The study explores regional approaches to integrated care, focusing on regions with regular municipality-based and integrated unified health and social care administration. The aim is to describe a governance approach that supports care integration in the regions.n = 176) on regional health and social services within 20 specialised care authorities. The document data were supplemented with interviews of national health and social system evaluation officers. In our analysis, we used deductive content analysis and identified conceptual approaches of social and health care integration according to elements of integrated care governance.The study draws on analysis of integrated care governance using an extensive collection of administrative documents (Overall, integrated care governance was relatively well advanced. All regional authorities had established at least some preconditions for integrated governance. The stage of integration varied in the different elements of integrated care governance. The regions with unified integrated administrations enabled the more advanced models of integrated care.Various models for cooperation between regional health and social care authorities have emerged in the regions to identify good integrated care practices. The study suggests that the applied theoretical framework and presented elements of integrated care governance can be used to monitor development of care integration. The social and health system – and the degree to which it functions as it was designed – plays a critical role in promoting, restoring, and maintaining people’s health and well-being. In several countries, including Finland, health and social care systems have been reoriented to embrace an integrated, people-centred approach to improve quality, people’s experience, and sustainability of the service systems 2. In Fin34The need for better interplay and processes between various sectors of health and social services that are more fluent is evident. First, demographic and epidemiological changes, the rising expectations of the population, and accentuated clients’ rights put pressure on reforming the health system. Second, the development of medical technology and information systems and restrictions due to economic constraints require reforms . In addi3Integration has recognised effects on the delivery of high-quality care that is more cost-effective . HoweverA need for a conceptual framework to understand integrated care and social services from a governance viewpoint is prevalent 91011. Th910146Nicholsson and colleagues 10 identiThe general aim of the study is to assess the development of the governance of health and social care integration in Finland. First, we explore regional approaches to integrated care in Finland by using Nicholson et al.’s 10 concepIn Finland, health and social services as well as most other welfare services, including schools, libraries, and children’s day care, are based on public funding and provision through the highly decentralised responsibility of the mostly small municipalities. The municipalities form joint municipal authorities to offer specialist services and, in case of smaller municipalities, for primary care and social services, too. To finance the services, the municipalities have the right to levy taxes. In addition, they obtain funding through state transfers and users’ fees. The Finnish health and social care system has been described in detail elsewhere 917181920.171819In the statutory health care system, the country is divided into 20 hospital districts. The municipalities manage and fund the hospital districts within their respective catchment areas, and they are responsible for organizing and providing specialist medical services for the residents of member municipalities. Each district runs a regional hospital. Each hospital district belongs to one of the five university hospital catchment areas (UHCAs) led by the hospital districts associated with the medical schools in five major cities . The UHCAs coordinate the provision of specialised medical care, information systems, medical rehabilitation, and procurement 1819.18In terms of primary health care, municipal health centres provide a wide range of curative and preventive services, such as general practice consultations, maternity and child health clinics, dental health services, and mental health and substance abuse services. The health centres are managed by about 170 primary health care authorities, which are administratively either joint municipal bodies or single municipalities 1619. Mos16Due to local arrangements, the health and social services in Finland are under two separate types of regional administration. The regular way to arrange services, which is defined in legislation, involves a separate authority for specialized health services and then several independent municipal authorities for primary health care and social services (which may or may not work in an integrated manner). The specialized health care authority is responsible for coordinating health services but how this is practiced varies between regions.A new type of regional administration is a regional joint authority, which municipalities form through voluntary agreements. Currently, eight out 20 regions have a joint authority of this type. On average, these regions are smaller, and altogether they constitute around 20% of the Finnish population . In thesThe municipalities and the health and social care authorities in Finland have developed their health and social services in extreme uncertainty for the last 15 years due to the government’s series of failed attempts to reform the health and social care system 571620. I5716In terms of developing service arrangements and integrated care, the situation in each region has constantly changed, and the municipalities and the health and social authorities have adapted their operations to government policy processes and local circumstances, which has resulted in variations in the pace of reforms, such as implementing integrated care.At the beginning in 2023, the so-called “well-being services counties” will take responsibility for organizing all health and social care services. After the reform, Finland will have 21 new well-being services counties. In addition, Helsinki will organize and continue to produce its own social and health care services in the future [As in many other countries, the aging population in Finland significantly influences the development of health and social services. The life expectancy of the Finns at age 65 now exceeds 20 years. In 2017, 21% of the population was 65 and older. Three in five of those aged 65 or older reported having at least one chronic condition or disability, which is a higher proportion compared to other EU countries . In addi16The general aim of the study is to assess governance of health and social care integration in Finland. First, we explore regional approaches to integrated care in Finland by using Nicholson et al.’s 10 concepn = 176) from the 20 regional care authorities and additional interviews of national health and social care evaluation officers (n = 5). The interviews were conducted via Microsoft Teams, and semi-structured discussion was based on the analysis carried out. The study analyses administrative and planning documents on health and social services from the 20 regions in Finland. The documents were collected in May–June 2019 and completed in 2020. The data included most recent documents from relevant periods, such as recent annual reports, organizational plans, agreements between authorities and municipalities, and regional plans for intended national health and social service reforms.The study is a qualitative review that consists of two phases  comprisiIn the first phase, we analysed the documents using deductive content analysis in terms of the governance elements supporting integrated care. We adapted the frame of analysis from Nicholson et al. 10, who iAccording to the levels, the presentation of the key elements in each document was classified into a level ranging from 0 to 4, using scale of half decimals. This was based on a choice made by the four researchers. We identified the descriptions of the elements in the regional planning and administrative documents and categorised the regions for each element into four levels according to the scale given in In the second phase, we compared our findings on the identification of the governance elements by interviewing the five evaluation officers responsible for regional assessments within the national annual health care and social services evaluation. The purpose of the supplementary interviews was to compare the consistency of the results with the views of evaluation officers who have deep knowledge of the regions. The annual evaluation is carried out by the Finnish Institute for Health and Welfare and is coordinated regionally by the evaluation officers. Rissanen et al.  describejoint planning, shared health and social care priorities, and client/community engagement. In addition to these elements, measurement of data and continuing professional development reached at least Level 2 (developed) in all regions. Of the ten elements, information communication technology, change management, population focus, and innovations showed differences between regions with the regular and unified integrated administration.The most advanced elements of integrated care governance in the Finnish health and social care system were Regions with unified regional administration have joint boards and work groups of stakeholders, who implement strategy in action. Regions with regular administration have so far planned a common strategy, but the municipal authorities have the right to make independent decisions.The modelling of the service paths between primary and specialized care has been piloted in most regions. For instance, in North Savo Health Care District, some services have functioned seamlessly for a long time between primary and special health care and between different sectors . In Satakunta Health Care District, modelling of the service paths and descriptions of the service processes has been planned in Jyväskylä, the central city of Central Finland district, population and officials had to wait until the brand-new central hospital (NOVA) was made ready. New facilities have been constructed without borders between specialized and primary health care. In South Karelia Health and Social Care Region, all services for children and young people have been organized in a new way. Services for children and young people from specialized care, primary care, and social services are organized under joint management. Similarly, in North Karelia, health and social services are organized jointly in health and social centres’ multi-professional teams . In these integrated joint authorities, one management team plans the integrated services instead of 15–20 municipalities and a hospital.A wide range of instruments has been used for quality improvement. Typically, information concerning client satisfaction  is gathered in every region, but in many cases with different methods. The degree to which the quality information has been used across the borders of sectors to foster integration is difficult to determine due to missing information in documents.In Finland, requirements for the formal education of the health and social care staff are high. Much training occurred, but the documents do not reveal the degree to which interprofessional and intersectoral training has been arranged. There are mentions, such as “common training” in South Ostrobotnia and North Karelia and “partly multiprofessional” training in Kanta-Häme.incentives were not recognised as having been used in supporting integrated care in any region. As stated above, health and social services in Finland are mainly funded and provided by the public sector and the professionals are mainly salaried municipal sector employees. Health and social care authorities may use incentives for employees but often it is done for purposes other than care integration, such as supporting recruitment.Although most elements of overall integrated care governance were advanced to at least some extent, The national evaluation officers mostly confirmed our findings based on their expertise, and the differences between grades formed by researchers and the evaluation officers’ views were minor. Main discrepancies involved the extent of implementation of individual governance elements that had been insufficiently described or recognised in the regional documents.joint planning of the integration of services have been under construction in all regions. Regarding integrated information communication technology, the advantages of integrative information systems are also widely recognized. In most regions, however, the health and social care client-record systems are fragmented . Almost all regions having the regional joint authority also had a unified information system in health care (the same system in primary and secondary care), and some had a unified system in health and social care, even though at the time of the study the client records could not be used across health and social care due to legal restrictions.Due to the planned national health and social care system reform, the structures of joint planning and integrated information communication technology, the integrated care authorities made a difference to the regions with regular administration for the element of change management . Only two of the integrated care authorities had been launched before 2019, which probably explains why integrated care governance elements had not yet strengthened in these newly established authorities. However, the region of South Karelia, which was established in 2010, received the highest grades for all the elements of integrated care governance  has been widely acknowledged and already demonstrated in most regions.On average, the regions with integrated regional administration had higher grades in terms of implementing the different elements of integrated care governance, but for most elements, the difference was minor. In addition to the governance elements of In This study gives a picture of integrated health and social care governance in Finland in different administrations. In general, integrated care is already relatively well advanced in Finnish health and social care. Because local governments, municipalities, and municipal joint organisations run public health and social services, collaboration across sector borders has been relatively uncomplicated to organise. Still, challenges to organising co-operation and coordination between health and social care as well as between primary care and secondary and specialized care have arisen, because municipalities organise the first and hospital districts the latter. In recent years, in eight of 20 regions, the municipalities have voluntarily established the joint health and social care authorities running all health and social services under a single administration 17181920.171819Our results strongly suggest that the integrated organizations, joint management, and funding in the new joint authorities have an effect on integration. In the integrated joint authorities’ joint planning, building shared priorities, change management, and integrated information systems were at a higher level. It is possible that building a joint strategy, shared values, unified organizational culture, and practices are easier when the management is under one executive team instead of executive teams of several municipalities and one hospital district, which is the case in the regions with regular administration. However, in several regions, despite the separate management groups, the integrated governance elements seemed to be well developed. However, because the analysis in the study is based on documents analysed using Nicholsson et al.’s 10 framewjoint planning, population focus, measurement of data, continuing professional development, and client/community engagement. In our study, these five elements at least reach the level of “planned to be implemented in the whole region” in all regions. Several factors have contributed to this. Public health and social services funded and provided by municipalities and joint municipal organizations have obviously supported integration. In addition, government policies and reform plans have subscribed to integrated care in recent years [18integrated information communication technology and change management. In part, this may be because in a document-based analysis, the elements of change management in health and social care planning documents are challenging to identify and the ways to describe these elements in documents vary regionally. The study confirms the contributions of previous studies that showed multiple elements are required to ensure successful and sustainable integration efforts. [23According to our experience, extending the presented ten elements to an analysis of the integration of social services with specialized and primary health care was feasible. In terms of a more granular analysis of elements of governance that support integrated care 17, half nt years 1822. Howefforts. 2324.The interviews of the national evaluation officers confirmed our findings. The agreement was quite high. The main differences emerged over whether the district had planned to implement the element in question or whether the element was already implemented in some parts of the region. Care integration was often at a very high level in some municipalities, especially in the regions with traditional administration, but development was weaker in other municipalities. Although it is possible to analyse integration based on a specific theoretical model, deep knowledge of the region is highly important to draw an analysis of the level of integration. Nicholsson et al.’s theory has been applied in the Australian  health sIn summary, integrated care has been planned but implementation is partly fragmented and is dependent on regional features such as financial resources, aging of the population, and regional politics. However, integrated administration of health and social services does not determine how the integration has been developed in the regions, but it must be noted that the regions with integrated administration are represented by rather young organizations. In general, the integration has placed more focused on integrating primary care and specialised health care, rather than integration between health and social services. In the regions with integrated administration, integration between health and social services has seen greater development.In Finland, as in many other countries, a clear driver of integrated care is cost containment . In thisPromoting integration should be inclusive, and thus clients should be more strongly integrated into the development of operating models of integrated care to promote quality, efficiency, client-oriented culture and cost-effectiveness.The key findings of this study confirm that more research on social and health care governance integration and its measurement is needed so that countries and regions with various kind of social and health care systems can be measured, analysed, and studied to understand the current state of integration. Suitable models and indicators need to be developed so that integration can be benchmarked at the national and international levels. Integration is a matter of coordinated and seamless service paths, which is likely of interest regardless of the system, region, or country. Integration or lack thereof can have a very large influence on the success of services that clients need.Clients who require multidisciplinary services often use both social and health care services, and thus integration is more important from orientation, effectiveness, and cost viewpoints. Integrated governance creates the basis for the implementation of practical integration between social and health care. However, integrated governance also lays the foundation for an operating culture, when social and health care organization has a common shared interest and values in promoting the integration. Integration is at its best an automation tool for service coordination.Our study has some limitations. First, because regional planning in Finnish health and social care primarily focuses on health services, our analyses based on regional administrative and planning documents have probably been less detailed on integration comprising social services. Second, the quality of documents varied across regions. Some documents seemed to be quite positive concerning integrative care in the region. The descriptions concerning the state of affairs may not be as objective as we could expect. Moreover, some elements of governance of integration were not described at all in the documents or in a very narrow way. Third, in our study we were not able to investigate the actual implementation of integrated care.The study showed that integration of social and health care consists of several separate elements that are closely connected to each other 10. Their3Overall, our approach as such has proven feasible and the deductive content analysis carried out allowed us to identify various elements for integrated care governance. Consequently, it seems feasible to use elements of integrated care governance to monitor development of integrated care in regions in a way that is more structured. The analysis also provides an overview at the national level.In further research, based on this analytical integrated governance framework, it is possible to apply an assessment and monitoring tool for to measure the reform of government health and social care as well as regional development projects relative to the progress of integrated care.


Variables: sociodemographics, labor, and health conditions, QOL (WHOQOL-BREF). Normality tests, descriptive statistics, and bivariate analyzes were performed. Factors associated with QOL were established using multivariate linear regression. A second qualitative phase with two focus groups (FGs) delved into those aspects of relevance, through qualitative content analysis and triangulation of information. The multivariate linear regression analysis showed that the factors associated with the QOL scores were in the case of men and negatively (QOL decreases): having low social support (p < 0.001), reporting poor mental health (p < 0.01). For women, QOL scores were negatively associated with low social support (p < 0.001), reporting poor general and mental health (p < 0.01), having greater stress at work (p < 0.05), having a temporary contract (p < 0.05), and living in a medium or low socioeconomic status (p < 0.05). The analysis of the FG allowed us to understand how QOL is permeated by the social context. The specialization of periodontics has generated a change in living conditions, and an adaptation to the workplace that allows them to gain recognition and a higher QOL. In conclusion, the QOL of periodontists is defined in subjective terms (standards) and related to social and labor conditions. Follow-up and evaluation strategies of the general conditions of these clinical specialists in Colombia are required.This study analyzed the association of the sociodemographic, labor, and health conditions on the quality of life (QOL) of the periodontists in Colombia. A mixed study  was conducted. The first quantitative phase was carried out by a cross-sectional survey ( Quality of life (QOL) has been defined from numerous approaches and perspectives and denotes, in general terms, a multifactorial and multidimensional concept . AlthougFrom this perspective, a linked element to QOL is the labor aspect. In fact, there exists some research focused on evaluating the QOL at work and/or labor well-being . For insFor dentists, including their specialties, it has been observed that QOL is a matter of growing concern . This siFor instance, the neoliberal economic model has generated some changes with regard to professional work of the health workers and specifically on the general and specialized dentistry . PreviouStudies conducted on QOL within oral health professionals use instruments that allow its assessment through the individual experience including multiple factors and spheres of human, social, and work development ,6,7,14. A mixed-methods study with an explanatory sequential design was proposed ,16. In tA cross-sectional online survey (by using the Google Forms tool) was applied. As participation criteria, those dentists residing in Colombia, with a specialist title in periodontics or related areas, who also carried out their professional practice in the country and who wished to participate, were included. Other specialists and professionals who were unable to be contacted or accepted to participate in the study were not included. Various strategies to recruit people were used: emails provided by associations of periodontists, use of social networks (Facebook and WhatsApp), nominal sampling or snowballing through referrals, and forwarding the questionnaire to colleagues and relatives. The fieldwork of the survey was conducted between Abril-October 2021 and a final sample of 187 participants  was achieved. A pilot study was carried out on a sample of 10 periodontists to improve the intelligibility of the questionnaire, and to assess the time to completion for the respondents and the internal consistency of the questions.Quality of life (QOL) was measured by the WHOQOL-BREF ,19. ThisReliability testing was performed by calculating the Cronbach’s alpha coefficient for WHOQOL-BREF, GHQ-12, and Duke-UNC-11 instruments in the sample. The following values were obtained: (1) WHOQOL-BREF: Global: 0.919 and for the domains physical: 0.766; psychological: 0.800; social relationships: 0.742; environment: 0.845; (2) GHQ-12: 0.710; (3) Duke-UNC-11: 0.902 .® for Windows  was used to carry out all of the analyses (separately for men and women). All variables underwent descriptive analysis. Normality distribution was tested by the WHOQOL-BREF and other quantitative variables (Kolmogorov–Smirnov test). Tests of statistical significance were carried out to observe differences among variables according to their nature .SPSS software version 22.0-IBMn = 6), labor (n = 22), and health (n = 4) variables. Belonging was determined by evaluating the compliance with the assumptions of linearity, non-collinearity and normality, constant variance, and correlation of residuals. Due to the specificities of the statistical calculations in the software, different models (adjusted and unadjusted) were carried out. Non-statistically significant variables were not included in the definitive adjusted models. For the physical domain, seven models were made for females and two models for males where the adjusted final model only included seven variables with statistical significance for women and two variables for men. For the psychological domain, two models were performed for women and three for men and the final adjusted model included two statistically significant variables for women and three variables for men. In the case of the social relationships domain, two models were carried out for women and three models for men, and the adjusted final model included two and three statistically significant variables for men and women respectively. Finally, for the environmental domain, two models were carried out for women and a single model was established for men. The adjusted final model included two statistically significant variables for females and one for males.A linear multivariate regression analysis was carried out to identify possible predictors of the scores of QOL by using the stepwise method. Four multivariate linear regressions (for the same quantity of domains of the WHOQOL-BREF) were calculated including sociodemographic (Two focus groups (FGs) were carried out and participated teen respondents that previously completed the online survey (selected for convenience). This technique was chosen to obtain a collective discourse by the dialogue and interaction of the participants. FGs were conducted by the research team using Microsoft Teams (remote means). Through the opinions and experiences of the participants, we dept on the information obtained from the survey. For that purpose, the research group designed a guide of topic to be included in the FGs and we focused on the factors that determine the quality of life in this group, by analyzing their particular context. We asked for the concept of quality of life, social and particular determinants, the general context of periodontitis, and variables significantly associated with QOL. FGs lasted between 90 and 120 min and were digitally recorded and transcribed verbatim. Fieldwork of FGs was carried out between March and April 2022. A thematic analysis was carried out to recognize trends of information found in the participants’ discourses. All analyses were carried out manually (without using support software). The text fragments were grouped into four categories.Triangulation methods were applied, achieving the integration of both substudies . An explThe research process followed Colombian regulations  and the bioethics research committee of the Faculty of Dentistry of the University of Antioquia  approved this study. Individuals’ participation was voluntary and informed consent was obtained from study participants.The working day had a median of between 35 and 40 h/week, and 19% of women and 58% of men earn more than 6 million Colombian pesos per month (approx. 1500 U$). Between 72 and 92% of those surveyed consider the salary to be enough to cover different types of expenses, although 40% of women and 55% of men mention not being well paid for the time they dedicate to work. Moreover, 30% of women mention being dissatisfied with their job and 84% of men mention that the job is stressful. There is evidence of a median annual participation of 2 ± IQR 2 annual academic events in men.Considering the health variables, 74% of males and 43% of females mentioned sports practice. 85% and more of both sexes referred to having a good self-rated health, although 62% of males and females perceived poor mental health. A low social support is perceived in 13% of women (a lower percentage in men). Considering the WHOQOL-BREF domains, the median of scores surpassed 59 points, being higher in the physical dimension and lower in the environment. In almost all cases, the QOL scores are lower in women, with the exception of the social relationships domain (the score is the same).In For males , having The multivariate analysis through linear regression  showed tThe analysis of the focus groups (FGs) allowed us to explore the factors that were relevant according to the findings that drew attention to the statistical models.The main categories of analysis are shown below .Quality of life is to be able to be happy with what you do, in what you do, without needing to have many things, living with enough. In my opinion that is quality of life, it’s not about having, but about being and finding happiness in what you do and in your life purpose”.“(FG 2)QOL from the periodontists’ perspective did not differ greatly from the theoretical definitions that have been previously established by the scientific literature. They recognized that QOL is an individual concept, which depends on social and individual aspects against a system of standards and values. They understood the importance of happiness and balance in different spheres and spaces  compared to the fulfillment of a life purpose. Similarly, they considered that being able to reconcile and enjoy family and affective life and free time with their personal and economic support contributes to improving QOL .(…) Working conditions will always be poor for us, not for the owners of the clinics, they always say … I am not the owner of a large clinic because I have experienced work exploitation, that’s the word. They have their point of view as employment creators, as people who have to pay rent, but we are working in totally disadvantageous conditions”.“(FG 1)They highlighted the importance of working conditions as a social determinant that impacts well-being and QOL. There are differences while considering the time and work experience of the periodontist. Furthermore, they perceived that newly graduated specialists must work in different workplaces to stabilize economically . HoweverWhile comparing the working conditions against other specialties, dualities are presented in the perception of the study participants. On the one hand, they stated that some periodontal procedures represent greater economic value when compared to other treatments such as orthodontics, endodontics, and general dentistry. This situation could represent higher income for them . HoweverTeaching and research activities are considered as satisfiers of the QOL. Although they do not represent a high economic utility, they possibly generate additional benefits such as interactive activities with the postgraduate students to share academic aspects . SimilarWorking with the human body will always be an activity that creates high levels of stress, right? What we do is a high-responsibility profession, so anyway we are always subjected to stress and spending long hours sitting in a chair can generate other types of damage, on a physical level, so then you have back pain, leg pain, waist pain, and that will have an effect on your daily life one way or another”.“(FG 1)The QOL cannot be delinked from the health concept. From the participants’ perspective, periodontics represents a personal and professional challenge with positive factors. Nevertheless, the academic load and the health care demands for the patients could generate stress, physical wear, and muscular pain, among other symptoms . RestingMore support among us, more balance in terms of practice and competition among all, not trying to trample on others, but instead enjoying the benefits and the good things of others, and each one working at ease and content with their own things”.“(FG 2)Finally, participants in FGs mentioned some situations that could contribute toward improving QOL and are circumscribed in labor and social fields. They ask for greater recognition of the periodontist, higher support and collegiality, training in entrepreneurship in the universities, and less labor exploitation .The major findings of this study showed a QOL reported as high by the periodontists that participated in the study. Differences in scores of the domains of the WHOQOL-BREF were observed, according to sociodemographic, occupational, and health factors. Multivariate analyses showed some factors that have a significant association with QOL in a negative or positive way. Additionally, there were some sex differences in QOL scores. The discourses analyzed confirmed quantitative data, highlighting the influence of the labor conditions in the QOL, and in turn, the relationship that exists between the presence of greater physical demands and stress. In the participants’ opinion, QOL is a concept that is consistent with standards and values and is defined in terms of balance in the spheres of human development that lead to well-being. To our knowledge, this is the first study conducted in Colombia investigating the QOL in periodontists using a mixed-method research design.This study assumed a gender perspective in data analysis. This is in line with the international set of guidelines to support the systematic presentation of sex and gender in research across all disciplines . The scoIn this regard, some considerations must be taken while interpreting the data. The first aspect to be analyzed is the homogeneity of the sample in sociodemographic, labor, and economic terms. However, specific factors must be analyzed since the multivariate models showed some subtle differences in the perception of the factors that influence QOL in the respondents. For instance, in the physical domain, the QOL is more affected in females by labor and health factors, whereas in males, the QOL is more associated with social support and participation in educative activities. In the social domain, the experience as a periodontist in men was important, and the socioeconomic status was related to the QOL in the environmental dimension for women. All these factors are related to other variables specified in the linear regression interaction models.The second round of analysis is related to the representations and social constructions made in front of the QOL and other cultural determinants. In this regard, exploring other differential situations between sexes related indirectly to QOL could be interesting. For example, a qualitative study conducted on female dentists in India , showed A study conducted in Saudi Arabia showed that when general dentists and specialists are compared, QOL tends to be better for the latter  . An IndiComplementing the above discussion, QOL was closely related to employment and work conditions, and this was evidenced in the quantitative results wherein a lower score in the environmental domain is related to financial resources, safety, health, and job opportunities in each population . It has Teaching and research activities had a positive influence on QOL . These findings could possibly be explained by the decreasing physical demands and less clinical practice time. These factors prevent the occurrence of physical health disorders . FurtherThis study established a strong association between the indicators of self-rated health  and mental health (both sexes) with QOL. In the first case, it is important to analyze and consider the possible presence of labor risk factors; for instance, working in uncomfortable positions in the dental office for long periods and assisting a lot of patients during the workday ,28. A stThis situation is complemented by other studies that mention that scaling and root planning could be the procedures with the highest risk and represent the main cause of musculoskeletal disorders in the hands and arms . An impoPoor mental health and labor stress were negatively associated with QOL. Some studies have commented that working in the dental practice is a job that demands both the body and the mind, which would generate chronic stress and harm the psychological health of the professional ,32,33; aAnother element of interest is social support, which is related to family, friends, and colleagues’ resources of individuals in their immediate social space. This variable and the participation in academic and social events were considered as positive predictors for QOL in the multivariate analysis for men and women. This relationship was corroborated with focus groups where discourses mentioned that after mandatory social isolation, meeting with colleagues and friends allows individuals to have more interaction and social well-being. In this regard, it is important to mention that there are factors related to greater social control and social support in the work context that contribute to reducing work overload, as mentioned in a study carried out in Sweden . Moreoven = 187), which allowed analysis with a sex/gender perspective, there may be external circumstances that could affect the results of the study since the decision to answer the survey may be related to the QOL perceptions and results could be underestimated. In this regard, a literature review shows that survey response rates among health personnel tend to be lower than the general population due to their demanding work schedules [While interpreting the results of this study, it is important to consider its strengths and limitations. Data collection instruments were carefully planned and had internal validity processes, both by pilot testing and consistency and validation of the questionnaires related to QOL as well as the reliability and rigor of the qualitative techniques used. The use of mixed models enables a social reality approach through the triangulation of results and their complementarity. As limitations, it is important to consider the circumstances of the sample selection processes, the results cannot be inferred from the general population of specialists, although it is not a population study with probabilistic sampling. The nature of the study does not support causal relationships, but associations between variables and holistic understandings between categories of analysis. Although there was high participation of professionals . This is consistent with multivariate analyses where variables with greater predictive capacity were those related to health indicators, supplemented with qualitative analyzes. Possible explanations include factors related to sample size and type (relative homogeneity of demographic and work aspects). This same situation concerning the effect of sample size was highlighted in a study of pediatric dentists .Taking into account the scientific literature on the related topic, recognizing the limitations of this study, and the scarcity of studies with multi-method approaches, the findings contribute to the generation of a scientific agenda on this topic of interest. This research can be considered a gateway that, on the one hand, understands the reality of specific groups in the country, and establishes follow-up strategies on issues that concern the clinical dental specialties in social, labor, educational, and QOL aspects. Further research should examine other indicators of quality of life, work, and health.Finally, the impact of the COVID-19 pandemic on the terms and conditions of Colombian and dental practitioners around the world cannot be ignored . This efIn this study, although QOL scores were good for the study participants (the scores surpassed 59 points), multiple factors exert a positive or negative influence. The QOL determinants are explained by subjective aspects  including elements of the social and economic context that influence at a personal and professional level. Specifically, in the quantitative component, the factors that had the greatest association on the QOL of periodontists in Colombia were social support, mental and general health, frequency of participation in academic events, work experience as a periodontist, having a well-paid job, stress at work, carrying out teaching/research activities. These associations were corroborated by the discourses in the qualitative component. This situation highlights the particularities of QOL in different social groups, its multifactorial character, and the need for intersectoral and interdisciplinarity for its care, promotion, or research in oral health professionals.


To determine nursing outcomes in individuals with intestinal stoma and the relationships between them and sociodemographic and clinical variables.Cross-sectional study performed with 102 subjects at the General Surgery Unit of a first-level hospital.Data on the presence of nursing outcomes were collected using the Nursing Outcomes Classification. Data on sociodemographic and clinical variables were also collected. Univariate and bivariate data analyses were performed.p < 0.05) among the outcomes. The outcome scores ranged from 2 to 3, indicating a moderate level of impairment in the physical, psychological, and social spheres of these patients. The scores in the indicators on Participation in making health decisions and Knowledge of stoma care improved in the period of continuity of care compared to the postoperative period, being this difference statistically significant (p < 0.001).Outcomes related to participation in making health decisions and knowledge of ostomy care were assessed across the study sample. Period of care (post-operative and follow-up) was the most common significant variable (The care plan for individuals with intestinal stoma needs to include indicators measuring patient participation in making decisions related to their condition, as well as indicators related to their knowledge and self-care of their stoma. Relevance to clinical practice: This study aims to determine the nursing outcomes in individuals with intestinal stoma and the relationships between them and sociodemographic and clinical variables. It provides the opportunity to plan achievable objectives with patients using a system of indicators that facilitate their assessment and monitoring. Colorectal cancer (CRC) is one of the most common diseases in Western countries. It is estimated that, in EU countries in 2020, colorectal cancer accounted for 12.7% of all new cancer diagnoses and 12.4% of all deaths due to cancer. Approximately 191,053 and 150,366 cases of colorectal cancer were diagnosed in Europe in men and women respectively, and around 87,185 men and 68,920 women died from this disease , including ulcerative colitis or Crohn’s Disease, in abdominal trauma and in inherited disorders such as familial adenomatous polyposis. In Spain there are approximately 70,000 individuals with an ostomy and each year there are 16,000 new cases .Nursing care plans are vehicles for communication. They are records of the care provided and are essential tools for day-to-day care. Care plans are structured according to the nursing care system in place and can therefore take various forms . NursingPatients with intestinal stoma face a number of physical changes that are related to altered defecation patterns: altered body image and altered sexual function. They are also forced to make changes in diet, physical activity, leisure, work, and clothing. As well as having their physical aspects affected, patients often experience psychosocial problems, including depression, feelings of shame, anxiety, low self-esteem, isolation, and social stigma, which also affect their family environment .Family support plays an important role in the acceptance of the stoma. The ability to actively listen to and support family and friends in dealing with the patient’s feelings helps them to overcome problems and to strengthen the family relationship. The attitude of the spouse in this situation is particularly important. Studies show that acceptance of body image improves sexual desire when partners are understanding and supportive. These patients usually experience a decrease in libido and sexual relations, which is related to lack of confidence and coadjuvant psychological alterations .Self-care plays an important role in the patient’s own physical and psychosocial adaptation. Most individuals with an intestinal stoma have difficulties in self-care. The main problems patients encounter are stoma leaks, peristomal skin problems, and difficulty in stoma care, as they need to frequently change the pouching system, which takes some patients about 30 min , 9.In order to provide patients with adequate nursing care, it is necessary to develop care plans that facilitate the standardisation of care while serving as a mechanism for communication between the different professionals involved. This must take place within the framework of the nursing process and taking into consideration the importance of care plan individualisation, thus ensuring the good quality of care by using a scientific method.The nursing process incorporates standardised languages to reduce variability of care in clinical practice, which is how high quality and continuity of care are achieved. Currently, the most widely used nursing standardised languages are NANDA, which identifies the needs or problems in patient care; the Nursing Interventions Classification (NIC), which lists the interventions needed to address these problems; and the Nursing Outcomes Classification (NOC), which assesses the outcomes of these interventions .The availability of standardised languages provides nurses with benefits related to improved communication, assistance in the delivery of patient care, increased visibility of the nursing profession through nursing interventions, nursing practice outcomes, and education of future nurses. The Nursing Outcomes Classification (NOC) is a standardised nursing language that has been translated into nine languages and has been used to explore and describe nursing practice in a variety of nursing practice specialisms, patient groups, and healthcare settings , 12. RecTo determine nursing outcomes (NOC) and their indicators in individuals with an intestinal stoma and the relationships between them and sociodemographic and clinical variables.This study used a cross-sectional descriptive design, following the STROBE guidelines . It was The study population included patients with an intestinal stoma who were admitted for surgery or receiving ongoing care. The exclusion criteria were as follows: patients under 16 years of age (in whom stomas are rare), patients with cognitive impairments that might hinder their assessment, and patients who did not wish to participate. Consecutive sampling was used until 102 subjects were recruited. Data were collected between February and April 2017. All subjects who agreed to participate in the study during that period were selected.Data on the following sociodemographic and clinical variables were collected: age (years), sex , membership in a patient association (yes/no), family member with an ostomy (yes/no), stoma site marking (yes/no), medical diagnosis , time with the stoma (less than one year/more than one year), and period of care (post-operative period and follow-up period). The post-operative period of care began when the patient was discharged from the recovery room and ended when the patient was discharged from the hospital. Then, the follow-up period began.A series of 30 NOC outcomes and their indicators related to physical and psychological aspects of care were selected as main variables. The NOC was used to collect data on nursing outcomes. The presence or absence of NOC outcomes and their indicators was recorded based on a previously prepared list of outcomes. The process of selecting these outcomes and the list itself were based on a previous qualitative metasynthesis on the experiences of patients with intestinal stoma . SubsequEach patient was assessed in the unit itself. To this end, a notebook was prepared with instructions, ethical considerations, the list of variables, and the outcomes selected for analysis. The data were collected in a brief interview conducted by a nurse with experience in stoma therapy and NOC terminology. During data collection, the nurse introduced themselves to the patient, explained the purpose of the study to them, requested their participation in the study, and handed them the informed consent form to sign. Once the patient had been assessed by the nurse, the nursing supervisor of the gastroenterology ward, an expert in stoma therapy, examined and verified the selected data. No patients refused to participate.More details on the sample and data collection process can be found in two previous publications related to this research , 16.Each NOC outcome includes a label, a definition, and a 4-digit code, as well as a list of indicators that are selected by nurses to assess the overall outcome of the care plan for each patient. These indicators are measured using a Likert scale, in which the intensity or frequency of a described situation is represented by a number from 1 to 5, where 1 is the worst possible situation for the patient regarding a given indicator and 5 is the best possible situation. Each indicator consists of 6 digits, the first four of which correspond to the digits of the NOC outcome to which they belong .Data were collected in a Microsoft Excel spreadsheet and then exported to IBM Statistical Package for the Social Sciences (SPSS), version 23, for data analysis.Firstly, the NOC outcomes and their indicators were analysed as binary variables (presence or absence thereof in each case) and expressed as absolute frequencies and percentages. Contingency tables and the chi-squared test were used to contrast the other variables with each NOC outcome and their indicators. Fisher’s exact test was used when the conditions required for the previous test were not met. Odds ratios and confidence intervals (95%) were taken as measures of effect size for statistically significant associations. Student’s t-test was used to compare each NOC outcome in relation to age, as age was normally distributed.Secondly, the NOC indicator scores were analysed as continuous variables expressed as mean, standard deviation, median, IQR, and CI (95%). In addition, a bivariate analysis was performed using a non-parametric test because the distribution of the variables did not fulfil the normality criterion. Each NOC indicator was compared with the rest of the factors using the non-parametric Mann-Whitney U test. Age (as the only continuous factor) was compared with the NOC indicators using Spearman’s non-parametric correlation. This analysis was performed on the NOC outcomes which had 20 or more valid cases .The normality of the continuous data was tested using the Kolmogorov-Smirnov test when the n of each subgroup was at least 50, or the Shapiro-Wilk test when the n of each subgroup was lower than 50.p < 0.05.The statistical significance threshold for all tests was set at This study was approved by the Research Ethics Committee of the province of Granada, Spain, under file number PI-0564-2011. Each patient was given a fact sheet with the research objectives. All patients gave their informed consent prior to their participation. Their data were handled with strict confidentiality at all times, ensuring patient anonymity by using an identification code. The nurse in charge of collecting the data ensured the confidentiality of the information.The process of selecting these outcomes and the list itself were based on a previous qualitative metasynthesis on the experiences of patients with intestinal stoma. The responses and clinical judgement of the nurses participating in the study were used to determine the presence or absence of each outcome and to determine the score of the indicators in each case. Once the patient had been assessed by the head nurse, the gastroenterology ward nurse supervisor, an expert in stoma therapy, reviewed and verified the collected data. The decisions of which outcomes to include were then made on the basis of a judicious discussion between the head nurse and the nursing supervisor.The sociodemographic and clinical characteristics of the sample are shown in To assess the prevalence of each NOC outcome in the sample, the percentage of subjects presenting with that outcome was analysed .Thus, the following were present in all cases: the NOC “Participation in making Health Care Decisions (1606)” and its indicators “Seeks reputable information (160603)”, “Defines available options (160604)”, and “Identifies available support for achieving desired outcomes (160610)”, as well as the NOC “Knowledge: Ostomy Care (1829)” and its indicators “Skin care needs around ostomy (182903)”, “Diet modifications (182911)”, and “Fluid intake requirements (182912)”.We analysed the prevalence of all factors, considering that the NOC outcome was present. The variables Sex, Being a member of an ostomy association, Time with stoma, and especially Period of care were significantly associated with a number of NOC outcomes and their indicators. The variables Family member with an ostomy, Medical diagnosis, and Stoma site marking did not show any significant association .The results obtained from the descriptive analysis of the NOC outcomes with 20 or more cases can be seen in The aim of this study was to determine NOC outcomes in patients with intestinal stoma and to identify their associations with sociodemographic and clinical variables. This study is in line with previous studies using NANDA diagnoses  and NIC Period of care is the most influential factor. Patients’ willingness to address their problem must be highlighted. Their knowledge and care of the stoma are also relevant aspects that must be included in the care plan from the time of the surgery and throughout the continuity of care. This implies including indicators related to these two aspects, which were found to be applicable to the sample in 100% of the cases. Nutritional status and anxiety should be assessed immediately after surgery. The assessment of indicators on body image, social involvement, and tissue integrity are particularly important in patient care and should be assessed, especially in the period of continuity of care, once the acute phase of the process is over. The other outcomes and indicators analysed failed to show a clear association in one period or another, suggesting that their inclusion in the care plan should be considered depending on the individual circumstances of each patient..Another objective was to assess the status of the sample analysed on the basis of the scores obtained on the NOC indicators. The mean scores of the analysed indicators ranged between 2 and 3 (maximum = 5 points), indicating a moderate level of deterioration in patient condition. It is important to note that the scoring is fairly homogeneous between the indicators for the biological, psychological, and social status of the patients. It is important to highlight that score of the indicators improve when comparing the period of continuity of care versus the postoperative period, more significantly indicators on making health decisions and knowledge of stoma careThere are few studies in which NANDA, NOC, or NIC nursing taxonomies have been used in patients with gastrointestinal stoma. As a result, it is difficult to discuss this study in comparison with previous research. Instead, we provide proposals for care plans and discuss the results of a number of clinical case studies.The presence of an intestinal stoma can negatively affect patients’ quality of life, influencing their physical, psychological, and social spheres. This is consistent with the results of our study, in which the impact of the indicators extends to the different spheres of health. Regarding the physical sphere, once the stoma is created, the integrity of the skin must be preserved to ensure the correct adherence of the ostomy pouch to the body and to avoid complications that can occur if good care is not taken, such as irritation, fracturing, and peristomal pain. It is true that various studies report different incidence rates of patients with peristomal pain, which will depend on the individual characteristics of each patient. All of these complications can be reduced and even avoided . In thisContinuity of care after discharge reduces the occurrence of complications and improves quality of life over time. Also, marking the stoma site according to the anatomical characteristics of each individual and the information provided prior to surgery can lead to a lower incidence of complications . In factThe formation of a stoma after surgery has a negative impact on patients with intestinal stoma, influencing their postoperative period and thus their level of self-esteem. For a better adaptation to the new changes in the coping phase, patients should accept their own diagnosis. Adequate care by nursing professionals will have a positive impact on the patient, who will be able to promote self-care after discharge and avoid complications related to eating, inactivity, hygiene, and social interaction , 22. On The scarce presence of indicators related to social and family support is noteworthy. The data from this study provide little evidence on this issue, although family support is crucial for coping with the presence of the intestinal stoma and the disease. Family ties prior to the new change process are essential to fostering greater unity or separation in the family network when faced with an unfamiliar phenomenon. Once healthcare professionals have assessed the relationship between family members and the patient, they may offer them recommendations and advice . Our resCaregivers are another major gateway to the process of change, as they also have to adapt and cope with change, being the main support for patients. As such, they may also see their quality of life declining physically, psychologically and socially. Caregivers receive help and training, but only during the initial stage or during hospitalisation, and it is only later that the psychological distress and anxiety of seeing their relatives suffer emotionally arises. They feel overwhelmed by the burden of care, their worries, and the difficulty of taking care of their own health issues, so nursing professionals must include them in the care plans from the beginning to the end of care .This study is not without limitations. Firstly, as this is an observational, cross-sectional study, we cannot verify whether the associations found reflect the true causal relationship between the variables, so they should be regarded as causal hypotheses that need to be tested in follow-up studies involving a larger sample size. Secondly, this study is based on a list of NOC outcomes developed from a previous study. As a result, relevant outcomes may have been left out of the study. This is partly countered by the expert peer review of the 30 NOC outcomes presented. Furthermore, the inclusion of each patient’s outcomes was supervised by a second observer, although it was not an on-site assessment, an aspect that will be improved in future research. Thirdly, the previous study is based on a comprehensive review of the published scientific literature on the needs expressed by ostomy patients.Finally, new related factors could be included in future studies. For instance, stoma permanence is a relevant factor that was not explored in this study. Another aspect highlighted by other studies is the financial status and level of education of patients , 26, whiThe analysis of the Nursing Outcomes Classification in such a specific context can serve as a guide for helping nurses to develop individual care plans focused on patients with intestinal stomas. It can help to assess the impact of the interventions implemented by nurses. The availability of standardised outcomes is essential for documentation purposes in electronic records, for use in clinical information systems, for the advancement of nursing knowledge, and for the education of professional nurses and students. This study is thus intended to fill the gap in the existing literature regarding studies using the NOC in a specific care setting with these specific patients. Consequently, the implementation of these plans will ensure the good quality of care and the continuity of care, favouring the management of the disease process and benefitting the patient’s situation , while sIn the development of a care plan for individuals with an intestinal stoma, it is relevant to include indicators measuring their participation in making decisions related to their condition, as well as other indicators related to their knowledge and self-care of the stoma. It is also relevant to address their psychosocial needs, including their related indicators, while taking into consideration the individualisation of care necessary in the nursing process.Based on the scores obtained from the NOC indicators analysed, it can be concluded that the physical, psychological, and social spheres of the individuals with an ostomy are clearly impaired. The data obtained show a moderate degree of impairment in the indicators analysed, which is also associated with the period of care that the patient is undergoing and, consequently, with when the stoma was performed.


Cloud computing and dashboard visualisation were deployed to enable automated and repeatable data pipelines and data analytics at scale and to provide insights in near-real time. The testing of the DT prototype in a motorway project in the Northeast of England successfully demonstrated its ability to produce key insights by using the following approaches: (i) To predict equipment utilisation ratios and productivities; (ii) To detect the percentage of time spent on different tasks , the distance travelled by equipment over time and the speed distribution; and (iii) To visualise certain earthwork operations.Current research on Digital Twin (DT) is largely focused on the performance of built assets in their operational phases as well as on urban environment. However, Digital Twin has not been given enough attention to construction phases, for which this paper proposes a Digital Twin framework for the construction phase, develops a DT prototype and tests it for the use case of measuring the productivity and monitoring of earthwork operation. The DT framework and its prototype are underpinned by the principles of  Earthwork is one of the most expensive and critical work packages in large infrastructure projects. Its operation is complex and involves the deployment of an extensive range of heavy earthmoving equipment, such as excavators, loaders, bulldozers and dump trucks, which represent one of the most critical resources for the performance of civil engineering projects, because they are responsible for getting sites ready and for building and moving materials across sites. Plants, particularly heavy earthmoving equipment, such as excavators, bulldozers and trucks, account for a significant percentage of project costs of construction projects, ranging from 10% in commercial projects to 50% in major infrastructure projects, including highways, rail lines and energy projects , Internet-of-Things (IoT), cloud computing and visualisation technologies, Digital Twin (DT) has emerged to lead new technology progress in data-centric construction management. As a digital innovation, Digital Twin provides an opportunity to reduce emissions, delays and costs linked to earthwork operation. However, it requires reliable and effective methods to track devices, measure their performance, and monitor the overall operation of earthwork activities  sensing devices, AI-based data analytics, and visual dashboard. This DT solution provides near real-time analytical and visual insights into earthwork equipment’s usage by detecting patterns, so as to improve equipment productivity. Tested on a real construction site consisting of a large motorway project in three selected scenarios, the proposed DT prototype shows how different layers of DT interact, with the visual dashboard providing a centralised view for monitoring earthwork equipment’s productivity and operation.The remainder of this paper is organised as follows: Sect. The availability of three core DT parts, i.e.: IoT sensing devices used to capture data about equipment; AI or ML used to analyse performance; and the visual dashboard used to showcase the equipment and on-site performance and operation in real or near real time.The coverage of three key management functions for earthwork equipment, i.e.: visualisation, activity recognition, and productivity estimation.The type of IoT data captured in the forms of images, videos and other sensor data formats.The automation for the availability of automated data pipelines supported by cloud computing: it is necessary for producing scalable AI and ML to cope with the level of automation required in large civil engineering projects for large footprints and dynamic natures of earthwork operation. The automation in implementing data pipelines is also necessary for meeting the first requirement of real- or near real-time dashboard.descriptive, diagnostic, predictive, and prescriptive. Descriptive analytics addresses questions arising from the past until the present moment. For example: “What has happened?” and “What is happening now?” Diagnostic analytics examines data to explain the reasons of underlying events and addresses the question of “Why did it happen?” Predictive analytics attempts to provide future trends by answering such questions as “What will happen?” and “Why will it happen?” Finally, prescriptive analytics provides foresights to decision makers by informing them of answers to “What should be done?” and “Why should it be done?” This categorisation of data analytics types is a modified version of the theoretical framework provided by Matthews et al.  in a contextualised environment .The types of data analytics provided, including s et al.  for utilVarious digitalisation-based approaches have been explored by other researchers for improving the management of equipment and monitoring their performance. An extensive summary and characterisation of these researches is described in Table The existing literature is analysed and mapped against these criteria, and it is found that except for one study by Salem and Moselhi , other sA variety of techniques were used by the existing researches to collect data about equipment, including: smartphone sensors  on the excavation site”  it has the three core DT parts: IoT sensing devices, machine learning techniques, and real- or near real-time dashboard; (ii) it has the ability to provide data analytics at descriptive, diagnostic, predictive and prescriptive levels; and (iii) it incorporates a data pipeline to enable both automated data pipelines and data analytics in a timely manner. To bridge the gaps above, this study proposes a DT framework for construction sites, while developing and testing a DT prototype of earthwork equipment that can help measure the productivity of earthwork equipment and monitor the performance of earthwork operation.For on-going effort of commercialising the solution proposed in this study, some commercial solutions in the industry were analysed, especially those from Original Equipment Manufacturers (OEM), finding that most of them rely on telematics data, and two main telematics-based solutions are developed by MachineMaxVersatility: The ability of DT to accomplish a range of use cases for a multitude of actors  and resource types .Scalability: The ability of DT to provide a scalable architecture that enables its extension with further functionalities through flexible data input/import and external linking.Usability: The ability of DT to provide insights in an intuitive and understandable manner .Automation: The ability of DT to provide a suitable level of automation for its core functions , so as to meet the need for repeatable deployments at scale in large-size projects.Accuracy: The ability of DT to consistently deliver accurate outputs .A DT framework is designed in this study to provide an efficient and accurate approach to measure the utilisation level of earthwork equipment and monitor the productivity and operation of earthwork programmes in large infrastructure projects. Based on data produced from BIM methods, IoT, site maps and programmes, the framework implements data pipelines with cloud technologies and applies machine learning for measuring and monitoring on-site equipment performance. A digital dashboard is used to visualise tasks and resource performance against visual representation of construction sites. The conceptualisation of the framework and the technological choice underpinning its prototype are based on the criteria for characterising and analysing the related studies in the previous section. These criteria are reformulated below as general principles to underpin the proposed DT framework and its prototype:The proposed DT framework consists of five key components: (i) system actors; (ii) data; (iii) Application Programming Interface (API); (iv) Artificial Intelligence (AI); and (v) dashboard visualisation Fig. .Fig. 1CoActors refers to the users and systems that interact with DT. For monitoring earthwork equipment’s productivity, the identified actors include the Plant Hire/Owner, the Earthmoving Equipment, and the User. The Plant Hire/Owner supplies earthmoving equipment, ensures it is maintained and performs as expected, and makes it available when required. The earthmoving equipment itself is an Actor, which interacts with the DT system. IoT data can be captured from the equipment in use. Earthwork equipment is linked to a works programme as a resource, which allocates tasks throughout the construction process. Lastly, the User of the DT system is also an Actor. Whilst the system is primarily designed for Site Manager to acquire an overview of equipment performance in a project, it also provides insights for Project Manager and Site Supervisor. Project Manager is concerned with the overall performance of a site and is responsible for communication with other trades on site and the client. A site manager is responsible for managing the overall site operation, works with several site supervisors, and reports to Project Manager. Site Supervisor is responsible for one or more areas of a site and manages all workface operational measurements, including health and safety, while reporting both to the site manager and the project manager. The research by Kassem et al. . BLOBs are collected every 10 s and posted to an API, which processes the data into a database . In this way, the data captured can be stored on a phone offline in the event of a connection loss. Once a successful receipt of data is confirmed by the API, the data will be deleted from the device and a new BLOB will then be created. BLOBs are collected in the JSON format and reformatted in the database, so as to make it useable for the system. Data are then linked to a resource object in the programme, which in turn is linked to tasks.Lastly, the progress data are integrated with BIM data to deliver a near real-time data visualisation of the earthwork operation and the construction progress. Collections of viewable 3D objects within a site BIM model are associated with the tasks within the programme. As these tasks are completed within the programme, the objects can be added to a site view of the project.https://aquila.bimacademy.io/api/docs. Via the user interface, users can amend such data as organisation, user, programme, task and resource. Changes to the data are then processed via the API, which would then update the database. Finally, the API interfaces with the AI engine to push CSV data to the engine for processing.The API in the DT framework is to link the components together by providing an interface to capture and store data from IoT devices and push the data to the AI engine and the dashboard. In the proposed DT prototype, the API is built based on the OpenAPI specification , which provides a holistic view of programmes, sites, IoT and AI insight data .An AI4ACM dashboard Fig.  is creatThe integrated DT currently supports a set of full-stack architecture Fig. , which iThe API acts as another engine to capture and process the data from sensors, BIM and programme, so it can be linked and manipulated via the AI engine and dashboard. The API is sensor agnostic and able to consume data from any device that conforms to the API data schema. For example, the case study for testing the DT uses the IoT data  from a smart phone. This pattern provides flexibility in capturing and transmitting data, while helping overcome the challenges present in the current telematics systems, e.g., inconsistencies in the types of data captured, the definition of key variables and their data reporting intervals . The general contractor was responsible for the overall management of the project, covering the project’s planning, co-ordination and delivery. The earthworks company was responsible for providing resource plans, which detailed what resources were allocated to which tasks within the project programme of works. The plant equipment was hired from a rental company, which sourced equipment from different OEMs. The resources used in the project included excavation, shaping and hauling vehicles. Each of these plant equipment categories were manually added to the database, along with the details of each instance of the resources used in the project.The programme was produced as a digital record created within Primavera P6 Enterprise Project Portfolio Management. And then, the project programme was exported as a Microsoft Excel file from Primavera. The tasks, task duration, task start and finish dates, and the critical path programme data were imported from the Excel file into the API, which stored the data in a database. The resource plan was provided as a hard copy of a manually updated programme of resources. A preformatted form was provided with handwritten notes, which detailed which resources were related to what tasks within the project programme. The resource data were then allocated to the tasks via the API and stored within the database. The IoT devices were installed within the cab of the physical resources and linked to the resources in the API via QR code. This design allowed any IoT device to be assigned to any task. When a device was registered to a new resource, the API would modify the information on which task the device became assigned to, so that devices are equipment agnostic and reusable across different resources. Data were pushed from the devices to the API, which in turn pushed the relevant sensor and programme data to Google Storage for processing by the AI engine. Finally, the output from the AI engine was queried by both Aquila and Google, so as to create insights from the data.round trip of a truck and the AI engine could not be effectively tested on that project. In this study, a round trip is defined as the entire process of a truck to load earth, haul the earth to a dumping point, dump the earth, and return to collect more earth, as required under the task assigned to the vehicle. In order to address this limitation, IoT data were captured from another real construction site, so as to demonstrate the AI insights that could be captured from equipment working on a full round trip. Three test scenarios were developed to understand what insights could be gained from the data.Although a full DT of the A19 motorway project was developed, the limitation measures against Covid-19 prevented site access, so we were unable to capture enough data about the Three test scenarios were developed to demonstrate the following data: earthwork equipment utilization rates; task status; equipment distance and time; and speed distribution of equipment on site.utilisation ratio of a Komatsu PC220LC Hydraulic excavator on a demolition project, with a smartphone mounted in the cabin of the excavator. The gyroscope data were captured by a 3-axis accelerometer at the frequency of 8 Hz and then used as the input for training the deep learning model introduced by Mahamedi et al.  can be found in research by Mahamedi et al. . In addiScenario 2 presented predictions Table  of the pThe output from Scenario 3 demonstrated the distance for trucks to move over a period Fig. . If therEarthwork equipment represents a significant portion of resources in construction projects, while forming a major contributor to onsite and off-site congestion and pollution. It is always on the critical path of most civil and building projects. The existing literature proposes that a more effective approach to measure the productivity and monitor the performance of equipment—can enhance the utilisation of earthwork equipment and the performance of projects  from each equipment, apply AI to predict the performance of earthwork equipment by using automated data pipelines and AI in near real time, and present results in two visualisation dashboards . A methodology for a data pipeline that enables automated data collection, pre-processing and analytics in a timely manner based on GCP tools’ functions is also introduced as part of the DT framework and prototype.The studies reviewed and the commercial applications now available can capture equipment’s operational data either through telematics or IoT sensors, but such data are not linked to earthwork programmes or site 3D models or site maps. This missing linkage limits the usefulness of DT, especially for general contractors who are responsible for the timely execution of earthwork programmes. This defect also limits the ability to derive planning foresights and test various resource levels and their combinations. In the DT framework and prototype proposed in this study, the linking of IoT data from the field to work programmes and 3D BIM and/or geographical site maps was a fundamental element. In this way, site map data and near real-time or real-time updates of earthwork equipment’s locations can provide a holistic overview of sites at any point of time. Furthermore, the application of ML with Deep Neural Networks (DNNs) helps accurately predict earthwork equipment’s productivity in construction works.This study delivers several advancements over the exiting researches both at the global level (DT solution level) and the local level . At the global level, this study makes certain theoretical contributions with a DT framework for construction sites, including some general principles for construction DT. This forms an enhancement to the existing literature in terms of Digital Twin, because the existing literature is mainly focused on the operational or in-use phase of built assets, with very few studies on the construction and production phases of projects. In addition, for practical purpose at the global level, this study presents and demonstrates a full DT prototype for monitoring earthwork equipment’s productivity and on-site operation. The DT prototype proposed is composed of five key components  and instantiates the general DT framework and its principles.versatility, the DT is conceived to accomplish a range of use cases while preserving its ability to operate in a mixed fleet of equipment. Central to this feature is the deployment of smart phones as agnostic IoT sensors, which can be installed across excavators, trucks and other devices of various OEMs. Through the implementation of open APIs, the DT prototype makes DT more universal so that it can accommodate further functionalities and link external applications. The DT prototype also enhances usability through two dashboards, which help contextualise the operation of earthwork equipment. Automation is a key feature in the implementation of cloud-based data pipelines and AI. Finally, the accuracy of prediction of earthwork equipment’s productivity and performance is improved compared to using other approaches, such as telematics.At the local level, this study combines a few advancements in a set of DT system architecture to ensure it is accessible, universal, usable, automated and accurate. In terms of The insights derived through the DT about the performance of earthwork equipment can directly uncover blind spots in terms of productivity for site managers and project managers, especially in large infrastructure projects. The real implication of this capability to project control resides in the fact that such measurements can be repeated as much as required and implemented in near real time, an advantage that is not possible with the current project control methods. For example, the ability to frequently measure the performance of each equipment on site facilitates the regularity of applying project control techniques , which have been applied less regularly in the current practice, due to the big effort involved in massive measurements on site.The proposed DT framework and prototype is modular and scalable, thus allowing for targeted improvement and extension of specific elements . However, for effective usage, it requires both quality data and an adequate level of details. For example, the quality of the works programme data, and the details of the resources linked to tasks, and the way the data are captured, are all critical to the success of the proposed DT in construction sites based on the functioning of its AI and dashboard modules.This study is not without challenges and limitations. One of the key challenges is the Covid-19 restrictions, which prevented the timely access to the case study site and the deployment of IoT devices on a wide range of equipment, causing delays in capturing the data required to develop and optimises the AI engine model. To overcome this issue, an alternative site was used to capture data for the purpose of refining the AI engine and testing the initial solution. When site access was allowed, earthwork equipment operators imposed another barrier to data capturing, because the IoT devices used within the earthwork, which took the form of mobile phones, were often not turned on by the earthwork equipment operators, either because they forgot to do so or refused to do so intentionally, as they might not want their movements to be tracked. This suggests two aspects for consideration in future studies: (i) To examine such operators’ behaviour and concerns when working in digitally twined construction sites, so as to identify their ethical issues; (ii) To develop an IoT technical solution that can autonomously capture data while the earthwork equipment is operating, but without overlooking the aforementioned ethical issues and concerns.


The boom in social media with regard to producing and consuming information simultaneously implies the crucial role of online user influence in determining content popularity. In particular, understanding behavior variations between the influential elites and the mass grassroots is an important issue in communication. However, how their behavior varies across user categories and content domains and how these differences influence content popularity are rarely addressed. From a novel view of seven content domains, a detailed picture of the behavior variations among five user groups, from the views of both the elites and mass, is drawn on Weibo, one of the most popular Twitter-like services in China. Interestingly, elites post more diverse content with video links, while the mass possess retweeters of higher loyalty. According to these variations, user-oriented actions for enhancing content popularity are discussed and testified. The most surprising finding is that the diverse content does not always bring more retweets, and the mass and elites should promote content popularity by increasing their retweeter counts and loyalty, respectively. For the first time, our results demonstrate the possibility of highly individualized strategies of popularity promotions in social media, instead of a universal principle. Content popularity is the key goal for advertisers, innovators and influentials in communication ,2,3, andIn recent decades, many scholars focused on the comparison of behavioral differences between elites and the mass ,11,12,16RQ1. What are the behavioral differences between the mass and elites across various user groups and content domains?RQ2. Are there differences between the actions of the mass and elites to promote content popularity?RQ3. How to choose promotion strategies suitable for various user groups and content domains?To address the above gaps in the existing research, we determine to examine the following research questions (RQs):As a result of the scarcity of massive user data in social sciences and the complexity of multiple domains, many traditional methods  are challenging to implement because of the spatial limitations and high costs ,27. FortTo investigate the comparison between the mass and elites across user groups and content domains in a data-driven manner, techniques and methods from machine learning and social network analysis are employed in this study. With the help of a topic classifier adapted to the discourse system on Weibo , we use Tweeting and retweeting are the most frequent components of user behaviors on Weibo ,37, and This study is the first to disclose the behavior variations from elites to the mass across user groups and multiple domains in social media. With regard to splitting users into five groups and the contents into seven domains, an accurate and complete spectrum of behavior variations across domains is comprehensively established. With the help of a spectrum, what kinds of users targeted as behaviorally influential seeds in marketing-like applications can be optimally pinpointed.Comprehensive mapping between behavior variations and popularity promotions is established in rich perspectives ranging from activity patterns to various content characteristics. In particular, though targeting influentials are extensively exploited, this is the first time to study the popularity promotion for the mass. Appropriate strategies for popularity enhancement can accordingly be derived from the mapping in terms of taking both user groups and content domains into account.Machine learning and network analysis are jointly employed in this study, which enriches the practical methodologies in probing massive users in a communication study. Driven by massive tweets and huge retweet networks on Weibo, solutions involving artificial intelligence and intensive calculations are conducted to split user groups, cut content domains and draw the mapping, overcoming the high costs and low efficiency of conventional approaches.The main contributions of the paper are as follows:In social media, everyone is simultaneously a publisher and a listener of information, and all users equivalently constitute the communicator and audience elements in the communication model . AccordiAs a key issue, many studies regarding the comparison between elites and the masses inherently neglected the behavior variations across user groups and content domains ,11,12. IUser behavior is a direct reflection of the information diffusion in which tweeting and retweeting are two primary activities on Weibo and have been exploited extensively in previous efforts. High activity, also known as the frequency of posting, indicates a greater likelihood of exposure ,26,36. MContent popularity is the prime target in communication. Many factors underlying behaviors can affect content popularity, in particular, the narrative characteristics ,3,55. InThe Weibo data in this study were collected through its open API (application program interface). Over 140,000,000 tweets from the Weibo stream occurring from 10 October 2016 to 10 January 2017 were continuously crawled and, in total, we sampled 8,520,933 unique users. The signals delivered in these posts are sophisticated and are from every aspect of everyday life. Specifically, the JSON file of each tweet contains attributes of text, retweet status and user demographics such as the verified type, gender, address and the number of followers, suggesting that the content domains, user groupings and influence metrics can comprehensively be derived from these attributes. For each user, the tweeting frequency and retweet times are accumulatively counted based on the retweet status of the user’s tweets, and the other rarely updated demographics, such as gender and verified type, are obtained from the latest tweets in our data set.In particular, unlike Twitter, a distinctive verification mechanism on Weibo ensures the reliability of the user demographics, especially the verified types. On Weibo, users with certain verified types are known as the “Big Vs”  and the The main form of content on Weibo is text, and its topic can well represent the domain the content belongs to. Considering the massive text data, an automatic topic classifier is expected, and what is more, the appropriate number of domains is critical. In this study, a previously well-developed Naive Bayesian classifier is adopted to perform domain categorization . The claThe model performance is shown in The formation and development of elites is a dynamic process; this status is constantly changing by quantifying the interactive behaviors . Many rei and l centered on node i. Due to the uneven size of networks in various domains, we select the top The key element in marketing and information diffusion is a minority of influentials . After bAfter splitting the users into five groups and the contents into seven domains, how user behavior varies from the mass to elites can then be fully investigated. Focusing on the two primary behaviors of tweeting and retweeting, behavior variations will be specifically examined from the view of tweeting activity, homophily, loyalty and content characteristics, which together reconstruct a full angle of individual behavior on Weibo.Posting more tweets, i.e., being more active in social media, will bring more opportunities to be noticed ,26,36. HAt the mass level, for all domains, as shown in i. The distribution of the posting entropy of various users is shown in To measure the diversity of the content posted by various users, we calculate the posting entropy of different topics asUsers on Weibo would like to publish content containing short URLs (t.cn) jumping to images, news and videos to attract audiences . To perfThe percentages of tweets containing links at the mass and elite levels are shown in On the basis of the constructed forwarding network, we measure the retweeting homophily through the probability of edges connecting a pair of users with the same verified type (regardless of the edge weights). At the same time, we also calculate this indicator in the random network in which all edges are randomly rewired as a benchmark to test its significance. The comparison of the homophily between the real network and its random counterpart in each domain is shown in The weight of the edge in the network refers to the retweeting frequency which indeed reflects the loyalty of the retweeter. Considering that the tweet count of the target user will affect weights, here we use the probability that each tweet of the target user will be forwarded by each retweeter to represent the loyalty.The average loyalty of all retweeters of various user groups is shown in After the comparison of various behaviors between the mass and elites, some key actions for promoting popularity inspired by the behavioral differences are presented and testified. The experiments focus on these following questions: For users at both the levels of elites and the mass, what kinds of content will obtain more retweets? How does one enrich the content? Which is more important for retweeters, the number or the loyalty?In order to explore how content diversity affects retweets, we divide the individual posting entropy into several levels. Specifically, the entropy is 0 when the user only posts in one domain, 1 represents posting in two domains on average, 1.585 refers to three domains and so on. Considering that the richer the content is, the fewer the number of users there are, the grouping of users is divided into “”, according to the corresponding entropy values of “”. The average repost count and error bar of each group at the mass and elite levels are shown in In general, the contents with rich domains do not directly lead to more retweets and even have a negative impact on the groups of the ordinary and enterprise. Enterprises are inherently professional and ordinary users who pay attention to too many areas will be distracted , which wUpgrading or manipulating the formats of posted content to produce “vivid” stories is another feasible path for popularity promotion. Specifically, to enhance the popularity of posted content, actions such as adding the URLs of videos, news or pictures are pervasively adopted in social media ,26. HoweAfter merging all users’ tweets, the tweets of each user The results at the mass level are shown in The correlations at the elite level are presented in Different from the conclusion reached by Wang et al.  that tweFor each user on Weibo, the averaged retweet count per tweet is another direct reflection of the content popularity. In order to explore the impact of loyalty on the popularity of target users, the regression curves of various users at two levels are shown in Intuitively, the elites usually have a large number of retweeters which is also a key factor in popularity promotion, and this is why they were chosen. Therefore, we further explore how the retweeter count and loyalty influence the content popularity. Based on the retweet networks, a multiple regression analysis is performed with the averaged retweet count as the dependent variable, and the results of the mass and elites are shown in To address RQ3, we establish a complete picture of the different strategies and corresponding effects between the mass and elites across domains and groups from the perspectives of content diversity and links and loyalty, which can provide suitable ways for various users to increase their popularity.The behavioral comparison between influential elites and the mass grassroots is an important communication issue ,10,11,12Regarding the theoretical implications, our study enriches the literature on the behavior analysis of the mass and elites in multiple domains. Although existing studies have described the great difference in role and influence between the mass and the elites in information diffusion ,7,11,12,One important practical implication of our findings is that the mass and elites need to adopt their own appropriate strategies to promote popularity. Our study further provides empirical evidence of the differences in promotion strategies across user groups and domains. Unexpectedly, rich content with domain diversity would not always bring more retweets, which is even counterproductive for enterprises and ordinary users. This result is consistent with the previous study which suggests that people prefer the more professional websites for online shopping . MoreoveIn summary, users in social media need to find an individualized enhancement strategy that fits their behavioral characteristics rather than a mere copycat. Our findings fill the knowledge gaps of how the behavioral differences between the elite and the mass influence their marketing strategies in multiple domains and offer guidelines on both targeting seeds and strengthening promotions in realistic marketing-like scenarios.This paper has made a preliminary study on the relation between behavioral variations and popularity promotions, and a few limitations should be considered in reviewing the results. For example, the topic classification of this paper is suitable for the discourse system of Chinese Weibo, and the findings might not be directly extendable to other platforms and countries. Meanwhile, the mapping discussed here is assumed to be static, so a promising direction for future research is to gain an in-depth understanding of its spatiotemporal dynamics. Moreover, finding more strategies to enhance content popularity and analyzing them simultaneously is one of the future goals.