Global climate change poses a significant challenge in contemporary society, particularly affecting vulnerable populations like small farmers residing in arid and semiarid regions. This study aims to investigate the perception of health risks and adaptive responses in the semiarid region of Northeast Brazil (NEB). Four questions were formulated: (1) How do socioeconomic factors influence the perception of health risks during extreme climate events? (2) How do socioeconomic factors impact the adoption of adaptive responses to mitigate health risks during extreme weather events? (3) How does the perceived risk level affect the utilization of adaptive responses? (4) What is the influence of extreme climate events on the perceived risks and the adoption of adaptive responses?The research was conducted in the rural community of Carão, situated in the Agreste region of the State of Pernambuco, NEB. Semi-structured interviews were conducted with 49 volunteers aged 18 and above. The interviews aimed to gather socioeconomic information, including sex, age, income, access to healthcare services, family size, and education level. Additionally, the interviews explored the perceived risks and responses employed during different extreme climate events such as droughts or heavy rainfall. The perceived risks and adaptive responses data were quantified to address the research questions. Generalized linear models were employed to analyze the data for the first three questions, while the nonparametric Mann–Whitney test was used for the fourth question.The study found no significant differences in the level of perceived risk and adaptive responses between the two climate extremes. However, the quantity of adaptive responses was found to be directly influenced by the perceived risks, regardless of the type of extreme climate event.The study concludes that risk perception is influenced by various complex factors, including socioeconomic variables, and plays a critical role in the adoption of adaptive responses during extreme climate events. The findings suggest that specific socioeconomic variables have a more pronounced influence on how individuals perceive and adapt to risks. Furthermore, the results indicate a cause-and-effect relationship between perceived risks and the generation of adaptive responses. These findings contribute to a better understanding of the factors shaping risk perception and provide valuable insights for future studies in regions prone to extreme climate events. Climate change corresponds to changes in climate patterns on a global or regional scale over time . The effThe latest assessment from the Intergovernmental Panel on Climate Change (IPCC) highlights the significant impact of human influence on our atmosphere, oceans, and land, resulting in noticeable warming. Furthermore, the report emphasizes that human activities have contributed to an increased occurrence of extreme climate events like droughts and heatwaves since the 1950s. Scientists assert that global warming will persist in the short term 2021–2040), primarily due to the continued rise of CO2 emissions in most projected scenarios. Should CO2 emissions maintain their current levels, which the IPCC considers as intermediate, it is likely that temperatures will increase by 1.5 °C [021–2040,In a global scenario, Watts et al.  argued tWith the increase in the frequency of extreme climate events, institutions around the world have turned to research on climate change, its consequences, and its effects in all fields of society , 13, 14.For the purposes of this study, we understand risk as the exposure of an individual or group of individuals to potentially unfavorable circumstances . In turnAmong the aspects that can influence the perception of risk, as well as the adoption of adaptive responses, socioeconomic factors have been widely used in the scientific literature in different areas, including public health . With thThus, this work aims to understand which factors shape the perception and adaptation of a community of rural farmers in the semiarid region of Pernambuco in the face of health risks caused by climate change. For this, we built four questions, with their respective hypotheses and predictions.One of the questions in this study is: how socioeconomic factors influence the perception of health risks during extreme climate events? The hypothesis one (H1) is that income, sex, age, family size, education and access to health services influence the amount of perceived risks in periods of drought or extremes rainfall. The prediction is that all these factors will have a positive impact on the amount of perceived risk in both extreme climate events.Another issue raised is: how socioeconomic factors affect the adoption of adaptive responses to mitigate health risks during extreme weather events? The hypothesis two (H2) is that income, sex, age, family size, education and access to health services influence the amount of adaptive responses used during periods of drought or excessive rainfall. The prediction is that all these factors will have a positive impact on the number of adaptive responses used in both events.In addition, the study seeks to understand: how the amount of perceived risk affects the amount of adaptive responses used? Hypothesis three (H3) is that the amount of adaptive responsesFinally, the study intends to investigate: what’s the influence of extreme weather events on the amount of perceived risks and the amount of adaptive responses used? The hypothesis four (H4) is that drought, the most frequent climatic event, has a greater impact on the amount of perceived risks and adaptive responses used. The prediction is that the amount of perceived risks and the amount of adaptive responses used will be greater during periods of drought compared to periods of extremes rainfall.The study was carried out in the community of Carão Fig.   and the National Research Ethics Commission (CONEP), being approved under number 4.498.835. Volunteers selected to participate in the study signed the Free and Informed Consent Form, in accordance with Resolution no. 466/2012 of the National Health Council, which authorizes the collection, use and publication of available data.This work is linked to the project The Laboratory of Ecology and Evolution of Social-ecological Systems (LEA) has been conducting research in the community for approximately 13 years. Therefore, continuous communication between the group's researchers and the Carão community made the first contact about the present work feasible. Three visits were made to the community in July 2019, December 2019, and February 2020. On the first visit, we held a meeting with community residents at the local association, focusing on explaining the research objectives. After the meeting, the community agreed to be part of the study.The volunteers were submitted to semistructured interviews  in whichTo achieve greater methodological precision in the study, the questions were asked to obtain qualitative data, as we sought to know what the perceived risk was, what was the response used, and in which years did the greatest droughts and rains occur in the region. The questions were asked in this way to encourage the volunteers to provide us with information as accurately as possible, since if we asked for the quantity of each item, it would be difficult for them to tell us exactly how many risks they perceive, how many response they use and how many times droughts have occurred or rains.For the statistical analysis of the data, we transformed the cited risks and the adaptive responses used into quantitative variables. Therefore, each risk cited and each response used was converted into discrete quantitative variable. The categorization of qualitative data into quantitative data was carried out as follows: we asked the volunteer to cite health risks during periods of drought and extremes rainfall. Ultimately, we counted how many risks the volunteer had mentioned. For example, if the volunteer cited the risks dengue and flu and the response to risk its tea and drug, this volunteer cited two risks and two adaptative responses.The socioeconomic data collected were used as predictor variables in hypotheses 1 and 2. The variables are age, sex, education, access to public health services, family size and monthly family income. The age variable was categorized into three different levels: youth, adults and elderly. Youth included volunteers aged 18 to 25, adults aged 26 to 60, and seniors aged 61 to 100. The schooling variable was categorized into three distinct levels: complete high school, elementary school and illiterate. The variable “access to health services” is dichotomous; therefore, its answers are standardized as “yes” for volunteers who claim to have access and “no” for volunteers who claim not to have access to health services ——(Table In our best explanatory model for the influence of socioeconomic variables on risk perception in times of drought (Akaike Information Criterion—AIC = 175.26), only income had a significant effect , male sex  and family size  explained adaptive responses in periods of intense rainfall , sex , and family size influence the amount of adaptive responses used in rainy seasons. Elderly people (people aged 65 years or older) are often cited in the literature as one of the most vulnerable groups to climate change and its consequences , 58. OurGamble et al.  cite somThe results also indicate that male individuals use fewer adaptive responses in coping with health risks. These results are in line with those Rauf et al.  that poiThe amount of risks perceived in dry seasons and in rainy seasons also function as determining factors in the amount of adaptive responses used. The results of our third hypothesis demonstrate the existence of a linear relationship between the perceived risks and the adaptive responses used, and this happens both in dry and rainy seasons, which reveals to us what the strong alignment of perceptions with responses is context-independent. In addition, our fourth hypothesis found that there are no differences between the amount of perceived risks in dry and rainy seasons, and there are no differences in the amount of adaptive responses used in both periods. Our findings find interesting support in the literature, as in Budhathoki et al.  for examFaced with the challenges posed by global climate change, it is increasingly important to understand how different populations deal with the health risks arising from extreme climate events. In this sense, this study investigated the risk perception and adaptive responses of small farmers residing in semiarid regions of NE Brazil. The results showed that the amount of adaptive responses used by rural farmers is directly influenced by the amount of perceived risks, regardless of the type of climate extreme faced. In addition, the study emphasizes the importance of considering socioeconomic factors in the analysis of risk perception and the adoption of adaptive responses in extreme weather events. Our findings contribute to understanding the complexity involved in risk perception and the adoption of adaptive responses in extreme weather events. In addition, the results highlight the importance of considering risk perception as a central element for planning adaptation measures. This approach can contribute to promoting more effective adaptation measures and reducing the impacts of climate change on the health of the most vulnerable populations.Finally, it is important to acknowledge certain limitations of this study. Firstly, the sample size of small farmers in the semiarid regions may not be representative of the entire population, thus limiting the generalizability of the findings. Additionally, the study focused solely on the perspective of small farmers and did not incorporate the viewpoints of other stakeholders.Therefore, further research involving a more diverse range of participants and perspectives is warranted. Additionally, it should be noted that the study relied on self-reported data, which may be susceptible to recall bias or social desirability bias. The subjective nature of self-perception regarding risks and adaptive responses may introduce variations and interpretations among individuals.Future studies could consider employing objective measurements or incorporating multiple sources of data to enhance the validity and reliability of the findings. In conclusion, while this study provides valuable insights into the risk perception and adaptive responses of small farmers in semiarid regions, it is crucial to recognize the cited limitations. Addressing these limitations and conducting further research will contribute to a more comprehensive understanding of the complexities surrounding risk perception and the adoption of adaptive responses in extreme weather events. Moreover, it will support the development of tailored and effective adaptation policies that address the specific needs and vulnerabilities of local communities.


Background: This study aimed to find out the application of a sustainability model framework to test the financial sustainability of the healthcare system in Saudi Arabia and to suggest some reforms required to maintain a sustainable healthcare system in the country.Methods: To test the financial sustainability of the publicly funded healthcare system in Saudi Arabia, we applied analytical techniques using a sustainability model framework based on the framework indicators proposed previously by the Office of Sustainable Development, Bureau for Africa, U.S. Agency for International Development. An empirical time-trend analysis was also used to judge the financial sustainability of the healthcare system of Saudi Arabia in the future.Results: The results showed significant threats to the financial sustainability of the healthcare system. Saudi Arabia's revenues, gross domestic product (GDP), government budget, and Ministry of Health (MOH) budget were all directly influenced by the oil prices.Conclusion: The healthcare system in Saudi Arabia seems to be financially unsustainable, and the need for change is inevitable. Saudi's ambitious program of development “Vision 2030” will surmount the challenges faced by the country and will lead to substantial enhancements in the health sector in Saudi Arabia, and other opportunities for improvement do exist. Sustainability is a vast notion, and it is difficult to define because it includes philosophy, ecology, economy, sociology, and many other disciplines. The most famous definition of the concept emerged from the World Commission on Environment and Development Report of 1987, which states that sustainability is “development that meets the needs of the present without compromising the ability of future generations to meet their own needs" . The susAlthough the concept of financial sustainability has been widely circulated through academic, media, and political platforms, this concept is not agreed upon and is dealt with in different forms. In addition, the discussion about healthcare systems rarely deals with how to obtain financial sustainability or what are the political aspects resulting from the problems of this sustainability . The debPublicly financed healthcare systems across many countries are encountering a challenge in maintaining their financial sustainability as healthcare consumes a continually boosting portion of both the country's treasure and government expenditure. Resource scarcity, rising health spending as a proportion of the gross domestic product (GDP), and rises in the costs of health services due to factors affecting the demand and supply of these services are frequently quoted as grounds why healthcare systems need ever-increasing grants and reasons why inclusive public systems are not sustainable ,5. The rSince the 1970s, Saudi Arabia has placed great emphasis on providing healthcare to its citizens. Over the past 50 years, enhancements have been made in the capacity and excellence of healthcare services provided in the Kingdom. The public sector, including the Ministry of Health (MOH) and other healthcare facilities funded by the government, and the private sector are the providers of healthcare services in Saudi Arabia. The MOH remains the major supplier of healthcare services in Saudi Arabia, and its services are for free. The MOH has funds derived from the annual total government budget obtained mostly from oil revenues . The eviUnfortunately, the healthcare system in Saudi Arabia is under increasing pressure in spite of the sizable funds that the government can allot currently. The burden is secondary to the relevant challenges confronted by all healthcare systems that have public funds as mentioned earlier. These challenges include aging population, changing disease patterns into chronic diseases, increasing inactive daily routines, growing expenses, and increasing user anticipations ,12,14. AThis paper addresses the financial sustainability of the healthcare system in Saudi Arabia in terms of the financing of health expenditure and discusses the possible measures that might achieve that sustainability.To explore how the healthcare system is financed and to clarify the impact of a sustainability model on the financial aspect of Saudi Arabia's healthcare system, analytical techniques were utilized using a sustainability model framework. This sustainability model is based on the framework indicators proposed by the Office of Sustainable Development, Bureau for Africa, U.S. Agency for International Development in February 1999 , oil prices, percentage (%) of government budget, government budget (in millions), and total MOH budget (in millions) between 1990 and 2019. These variables have been chosen by this study as the key determinants of healthcare expenditure. Variables have been presented in their descriptive formats to check for their range, minimum, and maximum values.Looking at Saudi Arabia's economy between 1990 and 2019, we find that it relied heavily on oil prices, with the average participation of oil revenues calculated at 78% of the total revenues annually. It is also worth noting that the average participation of oil revenues from the total annual revenues has decreased over the past few years (2016 onward) to 65%, following the initiation of the impressive "Vision 2030." The heavy dependence on oil revenues led to many changes in economic activities in the Kingdom of Saudi Arabia during the mentioned years because of fluctuations in oil rates in the global market. Saudi Arabia's revenues, GDP, government budget, and MOH budget were all directly influenced by the oil prices. The relationship between oil prices, total revenues, and total expenditures is best seen where the steep upsurge in the oil prices in two periods, i.e., between 2003 and 2008 and between 2010 and 2013, resulted in a budgetary surplus, which had a positive impact on the government and MOH budget. The second-best example for the same relationship is seen in the period between 2014 and 2016, where the global crisis in oil markets led to the budgetary deficit and was reflected negatively on the government and MOH budget. The 1990s had an overall budgetary deficit that also led to a negative impact on the Saudi Arabian government and MOH budgets  could be the potential funding agency, while the MOH can assume the role of the regulator body. The PIF as a global impactful investor with a focus on sustainable investments that can launch or continue strategic initiatives to grow the national economy; an example of such initiative is Saudi Arabia’s Economic Cities. It is assumed that this approach will produce additional revenue to the funding body's allocated budget and alleviate pressure on the GDP, and it will also promote public-private partnerships. The Kingdom’s ambitious blueprint "Vision 2030" also stated an important strategy: to make Saudi Arabia the investment powerhouse by significantly improving investment competitiveness and launching promising sectors in the Kingdom. The pharmaceutical and medical sectors are among the best industries to invest in, and they will support the healthcare system. Such industries may be used for self-reliant consumption and revenues.Other sources of funding for the suggested framework could include “Zakat,” which is a mandatory religious taxation that has to be done annually. Saudis' attitude toward paying this tax is very acceptable, and people are happy to pay it. The allocating part of that tax for the funding of the healthcare system will provide additional resources, and the portion may be used in the frameworks of general and local funding. Moreover, voluntary personal donations could be seen as additional resources for the healthcare system. It could also be used at both the general and local levels of funding.Furthermore, when considering the efficient allocation and use of resources, the proportion of government health budget allocated to and the spending on primary care is not evident from available data. However, the assumption for this part is that there is a tendency to assign unequal budgets and different expenditures between primary care and on the acute care or specialist levels, with the latter being preferred. This assumption, if confirmed, will indicate an inefficient resource allocation and utilization. The high staff cost and dependency on international labor both represent other unfavorable factors for efficient allocation and harbor a high sustainability risk.Previous study investigating the National Health Service (NHS), the publicly funded healthcare system in England, linked the sustainability of the system to multiple factors. Effective health service provision and management of chronic illness is the primary aspect toward a sustainable healthcare system. Chronic diseases pose a risk to sustainability as they account for more than two-thirds of health expenses. Developing well-educated healthcare providers is another important contributor of financial sustainability . With thOne of the main limitations in our study is that the fiscal space analysis has not been studied. Other factors affecting the sustainability of the system  were not included in this paper. The framework proposed by Subhi Mehdi  did inclWith the current scenarios, the healthcare system in Saudi Arabia seems to be financially unsustainable as multiple financial indicators are unfavorable; therefore, the need for change is inevitable. The Kingdom of Saudi Arabia planned its “Vision 2030” to improve the economy and to surmount the challenges faced by the country. Our results support the emphasis to diversify the economy into a non-oil-revenue economy to promote economic growth and expansion of the Saudi nation. Although substantial enhancements have been made in the health sector in Saudi Arabia, other opportunities for improvement do exist. The rule of Saudi's Public Investment Fund or other governmental investment agencies would be a great opportunity for policymakers. Boosting the healthcare system funding could be achieved by enabling ways of recovering costs, sharing allocated budget by the local facilities, enhancing governance to achieve targets effectively and efficiently, and improving human resources for the health sector. In addition, the efficient use of resources, good management practice, and decentralization are crucial. Judicious amendments should be initiated in the health insurance industry to meet Vision 2030’s aims.


Undoubtedly, all sexes, races, ethnicities, and sexual orientations need representation in clinical trials. To increase health in a diverse population, the medical research supporting the development of new and existing medical therapies and diagnostics needs to be investigated in subsets of the target end users.Within the last decade, the focus on diversity in pre-clinical and clinical research has spread. Journals, governmental agencies, and funding bodies increasingly require that relevant groups are included in the (planned) research before publication or approval. This has led to health benefits for less favoured groups; e.g. in 2018, the Food and Drug Administration (FDA) in the USA required the manufacturers of zolpidem-containing insomnia drugs to reduce the recommended dose for women to half of that for men because new data—that had not been available during drug development 20 years previously—showed a slower drug metabolism in women than in men .While we welcome the increasing number of initiatives to diminish unbalanced diversity in clinical trials, we would like to highlight situations where diversity is not necessarily desirable. In our research centre, we conduct—among other studies—small, exploratory, physiology studies. These studies can be difficult to power properly since the exploratory nature involves uncertainty regarding the variance of the data points. Thus, increasing the diversity of the study population in this type of study might increase the noise-to-signal ratio uncontrollably and unnecessarily. To compensate for an increased noise, more participants would be needed, thus, demanding more time and resources spent on the study, in turn requiring more money raised, and most importantly, more participants enduring the procedures and potentially associated discomfort related to such studies. In our opinion, this would be a waste of resources.The nature of the research Whether the participants were recruited among a relevant population for the (patho)physiology, intervention, or diagnostic under investigation (including the recruitment of relevant controls)Which groups to include in later stage clinical trials to appropriately cover all relevant groups whom this research concernsWhether the findings of the study are generalizable to the wider populationThe point of the small, exploratory studies that we conduct is to test a scientific hypothesis in a limited sample size, which can then be followed up by larger studies if the initial study shows relevant results. If such exploratory studies were required to include four times the number of participants , very few would be performed given the limited availability of resources and the increasing practical and administrative work associated with such studies. However, it is important to highlight that recruiting participants from a selected group potentially may result in biased or incomplete findings, which limits their generalizability. This is not a problem in itself, but authors and reviewers of publications of early-phase clinical trials should address the limitations associated with this issue. Hence, we recommend that authors clearly state the following points in their publications, if applicable:In our experience, an increasing number of reviewers for scientific journals question and criticise the limited diversity of some of our small-scale whole-body human (patho)physiology studies. We expect this to be a consequence of the generally raised awareness of diversity in phase 3 clinical trials. However, in the context of small, explorative physiology studies, we find the critique inappropriate and misunderstood for the reasons laid out above. Thus, we believe that by addressing the inherent issues of the limited diversity among participants in small, exploratory trials in publications authors can highlight both the merits and limitations of such studies more appropriately.In conclusion, as much as the increased focus on diversity in participant populations of phase 3 and 4 clinical trials in general is long overdue, we advocate for a less strict approach towards diversity in small, exploratory studies taking the nature of this type of study into account.


Health and safety protocols have become a requirement to promote rural tourism (PRT). From this perspective, this paper empirically analyses how the health and safety dimensions influence the happiness of hotel managers and rural tourists in the post-Covid 19 era.A theory-based structural equation model will be carried out of activation of norms, that measure variables: sanitary, socioeconomic, and safety. Precisely, we will measure how those three attributes affect the managers-guests’ health in rural areas and their search for happiness at the rural destination. Based on the above, a field of study has been 215 rural tourist accommodations in the Extremadura region (Spain) and a sample population of 443 guests. Data were organised through the SEM-PLS path modelling.The results achieved statistically show the need to undertake a new model of healthier and safer tourism consumption that values the tourist resources of rural areas, especially nearby and sustainable destinations, based on the guiding principles of safety, health, and happiness.The first conclusion is that promoting tourist destinations under safe and healthy conditions has become a priority objective in the tourism industry. The second conclusion that follows from the first is that the variables safety and health and the pursuit of happiness are essential factors in promoting tourist destinations for rural hotel managers and rural tourists. The third conclusion related to the first two is that the opportunity that this study provides to develop strategies of an innovative, sustainable, and creative nature based on the relationships of the new trinomial of health, safety and happiness, from the perspective of happiness management. Recently, the World Health Organization (WHO) has published monographs on health and safety procedures. Many of them refer to topics related to the safety of clinical procedures, HIV prevention protocols, intensive care units, hand-washing techniques, etc . Under tIn the same vein, to ensure the welfare of citizens, the European Commission has established a series of recommendations to ensure the safety of free movement in the European Union . In SpaiTherefore, promoting tourist destinations under safe and healthy conditions has become a priority objective in the tourism industry . EnsurinFrom this perspective, this article has a double academic purpose. The first one is on how health and safety variables and the pursuit of happiness are essential factors in promoting tourist destinations for rural hotel managers and rural tourists. Moreover, the second, to fill the existing gap in the literature to demonstrate that the new trinomial of health, safety and happiness constitute key vectors to convey strategies of an innovative, sustainable, and creative nature that act as a driving force for tourism activity in the post-Covid-19 era. Hence, the need to implement public policies that promote the well-being of tourists through the promotion of exciting and healthy activities for people .After this introduction, the following section presents the conceptual framework. The third section develops the methodology used and describes the structural equation technique used and the dimensions of our theoretical model. The fourth section presents the results obtained in this academic work. Moreover, the last section formally shows the discussions and conclusions of the study, as well as future lines of research.Based on what has been read so far, this scientific study aims to statistically illustrate the potential of the dimensions of safety and health and their effect on happiness. The study will analyse whether these variables become dynamic and innovative forces that promote tourism destinations in rural ecosystems according to the guiding principles of excellence, well-being, quality, and respect for the environment. In the following sub-sections, a literature review of all the variables that make up the academic corpus of this article will be carried out. It will serve to establish the theoretical corpus of our research hypotheses.In the second quarter of 2020, most leading countries in the tourism sector ceased promotion and marketing activities in response to travel restrictions –16. DuriIn the new Covid-19 era, the promotion of destinations must consider the terrible effects of the pandemic on both the demand and supply side of tourism product sales . On the These new consumption patterns lead us to stop and explore the role played by the two essential variables that guarantee the tourist experience: safety and health, and how both affect the tourist’s happiness.This sudden onset of a pandemic crisis is pushing employees into current stressful situations in their workplace , 21, eroIn the current context of the pandemic, health authorities have proposed that tourism businesses need to ensure the safety of both the service provider and their customers . This neAccording to Anderson et al. , not onlThese responsible measures to reduce infection through Non-Pharmaceutical Interventions (NPI) are not only necessary to promote personal hygiene. It provides tourists with a degree of confidence of a psychological nature to overcome the brakes that may be put on any travel to a tourist destination. When responsible measures are employed to reduce infections, it helps tourists to overcome psychological barriers by providing an added motivational factor for travel .These psychological and social components based on providing safety to tourists allow the deployment of Non-Pharmaceutical Interventions (NPI) to depend not only on individual responsibility measures but also on community behaviour. Group action is even more important than individual actions to make correct and responsible use of NPIs to ensure safety .According to Huang et al.  attentioPsychological resilience depends on individuals’ level of risk tolerance. Tourists who have a high degree of rationality in assessing all the consequences of travel under pandemic conditions may reduce their fear of contagion when such health measures are employed . PsycholTourism has so far been understood as the primary producer of consumer experiences and expectations . The terSeveral methodologies exist to reduce the level of risk exposure, including seeking up-to-date information from the destination on how to avoid or minimise perceived risk and incorporating measures that adjust tourist behaviour to minimise its impact or avoid a risk .These two methodologies can be accompanied by the optimism-pessimism theory proposed by De Jonge, et al., (2008) . or the Protective Motivation Theory (PMT) allows the tourist to cope or not with environmental or personal threats when preparing for a trip that involves some kind of health risk . The firWhereas in adaptive coping there is a commitment to use all means to protect the health, in maladaptive coping decisions are made without consideration of the use of protective measures , 36.However, with the emergence of the pandemic, the concept of “safety” has shifted from adventure tourism to the health connotations of tourism. In hotels, the model of designing empathetic and unique experiences has shifted to contagion-free tourism experiences .Governments alone cannot address this challenge. Hence protocols are designed to reduce uncertainty and stress, convey safety, and ensure healthy modes of operation . In thisRegarding social distancing, the implementation of sanitation and hygiene measures is essential for hotels. WHO has provided practical guidance on providing safe water, sanitation, and hygienic conditions since the origin of the spread of the Covid-19 virus . Rural aBased on these cognitive arguments, the following hypotheses are formulated:Safety seeking in rural tourism destinations (S) influences health-seeking in rural tourism destinations (H.T.).The search for safety in the rural tourism destinations (S) influences the happiness sought by the tourist in a rural tourism destination (H.P.).The search for safety in the rural tourism destination (S) influences the promotion of the rural tourism destination (P.R.T).Having analysed the factors that define the safety of a tourist destination, we now turn to health as an attribute that has been especially valued due to the pandemic caused by Covid-19. Even though COVID-19 has had a major impact on the tourism industry globallyit has been less affected in rural areas . One regThose reasons make Extremadura popular among health tourists, as they offer a peaceful and natural environment for healing and rejuvenation. Rural tourism offers a quieter and more relaxed experience compared to busy urban areas, making it an attractive option for those seeking to escape the stresses of everyday life and avoid crowded places. On the other hand, social distancing measures and health concerns have also led many travelers to seek accommodation in rural homes or nature areas where safe distances can be maintained, and crowds avoided .There are multiple meanings of the concept of health tourism  and its The interests of these studies lie in demonstrating that happy human beings have high chance of enjoying a healthy, whole, and long life , 56. ThiRegarding this last variable, it is worth noting that there is extensive scientific literature on tourism management theories today. Many argue that leisure travel is a source of health and positive experiences . Both ofAccording to this theoretical substantiality, the intangible resource of happiness stands as a new Keynesian variable of wellness tourism from the perspective of happiness management . PerhapsAs a result of this research, there has been an interesting academic debate in recent years on the psychosocial determinants that tourism generates on the dimensions of health and happiness for both residents and visitors . Some ofMany scientific studies are currently adding to this line of research in two main ways. The first is exploring the destination’s promotional offers as a robust boost of health tourism in rural areas . An issuAll these cognitive arguments lead us to propose the following research hypotheses:Health seeking in rural tourism destinations (H.T.) influences rural tourism destination promotion (P.R.T).Health seeking in rural tourism destinations (H.T.) influences the happiness seeking tourists in rural tourism destinations (H.P.).Having analysed the effects of safety and health on happiness, we now study the influence of happiness as an essential factor when promoting a tourist destination.Happiness is understood as the valuation of an internal mood or emotional state that allows the individual to define those aspects or conditions of life that best suit their way of thinking and deciding . HappineAccording to  from datMcCabe and Johnson  argue thThe tourism model depends on the conditions of a destination based on the level of services provided, the economy of the territory, cultural identity, and care for the environment. All these variables influence tourism promotion and tourist happiness. In addition to this, the tourist’s perception and formation are the results of the different aspirations, emotions, and expectations of the tourist . TogetheAccording to Doran et al., (2015)  the theoThe role that happiness plays in the promotion of a tourist destination is also related to the theory of tourist attraction . An expeIn this sense, Ivlevs [89] highlights that the actions developed by tourists during their holidays dampen the happiness of the residents of tourist destinations. In contrast to these theories, recent studies show no economic and sustainable progress in the territories where tourism occurs . Rural tIn short, happiness becomes an attractive intangible resource that helps, on the one hand, to make individuals loyal to specific tourist destinations, and on the other hand, to design modern tourism marketing strategies aimed at showing those rural tourist destinations are sources of positive emotions, satisfaction, and health . In sum,visitor happiness (S) influences the promotion of rural tourism destinations (PDT).According to Schwartz  behaviouTranslating the Schwartz theory into the paper topic is worth saying that the consequences of a pandemic (consequence awareness: C.A.) lead to responsible actions through the development of responsible behaviours (R.B.). This behaviour is based on exploring the role played by “safety” and “health” by hotel managers and customers. Hence, responsible behaviour generates behaviour-transforming norms (T.N.) in two directions: “Ad intra”, adapting the new meaning of “safety” to those who provide the experience by complying with the characteristics of being hygienic, social distancing, and safety protocols established by the country’s health authority and treating “health” as a discipline related to wellness tourism offers tourists  PRT , (2) H.P. (Happiness): The pursuit of happiness in rural tourism destination, (3) H.T.:  The pursuit of health in rural tourism destination, (4) S: (Security) The pursuit of security in rural tourism destination. The model presented is shown in Fig.  PRT , with ages between 30 and 39 years (32%) and 40–49 (27%) mainly  have stayed overnight in rural hotels during July and August. Most of the tourists were young and middle-aged. 87% of the tourists were under 49 years old. Compared to the profile of the hotel managers, the educational level of the tourists is lower; 51% have reached a university or master’s degree level. However, the percentage of tourists with a bachelor’s degree (35%) is higher than that of hotel managers (20%).PLS-SEM is an experimental methodology based on primary or secondary data. This methodology is well suited for making predictions. It does not require a normal data distribution and is adaptable to small sample sizes . PLS-SEMThe PLS  technique SmartPLS 3 Version 26 was applied to build the statistical model. This version is especially recommended for composite site models . The SEMThe data have been processed using the multivariate PLS technique. This approach is recommended for social science analysis  in smallTable Fornell and Bookste in  analysisThe model should be analysed using the value obtained from the root mean square residual (SRMR). In our case, the value was 0.042, which did not exceed the approved 0.08 .After ensuring that the relationships between the constructs and indicators were acceptable, the structural or internal model was evaluated by examining the relationships between the constructs to predict the model’s viability . The mosTable According to the hypotheses obtained, we establish a difference between the response of hotel managers and tourists who have stayed in such hotels. The model meets all the hypotheses for hotel managers. Hypotheses 1 and 3 have a strong relationship between latent variables. In H1 safety seeking in rural tourism destinations and health-seeking in rural tourism destinations are strongly related . According to WHO safety noAccording to Castañeda-García, et al.,  health-sAccording to Wang et al., , it is iH1 also gives evidence to Protection Motivation Theory (PMT) . As pandHypothesis 3: The search for safety in the rural tourism destination (S) influences the promotion of the rural tourism destination (PDT) . H3 points to the important role that health authorities play in ensuring safety conditions in tourist destinations in the new Covid-19 era. The promotion of destinations stems from the consequences of the terrible effects of the pandemic on the tourism industry . These rThe promotion of destinations in the search for new opportunities and identifying new options that lead to a more responsible tourism model in terms of health factors .The recoNew studies in the field of tourism have shown how technology contributes to ensuring the well-being and safety of both tourists and residents . The devTechnological innovation in tourism addresses concerns related to the above four factors with particular emphasis on issues related to the safety of tourists’ lives, protection against contagion, etc., and health aspects during the Covid-19 pandemic. The use of technology thus becomes a suitable tool to promote destinations and the safety of visitors and residents .In the case of tourists, hypothesis 3  is not significant. It means that there is no direct relationship between safety and desire to repeat in the destination for tourists. This relationship is indirect. When safety is guaranteed in the tourist destination, tourists experience happiness . This state of happiness reached through the enjoyment of a safe destination subsequently promotes the rural hotel . Therefore, safety understood as an isolated phenomenon needs subsequent experience to become a tool for promoting the destination as a tourist destination.In highlighting the influence of tourism experiences on the happiness experienced by tourists, authors such as Hunt and Harbor  accentuaAbout the effect of health on the pursuit of happiness among hotel managers  and tourists  in both cases, the relationship is significant. Results such as those obtained allow us to contribute to the literature to provide empirical analyses of both constructs to possess solid literature on the impact these two parameters produce on health tourism , 68. As Similarly, health becomes an essential factor of tourism promotion in rural hotels for hotel managers  and the desired factor for customers of such tourism destinations . It allows tourism consumers to enjoy great positive experiences and carry healthy habits in tourist accommodations. Both aim to develop happiness . Given tAfter the Covid-19 eruption, a vision and approach to tourism destinations have expanded throughout the industry. Let us analyse the effect that both safety and health have on the happiness of hotel managers and tourists in the tourism industry in Spain. We can draw several conclusions from the study conducted.The first conclusion is that promoting tourist destinations under safe and healthy conditions has become a priority objective in the tourism industry . HoweverThe second conclusion that follows from the first is that the variables safety and health and the pursuit of happiness are essential factors in promoting tourist destinations for rural hotel managers and rural tourists .The third conclusion related to the first two is that the opportunity that this study provides to develop strategies of an innovative, sustainable, and creative nature based on the relationships of the new trinomial of health, safety and happiness, from the perspective of happiness management . It willThis study has had some limitations. First, the difficulty of organising joint variable selection sessions among managers of rural hotels. Therefore, the number of sessions had to be multiplied to reach the most significant number of participants in the study. It has caused a loss of information as it has not been possible to interact live among the hotel managers. The information has been processed and introduced in general terms at the beginning of each of the sessions. Secondly, it does not consider temporal and cross-sectional effects. Thirdly, that only hotel managers and tourists in Spain were surveyed. It means that the results arrived at in this research may be geographically limited. Moreover, the fourth, which has already been discussed throughout this article, is the scarcity of literature that empirically examines how the dimensions of safety, health and happiness influence the tourism promotion of rural hotels.Among the lines of future research, the research team proposes to specify further the factors that because happiness based on the measurement of authentic experiences to build a new model of hotel tourism promotion. Detailing the quality and variety of these experiences will allow hotel managers to focus on designing and taking more realistic, healthier, safer, and happier measures in the new dimension of the pandemic.Since the emergence of the Covid-19 pandemic, much of the research in the tourism discipline has focused on empirically exploring the dimensions of health and hygiene safety within tourism establishments , 121. ThBoth concepts investigate in a fragmented way in recent literature . This faEmployees in hotel establishments are characterised by carrying out their profession in an environment of high stress, anxiety, and emotional exhaustion . One of In the context of Covid-19, the happiness at work of workers in the tourism industry becomes one of the essential instruments for corporate governance, on the one hand, to build customer loyalty in this landscape of geopolitical uncertainty. Moreover, on the other hand, to design tourism marketing campaigns that shows that their establishments are sources of psychological well-being .From this perspective, the top management of tourism companies should undertake human resources policies that ensure their internal customers’ health, safety, and happiness. The empirical findings of this research show that this trinomial  has a very positive effect on the promotion of rural tourism destinations.This trinomial, therefore, becomes a precious catalyst for management to develop management models that enable them to enjoy a large number of tourists. It also requires ensuring the subjective well-being of the residents of tourist destinations, who are leisure consumers .Combining these two factors allows hotel establishments to become an ecosystem of positive emotions, health, and quality of life. Moreover, this will bring them significant competitive advantages and economic benefits in the post-Covid-19 era. Especially those that foster the certification of happiness management under sustainability, organisational justice, and corporate social responsibility .


Digital transformation is currently one of the most influential developments. It is fundamentally changing consumers’ expectations and behaviors, challenging traditional firms, and disrupting numerous markets. Recent discussions in the health care sector tend to assess the influence of technological implications but neglect other factors needed for a holistic view on the digital transformation. This calls for a reevaluation of the current state of digital transformation in health care. Consequently, there is a need for a holistic view on the complex interdependencies of digital transformation in the health care sector.This study aimed to examine the effects of digital transformation on the health care sector. This is accomplished by providing a conceptual model of the health care sector under digital transformation.First, the most essential stakeholders in the health care sector were identified by a scoping review and grounded theory approach. Second, the effects on these stakeholders were assessed. PubMed, Web of Science, and Dimensions were searched for relevant studies. On the basis of an integrative review and grounded theory methodology, the relevant academic literature was systematized and quantitatively and qualitatively analyzed to evaluate the impact on the value creation of, and the relationships among, the stakeholders. Third, the findings were synthesized into a conceptual model of the health care sector under digital transformation.A total of 2505 records were identified from the database search; of these, 140 (5.59%) were included and analyzed. The results revealed that providers of medical treatments, patients, governing institutions, and payers are the most essential stakeholders in the health care sector. As for the individual stakeholders, patients are experiencing a technology-enabled growth of influence in the sector. Providers are becoming increasingly dependent on intermediaries for essential parts of the value creation and patient interaction. Payers are expected to try to increase their influence on intermediaries to exploit the enormous amounts of data while seeing their business models be challenged by emerging technologies. Governing institutions regulating the health care sector are increasingly facing challenges from new entrants in the sector. Intermediaries increasingly interconnect all these stakeholders, which in turn drives new ways of value creation. These collaborative efforts have led to the establishment of a virtually integrated health care ecosystem.The conceptual model provides a novel and evidence-based perspective on the interrelations among actors in the health care sector, indicating that individual stakeholders need to recognize their role in the system. The model can be the basis of further evaluations of strategic actions of actors and their effects on other actors or the health care ecosystem itself. Digital transformation has gained an important role in strategic management research . Vial 22 describDue to the widespread implications of digital transformation, it is of high priority among the vast majority of organizations . This alVial’s  widely aIn this study, the term entity refers to “an individual organization, business network, industry, and society”  in the hThe outcome of digital transformation is a strategic alignment that drives both capability-driven changes  as well as efficiency and productivity changes  ,3,30. ThThe adoption of digital technologies in digital transformation is accompanied by the redefinition of the meaning of health and the provision of related services . ContrarRecent publications have therefore called for further discussions on the new perceptions of health among various stakeholders  and the Accordingly, this study answers two research questions: (1) What impact does digital transformation have on the value creation of the most essential stakeholders? and (2) What impact does digital transformation have on the relationships among the most essential stakeholders? To answer these questions, we derived evidence-based results from a systematic integrative review, supported by grounded theory. These results were then synthesized into a unifying model.This section describes the 2-staged methodology used in this qualitative study. First, we identified the most relevant stakeholders in the health care sector using a scoping review approach. On the basis of these results, we followed the integrative review process by Whittemore and Knafl , which iAlthough the literature provides some concepts of stakeholder classifications for the health care sector, their ability to generalize the stakeholder landscape in health care remains unclear. To create good prerequisites for the following integrative review and to ensure an adequate fit to the desired level of abstraction in our study, an appropriate stakeholder concept must be derived from the literature. To break the trade-off between efficiency and quality at this stage, a scoping review approach was chosen, as it is suggested for identifying key characteristics and factors related to a concept .On the basis of this scoping review approach, a nonsystematic literature search was conducted. Search terms such as stakeholders and health care were used in Google and Google Scholar to identify relevant concepts. Extensive forward and backward searches further augmented the results. Following the World Health Organization’s definition of a health system, results must aim to provide a holistic representation of the health care sector and identify entities   participThe results were then analyzed based on a grounded theory approach by Strauss and Corbin , with a The scoping review yielded 12 relevant stakeholder conceptualizations ,48-58. TConducting the integrative review, we complied with the PRISMA  extension for Scoping Reviews statement, and the completed checklist is provided in  OR Health Care 4.0 OR Healthcare 4.0 OR Health 4.0 was used to combine the domains of health care and digital transformation.Accordingly, the search term The databases Web of Science, PubMed, and Dimensions were chosen to carry out the literature search. Web of Science and PubMed qualify as principal resources for literature searches and capture the involved disciplines . DimensiIntroduction section, these responses must either improve the efficiency and effectiveness of internal processes of an organization, satisfy needs inside the ecosystem better or at lower costs than existing options, or redefine either its value proposition for or the relationship with its stakeholders. A mere digitization of a process without further strategic implications would not be sufficient to meet this criterion. Second, the entities referred to in the first criterion must include at least 1 of the identified stakeholders. Furthermore, articles must be written in German or English  were considered relevant .Search Strategy subsection in the Methods section.Although the methodology by Whittemore and Knafl  suggestsDuring the data analysis stage, grounded theory  was usedFor the actual data analysis, the MAXQDA software , a tool for computer-assisted qualitative and mixed methods data analysis , was useThis process resulted in the identification of clusters of value creation for the respective stakeholder groups. The same approach was applied to evaluate digital transformation–triggered changes in the relationships among stakeholders. The initial concepts were derived from the identification of text segments involving ≥2 relevant stakeholders. The underlying dynamics describing the changes in the relationships were then aggregated in a similar way as described for the changes in value creation in this section.Results section is structured as follows. First, the most essential stakeholder groups identified are described. Second, the impact of digital transformation on the value creation of each of the stakeholders is examined. Third, the relationships, shaped by the digital transformation, among the stakeholders are analyzed. A graphical representation of the conceptual model synthesizing the insights is presented in the Discussion section.The Methods section, the underlying principle of differentiation of the stakeholders was the value they provide for the ecosystem itself or other stakeholders in the system. Consequently, entities representing an organization, such as hospitals, or an individual, such as local physicians, were grouped together. Although they differ by internal processes, they do not differ in terms of their core value proposition for the system in general. Ultimately, 4 stakeholder groups were identified: governing institutions, payers, providers, and patients. As mentioned in the governing institutions considers relevant regulatory bodies  that define regulatory standards for the health care sector, affecting at least 1 of the other identified stakeholders. The stakeholder group payers refers to organizations specialized in the reimbursement of providers of medical treatments for the treatment of patients. Providers focus on the most pivotal type of service, that is, the provision of medical treatments to patients by organizations or individual physicians. Patients are an essential part of the vast majority of stakeholder concepts. For reasons of model complexity and clarity, other groups such as patient advocacy groups were not considered. The stakeholder group patients is defined as the receiver of medical treatments.The stakeholder group This section presents the results of the integrative review, in particular, on the value creation of stakeholders and the relationships among the stakeholders.A complete list of all the included literature results is provided in A co-occurrence analysis shows how often text segments have been assigned certain codes. Looking at both cornerstones of the conceptual model—value creation and relationships—certain trends are observable. The co-occurrence of value creation–related codes with stakeholder codes showed that the value creation of providers (90 segments), followed by patients (50 segments), received the most attention in the literature. Governing institutions (37 segments) and payers (11 segments) were less often addressed in the literature.The value creation of providers received the most attention in the identified literature. Similar to the effects of digital transformation on process efficiency and quality improvements in manufacturing , the codArtificial intelligence (AI) allows for efficiency improvements throughout the treatment process, from admission and diagnostics to treatment and administrative tasks ,126,166.Although big data is necessary to enable such a use of AI , it alsoMobile and wearable devices and apps allow for process efficiency improvements by supporting the workflows of both nursing staff  and physImprovements in the quality of treatments are mainly attributed to the emergence of AI and big data in medical environments. AI is used along the value chain of medical treatments. It facilitates knowledge management inside the provider organization , monitorWithout further specifications of the involved technologies, all elements of technology are dynamically connected in a closed loop to continuously improve medical interventions , to faciImprovements in diagnostics are primarily related to the advancements and interactions of certain technologies. Technologies such as the Internet of Things, mobile and wearable devices, and telemedicine allow the collection of patient-related data. This can be achieved in an automated fashion via interconnected sensors ,165,191 The digital transformation leads to fundamental changes in the self-conception of patients and how they are engaged in medical decisions and procedures. Thus, patients are increasingly taking an active part in the treatment process. This leverages efficiencies inside the system, which can consequently be characterized as the value creation of patients. In line with changes to the patient-provider relationship, the ongoing empowerment of patients does not necessarily shift value creation away from providers but increases value creation efforts on the patient side. Regarding the coding of segments, 3 distinct clusters could be identified: decision empowerment and engagement (33 segments), self-treatment (14 segments), and disease prevention (6 segments).Mobile and wearable devices and apps, in addition to the strive of patients to control their health-related tasks ,192, facAlthough the literature is often vague about specific technologies involved in the self-treatment process and the process itself ,100,176,The interconnectedness of a wide range of digital health technologies  encouragThe literature characterizes the value creation of governing institutions as a supporting role for the other stakeholders of the health care sector. The clusters describing the value creation of governing institutions are as follows: facilitate innovation (15 segments), define standards (12 segments), data security and privacy (8 segments), increased health care quality (5 segments), interoperability (4 segments), increased availability of health care (3 segments), increased health care efficiency (2 segments), and increased health care affordability (2 segments).Provider–Governing Institutions Relationship subsection). In general, governing institutions are expected to play a more active role in the further optimization efforts of the health care sector [The changing value creation of governing institutions is closely linked to network-like collaboration systems in the provider–governing institutions relationship  could yield different results. It is also possible that the term “digital health” would have yielded additional relevant results. However, owing to the broad scope of this term and the lack of association with the fundamentals of digital transformation in academic discussions, we decided to not consider this term in our search. As our approach yielded more relevant records than other works, we do not regard this search strategy as too narrow ,225.Given the novelty of this study, the sufficiency of the data involved in the research process was judged by 2 measures, the data basis of other studies and “theoretical saturation” . This stLooking at the theoretical saturation, the number of codes applied to text segments was >700. During the codification process, the most relevant code clusters emerged after approximately one-third of the literature was coded. The following research process further strengthened the results, rather than challenging it. This effect was also facilitated by the aim of this study to propose a conceptualization of the health care sector, which puts more emphasis on fundamental concepts rather than individual findings. On the basis of these 2 measures, we are confident that this study provides a sufficient coverage of the relevant literature.Second, it is possible that the full ramifications of digital transformation can only be recognized retrospectively in the future. Future research might challenge the view of recent literature that concepts such as changing value creation and relationships are essential for digital transformation and propose different determining factors of the transformation we are currently experiencing.Third, the grounded theory–based coding methodology itself, although followed rigorously, might rely on subjective perceptions of the researchers, thereby affecting the results.providers group includes both individuals  and organizations . The different characteristics of these entities may have implications for value creation or relationships that were not further differentiated in this study to address the need for ecosystem-level abstraction.The decisions made during the stakeholder identification also have considerable implications on the methodology and results of this study. Scholars providing in-depth analyses of the health care sector limit their perspective to comparable numbers of stakeholders ,57,58. OThe proposed conceptual model highlights the interconnectedness of stakeholders’ digital transformation facilitates in the health care sector. We introduced the concept of the virtually integrated health care ecosystem and elaborated on the central role of intermediaries inside the system. Stakeholders are encouraged to recognize the common goal of actors in the sector and to embrace novel forms of cooperation. The proposed model can therefore serve practitioners as a useful tool to evaluate strategic responses. In addition, policy makers are advised to recognize the emerging reality inside the health care sector and let it reflect on their policies. Finally, it provides researchers with a basis to guide further scientific discussions on the transformation of the health care sector.