The Brazilian Federal Government developed the Occupational Health and Safetypolicy for the Federal Public Servant, supported by the following axes:health surveillance and promotion, health assistance for the civil servant,and medical surveillance expertise. As a federal public institution, theFederal Institute of Northern Minas Gerais  is responsible for implementing this policy.This study aimed to identify the challenges and perspectives associated withthe health care provided to the servants of the Federal Institute ofNorthern Minas Gerais.This was a documentary and field study, with a qualitative and quantitativeapproach, conducted using documentary research and semi-structuredinterviews. The collected data were submitted to descriptive and categoricalcontent analyses.The Federal Institute of Northern Minas Gerais still presents severalproblems in the consolidation and structuring of the Occupational Health andSafety policy for the Federal Public Servant. Among the main obstacles facedare the lack of governmental and institutional support and theprecariousness of financial and human resources, mainly directed to the axisof health promotion and surveillance. The institution plans to conductperiodic medical examinations, the establishment of Internal HealthCommissions for Public Servants, and the implementation of a mental healthprogram.It is expected that the Federal Institute of Northern Minas Gerais will beable to perform better on the development of health policies and programsfor its workers. In Brazil, labor regulation began in the 1940s with theConsolidation of Labor Laws, which focused on individual and collectiverelations.7In order to consolidate actions in the area of occupational health and safety in thefederal public service, the Occupational Health and Safety policy for the FederalPublic Servant  wasintroduced in 2009, guided by actions of surveillance and health promotion, healthcare for the servant, and reports by medical experts. This policy is based on theinterrelation between these axes, on the individual’s biopsychosocial approach, onmultidisciplinary teamwork, on the evaluation of workplaces, and on epidemiologicalinformation.3As a strategy for the implementation of the PASS proposals, the Integrated Subsystemof Servant Health Care (Subsistema Integrado de Atenção àSaúde do Servidor - SIASS) was also created, which is responsible forcoordinating programs in the areas of health care, official investigation, and thepromotion and monitoring of the health of public servants.6 Due to this lack ofplanning, no roles have been defined for the servants responsible for theeffectiveness of the PASS, therefore servants and managers are not aware of it.Studies also show the need to expand the dialogue between health, labor, andmanagement policies, and among the public servants themselves.8Despite significant advances in the expansion of legal resources for itseffectiveness, it was observed that the implementation of this policy faces manychallenges. One of the most cited in the literature is the lack of planning, whichshows an erroneous perception of occupational health, with actions focused ondamages rather than on health promotion.The Federal Institute of Northern Minas Gerais , an institution of higher, basic and professional education, memberof the Federal Public Administration , is subject to the determinations of PASS. The health actions in theinstitution must be implemented in a systematic and programmatic way and executed bythe health surveillance and promotion teams, in order to meet the PASS premises.Thus, this study aimed to identify the challenges and perspectives facing the actionsof health care for the workforce at IFNMG guided by PASS.This was a documentary and field study, with a qualitative and quantitative approach,about the health care provided to staff at the IFNMG.The IFNMG is an educational institution with multiple campuses and a decentralizedorganization. It is structured in several departments, directorates, andcoordinators, to meet its objectives of teaching, research, and extension.Data were collected between 05/05/2018 and 05/31/2018, and, for this purpose,documentary research and semi-structured interview were used.12 among others. The semi-structuredinterview was prepared by the authors themselves and covered questions according tothe proposed objective.The documentary research was used to gather information about policies and actionsaimed at the health of public servants at IFNMG, by researching institutionalregulatory documents, including the General Regulation, the Internal Regulations,and the document on the Institutional Program of Health Care and Quality of Life ofPublic Servants (PIASQV),Six employees participated in the study, intentionally selected to occupy strategicpositions regarding the institution’s healthcare actions. They were four members ofthe institutional health care body , the director of human resources management,representing the body in which the health care functions are allocated, and aprofessional from the financial sector, to explain the resources invested inworkers’ health.The interviews were conducted individually, by a single researcher, after adherenceto the Free and Informed Consent Form. These meetings took place in the institutionitself and lasted 30 minutes on average.The interviews were recorded and transcribed, and their data were submitted tocategorical content analysis, using analytical description and subsequentinterpretation.13The study was approved by a duly recognized Research Ethics Committee  and by the institution involved, and it was developed according to theguidelines determined by Resolution no. 466/2012 of the Brazilian National HealthCouncil.14The IFNMG has a decentralized organization, with a rectory and 11 campusesdistributed in the mesoregions of the North of the state of Minas, in theJequitinhonha Valley, in the Mucuri Valley, and also in part of the Northwest ofMinas. The realities of these campuses are diverse, with similar characteristics anddemands in some aspects, but different in terms of regional specificities. While oneof them has a history of more than 60 years of experience in offering technicalcourses and a more consolidated structure, others were established only a few yearsago, some even without their own headquarters, offering only high school technicaleducation. This regional coverage is the result of a process of institutionalexpansion aimed at meeting the education and training needs of the local andregional society.In investigating the effectiveness of PASS in this institution, four thematiccategories were constructed:institutional bodies in the health care of public servants;health programs and actions aligned to the PASS;challenges in the implementation of health actions according to PASS; andinstitutional proposals in face of the reality experienced.The PASS establishes that the attributions related to the development of healthprograms and actions are up to the personnel management body of these bodies.The Directorate of People Management (A Diretoria de Gestão de Pessoas -DGP) of IFNMG, located in the rectory, recognizes and has assumed its role inthe health care of servers, as attested in the following speech: “The issue ofhealth promotion [...] represents one of the strategic aspects in the area ofPeople Management [...], and, therefore, we [...] have invested in thecomposition of a team under the conditions we have” (E1).However, this body also acknowledges the difficulties when fulfilling itsresponsibilities: “There are a number of limitations, including personnelshortages, resource constraints, and a lack of political clarity” (E1).11To put into practice what is established in the PASS, the DGP has a HealthAssistance and Quality of Life Coordination and a Workplace Safety Center .11The CASQV is composed of an administrative assistant, who articulates the actionsof this coordination, a psychologist, who also participates in these actions andperforms individual consultations, and a physician, who performs the medicalexaminations of the servants and takes part in some health promotion activities.The NST, on the other hand, is comprised of an occupational safety engineer, whoperforms occupational safety examinations and deals with occupational additionalrequests, and an occupational safety technician, who manages occupational healthand safety.10 Such realityis confirmed by the following report:Since they are located exclusively in the rectory, the activities developed bythese bodies are mainly directed at the rectory staff. On the campuses, theCoordinators of People Management (Coordenadorias de Gestão de Pessoas -CGP) are responsible for supporting and subsidizing the actions proposed byCASQV.We cannot effectively reach all campuses, visit them, meet people, talk tothem, and make the Coordination’s action reach them in a massive way, wework here thinking about the policies, applying them a little to the rectoryand trying to overflow a little to the campuses (E1).Some campuses have health professionals who, despite their functions beingfocused on student assistance, are also partners of CASQV, collaborating inactivities of this Coordination, when requested:We also have a very close connection with the health professionals on thecampuses, including doctors, psychologists, social workers, dentists,nutritionists, all these professionals… We have a relationship, and we areoften working together to develop actions on campuses (E2).15 Feedingthis platform is essential for the successful implementation of the PASS,especially with regard to health promotion and prevention actions.16The SIASS has the Integrated System of Human Resources Administration - Health as a platform for its activities, a systemdesigned to automate the health information of the federal publicservant.11It is important to point out that the SIASS unit at IFNMG does not have a healthsurveillance and promotion team as recommended by the PASS, therefore it usesthe same professionals that comprise the CASQV and the NST as aworkforce.As previously reported, the PASS is guided by the axes of health expertise,health care, and health surveillance and promotion. It was verified that,regarding the health expertise actions, IFNMG fulfills its role by providingmedical care to its employees, at the SIASS unit in the rectory and also at theother campuses where there is a medical professional.8 for a long time the health actions in the institutionswere restricted to conducting medical reports. For the authors, performing onlythese actions means leaving aside other peculiarities that involve the work andhealth issues present in the institutions. This emphasis on actions such asmedical-legal reports to the detriment of health promotion actions cancontribute to the risk of SIASS becoming only a medical-legal controlmodel.5According to Jackson Filho & Ponce,7Concerning healthcare actions, we verified that they are not conducted directlyby health professionals within the IFNMG. The Brazilian Federal Administrationoffers supplementary health benefits to its servants, intended for the medicaland dental care of servants and dependents, being a benefit shared between theAPF and the servants. Furthermore, the Brazilian public Unified Health System(SUS), offered to all Brazilian citizens, is also considered a healthcareresource in the context of the PASS.The inability to directly provide health care is a reality at several federalinstitutions, as this would require a proper structure in terms of material andhuman resources, which most institutions lack. The policy only establishes thebenefit of supplementary health without specifying the institutions’responsibility in terms of assistance.In the axis of health promotion and surveillance actions, we verified apredominance of campaigns, events, and lectures related to health and safety atwork. These actions are conducted in specific periods of the year in anon-systematic way, which can be seen in the excerpts of the followingstatements: “There is no systematic, programmatic nature of the performance, butsome actions have already become part of our annual calendar, such asvaccination campaign and, informative campaigns on certain topics” (E1).17 It is always important to point out that theseactions should focus on strengthening people’s health, encouraging healthyhabits and consequently preventing lifestyle-related diseases.19 Therefore, they have great importance within anyinstitution.Health promotion actions have improved over the years.5. Health promotion and preventionactions usually do not produce immediately visible results, which leads to thequestion of whether PASS has really fulfilled its role in improving the healthof employees.16One of the possible obstacles to the implementation of this axis at IFNMG is thatthe regulatory instruments of PASS do not determine which actions should bedeveloped or establish a requirement for its implementationPASS represents a promising policy, but the effectiveness of its practicesinvolves many challenges. Based on the report below, we observed that one ofthese challenges is the lack of financial resources: “A recurring remark fromthe team is that without financial resources they cannot do anything, right? Sowith few resources they do something, but if there are not enough, itdiscourages the team to present projects and solutions, with the perspectivethat the projects will not be sponsored” (E1).20 However, in the IFNMG budget there are no specificresources assigned for these actions. Since its implementation, CASQV and NSThave never had any specific resources, detached from the institution’s budget,to conduct their health activities, as verified in the following statement: “Weunderstand that without financial resources we cannot offer the necessaryservices and actions to our workers. We have already asked the Board ofDirectors for these resources two, three times, but in the current scenario,they haven’t been granted yet. So today CASQV has no resources of its own”(E2).The APF bodies are responsible for providing the necessary resources to implementhealth surveillance and promotion programs.22The lack of financial resources to conduct health actions is a common challengeamong agencies and institutions within the federal public service. The lack ofclarity in the definition of budget allocations for health care for employeeshas generated difficulties in implementing these actions.16 As for theinstitution, we notice the need for greater prioritization of investments inhealth promotion, as also described by other authors.6The lack of governmental and institutional support is also a challenge. Thedissonance between the creation of policies and the availability of resourcesfor their implementation has already been evaluated as a lack of governmentalsupport.Complementary to the lack of governmental support is the deficiency of normativeinstruments, which do not oblige federal public institutions to develop actionsto promote occupational health and safety. What exists is a recommendation.Public institutions follow the norms established for private companies, but theyare not obligatory. About this obstacle, it is interesting to analyze: “I seethat the public sector has a great inconsistency, it often creates the laws andimpose a reality for the private sector, while it is the largest body and hasthe largest number of employees, it leaves much to be desired in this aspect inits own administration” (E6).23The absence of mandatory preventive actions can have several negativeconsequences, among them: decentralized actions without guidelines; lack ofinfrastructure and specialized technical personnel; low level of satisfactionamong employees; among others.Just as there is a need for more effective action by the government and theinstitution, there is also a need for greater protagonism of the institutionalactors. The employees must understand that they need to be protagonists ofhealth actions, participating in institutional actions related to the health andsafety of the employee. In this sense, an interviewee reports: “The servant mustunderstand that he needs it, he needs to worry about his health as soon aspossible. [...] Then, we need to provoke the managers in the sense that they seethat this need exists” (E6).24consider the employee as the main actor in the work process related to healthcare initiatives related to PASS. They also argue that the construction of thislook at health requires the integrative action of the tripod institution,individuals, and collectivity.Gonçalves et al.Another challenge mentioned concerns the need for training of professionals whodeal with health actions within the SIASS unit of IFNMG: “The SIASS isstructured to perform various activities. [...] And these activities often havea very high degree of complexity, and there has not been [...] for some timenow, a training of the SIASS professional staff, this is a criticism at theBrazilian level.” (E3).25The formation and training of professionals to deal with the health programs andactions that integrate the PASS are foreseen in the policy itself.The lack of personal resources is also a major hindering factor in IFNMG. Thislack of human resources is not limited to the health department, located in therectory, but also extends to all campuses, as verified in the speeches:In the work safety area there is what we call SESMT, which is the SpecializedService in Safety Engineering and Occupational Medicine. This system isformed by a multi-professional team. [...] So, these professionals from thesafety area form a multi-professional team. [...] We are very far fromforming this multidisciplinary team (E4).We have already discussed the need for an occupational physician andpsychiatrist for ICD medical leaves. We also need a social worker, becausetoday withdrawals are only handled at the level of medical expertise, andthe server does not have a psychologist or a social worker, to monitormedical leaves (E2).25The difficulty in hiring new professionals through public exams was verified, dueto a government restriction on the number of public servants. It is known thatit is the responsibility of both the Union and the local agencies andinstitutions to ensure the provision of human resources necessary for theeffectiveness of the programs.Another major challenge faced by the institution is the multi-campuses format,which makes it difficult for servers from other campuses to access the actionsdeveloped by CASQV and NST, as can be seen in the speech:We are an institution of more than 1,300 servants with 11 units, so we arestill figuring out the best format for the CASQV to operate, to try andverify if this centralized structure in the rectory is feasible to meet allour public needs, even with the professionals I mentioned, or if theseservices, or part of them, need to be suddenly decentralized to the campusesso that this monitoring can be done on-site (E2).24 alsoreported the need for a greater “capillarity” of the actions developed at theuniversity concerning its geographic spaces. One option for the institutionwould be web-based programs. Studies have shown that these programs bringsignificant results in promoting worker health due to the advantages of mobileaccess to information. In addition, there are benefits for the employees, whocan participate at their convenience, as well as savings for the institutionwhen compared to face-to-face programs.26Gonçalves et al.The IFNMG bodies responsible for staff health have been working to make theinstitution’s health programs and actions a reality. Among some proposals, thereare periodic medical examinations, the creation of the Internal Commissions forPublic Servant Health (ICPSH), and the implementation of mental healthprograms.27 However, although specific resources have already beenmade available by the Federal Government to implement the exams, no companieshave expressed interest in the bidding process. Therefore, this resource is nolonger included in the institution’s budget.Several normative and institutional documents stipulate the need for periodicmedical exams.The proposed exams are a strategy to promote the health of public servants,through periodic monitoring of the health status of individuals and therecording of this information in the SIAPE-Health database for follow-up,monitoring, and construction of the epidemiological profile of public servants.Given its importance, these exams must be conducted. An alternative for IFNMG,which does not have health services with its own laboratory and infrastructure,would be to perform these exams through private health plans since thegovernment offers the benefit of supplementary health care.25 Theimplementation of the CISSP is already foreseen in regulatory documents thatdeal with the health of public servants.12 This candirectly influence the workers’ health since the workers’ health problems arelinked to several types of hazards in the work environment. The CISSP will allowan integrated approach to this environment, overcoming a fragmented approach tooccupational health and acting on the risk factors to which workers areexposed.28Another important initiative for the promotion of public health in the context ofthe PASS is the creation of the CISSP, which aims to propose actions aimed atpromoting health and humanization at work. With shared management, the CISSPaims to expand the autonomy of public employees so that they can contribute toregulating their activities, and negotiating changes in the environment and workorganization within the administration.29The establishment of a program of mental health actions is also established inthe PASS, regulated by Administrative Rule 1.261, May 5, 2010. According to thisstandard, the mental health procedures adopted must be in line with the publicpolicies on mental health and workers’ health.29 As in other educational institutions, mental disorders areamong the main causes of sick leave in the agencies. This reality awakens theneed for greater attention to mental health issues at work. In order to minimizeabsences and illness, it is imperative to identify the magnitude of the problemand its potential causes.30The mental health care provided in the institution consists of psychologicalcare, with no care or therapeutic purpose, and non-systematic health actions. Weverified that the IFNMG needs to develop more consistent and effective actions,according to government policies.The lack of funding brings uncertainties about the progress of the actions thatare currently conducted at IFNMG. While there is a consensus about the need forevolution of institutional programs and actions, the lack of resources preventssuch initiatives from advancing.A limiting factor of this study was the unilateral investigation. The view of theservers as users assisted by the institution’s health bodies was not evaluated.The results of this analysis allow a greater extrapolation of thisinvestigation, with the evaluation of the health of the servant from theservant’s perspective. It is suggested that this issue be addressed in furtherstudies, which will possibly bring significant contributions to the planning ofinstitutional health programs.The attention to the health and safety of staff at IFNMG is hindered by a lack ofhuman and financial resources. We emphasize the need for increased governmental andinstitutional support, especially directed to the axis of health promotion andsurveillance established by PASS.Despite the difficulties and challenges encountered, the institution is expected tobe more proactive in developing actions that improve the health of its employees,with the formulation of appropriate policies and prioritizing resources within theinstitutional framework.


Despite the recognised health benefits of physical activity, the physical activity levels of children and adolescents continue to decline. The concept of physical literacy (PL) is a promising holistic approach to physical activity promotion that addresses affective and cognitive domains in addition to physical and motor domains. In Germany, however, no uniform or widely used method exists for assessing PL in children. This research was conducted to compile information on international PL assessment systems for children and adolescents (up to 18 years of age), including their underlying definitions, structural designs and development processes, for the purpose of developing such a tool in Germany.A scoping review was conducted using PubMed, Web of Science and SPORTDiscus database entries. The initial search was conducted in July 2022, with a follow-up search performed in May 2023. Articles that operationalised the construct of PL and at least two of the three domains were identified and included. The procedure and assessment tools used to evaluate the individual domains and the overall PL construct were extracted from all selected articles.A total of 882 articles were identified; five were added after a manual search. After duplicates were removed, 563 articles were screened by title and abstract, and 40 articles met the inclusion criteria and were included in the review. In a review of these articles, 23 different assessment procedures were identified. Eight assessment procedures included PL as a superordinate construct. Twenty-two of the 23 procedures assessed the affective and physical domains, only 14 assessed the cognitive domain.Approximately half of the identified PL assessment systems addressed all three domains. Motor performance was most frequently integrated into the test procedures. Future developments in Germany should integrate all domains in the assessment to produce a holistic conceptualisation as the basis for appropriate funding. Physical activity and exercise play central roles in the healthy physical, psychosocial, cognitive, and emotional development of children and adolescents –3. DespiDue to the potential negative consequences of insufficient physical activity, including excessive weight gain, obesity, and motor deficits , the WHO. Margaret Whitehead proposed this term to describe participation and physical activity behaviour with a philosophical underpinning. According to Whitehead, the human being exists as a unity of body and mind (monism) and is the result of accumulated experiences in the world , which form the basis for one’s process of perception (phenomenology) [One possible theoretical basis for such interventions, which recognise this broader understanding of exercise and the promotion of exercise, is the concept of physical literacy (PL) . Margareenology) . Movemenenology) , and theenology) .Various culturally adapted definitions and (depending on the field of application) corresponding assessment systems have been developed from this theoretical framework –23. AmonCurrently no model or procedure for assessing PL is available for any age group in Germany. Before effective physical activity support measures for children and adolescents can be developed and compared, an adequate operationalisation of the domains or construct and a clear and uniform definition are needed . For thiA scoping review was conducted according to the guidelines of the Joanna Briggs Institute  and the An initial systematic literature search was conducted in July 2022 and followed by an updated search in May 2023 using three electronic sports science and medical databases: (i) MEDLINE (via PubMed), (ii) Web of Science, and (iii) SPORTDiscus. The literature search results were manually checked for duplicate publications. The search strategy combined the term ‘physical literacy’ and the target group of children and adolescents ).Participants: The target group of the articles had to include children and adolescents up to 18 years of age. Articles were excluded if the target group included children with specific pre-existing conditions, such as obesity.Concept: Only articles that focused on or operationalised the construct of PL were included. In addition, validation studies of PL assessment instruments were included. At least two of the three constituent PL domains  had to be covered in the assessment procedure. The cognitive domain was understood to be knowledge and understanding of changes to the body and psyche due to movement. The affective domain referred to the areas of motivation, self-efficacy, and self-confidence. The physical domain was related to motor skills, movement behaviour and fundamental movement skills.Context: All institutions for children and young people, such as kindergartens, schools, youth centres and community projects, were included as settings for the PL assessment systems. All nationalities were included. Assessment systems conducted at universities were excluded.Two independent reviewers (MG and SW) screened the identified articles for the specified inclusion criteria. The screening process was carried out using the program Rayyan  and was The exclusion criteria included contributions to conferences, scientific posters, and non-English or non-German articles. Conference papers were excluded due to their tendency to present the applied methodology with limited detail and incompleteness. If full-text access to a publication was unavailable, the author was contacted and asked to send the full text.Name of the first author, year of publication, and country of publication;The target group of the assessment tool;The underlying PL definition;Evaluation that the articles included an assessment of PL as a superordinate construct;The terminology used for the domains;The name and characteristics of the instrument used to evaluate each domain;The assessment of each domain.A standardised extraction protocol for summarising relevant variables was developed for this review. In accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) checklist for scoping reviews, the reviewers first checked five articles for completeness and applicability . The extThe literature search identified 882 articles Fig. . Five adThe test procedures identified in the literature can be found in Table All three PL domains were addressed in 12 assessment tools , 60, 63 The affective domain was also included in 22 of the 23 assessment procedures. Gu et al.’s  combinedThe cognitive domain was considered in 14 assessment systems , 63, 64.Only in eight of the 23 systems analysed, was PL assessed in the form of a total score resulting from the domain scores , 54, 57.Varying statistical procedures were used to validate the scoring systems. For some of the PLAY tools  as well PL is becoming increasingly important as a potential guiding concept for the promotion of physical activity and health due to its holistic approach. However, there is currently neither a uniform framework concept nor a corresponding assessment procedure established in Germany to develop and test appropriate interventions. A scoping review was thus conducted to summarise current definitions and test methods, including assessments of individual PL, for children and adolescents.A total of 23 models and procedures were identified, some of which varied considerably. As previous reviews have also shown, the assessment procedure developed depended on the underlying definition of PL and the context in which the procedure was used , 21.Only 12 assessment instruments addressed all core components of the Whiteheadian conceptualisation  was onlPresumably, this inconsistency in measuring the cognitive components of PL is due to the challenge of systematically capturing and, most importantly, to defining the content that should be addressed in this domain. There is currently no consensus on what knowledge regarding the effects of sport and exercise can be expected for children and adolescents at different age levels. The CAPL, for instance, is oriented towards the contents of the Canadian school sports curriculum . HoweverThis study was conducted based on a literature search of three databases: SPORTDiscus, PubMed and Web of Science. This approach covered a broad range of research in sports science and sports medicine, but educational literature was underrepresented. The databases used were chosen because of the health- and prevention-oriented focus of the scoping review.Only papers written in English were included in this work. The literature search did identify several articles from Asia that were not included due to the language of the text. Therefore, it cannot be ruled out that relevant literature may have been overlooked.During our publication process, a rapid increase in literature and assessment systems in the field of PL was observed. Therefore, a follow-up research was conducted, but it can be assumed that the research area is still expanding, further relevant and innovative developments will occur.Finally, it is possible that the requirement that at least two of the three domains be addressed in the PL assessment also led to a reduction in possible search results. However, we chose this approach to do justice to the holistic nature of the PL concept.The PL construct is a promising concept for promoting physical activity in childhood and adolescence because it considers multiple facets of physical activity and is thus intended to lay an essential foundation for an active lifestyle throughout the lifespan. However, to enable the development of concrete promotion measures based on this holistic approach, a clear and theory-based definition and assessment derived from it are needed. Unfortunately, the holistic nature of the approach, though promising, is precisely what makes adequate assessment a methodological challenge due to its complexity. In addition, the developmental stages of children and adolescents must be taken into account. A certain abstraction from the original construct may be unavoidable when putting the theory into practice, but the fundamental PL approach should always remain in focus. Priority should therefore be given to developing assessments that are holistic instruments rather than merely domain-specific constructs.


In Uganda, cervical cancer (CaCx) is the commonest cancer, accounting for 35.7% of all cancer cases in women. The rates of human papillomavirus vaccination and CaCx screening remain low. Digital health tools and interventions have the potential to improve different aspects of CaCx screening and control in Uganda.This study aimed to describe stakeholders’ perceptions of the telemedicine system we developed to improve CaCx screening in Uganda.We developed and implemented a smartphone-based telemedicine system for capturing and sharing cervical images and other clinical data, as well as an artificial intelligence model for automatic analysis of images. We conducted focus group discussions with health workers at the screening clinics (n=27) and women undergoing screening (n=15) to explore their perceptions of the system. The focus group discussions were supplemented with field observations and an evaluation survey of the health workers on system usability and the overall project.In general, both patients and health workers had positive opinions about the system. Highlighted benefits included better cervical visualization, the ability to obtain a second opinion, improved communication between nurses and patients (to explain screening findings), improved clinical data management, performance monitoring and feedback, and modernization of screening service. However, there were also some negative perceptions. For example, some health workers felt the system is time-consuming, especially when it had just been introduced, while some patients were apprehensive about cervical image capture and sharing. Finally, commonplace challenges in digital health  and challenges in cancer screening in general  also resurfaced.This study demonstrates the feasibility and value of digital health tools in CaCx screening in Uganda, particularly with regard to improving patient experience and the quality of screening services. It also provides examples of potential limitations that must be addressed for successful implementation. Cervical cancer (CaCx) remains one of the most common and most deadly cancers in low- and middle-income countries (LMICs), particularly in sub-Saharan Africa . There wCaCx is highly preventable through vaccination against human papillomavirus (HPV) and early screening. However, due to financial, sociocultural, and health system challenges, access to vaccines is limited and uptake is low in LMICs -7. OrganIn Uganda, data from a nationally representative sample of 6000 girls found that only 22% had been vaccinated against HPV , while saccuracy of VIA, for example, using smartphone-based colposcopy and cervicography to enable inexperienced screening staff to capture cervical images and share them with an expert for a second opinion [train artificial intelligence (AI) models, which could potentially substitute the expert when one is unavailable for a second opinion or supplement them [improve pathology services, which is another major challenge not only for CaCx but also for cancer control in general [enhancing clinical documentation and data management [Harnessing digital health tools and interventions has the potential to improve different aspects of CaCx screening and control in Uganda and other LMICs. For example, a common CaCx screening technique used in LMICs is visual inspection with acetic acid (VIA) . However opinion -45. Otheent them ,41,46. I general ,47,48. Snagement ,41,49. Anagement .The potential for digital health in Uganda and Africa at large is supported by the rapid penetration and adoption of digital innovations, such as smartphones, computers, and the internet, in this region. There is also a growing body of evidence on digital health solutions in Africa, particularly mobile health , showing a positive impact on treatment adherence by patients, the provision of health education and awareness of the general public, data collection and reporting, drug supply chain and stock management, and disease surveillance -53. HoweWe implemented a smartphone-based store-and-forward telemedicine system to support CaCx screening in Uganda. It consisted of the Gynocular (Gynius Plus AB)  portableThe objective of this paper was to describe the key stakeholders' (screening clinic staff and patients) perceptions of the telemedicine system for CaCx screening. Understanding their perceptions is crucial for ensuring that the intervention addresses their needs and is aligned with their constraints and workflows -62. SuchThis study took place from 2019 to 2021 at the UCI in Mulago, Kampala, Uganda, and at its satellite clinics in Arua , Jinja and Mayuge , and Mbarara . The UCI is a large national referral comprehensive cancer center; Arua, Jinja, and Mbarara are general referral hospitals; and Mayuge is a community cancer prevention and screening clinic. Before the study, CaCx screening clinics were operational at the UCI in Kampala, Mbarara, and Mayuge; therefore, the nurses here were more experienced in CaCx screening. Screening clinics at Jinja and Arua were operationalized during this study, and the nurses for these sites were trained at the UCI on VIA, cryotherapy, thermocoagulation, and related aspects of CaCx screening before being deployed at the respective satellite sites. Therefore, these nurses had limited experience with VIA.We screened a total of 2682 women from the 5 sites over the course of the project, with 322 (12%) diagnosed as VIA positive by the frontline nurses. Images from 2174 (81.1%) women were reassessed by a gynecologist and were used in AI model training. The gynecologist determined that 313 (14.4%) women screened positive (VIA positive or suspicious for cancer), and the best overall AI model performance was at 98% sensitivity, 82% specificity, 90% accuracy, and 0.97 area under the receiver operator characteristic curve.Participants included patients who presented for CaCx screening  and screening clinic staff (nurses who performed the screening and administrative staff). These individuals were selected because they are the most important stakeholders for the smartphone-based telemedicine intervention -60. As tThe study was informed by the Consolidated Framework for Implementation Research (CFIR) -72, whicThe FGDs were audio-recorded and transcribed by the first and second authors for analysis. A rapid deductive approach was followed ,74 in whWe supplemented the FGDs with the field observations of authors who were involved in the operation of the project, with insights from the clinical data collected during screening, and with an evaluation survey of the health workers at the end of the project. The evaluation survey assessed the system usability using the System Usability Scale (SUS) , as wellThe study was reviewed and approved by the UCI research ethics committee (UCIREC#17-2018) and was registered by the Uganda National Council for Science and Technology . All participants (patients and nurses) provided informed consent before participating in the study. The nurses also received training on good clinical practice and protection of human subjects. To ensure data privacy and confidentiality, the smartphones used in this study were password-protected, were strictly used for study purposes, had all other apps removed, and were always kept securely in the clinics. In addition, study identifiers were used instead of patient names in the ODK data collection forms. Participants received Ugandan Shilling (UGX) 20,000 (approximately US $5) as reimbursement for their time as per the UNCST guidelines.In total, 3 FGDs were conducted with 15 patients , 1 at each of the sites Arua, Mayuge, and Mbarara . In addition, 10 FGDs  were conducted with 27 nurses and administrators at Arua , Jinja , Mayuge , Mbarara , and UCI Kampala . All the staff were female (nurses), except 3 (11.1%), who were male (administrators). Of the health workers, 20 (74.1%) completed the evaluation survey. Generally, the CaCx screening nurses from all sites were positive about the intervention and considered it acceptable and useful. They mentioned the following as some of the perceived benefits or value additions of the system: (1) the ability to send an image for a second opinion when in doubt of the VIA results or for advice on the best treatment option for VIA-positive cases, depending on the size of the lesion; (2) the ability to consult and discuss with a colleague in the clinic using the image on the smartphone rather than keeping the patient long in the lithotomy position; (3) better illumination from the Gynocular unit’s light compared to ordinary torches; (4) better visualization of the cervix on the screen of the smartphone (with the possibility to zoom), both of which improve the nurses’ confidence and accuracy of assessment; and (5) ease of communicating findings to the patients by showing them images of their cervix. These benefits were highlighted both in the qualitative findings  as well In terms of usability, at least 16 (80%) of 20 nurses rated the system as having good usability  on 10 of the 14 SUS items see .The enthusiasm and perceived value of the intervention was highest for nurses from remote sites and those who were new to CaCx screening. The nurses at urban centers  considered the intervention useful but not an absolute necessity, since they often have access to consultants in case they need a second opinion or because they felt they already know how to conduct VIA assessments. These nurses also pointed out that with busy clinics, their priority is on screening and treating all women, even if it means overtreating some, instead of spending precious time on getting a second opinion to ensure accurate VIA results. The concern that using the telemedicine system is time-consuming was echoed by other nurses at rural clinics and was also reflected in the usability survey, but in this case, it was in relation to the need for assembling the different components of the system . This concern was particularly reported at the start of the project, but with experience, this ceased to be reported.Other challenges pointed out or observed included bad-quality images, especially at the start of the project ; an occasional slow internet connection or depletion of broadband data bundles; and difficulties in setting up the Gynocular unit with the phone, which caused the Gynocular harness to obstruct the phone camera lens. The nurses were also concerned about the lack of technical support to repair the Gynocular unit when it breaks down.When specifically asked about the AI, the nurses did not express any fear of AI threatening or replacing their role in the health care process. Instead, they were enthusiastic about the prospect of getting help from a machine when their skills are inadequate or when they are tired. They were particularly happy when there was agreement in the assessment between them and the AI, as this reassured them that they were managing patients correctly. Finally, in a small evaluation survey of the entire project, the AI was considered the most important component for patient care  compared to the other components .electronic data, which allows them to obtain an overview of the screening activities and support research, including the development of AI. They also highlighted the value of the system in enabling reviews of the nurses’ VIA assessments by gynecologists and providing them with feedback. From the consultations as well as analysis of the assessments made by the nurses versus those by the gynecologist during the training of the AI model, the areas where some nurses were struggling  were noted and feedback provided to them during site visits. Another perceived benefit was modernization of the screening service, which they thought would boost confidence in the clients and increase the uptake of screening services.Administrators and staff in charge of the clinics or in supervisory roles appreciated the intervention for providing access to Similar to the health workers, the patients were also generally positive about the intervention. They felt that it brought the consultant services closer to them, which otherwise would not be accessible. They also noted that with this technology, nurses would discuss among themselves, which showed them that they care. In addition, patients reported that nurses explained better using the images of the cervix. Even in cases where their condition would require a referral, patients felt that this intervention would ease the process since the referral site would already have their information. The nurses confirmed the patients’ perceptions and sentiments from their observations and interactions with them, saying that the women wanted to see their cervix and that they were happy knowing that consultants from a specialist hospital would be evaluating them.We specifically explored the issue of privacy and confidentiality with patients, considering the sensitivity of the data. Generally, patients were not worried, due to their trust in the professionalism of health care providers, while others pointed out that since the images did not contain personally identifying information, there was no problem sharing them. A few were concerned but felt the benefit of getting screened and an accurate assessment outweighed the potential negative consequences. However, for 1 (6.7%) patient, this privacy concern caused her to refuse screening. Unfortunately, this happened before the nurses explained the purpose and operation of the system and how privacy concerns are addressed, so she only decided based on incomplete information she obtained from other patients. Otherwise, the nurses’ explanations and showing patients the captured images helped allay privacy fears.In addition to the above-mentioned findings from the FGDs with health facility staff and patients, the research team made several observations that merit highlighting. A positive observation was that the time needed to train the nurses on the system  was fairly short. It took only 2-3 half-day sessions spaced about 2 weeks apart with remote feedback and troubleshooting of issues that arose.However, there were negative observations that could limit the impact of the intervention. First, there were few consultations or requests for a second opinion, which was the main aim of the intervention. These remote consultations were mostly at the start of the project and from the new sites . Second, we faced difficulties in software development and integration with the existing EMR system UgandaEMR (a distribution of OpenMRS) . AlthougIn this paper, we presented the experiences of implementing a smartphone-based telemedicine system for VIA-based CaCx screening at 5 screening clinics in different regions of Uganda. Generally, the health workers, health facility administrators, and patients attending CaCx screening were positive about the intervention and perceived it as useful and acceptable with high usability. The main cited benefits were related to improved patient experience, particularly better communication and understanding of the screening process and results using cervical images, and improved referral processes. Other benefits included improved VIA through teleconsultation, the use of AI algorithms, and supervision and feedback; modernization of the screening process, thus boosting patient confidence and trust in the screening; and improved clinical documentation and data management to support AI development and research and monitoring.This study is the first to report on the implementation of smartphone-based telemedicine and AI in CaCx screening in Uganda. Studies from Tanzania ,40,42, MAn important contribution of this study to the CaCx control literature is that it provides insight into the role of digital health tools in improving patient experience of the screening process. This is an area that few prior studies have highlighted ,40. ImprAt the same time, negative perceptions and barriers must be addressed to ensure maximum impact and long-term adoption. In our study, barriers related to the technology used were minimal and surmountable. For example, the steep learning curve and perception that the system is time-consuming were reported only in the early phase of the project. Concerns about patient privacy and confidentiality were also easily addressed by proper explanation by the screening nurses. However, barriers related to the outer context beyond our intervention, such as attitudes and health system limitations, pose a bigger challenge.The main objective of setting up this intervention was to facilitate remote consultation, but this only happened to a small extent. This could be explained by better visualization using the system and hence straightforward and confident assessment by the nurses at the front line. Indeed, when consultations were made, often these were about how to manage or coordinate referrals, rather than assessments. Another explanation for the limited consultations, especially at sites with more experienced nurses, is that these nurses seemed to not consider an inaccurate VIA assessment to be a problem. Instead, they were more concerned with screening as many women as possible, given the low screening coverage and high patient volumes. For them, screening is for triage where more accurate evaluation is performed by a gynecologist in case the VIA conclusion is not obvious. Nonetheless, these nurses saw value in other aspects of the intervention . This is an important issue to consider since adoption of digital interventions can be affected by misalignment of the users’ needs or pain points with the services of the digital solution or the problems it solves. Social marketing principles  can be uAnother limitation of our project is the sustainability challenge. The project has been running on grant funding and has not been fully institutionalized. Although this has to do with the UCI’s nascent digitalization journey  characterized by fragmented pilots of different digital health systems and tools, it nonetheless undermines the long-term sustainability and impact of this project. Going forward, sustainability plans and efforts should be explored, including integration with existing digital health systems, as well as collaboration with other implementers of similar systems, so as to reuse any available (open source) artifacts. This could also save costs, for example, in collection and curation of AI training data sets by reusing data collected by others doing similar projects.This study shows that digital health tools are useful for improving the accuracy of VIA, as well as improving patient experience, which is crucial for CaCx screening uptake. However, general barriers to digital health in LMICs , as well those specific for this telemedicine system , are also highlighted. These barriers must be addressed if telemedicine is to be harnessed to support CaCx control in Uganda.


Background and Objectives: The use of biomaterials in dentistry is extremely common. From a commercial perspective, different types of osteoconductive and osteoinductive biomaterials are available to clinicians. In the field of osteoconductive materials, clinicians have biomaterials made of heterologous bones at their disposal, including biomaterials of bovine, porcine, and equine origins, and biomaterials of natural origin, such as corals and hydroxyapatites. In recent years, it has become possible to synthesize nano-Ha and produce scaffolds using digital information. Although a large variety of biomaterials has been produced, there is no scientific evidence that proves their absolute indispensability in terms of the preservation of postextraction sites or in the execution of guided bone regeneration. While there is no scientific evidence showing that one material is better than another, there is evidence suggesting that several products have better in situ permanence. This article describes a preliminary study to evaluate the histological results, ISQ values, and prevalence of nano-HA. Materials and Methods: In this study, we planned to use a new biomaterial based on nanohydroxyapatite for implantation at one postextraction site; the nano-HA in this study was NuvaBONE . This is a synthetic bone graft substitute that is based on nanostructured biomimetic hydroxyapatite for application in oral–maxillofacial surgery, orthopedics, traumatology, spine surgery, and neurosurgery. In our pilot case, a patient with a hopeless tooth underwent extraction, and the large defect remaining after the removal of the tooth was filled with nano-HA to restore the volume. Twelve months later, the patient was booked for implant surgery to replace the missing tooth. At the time of the surgery, a biopsy of the regenerated tissue was taken using a trephine of 4 mm in the inner side and 8 mm deep. Results: The histological results of the biopsy showed abundant bone formation, high values of ISQ increasing from the insertion to the prosthetic phase, and a good reorganization of hydroxyapatite granules during resorption. The implant is in good function, and the replaced tooth shows good esthetics. Conclusions: The good results of this pilot case indicate starting the next Multicentric study to have more and clearer information about this nanohydroxyapatite (NH) compared with control sites. The dental clinical practice often involves the extraction of hopeless teeth and their replacement with osseointegrated implants. If anatomical conditions make this possible, and the residual socket is suitable for inserting an implant, it is possible to perform extraction and implant at the same time. If there is not enough volume and apical bone after the extraction to achieve primary stability of the fixture, the clinician will have to perform a guided bone regeneration procedure to restore sufficient quantity and quality of the bone to host an implant. The GBR takes into consideration the use of different types of biomaterials. In particular, reabsorbable biomaterials, before being replaced by bone, are degraded due to the pH of the solution that surrounds them or the phagocytic/osteocytic activity of macrophages and osteoclasts. On the other hand, nonabsorbable biomaterials occupy a space that cannot be replaced by bone and are encapsulated in the bone matrix.Based on their behavior toward bone cellular components, we can differentiate osteoconductive materials and osteoinductive materials .With the exception of autologous bone, synthetic growth factors, and amelogenins, other materials on the market are all osteoconductive.Osteoconduction is a biological characteristic common to all autologous bone substitutes, which, although occurring mostly in materials of bone origin, remains strongly conditioned by the bone activity of the recipient site . After pThe healing mechanism of these bone substitutes differs from that of autologous bone grafts; because of the absence of osteoinductive capacity, their healing mechanism delays, sometimes considerably, the times of neoangiogenesis and remodeling . The infbovine origin [However, if an immunological reaction occurs, the graft will undergo rejection, often after a latency period, which is characterized by the chronicity of the inflammatory process, the destruction of blood vessels, the formation of thrombi, and an increase in osteoclastic activity, with the consequent detachment of the graft from the recipient site . Among te origin  with a dequine origin [Materials of e origin  undergo porcine origin [Materials of e origin , which se origin , obtainePhylogenic hydroxyapatites  are alsoThey are formed by numerous channels with the interposition of 1 μm pores. The orientation of these channels allows the penetration of fluids and cells inside the biomaterial, thus significantly increasing the contact surface between biological fluids, and consequently, allowing faster colonization by macrophage cells.bioglass [These materials also have an excellent osteoinductive capacity and have a resorption time of 3 years. Synthetic bone substitutes deserve a separate discussion, as all of these biomaterials show that they possess osteoconductive capacity and maintain stable bonds with the newly formed bone over time. Morphologically, they can be porous, crystalline, amorphous, or granular. Among these biomaterials, we find bioglass  with a pPolyglycolic and polylactic acid polymers [Bioglasses contain silica as a flux, sodium oxide as a stabilizer, calcium oxide, and, to a lesser extent, phosphorus pentoxide. Their bioactivity is linked to the surface hydrolytic degradation process of glassy phosphosilicate . The coupolymers  are highThese materials come in the form of blocks, granules, and gels, and as they are not radiopaque, they allow a better evaluation of the formation of bone tissue in the months following their application. Currently, the use of polymers in the form of polylactic and polyglycolic acid gels, in a 50:50 ratio, is implemented in association with other heterologous materials , which bCalcium sulfate [ sulfate  hemihydrhydroxyapatite is another topic of our research [Finally, research ,20.Synthetic hydroxyapatite is one of the longest-standing and most studied synthetic materials on the market. This material represents the inorganic component of human bone and has a strong osteoconductive capacity. The various hydroxyapatites on the market are mostly synthesized as microgranules of various diameters ranging between 200 and 500 μm or alternatively in blocks. Their porosity varies from 70 to 90%, with pores that are connected to each other with spaces of 80 to 200 μm in between, which facilitates colonization by osteogenic cells. In these hydroxyapatites, the conformation of crystals is also important, as it is able to influence the processes of osteointegration by modulating the participation of physiological liquids, cells, and proteins. Their geometry also seems to constitute an ideal microenvironment to concentrate growth factors and stimulate neoangiogenesis. These materials are frequently used mixed with autologous bone to increase the volume of the graft, with an osteoconductive material that acts as a support. The resorption times of these materials are very long, up to 4 years, and are influenced by the size of the pores and granules.Nanocrystalline hydroxyapatites have recently been introduced to the market, with granules that have a very large specific surface area, which have been developed with the aim of shortening resorption time. There are many aspects that are still unknown regarding the morphology of these biomaterial particles and their size ,22,23,24Some authors have published in vitro studies in which the effectiveness of materials that are commonly used in other medical fields was evaluated. In particular, the in vitro studies on the efficacy of raloxifene carried out by Memè et al. ,33 demonAnother interesting way to use Ha is printed hydroxyapatite scaffolds; they could be used as a substitute for nanohydroxyapatite biomaterials used in clinical case reports. These 3D-printed hydroxyapatite scaffolds can be designed with a variety of pore sizes and architectures, which can be optimized to promote bone regeneration. Additionally, 3D-printed scaffolds can be customized to fit the specific needs of each patient ,41.Previous studies have unequivocally demonstrated that, at present, there is no biomaterial capable of being designated as the best in terms of osteoblast response; there is no scientific evidence suggesting that there is a biomaterial other than autologous bone, which is still defined today as the gold standard, capable of being osteoinductive and producing the best bone in terms of quality and quantity. Differences emerge regarding the quantity of residual biomaterial after 6/7/12 months in the bone cores performed in the grafted sites.The purpose of this communication is to bring attention to the initial results obtained in a pilot case that used nanohydroxyapatite (NH) in socket preservation, where a large defect was restored and where a standard-diameter implant was placed to replace the missing tooth with good esthetics and function.To evaluate and compare two postextraction sites treated with nano-HA in the posterior regions (test) and the control sites, thus involving 4 or 5 sites of the jaws, after 24 weeks of healing;To determine the bone values of these sites in an evaluation during implant site preparation;To determine whether the addition of nano-HA increases the amount of bone using a site evaluation;To determine the bone quality of the sites based on a histological evaluation.A total of 100 patients requiring extraction of two adjacent teeth in the same quadrant will be recruited from 5 centers (10 patients per center). The multicenter study has the following objectives:The present preliminary study with 1-year of follow-up was a study performed in a private clinic in compliance with the principles of the 1964 Declaration of Helsinki for medical research protocols and ethics and its later amendments. The patient signed an informed consent explaining the use of MTG prior to the surgical procedure. The surgical procedure was performed in accordance with the postmarket clinical follow-up (PMCF) UE 2017/745. Participant was a healthy patient requiring one dental implant in upper 1.6. For the inclusion and the exclusion criteria, this study used the same criteria as the next multicentric study indicated in Age >18 years old;General good health (ASA I-II);Adequate oral hygiene ;Two adjacent teeth to be extracted in the same quadrant in 4 and 5 sites.The inclusion criteria are as follows:Pregnant or within lactating period;Untreated periodontitis;Osteometabolic disease;Intravenous bisphosphonates therapy;History of chemotherapy or radiation therapy applied to the neck and head area;Frequent smoking habits (>15 cigarettes/per day);Absence of buccal bone plate;Patients with active local infection.The exclusion criteria are as follows:NuvaBONE  is an innovative line of synthetic bone graft substitutes that is based on nanostructured biomimetic hydroxyapatite for application in oral–maxillofacial surgery, orthopedics, traumatology, spine, and neurosurgery. NuvaBONE hydroxyapatite is a calcium phosphate biomaterial equivalent to the mineral matrix of human bone in morphology and composition . ParticuAfter local anesthesia, teeth will be extracted gently, and the residual sockets will be carefully debrided from all granulation tissue, rinsed, disinfected with sterile saline, and grafted. Randomization will indicate which socket will be grafted with pure NH and which will be grafted with NH associated with collagen gel.The sockets will be packed to achieve a good contact between the bone and the biomaterial, and periapical rx will be taken at baseline and at 3 and 6 months.At 6 months, implants will be inserted, and biopsies will be taken to assess the degree of regeneration induced by the two biomaterials. The ISQ of the implants will also be measured on the day of surgery and at 4 months after exposure. If the ISQ is higher than 65 at the time of insertion, a healing abutment will be placed as a one-time abutment. The implants will be followed and evaluated for up to 18 months, with periapical rx taken at 6/12/18 months.Histological analysis and stability of the regenerated bone will be evaluated as well.In the pilot study, a 46-year-old man in good health presented to our clinic with a broken upper molar . The roohttps://imagej.net/software/fiji/downloads accessed on 30 Septembrer 2023) by acquiring pictures at 4× magnification.At the 12-month mark, the procedure to insert an implant was planned. The implant  was placed at the bone level after harvesting a core of the bone and soft tissue using a 4 mm (inner portion) trephine. The biopsy was sent to the Università Politecnica delle Marche  for evaluation . The tisThe ISQ values of the implant were 62, 62 ; therefore, a healing abutment was connected after taking a digital impression of the implant .The healing abutment led to a very healthy peri-implant tissue , and theHistological observation  of the wToday, the use of biomaterials in the clinical practice of dentists is considered a routine practice. The dream of dentists is undoubtedly to have a “magic potion” capable of regenerating large volumes of bone and perhaps even accelerating healing times. Unfortunately, current scientific evidence highlights that this is not yet realistic, and the majority of biomaterials work in exactly the same way, that is, they provide an optimal scaffold to give blood clots the possibility of proceeding with optimal healing via primary intervention. Therefore, studies that take into consideration the dentin and pulp of extracted teeth subjected to decalcification to fill postextraction sites are not interesting; the shredded dentin continues to progress as part of the bone and presents a cost-free autologous material ,43,44,45The histological specimen of a nano-HA grafted area showed complete graft replacement with little remnants of the nano-HA graft material. It is known that the residual presence of biomaterial in newly formed bone alters not only the quantity but also the quality of the regenerated bone and the consequent possibility of inserting an osseointegrated implant in that site. Although more in-depth studies are necessary, we can assume that this result is due to the peculiar characteristics of Nano-Ha; in particular, the size of the particles, and the nanoporosity favored faster reabsorption and, consequently, left room for a greater quantity of mature bone. The presence of mature bone would explain the high ISQ value found at the time of implant insertion; the value also increased at the time of prosthesis. The increase in the ISQ value is explained by the completion of the osteointegration of the implant, which occurred precisely due to a normal vascular organization of the newly regenerated bone. This article presented a single case report, which means that the findings cannot be generalized to other patients. We used nanohydroxyapatite biomaterial without a control site, so we cannot conclude whether the results would be the same with or without biomaterial.For these reasons, a multicenter study is very important to answer many questions; however, in our pilot case, the quality and quantity of bone proved to be of a high level after an observation of the material undergoing reabsorption and replacement.high bone quality based on histological evaluation, high resonance frequency values based on the Osstell scale, and low residual material in the histological samples. There are many biomaterials on the market and testing a new biomaterial could be expensive and useless; the preliminary study served precisely to understand whether this nano-Ha possessed characteristics that would encourage a multicenter study.This case report showed the successful clinical use of a nano-HA graft for socket preservation. We want to indicate three good results on which we can focus our attention: The next multicentric study will be coordinated by the Polytechnic University of Marche and Dr Roberto Rossi.


Waste management is the main challenge in the transition away from the linear "take-make-dispose" economy. Incorporating the principles of circularity in waste management would facilitate the achievement of Sustainable Development Goals. This paper aims to provide state-of-the-art research about circular waste management in the fulfillment of the 2030 Agenda. For this purpose, bibliometric analysis by VOSviewer and SciMat software is used to define the evolution and to detect research trends. Based on the main gaps identified in studies, a research agenda to guide for further opportunities in this field is suggested. The results obtained four clusters that address sustainable industrial infrastructure, biological waste management, recycling in developing countries and recovery processes. Four research propositions are established, focusing on plastic waste management and generation trends, circular municipal waste management, more sustainable landfill management, and enablers such as indicators and legislation. The transformation towards more bio and ecological models requires social, regulatory and organizational tools that consider the best interests and capacity of companies, public authorities and consumers. In addition, policy implications are considered. Circular economy (CE) is a regenerative and restorative system, which allows the conservation of the value of raw materials by breaking with the concept of end-of-life of products, minimizing waste and emissions and increasing efficiency, through recycling, reusing, and remanufacturing, among others  with the commitment of public actors, industry and society  estimates that around 35% of employment is a direct result of food systems and the promotion and implementation of sustainable practices in the food system -including food waste and loss- which is still low, referring to unfulfilled SDG 2 Torero . UncolleThis study combines a bibliometric analysis carried out by VOSviewer and SciMat software, and an in-depth literature review of the articles published during the year 2021. Figure In the first phase, documents from the Web of Science Core Collection database were collected from the period 2009 up to September 2021. The keywords used were ‘circular economy’ and ‘waste management’. This generated a total of 1.395 papers. Then, it was selected articles by topic, which includes title, abstract and authors’ keywords. retrieving 966 documents. Thereafter, we sorted the data into groups of Social Sciences Citation Index, Science Citation Index Expanded, Arts and Humanities Citation Index, taking only articles into consideration, reaching a total sample of 576 articles that were extracted and including in this analysis after a double checked in order to eliminate inconsistences.Bibliometric methodology identifies research trends providing the knowledge structure about a specific field. By examining recent published articles, network analysis shows emerging fields , 2020 (Period 2) and 2021 (Period 3).In the third and last phase, a literature review of the articles related to circular economy and waste management is carried out, in accordance with 51 documents from the motor themes of the SciMat analysis in the third period, during the year 2021, to determine the latest trends and research in the field. Finally, a research agenda is exposed regarding trending topics analysed in this work.Figure Table The most influential authors are sorted by number of documents published and total citations, indicating the institutions and country which they work in, and the h-index –impact and productivity measure-. The most prolific author is Navarro Ferronato from the University of Insubria in Italy with 9 papers published and a total of 129 cites, followed by Vicenzo Torreta  from the same institution. The prevalence of Italian researchers is in line with the country's overall recycling rate for all types of waste which reaches 68%, well above the EU average (57%) published in the “Third Report on the Italian circular economy in 2021”  -SDG 11- is one of the main topics. Many of the papers related are case studies such as Vardopoulos et al.  which dePlastic waste management is greatly studied in connection with circularity practices in many of the articles published during 2021, such as the case studies carried out by Foschi et al. , which is essential, yet insufficient if sustainable production and consumption is to be achieved by 2030. The main research topics analysed in the articles published during year 2021 focus on (1) Municipal Solid Waste (MSW) with the design of new municipal waste recycling models such as the Pay-As-You-Throw (PAYT) pricing model  as a raw material or energy source in other sectors. Compared to incineration, which is highly polluting if the organic waste is mixed with other types of waste, there are more sustainable and energy-efficient alternatives such as anaerobic digestion  the construction of waste-to-energy plants makes it possible to burn solid waste to power electricity generators  has been analysed, showing that the most productive sources come from the field of environmental sciences, which conditions the main topics investigated and shows a clear lack of attention to social sciences. The most prolific authors come from two countries with a strong interest in environmental research in general and waste management in particular—Italy and China. In the case of China, this is due to its strong productive fabric and a prominent role in the generation of waste from the COVID-19 pandemic.Concerning RQ2, four clusters have been obtained related to industrial ecology -SDG 9-, waste management from the application of bio-based processes -SDGs 6, 7, 11 and 12-, water treatment, sustainable development and recycling in developing countries -SDG 12- and the cluster on new procedures for the recovery of resources -SDG 12-.To conduct analysis of the central topics and the patterns we used SciMat software, dividing the articles published in the field into three periods  showing the scientific literature development, as can be seen in the evolution map Fig. . The motThe most cited articles and the previous bibliometric analysis have shown the great interest generated among scientists in the management of urban waste and plastic waste, which has increased in the last two years in relation to sanitary waste. The circular economy means that recycling is not enough in the management of this waste. In addition to the reduction in the generation of waste, the incorporation of the "bio" concept in its treatment, which allows fibres, bioplastics and other biomaterials to be obtained, has been added. Along the same lines, the treatment of food waste allows it to be converted into animal feed, biofuels or even textiles. However, among the most cited articles, no research related to the use and recycling of wastewater was found -SDG 6-. Further research is needed to enable its use for biomass production or as a source of nutrients for micro-organisms of interest . In this way, it is crucial to develop three fundamental aspects. First, the use of new technologies to meet the various needs raised. Secondly, a new approach to urban waste management is required. And thirdly, to develop research from a holistic perspective that will require the use of theories and sciences from the environmental, social and economic fields.The results of this study offer academic contributions about circular waste management. Among the theoretical contributions is the establishment of state-of-the-art research on waste management linked to the circular economy, which will guide future research and fill existing gaps. To offer the most complete research review possible, a mixed methodology—bibliometric and systematic review of the most cited recent research—has been used. A bibliometric analysis was carried out with two software tools, taking advantage of the potential of both. Using complementary software validates the analysis results. In addition, this article provides a framework for research as a guiding point in waste management.Thus, lack of social research is a major drawback that requires urgent incorporation of new social or multidisciplinary studies. It can be considered that social and economic issues have not been sufficiently addressed in the literature. None of the clusters obtained have these dimensions as their motor theme. Dropping SDGs such as 8 -decent work and economic growth-.A guideline for practitioners about circular waste management is required. Findings reveal the need for a reference framework for scholars, practitioners and institutions.This article implies practical contributions for governments to achieve a transition towards more circular waste management. The research shows the technical feasibility of substituting certain materials, mainly plastic, or applying techniques that allow a step beyond recycling. It is necessary to focus on actions based on recovery, reduction, remanufacturing and redesign of plastic waste to fill this gap (Olatayo et al. The significant "bio" trend has spread to different types of waste and sectors. Thus, the circular management of waste will require the development of infrastructures, technologies and processes oriented to its application, which means waste management with less environmental impact, but also a generation of value of the product derived from the waste. This value can be manifested in new products -whether or not related to the original sector of the product from which the waste is derived- or renewable and sustainable energies (Ferreira et al. Addressing the limitations of this study, it’s worth underscoring the fact that WoS was the exclusive Database used to retrieve the final sample under analysis, and only articles published in English are studied, other languages were not considered. Despite the use of VOSviewer to display the co-occurrence analysis, the interpretation of the results is subjective, in accordance with the papers reviewed. In future works, other software can be combined such as CiteSpace or HistCite to visually create scientific maps.Regarding future research lines, the following aspects are considered a research agenda in the field of waste management and circular economy. The need to incorporate into waste management from a circular perspective such as: circular bioeconomy models, the construction of more robust eco-efficiency indicators to improve measurement and comparison between regions, and the consideration of new processes and techniques in the management of urban, food and plastic waste. Research is also required to manage waste in the construction and demolition of buildings and infrastructures from a sustainably innovative standpoint.The challenges facing waste management in meeting the 2030 Agenda are considerable. Circular economy facilitates the pathway but is not a miracle tool. The contribution of companies and industries requires the collaboration and awareness of consumers. To this end, public institutions must generate policies, regulations and incentives that create the most favorable framework possible. Having already surpassed half of the set timeframe towards meeting the SDG targets, urgent measures are required, and the Academy must lend its support in this regard.


Sugar-sweetened beverages (SSBs) are implicated in weight gain and adverse cardiometabolic heath. Social networks of stakeholders involved in providing potable water and sugar-sweetened beverages (SSBs) in high schools in Costa Rica were studied using social analysis network. In public and private schools, the interactions between the stakeholders in charge of providing beverages are fragmented and their role in preventing the availability of SSBs is weak. School canteen owners ultimately decide what beverages are available at school, which may cause students to choose beverages that increase the risk of overweight/obesity. It is therefore urgently necessary to improve the capacity for two-way interactions between the stakeholders to enhance their roles in the provision of beverages. Hence, it is essential to reinforce the stakeholders’ leadership, and set up innovative ways to exert it in order to develop a shared vision of the types of drinks that should be available in the school environment. A high consumption of sugar-sweetened beverages (SSBs) increases the risk of obesity in adolescents ,2,3, whiTo curb SSBs and added sugar consumption among schoolchildren and adolescents, the Costa Rican Ministry of Public Education issued a decree in 2012 to regulate the sales of SSBs and food on public school premises . The fooThe decree states that each school should establish a Health and Nutrition Committee that, together with the school principal and board, should oversee compliance with this regulation ,12. In aSocial network analysis (SNA) has been used to identify, map, and analyze the structure, composition, and patterns of interaction between all actors/stakeholders in a particular social system ,16,17,18This is an observational study that collected primary data with regard to stakeholders involved in the discussion networks’ provision of beverages in high schools in San Jose, Costa Rica. Data were collected over two months in 2022 via three sequential waves of data collection to arrive at the final discussion networks or the networks that consist of stakeholders who discuss the purchase or provision of beverages in their school. Private schools were added to the data collection to compare results with public schools.Data were collected from public and private urban high schools in San José, the capital of Costa Rica. This city includes 6.3% of the high school students in the country’s educational system, 50.2% of which are boys and 49.8% are girls. In general, 80% attend public schools and 20% attend private schools .We adapted the network dimension portion of the stakeholder-driven community diffusion survey, which has been implemented in the United States with acceptable reliability to assess social and work network properties ,23. GiveThe survey was designed to start with school principals  and continue with the people named by the ego  as those with whom the provision of beverages in the school environment was discussed. Subsequently, the survey was continued with the people mentioned by the alters  and so on. The survey was concluded when the beverage suppliers were mentioned by some alters.Each interviewee was asked about their sex, the type of school they worked in (private/public), and their function in the school . Then, they were asked to name up to 20 individuals with whom they discussed to provide water  and a list of beverages. The list came originally from the Beverage Intake Questionnaire (BEVQ-15)  on typicFor each person named, the respondent was asked to select the following from a close-ended list: (1) the type of beverage ”); (2) the sector (“Which sector does this person belong to? (choose one): school principal/administrative staff, School Board, Health and Nutrition Committee, school canteen, student dining room/cafeteria, beverage supplier, supplier of drinking water dispenser, Aqueducts and Sewers Services, local government, Ministry of Public Education”)  and following up with the second-degree ‘alters’ (the persons named in the survey completed by each ‘ego’). The number of participants and their characteristics  varied in each wave, since this depended on the relationship that each alter had with others alters (different actors linked to the provision of beverages in the school setting). Three waves of data collection were conducted. The third wave yielded a complete description of the network linked to the provision of beverages as respondents nominated already-named stakeholders and also the beverage suppliers. The same situation occurred in the six schools; therefore, it was not necessary to carry out additional waves to complete the description of the social network.The duration of each round varied from 1 to 4 days based on the availability of the alters mentioned by the ego or the alters mentioned by other alters. Data collection lasted two months as the start of each wave depended on the availability of school principals to meet with the researchers. Data were collected simultaneously in public and private schools, and the order in which each school was added to the study depended solely on the availability of the school principal (the ego actor).All surveys were administered in person in Spanish by a trained, bilingual researcher. In Wave 1, data were collected using the Qualtrics survey platform, and for waves 2 and 3, the paper survey was used, and data were then entered into the Qualtrics platform. The survey lasted approximately 15–20 min to complete.Ethical considerations: The study protocol was approved by the Bioethics Committee of the Costa Rican Institute for Research and Education on Nutrition and Health (INCIENSA) under number IC-2022-01.Collected data constitute 100% of the stakeholders that make up the social networks linked to the provision of beverages in public and private school settings. Therefore, regardless of the number of participants, the use of social network analysis is an appropriate methodology for this study, based on the premise that a social network consists of a finite set of actors and the relationships, or ties, defined on them ,30.Data collected from all three waves were combined to form a social network within each school using iGraph  between individuals or nodes (vertex) that make up the social network)  and StatWe used the following scenarios to create a directed network: (1) stakeholders A and B both responded to the survey and nominated each other (counts as two ties); (2) A and B responded, but A nominated B or B nominated A (counts as one tie); and (3) only A or B responded and nominated the other (counts as one tie). Once the directed networks were created, we ran a series of analyses, both descriptive and exploratory, to examine the presence of network and ego patterns within and across schools.First, descriptive analyses were performed on each school’s network to examine both network and ‘ego’ metrics. These metrics included density, centrality , and homophily . Network density is the measure of the number of ties within the network. Degree centrality is the number of ties an individual stakeholder  has. Closeness centrality measures the distance each individual stakeholder is from all other stakeholders. Betweenness centrality measures how many times an individual lies on the shortest path between two other individual stakeholders.Second, triads (or groups of three) and tetrads (groups of four) were assessed following this supposition: the tendency for individual i to be tied to individual k if a tie exists between individual i and individual j and between individual j and individual k. Identifying triads and tetrads in a network can be used to determine whether and why there is hierarchy, if that hierarchy is linked to transitivity , which can be linked to how information flows through a discussion network. Hierarchy in networks emerges from one-way ties. In other words, the directionality of an unreciprocated tie indicates a hierarchical difference, where the recipient of a tie occupies a higher position than the sender.Third, we built visualizations based on the reported frequency of contact and perceived stakeholder influence, as indicated by the thickness of each tie. To highlight differences, the thickness of the connection was scaled between 1 and 20 times the reported frequency (range: 1–5 points (pts); average: 2.89 pts) and influence  metrics. Thus, a low connection thickness represented a lower score and a high connection thickness represented a higher score. Generally, a high frequency of contact and a high perceived influence refer to scores of 4 pts and above, which corresponds to be involved in the provision of beverages weekly or more and rating a stakeholder as influential or highly influential, respectively. These visualizations also highlighted other raw data such as the different drinks that were discussed between stakeholders and each stakeholder’s sector or function within the school. These visualizations aided in examining whether there were any links between the frequency of contact, stakeholder influence, and hierarchy.Finally, we utilized the Clauset–Newman–Moore algorithm to examine community clustering to identify whether specific clusters or groups existed within schools and whether these clusters were based on sector affiliation or how stakeholders felt about each other .Data were collected from six schools (three public and three private). The ties and direction of connections between all stakeholders are illustrated by each school in Private School Beverage Discussion Networks: In private schools, the school principals, but mainly administrative staff , are directly connected to school canteen owners to discuss the types of beverages they would make available in their schools. In two private schools, this tie was bidirectional . Public School Beverage Discussion Networks: In public schools, the ‘egos’  primarily interacted with three entities regarding the provision of beverages in their schools: their School Board, their school’s Health and Nutrition Committee, and the school cafeteria. These interactions were bidirectional/reciprocal, meaning that these ‘alters’ also mentioned interacting with school principals regarding the provision of beverages. In terms of the types of beverages, these ‘egos’ and ‘alters’ reported that they discussed exclusively the provision of water (bottled or tap). School principals also interacted with the municipal water authorities regarding tap water in their schools.The School Board also interacted with the school cafeteria and with the school canteen owners to ensure only the provision of water (tap or bottled) in schools. However, school canteen owners did not name the School Board as part of their network in the provision of beverages. School canteen owners only named beverage suppliers as stakeholders with whom they discussed beverage provision in schools. In addition to bottled water, school canteen owners discussed up to eight different types of SSBs with beverage suppliers for public schools . None ofThe ties and networks resulting from the Health and Nutrition Committees at each public school were more equivocal: in one school, this committee was not mentioned at all as part of the school principal or School Board’s network regarding the provision of beverages in their school. In the other two public schools where this committee was mentioned, it was tied with school cafeteria personnel either bidirectionally or unidirectionally (the latter meaning that the school cafeteria personnel did not mention the committee in their network). In either case, the discussions were exclusively about the provision of tap water in schools.The level of influence on beverage provision within each school stakeholder network and the frequency with which stakeholders interacted was based primarily on two factors: school type and the organizational position of the stakeholder .Level of influence in private schools: School principals and administrative staff identified school canteen owners as frequent contacts with high influence on the purchase and provision of beverages in their schools. An exception to this trend is found in one private school where the administrative staff has a higher level of influence on the purchase and provision of bottled water and SSBs than the school canteen owners .Level of influence in public schools: In public schools, school principals named the Ministry of Public Education as a stakeholder with high influence  in shaping their understanding of the purchase and provision of beverages in schools. In contrast, other stakeholders in public schools, mainly in the School Board, had a higher frequency of contact with school canteen owners and tended to rate them as highly influential in the purchase and provision of only bottled water, even though school canteen owners (low-influence stakeholders) discussed that they offered a wide variety of SSBs in addition to bottled water. The Health and Nutrition Committee was perceived to have a low influence on the provision of water in school cafeterias (2.12 pts). Finally, school principals were identified by five types of stakeholders as being more influential regarding the provision of beverages compared to other stakeholders within the network , although they remained as having a lower frequency of contact (2.32 pts on average).Network metrics displayed in Comparing metrics, public schools had a higher degree of centrality  suggesting that stakeholders in public schools tend to be local connectors but are not necessarily connected to the wider network .In summary, beverage discussion networks in public schools were more interconnected compared to private schools, where it was often the school principal/administrative staff that connected directly with the beverage supplier. In the beverage discussion networks of public schools, water was discussed more than any other type of beverage among stakeholders, but school canteen owners discussed all other beverages, including SSBs. By contrast, in private schools, all types of beverages, including water and SSBs, were discussed between the ‘egos’  and the school canteen owners directly.The youth spend a significant amount of their lives in schools and around their classmates . The schAccording to a recent systematic review, legislative/environmental interventions were more effective than educational/behavioral interventions at decreasing SSBs consumption among adolescents, highlighting the power of well-implemented regulatory mandates to start lowering SSBs consumption in schools . HoweverIn Costa Rica, despite the national mandate, SSBs are still available in public school settings , indicatWhile the networks are simpler in private schools, particularly the influence of the administrative staff, it is insufficient to guarantee an adequate provision of healthy beverages to students. A more active role of the school principal in the monitoring of beverages provision, through a greater interaction with school canteen owners, could contribute to changing the picture, and provide a better eating environment in private schools.Given the actors’ deficient exercise of power in public and private schools, school canteen owners ultimately decide what beverages are available at school, which may cause students to choose beverages that increase the risk of overweight/obesity . This reThe results of this study should be interpreted from the perspective of its limitations and strengths. First, the study only included three public and three private schools, so the results cannot be generalized to the entire city of San Jose or the country at large. Nevertheless, the present work is a valuable addition to the scarce literature on networks involved in the provision of beverages in the school environment in Latin America. Second, participating schools were in urban areas, so the type of stakeholder networks and their interactions may differ from those in rural areas. Third, the study is cross-sectional and does not allow the identification of changes in the stakeholders that make up social networks or in the changes that occur in the interaction between them. Fourth, the respondents could have overestimated the assessment of their influence or that of other stakeholders due to their subjective perception since no objective measure was used to determine or confirm it. However, the SNA has become a theoretical, methodological, and technical alternative, which has resulted in new possibilities for social research. Fifth, our final discussion networks only accurately represent the organizational hierarchy within public and private schools included in our analyses. Finally, although this study included some artificially sweetened soft drinks , it did not perform an in-depth analysis of the availability of this type of beverage in the school setting. Given the deleterious repercussions for health associated with the consumption of artificially sweetened soft drinks , their aIn public and private schools, the interactions between the stakeholders in charge of providing beverages are fragmented and their role in preventing the availability of SSBs is weak and depends on decisions made by school canteen owners. This was evidenced by the SNA, which provided information on the existing stakeholders and institutional relationships, the existing decision framework and, therefore, the influence and exchange of information to achieve a school environment where healthy beverages are available.It is necessary to develop public health policies aimed at preventing non-communicable diseases from adolescence and complying with the third sustainable development goal, which indicates the urgency of guaranteeing a healthy life and promoting well-being for all at all ages . The ade