics-specific degree programs . These nThe pandemic has made inequities in access to education more visible, through the digital divide, financial concerns, and resulting conversations of barriers for minority groups. As we make our way into the 2020–2021 academic year, public health programs that have not done so may want to consider instigating or expanding temporary GRE waivers to more degrees and concentrations. Moving beyond the pandemic, there is a great deal more hesitancy on allowing more permanent GRE waivers. Several programs, such as Cornell, University of Iowa, and Ohio State, converted their temporary MPH GRE waivers to permanent , 20. UniFew studies on the GRE in public health programs have been conducted, but that is beginning to change. Boston University and University of North Carolina at Chapel Hill are currently conducting three-year studies to look at the impact of removing the GRE requirement on diversity and student success , 22. SevThe original contributions presented in the study are included in the article/JM drafted the initial manuscript, figures, edited, read, and approved the final manuscript.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.


During the initial phases of this closure, most institutions were at a loss on how to proceed with learning as universities in Nigeria use mainly the didactic lecturing model. As the lockdown progressed it became imperative to the institutions to set up e-learning media for continued instruction of students. It was found that in the institutions with e-learning facilities, the preclinical years remained mostly unaffected by the closure of medical schools due to the COVID-19 pandemic, while all institutions came to a standstill as regards providing a suitable alternative for clinical exposure. This therein has caused loss of valuable time and a change in the calendar of the school year, making it uncertain as to when the next set of qualified medical professionals will emerge in Nigeria. In this essay, we take a look at medical education in Nigeria, its challenges and progression in the COVID-19 era. We also take a look at the effect of the pandemic on learning and the subsequent interventions introduced to mitigate it.On March 20 Medical education in Nigeria: medical education commenced in the University College Hospital (UCH) Ibadan in 1948 and has since then evolved over subsequent generations. Most of the newer medical schools adopted the curriculum of the older schools with little or no modification [fication . HistoriThus, with the advent of the COVID-19 pandemic, there was no room for off-site or digital education in many of the medical training institutions in Nigeria. Adapting medical school in Nigeria to function efficiently during this pandemic has been an especially difficult endeavor because of the absence of infrastructure for digital learning. This commentary focuses on the need to review the curriculum across most medical training institutions in the country and introduce a dynamic digital component without diluting the core concept of the rigorous medical education. According to the Nigerian medical association, Nigeria produces 3,000 doctors annually with about 41,000 doctors currently working in the country. Data from the World Health Organization (WHO) has revealed that the doctor to patient ratio in Nigeria is four doctors per 10,000 patients, in comparison to other countries like the US and the UK with ratios of 26 and 28 doctors per 10,000 patients respectively [Historical perspective of medical education in Nigeria: during the pre-colonial era in Nigeria, medical care was essentially provided by traditional practitioners, who were trained as apprentices under relatives who were conversant with the art of healing. This is still the major source of medical care in some parts of Nigeria [ Nigeria . The fir Nigeria . This in Nigeria . Formal  Nigeria . This in Nigeria . The gra Nigeria .The very first set of medical students to graduate from Ibadan, Nigeria did so in the year 1960 utilizing the curriculum of the University of London with slight modifications in pediatrics with a focus on tropical diseases . MedicalMedical education during COVID-19 pandemic globally: the onset of the COVID-19 pandemic ushered in the closure of universities and medical institutions globally. With the most effective strategy for the prevention of COVID-19 being social distancing in the absence of a vaccine, it is not certain how long this closure will last. This sustained closure of medical schools has created a challenge which e-learning platforms like WebEx  and Zoom may help to solve [to solve . Medicalto solve . This alto solve . It willto solve .In a country like Turkey where medical education is transitioning into a more individualized model, physical presence is not required in the first 3 years except for laboratory sessions . VirtualIn resource constrained countries, the story is not the same with several challenges faced by medical educators in these settings hindering the continuity of medical education. In Brazil, it was observed that private universities were able to carry on by deploying electronic platforms which were not available to the public institutions. Unavailability of appropriate infrastructure and the presence of socially vulnerable students serve as a deterrence to online learning there . The absMedical education during COVID-19 pandemic in Nigeria: on March 20th, 2020, the Federal Government of Nigeria ordered the closure of all educational institutions including tertiary institutions as a precaution to reduce the spread of COVID-19 in the country. In Nigeria, where medical education largely involves person to person interaction, this posed a great challenge to continuing medical education. To study the impact of this pandemic on medical education in Nigeria, a survey was carried out involving 72 medical students in different levels from medical schools throughout Nigeria. Medical students from public and private medical schools were included in a bid to get a full picture of the situation and also pick up on observable disparities in their medical education.Findings from this survey showed that the majority (75%) of the participants stated that e-learning platforms were not used by their institutions prior to the pandemic. Interestingly, majority of those who stated that e-learning platforms were already in use were medical students from private institutions. With the mandatory closure of schools, 45% percent of the schools in this survey have managed to continue providing medical education to their students using various e-learning platforms. It was observed that all the private institutions continued education while only a few public institutions were able to continue providing education for their students. Furthermore, among the public medical schools, it was shown that the continuation of their education using e-learning platforms were available to some classes instead of all. The transition to e-learning by these medical schools was described to have taken about 4 - 8 weeks to put adequate structures in place. This shows that medical students were left with nothing to do for almost 2 months thereby creating a delay in their school calendar.Exploring the e-learning model used by these various institutions, it was shown that multiple e-learning platforms were used including Zoom, WhatsApp, Google classroom, WebEx  and institution owned platforms. Although the most commonly used platform was zoom, with a 75.6% use rate among the participants. The use of e-learning in medical education brings forth certain challenges when it comes to clinical clerkships and laboratory sessions. It was discovered that none of the schools had clear strategies to solve this problem as they deferred all clinical and laboratory sessions to when students that eventually return back to the clinical setting. In some schools, though clerkships had been deferred, a method of using pictures of disease conditions, videos of patient interactions and physical examinations were adopted for their medical students. The effectiveness of this method is uncertain.Transition to the e-learning model was unprepared for in Nigeria but inevitable due to the pandemic. As a result of this unpreparedness and the situation of Nigeria as a resource limited country, this new method of learning comes with different challenges. It was interesting to note that the challenges highlighted by the students in private institutions largely differed from those in public institutions. Challenges noted by students in private institutions ranged from problems of poor internet connection to the inability of lecturers to use the digital platforms. While for students in public institutions, their challenges are two pronged, institutional and personal. Institutional challenges included; industrial strike of university lecturers, poor funding and administrative capacity, absence of existing e-learning platforms in schools, lack of technical support and knowledge, while the challenges influenced by the students include non-ownership of devices/gadgets to access virtual resources and online platforms by majority of the student population, high cost of internet service subscription and epileptic power supply.Even though the private institutions appeared slightly more prepared for this transition, all the institutes are at a loss when it comes to graduating students without them completing their clinical exposure. Without the adequate infrastructure to bypass this challenge, the question is: will Nigeria induct final year students into the medical profession this year?Recommendations: in light of the above, the following are recommended for the advancement of medical education in Nigeria ( Nigeria : completIt is important to blend the current curricula with virtual learning models to enhance the learning experience of the students as well as strengthen the system for any eventualities in future. There is also the need for appropriate investment in personnel, equipment and infrastructure that will allow education to continue seamlessly regardless of environmental circumstances.